Evaluation of BOTOX® With Rehabilitation Therapy for the Treatment of Wrist and Hand Spasticity in Post-Stroke Patients - Full Text View

Sponsor:	Emory University
Collaborator:	Allergan
Information provided by:	Emory University
ClinicalTrials.gov Identifier:	NCT00565201

Purpose

The present study is designed to determine the safety and effectiveness of injections of BOTOX® in spastic muscles of the arm and hand compared with injections of saline (which would do nothing) when combined with rehabilitation therapy for the improvement of active function tasks in post-stroke patients. Injections will be targeted to reduce common spasticity patterns of the arm and hand which include: bent elbow, palm down forearm, bent wrist, thumb-in-palm, clenched fist, and other hand deformities. This will be done only at Emory University. Neither the doctor injecting the drug nor the subject receiving the drug will know if they are getting BOTOX® or saline. Which type of injection the subject receives will be completely randomized (like flipping a coin). All subjects will have rehabilitation therapy after their injections. Subjects will be assessed at a total of 5 scheduled visits (qualification (Week 1), Injection (Week 2), Evaluations on Weeks 8, 10, and 14. All subjects will receive rehabilitation therapy immediately after their injections for 1 hour a day, 3-5 times a week, for 4 weeks. The results from this project will provide valuable data on the ability of BOTOX® and physical rehabilitation to provide effective treatment to spastic muscles of the arm and hand after stroke. This project has the potential to increase the availability of effective rehabilitation techniques to patients with stroke.

Condition	Intervention	Phase
Stroke	Drug: Botox and rehab Drug: Placebo and rehab	Phase 0

Study Type:	Interventional
Study Design:	Treatment, Randomized, Double Blind (Subject, Caregiver, Outcomes Assessor), Crossover Assignment
Official Title:	Evaluation of BOTOX® (Botulinum Toxin Type A) in Combination With Rehabilitation Therapy for the Treatment of Wrist and Hand Muscle Overactivity in Post-Stroke Patients

Resource links provided by NLM:

MedlinePlus related topics: Botox Rehabilitation

U.S. FDA Resources

Further study details as provided by Emory University:

Primary Outcome Measures:

Wolf Motor Function Test [ Time Frame: Baseline, Pre-therapy, Post-therapy, and 1 month after therapy ] [ Designated as safety issue: No ]
Arm Motor Ability Test [ Time Frame: Baseline, Pre-therapy, Post-therapy, and 1 month after therapy ] [ Designated as safety issue: No ]

Secondary Outcome Measures:

Stroke Impact Scale [ Time Frame: Baseline, Pre-therapy, Post-therapy, and 1 month after therapy ] [ Designated as safety issue: No ]
Modified Ashworth Scale [ Time Frame: Baseline, Pre-therapy, Post-therapy, and 1 month after therapy ] [ Designated as safety issue: No ]
Upper Extremity range of motion measurements [ Time Frame: Baseline, Pre-therapy, Post-therapy, and 1 month after therapy ] [ Designated as safety issue: No ]
Caregiver questionnaire [ Time Frame: Baseline, Pre-therapy, Post-therapy, and 1 month after therapy ] [ Designated as safety issue: No ]

Estimated Enrollment:	30
Study Start Date:	October 2007
Estimated Study Completion Date:	October 2010
Estimated Primary Completion Date:	October 2010 (Final data collection date for primary outcome measure)

