Exercise For Sub-acute Stroke Patients in Jamaica (JAMMS)

This study is currently recruiting participants. (see Contacts and Locations)
Verified August 2013 by Baltimore VA Medical Center
Sponsor:
Collaborator:
Information provided by (Responsible Party):
Rich Macko, Baltimore VA Medical Center
ClinicalTrials.gov Identifier:
NCT01392391
First received: July 11, 2011
Last updated: August 22, 2013
Last verified: August 2013
  Purpose

Chronic hemiparetic stroke is associated changes in body composition, skeletal muscle and cardiometabolic health; specific changes include paretic limb muscular atrophy, increased intramuscular fat deposition, elevated prevalence of impaired glucose tolerance and type 2 diabetes. This randomized intervention study compares a 6 month task oriented exercise programs versus control with both groups receiving best medical stroke care according to American Stroke Association "Get with the Guidelines". The hypothesis is that is 6 months of task-oriented exercise initiated early across the sub-acute period of stroke can prevent or ameliorate the natural course of these body composition, skeletal muscle and cardiometabolic health changes.


Condition Intervention Phase
Stroke
Procedure: Task Oriented Exercise Training
Procedure: Stroke Care "Get with the Guidelines"
Phase 2

Study Type: Interventional
Study Design: Allocation: Randomized
Endpoint Classification: Safety/Efficacy Study
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Treatment
Official Title: Jamaica and Maryland Mobility in Stroke

Resource links provided by NLM:


Further study details as provided by Baltimore VA Medical Center:

Primary Outcome Measures:
  • Thigh and Abdominal muscle and fat [ Time Frame: Baseline and 6 months ] [ Designated as safety issue: No ]
    CT scans to determine 1) mid-thigh cross sectional area for muscle area, intramuscular and subcutaneous fat area, and quality of lean tissue mass, 2) abdominal fat area.

  • Whole body protein and skeletal muscle synthesis and breakdown [ Time Frame: Baseline and 6 months ] [ Designated as safety issue: No ]
    Serial blood sampling and pre-/post-muscle biopsies in the fasted and fed state

  • Muscle myosin heavy chain isoform (MHC) proportions [ Time Frame: Baseline and 6 months ] [ Designated as safety issue: No ]
    Analysis of muscle biopsies for MHC fiber type proportions

  • Leg Strength [ Time Frame: Baseline and 6 months ] [ Designated as safety issue: No ]
    1 repetitive maximum strength for leg extension, quadriceps and hamstring muscles

  • Fitness [ Time Frame: Baseline and 6 months ] [ Designated as safety issue: No ]
    VO2 peak testing with open circuit spirometry

  • Glucose tolerance [ Time Frame: Baseline and 6 months ] [ Designated as safety issue: No ]
    2 hour oral glucose tolerance test with serial blood sampling every 30 minutes for glucose and insulin


Secondary Outcome Measures:
  • Muscle TNF alpha [ Time Frame: Baseline and 6 months ] [ Designated as safety issue: No ]
    Analysis of muscle biopsy samples for TNF levels

  • Mobility and balance [ Time Frame: Baseline and 6 months ] [ Designated as safety issue: No ]
    Stroke deficit profile will be indexed by NIH Stroke Scale, modified Ashworth, timed walks, Short Physical Performance Battery, Berg Balance.


Estimated Enrollment: 150
Study Start Date: July 2011
Estimated Study Completion Date: April 2016
Estimated Primary Completion Date: April 2016 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: Exercise
Task-oriented exercise training (aerobic, strength, and balance exercises)
Procedure: Task Oriented Exercise Training

Treadmill training with safety harnesses begin at 6 to 15 minutes total duration at 40-50% maximal heart rate reserve 3 times per week, increasing to 60-70% maximal heart rate reserve for 30 minutes for 6 months.

Group dynamic balance exercise immediately follow the treadmill training 3 times a week. Participants also receive Best Stroke Care according to "Get with the Guidelines"

Active Comparator: Stroke Care
Best Medical Care in Jamaica adapted from the American Stroke Association "Get with the Guidelines".
Procedure: Stroke Care "Get with the Guidelines"
Post-stroke care is applied according to the recommendations of the American Stroke Association "Get with the Guidelines" adapted for Jamaica

Detailed Description:

Stroke leads to profound cardiovascular deconditioning and secondary abnormalities in paretic skeletal muscle that worsen cardiovascular health. Conventional rehabilitation focuses on restoration of daily function, without an adequate exercise stimulus to address deconditioning or the muscle abnormalities that may propagate insulin resistance (IR) to worsen risk for type 2 diabetes mellitus (T2DM) and recurrent stroke. By the time individuals reach chronic stroke (>6 months), we report hemiparetic body composition abnormalities including paretic leg muscular atrophy, increased intramuscular area fat, and a major shift to fast myosin heavy chain (MHC). All of these factors promote IR, which has been linked to reduced muscle protein synthesis in aging that may be reversible with exercise. We also find elevated tumor necrosis factor alpha (TNFα) in paretic leg muscle, suggesting that inflammation may affect protein synthesis and breakdown, similar to sarcopenia in aging. Yet, no prior studies have considered stroke as a catabolic syndrome modifiable by early exercise to improve muscle and cardiometabolic health.

Aim #1. Paretic (P) and non-paretic (NP) leg mixed muscle protein synthesis and breakdown in the fed and fasted state, TNFα expression, thigh muscle volume and strength.

Hypothesis 1: Paretic leg has reduced muscle protein synthesis and increased breakdown compared to non-paretic leg; TEXT will increase mixed muscle protein synthesis and reduce breakdown to increase muscle volume and strength by the mechanism(s) of reducing inflammation in the paretic leg, compared to controls.

