An interventional study of Anodal bilateral motor cortex and cathodal spinal tDCS and Sham bilateral motor cortex and sham spinal tDCS in Amyotrophic Lateral Sclerosis, sponsored by Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia. Completed at 1 site in Italy. Open to participants aged 18 Years to 85 Years. Per ClinicalTrials.gov, last updated 2020-03-03.
Sponsored by Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia · Not applicable, Interventional, and Treatment
Amyotrophic Lateral Sclerosis (ALS) is a motor neuron disease, which is a group of neurological disorders that selectively affect motor neurons, the cells that control voluntary muscles of the body. The disorder causes muscle weakness and atrophy throughout the body due to the degeneration of the upper and lower motor neurons. Current drugs approved for ALS treatment only modestly slow disease progression.
Transcranial direct current stimulation (tDCS) is a non-invasive technique, which has been demonstrated to modulate cerebral excitability in several neurodegenerative disorders and modulate intracortical connectivity measures.
In this randomized, double-blind, sham-controlled study, the investigators will evaluate whether a two-weeks' treatment with bilateral motor cortex anodal tDCS and spinal cathodal tDCS can improve symptoms in patients with amyotrophic lateral sclerosis and modulate intracortical connectivity, at short and long term.
Amyotrophic Lateral Sclerosis (ALS) is a motor neuron disease, which is a group of neurological disorders that selectively affect motor neurons, the cells that control voluntary muscles of the body. The disorder causes muscle weakness and atrophy throughout the body due to the degeneration of the upper and lower motor neurons. Current drugs approved for ALS treatment only modestly slow disease progression.
Transcranial direct current stimulation (tDCS) is a non-invasive technique, which has been demonstrated to modulate cerebral excitability in several neurodegenerative disorders and modulate intracortical connectivity measures.
In this randomized, double-blind, sham-controlled study, the investigators will evaluate whether a two-weeks' treatment with bilateral motor cortex anodal tDCS and spinal cathodal tDCS can improve symptoms in patients with amyotrophic lateral sclerosis and modulate intracortical connectivity, at short and long term.
Subjects will be randomized in two groups, one receiving a 10 day (5 days/week for 2 weeks) treatment with anodal bilateral motor cortex tDCS and cathodal spinal tDCS and the other receiving sham stimulation with identical parameters. After the intervention, patients will be reassessed with a clinical and neurophysiological evaluation at 2 weeks, 2 months and 6 months after treatment. Furthermore, blood neurofilaments will be measured at each time point.
Clinical evaluation will include the ALSFRS-R, ALSAQ-40, CBI, EQ-5D-5L, muscle strength evaluated with the MRC scale.
Neurophysiological evaluation will include measures of intracortical connectivity, evaluated with transcranial magnetic stimulation (TMS) as short interval intracortical inhibition (SICI-ICF), long interval intracortical inhibition (LICI), short interval intracortical facilitation (SICF).
Exclusion Criteria:
10 days anodal bilateral motor cortex and cathodal spinal tDCS
Device: Anodal bilateral motor cortex and cathodal spinal tDCS
10 days sham bilateral motor cortex and sham spinal tDCS
Device: Sham bilateral motor cortex and sham spinal tDCS
10 sessions of anodal bilateral motor cortex and cathodal spinal transcranial direct current stimulation (5 days/week for 2 weeks)
10 sessions of sham bilateral motor cortex and sham spinal transcranial direct current stimulation (5 days/week for 2 weeks)
Change in Muscle Strength From Baseline
A megascore is obtained by summing scores of single muscles (shoulder abductors, elbow flexors and extensors, wrist flexors, thumb opponent, hip flexors, knee flexors and extensors, and ankle dorsiflexors and extensors on both sides) manually evaluated according to the Medical Research Council (MRC) scale, which ranges from 0 (no movement) to 5 (normal contraction). The score for each muscle is summed, with scores ranging from 100 (no impairment) to 0 (most severe impairment).
