Transcutaneous and Epidural Stimulation in SCI
- Conditions
- Paraplegia, CompleteParaplegia; TraumaticParaplegia, Spinal
- Interventions
- Device: Transcutaneous spinal cord stimulatorDevice: Epidural spinal cord stimulator system
- Registration Number
- NCT04627441
- Lead Sponsor
- Kristin Zhao, PhD
- Brief Summary
The study seeks to improve the scientific understanding of how two electrical stimulation techniques, one which delivers electricity to the skin surface over the spine (transcutaneous electrical spinal stimulation \[TESS\]) and another which is implanted onto the dura mater of the spinal cord (epidural electrical stimulation \[EES\]), facilitate spinal circuitry to enable function after SCI.
- Detailed Description
The study will compare motor activity and clinical outcomes over the course of TESS and EES in combination with physical rehabilitation.
The primary outcome data collected will be used to characterize and compare spinal sensorimotor activity in muscles below the level of injury during TESS and EES-enabled motor tasks in persons with chronic motor complete paralysis of the lower extremities due to traumatic SCI. Furthermore, data collected will be used as a proof of concept that TESS can be used to determine recovery of function during EES-enabled motor tasks. Following exposure to each stimulation intervention, data collection will include changes to spasticity, body composition, metabolic variables, and spinal imaging to assess the effect of either TESS or EES stimulation.
Recruitment & Eligibility
- Status
- WITHDRAWN
- Sex
- All
- Target Recruitment
- Not specified
- Spinal cord injury due to trauma located between the seventh cervical (C7) and tenth thoracic vertebrae (T10)
- American Spinal Injury Association grading scale of A or B (4 each of A and B) below the level of SCI
- Intact spinal reflexes below the level of SCI
- At least 1-year post-SCI
- At least 22 years of age
- Willing to use medically acceptable methods of contraception, if female and of child-bearing potential
- Currently a prison inmate, or awaiting trial, related to criminal activity
- Pregnancy at the time of enrollment
- Dual energy x-ray absorptiometry (DEXA) t-score <-3.5 at spine and femur head
- History of chronic and/or treatment resistant urinary tract infection
- Unhealed decubitus ulcer
- Unhealed skeletal fracture
- Untreated clinical diagnosis of depression
- Presence of joint contractures or an Ashworth spasticity score of 4
- Active anti-spasticity medication regimen within 3 months prior to study enrollment
- Presence of transcranial magnetic stimulation-evoked potentials in leg muscles
- Undergoing, or planning to undergo, diathermy treatment
- Active participation in another interventional clinical trial
- Presence of conditions or disorders which require MRI monitoring
- A history of coagulopathy or other significant cardiac or medical risk factors for surgery
- Current use of a ventilator
- Clinically diagnosed cardiopulmonary complications such as chronic obstructive pulmonary disease, cardiac failure, or heart arrhythmia that contraindicate changes in body position such as supine-to-sit-to-stand activities, prolonged standing, or stepping
- Mass > 113 kg (250 pounds)
- History of frequent hypotension characterized by light headedness, or loss of consciousness
- History of frequent hypertension characterized by headache, or bradycardia
- History of frequent, severe, autonomic dysreflexia
- Any illness or condition which, based on the research team's assessment, will compromise with the patient's ability to comply with the protocol, patient safety, or the validity of the data collected during this study.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- SINGLE_GROUP
- Arm && Interventions
Group Intervention Description TESS-EES Transcutaneous spinal cord stimulator Transcutaneous Electrical Spinal Stimulation (TESS), used during the first month of training sessions, followed by Epidural Electrical Stimulation (EES) during the final 6-month training period. TESS-EES Epidural spinal cord stimulator system Transcutaneous Electrical Spinal Stimulation (TESS), used during the first month of training sessions, followed by Epidural Electrical Stimulation (EES) during the final 6-month training period.
- Primary Outcome Measures
Name Time Method Electromyography Baseline, End of TESS, Start of EES, End month 6 EES Change in measurements of electrical activity at major muscle groups below the level of injury.
