Clinical Trial Details
— Status: Withdrawn
Administrative data
| NCT number |
NCT02346630 |
| Other study ID # |
2013-P-002440 |
| Secondary ID |
|
| Status |
Withdrawn |
| Phase |
Phase 4
|
| First received |
|
| Last updated |
|
| Start date |
March 2015 |
| Est. completion date |
March 2017 |
Study information
| Verified date |
December 2021 |
| Source |
Spaulding Rehabilitation Hospital |
| Contact |
n/a |
| Is FDA regulated |
No |
| Health authority |
|
| Study type |
Interventional
|
Clinical Trial Summary
Stroke is the leading cause of acquired long-term disability in adults in developed
countries. Despite aggressive rehabilitation, lasting upper extremity impairment remains in
the majority of stroke survivors. It is hypothesized that enhancing neuroplasticity through
the combination of drug therapy and physical therapy could enhance outcomes for stroke
survivors. The combination of levodopa and intensive physical therapy shows promise in
enhancing the functional motor recovery of stroke patients during the sub-acute and chronic
period without reported significant side effects. Robotic-aided training is a promising tool
that has the potential to deliver high-intensity, task-oriented, reproducible therapy that
can decrease the burden on a therapist. Since the evidence behind dopaminergic potentiation
of neuroplasticity and stroke recovery is promising, it is the investigators aim to combine
dopaminergic drug therapy with highly intensive robotic-assisted therapy to provide superior
upper extremity functional recovery over traditional stroke rehabilitation.
Description:
Every year, approximately 795,000 people suffer a new or recurrent stroke in the United
States, meaning that every 40 seconds someone has a stroke. In the United States, stroke is
the third most frequent cause of death and the leading cause of lasting hemiparesis and adult
disability. Since the prevalence of stroke increases with age, and since the world population
is aging, the incidence of stroke is expected to rise in the coming years. This will become a
significant societal burden since the care of stroke survivors is costly, to the individual
and to society.
Post-stroke upper extremity (UE) impairment usually implies initial weakness, with subsequent
diminished dexterity and limitation or incapacity for reaching, transport and grasping
movements since the onset. Survivors may regain partial or, less often, complete muscle
strength in the affected UE during the recovery process. However, a persistent degree of
weakness and evolution to secondary complications as spasticity (characterized by increased
flexor hypertonia), shoulder pain and contractures is frequent. These additional issues are
associated with greater impairment, worse function and lower health-related quality of life.
Treatment interventions for hemiparesis after stroke usually include stretching,
strengthening of antagonist muscles, splinting, oral medications, and focal injections
(phenol or botulinum toxin) and intrathecal baclofen. However, the amount, intensity and
length of therapies still need further investigation. Despite adequate traditional treatment,
a high number of patients are still permanently limited as a consequence of stroke. Based on
motor learning theories, recent studies have demonstrated that intensive, repetitive,
task-oriented therapies can help the paretic extremity "relearn" how to perform movements
that were lost after brain damage.
ROBOTIC-ASSISTED UPPER-LIMB TRAINING WITH ARMEO®
Current evidence has shown that rehabilitation without specific training will not result in
measurable outcomes. Factors such as intensity and specificity of motor training are
important to achieve recovery of motor function, especially in the chronic phase of the
stroke. There is robust evidence that highly-repetitive movement rehabilitation could improve
motor and functional ability, based on its role in motor learning processes.Robotic devices
have become a very important area of research because of their capacity to achieve
high-intensity and specificity therapies.
In this proposed project, we plan to use the Armeo robotic system to deliver motor training
therapy. The Armeo system is an adjustable arm orthosis that has received FDA 510k exemption.
It passively counterbalances the weight of the arm, thereby reducing the effort required by
the paretic arm to overcome gravity. The device is able to augment feedback through a virtual
environment (i.e. computer games). The tasks presented in the virtual environment are
designed to achieve functional movements, i.e. the subject has to perform tasks such as
reaching for objects as part of the game. Gravity compensation, which can reduce the level of
difficulty of performing an activity, facilitates active arm movement, especially when it
involves training in grasping and reaching. By using the Armeo system, we hope to achieve
repetitive training of reach, grasp, and release in an engaging environment that can be
adapted to individual capabilities. We also expect to enable stroke survivors whose motor
weakness may have excluded them from performing repetitive therapy tasks to participate in
this study.
LEVODOPA Several agents have widely proved their influence on neuronal plasticity. Among
these agents, pharmacological drugs increasing the availability of Central Nervous System
(CNS) neurotransmitters (dopamine, norepinephrine, serotonin, acetylcholine and hista mine)
have shown the ability to modulate excitability in cortical neurons and exert a subsequent
facilitator effect in neuroplasticity. In this regard, several studies have been conducted in
the past two decades investigating, among other agents, the effects of amphetamines,
selective serotonin reuptake inhibitors, donepezil, psychostimulants as methylphenidate and
dopaminergic agents. Levodopa (LD) is a desirable drug to evaluate because of its safe action
profile. This oral medication is a precursor of dopamine (DA) that is actively transported
across the blood-brain barrier and is converted to DA in the CNS and peripheral tissues.
Approximately 95% of LD is converted to DA, stimulating dopaminergic neurotransmission, and
the remaining 5% is converted to norepinephrine and affects adrenergic neurotransmission. DA
plays a role in the formation of motor memories and thereby facilitates neuroplasticity,
through the strengthening (long term potentiation, LTP) or weakening (long term depression,
LTD) of the neuronal synapses, thereby generating neuroplasticity. DA has an inverted U-shape
concentration curve effect to facilitate LTP. In previous studies doses of 100mg generated a
facilitator effect, and 25 mg and 200 mg exerted an inhibitor effect on human cortex. This
pharmacological agent has shown promising results in the treatment of stroke by enhancing
functional motor recovery in the sub-acute and chronic period, in combination with intensive
physical therapy, without reported significant side effects. In the acute and sub-acute
phases, LD was demonstrated to improve functional motor skills that were maintained at three
weeks follow up. LD also showed an additional benefit on the activities of daily living and
in the severity of the stroke. In the chronic period, a single dose of LD combined with
physical therapy for five weeks enhanced the formation of training-dependent elementary motor
memory while improving UE dexterity.
COMBINING LEVODOPA/CARBIDOPA WITH THE ARMEO SYSTEM
It is our hypothesis that the intake of levodopa/carbidopa LD/CD in combination with
intensive robotic-assisted therapy will provide better outcomes in functional recovery tests
than the same training alone. We also hypothesize that these improvements could be correlated
with changes in motor cortex excitability. Current strategies to improve motor recovery after
stroke focus on neuroplasticity and neuromodulation. There is growing interest in the
combination of therapies and strategies to enhance plasticity and thereby functional recovery
through the rehabilitation process. It is frequently hypothesized that the combination of
drug therapy and physical rehabilitation could provide better outcomes by enhancing
neuroplasticity phenomenon
We propose a randomized, double-blind, placebo-controlled study of LD/CD in combination with
repetitive upper-extremity functional task-oriented and robotic-aided training.
