Whole Body Systems Neuromodulation

The Kentucky Spinal Cord Injury Research Center’s Whole Body Systems Neuromodulation focuses on studying the combination of neuromodulation and rehabilitation strategies to restore motor function in individuals with spinal cord injury. We study various aspects of motor recovery including movement, standing, and locomotion. We understanding how controlled electrical stimulation to the lower portion (lumbosacral) of the spinal cord enables the recovery of specific functions of the nervous system.

Our mission is to advance the continuum of care and cure.

Program Overview

Interventions

Cardiovascular Assessments

• Orthostatic Stress Test (CV-Cat)
  This test assesses the cardiovascular responses to postural changes. Beat-by-beat blood pressure, heart rate, cerebral blood flow, echocardiographic measures of the heart and vessels, pulse wave velocity, and respiratory kinematics are measured while participants lay on their backs and when the position is rapidly changed to the head up tilt position. During this test, before and after the position change, licensed personnel may also take blood samples from a catheter inserted into the antecubital vein to measure catecholamine levels.
• Ambulatory Blood Pressure and Heart Rate Monitoring (ABPM and BioRadio)
  Performed outside of the laboratory, heart rate and blood pressure are monitored with portable devices as the individual completes normal daily activities with a regular sleep schedule. Each participant is asked to complete a daily diary of any activity that may alter blood pressure or heart rate.  The blood pressure is recorded at set intervals while heart rate is monitored continuously. Participants may also be given the Autonomic Dysfunction Following Spinal Cord Injury (ADFSCI) questionnaire that asks about their blood pressure stability and episodes of autonomic dysreflexia during their daily life.
• Cardiovascular and Respiratory Stimulation Configuration Mapping (CVsc-ES and RTsc-ES)
  These assessments are used for finding the optimal cardiovascular and respiratory epidural stimulation configurations to modulate arterial blood pressure and the motor control of breathing. These assessments may be done with recordings of muscle activity, blood pressure, heart rate, respiratory rate, and lung volume and airway pressure.
• Arterial pulse wave velocity (aPWV)
  Blood vessel properties are assessed using a pressure detection technique. The test is performed while the participant is laying down or in the head up tilt position. Pressure sensors are placed over the carotid and femoral artery pulse locations for 7-10 consecutive beats. The software calculates the mean velocity of the pulse waves and compares the values to a normative data set.
• Trans-Cranial Doppler
  A special headset with ultrasound sensors that rest against the temples is placed on the participant to measure the blood flow in the middle cerebral and posterior cerebral arteries. This technique of measuring blood flow in the brain can be paired together with other assessments of cardiovascular, pulmonary, and cognitive function.
• Echocardiography
  This assessment, utilizing Doppler Ultrasound, is used to assess the function of the heart.
• Vascular Ultrasound:This assessment, utilizing Doppler Ultrasound, is used to assess the function of the major blood vessels in the body.
• Immunological Blood Panel (IBP)
  For this test, two tablespoons of blood are drawn and analyzed to provide information about the individual’s immune system, the gene profile of the blood cells, as well as the number and type of blood cells in the sample.
• Cognitive Assessment Battery (CAB)
  This series of tests is used to assess various domains of cognitive function such as memory and verbal fluency. These tests may include remembering a list of words read out loud, identifying colors and shapes, looking for patterns, generating a list of words beginning with a certain letter, etc. During these tests blood pressure, heart rate, cerebral blood flow, respiratory rate and CO₂ levels may be monitored.

