Combinational Rehabilitative Therapy and Functional Brain Imaging for Patients Recovering From Motor Stroke
Condition: Ischaemic Stroke
MeSH terms: Stroke; Ischemic Stroke
Study type: Interventional
Phase: Phase 3

Summary: 
      The present proposal aims to assess whether a combined rehabilitation approach using virtual
      reality based therapy with motivational feedback, levodopa for pharmacotherapy and standard
      rehabilitative occupational therapy and physiotherapy will lead to signifcantly better
      outcomes for stroke recovery.

      It is a randomised controlled trial with blinding of the assessors only. It will be preceeded
      by a Phase 1 pilot trial of the VR physiotherapy and standard therapy only. Recruited
      in-patient rehabilitation ward patients who have recently suffered stroke will be randomized,
      through a computer-based random number generator, to either one of two treatment arms:

        1. Control occupational therapy + pharmacotherapy for 2 weeks

        2. Assisted Virtual-Reality physiotherapy + pharmacotherapy for 2 weeks
    

Detailed description: 
      The study is designed as a single-blinded randomized controlled trial, preceeded by a Phase 1
      pilot trial of the VR physiotherapy and standard therapy only.

      Phase 1 will comprise of recruitment of up to 5 patients who have recently suffered a stroke
      who will be informed that they will receive ten 15- 30 minutes of VR therapy in addition to
      their standard stroke therapy. They will not receive any pharmacotherapy during this period.
      At the start and end of the VR phase, clinical assessment (Fugl-Meyer scores, Action Research
      Arm Test) will be made of each patient by a blinded clinician investigator.

      From this data, calibration to the VR program will be made to ensure reproducibility of
      effectiveness of movements assessed.

      Subsequently, for the main phase of the trial, recruited in-patients who have recently
      suffered stroke will be randomized, through a computer-based random number generator, to
      either one of two treatment arms:

        1. Control occupational therapy + pharmacotherapy

        2. Assisted Virtual-Reality physiotherapy + pharmacotherapy

      Each patient will receive an initial functional Magnetic Resonace Imaging (fMRI) scan prior
      to the start of the study. The initial pilot single-centre study will be run in the Singapore
      General Hospital Rehabilitation Ward across a 2-week period, where participants will undergo
      daily 15-30 minute VR based therapy in addition to the physiotherapy/occupational therapy
      session they receive daily.

      The VR therapy session consists of the subject interacting with a computer-based program in
      which they guide an avatar to gather items by using flexion and extension gestures of the
      affected upper limb. VR therapy sessions will last for 15-30 minutes depending on the
      subject's tolerance and participation. For patients who are unable to overcome gravity fully,
      they can still participate in this therapy by resting their arm on a table.

      Patients will receive a single dose of 100mg levodopa in combination with benserazide 2-3
      hours before an additional half an hour of occupational therapy to the weaker arm or VR
      therapy session, depending on the assigned group.

      At the start and end of the trial, clinical assessment (Fugl-Meyer scores, Action Research
      Arm Test and Functional Independence Measure) will be made of each patient by a blinded
      clinician investigator. At the final (10th) session, patients will undergo the final fMRI
      scan. MRI scans will be analysed by blinded assessors.
    

Intervention name(s): Levodopa; Virtual Reality based therapy
Intervention type(s): Drug; Other
Intervention description(s): Levodopa 100mg with benserazide 25mg will be administered 3 hours prior to the start of the daily PT/OT session to maximize its pharmacokinetic window ie. blood plasma levels in the narrow window during which functional rewiring of neural circuits is thought to occur.
Levodopa at the lowest available dose (100mg P.O qd) has been shown to improve motor function of stroke patients and their corresponding quality of life. The treatment proposed can be incorporated into their daily rehabilitation routine. Early intervention (within 7-21 days of the infarct) raises the chance for neuroplasticity and improved recovery of their motor function in the short and long run. Levodopa has been proven to be safe to be used in stroke patients (Lancet. 2001 Sep 8;358(9284):787-90., Arch Phys Med Rehabil. 2008 Sep;89(9):1633-41.), however, the side effects of this medication may include nausea, unusual tiredness, dizziness, excessive watering of mouth.; The VR therapy session consists of the subject interacting with a computer-based program in which they guide an avatar to gather items by using flexion and extension gestures of the affected upper limb. VR therapy sessions will last for 15-30 minutes depending on the subject's tolerance and participation. For patients who are unable to overcome gravity fully, they can still participate in this therapy by resting their arm on a table.
Other intervention name(s): Madopar
Intervention MeSH terms: Levodopa
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: stroke, virtual reality based therapy