Spinal Cord Injury
Conditions
Keywords
Robotic Exoskeleton, Epidural Stimulation, Transspinal stimulation, Spinal cord injury, Rehabilitation
Brief summary
Spinal cord injury (SCI) leads to several health-related consequences often linked to reduced levels of physical activity. Direct stimulation of the spinal cord, either through implanted devices or surface stimulation, has been combined with intense physical therapy assisted treadmill walking to facilitate independent standing and stepping. These current methods require 3-4 highly skilled therapists and may not be feasible in all rehabilitation settings, especially when considering the growing number of SCI patients each year. Therefore, the use of robotic exoskeleton suits combined with direct stimulation of the spinal cord (requiring 1-2 therapists) may offer an alternative rehabilitation approach to overcome their limited abilities to stand and walk. Such improvements may also help to reverse or eliminate other health-related consequences associated with SCI. The pilot work will provide the preliminary evidence required to design future clinical trials for Veterans and civilians with SCI to restore overground mobility.
Detailed description
Restoring locomotion following spinal cord injury (SCI) has been the focus of years of research aimed at ameliorating several of health-related comorbidities. Spinal cord epidural stimulation (SCES) exhibits the rehabilitation potential of restoring locomotion in individuals with SCI when combined with intensive locomotion training. Despite this potential, such protocols are likely impractical when applied across large clinical SCI populations due to high monetary costs. Similar to SCES, transspinal stimulation (TS) has also exhibited neuromodulatory benefits by externally stimulating lumbro-sacral neural circuity to generate step-like activities in persons with complete SCI; however, these techniques also require intense gait training. Recently robotic exoskeletons have been used as a promising tool to circumvent limitations associated with labor-intensive locomotor training, and have been safely used as an effective approach in improving levels of physical activity in persons with complete SCI. Recent work has demonstrated the benefits of combining EAW and neuromodulatory techniques. Following 12-weeks of EAW+SCES training, improvements in locomotion led researchers to decrease the amount of EAW swing assistance to 35% in a person with a C7 complete SCI. This was accompanied by 573 unassisted steps, which represents 50% of the total number of steps taken during that session. Electromyographic (EMG) activity also increased during both stance and swing phases, reflecting the individual's ability to rhythmically fire paralyzed muscles during EAW+SCES. Additionally, cardio-metabolic loads were increased during exoskeletal stepping when combined with SCES as compared to stepping without SCES. The participant also showed a modest decrease in his total and regional absolute fat mass. These preliminary findings suggest that neuromodulation using SCES with exoskeletal ambulation may provide a feasible rehabilitation approach for persons with SCI. The goal of the current study is to examine and compare the effects of EAW combined with SCES or TS in persons with motor complete SCI. The data generated from this application will also enable larger clinal trials to explore ways to optimize exoskeletal assisted gait training through the use of different neuromodulation modalities with SCI. Following a repeated-measure design, 10 participants with chronic, motor complete (AIS A and B) SCI (age:18-60 years) will be randomly assigned to participate in either 6-months of EAW+SCES (n=5) or EAW+TS (n=5) training. The entire duration of the trial will be approximately 1 year for each participant. Initially, participants will undergo 3-months of EAW training (3 sessions/week), which will be followed by randomization into either a EAW+SCES group or EAW+TS group for an additional 6-months of training (both groups: 3 sessions/week) and a 3-month follow-up period for both groups. Measurements at baseline (BL: prior to EAW) and 4 post-intervention timepoints will occur every 3-months (P1: following 3-months of EAW; P2: following 3-months of EAW+TS or EAW+SCES; P3: after completing 6-months of EAW+TS or EAW+SCES; P4: 3-months after termination of EAW+TS or EAW+SCES). This pilot work will have 3 specific aims: Aim 1. The investigators will determine and compare improvements to locomotor control following 6 months of EAW+TS and EAW+SCES as measured by 10-meter walking speed, the number of unassisted EAW steps, and EMG activity. Aim 2. The investigators will determine and compare improvements to cardio-metabolic risk factors following 6 months of EAW+TS and EAW+SCES as measured by total and regional body composition, oxygen uptake, and fasting lipid profile. Aim 3. The investigators will determine and compare improvements in bladder health following 6 months of EAW+TS and EAW+SCES as measured by bladder filling and emptying
Interventions
DEVICEEAW+SCES (exoskelton and spinal cord epidural stimulation)
Three months of exoskeleton training followed by 6 months of epidural stimulation.
DEVICEEAW+TS (exoskelton and transspinal stimulation)
Three months of exoskeleton training followed by 6 months of transspinal stimulation.