Motor Systems Assessments

• The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI): We use this examination to score your level of motor and sensory impairment and the severity of your spinal cord injury.
• Modified Ashworth Scale: We evaluate the resistance of your muscle when a clinician moves your joint through a range of motion.
• Neuromuscular Recovery Scale: We evaluate your ability to perform 11 different functional tasks in sitting and/or standing position.  You will be provided with manual assistance while you perform these tasks to ensure your safety.
• 10 meter walk test: This assessment allows us to evaluate your level of mobility. We determine how fast you can safely walk on a straight line over a 10m distance.
• 6 minute walk test: This assessment allows us to evaluate your level of endurance. We determine the maximal distance you can walk over a 6 minutes period around a short track.
• BERG Balance Scale: We use this assessment to assess your static and dynamic balance and falls risk.  It includes 14 functional tasks to be performed in in sitting and standing positions.  We score your performance to each task based on how long and how much assistance you need.
• Timed Up and Go Test: We use this test to assess your mobility, balance, walking ability and fall risk. Starting seated in an armchair (17-18.5 inches height) with your back against the chair, you are instructed to stand, walk 3 meters at safe, comfortable pace, turn around, walk back to the chair, and have a seat.
• Manual Muscle Test: We use this test to evaluate the strength of your muscles across your entire body (upper limbs, trunk, lower limbs).
• The Activity-based Balance Level Evaluation (ABLE Scale): Using a series of tasks, we evaluate your balance while you are sitting, standing, and walking.
• Standing: We test how long you can stand using your current assistive device.
• Walking: We assess your ability to walk both over ground and on a treadmill that has been fitted with a harness specifically designed for individuals with spinal cord injury. We measure the basic spatio-temporal parameters (step length, step frequency, stance duration, swing duration, double-support duration) of your gait while you are walking. We study the movement of your body segments (trunk, pelvis, thighs, lower legs, feet) and joints (hip, knee, ankle). We analyze the forces you apply to the ground while you are walking. We also study how your nervous system activates the muscles that generate the walking movement.
• Cycling: We assess your ability to pedal on a cycle ergometer specifically designed for individuals with spinal cord injury. We study the movement of your body segments (pelvis, thighs, lower legs, feet) and joints (hip, knee, ankle). We analyze the forces you apply to the pedals when you are pedaling. We also study how your nervous system activate the muscles that generate the pedaling movement.
• Reaching: We assess your ability to move your hands towards a series of target positions. We study how fast and how precisely you can reach targets that are located in different positions. We study the movement of your body segments (pelvis, trunk, upper arms, lower arms, hands) and joints (shoulder, elbow, wrist). We also study how your nervous system activates the muscles that generate the reaching movement.
• Grasping: We assess your ability to pick up an object with your hands. We study how much force you can produce with your hand and finger muscles and how precisely you can adjust this force. We analyze the forces you produce alongside how your nervous system activates the muscles.

Neurophysiology Assessments

• Functional Neurophysiological Assessment (FNPA): Sensors placed on a combination of muscles in the arms, legs, trunk, or neck give measurements on how the individual’s neurological system is functioning to control movement when the participant is asked to perform a variety of tasks
• Acoustic Startle reflex (ASR): This assessment is a recording of the muscle reflexes when the participant is startled by loud unexpected sounds at unknown intervals using headphones in a quiet room. These responses give us insight to the strength of the reticulospinal pathway./
• Galvanic Vestibular Stimulation (GVS): a small electrical current is sent though one side of the neck to the other to stimulate the balance system while the participant is sitting, standing, or laying down; this is an assessment of the vestibulospinal pathway.
• Propriospinal Pathway Stimulation (PS): Electrical or magnetic stimulation is applied to several nerves and the responses are measured in multiple muscles. The goal of this assessment is to test inter-limb muscle reflexes and therefore the strength of the propriospinal pathway which can serve as an alternate pathway for motor commands .
• Multisegmental Motor Responses (MMR): Electrical stimulation will be sent though a pad on the midline of the back during different and muscle responses will be recorded through sensors placed over the skin. This is an assessment of the excitability of the spinal cord.
• Transcranial Magnetic Stimulation (TMS): Responses of the nerve pathways running from the brain to the spinal cord is evaluated using magnetic stimulation to the brain. Additionally, TMS can be used to assess excitability of cortical circuits.
• Spinal Magnetic Stimulation: Magnetic stimulation is applied to the back along the spine and sensors on the skin record muscle activity in the legs. The assessment is to determine if magnetic stimulation is effective in reaching consistent activation of spinal circuitry.
• Hoffman Reflex (H-Reflex): Electrical stimulation is applied to peripheral nerves in the body and sensors on the skin will measure the responses of the muscles in response to stimulation. This is an assessment of the excitability of the spinal cord.
• Antidromic Motoneuron Activation (F waves): Electrical stimulation is applied to peripheral nerves and responses in distal muscles are recorded. This measurement gives insight to the excitability of the neurons that control your muscles (motoneurons).
• Somatosensory Evoked Potential (SSEP): the activity of the brain is recorded during electrical stimulation to the wrist and ankles. This is an assessment of the ability of the brain, spinal cord and sensory cortex to conduct signals in response to stimuli.
• Evoked Response Potential (ERP): Similar to the SSEP assessment, this is a more in-depth look into the sensory cortex part of the brain using a rage of 5-64 sensors placed along the scalp and/or jaw. There will be continuous recording of brain wave (EEF) data throughout the experiments as well as sensors on the upper and lower back and behind the knee.
• Sympathetic Skin Responses (SSR): low amounts of electrical stimulation is applied to nerves in the hands and feet using electrodes placed on the skin, sensors measure sympathetic skin responses.
• Spinal Cord Magnetic Resonance Imaging (scMRI): Images of the spinal cord are taken using MRI scans and will be analyzed at various levels of the cord for measurements of flow of the fluid in spinal cord, and flow in the arteries and veins.
• Functional Magnetic Resonance Imaging (fMRI): MRI scanning technology is used to generate images of the brain using magnetic properties of blood.
• Diffusion Tensor Imaging (DTI): MRI scans of the brain and spinal cord generate images that are used to measure amounts of water spread throughout damaged and undamaged tissue, the assessment also provides information about the flow and pressure of fluid with in the brain and spinal cord

