Remote Ischaemic Conditioning for Fatigue After Stroke (RICFAST) - a Pilot, Double-blind, Randomised, Placebo Controlled Trial
Phase: NA
Conditions: Stroke, Ischemic, Stroke Hemorrhagic, Fatigue
Sponsor: Sheffield Teaching Hospitals NHS Foundation Trust

 
 
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-Study protocol 
 
Title: Remote Ischaemic Conditioning for Fatigue After Stroke (RICFAST) – a 
pilot, single-blind, randomised, placebo controlled trial. 
 
1. Project details  
1.1. Investigator details  
 
Chief & Principal Investigator  
 
Name and Title:  Dr Ali Ali 
Job Title:  Consultant Stroke and Geriatrics 
Employer: Sheffield Teaching Hospitals NHS Trust 
Directorate: Geriatrics and Stroke Medicine           
Address: Glossop Road, Sheffield, S10 2JF 
Telephone:   0114 2711768      
Email:  ali.ali@sth.nhs.uk  
 
Co-Investigator 
 
Name and Title; Prof Arshad Majid 
Job Title; Professor Cerebrovascular neurology 
Employer; University of Sheffield. 
Address; Glossop Rd, Sheffield. 
Telephone:  
 
 
 
Email: Arshad.majid@sheffield.ac.uk 
 
Co-Investigator 
 
Name and Title; Ms Bethany Moyle 
Job Title; Doctoral Fellow 
Employer; University of Sheffield 
Address; Glossop Road, Sheffield, S10 2JF 
Telephone:   
 
 
 
Email: bjemoyle1@sheffield.ac.uk  
 
 
Co-Investigator 
 
Name and Title; Dr Kirsty Harkness 
Job Title; Consultant Neurology and Stroke 
Employer; Sheffield Teaching Hospitals NHS Trust 
Directorate: Neurosciences 
Address: Glossop Road, Sheffield, S10 2JF 
Telephone: 0114 2434343  
 
Email: Kirsty.harkness@sth.nhs.uk  
 
Co-Investigator 
 
Name and Title; Dr Jessica Redgrave 
Job Title; Consultant Neurology and Stroke 
Employer; University of Sheffield 

 
 
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Address; Glossop Road, Sheffield 
Telephone: 0114 2434343  
 
Email: Jessica.redgrave@sth.nhs.uk 
 
 
Co-Investigator 
 
Name and Title; Prof Iain Wilkinson 
Job Title; Professor of Magnetic Resonance Physics 
Employer; University of Sheffield 
Address; Glossop Road, Sheffield 
Telephone: 0114 215 9606  
 
Email: I.d.wilkinson@sheffield.ac.uk 
 
Co-Investigator 
 
Name and Title; Dr Nigel Hoggard 
Job Title; Clinical Lecturer and Honorary Consultant Radiologist 
Employer; University of Sheffield 
Address; Glossop Road, Sheffield, S10 2JF 
Telephone:  0114 215 9607 
 
Email: n.hoggard@sheffield.ac.uk  
 
 
1.2. Sponsor details 
 
Name and Title: Samantha Walmsley 
            
Address: Clinical Research Office, D Floor, Royal Hallamshire Hospital,  
Gloss Road, Sheffield, S10 2JF 
Telephone:  Email: Samantha.walmsley@sth.nhs.uk 
  
1.3. Project title  
 
Remote Ischaemic Conditioning for Fatigue After Stroke (RICFAST) – a pilot 
double-blind, randomised, placebo controlled trial. 
 
1.4. STH Project Reference number  
 
STH19508 
 
1.5. Protocol version number and date 
  
 Version 2 09/07/2018 
1.6. STH Directorate affiliation  
 
Department of Neurosciences and the department of Geriatrics and Stroke, Sheffield 
Teaching Hospitals NHS Trust 
 
 
 
 
       Sheffield Teaching Hospitals NHS Trust 

 
 
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2. Research questions:  
 
1- Do stroke patients undergoing rehabilitation find it acceptable to undertake 
chronic remote ischaemic conditioning (CRIC) for a period of 6 weeks?  
2- Is it feasible to undertake a randomised control trial of CRIC to reduce fatigue 
and enhance the physical performance of patients undergoing rehabilitation 
following stroke? 
 
 
3. Abstract 
 
Background  
 
Remote ischaemic conditioning (RIC) is a when ischaemia is induced to a limb for 
short periods of time by inflating pressure cuffs around arms or legs to above systolic 
pressures (mmHg). This procedure is performed for periods that avoid physical injury 
to the limbs, but induce neurohormonal, systemic or vascular changes in the body. 
These changes often result in improved collateralisation of blood supply to various 
areas of the body as well as improved efficiencies of cellular metabolism [Pell et al 
1998]. This may have enhancing effects on physical abilities of patients undergoing 
rehabilitation after stroke, particularly when aiming to improve endurance and fatigue. 
Fatigue affects can affect up to 75% of patients who suffer a stroke [Wu et al 2014], 
which can be physical, cognitive or emotional, and can be a large barrier to 
progressing rehabilitation among such patients.  
 
 
Method  
 
In this pilot randomised controlled trial, a minimum of 34 patients who have suffered 
an ischeamic or haemorrhagic stroke who suffer from fatigue, will be recruited and 
randomised to receive either RIC or sham intervention protocols for 6 weeks (1 
session of 4 cycles three times weekly). Each session will take approximately 40 
minutes and will be administered by a post-graduate researcher. 
 
Socio-demographic and clinical data will be collected at baseline by a clinical 
researcher at the assessment and rehabilitation centre (ARC), Nether Edge Hospital, 
Sheffield, or the clinical research facility (CRF) or the stroke unit (SU), Royal 
Hallamshire Hospital (RHH). Outcome measures including: fatigue measures (fatigue 
severity scale), duration of therapy undertaken (mins/week), peak oxygen 
consumption (mL/Kg/min), physical activity measures (activity monitor and 
questionnaire), Barthel Index (BI), PHQ9 and GAD 7 (measures of depression and 
anxiety), Modified Montreal Cognitive Assessment (MOCA, cognition), modified 
Rankin Score (mRS), and EQ-5D (measure of quality of life), will be assessed at 
baseline and at the end of the intervention period (week 6). Participants will undergo 
ECG analysis and have blood tests including full blood count, renal function, liver 
function, coagulation profile, and inflammatory markers, taken at baseline and at 6 
weeks. These will be done in addition to routine care for the purposes of ensuring 

 
 
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participant safety and to review any changes RIC may cause. Healthcare utilisation 
and recurrence of vascular events will also be abstracted from electronic health 
records, including the number of hospital admissions, and new major vascular 
diagnoses. Follow up at 3, 6 and 12 months will collect data on Fatigue, PHQ-9, 
GAD, mRS, EQ-5D, recurrent vascular events and healthcare utilisation.  
 