Sponsors
VA Office of Research and Development
Virginia Commonwealth University
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Intervention model description
Exoskeletal assisted walking and spinal cord epidural stimulation (EAW+SCES) Exoskeletal assisted walking and Transspinal stimulation (EAW+TS)
Eligibility
Sex/Gender
MALE
Age
18 Years to 70 Years
Healthy volunteers
No
Inclusion criteria
* All participants will be between 18-70 years old, male, with traumatic motor complete SCI and level of injury of T10 and above, as determined by EMG testing and International Standards for Neurological Classification of SCI (ISNCSCI) exam * All participants will undergo ISNCSCI examination for neurological level and function and only those with American Spinal Injury Classification (AIS A and B; i.e. motor deficit below the level of injury) will be included
Exclusion criteria
Participants with any of the following pre-existing medical conditions will be excluded from the current trial: * Diagnosis of neurological injury other than SCI, including cauda equina or distal conus injuries resulting in limb or sacral areflexia * Unhealed fracture in either lower or upper extremities * Severe scoliosis, hip knee range of motion (ROM) or flexion knee contractures preventing positioning in an exoskeleton or plantarflexion contracture greater than 20 degrees * Untreated or uncontrolled hypertension defined as high resting blood pressure greater than 140/90 mmHg and severe orthostatic hypotension (drop greater than 20 mmHg compared to resting supine blood pressure) or incapable to maintain a sitting or EAW standing posture * Other medical conditions including cardiovascular disease, uncontrolled type II DM, uncontrolled hypertension, and those on insulin, pressures sores stage 3 or greater, or symptomatic urinary tract infection * Unable to fit in the device for any reason * Taking anti-coagulants or anti-platelet agents, including aspirin if unable to be off this medication for medical reasons * Implanted pacemakers and/or implanted defibrillator devices * DXA T-Score less than -2.5. Scans done will include total body, dual hips and knees. Total hip BMD T-scores \< -3.5 and knee BMD scores of less than 0.6 g/cm2 * Functional upper and lower extremity ROM, strength, spasticity and skin integrity will also have assessed prior to enrollment in the program. * The Modified Ashworth Scale will be used to ensure safety of the participants prior to engagement in the rehabilitation program * Participants with severe spasticity or limited ROM will be excluded from the trial * This is based on the Ekso manufacturer's recommendations * Untreatable severe spasticity judged to be contraindicated by the site Physician * Pressure ulcer of the trunk, pelvic area, or lower extremities of grade 3 or more * Psychopathology documentation in the medical record or history that may conflict with study objectives * Any condition that, in the judgment of the principal investigator or medical provider, precludes safe participation in the study and/or increases the risk of infection
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| 10-meter Walking Speed (m/Sec) | Baseline (BL), Post-Intervention 1 (P1; 3 months following BL) and Pos-intervention 3 (P3; 6 months following P1) | After fitted in the robotic exoskeleton, the participant will be asked to walk for 10-meter distance and the time and speed will be determined. Measurements were conducted over the course of 9 months. |
| Muscles Electromyography (EMG) Activity (Micro-volts) | Baseline (BL), Post-Intervention 1 (P1; 3 months following BL) and Pos-intervention 3 (P3; 6 months following P1) | Representative EMG activities of the right VL muscle during the entire gait cycle of the 10 meter walking test at baseline (BL) and post-intervention (PI) measurements over the course of 9 months. In the EAW+SECES, participants had undergone EMG measurements during exoskeletal-10-meter walking test at baseline (BL) and after 6 months (P3) following implantation of spinal cord epidural stimulation (SCES). The EMG tests were performed at 100% exoskeletal assisted walking (EAW) or reduced EAW (RED-EAW) at Baseline and P3. At P3, the EMG tests were performed three times; one at 100%-EAW, RED-EAW without SCES and RED-EAW with SCES. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Percentage Fat Mass | Baseline (BL), Post-Intervention 1 (P1; 3 months following BL) and Pos-intervention 3 (P3; 6 months following P1) | Body composition will be captured using dual energy x-ray absorptiometry (DXA) to measure fat mass (FM; %) every 3 months during the course of 9-month trial. |
| Oxygen Uptake (L/Min) | [Time Frame: Baseline (BL), Post-Intervention 1 (P1; 3 months following BL) and Pos-intervention 3 (P3; 6 months following P1)] | Oxygen uptake during resting, standing and walking will be measured during 6 minutes walking test every 3 months during the course of the trial. |
| Fasting Lipid Profile (mg/dl) | [Time Frame: Baseline (BL), Post-Intervention 1 (P1; 3 months following BL) and Pos-intervention 3 (P3; 6 months following P1)] | After overnight fast, blood will be drawn to measure your circulating triglycerides, low and high density lipoproteins and cholesterol. |
| Fat-Free Mass | Baseline (BL), Post-Intervention 1 (P1; 3 months following BL) and Pos-intervention 3 (P3; 6 months following P1) | Body composition will be captured using dual energy x-ray absorptiometry (DXA) to measure fat mass (FFM; kg) every 3 months during the course of 9-month trial. |
Countries
United States
Contacts
PRINCIPAL_INVESTIGATORAshraf Gorgey, PhD PT
Hunter Holmes McGuire VA Medical Center, Richmond, VA
Baseline characteristics
| Characteristic | — |
|---|---|
| Age, Categorical <=18 years | 0 Participants |
| Age, Categorical >=65 years | 0 Participants |
| Age, Categorical Between 18 and 65 years | 4 Participants |
| Age, Continuous | 30.5 years STANDARD_DEVIATION 8 |
| Ethnicity (NIH/OMB) Hispanic or Latino | 0 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 2 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants |
| Region of Enrollment United States | 2 Participants |
| Sex: Female, Male Female | 0 Participants |
| Sex: Female, Male Male | 2 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 2 | 0 / 2 |
| other Total, other adverse events | 0 / 2 | 1 / 2 |
| serious Total, serious adverse events | 0 / 2 | 0 / 2 |
Outcome results
None listed