Motor and Autonomic Concomitant Health Improvements With Neuromodulation and Exercise (MACHINE) Training: A Randomized Controlled Trial in Individuals With SCI
Overview
- Phase
- Not Applicable
- Intervention
- Not specified
- Conditions
- Spinal Cord Injuries
- Sponsor
- University of British Columbia
- Enrollment
- 12
- Locations
- 1
- Primary Endpoint
- Change in attempted voluntary motor activation (supine)
- Status
- Recruiting
- Last Updated
- 2 years ago
Overview
Brief Summary
Spinal cord injury (SCI) disrupts many aspects of life, including the loss of volitional movement and involuntary control of bodily functions; both crucial functional recovery priorities for this population. Mobility impairments and secondary complications limit an individual's ability to exercise, a behavior known to have wide-ranging functional and health benefits. This trial will investigate whether activity-based therapy (ABT), using body-weight-supported treadmill training (BWSTT), can change the strength of signals from the brain that control volitional movement, leading to improvements in seated balance as well as other important involuntary bodily (i.e. cardiovascular, urinary tract, bowel and sexual) functions. The investigators aim to determine whether these improvements can be augmented with the addition of non-invasive transcutaneous spinal cord stimulation (TSCS). This therapy has been shown to re-awaken dormant spinal circuits. In this randomized controlled trial, TSCS with ABT, using BWSTT (three sessions/week for twelve weeks), will be compared to ABT+SHAM in individuals with chronic motor-complete spinal cord injury (SCI). Those in the ABT+SHAM group will be given the option to complete an ABT+TSCS open-label follow-up. Before and after training, the following outcomes will be assessed by validated methods: corticospinal excitability, motor function, and seated balance (Hypothesis 1 - Motor Function); severity and frequency of blood pressure instability, urinary tract, bowel, and sexual dysfunctions (Hypothesis 2 - Autonomic Functions); and general health (Hypothesis 3 - Quality of Life). This collaborative project is between consumers with SCI and clinicians/scientists with expertise in SCI care (kinesiologists, physiotherapists, physiatrists, sexual health clinicians). Compared to ABT alone, the investigators anticipate that ABT+TSCS will result in superior improvements in motor and autonomic functions in individuals with SCI.
Detailed Description
Spinal cord injury (SCI) is a severe disorder resulting in not only in motor deficits (i.e. paralysis) but also a myriad of autonomic dysfunctions (i.e. urinary tract/bowel/sexual impairments and blood pressure instability). The restoration of motor as well as autonomic functions remains among the top priorities for individuals with SCI. Individuals with SCI develop cardiovascular (CV) disease at a younger age and at greater rates than individuals without injury. Both low levels of physical activity and profound blood pressure (BP) instability, commonly experienced by individuals with injuries at or above the sixth thoracic level, likely explains the heightened risk. Neurogenic lower urinary tract (LUT) dysfunction impacts over 90% of individuals with SCI. This dysfunction leads to vesico-ureteral-renal reflux, urinary tract infections, bladder stone formation, and impaired renal function - ultimately leading to significant disease burden and poorer health-related quality of life. Bowel function is also significantly compromised after SCI, presenting as constipation, impaired colonic motility and loss of volitional control resulting in episodes of fecal incontinence - predisposing an individual to increased risk of long-term complications. Over 60% report that bowel dysfunction adversely impacts quality of life. Lastly, severe impairments in sexual function following SCI include erectile dysfunction, ejaculatory disorders/ anejaculation in men and reduced vaginal lubrication in women, with both sexes experiencing orgasmic difficulties or anorgasmia as well as alterations in sexual drive and sexual satisfaction. Activity-based therapy (ABT) is a common and an effective means to improve walking function post-injury and can facilitate general health maintenance; this includes an enhancement of neural BP control, as well as bladder, bowel, and sexual functions. Neuromodulation, potentially activating isolated spinal cord neuronal circuitry, has received significant recognition in recent years as a promising approach to target various neurological dysfunctions. The immense therapeutic potential of epidural spinal cord stimulation demonstrates mitigation of spasticity in individuals with motor-incomplete injuries. Moreover, this stimulation improved ability to generate rhythmic, locomotor-like limb movements, and restored voluntary control of functional movements in individuals with motor-complete injuries. Our past exciting and ground-breaking pilot work highlights the capacity for TSCS to modulate spinal circuits (An Autonomic Neuroprosthesis: Noninvasive Electrical Spinal Cord Stimulation Restores Autonomic Cardiovascular Function in Individuals with Spinal Cord Injury. J Neurotrauma. 2018;35(3):446- 451. doi:10.1089/neu.2017.5082). To administer TSCS, small adhesive electrodes are placed on the skin around the spinal cord and hips. The electrodes are connected to a machine that generates a small electric current. After turning the machine on, the participant may feel a small electric current under the electrodes, though it should not elicit any pain. Despite literature supporting the benefits of TSCS and ABT, the effects of pairing TSCS with ABT is largely unknown. These therapies are adaptable, non-invasive, and relatively affordable, with the potential to simultaneously benefit both motor and autonomic functions. Randomized controlled trials are needed to better validate these interventions for clinical settings. Project Rationale: Motor paralysis and autonomic dysfunctions have been identified as a major priority for recovery by individuals with SCI. Addressing these dysfunctions may ultimately translate to improved health-related quality of life (HRQOL). The use of ABT with non-invasive and adaptable TSCS has the potential to reduce CV disease risk factors and other autonomic dysfunctions in this at-risk population.
