BrainSTIM: Brain State-dependent Stimulation to Improve Movement

Sponsor

University of Michigan (Other)

Overall Status

Recruiting

CT.gov ID

NCT05103176

Collaborator

National Institute of Neurological Disorders and Stroke (NINDS) (NIH)

Enrollment

Location

Arms

16.5

Anticipated Duration (Months)

3.9

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

Repetitive transcranial magnetic stimulation (rTMS) is a powerful tool to non-invasively modulate brain circuits, brain plasticity, and behavior. This proposal will test the hypothesis that controlling behavioral state during focal multi-day rTMS of a brain region involved in grasping movements will enhance the functional specificity of the neuromodulation action among distributed brain regions involved in voluntary motor control and concomitantly improve manual dexterity. Results from this study will be used to optimize rTMS therapy for individuals with neuromotor impairments by controlling behavioral state to improve the efficacy of rTMS treatment.

Healthy volunteers that qualify for this study will have motor skill assessments and basic neuromotor testing (using neurophysiology with TMS and functional Magnetic Resonance Imaging (fMRI) scans). Participants will be asked to come in for up to nine sessions that include 1 screening session, 5 consecutive daily rTMS sessions and 3 assessment sessions with resting-state and task-based fMRI, neurophysiology with TMS, and hand motor tasks over the course of 3-4 weeks.

Condition or Disease	Intervention/Treatment	Phase
Healthy	Device: TMS Behavioral: Object directed grasping	N/A

Detailed Description

This study will examine a particular type of rTMS, known as theta burst stimulation (TBS), which has been shown to induce longer lasting effects than other forms of rTMS, making TBS an important tool for therapeutic applications. While TBS provides relatively focal stimulation, effects on the brain occur through interconnected networks in ways that are poorly understood. Moreover, stimulation is highly state-dependent, and the use of rTMS in most therapeutic settings, such as the treatment of motor impairments, leaves behavioral state uncontrolled. Augmenting rTMS therapy by inducing specific behavioral states is an attractive idea for improving therapeutic rTMS, but the relevant knowledge base is sparse. To address this critical gap, this exploratory R21 proposal will examine the effects of TBS and behavioral state on brain and motor behavior. The investigators will test the broad hypothesis that when TBS is applied during a controlled behavior state, motor function will be facilitated, compared to stimulation when behavioral state is uncontrolled. The investigators will focus on the posterior parietal cortex (PPC), and associated parietofrontal circuits, which subserve skilled grasp control, an ability known to be impaired in stroke, traumatic brain injury, and other motor disorders. The investigators will collect functional magnetic resonance imaging (fMRI), neurophysiological measures with TMS, and behavioral measures in all subjects for three different interventions.

In Aim 1, the investigators will show improvement in action performance by manipulating the behavioral state during PPC stimulation.

In Aim 2, the investigators will demonstrate modulation of neurophysiological aftereffects of PPC stimulation on motor output by manipulating behavioral state.

In Aim 3, the investigators will assess the relationship between brain connectivity, plasticity and behavior in response to the behavioral state during brain stimulation.

Impact: Results will provide insights into the effects of rTMS and behavioral state on the brain and behavior. This knowledge will lay a mechanistic foundation for future studies to show how controlling behavioral state during rTMS can improve therapeutic efficacy in neurological disorders.

Study Design

Study Type:

Interventional

Anticipated Enrollment :

65 participants

Allocation:

Randomized

Intervention Model:

Parallel Assignment

Intervention Model Description:

The investigators will use a randomized block design with up to 65 subjects in up to nine sessions. The first session will screen subjects before enrolling subjects into study. Three sessions will collect functional magnetic resonance imaging (fMRI) scans, neurophysiological measures with TMS, and behavioral measures. After a baseline testing session, subsequent sessions over five days will entail rTMS, followed by two assessments to evaluate the effects of stimulation on brain and behavior. rTMS intervention sessions will consist of: (i) Posterior Parietal Cortex (PPC) stimulation alone, (ii) PPC stimulation paired with a grasp task or (iii) vertex stimulation (as a control condition) paired with a grasp task. Duration of study: Approximately 3-4 weeks (depending upon scheduling)The investigators will use a randomized block design with up to 65 subjects in up to nine sessions. The first session will screen subjects before enrolling subjects into study. Three sessions will collect functional magnetic resonance imaging (fMRI) scans, neurophysiological measures with TMS, and behavioral measures. After a baseline testing session, subsequent sessions over five days will entail rTMS, followed by two assessments to evaluate the effects of stimulation on brain and behavior. rTMS intervention sessions will consist of: (i) Posterior Parietal Cortex (PPC) stimulation alone, (ii) PPC stimulation paired with a grasp task or (iii) vertex stimulation (as a control condition) paired with a grasp task. Duration of study: Approximately 3-4 weeks (depending upon scheduling)

