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Impact Of Physiotherapy And Botox In Improving Functional Outcomes Among Post Stroke Focal Dystonia Patients

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. Identifier: NCT03664375
Recruitment Status : Completed
First Posted : September 10, 2018
Last Update Posted : September 10, 2018
Information provided by (Responsible Party):
Muhammad Umar, Isra University

Brief Summary:
This study was conducted to assess the combine role of Physiotherapy by providing task specific trainings and Botulinum Toxin Type A in improving the functional outcomes of upper limb in post stroke patients with focal hand dystonia.

Condition or disease Intervention/treatment Phase
Focal Hand Dystonia Other: Botulinum toxin type A Other: Task Specific Training Not Applicable

Detailed Description:
Post-stroke hemiparesis, with dystonia, is a major cause of disability. Dystonia can hinder the functional activities making patient dependent on others for performance of daily living activities. Dystonia not only limits the physical activity of the patient but also affects their quality of life significantly. Various treatment protocols have been used in the literature for treatment of focal hand dystonia in the past including deep brain stimulation, kinesio taping, sensory oriented training, splinting, extracorporeal shock wave therapy and botox. Out of these Botox has gained much importance but it results only in improving the passive range of motion and has no consensus in improving the active range of motion and functional independence of the patient. The current study was planned to determine the effects of botulinum toxin type A combined with task-specific therapy, for post-stroke focal dystonia of upper limb.

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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 39 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Intervention Model Description: A total of 46 patients were recruited in the study using non-probability purposive sampling and were divided randomly into two equal groups; control and experimental group, by sealed envelope method. The experimental group received botulinum toxin A followed by task specific training, while the control group received only task-specific training for 12 weeks. Data was collected at baseline, after 4 weeks, 8 weeks and 12 weeks by using upper extremity items of Motor Assessment Scale and Fugl Meyer Assessment scale of upper limb, Stroke specific quality of Life, Arm dystonia Disability scale and WOLF Motor function test.
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Impact Of Physiotherapy And Botulinum Toxin Type-A In Improving Functional Outcomes In Upper Limb Focal Dystonia Among Post Stroke Patients
Actual Study Start Date : November 2015
Actual Primary Completion Date : August 2016
Actual Study Completion Date : December 2016

Arm Intervention/treatment
Experimental: Experimental Group
The experimental group received botulinum toxin type A. After one week of Botox administration, a specially made task specific training program was started for these patients. It was provided for a duration of one hour and for three times per week for a total of 12 weeks by a trained physiotherapist.
Other: Botulinum toxin type A
All patients in the experimental group received a BoNT-A injection. The injected total dose for individual patient in the experimental group was 100 units which is equivalent to approximately 300-500 Units of Dysport (the other type of BoNT-A available). The Botox was injected by the neurophysician intramuscularly using insulin U100 syringe and determination of muscles for injection was assessed clinically.

Other: Task Specific Training
Task specific training is the repetition of a specific task until expertise is reached. More challenging tasks are added as a means of progression

Placebo Comparator: Control Group
The control group received only task specific training program with the same protocol as for the experimental group; for a duration of one hour and for three times per week up to a total of 12 weeks by a trained physiotherapist
Other: Task Specific Training
Task specific training is the repetition of a specific task until expertise is reached. More challenging tasks are added as a means of progression

Primary Outcome Measures :
  1. Action Research Arm Test (ARAT): [ Time Frame: 12 weeks ]
    It assessed specific changes in limb function by 19 items grouped in four subscales. The total score ranged from 0 to 57. The lower score indicated no movement and upper score indicated normal performance of the patient.

  2. MOTOR ASSESSMENT SCALE (MAS) [ Time Frame: 12 weeks ]
    It was a performance-based scale, based on a task-oriented approach to evaluate and assesses performance of functional tasks rather than isolated patterns of movement. All items were assessed using a 7-point scale from 0 - 6. A score of 6 indicated optimal motor behavior.

  3. WOLF MOTOR FUNCTION TEST (WMFT) [ Time Frame: 12 weeks ]
    It quantified motor ability through timed functional tasks. It used a 6-point ordinal scale with "0" = "does not attempt with the involved arm" to "5" = movement appears to be normal."

  4. FUGL- MEYER ASSESSMENT TEST [ Time Frame: 12 weeks ]
    It was a performance-based impairment index to measure motor functioning. The total score possible was from 0 - 66, with higher function showing the improved level of independence

Secondary Outcome Measures :
  1. Severity Of Dystonia [ Time Frame: 12 weeks ]
    The Arm Dystonia Disability Scale: The severity of dystonia was assessed using 0 (None) to 3 (Marked Difficulty in performing activity

  2. Stroke Specific Quality Of Life [ Time Frame: 12 weeks ]
    The stroke specific Quality Of Life was administered to patients which rated their Quality of life

Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years to 65 Years   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • Patients having first episode of unilateral stroke
  • At least 6 months of post stroke duration presenting with post stroke focal dystonia of the upper limb.
  • No previous exposure of the affected hand of Botox.
  • Reduced upper limb functions
  • Both genders will be included equally.

Exclusion Criteria:

  • Significant speech or cognitive impairment which impedes the ability to perform the assessment.
  • Other significant upper limb impairment e.g. fracture or frozen shoulder within 6 months.
  • Severe arthritis, amputation, evidence of fixed contracture, pregnancy or lactating womens.
  • Other diagnosis likely to interfere with rehabilitation or outcome assessments, e.g. blind, malignancy,
  • Other conditions which may contribute to upper limb spasticity, e.g. multiple sclerosis, cerebral palsy.
  • Use of botulinum toxin to the upper limb in the previous 4 months.
  • Contraindications to intramuscular injection.
  • Contraindications /allergy to botulinum toxin type A, which include bleeding disorders, myasthenia gravis and concurrent use of aminoglycosides.

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Responsible Party: Muhammad Umar, Principal Investigator, Isra University Identifier: NCT03664375     History of Changes
Other Study ID Numbers: IIRS-IUISB/PHD/008
First Posted: September 10, 2018    Key Record Dates
Last Update Posted: September 10, 2018
Last Verified: September 2018
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Yes
Supporting Materials: Study Protocol
Statistical Analysis Plan (SAP)
Informed Consent Form (ICF)
Clinical Study Report (CSR)

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No

Keywords provided by Muhammad Umar, Isra University:
Dystonia Task-specific training Botulinum toxin type A

Additional relevant MeSH terms:
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Dystonic Disorders
Neurologic Manifestations
Nervous System Diseases
Signs and Symptoms
Movement Disorders
Central Nervous System Diseases
Botulinum Toxins
Botulinum Toxins, Type A
Acetylcholine Release Inhibitors
Membrane Transport Modulators
Molecular Mechanisms of Pharmacological Action
Cholinergic Agents
Neurotransmitter Agents
Physiological Effects of Drugs
Neuromuscular Agents
Peripheral Nervous System Agents