An electrocardiogram (ECG) will be performed on each participant at the beginning 
of the study and analysed for rate, rhythm, QT interval (QTc) and QRS morphology. 
Eight patients, randomly selected (4 CRIC arm and 4 sham) will also undergo MRI 
perfusion of the brain and brain spectroscopy at baseline and at week 6. This will 
evaluate changes detected in cerebral perfusion and in levels of tissue metabolites 
including: N-acetyl aspartate (that may indicated loss or damage to neuronal tissue), 
creatine (that may indicate cell death through ischaemia), and lactate (that may 
indicate anaerobic glycolysis) [Jansen 2006]. This will be done at the Royal 
Hallamshire Hospital. These participants will also have blood samples taken along 
with the other blood samples described that will be stored for future analysis (GLP-1, 
heat shock proteins, and micro-RNA analysis for pro-inflammatory and anti-
inflammatory gene expression) with the patients consent. These samples will be sent 
to the Stoller Biomarker Discovery Centre (SBDC) in Manchester biochemical 
analysis. 
 
A manual sphygmomanometer will be used to perform the conditioning protocol. The 
protocol will involve 4 x 5 minute cycles of arm or leg cuff inflation (to 200 mmHg of 
systolic blood pressure) followed by 5 minutes of deflation. The sham arm or leg will 
inflate cuff pressures to 10 mmHg, for the same number of cycles. 
 
Acceptability of the intervention will be evaluated via the use of symptom diaries 
completed by patients throughout the intervention period that will aim to record any 
adverse events or unexpected symptoms, as well as acceptability measured using 
Likert scales. A clinical researcher will review participants 3 times weekly to provide 
support and review acceptability. Six participants will be invited to participate in 
semi-structured qualitative interviews with one of the study clinicians to allow an in-
depth exploration of participant expectations and experiences of the treatment. This 
will take place during the last scheduled visit or at another mutually exclusive time 
between participant and research clinician. 
 
Study feasibility will be determined by success criteria based on recruitment, outcome 
measure assessment, compliance with intervention and follow up (see primary 
outcomes section). 
 
 
Results  
 
Safety and success criteria - The main outcomes of this pilot RCT will be the safety, 
compliance, and acceptability of delivering a 6-week programme of CRIC 
intervention, and study feasibility. Safety will be defined as the absence of any serious 
adverse events (as defined by National Research Ethics Service – see safety section) 
related to CRIC. Compliance will be defined as the achievement of 80% of intended 
CRIC cycles, while acceptability of RIC will be defined as less than 1/3 of patients 

 
 
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reporting moderate or greater discomfort (scale 3 or 4 on Likert) associated with 
CRIC, as well as overall positive responses from qualitative interviews. Study 
feasibility will be defined as the ability to recruit to target (4 patients within the first 2 
months), and completion of > 80% of baseline and follow up assessments.  
 
Secondary outcomes will involve a comparison of changes in the outcome measures 
assessed at baseline and at 6 weeks, between CRIC and sham treatment arms to 
provide an estimate of effect size for informing the design / sample size of a future 
study. Continuous data will be compared using parametric or non-parametric analyses 
depending on whether data distribution is normal or not. Categorical data will be 
compared using Chi-square or one-way Anova. However, due to small sample size, 
appropriate power to detect significant differences for these measures will not be 
reached. This is primarily an exploratory study and the majority of data will be 
reported descriptively. 
 
 
4. Originality 
 
Remote ischaemic conditioning and its protective effects were discovered 30 years 
ago, in canine models of myocardial ischaemia [Murry et al 1986]. Since then its 
application has been tested for myocardial protection in elective [Cheung et al 2006] 
and emergent [Yellon et al 2015] coronary interventions, in animal and human models 
of cerebrovascular ischaemia [Hahn et al 2011, Hougaard et al 2014], and, more 
recently, to enhance physical performance in athletes [Tocco et al 2015, Patterson et 
al 2014]. This latter finding may be related to RIC induced changes in vasomotor 
responses that improve oxygen delivery to muscles [Duncker et al 1993] or improved 
preservation of endothelial function [Kharbanda et al 2001] during exercise-induced 
ischaemia. One small study investigated the use of RIC on exercise capacity in 
patients with heart failure [Mcdonald et al 2014] but no studies have yet investigated 
its use in patients undergoing rehabilitation after stroke. Further, no studies have 
evaluated the effects of RIC on fatigue, nor have any studies evaluated the effects of 
RIC on tissue metabolites in-vivo as examined by MRI brain perfusion and tissue 
spectroscopy. 
 
 
5. Background 
 
Remote ischaemic conditioning (RIC) is the phenomenon whereby brief episodes of 
reversible ischaemia are applied to a particular tissue or organ. This has been shown 
to be beneficial in the context of subsequent ischaemia of sufficient intensity to cause 
cell death. Since 1986, investigators have highlighted that RIC can reduce cardiac 
infarct size [Murray et al 1986], via release of ‘protective factors’ [Przyklenk et al 
1993], that has seen its use extend to planned cardiac interventions [Sharma et al 
2015] as well as acute stroke [Hahn et al 2011, Hougaard et al 2014]. A number of 
mechanisms for these effects have been proposed: 
 
Neuronal pathway – an intact peripheral and autonomic neural circuit appears to be 
critical to modulate the effects of RIC as the use of ganglionic blockers (e.g. 
hexamethonium or trimetaphan) [Gho et al 1996, Loukogeorgakis et al 2005] or nerve 

 
 
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resection (peripheral and vagotomy) [Lim et al 2010, Brzozowksi et al 2004] inhibit 
these effects. Release of endogenous factors in the conditioned tissue such as 
adenosine and bradykinin are thought to stimulate C fibres in particular [Xiao et al 
2001], that then medicate protection at a distant organ.  
 