Time frame: Baseline - 2 weeks - 2 months - 6 months
Change in Short-interval Intracortical Inhibition (SICI) From Baseline
By using transcranial magnetic stimulation (TMS), the investigators will evaluate the effects of tDCS on short-interval intracortical inhibition (SICI) from baseline
Time frame: Baseline - 2 weeks - 2 months - 6 months
Change in the ALSFRS-R Score From Baseline
Change in the ALS Functional Rating Scale (ALSFRS-R) score from baseline. The ALSFRS provides a physician-generated estimate of the patient's degree of functional impairment, which can be evaluated serially to objectively assess any response to treatment or progression of disease. The ALSFRS includes ten questions that rate the patients level of functional impairment in performing one of ten common tasks. Each task is rated on a five-point scale from 0 (can't do) to 4 (normal ability). Individual item scores are summed to produce a reported score of between 40 (no impairment) and 0 (severe impairment).
Time frame: Baseline - 2 weeks - 2 months - 6 months
Change of Quality of Life From Baseline: ALSAQ-40 Scale
Change of quality of life from baseline evaluated with the ALSAQ-40 scale. The Amyotrophic Lateral Sclerosis Assessment Questionnaire (ALSAQ) is a patient self-report health status scale. The ALSAQ is specifically used to measure the subjective well-being of patients with amyotrophic lateral sclerosis. There are 40 items/questions with 5 discrete scales: physical mobility (10 items), activities of daily living and independence (10 items), eating and drinking (3 items), communication (7 items), emotional reactions (10 items). Patients are asked to think about the difficulties they may have experienced during the last two weeks (e.g. I have found it difficult to feed myself). Patients are asked to indicate the frequency of each event by selecting one of 5 options (Likert scale): never/rarely/sometimes/often/always or cannot do at all. The total ranges from 0 (no impairment) to 160 (severe impairment).
Time frame: Baseline - 2 weeks - 2 months - 6 months
Change of Quality of Life From Baseline: EQ-5D-5L Scale
Change of quality of life from baseline evaluated with the EQ-5D-5L scale. The descriptive system comprises five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate problems, severe problems and extreme problems. The patient is asked to indicate his/her health state by ticking the box next to the most appropriate statement in each of the five dimensions. The scale ranges from 5 (no impairment) to 25 (severe impairment).
Time frame: Baseline - 2 weeks - 2 months - 6 months
Change of Quality of Life From Baseline: EQ-VAS Scale
Change of quality of life from baseline evaluated with the EQ-VAS scale. The EQ VAS records the patient's self-rated health on a vertical visual analogue scale, where the endpoints are labelled 'The best health you can imagine' and 'The worst health you can imagine'. The VAS can be used as a quantitative measure of health outcome that reflect the patient's own judgement. The scale ranges from 0 (severe impairment) to 100 (no impairment).
Time frame: Baseline - 2 weeks - 2 months - 6 months
Change in Caregiver Burden (CBI)
Change of quality of life from baseline evaluated with the CBI scale. The CBI scale is 24- item scale designed to assess the experience of caregivers of older people. The multidimensional instrument assesses five domains of burden (time-dependence, developmental, physical, social, and emotional). Items are scored on a 4-point scale, ranging from "not at all descriptive" to "very descriptive". The scale ranges from 0 (no impairment) to 96 (severe impairment).
Time frame: Baseline - 2 weeks - 2 months - 6 months
Change Intracortical Facilitation (ICF) From Baseline
By using transcranial magnetic stimulation (TMS), the investigators will evaluate the effects of tDCS on intracortical facilitation (ICF) from baseline
Time frame: Baseline - 2 weeks - 2 month - 6 months
| Milestone | Real tDCS | Sham tDCS |
|---|---|---|
| Started | 20 | 10 |
| Completed | 20 | 10 |
| Not completed | 0 | 0 |
| Milestone | Real tDCS | Sham tDCS |
|---|---|---|
| Started | 20 | 10 |
| Completed | 16 | 8 |
| Not completed | 4 | 2 |
| Withdrew: Adverse event | 4 | 2 |
A megascore is obtained by summing scores of single muscles (shoulder abductors, elbow flexors and extensors, wrist flexors, thumb opponent, hip flexors, knee flexors and extensors, and ankle dorsiflexors and extensors on both sides) manually evaluated according to the Medical Research Council (MRC) scale, which ranges from 0 (no movement) to 5 (normal contraction). The score for each muscle is summed, with scores ranging from 100 (no impairment) to 0 (most severe impairment).
