Abstract
Botulinum toxin A (BoNT-A) has been shown effective for poststroke lower limb spasticity. Following injections, a wide range of multidisciplinary approach has been previously provided. The purpose of this pilot, single-blind, randomized controlled trial was to determine whether BoNT-A combined with a regime of a four-week ankle isokinetic treatment has a positive effect on function and spasticity, compared with BoNT-A alone. Secondly, the validity of the use of an isokinetic dynamometer to measure the stretch reflex at the ankle joint and residual strength has been investigated. Twenty-five chronic stroke patients were randomized to receive combined treatment (n = 12; experimental group) or BoNT-A alone (n = 13; control group). Outcome measures were based on the International Classification of Functioning, Disability and Health. An isokinetic dynamometer was also used for stretch reflex and strength assessment. Patients were evaluated at baseline (t0), after five (t1) and eight weeks after the injection (t2). The experimental group reported significantly greater improvements on lower limb spasticity, especially after eight weeks from baseline. Gait speed (10-m walk test) and walking capacity (6-min walking test) revealed statistically significantly better improvement in the experimental than in control group. Peak resistive ankle torque during growing angular velocities showed a significant reduction at the higher velocities after BoNT-A injections in the experimental group. Peak dorsiflexor torque was significantly increased in the experimental group and peak plantarflexor torque was significantly decreased in control group. Alternative rehabilitation strategies that combine BoNT-A and an intense ankle isokinetic treatment are effective in reducing tone and improving residual strength and motor function in patients with chronic hemiparesis.
Highlights
Stroke is one of the leading causes of mortality and a major cause of disability worldwide.Spasticity, with an occurrence after stroke of between 18% and 38%, may interfere with the execution of daily activities, social participation, and quality of life [1].In patients with lower limb spasticity after stroke, spastic equinus foot represents a prolonged abnormal lower limb posture and affects gait, standing, and transfer [2]
Botulinum toxin A (BoNT-A) is a well-established treatment in the management of poststroke spasticity, but evidence, in terms of functional gain during gait, is still debated, considering that only few studies showing effective improvements and others reporting not relevant results on its functional efficacy [19,32,33]
Our results showed that patients allocated to the experimental group (BoNT-A + isokinetic training) obtained significantly greater reduction in muscle overactivity as measured by rPT and TSA than control group
Summary
In patients with lower limb spasticity after stroke, spastic equinus foot represents a prolonged abnormal lower limb posture and affects gait, standing, and transfer [2]. This deformity is reported in 18% of stroke patients [3]; spasticity of posterior muscles of the leg and weakness (especially the tibialis anterior and the peroneus muscle) with tendon shortening complicate balance and gait. Calf muscle spasticity typically causes foot deformity, which results in the loss of heel strike, reduced toe clearance, and an inadequate base of support. These impairments decrease multiple aspects of gait ability: cadence, stride length, speed, capacity, and stability [4,5]
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