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

Study Overview
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Brief Summary
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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.

Detailed Description
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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.

Official Title
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Impact Of Physiotherapy And Botulinum Toxin Type-A In Improving Functional Outcomes In Upper Limb Focal Dystonia Among Post Stroke Patients

Conditions
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Focal Hand Dystonia

Intervention / Treatment
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* Other: Botulinum toxin type A
* Other: Task Specific Training


Participation Criteria
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Eligibility Criteria
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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.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional 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)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Experimental Group<br>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<br>* 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.<br>Other: Task Specific Training<br>* Task specific training is the repetition of a specific task until expertise is reached. More challenging tasks are added as a means of progression<br>|
| Placebo Comparator: Control Group<br>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<br>* Task specific training is the repetition of a specific task until expertise is reached. More challenging tasks are added as a means of progression<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Action Research Arm Test (ARAT): | 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. | 12 weeks | 
| MOTOR ASSESSMENT SCALE (MAS) | 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. | 12 weeks | 
| WOLF MOTOR FUNCTION TEST (WMFT) | 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. | 12 weeks | 
| FUGL- MEYER ASSESSMENT TEST | 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 | 12 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Severity Of Dystonia | The Arm Dystonia Disability Scale: The severity of dystonia was assessed using 0 (None) to 3 (Marked Difficulty in performing activity | 12 weeks | 
| Stroke Specific Quality Of Life | The stroke specific Quality Of Life was administered to patients which rated their Quality of life | 12 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Dystonia Task-specific training Botulinum toxin type A