Arms	Assigned Interventions
1: Experimental Patients will receive BOTOX® (100 to 360 U) injected into the any of the following muscles: 30-100U in the Flex. Dig. Sublimes (3 sites), 30-100U in the flex. Carpi Rad. (3 sites), 30- 100 U flex Carpi Ulnaris (3 sites), 30-100 U in the flex Dig Superficiali ( 3 sites), 25U Prontator Teres (1 site), 25 U Brachioradialis (1 site). Physical Rehabilitation: One hour session divided into 3 categories of treatment - 1.) Pre-functional/modalities for a general guideline of treatment; 2.)Repetitive task practice and strengthening; 3.)Functional activities - ADL and IADLs.	Drug: Botox and rehab Patients will BOTOX® (100 to 360 U) injected into any of the following muscles: 30-100U in the Flex. Dig. Sublimes (3 sites), 30-100U in the flex. Carpi Rad. (3 sites), 30- 100 U flex Carpi Ulnaris (3 sites), 30-100 U in the flex Dig Superficiali ( 3 sites), 25U Prontator Teres (1 site), 25 U Brachioradialis (1 site) followed by Physical Rehabilitation: One hour session divided into 3 categories of treatment - 1.) Pre-functional/modalities for a general guideline of treatment; 2.)Repetitive task practice and strengthening; 3.)Functional activities - ADL and IADLs.
2: Placebo Comparator Patients will placebo saline (100 to 360 U) injected into any of the following muscles: 30-100U in the Flex. Dig. Sublimes (3 sites), 30-100U in the flex. Carpi Rad. (3 sites), 30- 100 U flex Carpi Ulnaris (3 sites), 30-100 U in the flex Dig Superficiali ( 3 sites), 25U Prontator Teres (1 site), 25 U Brachioradialis (1 site) followed by Physical Rehabilitation: One hour session divided into 3 categories of treatment - 1.) Pre-functional/modalities for a general guideline of treatment; 2.)Repetitive task practice and strengthening; 3.)Functional activities - ADL and IADLs.	Drug: Placebo and rehab Patients will receive placebo saline (100 to 360 U) injected into any of the following muscles: 30-100U in the Flex. Dig. Sublimes (3 sites), 30-100U in the flex. Carpi Rad. (3 sites), 30- 100 U flex Carpi Ulnaris (3 sites), 30-100 U in the flex Dig Superficiali ( 3 sites), 25U Prontator Teres (1 site), 25 U Brachioradialis (1 site) followed by Physical Rehabilitation: One hour session divided into 3 categories of treatment - 1.) Pre-functional/modalities for a general guideline of treatment; 2.)Repetitive task practice and strengthening; 3.)Functional activities - ADL and IADLs.

Arms

Assigned Interventions

1: Experimental

Patients will receive BOTOX® (100 to 360 U) injected into the any of the following muscles: 30-100U in the Flex. Dig. Sublimes (3 sites), 30-100U in the flex. Carpi Rad. (3 sites), 30- 100 U flex Carpi Ulnaris (3 sites), 30-100 U in the flex Dig Superficiali ( 3 sites), 25U Prontator Teres (1 site), 25 U Brachioradialis (1 site).

Physical Rehabilitation: One hour session divided into 3 categories of treatment - 1.) Pre-functional/modalities for a general guideline of treatment; 2.)Repetitive task practice and strengthening; 3.)Functional activities - ADL and IADLs.

Drug: Botox and rehab

Patients will BOTOX® (100 to 360 U) injected into any of the following muscles: 30-100U in the Flex. Dig. Sublimes (3 sites), 30-100U in the flex. Carpi Rad. (3 sites), 30- 100 U flex Carpi Ulnaris (3 sites), 30-100 U in the flex Dig Superficiali ( 3 sites), 25U Prontator Teres (1 site), 25 U Brachioradialis (1 site) followed by Physical Rehabilitation: One hour session divided into 3 categories of treatment - 1.) Pre-functional/modalities for a general guideline of treatment; 2.)Repetitive task practice and strengthening; 3.)Functional activities - ADL and IADLs.

2: Placebo Comparator

Patients will placebo saline (100 to 360 U) injected into any of the following muscles: 30-100U in the Flex. Dig. Sublimes (3 sites), 30-100U in the flex. Carpi Rad. (3 sites), 30- 100 U flex Carpi Ulnaris (3 sites), 30-100 U in the flex Dig Superficiali ( 3 sites), 25U Prontator Teres (1 site), 25 U Brachioradialis (1 site) followed by Physical Rehabilitation: One hour session divided into 3 categories of treatment - 1.) Pre-functional/modalities for a general guideline of treatment; 2.)Repetitive task practice and strengthening; 3.)Functional activities - ADL and IADLs.

