Cervical Spondylotic MyelopathyNCT03810781
Postural Stability in Cervical Spinal Myelopathy
An observational study of Cervical Spondylotic Myelopathy, run by VA Office of Research and Development at 1 site in United States.
Trial summary
Veterans are at heightened risk of developing cervical spondylotic myelopathy (CSM) from rigors of military service. Balance and posturography are negatively affected in CSM, but require expensive equipment, and extensive training of personnel for data acquisition and interpretation. Read more about this study
- Who is it for?
- Ages 18 years and olderHealthy volunteers can take part
- Conditions the study is for
- Cervical Spondylotic Myelopathy
- How many people
- 8 participants
- Where
- 1 siteUnited States
- Study dates
- 7 Feb 2019to 1 Sep 2022
- Phase
- Observational
- Are there results?
- Yes, posted in the registrySummary in the doctors' view
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 years and older
- All sexes
- Healthy volunteers accepted
- Adult, Older adult
Study population: US Veterans.
Who may be able to join
- Patients in the CSM group will be selected based on clinical criteria. Inclusion criteria for the CSM group are:
- symptoms of myelopathy in upper and lower extremities and stenosis of the cervical spine demonstrated by MRI or myelography
- lower extremity muscle strength of 4 as quantified by manual muscle test (MMT) 36 or above
- ability to stand without support with eyes closed for 30 s or more
- Veterans in the control group will be recruited from the SVAMC and surrounding community using printed advertisements
Who cannot join
- presence of lower extremity or lumbar spine disease
- peripheral neuropathy
- history of other neurological disorder
- inability to stand in an upright position with both feet together and eyes closed
- Although the SVAMC population is predominately Caucasian and male, every effort will be made to recruit minorities and women
- The proposed study will neither target for recruitment nor will the investigators exclude pregnant women
Trial locations and contacts
1 site in 1 country.
United States1 site
Syracuse VA Medical Center, Syracuse, NY
Syracuse, New York, 13210
About this study
Official title: Study of Postural Stability in Subjects With Myelopathy Using a Portable Virtual Reality Balance Protocol
Veterans are at heightened risk of developing cervical spondylotic myelopathy (CSM) from rigors of military service. Balance and posturography are negatively affected in CSM, but require expensive equipment, and extensive training of personnel for data acquisition and interpretation. The Virtual Environment TBI Screen (VETS) is a simple and inexpensive construct that could be implemented as an aid in diagnosis and as an objective means to compare treatment modalities and track recovery. The goal for the SPiRE is to generate the critical data to support rigorous Merit studies of posturography for assessments of clinical course in the treatment and rehabilitation of CSM. The investigators' ultimate goal, if the SPiRE is successful, is to phase in objective posturography assessments as VA standard of care in CSM.
Read the detailed description
COVID-19 administrative hold
Veterans are at heightened risk of developing cervical spondylotic myelopathy (CSM) from rigors of military service. Diagnosis of CSM involves a set of clinical findings and is confirmed by imaging the spine.
Gait impairment and disturbances of stance control are hallmarks of CSM and are a consequence of abnormalities in proprioception due to dorsal column tract damage of the spine. Currently, gait and balance deficits rely on clinical level assessments and judgement for detection. An objective measure of posturography has the benefit of: a) quantifying balance-related disability in CSM, b) facilitating structure-functional assessments in CSM, and c) quantifying the degree surgical interventions affect posturography and recovery of function in CSM.
Objective and sensitive means for assessing balance and posturography exist, but are not routinely incorporated in diagnosis or functional tracking of progress after interventions such as surgery. A barrier may be accessibility of posturography and ease of assessments. The Virtual Environment TBI Screen (VETS) was devised using Army Rapid Innovation Development funding to objectively assess balance and posturography in a cost effective, but sensitive manner. VETS involves virtual environments and computerized posturography and is proving to be a sensitive system facilitating diagnosis, treatment, and mitigation of balance dysfunction associated with mTBI.
