Spinal Stimulation Sit-to-Stand Training After Spinal Cord Injury

Recruitment and Initial Assessment:

Participants will be recruited from London Spinal Cord injuries Centre (LSCIC) at the Royal National Orthopaedic Hospital (RNOH) and Neurokinex neurological rehabilitation centres where the 8-week (24-session) training intervention will be carried out. The study will also be advertised via relevant newsletters, bulletin boards, websites and mailing lists.

First Appointment (Visit 1 - 1 session at RNOH):

Each participant will attend an initial session at the RNOH in Stanmore, lasting one to two hours. Participants will be given the opportunity to ask questions about the study and informed consent to participate in the study will be taken.

Following this, we will perform some simple tests to check muscle response to stimulation without undue discomfort. Stimulating electrodes will be placed over the lower back and recording electrodes will be placed on lower limb muscles. The BCMA will then be completed: participants will be placed in the supine position and asked to perform a number of motor tasks in response to verbal cues (e.g. bring knee to chest). Stimulation will then be delivered in varying patterns (e.g. pulse width and frequency) and intensities (0mA to 100mA) and responses will be recorded from lower limb muscles. From this, optimal electrode position, and threshold level to stimulation will be defined. Trains of stimulation will then be applied at a range of frequencies (1-100Hz) and intensities 0mA to 100mA (or the highest intensity tolerated by the participant, whichever is lower). This will provide information on the pre-intervention ability of the participant. At the end of this session we will arrange with the participant a date for the next baseline session at the Neurokinex location most convenient for the participant to travel too.

Heart rate and blood pressure will be monitored intermittently during all stimulation procedures with a blood pressure monitor. This will be taken before beginning to record a baseline response and any significant rise in systolic and diastolic blood pressure greater than 20 mmHg systolic or 10 mmHg diastolic above baseline is an indication of autonomic dysreflexia (AD). If an event of AD occurs we will temporarily remove the stimulation until blood pressure returns to baseline. If this effect continues to occur this participant will be withdrawn from the study.

Baseline Session (Visit 2 - 1 session at Neurokinex):

During the baseline session, we will record measures of participant's ability to perform sit-to-stand onto force plates both with stimulation and without stimulation. Again, adhesive electrodes will be placed over the lower back and lower limb muscles and a small device called a goniometer will be positioned across the knee joint to measure its position. SS parameters (intensity, frequency) will be defined based on the results of the first appointment. Participants will then perform sit-to-stand with and without stimulation. This will be performed using the Keiser Power Rack: a device that assists transferring in the sit-to-stand manoeuvre by partially supporting your bodyweight. During the SS testing, stimulation will be delivered during each transition from the seated position to standing, maintained during standing for approximately 4-5 minutes (with intensity reduced if required for comfort) and switched off during sit-down for approximately 2-3 minutes. Training will last for 45 mins (including application of harness \& electrodes 1 hour). A neurological assessment using the ASIA Impairment Scale (AIS) will also be performed and participants will be asked to complete questionnaires/forms to assess your well-being, independence and bladder function following the session.

Optionally, the patient's recent clinical urodynamics results will be obtained from RNOH.

Training (Visits 3-26; 24 sessions (3days/week) at Neurokinex):

Participants will be purposively assigned to either the control (sit-to-stand training; n=5) or test (sit-to-stand training with spinal stimulation; n=5) group, based on the results of the baseline neurological assessment performed at the baseline session (ASIA; Appendix 11). An 8-week (24-session) training intervention will be carried out at Neurokinex (participants enrolled site) (http://www.neurokinex.org/). Each participant will be required to attend Neurokinex for training 3 times per week for 8 weeks; each session will last approximately one hour.

During each session:

• Participants will receive 40 minutes of sit-to-stand training using the Keiser Power Rack. With the amount of body weight assistance set to provide minimal assistance, and will be adjusted as necessary throughout training.
• Nintendo Wii Balance Boards will also be positioned under each foot to measure loading during stance and two load cells will read the amount of force offset by the grip bar whilst transferring/standing.
• Five sit-to-stands will be completed in each session, as follows: transfer from sit-to-stand, 4-5 mins standing, transfer from stand to sit-down, 2-3 mins rest.

The test group will additionally receive SS during training. SS parameters (intensity, frequency) will be defined based on the results of the first appointment (see above), and will be modified during training as required. SS will be delivered during each transition from the seated position to standing, maintained during standing (with intensity reduced if required for comfort) and switched off during sit-down.