Drug: Placebo and rehab

Patients will receive placebo saline (100 to 360 U) injected into any of the following muscles: 30-100U in the Flex. Dig. Sublimes (3 sites), 30-100U in the flex. Carpi Rad. (3 sites), 30- 100 U flex Carpi Ulnaris (3 sites), 30-100 U in the flex Dig Superficiali ( 3 sites), 25U Prontator Teres (1 site), 25 U Brachioradialis (1 site) followed by Physical Rehabilitation: One hour session divided into 3 categories of treatment - 1.) Pre-functional/modalities for a general guideline of treatment; 2.)Repetitive task practice and strengthening; 3.)Functional activities - ADL and IADLs.

Detailed Description:

After a stroke, patients commonly experience tightness in their affected arm from wrist and hand muscle overactivity called spasticity. Spasticity is difficult to manage with only one type of treatment. Usual treatments of spasticity are not very effective and may produce unwanted side effects. Untreated spasticity may result in muscular problems and decrease a patient's general ability to function and thus affect his/her quality of life.

BOTOX®, a botulinum toxin type A produced from Clostridium botulinum, blocks certain chemicals that cause spasticity. With appropriate injections of BOTOX® in the correct muscle, it can change the tightness in the muscle temporarily. Published reports indicate that several hundred adult patients with arm and/or leg spasticity of various causes (e.g., poststroke, multiple sclerosis and traumatic brain injury) have benefited from injections of BOTOX® in the spastic muscle. The efficacy of BOTOX® in patients with post-stroke spasticity in their arms and hands has been demonstrated in seven phase 2 placebo-controlled studies and two phase 3 studies.

The present study is designed to determine the safety and effectiveness of injections of BOTOX® in spastic muscles of the arm and hand compared with injections of saline (which would do nothing) when combined with rehabilitation therapy for the improvement of active function tasks in post-stroke patients. Injections will be targeted to reduce common spasticity patterns of the arm and hand which include: bent elbow, palm down forearm, bent wrist, thumb-in-palm, clenched fist, and other hand deformities. This will be done only at Emory University. Neither the doctor injecting the drug nor the subject receiving the drug will know if they are getting BOTOX® or saline. Which type of injection the subject receives will be completely randomized (like flipping a coin). All subjects will have rehabilitation therapy after their injections. Subjects will be assessed at a total of 5 scheduled visits (qualification (Week 1), Injection (Week 2), Evaluations on Weeks 8, 10, and 14. All subjects will receive rehabilitation therapy immediately after their injections for 1 hour a day, 3-5 times a week, for 4 weeks. The results from this project will provide valuable data on the ability of BOTOX® and physical rehabilitation to provide effective treatment to spastic muscles of the arm and hand after stroke. This project has the potential to increase the availability of effective rehabilitation techniques to patients with stroke.

Eligibility

Ages Eligible for Study:	18 Years to 70 Years
Genders Eligible for Study:	Both
Accepts Healthy Volunteers:	Yes

Criteria

Inclusion Criteria:

Male or female, 18 to 70 years of age
Written informed consent
Written Authorization for Use and Release of Health and Research Study Information has been obtained
Medically stable condition in the investigator's opinion
History of stroke (hemorrhagic or ischemic) that resulted in a unilateral, upper-limb focal spasticity pattern of the wrist and fingers
EMG evidence of volitionary activiation of wrist and finger extensor and flexor muscles
Active range of motion (to be repeated 3 times by the patient): The ability to initiate wrist extension of at least 10 degrees from a fully flexed position with the forearm supported and stabilized in a pronated position. Active shoulder flexion and abduction to 45 degrees and no less than -30 degrees of elbow extension.
Mini-Mental State Exam (MMSE) >24
If on an anti-spasticity medication regiment at the time of qualification, the dose regimen must have been stable 1 month prior to study enrollment
Ability to follow study instructions and likely to complete all required visits