Humoral pathway – The presence of a blood-borne factor (or factors) that mediates 
the protective effects of RIC is suggested by two observations Firstly, blood from a 
conditioned organ or animal can exert its protective effects in a naïve recipient that is 
subsequently affected by ischaemia [Dickson et al 2001, McDonald et al 2014]. 
Secondly, following ischaemic conditioning, a period of reperfusion to an organ (e.g. 
the heart) is required for the protective effects to be observed [Weinbrenner et al 
2002].  
 
Systemic response - RIC in healthy controls has also been shown to modulate the 
immune response, with suppression of pro-inflammatory genes, such as those 
involved in leucocyte motility and function [Saxena et al 2010], as well as 
upregulation of anti-inflammatory genes encoding factors such as heat-shock-protein 
70 and calplastin [Konstantinov et al 2004].  
 
More recently however, the use of RIC to enhance physical performance in athletes 
has drawn great interest. To date there have been 8 randomised controlled trials 
(RCTs) investigating this in long distance running, sprinting, cycle ergometry and 
swimming [Sharma et al 2015]. All have used RIC protocols that are similar to those 
used in cardiac populations, with conflicting results: 5 revealed significant 
improvements in outcomes such as power output, time-trial performance, lower serum 
lactate levels, and maximal exercise performance; while 3 showed no added benefit 
over control or sham. It has been postulated that these effects are derived due to 
vasodilatory effects of RIC mediated by adenosine in the vascular bed, as well as 
effects on mitochondrial function that improve efficiency of oxygen utilisation within 
the musculature [Duncker et al 1993]. These properties may be useful if applied to 
patients suffering recent stroke who are undergoing rehabilitation. Up to 75% of 
patients experience fatigue following stroke [Wu et al 2014] that can be physical and 
cognitive. Stroke often results in impairments of physical or cognitive function that 
reduce the efficiency of activities, and can increase their oxygen consumption 
requirements by 50% [Walters et al 1989, Olney et al 1991]. Fatigue is often cited as a 
reason for limiting rehabilitation after stroke. The effects of RIC on improving blood 
and oxygen delivery to muscles, and on improving the efficiency of oxygen utilisation 
may help this group of patients and should be investigated. 
 
 
Alignment of Strategic objectives of the directorate 
 
The host institution is Sheffield Teaching Hospitals in collaboration with University 
of Sheffield. The NHS sponsor is an active participant in stroke trials and the 
University of Sheffield (affiliation of the Principal Investigators) is committed to the 
development of original research in stroke. Dr Ali is a consultant stroke physician, 
geriatrician, and senior honorary lecturer at the University of Sheffield. Dr Kirsty 
Harkness and Jessica Redgrave are consultant stroke physicians and senior honorary 
lecturers at the University of Sheffield. Both are committed to developing original 

 
 
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research studies in the area of stroke rehabilitation. Professor Arshad Majid is a 
professor of neurovascular science at the University of Sheffield and an honorary 
consultant in neurology specialising in stroke at Sheffield Teaching Hospitals. The 
trial will be conducted in compliance with the protocol, Good Clinical Practice, STH 
Standard Operating Procedures and applicable regulatory requirements. Bethany 
Moyles is a PhD student at the University of Sheffield who has experience in 
recruiting to stroke research trials. This research project also aligns with the strategic 
objectives of the Biomedical Research Centre (BRC) in developing studies evaluating 
mechanisms and effects of interventions that are likely to result directly in improved 
patient outcomes and experiences. 
 
 
6. Plan of investigation  
 
 
Aim 
 
1- To assess if stroke patients undergoing rehabilitation find it acceptable to 
undertake chronic remote ischaemic conditioning (CRIC) for a period of 6 
weeks?  
2- To establish if it is feasible to undertake a randomised control trial of CRIC to 
reduce fatigue and enhance the physical performance of patients undergoing 
rehabilitation following stroke? 
 
 
6.1. Methods Justification 
 
We will aim to be as inclusive as possible for eligibility into the study, but will utilise 
exclusion criteria that have been used in prior trials of RIC in cardiac and stroke 
populations such as the presence of peripheral neuropathy, and cerebrovascular or 
cardiovascular hospitalisation within 4 weeks [Lavi et al 2014, Hougaard et al 2014]. 
The need for participants to be at least 6 weeks post stroke and discharged into the 
community reflects the preference for patient’s neurological and cardiovascular status 
to have stabilised. Enough time should have elapsed from what may have been a 
severe ischaemic or haemorrhagic event that is likely to have induced a response 
similar to, if not more intense than RIC.  
 
The outcome measures and scales that will be used in the study (e.g. fatigue severity 
score, PHQ-9, GAD, MOCA, EQ-5D, VO2 max, 6MWT) have all been validated in 
stroke populations [Mead et al 2007, Van Hout et al 2012, Blackburn et al 2013, Eng 
et al 2004].  
 
We have used the fatigue severity scale-7 (FSS-7) for fatigue assessment [Krupp et al 
1989]. This is a 7-item self-administered questionnaire that measures the effect of 
fatigue on a persons activities and lifestyle. Each item is scored on a 7-point scale 
with 1 = strongly agree and 7 = strongly disagree. The scores thus range from 7 to 49, 
with the greater the score indicating greater fatigue [Lerdal et al 2011]. There are 
population normative results [Valko et al 2008], and minimal clinically important 

 
 
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differences (MCID) published [Nordin et al 2016], and this fatigue scale is the most 
commonly studied in patients with stroke [Mead et al 2007].  
 
The protocol for CRIC (ischaemia-reperfusion cycle duration of 5 minutes each, 
repeated 4 times with maximum pressures of 200 mmHg) is reflective of those used 
most commonly among prior cardiac and stroke studies that have resulted in positive 
responses with regard to physical performance measures (VO2 max) [Sharma et al 
2015]. While a ‘washout period’ for the neurohumoral effects of RIC has been 
estimated at 7 days [Housenloy et al 2010] we have decided not to pursue a cross-over 
design, as this remains controversial. Further, while we will aim to for participants to 
complete 5 minutes of the intervention inflation cycles, we will be evaluating the 
acceptability of the intervention, and thus we will allow participants to tolerate as long 
a duration of inflation as they can and record this during the follow up visits. If 
participants cannot tolerate arm conditioning they will be offered leg conditioning as 
this study aims to assess acceptability of the treatment. 
 
