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Rehabilitation and Cortical Remodeling After Surgical Intervention for Spinal Cord Injury

Primary Purpose

Spinal Cord Injuries, Tetraplegia, Cervical Spinal Cord Injury

Status
Recruiting
Phase
Phase 2
Locations
United States
Study Type
Interventional
Intervention
Upper limb robotic training
Nerve transfer surgery
Sponsored by
Burke Medical Research Institute
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Spinal Cord Injuries focused on measuring robotics, hand function

Eligibility Criteria

18 Years - 50 Years (Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  • Tetraplegia (cervical lesion) with some degree of motor dysfunction in the hand
  • Motor incomplete or complete lesion (measured by the ASIA Impairment Scale, A, B, C, D).
  • Chronic lesion (at least 6months after the injury)
  • Demonstrate stability of motor examination for at least six months.
  • Retain intact innervation within paralyzed target muscles (axon recipient) as determined by electrodiagnostics.
  • Have muscles innervated by the nerves to be used for the transfers (axon donors) of MRC grade 4/5 or greater and sufficient innervation as determined by electrodiagnostics.
  • Have access to an at home caregiver who can assist with customary postsurgical physical therapy.
  • Ability to give informed consent and understand the tasks involved.

Exclusion Criteria:

  • Presence of potential risk factor for brain stimulation: history of seizures, presence of surgically implanted foreign bodies such as a pacemaker, metal plate in the skull, and metal inside the skull.
  • History of head trauma and/or cognitive deficit
  • Medically unstable
  • Contraindicated for nerve transfer surgery.

Sites / Locations

  • Burke Neurological InstituteRecruiting

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Active Comparator

Arm Label

Nerve transfer + robotic training

Nerve transfer + delayed robotic training

Arm Description

Participants will receive nerve transfer surgery at Massachusetts General Hospital in Boston, MA. One year after the surgery, participants will receive six weeks of upper limb robotic training at the Burke Neurological Institute in White Plains, NY.

Participants will receive nerve transfer surgery at Massachusetts General Hospital in Boston, MA. One year + six weeks after the surgery, participants will receive six weeks of upper limb robotic training at the Burke Neurological Institute in White Plains, NY.

Outcomes

Primary Outcome Measures

Change in Box and Blocks test score
The Box and Blocks test measures how many blocks a person can grasp and transfer in one minute. A higher score is associated with better hand function.

Secondary Outcome Measures

Upper extremity motor score (UEMS)
The Upper extremity motor score (UEMS) tests the clinical motor strength from 0 to 5 from each key muscle using the ASIA scale. This sum score ranges from 0 (paralyzed) to 25 (normal) in each limb.
Spinal Cord Independence Measure (SCIM III)
The Spinal Cord Independence Measure (SCIM III) measures the ability of patients with SCI to perform everyday tasks according to their value for the patient. SCIM is used for quantitative functional outcome assessment following interventions designed to promote recovery from spinal cord injury and to increase functional achievement; and it covers 19 tasks in 16 categories (score range 0-100); all activities of daily living, grouped into four areas of function (subscales): Self-Care (scored 0-20), Respiration and Sphincter Management (0-40), Mobility in Room and Toilet (0-10), Mobility Indoors and Outdoors (0-30).
Modified Ashworth Scale
The Modified Ashworth Scale (MAS) will be used to measure change in spasticity. The scale is a scale from 0 to 4 that measures muscle stiffness. A higher score is associated with greater spasticity.
Single pulse transcranial magnetic stimulation
Changes in resting motor threshold (RMT), motor evoked potential (MEP) amplitude will be measured in each muscle of both arms using a MagStim X100 stimulator (MagStim) and a figure-8 coil. We will investigate the neurophysiological correlates of function, and the characteristics of participants who respond better to the training.

Full Information

First Posted
July 30, 2019
Last Updated
June 8, 2022
Sponsor
Burke Medical Research Institute
Collaborators
Massachusetts General Hospital
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1. Study Identification

Unique Protocol Identification Number
NCT04041063
Brief Title
Rehabilitation and Cortical Remodeling After Surgical Intervention for Spinal Cord Injury
Official Title
Rehabilitation and Cortical Remodeling After Surgical Intervention for Spinal Cord Injury
Study Type
Interventional

2. Study Status

Record Verification Date
June 2022
Overall Recruitment Status
Recruiting
Study Start Date
July 26, 2019 (Actual)
Primary Completion Date
December 31, 2025 (Anticipated)
Study Completion Date
December 31, 2026 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
Burke Medical Research Institute
Collaborators
Massachusetts General Hospital

