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Trial registered on ANZCTR

Registration number

ACTRN12621001598875

Ethics application status

Approved

Date submitted

25/10/2021

Date registered

22/11/2021

Date last updated

14/01/2024

Date data sharing statement initially provided

22/11/2021

Type of registration

Prospectively registered

Titles & IDs

Public title

Electrical stimulation-eccentric muscle strength training in people with spinal cord injury

Scientific title

Effects of electrically-evoked eccentric strength training on muscle mass, strength, spasticity and quality of life in people with spinal cord injury.

Secondary ID [1]

None

Universal Trial Number (UTN)

Trial acronym

Linked study record

This is a follow-up study from ACTRN12618000018213, however it is been conducted in a different organisation, as the main researcher has done this previous study as part of her PhD studies at Edith Cowan University, and it is currently working at Central Queensland University, QLD, Australia.

Health condition

Health condition(s) or problem(s) studied:

spinal cord injury

Condition category

Condition code

Physical Medicine / Rehabilitation

Physiotherapy

Neurological

Other neurological disorders

Injuries and Accidents

Other injuries and accidents

Intervention/exposure

Study type

Interventional

Description of intervention(s) / exposure

Neuromuscular electrical stimulation combined with eccentric muscle strength training in people with SCI:
We will conduct a non-randomised 6-week pilot clinical trial study intervention in four persons with spinal cord injury (SCI), lesion below the level of C6 (age range = 18-65 years, ASIA A-D). Participants will be recruited from the local community (Rockhampton).

Description of the intervention

Protocol: NMES eccentric training will commence after the warm-up and testing that will be described under "Control Test". Intensity of the intervention will be informed by the baseline twitch torque knee extension test. 3 sets of 5 repetitions will be completed at half the current intensity used to evoke the maximum isometric tetanic torque as part of the ‘warm-up’. The stimulation amplitude will be controlled manually to make sure the force profile in each repetition does not drop significantly due to fatigue. The dynamometer will flex the knee at 30°·s-1 to provide a concentric action from 90°of flexion to full knee-extension and an eccentric action from full knee extension to 90°of flexion. The bouts of electrical stimulation will only be delivered during the eccentric phase (i.e. from full knee extension to 90 degrees of knee flexion). In-built safety limits will be set so torques 10% greater than the target torque, which may be produced through spasms, will trigger the system to immediately stop the stimulation delivery in order to minimise injury risk. Three attempts will be given for individuals to complete the training without triggering the safety mechanism before the session will be ended. During the consequent intervention session, the current intensity used will evoked 80% of the maximum tetanic torque. Thereafter, current intensities of 100% will be used, with 5 sets of 10 repetitions being completed during all training sessions. The intensity of exercise will increase as the muscle strength increases. Participants who are unable to complete a session due to spasms will repeat exercise at the next session; progression to full training will only occur once the training can be done without detectable spasm.

All intervention sessions will be conducted by two people, one is a Senior Physiotherapist with research experience and a the second one is a trained research assistant. The participants will be asked to keep their physical training routine consistent for the duration of the experiment.
The duration of each session will be 1 hour approximately. Session attendance checklist will be used to monitor adherence to the intervention.
The procedures that will be used in this study will be similar from a methodology used in a previous study in people with spinal cord injury (SCI): Trial ID: ACTRN12618000018213.

Intervention code [1]

Treatment: Devices

Comparator / control treatment

No control

Control group

Uncontrolled

Outcomes

Primary outcome [1]

Knee-extension torque measurements using an isokinetic dynamometer (Biodex System 3 Pro Ronkonkoma, NY). Evoked tetanic knee-extension torque is the primary outcome, as this is the amount of force developed by the muscle as a result of the electrical stimulation.

Timepoint [1]

Testing will be completed on four occasions: 1) baseline (T0); 2) after a 2 -week control period (T1); 3) within 3-5 days after the completion of the 6-week intervention (T2); and 4) between 4-6 weeks after the intervention (T3).

Primary outcome [2]

Muscle cross-sectional area of quadriceps femoris (CSA-QF) using B-mode axial-plane ultrasonography.

Timepoint [2]

1) baseline (T0); 2) after a 2 -week control period (T1); 3) within 3-5 days after the completion of the 6-week intervention (T2); and 4) between 4-6 weeks after the intervention (T3).