Studies

Bladder Function Assessments

Bladder and Bowel designs protocols using standard medical and research equipment to obtain objective assessments of urogenital and bowel functions. These assessments are essential to helping us better understand, improve and ultimately overcome dysfunction in these areas.

• Questionnaire
  Adapted from an internationally accepted standardized questionnaire (Biering-Sorensen et al. (2018)  Spinal Cord Ser Cases. 2018 Jul 6;4:60-Version 2) our Bladder Function Questionnaire is used to assess overall bladder health and management.
• Bladder Diary
  An individual’s record of liquid intake and urine output provides valuable insight into kidney and bladder function and use of our Bladder Diary complements our lab-based assessments.
• Uroflowmetry
  Measures the amount of urine emptied during urination as well as the speed (rate) and pattern (constant, interrupted) of urination.
• Cystometrogram (CMG)
  Measures the size of your bladder (how much fluid your bladder can hold) and how full the bladder is when you begin to feel the need to urinate. It also records the pressure inside the bladder during bladder filling and emptying.
• Electromyography (EMG)
  Small sensors are used to measure the strength and electrical activity of muscles and nerves in and around the bladder and sphincters (the pelvic floor).
• Bladder and Kidney Ultrasound
  A noninvasive technique that transmits sound waves through the body; images of the bladder and kidneys help to assess damage from chronic high pressure in the bladder and potential backflow of urine into the kidneys (urinary reflux).

Bowel Function Assessments

• Questionnaire
  Adapted from an internationally accepted standardized questionnaire (Krogh et al. (2017) Spinal Cord 55: 692–698-Version 2) our Bowel Function Questionnaire is used to assess overall bowel health and management of fecal elimination.
• Anorectal Manometry (ARM)
  Evaluates bowel function in individuals that have difficulty with constipation and/or experience stool leakage. It measures the strength of the anal sphincter muscles, sensation in the rectum as well as the neural reflexes necessary for bowel movements.

Sexual Function Assessments

• Questionnaires
  Standardized questionnaires are used to assess overall sexual health and management in both Males (adapted from Rosen, R. et al. (2006) Urology 68 (Suppl 3A): 6-16 and Alexander, M. et al. (2011) Spinal Cord 49: 795-798) and Females (adapted from Alexander, M. et al. (2009) The Journal of Spinal Cord Medicine 32 (3): 226-236 and Alexander, M. et al. (2011) Spinal Cord 49: 787-790).

Scientific Director

Susan Harkema, PhD

Principal Investigator

Maxwell Boakye, MD

Principal Investigator

Alex Ovechkin, MD, PhD

Principal Investigator

Beatrice Ugiliweneza, PhD, MSPH

Principal Investigator

Charles Hubscher, PhD

Principal Investigator

Yury Gerasimenko, PhD, D Sci

Medical Team

Clinical Director

Maxwell Boakye, MD

Sarah Wagers, MD

Darryl Kaelin, MD

Research Team

Technology Advancement

Collaborators

Sponsors