Plantar Flexor Spasticity Research Articles

A Comparitive Study on the efficacy of Cryostretches Versus Hold- Relax on Plantar Flexors Spasticity in the Subjects with Stroke

Aim of The Study: To evaluate the efficacy of cryostretches versus hold-relax on plantar flexors spasticity in the subjects with stroke. Objectives of the Study: • To evaluate the efficacy of cryostretches on plantar flexors spasticity in the subjects with stroke. • To evaluate the efficacy of hold-relax on plantar flexors spasticity in the subjects with stroke. • To compare the efficacy of cryostretches and hold-relax on plantar flexors spasticity in the subjects with stroke. Methodology: 30 hemiplegic patients were divided into two groups, Group-1 received cryostretches (n=15). It contains 20 min of cooling, followed by 5-6 repetitions of 65 sec stretches are applied with a 20 sec rest between the stretches with three 5 sec isometric contractions interspersed through out the stretch, and Group II with hold- relax (n=15), in this the plantar flexors was made to contract isometrically for 6-8 sec, followed by immediate relaxation during which the muscle was taken into new lengthened position (dorsiflexion) which was held for 10 sec; it was repeated 5-6 times with a rest period of 20 sec between each stretch, for a period of 6 days in a week for 6 weeks. Statistical Analysis: Paired T- test and Unpaired T-test has been carried out to observe the treatment impact with in the groups and between the groups before and after the treatment. Results: After a 6 week treatment period, the subjects in the Group I (cryostretches) compared with the subjects in the Group II (Hold-relax) had shown a statistically significant improvement with the out come measures at 0.05 level. Conclusion: Cryostretches was found much effective in reducing spasticity which helps to enhance and upgrade functional outcome of the patients.

Ankle dorsiflexor, not plantarflexor strength, predicts the functional mobility of people with spastic hemiplegia

To determine the relationships between affected ankle dorsiflexion strength, other ankle muscle strength measurements, plantarflexor spasticity, and Timed "Up & Go" (TUG) times in people with spastic hemiplegia after stroke. A cross-sectional study. A university-based rehabilitation centre. Seventy-three subjects with spastic hemiplegia. Functional mobility was assessed using TUG times. Plantarflexor spasticity was measured using the Composite Spasticity Scale. Affected and unaffected ankle dorsiflexion and plantarflexion strength were recorded using a load-cell mounted on a foot support with the knee bent at 50º and subjects in supine lying. TUG times demonstrated strong negative correlation with affected ankle dorsiflexion strength (r = -0.67, p ≤ 0.001) and weak negative correlations with other ankle muscle strength measurements (r = -0.28 to -0.31, p ≤ 0.05), but no significant correlation with plantarflexor spasticity. A linear regression model showed that affected ankle dorsiflexion strength was independently associated with TUG times and accounted for 27.5% of the variance. The whole model explained 47.5% of the variance in TUG times. Affected ankle dorsiflexion strength is a crucial component in determining the TUG performance, which is thought to reflect functional mobility in subjects with spastic hemiplegia.

The Effect of Extracorporeal Shock Wave Therapy on Lower Limb Spasticity in Subacute Stroke Patients

ObjectiveTo evaluate the effect of extracorporeal shock wave therapy (ESWT) on lower limb spasticity in subacute stroke patients.MethodsWe studied thirty hemiplegic subacute stroke patients with ankle plantar flexor spasticity. ESWT was applied for 1 session/week, with a total of 3 sessions at the musculotendinous junction of medial and lateral gastrocnemius muscles. Patients were evaluated both clinically and biomechanically at baseline, after sham stimulation, and at immediately 1 week and 4 weeks after ESWT. For clinical assessment, Modified Ashworth Scale (MAS), clonus score, passive range of motion of ankle, and Fugl-Myer Assessment for the lower extremity were used. A biomechanical assessment of spasticity was conducted by an isokinetic dynamometer. Two parameters, peak eccentric torque (PET) and torque threshold angle (TTA), were analyzed at the velocities of 60°/sec, 180°/sec, and 240°/sec.ResultsAfter sham stimulation, there were no significant changes between each assessment. MAS and PET (180°/sec and 240°/sec) were significantly improved immediately and 1 week after ESWT. However, these changes were not significant at 4 weeks after ESWT. PET (60°/sec) and TTA (60°/sec, 180°/sec, and 240°/sec) were significantly improved immediately after ESWT. Yet, these changes were not significant at 1 week and 4 weeks after ESWT as well.ConclusionLower limb spasticity in subacute stroke patients was significantly improved immediately after ESWT. Although the therapeutic effect of ESWT reduced with time and therefore was not significant at 4 weeks after ESWT, the degree of spasticity was lower than that of the baseline. Future studies with a larger sample of patients are warranted in order to verify the protocols which can optimize the effect of ESWT on spasticity.