Primary outcome [3]

Spasticity measure using the Spinal Cord Injury Spasticity Evaluation Tool (SCI-SET)

Timepoint [3]

1) baseline (T0); 2) after a 2 -week control period (T1); 3) within 3-5 days after the completion of the 6-week intervention (T2); and 4) between 4-6 weeks after the intervention (T3).

Secondary outcome [1]

Quality of life measure (QoL) using the Quality of life Index (QLI) for people with spinal cord injuries (SCI).

Timepoint [1]

1) baseline (T0); 2) after a 2 -week control period (T1); 3) within 3-5 days after the completion of the 6-week intervention (T2); and 4) between 4-6 weeks after the intervention (T3).

Secondary outcome [2]

Peak twitch torque will be measured using an isokinetic dynamometer (Biodex System 3 Pro Ronkonkoma, NY). This is the amount of evoked muscle force elicited by a specific current of electrical stimulation, called twitch.

Timepoint [2]

1) baseline (T0); 2) after a 2 -week control period (T1); 3) within 3-5 days after the completion of the 6-week intervention (T2); and 4) between 4-6 weeks after the intervention (T3).

Eligibility

Key inclusion criteria

Inclusion criteria: age 18-65 years; SCI longer than 6 months that led to complete or incomplete paraplegia or tetraplegia; level of injury between C2 and L5; AIS (American Spinal Cord Injury Association Impairment Scale) A, B, C or D; have medical permission to enrol in an intensive exercise program; and able to attend consistently two times per week for 6 weeks in addition to committing to baseline and follow up testings at CQUniversity North Rockhampton, QLD, Australia laboratory located on Building 81.

Minimum age

18 Years

Maximum age

65 Years

Sex

Both males and females

Can healthy volunteers participate?

Key exclusion criteria

Acute phase of injury (less than 6 months from injury); ventilator dependent, other associated neurological disease; and complications such as severe urinary infection, pressure ulcers, previous lower-limb fractures or any other health condition that may constrain the participation in an exercise program.

Study design

Purpose of the study

Treatment

Allocation to intervention

Non-randomised trial

Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)

Methods used to generate the sequence in which subjects will be randomised (sequence generation)

Masking / blinding

Open (masking not used)

Who is / are masked / blinded?

Intervention assignment

Single group

Other design features

Phase

Not Applicable

Type of endpoint/s

Efficacy

Statistical methods / analysis

Repeated ANOVA tests will be used to compare T0,T1,T2 and T3 in peak twitch torque, evoked tetanic torque, cross-sectional area (CSA), symptoms of spasticity, and QoL outcomes. Reliability of the outcome measures between the baseline and control tests will be assessed using the intra-class correlation coefficient (ICC). Statistical significance will be set at an alpha level of equal to or less than 0.05 and values will be reported as mean and SD.

Recruitment

Recruitment status

Completed

Date of first participant enrolment

Anticipated

1/02/2022

Actual

2/05/2022

Date of last participant enrolment

Anticipated

1/02/2023

Actual

2/05/2022

Date of last data collection

Anticipated

31/03/2023

Actual

31/03/2023

Sample size

Target

Accrual to date

Final

Recruitment in Australia

Recruitment state(s)

QLD

Funding & Sponsors

Funding source category [1]

University

Name [1]

Central Queensland University

Address [1]

Bruce Highway, North Rockhampton campus, QLD, Australia (4702)

Country [1]

Australia

Primary sponsor type

Individual

Name

Vanesa Bochkezanian

Address

Central Queensland University. Building 34 Office 1.02, Bruce Highway, Rockhampton North, QLD, Australia 4702

Country

Australia

Secondary sponsor category [1]

None

Name [1]

n/a

Address [1]

n/a

Country [1]

Ethics approval

Ethics application status

Approved

Ethics committee name [1]

Central Queensland University Human Research Ethics Committee

Ethics committee address [1]

Research Division (Building 32 Level 2)
CQUniversity Australia
Bruce Highway
North Rockhampton QLD 4701
Australia

Ethics committee country [1]

Australia

Date submitted for ethics approval [1]

03/11/2021

Approval date [1]

22/02/2022

Ethics approval number [1]

Summary

Brief summary

People with spinal cord injuries (SCI) experience changes in their muscles and health. One of these changes is muscle wasting typically due to disuse. One solution to reduce muscle wasting in people with SCI may be to use an eccentric-concentric strength training modality.

