The enhancing spontaneous recovery after stroke study (ESPRESSo): A randomised controlled trial

ESPRESSo is a Phase IIa biomarker-guided stroke rehabilitation trial that aimed to determine if a 3-week programme of high-dose, high-intensity (HDHI) video game-based neuroanimation therapy (NAT) could improve upper limb recovery and outcomes early after stroke. Sixty-four participants were randomised into NAT (n=31) or conventional therapy (CoT) groups (n=33) and began intervention within two weeks of stroke. Participants were given 90 minutes of therapist time per weekday for three weeks to undertake intensive upper limb therapy over and above their usual customary care. Outcomes were obtained immediately post-intervention, three and six months post-stroke. The primary endpoint was upper limb capacity at three months on the Action Research Arm Test (ARAT) score. Secondary outcomes were Fugl-Meyer assessment (FM-UE), hand dexterity, reaching kinematics and transcranial magnetic stimulation-derived measures across post-intervention time points. Data from all participants were analysed for intention to treat, while fifty-four met the weekly target of active therapy minutes, permitting inclusion in a per protocol analysis. The average weekly time on task increased over the intervention period, with progressively greater distances of arm movements (NAT) or task repetitions (CoT) made each week. Still, during the final week of intervention, participants analysed per protocol spent an average of only 50 (NAT) - 66% (CoT) of the extra time available on task. For the intention-to-treat analysis, there was no effect of group at the primary endpoint. For the per protocol analysis, there was no effect of group or group by time interaction for any secondary outcome measure. An expected effect of time was observed indicative of recovery from impairment (mean ΔFM at 6 months = 23 points), increased activity capacity (mean ΔARAT at 6 months = 31 points) and improved secondary neuroscientific measures. Per protocol participants from both groups were compared to an historical cohort matched for baseline age, stroke severity and impairment who only received usual customary care. Despite three-fold difference in active upper limb therapy minutes there were no differences in the three-month ARAT or ΔFM. Indeed, the recovery in FM-UE at 3 months was proportional to baseline impairment, suggesting that the gains could be entirely attributable to spontaneous biological recovery alone. While patient-related factors limited the dose of therapy achievable in this trial, clinician and service-related factors would also need to be overcome in routine clinical practice, to deliver equivalent doses at this early phase. It may be necessary to forego HDHI therapy approaches until the late sub-acute phase.