Masking:

Single (Participant)

Masking Description:

Subjects will be randomly assigned to one of the 3 arms of the study. Subjects will be blind to which arm they are in, however, will be aware of what is involved within each of the arms.

Primary Purpose:

Basic Science

Official Title:

Leveraging Behavioral State to Enhance Specificity of Non-invasive Brain Stimulation on Motor Circuits

Actual Study Start Date :

Feb 15, 2022

Anticipated Primary Completion Date :

Jul 1, 2023

Anticipated Study Completion Date :

Jul 1, 2023

Arms and Interventions

Arm	Intervention/Treatment
Experimental: To PPC, with concurrent task This arm will receive intermittent theta bust stimulation to the PPC site while subjects perform a grasp task	Device: TMS A MagPro X100 magnetic stimulator with a 90mm figure-8 coil (MC-B70, MagVenture Inc.) will be utilized to deliver brain stimulation. All participants will receive five consecutive days of stimulation. The 3-minute session of intermittent Theta Burst Stimulation (iTBS) will consist of 10 bursts of high-frequency stimulation (a 2 s train of 3 biphasic waveform pulses at 50 Hz repeated every 200 ms at 80% AMT) repeated every 10 s for a total of 190 s (600 pulses) to the target area. The target area will be located using BrainSight2 neuronavigation system. The baseline structural scan obtained during the scan 1 will be utilized for this localization process. Other Names: MagPro X100 TMS system Behavioral: Object directed grasping Subjects will perform a precision grip with the right hand towards either a small or large target object positioned in front of them. The illumination of an LED (green or red) will instruct the subject to plan a precision grip towards either a small or large target object positioned in front of them. After ~1 second, the LED will extinguish and cue subjects to execute the intended object-directed hand action. The presentation of the visual stimuli will be synchronized with the iTBS stimulation, which will occur 800ms before the onset of every "GO" cue in order to modulate cortical activity during both the planning and execution phase of the action.
Experimental: To PPC, without a concurrent task This arm will receive intermittent theta bust stimulation to the PPC site without a concurrent task	Device: TMS A MagPro X100 magnetic stimulator with a 90mm figure-8 coil (MC-B70, MagVenture Inc.) will be utilized to deliver brain stimulation. All participants will receive five consecutive days of stimulation. The 3-minute session of intermittent Theta Burst Stimulation (iTBS) will consist of 10 bursts of high-frequency stimulation (a 2 s train of 3 biphasic waveform pulses at 50 Hz repeated every 200 ms at 80% AMT) repeated every 10 s for a total of 190 s (600 pulses) to the target area. The target area will be located using BrainSight2 neuronavigation system. The baseline structural scan obtained during the scan 1 will be utilized for this localization process. Other Names: MagPro X100 TMS system
Experimental: To vertex, with concurrent task This arm will receive intermittent theta bust stimulation to the vertex site (control condition) while subjects perform a grasp task	Device: TMS A MagPro X100 magnetic stimulator with a 90mm figure-8 coil (MC-B70, MagVenture Inc.) will be utilized to deliver brain stimulation. All participants will receive five consecutive days of stimulation. The 3-minute session of intermittent Theta Burst Stimulation (iTBS) will consist of 10 bursts of high-frequency stimulation (a 2 s train of 3 biphasic waveform pulses at 50 Hz repeated every 200 ms at 80% AMT) repeated every 10 s for a total of 190 s (600 pulses) to the target area. The target area will be located using BrainSight2 neuronavigation system. The baseline structural scan obtained during the scan 1 will be utilized for this localization process. Other Names: MagPro X100 TMS system Behavioral: Object directed grasping Subjects will perform a precision grip with the right hand towards either a small or large target object positioned in front of them. The illumination of an LED (green or red) will instruct the subject to plan a precision grip towards either a small or large target object positioned in front of them. After ~1 second, the LED will extinguish and cue subjects to execute the intended object-directed hand action. The presentation of the visual stimuli will be synchronized with the iTBS stimulation, which will occur 800ms before the onset of every "GO" cue in order to modulate cortical activity during both the planning and execution phase of the action.