We will use a sham intervention in patients randomised to the control group that 
involves inflation of the limb cuff to 20mmHg. This has been chosen as it is the most 
common sham protocol used in prior studies.  It is recognised that it may be difficult 
to ensure participant blinding due to the pressure differences with cuff inflations. 
However, care will be taken to ensure the patient information leaflet will describe the 
intervention as an inflation of the cuff, without mention of the pressures that would be 
expected. The sham CRIC will be designed to make the same noises that the true 
CRIC intervention will make and for the same length of time. Outcome assessments 
will be blinded to randomisation as they will be undertaken by a researcher not known 
to the participants before and who will not ask about the intervention during the 
assessments. An online randomisation system will be used rather than sealed envelope 
randomisation. 
 
We 
will 
document 
adverse 
events 
using 
standard 
NRES 
definitions 
(www.hra.nhs.uk). For example, serious adverse events (SAE) will include events that 
result in death, are life-threatening, require hospitalisation or result in persistent or 
significant disability, or is a congenital anomaly or birth defect. There are no 
agreements or guidelines on what is considered an acceptable rate of adverse events 
as this is dependent on the study population, comorbidities etc. Adverse events need 
to be scrutinised to determine whether they are likely to be related to the intervention 
itself. For the purposes of this pilot RCT (n=34) we will define safety as there being 
no serious adverse events relating to CRIC and less than 10 adverse events in total 
across all 34 participants. 
 
Six participants recruited to the study will also undertake qualitative semi-structured 
interviews using topic guides with a researcher trained in thematic analysis to gain 
insight into their experiences with CRIC. This will help evaluate the acceptability of 
CRIC by asking about both positive and negative experiences, as well as explore 
unanticipated effects of the treatment. The researcher will also enquire as to the 
barriers and facilitators to successful recruitment and retention to the study, which 
will help with future clinical trials and the potential implementation of CRIC into 
clinical practice. 
 

 
 
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The use of MRI perfusion of the brain and tissue spectroscopy to evaluate any effects 
of CRIC on tissue composition is novel. We still do not have complete understanding 
of how RIC exerts its effects, particularly in humans, and as such this study will 
provide an opportunity to further evaluate this. If RIC causes a cascade of effects that 
result in improved tissue perfusion or efficiency in oxygen metabolism then we may 
see changes in cerebral perfusion and / or the metabolites detected in the brain 
(spectroscopy). Prof Iain Wilkinson will facilitate scanning and interpretation of 
scans. 
 
6.2. Design 
 
Pilot, double blind, randomised, placebo controlled trial within a single centre. 
 
 
6.3. Setting 
 
Participants will have baseline and subsequent clinical assessments, at the ARC, 
Nether Edge Hospital, Sheffield or the Clinical Research Facility or the Stroke Unit at 
the RHH. 
 
 
6.4. Participants: 
 
A minimum of 34 participants will be recruited from the community stroke services 
over 24 months from August 2018 to August 2020 (GANTT chart). All participants 
will have supervised CRIC delivered by a clinical researcher at scheduled study visits 
to ARC. 
 
Inclusion criteria: 
 
 Adults (aged > 18 years) who have had an ischaemic or haemorrhagic stroke 
at least 6 weeks prior. 
 Symptoms of debilitating fatigue for at least 4 weeks (fatigues severity score 
of 28 or more). 
 
 
 
Exclusion criteria: 
 
 History or presence of significant peripheral vascular disease in the upper 
limbs. 
 History or presence of complex neuropathic pains or peripheral neuropathy in 
the arms. 
 Presence of lymphoedema in the arms. 
 Presence of skin ulceration to the arms. 
 Hospitalisation for cardiovascular or cerebrovascular disease within the last 4 
weeks. 
 Uncontrolled arrhythmia, hypertension, diabetes or angina. 

 
 
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 Third degree heart block or progressive heart failure. 
 Acute aortic dissection, myocarditis, or pericarditis. 
 Acute deep vein thrombosis, pulmonary embolism or pulmonary infection. 
 Suspected or known dissecting aneurysm. 
 Uncontrolled visual or vestibular disturbance. 
 Known or suspected cause of fatigue e.g. obstructive sleep apnoea (Epworth > 
15), depression (PHQ-9 > 14). 
 Modified Rankin Score > 4. 
 
 
 
6.5. Sample Size 
 
The sample size of at least 34 has been chosen based on the number of participants 
evaluated in studies of physical performance in athletes (range 11 – 25) that reported 
outcome measures based on exercise performance e.g. running speed, peak and mean 
power outputs, trial time performances, oxygen consumption. Further, a cross-over 
RCT of RIC to improve peak oxygen consumption in heart failure included 20 
patients [McDonald et al 2014]. A sample size of 30 is also quoted as the minimum 
number of patients required for the purposes of feasibility assessment [Lancaster et al 
2004].  
 
One of our main outcomes is safety of CRIC in patients with stroke. If we concentrate 
on the definition of serious adverse events (SAE) (i.e. any event that results in death, 
is life-threatening, requires hospitalisation or results in persistent or significant 
disability, or is a congenital anomaly or birth defect), then if we do not see any SAEs 
related to CRIC then we can be 95% confident that the true SAE rate lies between 0 
and 12% [Bland M 2005]. 
 
There are no studies reporting the effect sizes of RIC on fatigue. One of the key 
outcomes of this pilot will be to provide information for a power calculation required 
for a definitive RCT of RIC to improve fatigue. However, the FSS-7 is a 7-item self-
administered questionnaire that measure the effect of fatigue on various physical and 
social activities. Each domain is scored out of 7 with a maximum score of 49, the 
higher the score the greater the fatigue. The average FFS-7 score for healthy adult 
population is 23 points (SD0.7) [Grace et al 2006], and the reported minimal 
clinically important difference (MCID) in this score associated with improvement 
ranges between 2 and 12 for deterioration and improvement [Nordin et al 2016].  
 