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
Yes
Data Monitoring Committee
No

5. Study Description

Brief Summary
The aim of this study is to determine the effects of rehabilitation on dexterous hand movements and cortical motor map changes in tetraplegic patients following nerve transfer surgery. The working hypothesis is that robot-assisted, intensive rehabilitation will support the return of hand and arm function and strengthen the cortical representations of targeted muscles. The investigators will assess this through TMS mapping and clinical measures of hand and arm function.
Detailed Description
The recovery of hand and arm function is of critical importance for decreasing long-term care costs and increasing quality of life for individuals with tetraplegia due to spinal cord injury (SCI). A subset of these individuals, with injuries in the mid to low cervical spinal cord, are candidates for nerve transfer surgery. Nerve transfer surgery restores function after SCI through coaptation of redundant, intact donor nerves to recipient nerves arising at or below the level of SCI. The use of nerve transfer after SCI is relatively novel and many patients exhibit a remarkable recovery of hand and arm motor function in the months that follow, however others show a much more limited recovery. The extent of recovery is likely limited, in part, by variability in rehabilitation and the ability of the motor cortex to incorporate the new peripheral circuitry resulting from this surgical procedure. There is a critical need to determine the response of cortical motor networks to nerve transfer and the role that rehabilitation plays in supporting cortical plasticity and motor recovery. If this need is not met, incomplete recovery from this state-of-the-art surgical intervention will persist and the potential application to a wider patient population will not be realized. The investigators will test the central hypothesis that nerve transfer surgery after cervical SCI creates a novel cortical motor network, which can support the return of dexterous hand/forelimb function through rehabilitation-dependent remodeling. The hypothesis has been based upon 1) previous work in an animal model showing that rehabilitation reshapes cortical motor maps, 2) the pioneering work of a handful of clinicians, including the study collaborator, Justin Brown, that have applied nerve transfer to bypass spinal levels affected by injury, and 3) recent work using transcranial magnetic stimulation (TMS) in human SCI to map the cortical representation of arm muscles in the zone of partial preservation, and the ability to improve hand-arm function through intensive robotic training in chronically impaired subjects. The use of TMS to map cortical motor networks will allow the investigators to measure the cortical reorganization resulting from nerve transfer and determine the extent to which rehabilitation can engage this alternative cortical motor network. The rationale for the proposed studies is that a determination of the mechanisms that support rehabilitation-mediated recovery after nerve transfer will be required for optimizing and refining current clinical practice.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Spinal Cord Injuries, Tetraplegia, Cervical Spinal Cord Injury
Keywords
robotics, hand function