Arm

Intervention/Treatment

Experimental: To PPC, with concurrent task

This arm will receive intermittent theta bust stimulation to the PPC site while subjects perform a grasp task

Device: TMS

A MagPro X100 magnetic stimulator with a 90mm figure-8 coil (MC-B70, MagVenture Inc.) will be utilized to deliver brain stimulation. All participants will receive five consecutive days of stimulation. The 3-minute session of intermittent Theta Burst Stimulation (iTBS) will consist of 10 bursts of high-frequency stimulation (a 2 s train of 3 biphasic waveform pulses at 50 Hz repeated every 200 ms at 80% AMT) repeated every 10 s for a total of 190 s (600 pulses) to the target area. The target area will be located using BrainSight2 neuronavigation system. The baseline structural scan obtained during the scan 1 will be utilized for this localization process.

Other Names:

MagPro X100 TMS system

Behavioral: Object directed grasping

Subjects will perform a precision grip with the right hand towards either a small or large target object positioned in front of them. The illumination of an LED (green or red) will instruct the subject to plan a precision grip towards either a small or large target object positioned in front of them. After ~1 second, the LED will extinguish and cue subjects to execute the intended object-directed hand action. The presentation of the visual stimuli will be synchronized with the iTBS stimulation, which will occur 800ms before the onset of every "GO" cue in order to modulate cortical activity during both the planning and execution phase of the action.

Experimental: To PPC, without a concurrent task

This arm will receive intermittent theta bust stimulation to the PPC site without a concurrent task

Device: TMS

Other Names:

MagPro X100 TMS system

Experimental: To vertex, with concurrent task

This arm will receive intermittent theta bust stimulation to the vertex site (control condition) while subjects perform a grasp task

Device: TMS

Other Names:

MagPro X100 TMS system

Behavioral: Object directed grasping

Outcome Measures

Primary Outcome Measures

Percentage change in the time to complete the nine-hole peg test (9-HPT) to immediate post-intervention [Baseline and immediate post-intervention (up to 30 min)]
9-hole peg test is a manual dexterity measure, estimated as the time required to complete the task (seconds)
Percentage change in amplitude of motor evoked potential (MEP) to immediate post-intervention. [Baseline and immediate post-intervention (up to 60 min)]
Motor cortical excitability is measured by electromyography using MEPs elicited by TMS
Change from baseline functional connectivity to PPC stimulation target within the cortical grasping network to immediate post-intervention. [Baseline and immediate post-intervention (up to 60 min during fMRI)]
Resting-state connectivity of low frequency BOLD fluctuations for a seed at the PPC
Change from baseline Blood Oxygen Level-Dependent (BOLD) activation, voxelwise in the cortical grasp network to immediate post-intervention. [Baseline and immediate post-intervention (up to 60 min during fMRI)]
Parietal-frontal cortical grasping network defined by BOLD change while subject performs the precision force-tracking task