6.6. Recruitment 
 
Potential participants will be identified from the stroke unit and stroke follow up 
clinics at the Royal Hallamshire Hospital, Beech Hill rehabilitation Centre, the 
Assessment and rehabilitation Centre at Nether Edge Hospital and by the Community 
Stroke Services. Any patients meeting the eligibility criteria for the study will be 
highlighted by clinicians working in these areas and will give these patients a copy of 
the study information sheet. An aphasia friendly version of the information sheet is 
also available. Patients will be asked whether they are happy to be contacted by a 

 
 
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member of the research team. Dr Ali (PI) will telephone the patient, and answer any 
questions they may have. If the patient meets the inclusion criteria and is happy to 
take part, Dr Ali will obtain verbal consent and arrange a mutually convenient time 
for them to attend ARC at Nether Edge Hospital, or the Clinical Research Facility or 
the Stroke Unit, RHH, for the first clinical meeting. This will include obtaining 
consent, socio-demographic and clinical data collection and baseline outcome 
measures. 
 
Further information on the recruitment sources: 
 
 Stroke unit, Royal Hallamshire Hospital – approximately 950 patients are 
diagnosed with stroke and are admitted to the stroke unit annually in Sheffield. 
There are 9 physicians who work primarily in stroke, and 3 research nurses 
who will be able to help identify potential participants. 
 Stroke clinic, Royal Hallamshire Hospital – this reviews patients between 6 & 
8 weeks following their discharge from hospital and represents a further 
opportunity to highlight eligible patients. All patients are screened for fatigue 
during their clinic visits. 
 Beech Hill Rehabilitation Centre – 32 bedded unit for ongoing rehabilitation 
often managing patients up to 3 months after stroke. 
 Community stroke service – provide rehabilitation to patients suffering stroke 
within their own homes after discharge from hospital. This continues for up to 
3 months after stroke. Community stroke staffs are well experienced in 
identifying patients eligible for stroke trials. 
 Assessment and Rehabilitation Centre, Nether Edge Hospital – receives 
approximately 140 referrals for patients with chronic stroke (after discharge 
from the community stroke services) annually who have ongoing 
rehabilitation needs.  
 
 
6.7. Outcome measures 
 
Primary outcomes – Success Criteria 
 
1. Safety of CRIC in patients with stroke will be assessed by review of blood 
counts and ECGs at the end of the RIC treatment intervention, by review of 
the diary of side effects and investigation of any adverse events. Side effect 
diaries will include assessments of acceptability based on Likert scales as well 
as free-text sections.   
i. No serious adverse event (SAE) directly related to CRIC. 
ii. Less than 5 participants experiencing any SAE. 
2. Participant acceptability will be assessed from grade (on a scale of 0-5) of 
discomfort associated with RIC, from review of participants’ diary recordings 
and from the responses given by the participants undertaking the qualitative 
interviews with researchers. 
i. Less than 1/3 of participants reporting moderate or greater 
discomfort. 
3. CRIC compliance will be assessed using the mobile compliance application. 

 
 
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i. More than 80% of intended CRIC cycles completed. 
4. Study feasibility will be assessed by review of patient recruitment, outcome 
measure assessments recorded, and number of follow up assessments 
completed.  
i. Four patients recruited within the first 2 months. 
ii. >80% of outcome measure assessments and follow up 
assessments completed. 
 
 
Secondary outcomes 
 
The following outcome measures will be undertaken at baseline, and after the 6-week 
intervention period: 
 
1. Full blood count, U&Es, LFTs, inflammatory markers (CRP, ESR) 
2. Therapy time (mins). 
3. Physical activity monitoring (ACTiheart, CamnTech). 
4. Global physical activity questionnaire (GPAQ). 
5. Six minute walk test (6MWT). 
6. Peak oxygen consumption (VO2 max, ml/Kg/min). 
7. Multidimensional fatigue inventory (MFI) [Donovan et al 2014]. 
8. Modified Rankin Score (mRS) [Bonita and Beaglehole 1988]. 
9. Barthel index (BI) [Mahoney and Barthel 1965]. 
10. PHQ9 and GAD7 [Martin et al 2006, Ruiz et al 2011]. 
11. MOCA [Nasreddine et al 2005]. 
12. EQ-5D [Van Hout et al 2012]. 
13. Electronic health record abstraction for vascular events and healthcare 
utilisation. 
 
Secondary outcomes for a subset of patients (n=8) 
 
The following outcome measures will be undertaken in the subset of patients who 
consent to having the MRI perfusion and spectroscopy studies as well as the blood 
analysis of biomarkers (4 CRIC and 4 sham): 
 
1. GLP-1, heat shock protein 
2. Micro-RNA analysis for pro-inflammatory and anti-inflammatory mediators 
and gene expression.  
3. Cerebral perfusion (ml/min). 
4. Cerebral metabolites (spectroscopy). 
 
Stoller Biomarker Discovery Centre 
 
Samples taken for biomarker analysis will be stored and sent to the SBDC in two 
batches (at baselines after recruitment of all participants, and after 6 week follow up 
visits are complete). During this time they will be stored at -20 degrees celcius in the 
stroke research freezer, L floor, Royal Hallamshire Hospital. They will be transported 
by recorded courier to Professor Anthony Whetton at the SBDC. A materials transfer 

 
 
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agreement for the transfer of human tissue (plasma) will be in place prior to the study 
start date. 
 
Feasibility to undertake these assessments will be assumed if more than 80% of 
intended assessments are completed. 
 
 
Qualitative Interviews – subset of 6 patients 
 
Qualitative interviews will be undertaken to evaluate the acceptability of CRIC by 
asking participants to describe their expectations and experiences of the treatment. 
They will also investigate facilitators and barriers to use and compliance with the 
treatment interventions. Semi-structured interviews will be undertaken and recorded 
digitally and transcribed verbatim before undergoing thematic analysis [Braun and 
Clarke 2006].  
 