Aim # 2. Glucose tolerance, fitness, and muscle phenotype. Hypothesis 2: TEXT will improve fitness levels, insulin and glucose response to oral glucose challenge, and increase paretic leg slow twitch (slow MHC) muscle molecular phenotype.

This randomized study investigates the hypothesis that in African-Jamaican adults with recent hemiparetic stroke, 6 months of TEXT across the sub-acute and into the chronic phase of stroke will improve paretic leg muscle and cardiometabolic health, compared to controls receiving best medical care.

Phase 1 consists of recruitment and screening of individuals with mild to moderate hemiparetic stroke from UWI Accident and Emergency Room and Neurology Stroke Clinics. Phase 2: Subjects with hemiparetic gait ≤ 8 weeks post-stroke who are not wheelchair bound or bed are approached for informed consent, medical, neurologic, blood tests, and treadmill (TM) exercise tests to determine study eligibility. Phase 3 baseline testing includes measures of fitness, oral glucose tolerance test (OGTT), body composition, bilateral vastus lateralis muscle biopsies, stable isotope measures of protein synthesis and breakdown. Phase 4: Eligible subjects are randomized to 6 months 3x/week TEXT or control group with best medical care alone that includes American Stroke Association (ASA) physical activity guideline recommendations for walking 4x/week. Randomization is stratified based on glucose tolerance (normal vs. abnormal) and gait deficit severity. Subjects have limited 3 month testing of fitness levels (VO2 peak), body composition, fasting glucose and insulin levels to document the natural history (controls) and temporal profile of exercise-mediated adaptations (TEXT) as they transition from the sub-acute into chronic phase of stroke. Phase 5 is 6-month post-intervention testing.

  Eligibility

Ages Eligible for Study:   18 Years to 85 Years
Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Ischemic stroke within 8 weeks
  • BMI of 18-40 kg/m2
  • Able to walk 3 minutes with handrails, assistive device, or standby aid

Exclusion Criteria:

  • Actively exercising for >30 minutes per day for 5 days per week
  • Increased alcohol consumption (> 2 oz. liquor, 8 oz. wine, 24 oz. beer per day)
  • Active abuse of other illegal and illicit drugs
  • Cardiac History of: a) unstable angina, b) recent (<3 months) myocardial infarction, congestive heart failure (NYHA category II-IV), c) hemodynamically significant valvular dysfunction
  • Medical History: a) peripheral arterial disease with vascular claudication making exercise challenging, b) orthopedic or chronic pain condition(s) restricting exercise, c) pulmonary or renal failure, d) active cancer, e) untreated poorly controlled hypertension measured on at least 2 occasions (greater than 160/100), f) HIV-AIDS or other known inflammatory responses, g) sickle cell anemia, h) medications: heparin, warfarin, lovenox, or oral steroids, j) currently pregnant
  • Endocrine History: a) type 1 diabetes or insulin dependent type 2 diabetes, b) poorly controlled type 2 diabetes (HbA1C > 10)
  • Neurological History: a) dementia (Mini-Mental Status score < 23 or < 17 if education level at or below 8th grade) and clinical confirmation by clinical evaluation, b) severe receptive or global aphasia that confounds testing and/or training, operationally defined as unable to follow 2 point commands, c) hemiparetic gait from a prior stroke preceding the index stroke defining eligibility (more than one stroke), d) neurologic disorder restricting exercise such as Parkinsons or myopathy, e) untreated major depression (CESD > 16 or clinical confirmation), f) muscular disorder (s) restricting exercise
  • Muscle biopsy exclusion criteria: a) anti-coagulation therapy with heparin, warfarin, or lovenox (anit-platelet therapy is permitted), b)bleeding disorder
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT01392391

Contacts
Contact: Richard F Macko, MD 410-605-7063 rmacko@grecc.umaryland.edu
Contact: Terrence Forrester, MD 876-702-4687 terrence.forrester@uwimona.edu.jm

Locations
United States, Maryland
University of Maryland Active, not recruiting
Baltimore, Maryland, United States, 21201
Jamaica
University of West Indies Recruiting
Kingston, Mona 7, Jamaica
Contact: Terrence Forrester, MD    876-7024687    terrence.forrester@uwimona.edu.jm   
Contact: Sandra Boynes    876-927-1884    sandra.boyne@uwimona.edu.jm   
Principal Investigator: Terrence Forrester, MD         
Sub-Investigator: Sandra Boynes         
Sponsors and Collaborators
Baltimore VA Medical Center
Investigators
Principal Investigator: Richard F Macko, MD University of Maryland
Principal Investigator: Terrence Forrester, MD University of West Indies
  More Information

Additional Information:
Publications:
Responsible Party: Rich Macko, MD, Baltimore VA Medical Center
ClinicalTrials.gov Identifier: NCT01392391     History of Changes
Other Study ID Numbers: HP-00048469, R01HD068712
Study First Received: July 11, 2011
Last Updated: August 22, 2013
Health Authority: United States: Federal Government
Jamaica: Ministry of Health

Keywords provided by Baltimore VA Medical Center:
Stroke
Exercise
Protein synthesis
Protein breakdown
Muscle atrophy
Muscle phenotype
Inflammation
Insulin resistance
Fitness

Additional relevant MeSH terms:
Stroke
Cerebral Infarction
Cerebrovascular Disorders
Brain Diseases
Central Nervous System Diseases
Nervous System Diseases
Vascular Diseases
Cardiovascular Diseases
Brain Infarction
Brain Ischemia

ClinicalTrials.gov processed this record on August 18, 2014