Spinal Cord Injuries
Conditions
Keywords
Spinal neuromodulation, Transcutaneous stimulation, Spinal cord stimulation, Neuroanatomy, Neurorehabilitation
Brief summary
Chronic spinal cord injury (SCI) is a debilitating disorder in Veterans and the broader U.S. population that does not have a cure. Veterans with severe SCI demonstrate permanent loss of sensory and motor function below their injury resulting in decreased quality of life and independence. Recently, electrical spinal neuromodulation has emerged as a potential approach to restore voluntary motor function and locomotion in persons with chronic SCI. However, spinal neuromodulation has yet to translate to clinical use due to small sample sizes in research studies and a lack of information on which patients would benefit. Here, the investigators propose a novel approach to evaluate the priorities and barriers faced by Veterans with SCI to use spinal neuromodulation, understand the neural connections remaining in Veterans with severe SCI, and determine potential functional improvements using non-invasive spinal neuromodulation technology. This research represents the first step towards deploying techniques that could dramatically improve function and quality of life for Veterans with SCI.
Detailed description
The International Standards for Neurological Classification of SCI (ISNCSCI) exam is used to classify spinal cord injury (SCI) severity by determining the neurological injury level and functional completeness of SCI. However, anatomical, physiological, and functional studies have indicated that many participants with ISNCSCI-defined complete SCI retain connectivity through the SCI lesion. Due to the heterogeneity of SCI and the small-N in prior spinal neuromodulation studies, there are no diagnostic criteria to determine how SCI lesion profile affects the ability to restore sensorimotor function in the presence of spinal neuromodulation. Development of this knowledge is necessary to design precise spinal neuromodulation approaches and clinical trials that could restore function and improve quality of life for Veterans with chronic SCI. First, stakeholders will be engaged to define research priorities, meaningful outcomes, and barriers to participation in neuromodulation trials. The potential impact of neuromodulation and priorities of Veterans with SCI and their caretakers will be assessed across a nationwide survey. Spinal neuromodulation will be evaluated to determine how it could impact clinical practice and treatment of Veterans though survey of SCI physicians. Qualitative feedback will be obtained from Veterans with SCI regarding the expected and achieved outcomes with neuromodulation prior to and after undergoing functional neuromodulation experiments. Next, baseline anatomical and physiological connectivity measurements across ISNCSCI scores will be established. Veterans with SCI across INSCSCI grades will be recruited to determine residual spinal connectivity. Spinal cord anatomy will be assessed above, below, and at the SCI lesion through MR neuroimaging. Descending corticospinal connectivity will be evaluated with transcranial magnetic stimulation and ascending afferent signals will be evaluated through somatosensory evoked potentials. Finally, functional spinal connectivity during spinal neuromodulation will be evaluated. Volitional motor output will be assessed with and without non-invasive spinal neuromodulation. The sensory effects of spinal neuromodulation will be assessed through user reports of pain and somatosensation. Potential functional improvements in activities of daily living will be assessed with and without spinal neuromodulation.
Interventions
DIAGNOSTIC_TESTNeurophysiological and anatomical testing
All participants will undergo neurophysiological testing (transcranial magnetic stimulation and somatosensory evoked potentials) to determine residual neural connectivity. All participants will also undergo MRI of the spine to evaluate residual neural connections and changes above and below lesion. These values will be compared to the standard clinical evaluation of spinal cord injury (ISNCSCI exam).
All participants will undergo spinal neuromodulation through non-invasive transcutaneous spinal stimulation to determine the effects on voluntary motor function, sensation, and activities of daily living.
Sponsors
VA Office of Research and Development
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
BASIC_SCIENCE
Masking
NONE
Masking description
Due to the uniqueness of each injury, all staff will be aware of each participant's history. All participants will receive the same intervention.
Intervention model description
All participants will be Veterans with spinal cord injury to evaluate neurophysiological and functional effects of non-invasive spinal neuromodulation.
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* All participants must be able to independently read and understand study information materials necessary to ensure informed consent * All participants must have a chronic spinal cord injury occurring \>1 year prior to study enrollment * Ability to follow simple commands in English
Exclusion criteria
* Contraindications to the use of external magnetic or electrical stimulation (e.g., epilepsy, intracranial metal, implanted electrosensitive device, etc.) * Significant neurological comorbidities that may affect neurophysiological recordings * Functional disability prior to spinal cord injury * Visual or auditory disorders limiting ability to participate in study procedures * Pregnancy * Primary psychiatric disorders or dissociative mental symptoms that impair informed consent * Significant chronic pain that may preclude an magnetic resonance imaging (MRI) scan or performing neurorehabilitation exercises * Frequent and significant spasticity that may preclude an MRI scan or neurorehabilitation exercises
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Axial completeness of chronic spinal cord injury (SCI) based on spine magnetic resonance imaging (MRI) | 5 years | Spared region volume at the injury site as assessed by spine MRI will be compared with clinical SCI score as measured by the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) exam. |
| Sagittal completeness of chronic spinal cord injury (SCI) based on spine magnetic resonance imaging (MRI) | 5 years | Intramedullary lesion length will be measured via spine MRI and compared with clinical SCI score as measured by the ISCNSCI exam. |
| Presence of descending connections in chronic spinal cord injury based on transcranial magnetic stimulation | 5 years | The latency of transcranial magnetic stimulation pulses will be measured via electromyography and compared with clinical SCI score as measured by the ISCNSCI exam. |
| Presence of ascending connections in chronic spinal cord injury based on somatosensory evoked potentials. | 5 years | The latency of somatosensory evoked potential pulses will be measured via electromyography and compared with clinical SCI score as measured by the ISCNSCI exam. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Research priorities of Veteran spinal cord injury stakeholders | 2 years | The research priorities of Veterans with chronic spinal cord injury will be obtained and compared with previously published results in the non-Veteran population. |
| Voluntary motor function in the presence of non-invasive stimulation | 5 years | Increases in electromyography will be assessed with and without the use of non-invasive transcutaneous spinal stimulation. |
| Sensory responses in the presence of non-invasive stimulation | 5 years | Participants will self-report any changes in sensation during the application of non-invasive transcutaneous spinal stimulation. |
Countries
United States
Contacts
CONTACTJonathan S Calvert, PhD MD
PRINCIPAL_INVESTIGATORJonathan S Calvert, PhD MD
VA Northern California Health Care System, Mather, CA
Outcome results
None listed