Investigators
Andrei Krassioukov
Principal Investigator
University of British Columbia
Eligibility Criteria
Inclusion Criteria
- Not provided
Exclusion Criteria
- Not provided
Outcomes
Primary Outcomes
Change in attempted voluntary motor activation (supine)
Time Frame: Weeks 2 and 14
While lying in the supine position, the following voluntary motor contractions will be attempted: trunk flexion, hip flexion, knee flexion, knee extension, ankle dorsiflexion, and ankle plantar flexion. Surface EMG recordings will be taken from the rectus abdominis, rectus femoris, biceps femoris, vastus lateralis, tibialis anterior, soleus, and gastrocnemius. The root mean square (RMS) EMG amplitude from each muscle during rest and the attempted contraction for each participant and each trial will be calculated to explore presence of muscle activity in each movement.
Change in attempted voluntary motor activation (walking)
Time Frame: Weeks 2 and 14
Participants will attempt to voluntarily activate lower limb muscles while walking in the body-weight-supported treadmill system. Surface EMG recordings will be taken from the rectus femoris, biceps femoris, vastus lateralis, tibialis anterior, soleus, and gastrocnemius. The root mean square (RMS) EMG amplitude from each muscle during rest and stepping for each participant and each trial will be calculated to explore presence of muscle activity during walking.
Change in lower limb proprioceptive sense
Time Frame: Weeks 2 and 14
Lower limb proprioceptive sense will be quantified using previously validated assessments of joint position sense and movement detection sense using custom software of the Lokomat. Kinesthesia and joint position sense will be determined.
Change in blood pressure regulation
Time Frame: Weeks 2 and 14
Blood pressure variability will be measured using a 24-hour ambulatory blood pressure monitor (24-Hr ABPM) which records blood pressure every 15 minutes during the daytime period, and then every hour during the night-time period. Changes in systolic blood pressure will be determined.
Secondary Outcomes
- Change in seated, dynamic balance control(Weeks 2 and 14)
- Change in lower urinary tract function measured by the NBSS(Weeks 2 and 14)
- Change in spinal excitability(Weeks 2 and 14)
- Change in seated, static balance control(Weeks 2 and 14)
- Change in severity of orthostatic hypotension(Weeks 2 and 14)
- Change in corticospinal excitability(Weeks 2 and 14)
- Change in severity of cardiovascular dysfunction by the ADFSCI(Weeks 2 and 14)
- Change in lower urinary tract function measured by the I-QOL(Weeks 2 and 14)
- Change in subjective experience of sexual functioning measured by a semi-structed interview(Weeks 2 and 14)
- Change in quality of life measured by the SF-36(Weeks 2 and 14)
- Change in bowel function measured by the NBDS(Weeks 2 and 14)
- Change in sexual function (for female participants) measured by the FSFI(Weeks 2 and 14)
- Change in cardiac structure and function(Weeks 2 and 14)
- Change in fatigue measured by the FSS(Weeks 2 and 14)
- Change in spasticity measured by the SCI-SET(Weeks 2 and 14)
- Change in pain measured by the International SCI Pain Basic Data Set (version 2)(Weeks 2 and 14)
- Change in sexual function (for male participants) measured by the IIEF-15(Weeks 2 and 14)