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The purpose of this study is to test a strategy to potentiate functional recovery of lower limb motor function in individuals with spinal cord injury (SCI). The FDA approved drug, Dalfampridine (4-AP). 4-AP will be used twice-daily in combination of Spike-timing-dependent plasticity (STDP) stimulation and STDP stimulation with limb training.
Currently, research has shown that 4-AP has a positive effect on sensory and motor function rehabilitation in humans with chronic SCI in addition to decreasing recorded spasticity, increased sensation, and decreased pain. A pharmacokinetic study showed that twice-daily administration of sustained release 4-AP maintains a steadier plasma concentration. Utilizing limb training to promote recovery of motor function is enhanced by eliciting STDP in the limbs. An important strength of this aim is the combination of training and STDP, which aims to enhance the beneficial effects of motor training by promoting plasticity in the corticospinal pathway. Training effects on physiological pathways will be explored and correlated with lower limb motor function. We hypothesize that introducing 4-AP into the STDP stimulation and STDP stimulation with training will further improve motor function rehabilitation in patients with chronic SCI.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| 4-AP(AM) + STDP stimulation + training + 4-AP(PM) | Experimental | The effects of the functional recovery of the lower-limb muscles will be determined after 40 sessions of twice-daily-dosing 4-AP, STDP stimulation and training. |
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| Placebo(AM) + STDP stimulation + training + Placebo(PM) | Placebo Comparator | The effects of the functional recovery of the lower-limb muscles will be determined after 40 sessions of twice-daily-dosing Placebo, STDP stimulation and training. |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Dalfampridine | Drug | The study drug (4-AP) will be administered as a 10 mg dose twice a day. |
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| Measure | Description | Time Frame |
|---|---|---|
| Change in TMEPs | Electrical stimulation will be performed placing the cathode on the upper thoracic between the spinal processes between T3 and T4 vertebrae and the anode at ~10 cm above | TMEPs measured at baseline, at 6 weeks (post 20 sessions), and at 12 weeks (post 40 sessions). |
| Change in MVC | Individuals will perform a maximum voluntary contraction (MVC) of each targeted muscle (quadriceps femoris, tibialis anterior or soleus) through surface electrodes secured to the skin over the belly of each muscle. Ankle flexion torque will be measured by measured by force sensors. | MVC measured at baseline, at 6 weeks (post 20 sessions), and at 12 weeks (post 40 sessions). |
| Measure | Description | Time Frame |
|---|---|---|
| Change in 10-meter walk test | We will use the 10-meter walk test to quantify walking speed in meters per second. The same percentage of body-weight support will be used during pre- and post-assessments. Less time to walk 10-meter indicates better outcome. | 10-m walk measured at baseline, at 6 weeks (post 20 sessions), and at 12 weeks (post 40 sessions). |
| Measure | Description | Time Frame |
|---|---|---|
| Changes in spinal excitability | We will measure spinal excitability by measuring F-wave and H-reflex in soleus and TA muscles. Post-Activation Depression (PAD) of the H-reflex will also be quantified in soleus muscle | Changes in spinal excitability will be measured at baseline, at 6 weeks (post 20 sessions), and at 12 weeks (post 40 sessions). |
Inclusion Criteria:
Exclusion Criteria:
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Monica Perez, PT, PhD | Contact | 312-238-2886 | mperez04@sralab.org | |
| Bing Chen, PhD | Contact | 312-238-7895 | bchen03@sralab.org |
| Name | Affiliation | Role |
|---|---|---|
| Monica Perez, PT, PhD | Shirley Ryan Ability Lab | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Shirley Ryan Abilitylab | Recruiting | Chicago | Illinois | 60611 | United States |
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| ID | Term |
|---|---|
| D013119 | Spinal Cord Injuries |
| ID | Term |
|---|---|
| D013118 | Spinal Cord Diseases |
| D002493 | Central Nervous System Diseases |
| D009422 | Nervous System Diseases |
| D020196 | Trauma, Nervous System |
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| ID | Term |
|---|---|
| D015761 | 4-Aminopyridine |
| D015444 | Exercise |
| ID | Term |
|---|---|
| D000631 | Aminopyridines |
| D000588 | Amines |
| D009930 | Organic Chemicals |
