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Botox for Cervical Dystonia Following EMG Mapping

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: NCT00773253
Recruitment Status : Completed
First Posted : October 16, 2008
Results First Posted : October 13, 2011
Last Update Posted : October 13, 2011
Information provided by (Responsible Party):
University of California, San Francisco

Brief Summary:
The purpose of this study is to determine how to improve treatment of patients with cervical dystonia who have not been helped with standard Botox injections. This study is for patients with cervical dystonia who have not benefited from treatment with Botox using conventional "single lead electromyographic (EMG) techniques" for injection. The study aim is to see if these patients may have significantly more benefit if their Botox is injected into muscles that have been chosen with a multi-channel EMG mapping study of the neck prior to Botox injection.

Condition or disease Intervention/treatment Phase
Cervical Dystonia Drug: Botulinum toxin A Phase 4

Detailed Description:

The most common type of primary late-onset dystonia is cervical dystonia. Botulinum toxin A (BTX-A) injections are a safe and effective treatment for cervical dystonia in a majority of patients, however, a significant minority of patients (between 15 and 25%) have a suboptimal response to Botulinum toxin therapy. It is unclear why some patients do not respond maximally to neurotoxin therapy.

Studies using needle electromyographic "mapping" in the evaluation of cervical dystonia have revealed that clinical examination alone is insufficient for determining which muscles contribute to the dystonic movement. When compared to needle electromyography (EMG) "mapping studies", experienced movement disorders specialists correctly identify only 59% of active muscles and believe that 25% of muscles which upon EMG evaluation are found to be quiescent, are involved in the dystonia. The selection of incorrect muscles for injection of Botulinum toxin may explain why some patients have a sub-optimal response.

This study seeks to measure outcomes when the muscles involved in dystonia are identified using "mapping" via an 8-12 channel EMG. In the proposed study, the most involved/active dystonic muscles will be correctly identified through simultaneous 8-12 channel mapping resulting in a more informed injection strategy, which may improve response to Botulinum toxin A treatment as compared to single lead EMG based injections. This study changes routine clinical care only by adding the step of studying the muscles of the neck with simultaneous EMG mapping to allow a more objective injection strategy.

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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 10 participants
Allocation: Randomized
Intervention Model: Crossover Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Pre-injection, Multi-channel EMG Mapping to Optimize Botulinum Toxin Type A Efficacy in Cervical Dystonia.
Study Start Date : April 2008
Actual Primary Completion Date : October 2010
Actual Study Completion Date : January 2011

Arm Intervention/treatment
Active Comparator: standard EMG-guided Botox injection
All patients will undergo injection using conventional single channel EMG-guided technique. This will be used as a baseline for multi-channel mapping-based injections. Patients will be randomized to undergo single-channel vs. multi-channel assessment upon study entry and will then cross over to the alternate arm.
Drug: Botulinum toxin A
All patients will be treated with Botox using both single-channel and multi-channel EMG mapping.
Other Name: Botox

Experimental: Multi-channel EMG-guided Botox injection
Patients will receive multi-channel EMG-guided Botox injection before or after they have been treated with single-channel EMG-guided Botox, depending on which group they are assigned in the cross-over design.
Drug: Botulinum toxin A
All patients will be treated with Botox using both single-channel and multi-channel EMG mapping.
Other Name: Botox

Primary Outcome Measures :
  1. Pre- and Post-injection Toronto Western Spasmodic Torticollis Rating Scale(TWSTRS): Global Clinical Impression Scale (GCI); Visual Analog Scale(VAS) [ Time Frame: pre-injection, week 16, 20, 36, and 40 ]
  2. Mean Percentage Change in Total Toronto Western Spasmodic Torticollis Rating Scale [ Time Frame: 48 weeks ]
    Mean Percentage change in Toronto Western Spasmodic Torticollis Rating Scale. This scale ranges from 0 (normal) to 85 (very severe).

Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years to 75 Years   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion criteria:

  • Male or female subjects, 18 to 75 years of age.
  • Ability to follow study instructions and complete all required visits.
  • Subject meets diagnostic criteria for idiopathic primary cervical dystonia.
  • Subject has at least moderate severity Cervical Dystonia, with a baseline rating of at least 30 on the total TWSTRS and at least 15 on the TWSTRS motor severity subsection.
  • Patients have had a suboptimal response to 2 previous Botulinum toxin injections at an outside facility.
  • Patients will not have received Botulinum toxin within 16 weeks of the start of the study.
  • In order to not confound the clinical response to BTX-A injections, all patients enrolled must have been on a stable medication regimen for 30 days. If they are not on medication at the initiation of the study, they will not be started on medication. Patients must be on the same medication regimen through the entire study including assessment of both single lead EMG based injections and "mapping" based injections. Medications cannot be stopped during the study to avoid confounding the clinical response to BTX-A.

Exclusion Criteria:

  • Known allergy or sensitivity to any of the components in BTX-A.
  • Uncontrolled clinically significant medical condition other than the condition under evaluation
  • Females with a positive pregnancy test, or who are breast-feeding, planning a pregnancy during the study, who think that they may be pregnant at the start of the study or females of childbearing potential who are unable or unwilling to use a reliable form of contraception during the study.
  • Participation in another medication or device study or within 3 months of enrollment in this study.
  • Patients know to have a positive frontalis test or have previously tested positive for the presence of BTX-A antibodies will be excluded.
  • Any known evidence of cervical contractures or significant spinal deformity.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT00773253

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United States, California
University of California, San Francisco
San Francisco, California, United States, 94143
Sponsors and Collaborators
University of California, San Francisco
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Principal Investigator: Graham A. Glass, M.D. University of California, San Francisco

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Responsible Party: University of California, San Francisco Identifier: NCT00773253     History of Changes
Other Study ID Numbers: Allergan cervical dystonia
First Posted: October 16, 2008    Key Record Dates
Results First Posted: October 13, 2011
Last Update Posted: October 13, 2011
Last Verified: September 2011

Keywords provided by University of California, San Francisco:
cervical dystonia
idiopathic primary cervical dystonia

Additional relevant MeSH terms:
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Botulinum Toxins
Botulinum Toxins, Type A
Dystonic Disorders
Neurologic Manifestations
Nervous System Diseases
Signs and Symptoms
Movement Disorders
Central Nervous System Diseases
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