The working hypothesis is VETS testing will enhance clinical judgements regarding CSM. The SPiRE is designed to provide data critical to a more extensive program of research incorporating posturography into treatment and rehabilitation of CSM.
First, a limited comparative study of standing balance will be conducted of 20 Veterans being evaluated for cervical spine surgery to treat CSM and 20 otherwise healthy Veterans. Second, posturography of the Veterans undergoing surgery to treat CSM will be tracked during their scheduled follow up visits to determine the degree VETS scores are affected by surgery and to track recovery from CSM.
Patients in the CSM group will be selected based on clinical criteria. Veterans in the control group will be recruited from the Syracuse Veterans Affairs Medical Center (SVAMC) and surrounding community.
For VETS testing, the Veteran will stand directly on a firm surface or foam pad placed on top of a Wii Balance Board (WBB). There are six conditions manipulating surface (firm or foam surface) and visual input (eyes open viewing a static scene, eyes closed, and eyes open viewing a dynamic visual scene). The primary measure is the center of pressure (COP) sway area. These 6 conditions allow for an assessment of generalized vs specific deficits in COP sway area considering proprioception, dependence of visual input and visuo-proprioceptive integration.
AIM 1A: Determine whether and to what degree balance is altered in CSM. The degree of COP sway will be compared between CSM and controls in the six conditions comprising VETS testing.
AIM 1B: Determine whether VETS enhances sensitivity and selectivity in the diagnosis of CSM. Composite measures of balance will be related to clinical assessment tools and their relationship with MRI.
AIM 2: Evaluate the VETS scores after surgery to treat CSM. The degree of COP sway area under the 6 conditions will be compared before surgery, 2 weeks, 6 weeks and 6 months after surgery (corresponding with post-operative clinical assessments).
The ultimate goal is to validate and incorporate objective balance testing into routine assessment for CSM to aid in disambiguating CSM, to improve functional assessments of recovery, and to aid in evaluations of different treatment and rehabilitation strategies in CSM for the Veteran population.
- Conditions
- Cervical Spondylotic Myelopathy
- Keywords
- Posturography, Spinal Cord Injury
- Medical subject headings
- Spinal Cord Injuries
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
| Study group | Role | What they receive |
|---|---|---|
| Cervical Spondylotic Myelopathy (CSM) | Degenerative cervical myelopathy, encapsulates a cascade of events leading to significant degenerative changes in discs, formation of osteophytes, facet hypertrophy, calcification of the posterior longitudinal ligament and ligamentous flavum with resultant canal stenosis and segmental instability. |
What is being measured
The primary outcome is the main question the study is designed to answer.
Virtual Environment TBI System (VETS) Assessment of Static Posturography
The postural stability task involves six conditions during which Veterans are instructed to look straight ahead and maintain an upright stance as stably as possible. Veterans are barefooted with feet comfortably placed ~25 cm apart. The six conditions are (1) Eyes Open (EO) Firm (2) Eyes Closed (EC) Firm, (3) Dynamic Scene (DYN) Firm, (4) EO Foam, (5) EC Foam, and (6) DYN Foam. a) Comparison of CSM vs. Control and within-subject visual (EO,EC, and DYN) and surface conditions (FIRM and FOAM). b) Comparison of balance and posture at Pre-surgery for CSM group to age and gender matched non-CSM controls. Only pre-surgery data in CSM group was collected due to COVID-19.
Measured: Pre-Surgery compared to otherwise healthy Veterans
Change in Static Posturography (VETS)
The Pre-surgery CSM group recruited for VETS (Static Posturography) measurement will also serve as the sample for the change in VETS measurement as a change in centimeters (cm). This is a longitudinal assessment of balance following surgical intervention for CSM.
Measured: Pre-surgery compared to 2 weeks, 6 weeks, and 6 months post-surgery VETS factors. The Post-surgery endpoints are normally scheduled clinical follow ups.