 
 
6.8. Study Protocol  
 
Participants that are eligible and have expressed an interest in participating in the 
study will be contacted by a researcher to arrange a mutually convenient time to meet 
with a clinical researcher. At this initial visit a consent from will be signed and then 
the FFS-7 completed. If the patient scores equal to or greater than 28 (overall score) 
they will be eligible to participate in the study. Following this, the researcher will 
collect baseline sociodemographic and clinical data and perform an ECG and take 
blood tests. Samples of blood will also be stored with patients consent for further 
analyses at a later date. The 6MWT and VO2 max will be undertaken in this initial 
visit. Participants will be randomised in a 1:1 ratio, by an online block allocation 
system (Sealed Envelope Ltd. 2017. Simple randomisation service) to the order in 
which they receive CRIC or sham intervention (approximately 17 participants to each 
arm). Another session within the same week will be scheduled to complete baseline 
assessments (questionnaires, scales, activity measures) and demonstrate use of the 
activity monitors and the intervention/sham procedure. The participants will then start 
the CRIC/sham procedure 3 times weekly for 4 weeks, and will attend the ARC, 
Nether Edge Hospital, or the Clinical Research Facility or the Stroke Unit, RHH, for 
supervision of the intervention and their routine therapy depending on their routine 
clinical schedule and preference. Four participants from each group will be randomly 
selected using the online randomisation software to undergo an MR perfusion of the 
brain and MR spectroscopy of the brain. This will occur at The Royal Hallamshire 
Hospital.  
 
The CRIC/sham stimulus will consist of 4 cycles of 5 minutes of upper or lower 
(depending on tolerability) limb ischaemia followed by 5 minutes of reperfusion. This 
will be delivered using a manual shygnomanometer applied to the upper arm or leg 
and activated to go through 4 cycles (see figure 1). The blood pressure cuff in the 
active treatment arm will inflate to 200 mmHg (arm) and 220 mmHg (leg), while the 
sham arm cuff will inflate to 20mmHg. Participants will also be given a symptom 
diary to record general acceptability, and any untoward or unexpected effects of the 

 
 
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interventions. A clinical researcher will review participants at each visit to find out 
how things are going, review the symptoms diary, as well as the activity monitors.  
 
 
 
 
 
 
 
 
 
 
 
 
 
After 6 weeks, a follow up face-to-face visit will be undertaken to complete follow up 
assessments. These will include all the assessments undertaken in the first week along 
with a review of hospitalisations abstracted from electronic health records. 
Participants will have their ECG and blood tests repeated and once again a blood 
sample will be stored for further analysis at a later date. The 8 participants who 
underwent MRI scanning will have these scans repeated. This will be the end of the 
study intervention. All participants will be invited to participate in semi-structured 
interviews during week 7 until the first six participants agree. This will further 
evaluate the acceptability, and feasibility of the study interventions. At 3, 6 and 12 
months post randomisation a telephone follow up assessment will take place that will 
record mRS, EQ-5D, FFS-7, PHQ-9, GAD, and healthcare utilisation abstracted via 
electronic health records. Participant involvement in the study will then be complete 
(see figure 2). 
 
 
 
6.9. Monitoring outcomes 
 
The ECG, blood tests (FBC, U&E, LFT, Coagulation) will be undertaken at the initial 
visit and reviewed by a stroke physician. Any concerns or significant abnormalities 
will be referred to the principle investigator for appropriate action to ensure the safety 
of the participant. Weekly review of the symptom diaries by the researchers will 
identify adverse and serious adverse events, which will also be referred to the PI for 
review and action. 
 
 
6.10. Safety assessments 
 
Any adverse events will be documented in accordance with National Research Ethics 
Service (NRES) and investigated by the researchers for any relationship to the study 
intervention. These will be reviewed at a weekly research meeting with the research 
clinicians. 
 
 
Figure 1. Chronic remote 
ischaemic conditioning 
(CRIC). 

 
 
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6.11. Withdrawal 
 
Participants will be advised that they can withdraw from the study at any time without 
giving a reason and without this affecting their clinical care. They will be removed 
from the study but with their consent, data already collected will be used to help 
determine feasibility criteria for the study. 
 
 
6.12. Data Collection Tools 
 
All scales and measures used in this study have been validated in prior research in 
stroke patients. A data collection proforma will be used to record age, sex, comorbid 
disease, smoking and alcohol status, medication use, stroke severity (NIHSS), 
location, type (ischaemic or haemorrhagic), and aetiology (TOAST classification), 
mRS, date of onset and treatments initiated. Standardised adverse event case report 
forms will be completed for each participant in accordance with National Research 
Ethics Service (NRES) guidelines. The semi-structured qualitative interviews between 
consenting participants and a study researcher will be recorded using digital recording 
equipment and later transcribed verbatim. The researcher will use a topic guide to 
facilitate the interview. Copies of the assessment measures, data collection proforma 
and interview topic guide are attached as an addendum to this protocol. 
 
 
 
 
 
 
 
 
 
 
Figure 2. Study flow diagram 

 
 
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6.13. Quality Control and assurance 
 

 
 
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The study will be monitored and audited in accordance with Sheffield Teaching 
Hospitals Standard Operating Procedures for monitoring and audit.  
 
 
6.14. Project duration 
 
Participant recruitment is anticipated to run from August 2018 to August 2020. 
Protocol development and submission, and ethical approval application will be 
completed prior to this date. It is anticipated that data analysis, thesis completion, and 
manuscript completion will take another 6 months (see GANTT chart). 
 
 
7. Statistical opinion 
 
As this pilot study is exploratory in nature and undertaken primarily for feasibility, 
only a rudimentary sample size calculation has been performed (see sample size 
section).  The results will be mainly descriptive in nature describing safety, and 
acceptability of CRIC as well as feasibility of undertaking the study schedule, 
according to success criteria described in section 6.7 Outcome measures. 
 
Between group differences in baseline characteristics will be compared using 
parametric (students t-test) and non-parametric (Mann-Whitney U, Chi square) tests 
depending on normality of distribution. With regards to the FFS-7 score (for fatigue), 
within-person differences, adjusted for appropriate baseline characteristics will be 
compared between CRIC and sham arms using ANOVA. Dr Karen Kilner is a 
medical statistician at SHU that has been consulted with regards to the study statistics. 
 