| units on a scale | Real tDCS | Sham tDCS |
|---|---|---|
| Baseline | 74.7 ± 0.0 | 74.7 ± 0.0 |
| 2 Weeks | 76.4 ± 0.2 | 74.5 ± 0.3 |
| 2 Months | 76.4 ± 0.4 | 72.9 ± 0.6 |
| 6 Months | 75.9 ± 0.6 | 72.0 ± 0.9 |
By using transcranial magnetic stimulation (TMS), the investigators will evaluate the effects of tDCS on short-interval intracortical inhibition (SICI) from baseline
| millivolts | Real tDCS | Sham tDCS |
|---|---|---|
| Baseline | 1.0 ± 0.1 | 1.0 ± 0.1 |
| 2 weeks | 0.4 ± 0.1 | 1.0 ± 0.1 |
| 2 Months | 0.5 ± 0.1 | 0.9 ± 0.1 |
| 6 Months | 0.6 ± 0.1 | 1.0 ± 0.1 |
Change in the ALS Functional Rating Scale (ALSFRS-R) score from baseline. The ALSFRS provides a physician-generated estimate of the patient's degree of functional impairment, which can be evaluated serially to objectively assess any response to treatment or progression of disease. The ALSFRS includes ten questions that rate the patients level of functional impairment in performing one of ten common tasks. Each task is rated on a five-point scale from 0 (can't do) to 4 (normal ability). Individual item scores are summed to produce a reported score of between 40 (no impairment) and 0 (severe impairment).
| units on a scale | Real tDCS | Sham tDCS |
|---|---|---|
| Baselin | 31.5 ± 0.0 | 31.5 ± 0.0 |
| 2 Weeks | 32.5 ± 0.2 | 31.8 ± 0.3 |
| 2 Months | 32.0 ± 0.4 | 30.4 ± 0.5 |
| 6 Months | 30.4 ± 0.5 | 29.7 ± 0.7 |
Change of quality of life from baseline evaluated with the ALSAQ-40 scale. The Amyotrophic Lateral Sclerosis Assessment Questionnaire (ALSAQ) is a patient self-report health status scale. The ALSAQ is specifically used to measure the subjective well-being of patients with amyotrophic lateral sclerosis. There are 40 items/questions with 5 discrete scales: physical mobility (10 items), activities of daily living and independence (10 items), eating and drinking (3 items), communication (7 items), emotional reactions (10 items). Patients are asked to think about the difficulties they may have experienced during the last two weeks (e.g. I have found it difficult to feed myself). Patients are asked to indicate the frequency of each event by selecting one of 5 options (Likert scale): never/rarely/sometimes/often/always or cannot do at all. The total ranges from 0 (no impairment) to 160 (severe impairment).
| units on a scale | Real tDCS | Sham tDCS |
|---|---|---|
| Baseline | 45.0 ± 0.0 | 45.0 ± 0.0 |
| 2 Weeks | 40.1 ± 2.0 | 38.3 ± 2.8 |
| 2 Months | 38.8 ± 1.8 | 41.0 ± 2.5 |
| 6 Months | 41.9 ± 2.2 | 42.4 ± 3.1 |
Change of quality of life from baseline evaluated with the EQ-5D-5L scale. The descriptive system comprises five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate problems, severe problems and extreme problems. The patient is asked to indicate his/her health state by ticking the box next to the most appropriate statement in each of the five dimensions. The scale ranges from 5 (no impairment) to 25 (severe impairment).
| units on a scale | Real tDCS | Sham tDCS |
|---|---|---|
| Baseline | 13.0 ± 0.0 | 13.0 ± 0.0 |
| 2 Weeks | 12.2 ± 0.5 | 13.6 ± 0.8 |
| 2 Months | 12.6 ± 0.5 | 14.2 ± 0.7 |
| 6 Months | 13.3 ± 0.6 | 14.3 ± 0.9 |
Change of quality of life from baseline evaluated with the EQ-VAS scale. The EQ VAS records the patient's self-rated health on a vertical visual analogue scale, where the endpoints are labelled 'The best health you can imagine' and 'The worst health you can imagine'. The VAS can be used as a quantitative measure of health outcome that reflect the patient's own judgement. The scale ranges from 0 (severe impairment) to 100 (no impairment).