Neuromuscular electrical stimulation (NMES) is commonly applied to muscles (using stick-on pad electrodes) to improve muscle strength in people with spinal cord injuries (SCI). This improvement in muscle strength is also thought to decrease muscle spasticity and improve quality of life. One modality that has promising results in muscle strength with lower loads is the use of eccentric contractions in combinations with concentric contractions. However, there is little research on NMES used as an eccentric-concentric mode in people with SCI. Thus, the current study is a proof-of-concept trial for the future use of eccentric-concentric training in people with SCI. 

The aim of the current study is to quantify the amount of force your thigh muscles produce during this type of electrical stimulation after a 6-week NMES intervention. Also, we will identify if this type of electrical stimulation produces less spasticity in the following days and after the 6-week intervention. Finally, we will identify if this type of NMES makes any changes in quality of life.

Trial website

Trial related presentations / publications

Public notes

Additional information about methods for this study:
Control test: The same procedures as in baseline will be performed 2 weeks after. In addition, during the testing session of T1 (i.e., 2 weeks after baseline [T0]), 3 sets of 10 repetitions of isometric evoked contractions will be performed at a long quadriceps muscle length at 90 degrees knee flexion and 85 degrees hip flexion. These isometric contractions will aim to provide a protective effect against muscle damage in the following interventions sessions (Aldayel, Jubeau, McGuigan, & Nosaka, 2010; Slade, Bickel, & Dudley, 2004) and reduce the reflexive response of some participants; in our previous study, spasms were evoked in the first 1 – 3 sessions in some individuals with SCI
 During both of these testings participants will be familiarised with the outcome measures, and intervention procedures. During the intervention period the participant will continue their normal physical activities, including any rehabilitation, and their usual medical regime (e.g., medications). The intervention will be performed twice a week (with at least 48 hours in between) for 6 weeks. All testing and intervention sessions will be completed at the same time of day under identical conditions. 

The following data collection procedures will be performed at each testing timepoint.
Muscle cross-sectional area (CSA): 
Quadriceps femoris (QF, i.e., sum of VM, VL, VI and RF) CSA will be measured using B-mode axial-plane ultrasonography. The participant will rest supine for 15 min prior to testing to minimise fluid shifts before images are captured with a 10 MHz linear-array probe (60 mm width) using the extended field-of-view technique (EFOV) (Noorkoiv, Nosaka, & Blazevich, 2010). A line from the central point of the patella to the medial aspect of the anterior superior iliac spine (ASIS) will be marked to obtain the images (Noorkoiv et al., 2010). One line perpendicular to this will be marked at 50% of the distance from the greater trochanter to the lateral epicondyle (Noorkoiv et al., 2010) and transversal line will be drawn across the thigh. A continuous single view will then be obtained by moving the probe transversely across the thigh on the marked line. Two images will be obtained consecutively. Minimal pressure will be applied with the probe to avoid compression of the muscle. Cross-sectional area of quadriceps femoris (CSAQF)will be measured using ImageJ digitising software (1.46r, Wayne Rasband, National Institutes of Health, USA) for each muscle (VM, VL, VI and RF) and for the whole quadriceps femoris (QF) with the mean of the two images taken as CSA. Between session or test-retest reliability analysis (e.g., intra-class correlation coefficients) will be performed for CSA measures at baseline and after the 6-week control period (i.e., between T0 and T1 time points). 

