Neural Plasticity and Motor Recovery After Upper Extremity Motor Training in People With c-SCI

Background of the study:

Paralysis or paralysis is the most common effect of spinal cord injury (SCI) on individuals. Paralysis affects the ability to walk, perform self-care, live independently and participate in work and leisure activities. In individuals with cervical spinal cord injury, arm and hand function is very important. The most promising and easily implemented intervention that could promote neurological recovery and make a lasting difference in the lives of people with spinal cord injuries is early and intensive motor training aimed at recovery below the injury level. This intervention takes advantage of the early plasticity of the nervous system. By maximizing muscle activation in the first few weeks after injury, we can target the nervous system's unique capacity for neural plasticity where changes can occur in central and peripheral motor systems.

Objective of the study:

This project aims to investigate peripheral and central neuroplasticity following an early (\<13 weeks after injury) and intensive (8 weeks of 6 hours of additional therapy) upper extremity motor training program (EIUMT) aimed at recovery below the lesion level. This project has 4 objectives: to investigate 1) central neural plasticity (identify changes in cortical neuroplasticity and corticospinal excitability; 2) peripheral neural plasticity (identify change in axonal excitability and number of motor units); 3) clinical motor recovery of the upper limbs and 4) relationships between dose dimensions of motor intervention and clinical and neurophysiological outcome measures after EIUMT. Advanced neurophysiological measurements and clinical measurements will be taken before and after EIUMT and at 6-month follow-up.

Study design:

a multicenter pragmatic randomised controlled study in 2 countries

Study population:

44 persons with cervical spinal cord injury (22 participants in the control and intervention groups) Inclusion criteria: Individuals are eligible to participate if they have suffered a traumatic or non-traumatic cervical spinal cord injury within the previous 13 weeks, have AIS (ASIA Impairment Scale) A lesion with motor function more than three levels below motor level (on one or both sides) or have AIS C or AIS D lesion (as defined by the International Standards for the Neurological Classification of spinal cord injury), are older than 16 years of age, have received permission to begin rehabilitation and are likely to remain an inpatient for the next 8 weeks.

Exclusion criteria: Participants will be excluded if they have a significant medical or physical condition or psychiatric illness that could prevent the person from participating in the study or would place the person at unacceptable risk if they were to participate.

Intervention:

The intervention group receives 6 hours of motor training each week. This involves active and targeted motor training of all affected muscles below the injury level in the context of functional activities.

The control group receives only standard rehabilitation and care.

Primary study parameters/outcome of the study (Baseline vs 8 weeks after randomisation):

Central plasticity via: Single pulse TMS (transcranial magnetic stimulation) (Resting Motor Threshold) Peripheral plasticity via: Peripheral nerve assessment (Compound muscle action potential (CMAP)) Functional recovery via: Grades redefined assessment of strength, sensibility and Prehension (GRASSP)

Secondary study parameters/outcome of the study:

Clinical Measures: Upper Extremity Motor Score, Spinal Cord Independence Measure (SClM-selfcare); Van Lieshout Test (VLT); Hand-Held Dynamometry; accelerometry (session density: active therapy time/session length); perceived difficulty and exertion) Central plasticity: Single Pulse TMS: Stimulus-Response Function, Cortical mapping, Paired pulse TMS: SICI (short interval intracortical inhibition); LICI (long interval intracortical inhibition) Peripheral plasticity: NET (Nerve excitability testing) and MScanFit MUNE.

• Single-pulse TMS: Stimulus Response Curve [Time frame: - before intervention; at 4 weeks (inbetween measure), at 8 weeks (after intervention) and at 6 months follow-up]
• changes SICI [Time frame: - before intervention; at 8 weeks (after intervention) and at 6 months follow-up]
• changes in LICI [Time frame: - before intervention; at 8 weeks (after intervention) and at 6 months follow-up]
• changes in MscanFit MUNE [Time frame: - before intervention; at 4 weeks (inbetween measure), at 8 weeks (after intervention) and at 6 months follow-up]
• changes in single pulse TMS: mapping [Time frame: - before intervention; at 8 weeks (after intervention) and at 6 months follow-up]
• changes in NET (Nerve excitability testing) [Time frame: - before intervention; at 4 weeks (inbetween measure), at 8 weeks (after intervention) and at 6 months follow-up]
• changes in behavioral measures: Upper extremity motor score [Time frame: - before intervention; at 8 weeks (after intervention) and at 6 months follow-up]
• changes in Spinal Cord independence Measures [Time frame: - before intervention; at 8 weeks (after intervention) and at 6 months follow-up]
• changes in Van Lieshout Test [Time frame: - before intervention; at 8 weeks (after intervention) and at 6 months follow-up]
• changes in hand held dynamometry [Time frame: - before intervention; at 8 weeks (after intervention) and at 6 months follow-up]
• Goal satisfaction [Time frame: - before intervention; at 8 weeks (after intervention) and at 6 months follow-up]