Secondary outcomes (8)
Nurick Scale
The Nurick scale is a 6-grade ordinal scale assessing gait impairment, with grades ranging from 0 (signs and symptoms of root involvement but no evidence of spinal cord disease) to 5 (chair bound or bedridden). The aggregate value of the Nurick scale will be related to posturography. Classification Scheme:
- Grade 0: signs or symptoms of root involvement but without evidence of spinal cord disease
- Grade 1: signs of spinal cord disease but no difficulty in walking.
- Grade 2: slight difficulty in walking which does not prevent full-time employment
- Grade 3: difficulty in walking which prevented full time employment or the ability to do all housework, but which was not so severe as to require someone else's help to walk
- Grade 4: able to walk only with someone else's help or with the aid of a frame.
- Grade 5 : chairbound or bedridden.
Measured: PreSurgery compared to otherwise healthy Veterans
Neck Disability Index (NDI)
NDI is related to VETS posturography to determine sensitivity of standing posture to degree of disability. The NDI is a 10-item questionnaire addressing function activities (personal care, lifting, reading, work, driving, sleeping, and recreation), pain intensity, concentration, and headache. For each item, patients make their ratings on a 6-point Likert scale with values 0 = no disability and 5 = complete disability. Summed scores for each category are multiplied by 2 to give a total NDI score ranging from 0-100. Score: /50 Transform to percentage score x 100 = %points. Scoring: Example:16 (total scored)50 (total possible score) x 100 = 32% If one section is missed or not applicable the score is calculated: 16 (total scored)45 (total possible score) x 100 = 35.5% Minimum Detectable Change (90% confidence): 5 points or 10 %points
Measured: PreSurgery compared to otherwise healthy Veterans
Short Form-36 Version 2 (SF-36v2)
The SF-36 questionnaire consists of eight scales yielding two summary measures: physical and mental health. The physical health measure includes four scales of physical functioning (10 items), role-physical (4 items), bodily pain (2 items), and general health (5 items). The mental health measure is composed of vitality (4 items), social functioning (2 items), role-emotional (3 items), and mental health (5 items). The SF-36 offers a choice of recall format at a standard (4 week) or acute (1 week) time frame. Likert scales and yes/no options are used to assess function and well-being on this 36-item questionnaire. To score the SF-36, scales are standardized with a scoring algorithm or by the SF-36v2 scoring software to obtain a score ranging from 0 to 100. Higher scores indicate better health status, and a mean score of 50 has been articulated as a normative value for all scales.
Measured: PreSurgery compared to otherwise healthy Veterans
EC FIRM/EO FIRM Ratio
From the VETS, a ratio corresponding to the Rhomberg ratio of COP sway will be used to determine the degree static posture depends on visual input. The Romberg test used in posturography compares postural sway in eyes open (EO) and eyes closed (EC) conditions. The Romberg ratio was calculated in the traditional manner, i.e. EC/EO. The ensuing Romberg ratio (EC/EO) is used to assess visual dependency in postural stability. Higher Romberg ratios reflect greater instability with closed eyes, ( a greater amount of postural sway during eyes closed) whereas a ratio < 1 indicates higher stability in the EC versus EO condition.
Measured: PreSurgery
EO FOAM/EO FIRM
From the VETS, a ratio of COP sway will be used to determine the degree static posture is affected by reduced proprioception.
Measured: PreSurgery compared to otherwise healthy Veterans
EC FOAM/EO FOAM Ratio
From the VETS, a ratio of COP sway will be used to determine the degree of loss of visual information. Loss of visual information compounds reduced proprioceptive ability in static balance.
Measured: PreSurgery compared to otherwise healthy Veterans
DYN FOAM/DYN FIRM Ratio
From the VETS, a ratio of COP sway will be used to determine how roll vection is induced by loss of proprioception.