Secondary Outcome Measures

Percentage change in the time to complete the nine-hole peg test (9-HPT) to 1-week post-intervention [Baseline and 1-week post-intervention (up to 30 min)]
9-hole peg test is a manual dexterity measure, estimated as the time required to complete the task (seconds)
Percentage change in amplitude of motor evoked potential (MEP) to 1-week post-intervention. [Baseline and 1-week post-intervention (up to 60 min)]
Motor cortical excitability is measured by electromyography using MEPs elicited by TMS
Change from baseline functional connectivity to PPC stimulation target within the cortical grasping network to 1-week post-intervention. [Baseline and 1-week post-intervention (up to 60 min during fMRI)]
Resting-state connectivity of low frequency BOLD fluctuations for a seed at the PPC
Change from baseline Blood Oxygen Level-Dependent (BOLD) activation, voxelwise in the cortical grasp network to 1-week post-intervention. [Baseline and 1-week post-intervention (up to 60 min during fMRI)]
Parietal-frontal cortical grasping network defined by BOLD change while subject performs the precision force-tracking task
Change from baseline Blood Oxygen Level-Dependent (BOLD) activation, voxelwise in whole brain to immediate post-intervention. [Baseline and immediate-intervention (up to 60 min during fMRI)]
Parietal-frontal cortical grasping network defined by BOLD change while subject performs the precision force-tracking task
Change from baseline Blood Oxygen Level-Dependent (BOLD) activation, voxelwise in whole brain to 1-week post-intervention. [Baseline and 1-week post-intervention (up to 60 min during fMRI)]
Parietal-frontal cortical grasping network defined by BOLD change while subject performs the precision force-tracking task
Percentage change in accuracy to precision force-tracking task to immediate post-intervention [Baseline and immediate post-intervention (up to 60 min during fMRI and outside scanner)]
Squared distance (error) from the cursor to the target in precision force-tracking task, estimated as the root mean squared error (RMSE)
Percentage change in accuracy to precision force-tracking task to 1-week post-intervention [Baseline and 1-week post-intervention (up to 60 min during fMRI and outside scanner)]
Squared distance (error) from the cursor to the target in precision force-tracking task, estimated as the root mean squared error (RMSE)
Percentage change in the mean choice reaction time to immediate post-intervention [Baseline and immediate post-intervention (up to 30 min)]
Mean reaction time for subjects responding in the 2-choice reaction time control task, for correct responses
Percentage change in the mean choice reaction time to 1-week post-intervention [Baseline and 1-week post-intervention (up to 30 min)]
Mean reaction time for subjects responding in the 2-choice reaction time control task, for correct responses
Percentage change in the normalized motor evoked potential (MEP) size to immediate post-intervention. [Baseline and immediate post-intervention (up to 60 min)]
Parietal-motor functional connectivity is measured by electromyography using MEPs elicited by dual-site TMS, while subjects perform an object-directed grasp/subjects are at rest
Percentage change in the normalized motor evoked potential (MEP) size to 1-week post-intervention. [Baseline and 1-week post-intervention (up to 60 min)]
Parietal-motor functional connectivity is measured by electromyography using MEPs elicited by dual-site TMS, while subjects perform an object-directed grasp/subjects are at rest

Eligibility Criteria

Criteria

Ages Eligible for Study:

18 Years to 50 Years

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

Yes

Inclusion Criteria:

Women of child bearing age cannot be pregnant or trying to become pregnant
Ability to tolerate small, enclosed spaces without anxiety
Ability and willingness to give informed consent to participate
No history of neurological disorder
Right handed
English speaking

Exclusion Criteria:

Are left-handed
Are younger than 18 or older than 50 years old
Women who are pregnant, suspect they are pregnant, or are attempting to become pregnant
Have metal anywhere in the head, excluding the mouth
Have a pacemaker, deep brain stimulator, vagus nerve stimulator or any other medically implanted device
Have cochlear hearing implants
Are taking GABAergic, NDMA-receptor antagonist, or other drug known to influence neural receptors
Have any of the below conditions that would put participants at increased risk of having a seizure: a personal or family history of seizure/epilepsy, taking prescription drugs that lower the threshold for seizures, recent history of excessive alcohol consumption, history of alcohol addiction/dependence, recent history of recreational drug use, history of drug addiction/dependence
Have been diagnosed with any of the following: a stroke, brain hemorrhage, brain tumor, encephalitis, multiple sclerosis, Parkinson's disease or Alzheimer's disease, depression in the past 6 months, attention deficit disorder, schizophrenia, manic depressive (bipolar) disorder, normal pressure hydrocephalus or increased intra-cranial pressure, diabetes requiring insulin treatment, any serious heart disorder or liver disease
Have had a migraine in the past month
MRI specific exclusion criteria: Any relevant history of open-heart surgery, artificial heart valve, brain aneurysm surgery, braces or extensive dental work, cataract surgery or lens implant, or artificial limb or joint. History of foreign metallic object in the body such as bullets, BB's, pellets, shrapnel, or metalwork fragments. Claustrophobia, have uncontrollable shaking, or cannot lie still for one hour.