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 2
Interventional Study Model
Crossover Assignment
Model Description
All participants will receive nerve transfer surgery. Half of the participants will receive 6 weeks of robotic training starting one year after the surgery. The other half of the participants will receive 6 weeks of robotic training starting one year plus 6 weeks after the nerve transfer surgery.
Masking
Outcomes Assessor
Masking Description
The outcomes assessor will not have knowledge of the time point at which they are assessing the participant.
Allocation
Randomized
Enrollment
12 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
Nerve transfer + robotic training
Arm Type
Experimental
Arm Description
Participants will receive nerve transfer surgery at Massachusetts General Hospital in Boston, MA. One year after the surgery, participants will receive six weeks of upper limb robotic training at the Burke Neurological Institute in White Plains, NY.
Arm Title
Nerve transfer + delayed robotic training
Arm Type
Active Comparator
Arm Description
Participants will receive nerve transfer surgery at Massachusetts General Hospital in Boston, MA. One year + six weeks after the surgery, participants will receive six weeks of upper limb robotic training at the Burke Neurological Institute in White Plains, NY.
Intervention Type
Device
Intervention Name(s)
Upper limb robotic training
Intervention Description
Subjects will remain seated in their own wheelchair in front of the InMotion Hand™ Robot (Interactive Motion Technologies, Massachusetts, MA, Figure 6) facing a video screen. The arm of the participants will be abducted, forearm supported, and hand grasping a cone shaped handle. Velcro straps will lightly hold the forearm and fingers secure. The InMotion Hand™ robot attaches to the InMotion Arm™ robots to provide 'assisted-as-needed'™ gross grasp and release motion and support for functional reach. In each session, patients perform a total of 1024 movement repetitions (Cortes et al., 2013). Patients will receive a total of 18 sessions (3x/week, 6 weeks) comprising one hour of interactive hand robotic training. The interactive robotic features involve visuomotor task, moving the robotic manipulandum according to targets on a computer screen mounted at eye level.
Intervention Type
Procedure
Intervention Name(s)
Nerve transfer surgery
Intervention Description
C5 injury; Teres minor branch of axillary nerve transferred to long head of triceps branch of radial nerve (RN); Brachialis branch of musculocutaneous nerve to anterior interosseous nerve (AIN); Supinator branch of RN to posterior interosseous nerve (PIN). C6 injury; Teres minor branch of axillary nerve to long head of triceps branch of RN; Extensor carpi radialis brevis (ECRB) branch of RN to AIN; Supinator branch of RN to PIN. C7 injury with preserved triceps, loss of grasp/release; Pronator teres branch of median nerve to AIN; Terminal branch of ECRB branch of RN to flexor pollicis longus branch of AIN; Supinator branch of RN transferred to PIN. C7 injury with preserved triceps/finger extension, loss of grasp; Pronator teres branch of median nerve to AIN; Terminal branch of ECRB branch of RN to flexor pollicis longus branch of AIN.
Primary Outcome Measure Information:
Title
Change in Box and Blocks test score
Description
The Box and Blocks test measures how many blocks a person can grasp and transfer in one minute. A higher score is associated with better hand function.
Time Frame
1 year post surgery, immediately post training, minus baseline before surgery
Secondary Outcome Measure Information:
Title
Upper extremity motor score (UEMS)
Description
The Upper extremity motor score (UEMS) tests the clinical motor strength from 0 to 5 from each key muscle using the ASIA scale. This sum score ranges from 0 (paralyzed) to 25 (normal) in each limb.
Time Frame
1 year post surgery, immediately post training, minus baseline before surgery
Title
Spinal Cord Independence Measure (SCIM III)
Description
The Spinal Cord Independence Measure (SCIM III) measures the ability of patients with SCI to perform everyday tasks according to their value for the patient. SCIM is used for quantitative functional outcome assessment following interventions designed to promote recovery from spinal cord injury and to increase functional achievement; and it covers 19 tasks in 16 categories (score range 0-100); all activities of daily living, grouped into four areas of function (subscales): Self-Care (scored 0-20), Respiration and Sphincter Management (0-40), Mobility in Room and Toilet (0-10), Mobility Indoors and Outdoors (0-30).
Time Frame
1 year post surgery, immediately post training, minus baseline before surgery
Title
Modified Ashworth Scale
Description
The Modified Ashworth Scale (MAS) will be used to measure change in spasticity. The scale is a scale from 0 to 4 that measures muscle stiffness. A higher score is associated with greater spasticity.
Time Frame
1 year post surgery, immediately post training, minus baseline before surgery
Title
Single pulse transcranial magnetic stimulation
Description
Changes in resting motor threshold (RMT), motor evoked potential (MEP) amplitude will be measured in each muscle of both arms using a MagStim X100 stimulator (MagStim) and a figure-8 coil. We will investigate the neurophysiological correlates of function, and the characteristics of participants who respond better to the training.
Time Frame
1 year post surgery, immediately post training, minus baseline before surgery

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Maximum Age & Unit of Time
50 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Tetraplegia (cervical lesion) with some degree of motor dysfunction in the hand Motor incomplete or complete lesion (measured by the ASIA Impairment Scale, A, B, C, D). Chronic lesion (at least 6months after the injury) Demonstrate stability of motor examination for at least six months. Retain intact innervation within paralyzed target muscles (axon recipient) as determined by electrodiagnostics. Have muscles innervated by the nerves to be used for the transfers (axon donors) of MRC grade 4/5 or greater and sufficient innervation as determined by electrodiagnostics. Have access to an at home caregiver who can assist with customary postsurgical physical therapy. Ability to give informed consent and understand the tasks involved. Exclusion Criteria: Presence of potential risk factor for brain stimulation: history of seizures, presence of surgically implanted foreign bodies such as a pacemaker, metal plate in the skull, and metal inside the skull. History of head trauma and/or cognitive deficit Medically unstable Contraindicated for nerve transfer surgery.
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Liz Magier, MPA
Phone
914.368.31159
Email
elm2045@med.cornell.edu
Facility Information:
Facility Name
Burke Neurological Institute
City
White Plains
State/Province
New York
ZIP/Postal Code
10605
Country
United States
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Kathleen Friel, PhD
Phone
914-368-3116
Email
kaf3001@med.cornell.edu
First Name & Middle Initial & Last Name & Degree
Edmund Hollis, PhD
First Name & Middle Initial & Last Name & Degree
Kathleen Friel, PhD

12. IPD Sharing Statement

Plan to Share IPD
No

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Rehabilitation and Cortical Remodeling After Surgical Intervention for Spinal Cord Injury

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