| units on a scale | Real tDCS | Sham tDCS |
|---|---|---|
| Baseline | 51.6 ± 0.0 | 51.6 ± 0.0 |
| 2 Weeks | 56.3 ± 2.0 | 46.1 ± 2.8 |
| 2 Months | 53.2 ± 2.2 | 42.7 ± 3.1 |
| 6 Months | 54.7 ± 2.9 | 40.2 ± 4.0 |
Change of quality of life from baseline evaluated with the CBI scale. The CBI scale is 24- item scale designed to assess the experience of caregivers of older people. The multidimensional instrument assesses five domains of burden (time-dependence, developmental, physical, social, and emotional). Items are scored on a 4-point scale, ranging from "not at all descriptive" to "very descriptive". The scale ranges from 0 (no impairment) to 96 (severe impairment).
| units on a scale | Real tDCS | Sham tDCS |
|---|---|---|
| Baseline | 26.7 ± 0.0 | 26.7 ± 0.0 |
| 2 Weeks | 21.6 ± 1.1 | 30.0 ± 1.5 |
| 2 Months | 24.0 ± 1.4 | 30.4 ± 1.9 |
| 6 Months | 24.8 ± 1.3 | 30.7 ± 1.9 |
By using transcranial magnetic stimulation (TMS), the investigators will evaluate the effects of tDCS on intracortical facilitation (ICF) from baseline
| millivolts | Real tDCS | Sham tDCS |
|---|---|---|
| Baselin | 1.8 ± 0.1 | 1.7 ± 0.1 |
| 2 Weeks | 1.3 ± 0.0 | 1.7 ± 0.1 |
| 2 Months | 1.4 ± 0.1 | 1.7 ± 0.1 |
| 6 Months | 1.6 ± 0.0 | 1.6 ± 0.1 |
Collected over 6 Months follow-up. Non-serious events are listed at a 0% frequency threshold.
| Group | Deaths | Serious | Other |
|---|---|---|---|
| Real tDCS | 0/20 (0%) | 4/20 (20%) | 0/20 (0%) |
| Sham tDCS | 0/10 (0%) | 2/10 (20%) | 0/10 (0%) |
| Event | Real tDCS | Sham tDCS |
|---|---|---|
| PneumoniaRespiratory, thoracic and mediastinal disorders | 1/20 | 2/10 |
| Respiratory FailureRespiratory, thoracic and mediastinal disorders | 2/20 | 0/10 |
| Worsening of Global Clinical ConditionsMusculoskeletal and connective tissue disorders | 1/20 | 0/10 |
Baseline analysis are reported for 30 participants who completed the first intervention.
| Age, Continuous(years) | Real tDCS | Sham tDCS | Total |
|---|---|---|---|
| Mean | 60.5 ± 10.9 | 63.9 ± 11.3 | 61.7 ± 2.0 |
| Sex: Female, Male(Participants) | Real tDCS | Sham tDCS | Total |
|---|---|---|---|
| Female | 7 | 2 | 9 |
| Male | 13 | 8 | 21 |
| Race (NIH/OMB)(Participants) | Real tDCS | Sham tDCS | Total |
|---|---|---|---|
| American Indian or Alaska Native | 0 | 0 | 0 |
| Asian | 0 | 0 | 0 |
| Native Hawaiian or Other Pacific Islander | 0 | 0 | 0 |
| Black or African American | 0 | 0 | 0 |
| White | 20 | 10 | 30 |
| More than one race | 0 | 0 | 0 |
| Unknown or Not Reported | 0 | 0 | 0 |
| Region of Enrollment(participants) | Real tDCS | Sham tDCS | Total |
|---|---|---|---|
| Italy | 20 | 10 | 30 |
| Disease Duration(years) | Real tDCS | Sham tDCS | Total |
|---|---|---|---|
| Mean | 2.1 ± 1.4 | 1.8 ± 1.0 | 2.0 ± 0.2 |
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Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia