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Effect of Session Frequency of rESWT on Gastrocnemius Muscle Spasticity in Children With Spastic Type Cerebral Palsy

Primary Purpose

Spasticity, Muscle, Cerebral Palsy, Child; Spastic

Status
Completed
Phase
Not Applicable
Locations
Indonesia
Study Type
Interventional
Intervention
radial Extracorporeal Shockwave Therapy
Sponsored by
Rizky Kusuma Wardhani
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Spasticity, Muscle focused on measuring Spasticity, Cerebral Palsy, Children, ESWT, Frequency

Eligibility Criteria

5 Years - 18 Years (Child, Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  • patients with spastic CP aged 5 to 18 years old
  • at least one gastrocnemius with an Australian Spasticity Assessment Scale (ASAS) of 2 or more
  • ability of legal respondent to give written informed consent

Exclusion Criteria:

  • 6 months or less since the last botulinum injection on hamstring
  • surgical operation on lower limb within the last 12 months
  • severe contracture on gastrocnemius

Sites / Locations

  • Universitas Indonesia Fakultas Kedokteran

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Experimental

Arm Label

Five true ESWT sessions

Three true ESWT sessions and two sham ESWT sessions

Arm Description

A total of five sessions (1x/week) were conducted. A total of 1,500 pulses were delivered to each gastrocnemius muscle. The energy flux density was constant at 0.1 mJ/mm2 and the repetition frequency was at 4 Hz, with a pressure of 1.5 bars.

A total of three true ESWT (week 1, 3 and 5) and two sham ESWTs in (week 2 and 4) were conducted. For true ESWT sessions, a total of 1,500 pulses were delivered to each gastrocnemius muscle. The energy flux density was constant at 0.1 mJ/mm2 and the repetition frequency was at 4 Hz, with a pressure of 1.5 bars. For sham ESWT sessions, a total of 1,500 pulses were delivered to each gastrocnemius muscle with a 1 cm gap between between the probe and subject's skin. The energy flux density was constant at 0.1 mJ/mm2 and the repetition frequency was at 4 Hz, with a pressure of 1.5 bars.

Outcomes

Primary Outcome Measures

Baseline Spasticity of Gastrocnemius
Evaluated as the degree of resistance to passive movement using ASAS (0: no spasticity to 4: severe spasticity)
Spasticity of Gastrocnemius after first ESWT session
Evaluated as the degree of resistance to passive movement using ASAS (0: no spasticity to 4: severe spasticity)
Spasticity of Gastrocnemius after second ESWT session
Evaluated as the degree of resistance to passive movement using ASAS (0: no spasticity to 4: severe spasticity)
Spasticity of Gastrocnemius after third ESWT session
Evaluated as the degree of resistance to passive movement using ASAS (0: no spasticity to 4: severe spasticity)
Spasticity of Gastrocnemius after fourth ESWT session
Evaluated as the degree of resistance to passive movement using ASAS (0: no spasticity to 4: severe spasticity)
Spasticity of Gastrocnemius after fifth ESWT session
Evaluated as the degree of resistance to passive movement using ASAS (0: no spasticity to 4: severe spasticity)
Spasticity of Gastrocnemius four weeks after fifth (last) ESWT session
Evaluated as the degree of resistance to passive movement using ASAS (0: no spasticity to 4: severe spasticity)
Spasticity of Gastrocnemius eight weeks after fifth (last) ESWT session
Evaluated as the degree of resistance to passive movement using ASAS (0: no spasticity to 4: severe spasticity)
Spasticity of Gastrocnemius twelve weeks after fifth (last) ESWT session
Evaluated as the degree of resistance to passive movement using ASAS (0: no spasticity to 4: severe spasticity)

Secondary Outcome Measures

Full Information

First Posted
September 22, 2020
Last Updated
September 28, 2020
Sponsor
Rizky Kusuma Wardhani
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1. Study Identification

Unique Protocol Identification Number
NCT04574622
Brief Title
Effect of Session Frequency of rESWT on Gastrocnemius Muscle Spasticity in Children With Spastic Type Cerebral Palsy
Official Title
Effect of Session Frequency of Radial Extracorporeal Shock Wave Therapy (rESWT) on Gastrocnemius Muscle Spasticity in Children With Spastic Type Cerebral Palsy: A Double-Blinded, Randomized Clinical Trial
Study Type
Interventional

2. Study Status

Record Verification Date
September 2020
Overall Recruitment Status
Completed
Study Start Date
January 17, 2020 (Actual)
Primary Completion Date
June 17, 2020 (Actual)
Study Completion Date
June 17, 2020 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor-Investigator
Name of the Sponsor
Rizky Kusuma Wardhani

