Stroke
Conditions
Keywords
stroke rehabilitation, spasticity, Botulinum toxin type A injection, robot-assisted therapy, mirror therapy, randomized controlled trial
Brief summary
The aim of this study will be to determine and compare the immediate and longer-term effects of combination of BoNT-A injection and mirror therapy vs combination of BoNT-A injection and robot-assisted therapy.
Detailed description
The purpose of this project is to examine and compare the immediate and long-term effects of combined Botulinum toxin type A injection with mirror therapy (MT) and with bilateral robot-assisted (RT) in patients with spastic hemiplegic stroke. Spasticity, a common impairment after stroke, has a profound impact on activity and participation for patients. BoNT-A injection combined with rehabilitation training is recommended to enhance functional recovery for stroke patients with spasticity. Although the positive combination effects of BoNT-A with stretch, RT, and constraint-induced movement therapy were reported, the quality of the evidence was weak due to methodology limitations. In addition, patients with spasticity usually have lower motor function and worse sensory deficits than patients without spasticity. Designing the post BoNT-A injection rehabilitation program should consider the above issues. RT and MT are two interventions providing sensorimotor input for patient with low level of motor function. It is unknown whether combining BoNT-A injection with RT or with MT have positive effects and engenders differential effects on motor and related functional performance. At least 60 participants with chronic spastic hemiplegic stroke will be recruited and randomly assigned to one of 3 groups: BoNT-A injection with RT, BoNT-A injection with MT, and BoNT-A injection with control intervention (CI). All the post-injection interventions will be implemented 60 minutes/day, 3 days/week, for 8 weeks. The RT group will receive 30-minute RT, followed by 30-minute functional training. The MT group will receive 30-minute MT, followed by 30-minute functional training. The CI group will receive 60-minute rehabilitation program, such as bilateral arm training and functional task practice. Body function and structures outcome measures include Fugl-Meyer Assessment, Modified Ashworth Scale, Medical Research Council scale, myometer (Myoton-3), actigraph, and Pittsburgh Sleep Quality Index. Activity and participation measures include Wolf Motor Function Test, Ten meter walk test, Motor Activity Log, Nottingham Extended Activities of Daily Living Scale, and Canadian Occupational Performance Measure. In addition, to directly reflect a patient's unique needs and goals, Goal Attainment Scaling will be assessed. Evaluators will be blind to group allocation. The outcome will be measured at pre-treatment, post-treatment, and 3-month follow-up. This comparative efficacy study will be the first to examine and compare the immediate and long-term combination effects of BoNT injection with RT, MT, or CI. The follow-up assessments will provide the long-term effects of different treatments on health-related outcomes, which are crucial for community reentry. In addition, the results of objective assessments and patient-reported outcomes may lead to individualized upper limb training following BoNT-A injection for patients with spastic hemiplegic stroke.
Interventions
DRUGBotulinum Toxin Type A
To inject Botulinum toxin type A on the spasticity upper extremity for stroke patients.Doses and muscles selected for BoNT-A injection are individualized on the basis of a number of factors, including the spasticity patterns, severity of spasticity, and treatment goals
After injecting Botulinum toxin type A on the spasticity upper extremity, the RT group will receive a 45 minutes of robotic training and 30 minutes of training in functional training.
OTHERMirror therapy
After injecting Botulinum toxin type A on the spasticity upper extremity, the MT group will receive a 45-minute MT per session followed by 30 minutes of task-oriented functional training.
OTHERControl intervention
After injecting Botulinum toxin type A on the spasticity upper extremity, the CI group will receive 75-minute rehabilitation program, focusing on upper extremity training and including neurodevelopmental techniques, trunk-arm control, weight bearing by the affected arm, fine motor tasks practice, functional task practice, and practice on compensatory strategies for daily activities.
Sponsors
Chang Gung Memorial Hospital
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Willing to provide written informed consent * Clinical and imagine diagnosis of a first or recurrent unilateral stroke ≥ 3 months * Upper limb spasticity (Modified Ashworth scale of ≥ 2) * Moderate to severe movement impairment of U/E (FMA score ranging from 18 to 56) * No serious cognitive impairment (i.e., Mini Mental State Exam score \> 18) * Age ≥ 18 years
Exclusion criteria
* Pregnant * Bilateral hemispheric or cerebellar lesions * Significant visual field deficits or hemineglect * Contraindication for BoNT-A injection
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Motor function assessed on Fugl-Meyer Assessment (FMA) | Change from baseline at 5 months | The outcome will be measured at 3 time points: 0 week, 8 weeks, and 5 months after recruitment. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Muscle tone assessed on Modified Ashworth Scale (MAS) | Change from baseline at 5 months | The outcome will be measured at 3 time points: 0 week, 8 weeks, and 5 months after recruitment. |
| The functional state assessed on Myometer Assessment | Change from baseline at 5 months | The outcome will be measured at 4 time points: 0 week, 1 week, 8 weeks, and 5 months after recruitment. |
| The amount of movement assessed on Actigraph Assessment | Change from baseline at 2 months | The outcome will be measured at 2 time points: 0 week, and 8 weeks after recruitment. |
| The quality of sleep assessed on Pittsburgh Sleep Quality Index (PSQI) | Change from baseline at 5 months | The outcome will be measured at 3 time points: 0 week, 8 weeks, and 5 months after recruitment. |
| Walking speed assessed on Ten Meter Walk Test (10MWT) | Change from baseline at 2 months | The outcome will be measured at 2 time points: 0 week, and 8 weeks after recruitment. |
| The upper extremity motor ability assessed on Wolf Motor Function Test (WMFT) | Change from baseline at 5 months | The outcome will be measured at 3 time points: 0 week, 8 weeks, and 5 months after recruitment. |
| Muscle power assessed on Medical Research Council Scale (MRC) | Change from baseline at 5 months | The outcome will be measured at 3 time points: 0 week, 8 weeks, and 5 months after recruitment. |
| The instrumental activities of daily living assessed on Nottingham Extended Activities of Daily Living Scale (NEADL) | Change from baseline at 5 months | The outcome will be measured at 3 time points: 0 week, 8 weeks, and 5 months after recruitment. |
| The participant's perception of the performance assessed on Canadian Occupational Performance Measure (COPM) | Change from baseline at 2 months | The outcome will be measured at 3 time points: 0 week, 1week, and 8 weeks after recruitment. |
| The participants' individual goals assessed on Goal attainment scale (GAS) | Change from baseline at 5 months | The outcome will be measured at 4 time points: 0 week, 1 week, 8 weeks, and 5 months after recruitment. |
| Revised Notttingham Sensory Assessment (RNSA) | Change from baseline at 2 months | The outcome will be measured at 3 time points: 0 week, 1week, and 8 weeks after recruitment. |
| Stroke Impact Scale (SIS) | Change from baseline at 5 months | The outcome will be measured at 4 time points: 0 week, 1 week, 8 weeks, and 5 months after recruitment. |
| The quality of movement and amount of use assessed on Motor Activity Log (MAL) | Change from baseline at 5 months | The outcome will be measured at 3 time points: 0 week, 8 weeks, and 5 months after recruitment. |
Countries
Taiwan
Outcome results
None listed