Stroke
Conditions
Keywords
stroke, rehabilitation, telehealth, dopamine
Brief summary
This study explores the effects of telerehabilitation and a study medication on rehabilitation outcomes in patients with stroke resulting in arm weakness. Patients with arm weakness due to a stroke that happened in the past 30 days will be randomized into one of three groups: \[1\] TR and placebo (a sugar pill) on top of usual care; \[2\] TR and a medication (Sinemet 25/100) on top of usual care; \[3\] or usual care alone (no TR and no pill, but people in this group will be offered TR once the study is done). TR consists of 70 minutes/day of activities targeting arm function, 6 days a week for 6 weeks.
Detailed description
This is a randomized, double-blind, placebo-controlled study that involves the use of telerehabilitation to deliver additional therapy for persons with stroke. Participants with arm weakness due to a stroke in the past 30 days will be randomized into one of three groups: (1) TR + Sinemet on top of usual care, (2) TR + placebo (sugar pill) on top of usual care, or (3) usual care only (no TR, no pill). The hypothesis of this study is patients receiving TR will have significantly greater recovery of arm function compared to patients receiving usual care. In addition, Sinemet is hypothesized to significantly enhancing this improvement. Study participation will last up to 3 months and includes 4 in-person visits. At these visits, patients will undergo a battery of assessments including arm function, a single MRI scan of the brain, and blood draw for genotyping. Patients undergoing TR will receive arm motor training, which consists of 36 sessions of of assigned exercises, games, and stroke education; these are 70 minutes in length and take 6 days a week over 6-8 weeks. Subjects receiving TR will take a pill (Sinemet or placebo) prior to the TR training for the first 18 TR sessions; TR subjects will also continue usual care. Patients in the usual care group will not engage in TR or take a study pill, but will instead continue all of the therapies recommended by their medical team. At the end of the study, participants in the usual care group will be offered TR.
Interventions
DEVICETelerehabilitation
The telerehabilitation system will deliver rehabilitation treatment sessions via a secured internet-connected computer. TR sessions will be a combination of games, exercises, stroke education, assessments, in addition to videoconferencing with therapists to discuss progress, issues, goals, and changes to the treatment plan.
DRUGSinemet Pill
Sinemet 25/100 will be taken 1 hour prior to TR, for the first 18 sessions.
DRUGPlacebo
Placebo will be taken 1 hour prior to TR, for the first 18 sessions.
Sponsors
University of California, Los Angeles
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Masking description
Double blinded, placebo controlled, randomized. Participants and investigators will be blinded to the study group allocations (placebo vs Sinemet).
Intervention model description
Patients are randomized to TR + placebo, TR + Sinemet, or usual care
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Age 18 years or older 2. Stroke that has been radiologically verified and has time of onset 30 days or less from the time of randomization 3. ARAT score of \<32 (out of 57) at Visit 1 4. At Visit 1, either 1. BBT score with affected arm is at least 1 block in 60 seconds OR 2. There is a visible flicker in each of the following movements with gravity eliminated: wrist extension and finger flexion 5. At Visit 1, either 1. The range of motion against gravity must be ≥45 degrees in both the paretic shoulder and elbow OR 2. the patient must be able to use at least 3 different telerehab system input devices 6. Informed consent and behavioral contract signed by the subject (i.e., no surrogate consent)
Exclusion criteria
1. A major, active, coexistent neurological or psychiatric disease (e.g., alcoholism or dementia) 2. Major medical disorder that reduces subject's ability to comply with study procedures 3. Severe depression, defined as CES-D score \>24 at screening visit 4. Significant cognitive impairment, defined as presence of either 1. Montreal Cognitive Assessment (MoCA) score \<22 OR 2. Trail Making Test: Part A score ≤14 3. Note that lower scores may be permitted if due to aphasia and if the patient is specifically allowed by Dr. Cramer 5. Deficits in communication that interfere with reasonable study participation 6. Lacking visual acuity, with or without corrective lens, of 20/50 or better in at least one eye 7. Life expectancy \<6 months 8. Pregnant 9. Botox to arms, legs or trunk in the preceding 4 months, or expectation that Botox will be administered to the arm, leg or trunk within 3 months of study enrollment 10. Unable to successfully perform all 3 rehabilitation exercise test examples 11. Unable or unwilling to perform study procedures/therapy or attend study visits, or expectation of noncompliance with study procedures/therapy 12. Non-English or non-Spanish speaking, such that subject does not speak either language sufficiently to comply with study procedures 13. Isolation due to active COVID-19 14. Any contraindication to L-Dopa: 1. Patient is currently taking a monoamine oxidase inhibitor; if the patient took such a drug in the past, it must be discontinued at least two weeks prior to study enrollment 2. Known hypersensitivity to any component of Sinemet 3. Narrow-angle glaucoma; if wide-angle glaucoma is present, the patient can only be enrolled with explicit written approval from their ophthalmologist 4. History of melanoma or suspected melanoma 5. Patient is currently taking phenytoin, papaverine, isoniazid, or a dopamine D2 receptor antagonist (such as a phenothiazine, butyrophenone, or risperidone) 6. Currently taking a direct dopaminergic agonist 15. Expectation that subject will not have single domicile address during 6 weeks of therapy that has either Verizon wireless reception or a home WiFi network and that has space for TR system, and is within 30 miles of Cal Rehab
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in Action Research Arm Test Score From Baseline to 3 Months | Measured at baseline and 3 months later | Measures arm function using a scale that runs from 0 to 57 points, with higher scores indicating greater arm function. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Change in Arm Motor Fugl-Meyer Scale From Baseline to 3 Months | Measured at baseline and 3 months later | Measures arm motor impairment using a scale that runs from 0 to 66 points, with higher scores indicating greater arm motor function (less impairment) |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Telerehabilitation + Sinemet Patients will receive 36 telerehabilitation sessions targeting arm motor function. TR consists of 70 minutes/day of activities targeting arm function, 6 days/week for 6-8 weeks. Half of these sessions are supervised by a licensed therapist, and the other half are done independently. A study pill (Sinemet) is taken one hour before starting TR, for the first 18 sessions.
