Paired Associative Stimulation in Post-stroke Hand Motor Deficits (PAS-stroke)

Assessment of Paired Associative Stimulation Protocols Using Cerebellar or Visual Afferences in Post-stroke Hand Motor Deficits

Introduction The motor impairment of the upper extremity is the most common sequelae after ischemic stroke. Transcranial magnetic stimulation (TMS) is a promising non- invasive technique in the rehabilitation of motor deficits. However, its effect in post-stroke motor deficits remains moderate our days. To potentiate the effect of TMS, techniques called Paired Associative Stimulations (PAS) involving the integration of afferent sensory inputs at the level of the ipsilesional primary motor cortex were developed in healthy subjects. PAS techniques have shown a gain of corticospinal excitability by such phenomenon known as long Term Potentiation (LTP) and a gain of motor performance. The investigators would like to propose to evaluate two types of these techniques with a volley of visual afferents (visuomotor stimulation, V_PAS) or of cerebellar afferents (CER_PAS), because these two structures convey important information in the execution of the movement.

Design Multicenter, randomized, study, 60 patients in 3 parallel groups (V_PAS, CER_PAS, control group with sham and sham V_PAS CER_PAS), 5 days of treatment, clinical assessment, electrophysiological and MRI before, immediately post- and second post-assessments (4 weeks).

A group of 24 healthy subjects will undergo a parallel physiopathological study on the underlying mechanisms of cerebellar PAS

Objectives Main objective: To determine whether (and how) Paired Associative Stimulation technique (PAS) induces cerebral reorganization in the primary motor cortex compared to the control group.

Aim 2: Determine whether (and which) type of PAS is capable of inducing changes in motor performance of the upper limb paresis and duration Aim 3: Determine whether (and which) type of PAS is capable of inducing changes in excitability of the corticospinal tract and duration Aim 4: Determine how PAS techniques modify the functional connectivity during movement Aim 5: Determine if connectivity changes during induced movement correlate with clinical improvements Aim 6: Determine whether patients who benefit of a type of PAS have specific anatomical lesion characteristics (volume, afferent and efferent white matter fasciculi integrity)

Study Overview

• Status: Unknown
• Conditions: Stroke and Healthy Subjects
• Intervention / Treatment: Device: PAS

Detailed Description

Introduction The motor impairment of the upper extremity is the most common sequelae after ischemic stroke. Transcranial magnetic stimulation (TMS) is a promising non- invasive technique in the rehabilitation of motor deficits. However, its effect in post-stroke motor deficits remains moderate the investigators days. To potentiate the effect of TMS, techniques called Paired Associative Stimulations (PAS) involving the integration of afferent sensory inputs at the level of the ipsilesional primary motor cortex were developed in healthy subjects. PAS techniques have shown a gain of corticospinal excitability by such phenomenon known as long Term Potentiation (LTP) and a gain of motor performance. The investigators would like to propose to evaluate two types of these techniques with a volley of visual afferents (visuomotor stimulation, V_PAS) or of cerebellar afferents (CER_PAS), because these two structures convey important information in the execution of the movement.

Design Multicenter, randomized study, 60 patients in 3 parallel groups (V_PAS, CER_PAS, control group with sham and sham V_PAS CER_PAS), 5 days of treatment, clinical assessment, electrophysiological and MRI before, immediately post- and second post-assessments (4 weeks).

A group of 24 healthy subjects will undergo a parallel physiopathological study on the underlying mechanisms of cerebellar PAS Objectives Main objective: To determine whether (and how) Paired Associative Stimulation technique (PAS) induces cerebral reorganization in the primary motor cortex compared to the control group.

Aim 2: Determine whether (and which) type of PAS is capable of inducing changes in motor performance of the upper limb paresis and duration Aim 3: Determine whether (and which) type of PAS is capable of inducing changes in excitability of the corticospinal tract and duration Aim 4: Determine how PAS techniques modify the functional connectivity during movement Aim 5: Determine if connectivity changes during induced movement correlate with clinical improvements Aim 6: Determine whether patients who benefit of a type of PAS have specific anatomical lesion characteristics (volume, afferent and efferent white matter fasciculi integrity) Aim 7: for healthy subjects: determine the TMS parameters that will influence the response to cerebellar PAS protocols

Hypotheses

• The sensorimotor stimulation approach (V_PAS or CER_PAS) improves motor function of the hand compared to the control group. The CER_PAS approach may be more effective than V_PAS as the cerebellum plays a major role in the post-stroke recovery
• This improvement would be explained by an effect on brain reorganization by increasing the proportion of activation in the ipsilesional primary motor cortex comparing to the contralesional side, as well as strengthening the relationships between ipsilesional premotor and motor cortices.
• Clinical and electrophysiological effects observed in the combined approach are correlated with specific characteristics of the sensorimotor network assessed by MRI.