Measured: PostSurgery compared to otherwise healthy Veterans compared to otherwise healthy Veterans
DYN FIRM/ EO FIRM Ratio
From the VETS, a ration of COP sway to determine the degree roll vection is induced.
Measured: PreSurgery compared to otherwise healthy Veterans
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted22 Jan 2019
- Study start7 Feb 2019
- Primary completion1 Sep 2022
- Study completion1 Sep 2022
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Posted resultsParticipant flow, outcome measures and adverse events reported by the sponsor.
- Other trials for Cervical Spondylotic MyelopathyStudies of the same condition, open and under way.
- More trials run by VA Office of Research and DevelopmentThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Observational
- Observational model
- Case-control
- Time perspective
- Prospective
- Enrolment
- 8 participants (actual)
Sponsor and investigators
- Lead sponsor
- VA Office of Research and Development
- Sponsor type
- US federal agency
- Collaborators
- Temple University
- Responsible party
- Sponsor
- Investigators
- Richard J. Servatius, PhD, Principal investigator, Syracuse VA Medical Center, Syracuse, NY
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT03810781
- Sponsor's protocol ID
- F2882-P
- Other IDs
- RX002882-01A1
- Status last verified
- Nov 2025
- First submitted
- 16 Jan 2019
- Last updated
- 15 Dec 2025
- Results posted
- Yes, on ClinicalTrials.gov
- Data monitoring committee
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No
Study at a glance
From the registry record, last updated by the sponsor on 15 Dec 2025. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Study of Postural Stability in Subjects With Myelopathy Using a Portable Virtual Reality Balance Protocol
- ClinicalTrials.gov ID
- NCT03810781
- Acronym / sponsor ID
- F2882-P
- Conditions
- Cervical Spondylotic Myelopathy
- Keywords
- Posturography, Spinal Cord Injury
- Study type
- Observational
- Recruitment status
- Completed
- Enrolment
- 8 participants (actual)
- Lead sponsor
- VA Office of Research and DevelopmentUS federal agency
- Collaborators
- Temple University
- Study start
- 7 Feb 2019 (actual)
- Primary completion
- 1 Sep 2022 (actual)
- Study completion
- 1 Sep 2022 (actual)
- First posted
- 22 Jan 2019 (actual)
- Results
- Posted 15 Dec 2025
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
Veterans are at heightened risk of developing cervical spondylotic myelopathy (CSM) from rigors of military service. Balance and posturography are negatively affected in CSM, but require expensive equipment, and extensive training of personnel for data acquisition and interpretation. The Virtual Environment TBI Screen (VETS) is a simple and inexpensive construct that could be implemented as an aid in diagnosis and as an objective means to compare treatment modalities and track recovery. The goal for the SPiRE is to generate the critical data to support rigorous Merit studies of posturography for assessments of clinical course in the treatment and rehabilitation of CSM. The investigators' ultimate goal, if the SPiRE is successful, is to phase in objective posturography assessments as VA standard of care in CSM.
Detailed description
COVID-19 administrative hold
Veterans are at heightened risk of developing cervical spondylotic myelopathy (CSM) from rigors of military service. Diagnosis of CSM involves a set of clinical findings and is confirmed by imaging the spine.
Gait impairment and disturbances of stance control are hallmarks of CSM and are a consequence of abnormalities in proprioception due to dorsal column tract damage of the spine. Currently, gait and balance deficits rely on clinical level assessments and judgement for detection. An objective measure of posturography has the benefit of: a) quantifying balance-related disability in CSM, b) facilitating structure-functional assessments in CSM, and c) quantifying the degree surgical interventions affect posturography and recovery of function in CSM.
Objective and sensitive means for assessing balance and posturography exist, but are not routinely incorporated in diagnosis or functional tracking of progress after interventions such as surgery. A barrier may be accessibility of posturography and ease of assessments. The Virtual Environment TBI Screen (VETS) was devised using Army Rapid Innovation Development funding to objectively assess balance and posturography in a cost effective, but sensitive manner. VETS involves virtual environments and computerized posturography and is proving to be a sensitive system facilitating diagnosis, treatment, and mitigation of balance dysfunction associated with mTBI.