 
8. Project Management 
 
The project team (Dr Ali, Prof Majid, PhD student) will meet twice monthly to 
discuss problems that arise with recruitment and data analysis. The Principal 
Investigator will have overall responsibility for the study and will supervise, monitor 
and review work undertaken, the data collected and analysis performed. 
 

 
 
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Table 1. Study activity schedule. 
 
9. Expertise 
Visit 
Number 
Week 
Assessment 
 
Therapy 
Duration
(hrs) 
1 
1 
 
Screen eligibility. 
 
Consent. 
 
12 lead ECG. 
 
VO2 max. 
 
6MWT. 
 
Blood tests. 
 
MRI – 8 participants 
 
Demographic and clinical 
details. 
 
Outcome 
measure 
assessments. 
 
Delivery and explanation 
of symptom diary. 
 
Nil 
 
 
 
 
2.5 hours 
2 
1 
 
Outcome 
measure 
assessments. 
 
Delivery and explanation 
of symptom diary. 
 
Explanation 
of 
activity 
monitor. 
 
Treatment 
(CRIC/sham). 
 
 
1.5 hours 
(3-19) 
 
1-6 
 
Acceptability of treatment 
(RIC/sham). 
 
Symptom diary review. 
 
Activity monitor review. 
 
Treatment 
(CRIC/sham) 
 
1.5 hour 
20 
6 
 
12 lead ECG. 
 
VO2 max. 
 
6MWT. 
 
Blood tests. 
 
MRI – 8 participants. 
 
Outcome 
measure 
assessments. 
 
Activity monitor review. 
 
Healthcare utilisation. 
 
End of study 
intervention. 
2.5 hours 
21 
7 
 
Qualitative interview 
 
Nil 
0.75 hours 
(11) 
Telephone 
call 
12 
 
mRS. 
 
EQ-5D. 
 
PHQ-9 / GAD. 
 
FFS-7. 
 
Healthcare utilisation 
 
Nil 
 
1 hour 
(12) 
Telephone 
call 
26 
 
mRS. 
 
EQ-5D. 
 
PHQ-9 / GAD. 
 
FFS-7. 
 
Healthcare utilisation 
 
Nil 
 
1 hour 
(13) 
Telephone 
call 
52 
 
mRS. 
 
EQ-5D. 
 
PHQ-9 / GAD. 
 
FFS-7. 
 
Healthcare utilisation 
 
Nil 
1 hour 

 
 
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Dr Ali, Dr Harkness, Professor Majid, and Dr Redgrave are consultant physicians 
working in the field of stroke. Dr Ali has developed the stroke exercise referral 
programme and has worked closely with Sheffield International Venues. Both he and 
Dr Harkness work with stroke patients throughout the stroke pathway and have 
extensive experience in recruiting to commercial and non-commercial stroke research 
trials as well as trials recruiting patients with dementia and those with frailty. Both 
also have experience supervising MSc students. Professor Majid and Dr Redgrave 
have supervised numerous MSc and PhD students in original research projects and 
have also acted as principle investigators in NIHR trials. All clinicians are involved 
with the University of Sheffield medical undergraduate and MSc Neurosciences 
course. All have expertise in undertaking and publishing research in the area of 
stroke. Ms Bethany Moyles is a PhD student who has conducted original stroke 
research under the supervision of Dr Ali for her MSc. This involved recruitment and 
interviewing stroke patients for their experiences of exercise after stroke . She has 
experience in recruiting patients to research trials, as well as coordinating a patient 
and public group for stroke. 
 
The trial steering committee will include Dr Ali, Dr Nair (consultant neurologist), and 
Beth Moyles and a lay member (Mark Stevens). The group will meet twice yearly to 
ensure fidelity of the trial protocol, review recruitment and discuss any difficulties 
that may have arisen. 
 
 
10. Ethical Issues 
 
Safety;  
 
The principal investigators will be responsible for investigating any adverse events in 
accordance with National Research Service guidelines and the study will be halted 
immediately by the sponsor if any concerns arise about the safety of RIC. 
 
There have been over 39 clinical trials of ischaemic conditioning in patients with 
coronary artery disease and athletes [Sharma et al 2015], none of these trials have 
highlighted concerns over serious adverse events with regards to ischaemic 
conditioning. 
 
Confidentiality;  
 
Participant information (socio-demographic, clinical, outcome measure assessment) 
will be recorded on paper clinical research forms that will be furnished with a study 
number rather than the patient identifiers. This will then be transferred to an encrypted 
electronic database stored on a password protected Sheffield Teaching Hospitals 
research laptop, access to which will be restricted to researchers entering data and 
performing statistical analyses. Each study participant will be assigned a unique ID 
number, which will be the only "identifier" linked to data collected. A separate 
enrolment log will be kept updated by the researcher and held within a study file 
separate to the study site file. This will link these numbers to the participant’s 

 
 
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personally identifiable information. In this way, the participants’ data will be "pseudo-
anonymised" and no identifiable information will be kept with the actual study data. 
 
The research laptop, study site file and enrolment log will be stored in a locked office 
at Sheffield Teaching Hospitals, RHH. Participants will undergo baseline and follow 
up data collection at the ARC, Nether Edge Hospital, CRF or SU at the RHH. Rooms 
there are private and data collection will be conducted in a confidential manner. 
 
Six patients will also undergo semi-structured interviews. Interview guides and paper 
notes will also be kept in the study site files in the pseudo-anonymised manner. Audio 
recordings of the interviews will be stored digitally on an SD memory card, which 
will be broken to destroy data once the interviews are transcribed. Interviews will be 
undertaken in clinic rooms at STH that are also private. All interviews will be 
conducted in a confidential manner. The transcribed recordings will be anonymised 
and labelled using the study ID. The files containing the transcriptions of the 
interviews will be stored electronically but accessible only to members of the research 
team on password protected computers. When required, the files will be shared 
between research team members using a password protected flash drive, and copies 
will be deleted from the flash drive when no longer required. A printed copy of each 
transcript will be stored in the Study Site File after the study and the Site File will be 
kept securely on hospital property. 
 
The qualitative report is likely to contain direct quotations from the study participants 
but these will be anonymous and the participant will not be identifiable from the 
quotations used. 
  
