- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT01751854
Enhanced Motor Recovery Using Serotonergic Agents in Stroke
The information derived from this study will be critical to establishing appropriate rehabilitative interventions post-stroke. In particular, traditional use of pharmacological agents to alter motor function post-stroke is directed primarily at reducing the "positive" signs following upper motor neuron lesion, in particular spasticity, or enhanced, velocity-dependent stretch reflex responses to imposed stretch. While pharmacological management of spasticity certainly suppresses clinical and quantitative measures of hypertonia, there is little improvement in functional performance. In contrast, preliminary data on the administration of 5HT agents following neurological injury indicates an increase in motor performance (Pariente 2001) and recovery (Dam 1996), despite an increase in spastic motor activity (Stolp-Smith 1999; see Preliminary Data below). Understanding methods to maximize function following stroke despite potential, short-term increases in spastic motor activity may improve therapeutic intervention strategies. The general objective of this study is therefore to:
- quantify the effects of short-term SSRI administration on voluntary and spastic motor behaviors in individuals with chronic spastic hemiparesis,
- identify the changes in impairments and functional recovery of walking ability during BWSTT with the presence or absence of SSRIs.
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Walking ability post-stroke is characterized primarily by reduced walking speed and endurance and impaired postural stability which limits functional and societal reintegration. Decreased over ground walking speed is a result of decreased cadence, decreased stride length and increased non-paretic single limb stance duration. Mechanisms underlying reduced velocity are thought to include weakness in the paretic limb, particular hip flexor and plantarflexor strength, but may also be linked spastic motor behaviors and loss of inter- and intra-limb coordination. Rehabilitation efforts to improve strength and muscle coordination patterns during hemiparetic gait may improve gait quality and velocity and therefore improve performance of activities of daily living.
To improve gait performance and functional outcomes following neurological injury, rehabilitation efforts have focused on re-establishing normal walking patterns . Towards this end, the use of body-weight supported treadmill training (BWSTT) has demonstrated significant improvement in walking capability in individuals post-stroke and spinal cord injury . By supporting a portion of a subject's body weight over a treadmill and providing manual facilitation from therapists, previous research has demonstrated improvements in temporal-spatial gait patterns, including gait velocity , endurance (Macko 2005), balance , and symmetry. Importantly, the changes in impairments and functional limitations observed with intensive BWSTT are often greater than that achieved during conventional or lower intensity physical therapy. Given these benefits, particularly in those who require substantial walking assistance following stroke various robotic locomotor retraining devices have been developed to facilitate practice of "kinematically correct" stepping patterns to improve the consistency and duration of treadmill training.
While the changes observed following BWSTT are statistically and functionally significant, it remains unclear is the benefits of such intensive training paradigms are optimized. Specifically, across many larger studies in subjects with chronic stroke (i.e., those > 6 mo. post-injury), mean increases in walking speed range between 0.09 m/s to 0.15 m/s following 1-6 mos. of training. Even in current trials investigating changes in over ground walking speed in robotic- vs. therapist-assisted BWSTT, mean improvements over at least 18 subjects in each group vary from 0.07 to 0.13 m/s, respectively (please see Preliminary work: Pilot Study 1). While again statistically significant, such changes represent an approximate 10% improvement in gait speed as compared to healthy adults (Perry 1992).
To enhance the benefits of intensive BWSTT, many investigators continue to search for combined interventions to augment recovery. One potential adjunct that has received attention is the use of pharmacological agents. For example, anti-spastic medications (e.g., benzodiazepine, baclofen, tizanidine) have been used for decades (to reduce the presence or severity of involuntary, spastic reflexes in patients with stroke. Spasticity has traditionally been thought to be a primary limitation to functional mobility post-stroke, although this premise has been questioned recently . Indeed, many pharmacological agents are effective in reducing spastic motor behaviors although evidence for improvements in function following use of these agents post-stroke is limited. In addition, some evidence suggests that these agents reduce maximal voluntary strength and can impair learning of motor tasks.