The working hypothesis is VETS testing will enhance clinical judgements regarding CSM. The SPiRE is designed to provide data critical to a more extensive program of research incorporating posturography into treatment and rehabilitation of CSM.
First, a limited comparative study of standing balance will be conducted of 20 Veterans being evaluated for cervical spine surgery to treat CSM and 20 otherwise healthy Veterans. Second, posturography of the Veterans undergoing surgery to treat CSM will be tracked during their scheduled follow up visits to determine the degree VETS scores are affected by surgery and to track recovery from CSM.
Patients in the CSM group will be selected based on clinical criteria. Veterans in the control group will be recruited from the Syracuse Veterans Affairs Medical Center (SVAMC) and surrounding community.
For VETS testing, the Veteran will stand directly on a firm surface or foam pad placed on top of a Wii Balance Board (WBB). There are six conditions manipulating surface (firm or foam surface) and visual input (eyes open viewing a static scene, eyes closed, and eyes open viewing a dynamic visual scene). The primary measure is the center of pressure (COP) sway area. These 6 conditions allow for an assessment of generalized vs specific deficits in COP sway area considering proprioception, dependence of visual input and visuo-proprioceptive integration.
AIM 1A: Determine whether and to what degree balance is altered in CSM. The degree of COP sway will be compared between CSM and controls in the six conditions comprising VETS testing.
AIM 1B: Determine whether VETS enhances sensitivity and selectivity in the diagnosis of CSM. Composite measures of balance will be related to clinical assessment tools and their relationship with MRI.
AIM 2: Evaluate the VETS scores after surgery to treat CSM. The degree of COP sway area under the 6 conditions will be compared before surgery, 2 weeks, 6 weeks and 6 months after surgery (corresponding with post-operative clinical assessments).
The ultimate goal is to validate and incorporate objective balance testing into routine assessment for CSM to aid in disambiguating CSM, to improve functional assessments of recovery, and to aid in evaluations of different treatment and rehabilitation strategies in CSM for the Veteran population.
Study design
- Observational model
- Case-control
- Time perspective
- Prospective
- Number of arms
- 1
| Arm | Type | Receives |
|---|---|---|
| Cervical Spondylotic Myelopathy (CSM) | – | –Degenerative cervical myelopathy, encapsulates a cascade of events leading to significant degenerative changes in discs, formation of osteophytes, facet hypertrophy, calcification of the posterior longitudinal ligament and ligamentous flavum with resultant canal stenosis and segmental instability. |
Who may qualify
- Ages
- 18 years and older
- Sex
- All
- Healthy volunteers
- Accepted
- Age groups
- Adult, Older adult
- Study population
- US Veterans.
Key inclusion criteria (5 listed)
- Patients in the CSM group will be selected based on clinical criteria. Inclusion criteria for the CSM group are:
- symptoms of myelopathy in upper and lower extremities and stenosis of the cervical spine demonstrated by MRI or myelography
- lower extremity muscle strength of 4 as quantified by manual muscle test (MMT) 36 or above
- ability to stand without support with eyes closed for 30 s or more
- Veterans in the control group will be recruited from the SVAMC and surrounding community using printed advertisements
Key exclusion criteria (6 listed)
- presence of lower extremity or lumbar spine disease
- peripheral neuropathy
- history of other neurological disorder
- inability to stand in an upright position with both feet together and eyes closed
- Although the SVAMC population is predominately Caucasian and male, every effort will be made to recruit minorities and women
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Primary outcome
Virtual Environment TBI System (VETS) Assessment of Static Posturography
Time frame: Pre-Surgery compared to otherwise healthy Veterans
The postural stability task involves six conditions during which Veterans are instructed to look straight ahead and maintain an upright stance as stably as possible. Veterans are barefooted with feet comfortably placed ~25 cm apart. The six conditions are (1) Eyes Open (EO) Firm (2) Eyes Closed (EC) Firm, (3) Dynamic Scene (DYN) Firm, (4) EO Foam, (5) EC Foam, and (6) DYN Foam. a) Comparison of CSM vs. Control and within-subject visual (EO,EC, and DYN) and surface conditions (FIRM and FOAM). b) Comparison of balance and posture at Pre-surgery for CSM group to age and gender matched non-CSM controls. Only pre-surgery data in CSM group was collected due to COVID-19.