| D011725 | Pyridines |
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| Placebo | Drug | The placebo provided by the SRAL pharmacy that looks identical to the 4-AP, will be administered twice a day. |
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| STDP stimulation | Other | Paired stimulation will be given to the spinal cord and to peripheral nerves so that the signals are received at the spinal cord at a specific interval. |
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| Exercise training | Behavioral | Lower-limb exercises will involve over-ground walking, treadmill, walking and stair climbing training. |
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| Change in 6-minute walk test | We will measure the distance walked over 6 minutes. The same percentage of body-weight support will be used as in 10-meter walk test. The longer distance walked during 6 minutes indicates better outcome. | 6-min walk measured at baseline, at 6 weeks (post 20 sessions), and at 12 weeks (post 40 sessions). |
| Change in International Standards for Neurological Classification of Spinal Cord Injury exam | Motor part of the exam is completed through the testing of key muscle functions corresponding to 10 myotomes (C5-T1 and L2-S1) for right and left side separately. The strength of each muscle function is graded on a six-point scale ranging from 0 meaning complete paralysis to 5 meaning full strength. The total motor score is sum of all motor scores range from 0-100. Sensory part of the exam is completed through the testing of a key point in each of the 28 dermatomes (from C2 to S4-5) on the right and left sides of the body. At each of these key points, two aspects of sensation are examined: light touch and pin prick. Appreciation of light touch and pin prick sensation at each of the key points is separately scored on a three-point scale; 0-absent, 1-altered, and 2-normal or intact. 56 is the maximum score for both light touch and pin prick and the total sensory score ranges from 0 to 112. Higher scores represent better outcome for motor and sensory scores. | Scores measured at baseline, at 6 weeks (post 20 sessions), and at 12 weeks (post 40 sessions). |
| Change in EPT | We use electrical perceptual threshold (EPT) to measures the minimum amount of electrical current that the participant can perceive when applied to the lower limb dermatomes (L2-S2). | EPT will be measured at baseline, at 6 weeks (post 20 sessions), and at 12 weeks (post 40 sessions). |
| Change in surveys on ambulation, basic mobility, bowel and bladder management difficulties | The name of the questionnaire is Spinal Cord Injury Quality of Life (SCI-QOL) and we used four subdomains: ambulation, self-care, bowel management difficulties, and bladder management difficulties. Scores on all subdomains of SCI-QOL use a standardized T metric, with a mean of 50 and a standard deviation of 10. Ambulation and basic mobility subdomains assess the ability to engage in walking activities in different locations that vary based on speed, time and condition and the ability to manage stairs under different conditions. Bowel management difficulties subdomain measures an ability to carry out a bowel program; concerns about incontinence and bowel accidents; and the impact of bowel management on everyday living. Bladder management difficulties subdomain measures ability to carry out a bladder program; worry about bladder accidents; concerns about implementing one's bladder program; and impact on everyday living. Higher scores on all subdomains represent better outcome. | SCI-QOL measured at at baseline, at 6 weeks (post 20 sessions), and at 12 weeks (post 40 sessions). |
| Change in morphological characterization of corticospinal and reticulospinal pathways in MRI | In order to identify descending motor tract, brainstem and C2 cervical spinal cord images will be acquired on a MAGNETOM Prisma 3T system using a 64-channel birdcage head/neck coil. To quantify the effect of atrophy in oblique directions, we will measure the radius from the cord shape center of mass to its border, R(α), for angles α over the whole circle with an angular resolution of 6°. Mean measures of all 5 axial slices will be used for statistical from nerve roots, noise, and other confounding effects. | MRI measured at baseline, and at 12 weeks (post 40 sessions). |
| D014947 | Wounds and Injuries |
| D006573 |
| Heterocyclic Compounds, 1-Ring |
| D006571 | Heterocyclic Compounds |
| D009043 | Motor Activity |
| D009068 | Movement |
| D009142 | Musculoskeletal Physiological Phenomena |
| D055687 | Musculoskeletal and Neural Physiological Phenomena |