Telerehabilitation: The telerehabilitation system will deliver rehabilitation treatment sessions via a secured internet-connected computer. TR sessions will be a combination of games, exercises, stroke education, assessments, in addition to videoconferencing with therapists to discuss progress, issues, goals, and changes to the treatment plan. | 6 |
| Telerehabilitation + Placebo Patients will receive 36 telerehabilitation sessions targeting arm motor function. TR consists of 70 minutes/day of activities targeting arm function, 6 days/week for 6-8 weeks. Half of these sessions are supervised by a licensed therapist, and the other half are done independently. A study pill (Placebo) is taken one hour before starting TR, for the first 18 sessions. | 10 |
| Usual Care Participants in the usual care group will receive no TR or study pill, but will continue with the recommendations made by their care team. All participants will be offered TR at the end of the study. | 9 |
| Total | 25 |
Baseline characteristics
| Characteristic | Telerehabilitation + Sinemet | Total | Usual Care | Telerehabilitation + Placebo |
|---|---|---|---|---|
| Action Research Arm Test | 20.7 units on a scale STANDARD_DEVIATION 8.9 | 18.8 units on a scale STANDARD_DEVIATION 11.3 | 18.3 units on a scale STANDARD_DEVIATION 12.7 | 18 units on a scale STANDARD_DEVIATION 12.2 |
| Age, Continuous | 59.8 years | 64.4 years | 66.4 years | 65.2 years |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 1 Participants | 3 Participants | 1 Participants | 1 Participants |
| Race (NIH/OMB) Black or African American | 2 Participants | 6 Participants | 1 Participants | 3 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 1 Participants | 2 Participants | 0 Participants | 1 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) White | 2 Participants | 14 Participants | 7 Participants | 5 Participants |
| Sex: Female, Male Female | 0 Participants | 8 Participants | 3 Participants | 5 Participants |
| Sex: Female, Male Male | 6 Participants | 17 Participants | 6 Participants | 5 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk |
|---|---|---|---|
| deaths Total, all-cause mortality | 0 / 6 | 0 / 10 | 0 / 9 |
| other Total, other adverse events | 2 / 6 | 1 / 10 | 0 / 9 |
| serious Total, serious adverse events | 1 / 6 | 3 / 10 | 4 / 9 |
Outcome results
Primary
Change in Action Research Arm Test Score From Baseline to 3 Months
Measures arm function using a scale that runs from 0 to 57 points, with higher scores indicating greater arm function.
Time frame: Measured at baseline and 3 months later
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Telerehabilitation + Sinemet | Change in Action Research Arm Test Score From Baseline to 3 Months | 23.5 score on a scale | Standard Deviation 6.8 |
| Telerehabilitation + Placebo | Change in Action Research Arm Test Score From Baseline to 3 Months | 24 score on a scale | Standard Deviation 13.7 |
| Usual Care | Change in Action Research Arm Test Score From Baseline to 3 Months | 15.1 score on a scale | Standard Deviation 7.8 |
Secondary
Change in Arm Motor Fugl-Meyer Scale From Baseline to 3 Months
Measures arm motor impairment using a scale that runs from 0 to 66 points, with higher scores indicating greater arm motor function (less impairment)
Time frame: Measured at baseline and 3 months later
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Telerehabilitation + Sinemet | Change in Arm Motor Fugl-Meyer Scale From Baseline to 3 Months | 23.8 score on a scale | Standard Deviation 5.4 |
| Telerehabilitation + Placebo | Change in Arm Motor Fugl-Meyer Scale From Baseline to 3 Months | 21.9 score on a scale | Standard Deviation 12 |
| Usual Care | Change in Arm Motor Fugl-Meyer Scale From Baseline to 3 Months | 12 score on a scale | Standard Deviation 5.6 |