Perspectives Demonstrating beneficial effects would subsequently consider protocols in order to achieve a therapeutic effect in the long term. The low cost greatly facilitates the implementation of feasible treatments in routine care in specialized centers (or pilot research centers) and potentially useful in many patients. The study of the characteristics of responders and non-responders patients would provide "patient-oriented" treatment, which take into account the particularities of each subject.

• Study Type: Observational
• Enrollment (Anticipated): 60

Contacts and Locations

• Study Contact: Name: Charlotte ROSSO, PI; Phone Number: +331 42161854; Email: charlotte.rosso@gmail.com
• Study Contact Backup: Name: Sophie CORIOU, INSERM; Phone Number: +331 42165778; Email: sophie.coriou@inserm.fr

Study Locations

• France
  • Paris, France, 75013
    • Recruiting
    • ICM, CIC Neurosciences

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 85 years (Adult, Older Adult)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

• Sampling Method: Probability Sample

Study Population

Stroke patients

Description

Inclusion Criteria FOR PATIENTS:

• First event ischemic stroke with hand motor deficit
• Time since stroke > 30 days
• Stroke lesion sparing the primary motor cortex (hand knob area)
• Age between 18 and 85 ans

Exclusion Criteria FOR PATIENTS:

• No homonymous hemianopia
• No contra-indications for TMS and MRI
• Pregnancy
• Epilepsia
• Any pathology that threatened the 1 month follow up

Inclusion Criteria FOR HEALTHY SUBJECTS:

• Age between 18 and 85
• Right handed

Exclusion Criteria FOR HEALTHY SUBJECTS

• No contra-indications for TMS and MRI
• Pregnancy
• Any cerebral pathology or pathology that threatened the 1 month follow up

Study Plan

How is the study designed?

Number of groups / cohorts

4

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
V_PAS; Visuomotor paired associative stimulation protocol	Device: PAS
Sham V_PAS; Placebo group of Visuomotor paired associative stimulation protocol
CER_PAS; cerebellar-motor associative stimulation protocol	Device: PAS
Sham CER_PAS; Placebo group of cerebellar-motor associative stimulation protocol

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
change in lateralization indices in the primary motor cortex using functional magnetic Resonance	Change from Baseline to day 5 (Pre and post intervention)

Secondary Outcome Measures

Outcome Measure	Time Frame
change in motor score of the affected hand by the Jebsen Taylor Test	Change from Baseline to day 5 (Pre and post intervention)
change in corticospinal excitability by the motor evoked potentials	Change from Baseline to day 5 (Pre and post intervention)

Collaborators and Investigators

• Sponsor: Institut National de la Santé Et de la Recherche Médicale, France
• Investigators: Principal Investigator: Charlotte ROSSO, PI, Brain and Spine institute, INSERM UMR 1127, CNRS 7225

Publications and helpful links

General Publications

• Rosso C, Moulton EJ, Kemlin C, Leder S, Corvol JC, Mehdi S, Obadia MA, Obadia M, Yger M, Meseguer E, Perlbarg V, Valabregue R, Magno S, Lindberg P, Meunier S, Lamy JC. Cerebello-Motor Paired Associative Stimulation and Motor Recovery in Stroke: a Randomized, Sham-Controlled, Double-Blind Pilot Trial. Neurotherapeutics. 2022 Mar;19(2):491-500. doi: 10.1007/s13311-022-01205-y. Epub 2022 Feb 28.

Study record dates

Study Major Dates

• Study Start (Actual): September 17, 2014
• Primary Completion (Anticipated): January 1, 2018
• Study Completion (Anticipated): March 1, 2018

Study Registration Dates

• First Submitted: October 21, 2014
• First Submitted That Met QC Criteria: November 3, 2014
• First Posted (Estimate): November 5, 2014

Study Record Updates

• Last Update Posted (Actual): August 30, 2017
• Last Update Submitted That Met QC Criteria: August 29, 2017
• Last Verified: August 1, 2017

More Information

Terms related to this study

• Keywords: movement disorders; transcranial magnetic stimulation
• Additional Relevant MeSH Terms: Cardiovascular Diseases; Vascular Diseases; Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Stroke
• Other Study ID Numbers: C14-38; 2014-A01165-42 (Registry Identifier: IDBRCB)