Knee extension torque
The participant will be seated with the hip and knee joint angles at 85 and 90 degrees, respectively in the isokinetic dynamometer (Biodex). Once the participant has been positioned in the Biodex machine, neuromuscular electrical stimulation (NMES) will be delivered by a high-voltage constant-current electrical stimulator (400 V, DS7A, Digitimer Ltd., Welwyn Garden City, UK) through four self-adhesive stimulation electrodes (Axelgaard, PALS, USA) placed over the rectus femoris (RF), vastus lateralis (VL), and vastus medialis (VM). Two 5×10 cm electrodes will be placed over RF and one 5×5 electrode will be placed on each of the VM and VL approximately at their motor points using a split end cable. The electrodes will be placed to elicit the greatest twitch response with a low stimulation intensity. 
Each testing session will commence with a “warm-up” period consisting of paired electrical square-wave stimuli (two 1000 µs square-wave pulses, 5–ms interpulse interval) followed by a maximum of three tetanic trains (40mA) delivered to each leg separately every 20 seconds while the stimulation current will be increased from 30 mA in 10-mA increments until a plateau in the maximum peak twitch torque will be observed or the maximal current intensity reaches 99 mA. This plateau is defined as the maximal peak twitch torque and will be used as the target torque for the intervention. Subsequently, a tetanic train of NMES at 40 mA will be delivered followed by a maximum of three trains of NMES performed at different stimulation current intensities until reaching the closest value to the target torque. This last assessment is to confirm the current intensity needed to reach the target torque, which will be used during the Intervention sessions.

Spasticity and Quality of Life:  
The SCI Spasticity Evaluation Tool (Adams, Ginis, & Hicks, 2007) will be used to monitor subjective and objective symptoms of spasticity.  This tool is valid and reliable in people with SCI. The quality-of-life index (QLI) SCI version III (May & Warren, 2002) is a valid and reliable outcome measure and will be used to obtain measures of both satisfaction and importance regarding various aspects of life.

References
Adams, M. M., Ginis, K. A. M., & Hicks, A. L. (2007). The spinal cord injury spasticity evaluation tool: Development and evaluation. Archives of Physical Medicine and Rehabilitation, 88(9), 1185-1192. doi:10.1016/j.apmr.2007.06.012
Aldayel, A., Jubeau, M., McGuigan, M. R., & Nosaka, K. (2010). Less indication of muscle damage in the second than initial electrical muscle stimulation bout consisting of isometric contractions of the knee extensors. European Journal of Applied Physiology, 108(4), 709-717. doi:10.1007/s00421-009-1278-0
May, L. A., & Warren, S. (2002). Measuring quality of life of persons with spinal cord injury: external and structural validity. Spinal Cord, 40(7), 341-350. doi:10.1038/sj.sc.3101311
Noorkoiv, M., Nosaka, K., & Blazevich, A. J. (2010). Assessment of quadriceps muscle cross-sectional area by ultrasound extended-field-of-view imaging. European Journal of Applied Physiology, 109(4), 631-639. doi:10.1007/s00421-010-1402-1
Samaei, A., Bakhtiary, A. H., Hajihasani, A., Fatemi, E., & Motaharinezhad, F. (2016). Uphill and Downhill Walking in Multiple Sclerosis: A Randomized Controlled Trial. Int J MS Care, 18(1), 34-41. doi:10.7224/1537-2073.2014-072
Slade, J. M., Bickel, C. S., & Dudley, G. A. (2004). The effect of a repeat bout of exercise on muscle injury in persons with spinal cord injury. Eur J Appl Physiol, 92(3), 363-366. doi:10.1007/s00421-004-1103-8

Contacts

Principal investigator

Name

Dr Vanesa Bochkezanian

Address

Central Queensland University. Bruce Highway, North Rockhampton campus, QLD, Australia (4702)

Country

Australia

Phone

+61 0421166741

Fax

v.bochkezanian@cqu.edu.au

Contact person for public queries

Name

Vanesa Bochkezanian

Address

Central Queensland University. Bruce Highway, North Rockhampton campus, QLD, Australia (4702)

Country

Australia

Phone

+61 0421166741

Fax

v.bochkezanian@cqu.edu.au

Contact person for scientific queries

Name

Vanesa Bochkezanian

Address

Central Queensland University. Bruce Highway, North Rockhampton campus, QLD, Australia (4702)

Country

Australia

Phone

+61 0421166741

Fax

v.bochkezanian@cqu.edu.au

Data sharing statement

Will individual participant data (IPD) for this trial be available (including data dictionaries)?

No/undecided IPD sharing reason/comment

To protect privacy of participants as this is a pilot study

What supporting documents are/will be available?

No Supporting Document Provided

Results publications and other study-related documents

Documents added manually

No documents have been uploaded by study researchers.

Documents added automatically

No additional documents have been identified.

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