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No

5. Study Description

Brief Summary
Spasticity, defined as a velocity dependent increase in tonic stretch reflexes, is one of the most prominent motor problems that occur in patients with cerebral palsy (CP). This causes difficulty in achieving balance, mobility, and an upright stance. CP is a group of permanent disorders that affect the development of movement and posture caused by a non-progressive damage to the brain. Because CP occurs in 2-3 of 1000 individuals, it is one of the most common causes of severe physical disability in children. Mismanagement of spasticity can lead to contracture which is extremely difficult to treat and may result in severe functional disabilities. The current management of spasticity in CP includes physical therapy (i.e. passive stretching), oral medication, botulinum toxin injection, and surgery. Botulinum toxin injection has been proven to effectively reduce spasticity yet many patients are unable to get access to this treatment due to its high cost. Moreover, Botulinum toxin injection is currently not covered by the public health insurance of Indonesia. Therefore, other modalities which are more affordable and are non-invasive therapies should be considered as a treatment option for spasticity. Radial Extracorporeal Shockwave Therapy (rESWT) has been utilized in the medical practice for the treatment of several musculoskeletal disorders such as chronic tendinopathies and spasticity. It is hypothesized that ESWT has two main effects which include a direct effect from mechanical forces at the treatment point and an indirect effect from cavitation. Even though rESWT has less penetration capacity over the focused Extracorporeal Shockwave Therapy (fESWT), rESWT is still believed to be more superior to fESWT because it requires less precise focusing, is less painful, and costs less. These also make rESWT the more appropriate choice for children with CP. Many studies have proven the efficacy of ESWT in reducing spasticity in spastic CP patients with significantly long lasting effects. Despite promising results, there still has yet to be a recommended guideline for the treatment of spasticity in children using rESWT. One of the critical parameters needed to be determined is the frequency of treatment. Therefore, the objective of this study is to understand whether the reduction in gastrocnemius stiffness in children with spastic CP is influenced by the frequency of ESWT sessions.
Detailed Description
This study was designed as a double-blinded and randomized controlled trial. Pediatric CP patients from the Department of Physical Medicine and Rehabilitation at Rumah Sakit Umum Pusat Nasional Dr. Cipto Mangunkusumo (RSCM) are involved in this research. Participants were selected using the inclusion criteria as follow: 1) children with spastic CP who are 5 - 18 years old, 2) one or two gastrocnemius muscle with an Australian Spasticity Assessment Scale (ASAS) of two or more, 3) at least 6 months since the last botulinum injection on gastrocnemius, 4) no surgical operation on lower limb within the last 12 months, 5) absence of severe contracture on gastrocnemius, and 6) ability of legal caregiver to provide written informed consent. The spasticity of gastrocnemius was evaluated using ASAS (0: no spasticity to 4: severe spasticity). Data were collected at nine time points: 1) pre-ESWT, 2-6) immediately after each ESWT session, 7) 4 weeks after the last (fifth) ESWT session, 8) 8 weeks after the last (fifth) ESWT session, and 9) 12 weeks after the last (fifth) ESWT session. All patients were examined by the same physiatrist who was blinded to the protocol (i.e. not informed about the study and the group allocation) throughout the whole study. The investigators used a BTL-6000 SWT Topline (BTL, Czech Republic) to apply rESWT on gastrocnemius muscles. For the procedures, a 1.2 cm probe was used. A total of 1,500 pulses were delivered to each gastrocnemius muscle. The energy flux density was constant at 0.1 mJ/mm2 and the repetition frequency was at 4 Hz, with a pressure of 1.5 bars. For double-blinded treatment, 28 different spastic gastrocnemius muscles from 14 CP patients were allocated into two groups. Both groups had a true or sham ESWT for five consecutive weekly treatments. Group I received five true ESWT sessions. Group II received three true ESWT in session 1, 3 and 5 and two sham ESWTs in session 2 and 4. No anesthesia was given. Adverse events were closely monitored during and after therapy. Intra-group changes in ASAS were evaluated with Friedman analysis of variance from baseline, immediately after each ESWT, 4 weeks after last (fifth) ESWT, 8 weeks after last (fifth) ESWT and 12 weeks after last (fifth) ESWT; followed by post-hoc Wilcoxon signed-ranked test. Inter-group differences in ASAS reduction were analyzed using Mann-Whitney U- test. Statistical analysis was conducted using SPSS ver. 23.0 (IBM Corporation, Armonk, NY, USA). The level of significance was set at <0.05.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Spasticity, Muscle, Cerebral Palsy, Child; Spastic
Keywords
Spasticity, Cerebral Palsy, Children, ESWT, Frequency

7. Study Design

Primary Purpose
Treatment
Study Phase
Not Applicable
Interventional Study Model
Parallel Assignment
Masking
ParticipantCare ProviderOutcomes Assessor
Masking Description
Participants (including parents of patients), physiatrists who conducted ESWT and physiatrists who examined the patients' ASAS score are all blinded.
Allocation
Randomized
Enrollment
14 (Actual)

8. Arms, Groups, and Interventions

Arm Title
Five true ESWT sessions
Arm Type
Experimental
Arm Description
A total of five sessions (1x/week) were conducted. A total of 1,500 pulses were delivered to each gastrocnemius muscle. The energy flux density was constant at 0.1 mJ/mm2 and the repetition frequency was at 4 Hz, with a pressure of 1.5 bars.
Arm Title
Three true ESWT sessions and two sham ESWT sessions
Arm Type
Experimental
Arm Description
A total of three true ESWT (week 1, 3 and 5) and two sham ESWTs in (week 2 and 4) were conducted. For true ESWT sessions, a total of 1,500 pulses were delivered to each gastrocnemius muscle. The energy flux density was constant at 0.1 mJ/mm2 and the repetition frequency was at 4 Hz, with a pressure of 1.5 bars. For sham ESWT sessions, a total of 1,500 pulses were delivered to each gastrocnemius muscle with a 1 cm gap between between the probe and subject's skin. The energy flux density was constant at 0.1 mJ/mm2 and the repetition frequency was at 4 Hz, with a pressure of 1.5 bars.
Intervention Type
Device
Intervention Name(s)
radial Extracorporeal Shockwave Therapy
Intervention Description
rESWT was given on gastrocnemius muscles with the subject lying on prone position. No anesthesia was required.
Primary Outcome Measure Information:
Title
Baseline Spasticity of Gastrocnemius
Description
Evaluated as the degree of resistance to passive movement using ASAS (0: no spasticity to 4: severe spasticity)
Time Frame
pre-ESWT
Title
Spasticity of Gastrocnemius after first ESWT session
Description
Evaluated as the degree of resistance to passive movement using ASAS (0: no spasticity to 4: severe spasticity)
Time Frame
After first ESWT session (Week 1)
Title
Spasticity of Gastrocnemius after second ESWT session
Description
Evaluated as the degree of resistance to passive movement using ASAS (0: no spasticity to 4: severe spasticity)
Time Frame
After second ESWT session (Week 2)
Title
Spasticity of Gastrocnemius after third ESWT session
Description
Evaluated as the degree of resistance to passive movement using ASAS (0: no spasticity to 4: severe spasticity)
Time Frame
After third ESWT session (Week 3)
Title
Spasticity of Gastrocnemius after fourth ESWT session
Description
Evaluated as the degree of resistance to passive movement using ASAS (0: no spasticity to 4: severe spasticity)
Time Frame
After fourth ESWT session (Week 4)
Title
Spasticity of Gastrocnemius after fifth ESWT session
Description
Evaluated as the degree of resistance to passive movement using ASAS (0: no spasticity to 4: severe spasticity)
Time Frame
After fifth ESWT session (Week 5)
Title
Spasticity of Gastrocnemius four weeks after fifth (last) ESWT session
Description
Evaluated as the degree of resistance to passive movement using ASAS (0: no spasticity to 4: severe spasticity)
Time Frame
Four weeks after fifth (last) ESWT session (Week 9)
Title
Spasticity of Gastrocnemius eight weeks after fifth (last) ESWT session
Description
Evaluated as the degree of resistance to passive movement using ASAS (0: no spasticity to 4: severe spasticity)
Time Frame
Eight weeks after fifth (last) ESWT session (Week 13)
Title
Spasticity of Gastrocnemius twelve weeks after fifth (last) ESWT session
Description
Evaluated as the degree of resistance to passive movement using ASAS (0: no spasticity to 4: severe spasticity)
Time Frame
Twelve weeks after fifth (last) ESWT session (Week 17)

10. Eligibility

Sex
All
Minimum Age & Unit of Time
5 Years
Maximum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: patients with spastic CP aged 5 to 18 years old at least one gastrocnemius with an Australian Spasticity Assessment Scale (ASAS) of 2 or more ability of legal respondent to give written informed consent Exclusion Criteria: 6 months or less since the last botulinum injection on hamstring surgical operation on lower limb within the last 12 months severe contracture on gastrocnemius
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Rizky K Wardhani, M.D., Physiatrist
Organizational Affiliation
Universitas Indonesia Fakultas Kedokteran
Official's Role
Principal Investigator
Facility Information:
Facility Name
Universitas Indonesia Fakultas Kedokteran
City
Jakarta Pusat
State/Province
DKI Jakarta
ZIP/Postal Code
10430
Country
Indonesia

12. IPD Sharing Statement

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Effect of Session Frequency of rESWT on Gastrocnemius Muscle Spasticity in Children With Spastic Type Cerebral Palsy

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