Stroke Clinical Trial
Official title:
Combined Robot-assisted Upper Limb Training and Botulinum Toxin Treatment for Upper Limb Function and Spasticity: a Randomized Controlled Single-blinded Trial in 32 Chronic Stroke Patients.
To date, evidence of the effects of robotic training combined with OnabotulinumtoxinA focal treatment for spasticity is limited. The objective of this study were to compare the effects of robotic training against conventional rehabilitation on functional recovery, strength and spasticity, in stroke patients who underwent OnabotulinumtoxinA focal treatment for spasticity. We performed a single-blind, randomized, controlled trial involving 24 outpatients with diagnoses of stroke, divided in two groups (experimental and control group). Experimental group received specific robotic training for the upper limb with the device Armotion/Motore (Reha Technology AG, Olten, Switzerland). Our primary outcome was Fugl-Meyer Assessment Motor Scale (FMA). Secondary outcome were Action Research Arm Test (ARAT), Modified Ashworth Scale (MAS), Medical Research Council Scale (MRC) and surface Electromyography (EMG). 14 healthy age-matched controls underwent one session of sEMG acquisition to collect normative data.
This single-blind RCT with two parallel group was conducted according to the tenets of the
Declaration of Helsinki, the guidelines for Good Clinical practice, and the Consolidated
Standards of Reporting Trials (CONSORT).
Target population was chronic post-stroke patients who attend to the Neurorehabilitation Unit
(AOUI Verona) where they were assessed for eligibility.
Who satisfied inclusion and exclusion criteria were randomly allocated in one of two groups,
experimental group ad control group. Each patient, underwent BoNT injection in the paretic
limb. The dose of BoNT injected into the target muscle was based on the severity of
spasticity in each case. Different commercial formulations of BoNT were used according to the
pharmaceutical portfolio contracts of our Hospital (Onabotulinumtoxin A, Abobotulinumtoxin A
and Incobotulinumtoxin A). The dose, volume and number of injection sites were set
accordingly. A Logiq ® Book XP portable ultrasound system (GE Healthcare; Chalfont St. Giles,
UK) was used to inject BoNT into the target muscle.
Prior of the start of the study authors designed the experimental and the control group
protocols. Two physiotherapists, one for each group carried out the rehabilitation
procedures. Patients of both groups received 10 individual sessions (45 min/session, 2
sessions/week, five consecutive weeks). Treatments were performed in the rehabilitative gym
of the G.B. Rossi University Hospital Neurological Rehabilitation Unit.
A subgroup of patients in the experimental group were investigated by Electromyography during
the "hand-to-mouth" motor task (ARAT sub-item). The subject seated in a comfortable position
on a chair with backrest, the feet resting on the floor and the knees and hips flexed at 90°.
The start position consisted of the hand of the examined side lying on the distal third of
the thigh. Then, the patient was asked to touch his mouth with the palm of the hand at normal
speed and return to the starting position. The patient was instructed not move the head
toward the hand. No other indications regarding how to move the arm for not to influence the
spontaneity of the movement.
The EMG activity of 5 upper limb muscles of the affected side (deltoid scapular, deltoid
clavicular, pectoralis major - clavicular head, triceps brachii, biceps brachii) was measured
using pairs of self-adhesive surface electrodes. Disposable Ag-AgCl electrodes were placed
according to SENIAM guidelines with an inter-electrode spacing of 0.02 m. Before electrode
placement, the skin was shaved with a disposable, single-use razor and cleaned with
alcohol.28 Raw EMG signals were collected using BTS FREEEMG 300 wireless surface EMG sensors
(BTS spa, Milan, Italy) at a sampling rate of 1000 Hz. Raw EMG signals were processed with a
customized routine developed in MATLAB environment (MathWorks, USA). The raw EMG signal was
bandpass filtered at 20-450 Hz and then smoothed using a 20- ms root mean square (RMS)
algorithm to obtain the envelope. Signals were recorded in three conditions: 30 s during
resting position (basal), 5 s of maximal voluntary isometric contraction(MVIC), and during
the hand-to-mouth task.
The "hand-to-mouth" task was divided into two sub-phases through the definition of three
time-events: 1) start of the movement, 2) the moment when the hand touches the mouth and 3)
return to the initial position. The first sub-phase, named "elbow flexion phase", was defined
as the interval between the movement onset and the maximum elbow flexion. The second
sub-phase, named "return phase", refers to the interval between the maximum elbow flexion
until movement offset after returning to the starting position (Figure X). Normative data
were collected from 14 healthy age-matched controls undergoing one EMGs acquisition. The
time-events were determined using an accelerometer (BTS spa, Milan, Italy).
For the statistical analysis an intention to treat was used. Descriptive statistics included
means, standard deviation and graphs. The Shapiro-Wilk test was used to test data
distribution. Parametric or non-parametric tests were used for inferential statistics,
accordingly. The T-Test for unpaired data (or the Mann-Whitney test) was used for testing
between-group differences at T0 and T1. For this purpose, we computed the changes of score
(Δ) between T0-T1. The T-Test for paired data (or Wilcoxon signed rank tests) was used to
compare within-group changes over time. The level of significance was set p<0.05. Software
statistics SPSS 20.0 (IBM SPSS Statistics for Windows, Version 20.0, Armonk, NY, USA).
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