Consent; Patients will only be enrolled in the study if they have capacity to 
understand the study information sheet and give informed consent. All members of 
the research team have undergone GCP training, Participants are free to withdraw 
from the study at any time without giving a reason and without it affecting their 
clinical care.  
 
Participants will be free to undergo all other therapeutic activities (e.g. stroke 
rehabilitation, exercise, psychological therapies) during the study period and will be 
asked to record this in their study diaries. 
 
Travel Reimbursement; Participants will be reimbursed expenses of travel to and 
from scheduled study visits.  
 
 
11. Service Users 
 
A patient and public panel was consulted on the 6th September 2016 about practical 
aspects of undertaking the study (e.g. how to approach eligible patients, how long 
after stroke to include patients, the feasibility of undertaking the required outcome 
measure assessments) as well as reviewing the associated documentation (e.g. consent 
forms, participant information sheets, invitation letters etc). The panel, that included 8 
members who had suffered stroke or were the main carers for those with stroke, 
commented positively on the need for such a project and provided numerous 

 
 
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suggestions that ultimately resulted in changes to enhance the success of the study. 
These included: 
 
 Reducing the number of outcome measures undertaken in one sitting. 
Following this suggestion, baseline data collection and assessments were 
divided into 2 sittings. Further, carers / relatives will be able to assist 
participant completion of assessments if significant language impairment 
existed. 
 Production of an aphasia friendly participation information leaflet. 
 Increasing the number of eligible participants to include patients at any time 
after stroke. This was in response to many of the participants reporting 
ongoing feelings of fatigue after 12 months post stroke. 
 Ensuring baseline and follow up assessments are undertaken according to 
when patients are maximally alert, depending on participant preference. Some 
patients are more fatigued in the afternoons / early evenings, however some 
will be more fatigued in the mornings and as such, the option of afternoon 
assessments will be offered. 
 
In addition one of the PPI lay members has agreed to become a member of the 
trial steering committee (Mark Stevens). They will join Dr Ali, Dr Nair and Beth 
Moyles (PhD student) twice yearly to discuss study progress. 
 
 
12. Dissemination 
 
The study will aim to recruit a PhD student (University of Sheffield) to facilitate all 
aspects of the research project from screening through to recruitment, intervention 
delivery, data analysis and thesis write up. The study may take up an MSc 
postgraduate student (e.g. Neurosciences MSc, University of Sheffield) to help with 
data collection or analysis, or a particular aspect of the study during its course. In both 
instances the student/s will submit their dissertations and present their findings to the 
Neurology and Stroke department. The overall findings of the study will also be 
presented locally to the academic directorates of Neurosciences and the Combined 
Community and Acute care group. The research team will also aim to present the 
findings at international scientific meetings and will write up the findings for 
publication in peer-reviewed journals such as Stroke, Clinical Rehabilitation and 
Archives of physical medicine and rehabilitation. The study will also be registered on 
the Sheffield Teaching Hospital NHS Foundation Trust research database, and be 
advertised on the University of Sheffield website under the Biomedical Research 
page. 
 
 
 
 
 
13. Taking the Work Forward 
 

 
 
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With the pilot data generated from this project and the outcome from working with 
patients and public in the development of the proposal, we plan to submit an 
application to fund a trial involving a larger number of participants to evaluate the 
effect of CRIC on fatigue as well as improving physically activity after stroke, with 
sample size calculations for power to detect clinically meaningful improvements in 
outcomes such as fatigue, and peak oxygen consumption (VO2). We intend to apply 
to the NIHR to fund this trial.  
 
We will also look at any effect of CRIC on vascular risk (major cardio and 
cerebrovascular events abstracted from electronic health records) at 3, 6 and 12 month 
follow up to determine whether any signal indicating a secondary protective effect can 
be seen. If this is the case then a separate application for funding to evaluate CRIC in 
secondary vascular risk prevention will be developed.  
 
 
 
14. Intellectual Property 
 
RIC protocols have been used in many studies previously, and the current protocol is 
based on those most commonly used. CRIC has been used in a Chinese stroke 
population [Meng et al 2012]. Discussion with Medipex regarding any IP developed 
with the stroke population are ongoing. 
 
 
15. Costing 
 
 Travel expenses 
 Research assistant time 
 Room hire ARC 
 Recording equipment 
 Physical activity monitors 
 Blood tests 
 ECG analysis 
 Stationary / consumables 
 Statistician time 
 Equipment for VO2 max measurement 
 Qualitative interviewing 
 Online randomisation 
 Lab set up fee 
 Research and development administration 
 Results dissemination 
 
 
16. Funding arrangements 
 
We have been successful in an application for seed funding from the Ryder Briggs 
Trust to help fund this trial (£34,526.24). We have also received a further £9,500 from 
the stroke research fund. This has been met with funding from the Biomedical 

 
 
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Research Centre funding (£40,000) to put towards the PhD stipend and fees. We will 
aim to incorporate 1-2 Neuroscience MSc students over the course of the study that 
will help with extra lab fees.  
 
 
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from: https://www.sealedenvelope.com/simple-randomiser/v1/ [Accessed 13 
Mar 2018]. 
 
 
 
 
 
 
 
 
 
 
 

 
 
Study protocol  V2 09/07/18STH19508 IRAS:245385 
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2017 
2018 
2019 
2020 
2021 
 
Task 
N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J 
F M A M J 
J 
A 
Administration & Data Coordination 
Appoint Study 
Personnel  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Set up 
Administrative 
bases 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ethics/Approval 
Process 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
R&D approvals 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol/document 
refinement 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Site training  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Steering 
Committee 
Meetings 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Recruitment and 
Data Collection 
Recruitment 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Baseline 
assessments  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow-up 
assessments 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Qualitative 
interviews 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Analysis  
Safety and 
Feasibility  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Qualitative 
interviews   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
12 week follow up 
– secondary 
outcomes 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Long term 
outcomes 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Data and 
Project 
Manageme
Implement data 
management 
system / online 
randomisation 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Data Monitoring  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
Study protocol  V2 09/07/18STH19508 IRAS:245385 
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Publication-
Preparation 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dissemination  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Data Archiving  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
GANTT Chart.