Dopaminergic Enhancement of Rehabilitation Therapy Early After Stroke

Study Overview
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Brief Summary
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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
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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.

Official Title
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Dopaminergic Enhancement of Rehabilitation Therapy Early After Stroke

Conditions
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Stroke

Intervention / Treatment
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* Device: Telerehabilitation
* Drug: Sinemet Pill
* Drug: Placebo


Participation Criteria
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Eligibility Criteria
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INCLUSION CRITERIA Age 18 years or older Stroke that has been radiologically verified and has time of onset 30 days or less from the time of randomization ARAT score of <32 (out of 57) at Visit 1 At Visit 1, either BBT score with affected arm is at least 1 block in 60 seconds OR There is a visible flicker in each of the following movements with gravity eliminated: wrist extension and finger flexion At Visit 1, either The range of motion against gravity must be ≥45 degrees in both the paretic shoulder and elbow OR the patient must be able to use at least 3 different telerehab system input devices Informed consent and behavioral contract signed by the subject (i.e., no surrogate consent) EXCLUSION CRITERIA A major, active, coexistent neurological or psychiatric disease (e.g., alcoholism or dementia) Major medical disorder that reduces subject's ability to comply with study procedures Severe depression, defined as CES-D score >24 at screening visit Significant cognitive impairment, defined as presence of either Montreal Cognitive Assessment (MoCA) score <22 OR Trail Making Test: Part A score ≤14 Note that lower scores may be permitted if due to aphasia and if the patient is specifically allowed by Dr. Cramer Deficits in communication that interfere with reasonable study participation Lacking visual acuity, with or without corrective lens, of 20/50 or better in at least one eye Life expectancy <6 months Pregnant 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 Unable to successfully perform all 3 rehabilitation exercise test examples Unable or unwilling to perform study procedures/therapy or attend study visits, or expectation of noncompliance with study procedures/therapy Non-English or non-Spanish speaking, such that subject does not speak either language sufficiently to comply with study procedures Isolation due to active COVID-19 Any contraindication to L-Dopa: 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 Known hypersensitivity to any component of Sinemet Narrow-angle glaucoma; if wide-angle glaucoma is present, the patient can only be enrolled with explicit written approval from their ophthalmologist History of melanoma or suspected melanoma Patient is currently taking phenytoin, papaverine, isoniazid, or a dopamine D2 receptor antagonist (such as a phenothiazine, butyrophenone, or risperidone) Currently taking a direct dopaminergic agonist 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

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Patients are randomized to TR + placebo, TR + Sinemet, or usual care
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Telerehabilitation + Sinemet<br>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. Sinemet is taken one hour before starting TR, for the first 18 sessions. | Device: Telerehabilitation<br>* 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.<br>Drug: Sinemet Pill<br>* Sinemet 25/100 will be taken 1 hour prior to TR, for the first 18 sessions.<br>|
| Placebo Comparator: Telerehabilitation + Placebo<br>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. Placebo is taken one hour before starting TR, for the first 18 sessions. | Device: Telerehabilitation<br>* 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.<br>Drug: Placebo<br>* Placebo will be taken 1 hour prior to TR, for the first 18 sessions.<br>|
| No Intervention: Usual care<br>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. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 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 | Measured at baseline and 3 months later | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Arm Motor Fugl-Meyer Scale from baseline to 3 months | Measure arm motor impairment using a scale that runs from 0 to 66 points | Measured at baseline and 3 months later | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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stroke, rehabilitation, telehealth, dopamine