New evidence has emerged of a potentially powerful role of excitatory or facilitative modulatory agents in the treatment of motor impairments post-stroke. Based primarily on evidence from experimentally induced lesions in mammals, the application of monoaminergic (i.e., serotonin [5HT] and norepinephrine [NE]) agents excite vs. depress spinal or cortical excitability have gained momentum. In individuals post-stroke, for example, the use of amphetamines (directed primarily through NE pathways) had generated substantial interest as an adjunct to physical therapy interventions, although recent data may suggest no benefit from this agent. Further, the use of amphetamines may enhance the risk of cerebral or coronary vascular disease, which is already compromised in this patient population, and therefore limit the use of these agents in clinical practice.
In contrast, 5HT agents have also been shown to enhance spinal and/or cortical excitability, and may accelerate locomotor recovery following neurological injury when appropriate physical interventions are provided . In humans post-stroke, one study has demonstrated enhanced motor performance and cortical activity following a single dose of SSRIs. In another study of sub-acute stroke, SSRIs and not selective NE reuptake inhibitors improved function during inpatient rehabilitation. Interestingly, a small case report indicates a strong increase in spasticity following use of 5HTergic anti-depressive agents, indicating that both spinal and cortical excitability may contribute to altered motor function. Such findings have been replicated here (please see Preliminary work: Pilot Study I, although certainly require further assessment.
While the above findings are preliminary, two important questions arise. First, if both spastic and voluntary lower extremity activity are simultaneously altered following administration of commonly used anti-depressive medications, how does the relation between these variable alter motor function? Echoing tothers, how important is the prevalence of spasticity to impaired motor function post-stroke? Secondly, can the increased excitability of both spinal and cortical systems following SSRI accelerate motor recovery and the effectiveness of intensive physical rehabilitation strategies, as shown in reduced preparations? Such data are important for health care professionals treating individuals with neurological injury to: A) understand the previously unknown modulation in reflex or voluntary function following a seemingly innocuous agent; and, to B) provide the optimal neural excitability to accelerate motor performance and recovery post-injury.
Study Type
Enrollment (Actual)
Phase
- Phase 1
Contacts and Locations
Study Locations
-
-
Illinois
-
Chicago, Illinois, United States, 60611
- Rehabilitation Institute of Chicago
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- unilateral supratentorial stroke
- MMSE > 22
- > 6 months stroke duration
- < 0.9 m/s gait speed overground
Exclusion Criteria:
- lower extremity contracture
- osteoporosis
- Cardiovascular/metabolic/respiratory instability
- previous central/peripheral nerve injury
- concurrent medications interacting with SSRIs
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Crossover Assignment
- Masking: Quadruple
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: SSRI
SSRI alone or with training
|
SSRI alone or with training
Other Names:
|
Placebo Comparator: Placebo
Placebo alone or with training
|
Placebo alone or with training
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Time Frame |
---|---|
Peak treadmill speed
Time Frame: 4 weeks
|
4 weeks
|
Secondary Outcome Measures
Outcome Measure |
Time Frame |
---|---|
overground walking speed
Time Frame: 4 weeks
|
4 weeks
|
Other Outcome Measures
Outcome Measure |
Time Frame |
---|---|
gait kinematics
Time Frame: 4 weeks
|
4 weeks
|
EMG activity
Time Frame: 4 weeks
|
4 weeks
|
Collaborators and Investigators
Sponsor
Investigators
- Principal Investigator: Thomas G Hornby, Shirley Ryan AbilityLab
Publications and helpful links
Study record dates
Study Major Dates
Study Start
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Estimate)
Study Record Updates
Last Update Posted (Estimate)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Keywords
Additional Relevant MeSH Terms
- Cardiovascular Diseases
- Vascular Diseases
- Cerebrovascular Disorders
- Brain Diseases
- Central Nervous System Diseases
- Nervous System Diseases
- Stroke
- Physiological Effects of Drugs
- Neurotransmitter Agents
- Molecular Mechanisms of Pharmacological Action
- Psychotropic Drugs
- Serotonin Uptake Inhibitors
- Neurotransmitter Uptake Inhibitors
- Membrane Transport Modulators
- Serotonin Agents
- Antidepressive Agents
- Antidepressive Agents, Second-Generation
- Citalopram
Other Study ID Numbers
- STU00014257
- 1250--018 (Other Grant/Funding Number: NIDRR/FIP - H133G060124)
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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