Directing Neuroplasticity to Improve Rehabilitative Outcomes of the Upper Limb in Incomplete Quadriplegia

• Change in Upper Limb Function from Baseline [ Time Frame: Strength, activities and impairments will be measured at The patient will receive TMS during at baseline, post-5 weeks, post-10 weeks and 3-month followup ] [ Designated as safety issue: No ]
  Upper limb function will be measured by the Upper Extremity Motor Score (UEMS), capacity tasks in the form of the Grasp and Release Task (GRT) test, and pinch grip impariment that will be measured by a maximum voluntary isometric pinch force.
  
  

• Magnetic Resonance Imaging (MRI) of the brain [ Time Frame: The patient will receive MRI during at baseline, post-5 weeks, and post-10 weeks ] [ Designated as safety issue: No ]
  MRI will be used to measure changes in structure of the brain and its pathways as a result of training
  
  
• Physiology of Brain studied with Noninvasive Brain Stimulation using Transcranial Magnetic Stimulation (TMS) [ Time Frame: The patient will receive TMS during at baseline, post-5 weeks, and post-10 weeks ] [ Designated as safety issue: No ]
  TMS is a noninvasive technique of brain stimulation that examines the activity of regions of brain devoted to movement. Without implanting, or injecting or penetrating the brain, simply by using scalp-based recordings, TMS can assess functionality of the brain.
  
  

The long-term objective of this study is to optimize the rehabilitative potential in spinal cord injury (SCI) by maximally harnessing the potential available for functional neural plasticity. SCI is an important cause of serious, long-term disability in young adults. This fact, further complicated by rising disability-related costs, makes SCI a significant economic and social burden. Upper limb dysfunction is one of the most prevalent and debilitating impairments. More than 75% of patients with quadriplegia (paralysis of all 4 limbs following spinal cord injury in neck and upper back) prioritize return of upper limb function over any other lost function. Alleviating deficits of the upper limb may represent a cost-effective stategy to reducing the burden of SCI.

Although various exercise programs and neuromuscular stimulation methods have been employed to mitigate functional impairments of the arm and hand, success of these modalities is still debated. Evidence for efficacy of rehabilitation is inconclusive as outcomes are variable, confounded by methodological issues, and have shown poor generalizability. It is now speculated that limited succcess of rehabilitation emerges from inability of current methods to adequately harness the potential for significant neuroplasticity available in SCI.

Even though the site of damage in SCI does not involve the brain, the neural networks in the brain that control movement of the arm and hand are markedly affected. These regions lose their territory that the investigators argue could hamper effects of upper limb therapy. Our objective is to directly modulate adaptive plasticity in these regions of the brain to enhance function of the upper limb in iSCI. Our central hypothesis is that noninvasive brain stimulation, called transcranial direct current stimulation (tDCS), when delivered concurrently with rehabilitation will generate synergistic functional advantage. Adaptive plasticty would be obeserved as changes in structure of pathways emerging from the brain and the individual's function.