Kinematics Baseline, End of TESS, Start of EES, End month 6 EES Change in measurements of joint angles, measured in degrees.
Foot pressure Baseline, End of TESS, Start of EES, End month 6 EES Change in measurements of foot pressure through shoe-insole pressure sensors.
Overground ambulation [as appropriate to the subject] (1) Baseline, End of TESS, Start of EES, End month 6 EES Measurement of changes in overground mobility as measured by the Modified 6 Minute Walk Test. Trainers will assess the distance in meters which the subject can cover in 6 minutes, with a greater distance characterizing better overground mobility.
Overground ambulation [as appropriate to the subject] (2) Baseline, End of TESS, Start of EES, End month 6 EES Measurement of changes in walking impairment as measured by the Walking Index for Spinal Cord Injury. Trainers will assess overall level of impairment, ranging from most severe impairment (0) to least severe impairment (20), based on the use of devices, braces, and physical assistance of one or more persons.
Somatosensory evoked potentials Baseline, End of TESS, Start of EES, End month 6 EES Change in measurements of change in conduction in the peripheral nerves, cervical and lumbosacral spinal cord, deep brain structures, and sensory cortex, through surface electrodes.
Transcranial magnetic stimulation motor evoked potentials Baseline, End of TESS, Start of EES, End month 6 EES Change in measurements of stimulus intensity required to elicit muscle responses in muscle groups known to elicit optimal motor evoked potential responses, both above and below the level of injury.
Monosynaptic spinal reflex testing Baseline, End of TESS, Start of EES, End month 6 EES Change in measurements of stimulation intensity H and F wave thresholds and maximal responses through surface electrodes.
Trunk stability Baseline, End of TESS, Start of EES, End month 6 EES Change in measurements of trunk stability using the modified functional reach test (mFRT).
Injury severity: American Spinal Injury Association (ASIA) Impairment Scale Baseline, End of TESS, Start of EES, End month 6 EES Change in measurements of impairment of sensory and motor functions using the American Spinal Injury Association Impairment Scale. Individuals are classified from A" (complete spinal cord injury) to "E" (normal function). 28 dermatomes and 10 key muscles are assessed bilaterally. Results are summed to produce overall sensory and motor scores and are used in combination with evaluation of anal sensory and motor function as a basis for the determination of ASIA classification. Sensory scores are rated 0 (sensation absent) to 2 (normal), bilaterally for each of 28 dermatomes. Muscle function is rated 0 (total paralysis) to 5 (active movement, full range of motion against significant resistance) for each myotome. Upper Extremity Motor Subscores and Lower Extremity Motor Subscores are each scored from 0 to 50; the ASIA Motor Score is scored from 0 to 100. The presence of anal sensation and voluntary anal contraction are assessed as a yes/no.
- Secondary Outcome Measures
Name Time Method Metabolics - HDL cholesterol Baseline, End of TESS, Start of EES, End month 6 EES Measurement of change in HDL cholesterol value.
Body composition - lean mass Baseline, End of TESS, Start of EES, End month 6 EES Measurement by dual-energy x-ray absorptiometry (DEXA) of change in regional and total lean mass.
Metabolics - glucose Baseline, End of TESS, Start of EES, End month 6 EES Measurement of change in fasting glucose value.
Metabolics - total cholesterol Baseline, End of TESS, Start of EES, End month 6 EES Measurement of change in total cholesterol value.
Patient-reported bowel function (2) Baseline, End of TESS, Start of EES, End month 6 EES Measurement of change in bowel function using the International Spinal Cord Injury Bowel Function Basic Data Set (v2.0). Answers to qualitative questions are rated from 0 to 13, with a higher number indicating more problematic symptoms, and totaled for a score which categorizes neurogenic bowel dysfunction.
Male patient-reported sexual function (1) Baseline, End of TESS, Start of EES, End month 6 EES Assessment of change in sexual function using the International Spinal Cord Injury Male Sexual Function Basic Data Set (v2.0). Data from various male sexual function variables are aggregated into a single-page format for an abstract overview of male sexual dysfunction.