Exclusion Criteria:

Time since neurological event resulting in upper limb spasticity less than 3 months or greater than 24 months
Previous therapy with BOTOX® or any other botulinum toxin serotype for any condition within the last 12 months
Phenol or alcohol block in the study limb within 6 months of study enrollment visit
History (within 3 months of qualification) of or planned (during study period) casting of the study limb
Current treatment with an intrathecal baclofen pump
In the opinion of the investigator, profound atrophy of the muscles in the study limb that are targeted for injection
Previous surgical intervention in the study limb, except for routine orthopedic repair for bone fractures, in the last 6 months
Presence of fixed contracture of the study limb impairing functional activity
Clinically significant inflammation or condition in the study limb that, in the investigator's opinion, could limit joint movement (other than stroke or spasticity)
Clinically significant spasticity or contracture of the elbow (defined as an Ashworth score >3) or shoulder in the study limb, in the investigator's opinion would limit sue of the wrist and fingers
Changes in oral spasticity medications within 30 days of enrollment (dose of anti-spasticity medications should remain the same during the study)
Anticipated use of oral coagulants during the study
Known allergy or sensitivity to the study medication or its components
Infection or dermatological condition at anticipated injection sites
Current participation in another clinical study or within 1 month of the enrollment visit
Females who are pregnant, nursing, or planning a pregnancy during the study, or females of childbearing potential, not using a reliable means of contraception
Anticipated use during the study of concurrent therapies for treatment of upper motor neuron syndrome (eg, acupuncture)
Any medical condition that may put the patient at increased risk with exposure to BOTOX including diagnosed myasthenia gravis, Eaton-Lambert Syndrome, amyotrophic lateral sclerosis, or any other disorder that might interfere with neuromuscular function
Patient has a condition or is in a situation which in investigator's opinion may put the patient significant risk, may confound the study results, or may interfere significantly with patient's participation in the study

Contacts and Locations

Please refer to this study by its ClinicalTrials.gov identifier: NCT00565201

Contacts

Contact: Susan Murphy, BS	404-712-1928	smurph7@emory.edu
Contact: Aimee Reiss, MSPT	404-712-8685	areiss@emory.edu

Locations

United States, Georgia
Emory University	Recruiting
Atlanta, Georgia, United States, 30322
Contact: Susan Murphy, BS 404-712-1928 smurph7@emory.edu
Contact: Aimee Reiss, MSPT 404-712-8685 areiss@emory.edu
Principal Investigator: Steven L Wolf, PhD, PT
Principal Investigator: Byron Milton, MD

Sponsors and Collaborators

Emory University

Allergan

Investigators

Principal Investigator:	Steven L Wolf, PhD, PT	Emory University
Principal Investigator:	Byron Milton, MD	Emory University

More Information

No publications provided

Responsible Party:	Allergan corporation ( Allergan corporation )
Study ID Numbers:	2727
Study First Received:	November 20, 2007
Last Updated:	May 8, 2008
ClinicalTrials.gov Identifier:	NCT00565201 History of Changes
Health Authority:	United States: Institutional Review Board

Keywords provided by Emory University:

Stroke, Cerebrovascular accident, Spasticity, Arm, Hand

Additional relevant MeSH terms:

Cerebral Infarction
Physiological Effects of Drugs
Stroke
Nervous System Diseases
Vascular Diseases
Central Nervous System Diseases
Neuromuscular Agents
Brain Diseases

Cerebrovascular Disorders
Pharmacologic Actions
Brain Ischemia
Cardiovascular Diseases
Brain Infarction
Peripheral Nervous System Agents
Botulinum Toxin Type A

ClinicalTrials.gov processed this record on February 08, 2010