Change in Static Posturography (VETS)
Time frame: Pre-surgery compared to 2 weeks, 6 weeks, and 6 months post-surgery VETS factors. The Post-surgery endpoints are normally scheduled clinical follow ups.
The Pre-surgery CSM group recruited for VETS (Static Posturography) measurement will also serve as the sample for the change in VETS measurement as a change in centimeters (cm). This is a longitudinal assessment of balance following surgical intervention for CSM.
8 secondary outcomes
Nurick Scale
Time frame: PreSurgery compared to otherwise healthy Veterans
Neck Disability Index (NDI)
Time frame: PreSurgery compared to otherwise healthy Veterans
Short Form-36 Version 2 (SF-36v2)
Time frame: PreSurgery compared to otherwise healthy Veterans
EC FIRM/EO FIRM Ratio
Time frame: PreSurgery
EO FOAM/EO FIRM
Time frame: PreSurgery compared to otherwise healthy Veterans
EC FOAM/EO FOAM Ratio
Time frame: PreSurgery compared to otherwise healthy Veterans
DYN FOAM/DYN FIRM Ratio
Time frame: PostSurgery compared to otherwise healthy Veterans compared to otherwise healthy Veterans
DYN FIRM/ EO FIRM Ratio
Time frame: PreSurgery compared to otherwise healthy Veterans
Results and safety
Loading the posted results from ClinicalTrials.gov…
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 15 Dec 2025.
- Posted resultsParticipant flow, baseline, all outcome measures and adverse events.
- Individual participant dataSharing planned: No
Related trials for Cervical Spondylotic Myelopathy
Not yet recruitingObservational study
Biomarkers of Cervical Spondylotic Myelopathy
Cervical Spondylotic Myelopathy
Not yet recruitingObservational study
A Multicenter Registry-Based Study Across the Spectrum of Degenerative Cervical Myelopathy
Degenerative Cervical Myelopathy, Non-myelopathic Degenerative Cervical Cord Compression
Active, not recruiting
Multi-centre Study to Evaluate ACAF Versus Laminoplasty in Treating Cervical Ossification of the Posterior Longitudinal Ligament
Ossification of Posterior Longitudinal Ligament, Cervical Spondylosis With Myelopathy
RecruitingObservational study
Validity of the Turkish Translation of the Modified JOA
Spondylosis, Cervical, Spinal Cord Compression
Active, not recruiting
Cervical Spondylotic Myelopathy Surgical Trial
Cervical Spondylosis With Myelopathy
Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Richard J. Servatius, PhD principal investigator
Syracuse VA Medical Center, Syracuse, NY
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
An observational study of Cervical Spondylotic Myelopathy, run by VA Office of Research and Development at 1 site in United States.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 5 inclusion and 6 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 15 Dec 2025. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in United States. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
Yes. Results are posted in the registry (first posted 15 Dec 2025). A summary is in the For doctors view, and the full results are on ClinicalTrials.gov.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Virtual Environment TBI System (VETS) Assessment of Static Posturography (time frame: Pre-Surgery compared to otherwise healthy Veterans). The study lists 2 primary outcomes in all. It is what the study was designed to measure, not a finding.
Where can I read the original study information?
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 15 Dec 2025.