Spasticity Baseline, End of TESS, Start of EES, End month 6 EES Change in measurements of spasticity using the Spinal Cord Injury Spasticity Evaluation Tool (SCI-SET). Answers to qualitative questions are rated from -3 to +3, with a higher positive number indicating more helpful symptoms, and a lower negative number indicating more problematic symptoms. Scores are totaled for a score which categorizes the overall positive or negative impact of a subject's spasticity symptoms.
Bone mineral density Baseline, End of TESS, Start of EES, End month 6 EES Measurement by dual-energy x-ray absorptiometry (DEXA) of change in bone mineral content and bone density.
Body composition - body fat mass Baseline, End of TESS, Start of EES, End month 6 EES Measurement by dual-energy x-ray absorptiometry (DEXA) of change in regional and total body fat mass.
Body composition - android and gynoid fat percentage Baseline, End of TESS, Start of EES, End month 6 EES Measurement by dual-energy x-ray absorptiometry (DEXA) of change in regional and total android and gynoid fat percentage.
Body composition - bone mass Baseline, End of TESS, Start of EES, End month 6 EES Measurement by dual-energy x-ray absorptiometry (DEXA) of change in regional and total bone mass.
Metabolics - CBC Baseline, End of TESS, Start of EES, End month 6 EES Measurement of changes in complete blood count with differential.
Metabolics - calculated LDL cholesterol Baseline, End of TESS, Start of EES, End month 6 EES Measurement of change in calculated LDL cholesterol value.
Metabolics - triglycerides Baseline, End of TESS, Start of EES, End month 6 EES Measurement of change in triglycerides value.
Neurostimulator array location and migration Start of EES, End month 6 EES Evaluation of current array location via CT.
Patient-reported bladder function (2) Baseline, End of TESS, Start of EES, End month 6 EES Assessment of change in bowel function using the International Spinal Cord Injury Urodynamic Basic Data Set. Data from various urodynamic variables are aggregated into a single-page format for an abstract overview of bladder dysfunction.
Male patient-reported sexual function (2) Baseline, End of TESS, Start of EES, End month 6 EES Measurement of change in erectile dysfunction using the Sexual Health Inventory for Men (SHIM). Answers to qualitative questions are rated from 0 to 5, with a higher number indicating better erectile function, and totaled for a score which categorizes severity of erectile dysfunction.
Metabolics - non-HDL cholesterol Baseline, End of TESS, Start of EES, End month 6 EES Measurement of change in non-HDL cholesterol value.
Patient-reported bowel function (1) Baseline, End of TESS, Start of EES, End month 6 EES Measurement of change in bowel function using the Neurogenic Bowel Dysfunction Score. Answers to qualitative questions are rated from 0 to 5, with a higher number indicating more problematic symptoms, and totaled for a score which categorizes severity of neurogenic bowel symptoms.
Patient-reported bladder function (1) Baseline, End of TESS, Start of EES, End month 6 EES Measurement of change in bladder function using the Neurogenic Bladder Symptom Score. Answers to qualitative questions are rated from 0 to 5, with a higher number indicating more problematic symptoms, and totaled for a score which categorizes severity of neurogenic bladder symptoms.
Male patient-reported sexual function (3) Baseline, End of TESS, Start of EES, End month 6 EES Measurement of change in erectile dysfunction using the International Index for Erectile Function (IIEF). Answers to qualitative questions are rated from 0 to 5, with a higher number indicating better erectile function, and totaled for a score which categorizes severity of erectile dysfunction.
Female patient-reported sexual function (1) Baseline, End of TESS, Start of EES, End month 6 EES Assessment of change in sexual function using the International Spinal Cord Injury Female Sexual and Reproductive Function Basic Data Set (v2.0). Data from various female sexual and reproductive function variables are aggregated into a single-page format for an abstract overview of female sexual and reproductive dysfunction.
Female patient-reported sexual function (2) Baseline, End of TESS, Start of EES, End month 6 EES Measurement of change in sexual function using the Female Sexual Function Index (FSFI). Answers to qualitative questions are rated from 0 to 5, with a higher number indicating better sexual function, and totaled for a score which categorizes severity of sexual dysfunction.