Beyond muscular effects: depression of spinal recurrent inhibition after botulinum neurotoxin A

The natural target of the botulinum neurototoxin type A (BoNT-A) is the neuromuscular junction. When injected into a muscle, BoNT-A is internalized by motoneurone terminals where it functions as an endopeptidase, cleaving protein components of the synaptic machinery responsible for vesicle docking and exocytosis. As a result, BoNT-A induces a characteristic flaccid paralysis of the affected muscle. In animal models, BoNT-A applied in the periphery can also influence central activity via retrograde transport and transcytosis. An analogous direct central effect in humans is still debated. The present study was designed to address whether BoNT-A modifies the activity of the spinal recurrent inhibitory pathways, when injected at muscular level, in humans. To avoid methodological bias, the recurrent inhibition from an injected muscle (soleus) was investigated on an untreated muscle (quadriceps), and stimulation parameters (producing recurrent inhibition) were monitored on a third non-injected muscle but innervated by the same nerve as the soleus (flexor digitorum brevis). The experiments were performed on 14 post-stroke patients exhibiting spasticity in ankle plantarflexors, candidates for BoNT-A. One month after BoNT-A, the level of recurrent inhibition was depressed. It is suggested that the depression of recurrent inhibition was induced by BoNT-A, injected peripherally, through axonal transport and blockade of the cholinergic synapse between motoneurone recurrent collaterals and Renshaw cells.

Poststroke Spasticity Management

Poststroke spasticity (PSS) is a common complication associated with other signs and symptoms of the upper motor neuron syndrome, including agonist/antagonist co-contraction, weakness, and lack of coordination. Together, they result in impairments and functional problems that can predispose to costly complications. The goal of PSS management should take into consideration not only reduction of muscle hypertonia but also the impact of PSS on function and well-being. Therapeutic interventions focus on peripheral and central strategies, such as physical techniques to increase muscle length through stretching and pharmacological modulation. Although there are few comparative studies on the superiority of one method over another, it appears that optimal management of PSS involves a combined and coordinated compendium of therapies that encompass cost-effective pharmacological and surgical interventions, along with rehabilitative efforts. Spasticity, commonly defined as “a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neuron syndrome,”1 is a common complication of stroke. It contributes to the impairments and disabilities that negatively impact functional recovery. Consequently, PSS, along with weakness and lack of coordination, result in gait abnormalities and problems with arm use. In addition to functional limitations, spasticity, when inappropriately treated, may lead to reduced quality of life, increased pain, and joint contractures. Three community-based studies that followed-up stroke survivors for 3 to 12 months reported an incidence of PSS between 17% and 43%.2–4 Certain factors are recognized as predictors of PSS: stroke lesions in the brain stem; hemorrhagic stroke and younger age;5 and severe paresis and hemihypesthesia at stroke onset.3 To quantify the full impact of PSS, assessment should include a measure of passive stretch, volitional movement, and active/passive function.6,7 The benefit of …

Effects of ankle foot orthosis in stiff knee gait in adults with hemiplegia

Stroke survivors present a less efficient gait compared to healthy subjects due to abnormal knee flexion during the swing phase of gait, associated with spasticity of the rectus femoris muscle and overactivity of the ankle plantarflexors. It is relevant to understand the effect of the ankle foot orthosis (AFO) on gait in individuals with plantarflexor spasticity. The aim of this study was to compare the knee kinematics with an AFO/footwear combination and barefoot in post-stroke subjects with plantarflexor spasticity.Ten subjects with chronic hemiplegia were measured. Two kinematic variables were assessed during the swing phase of the paretic limb: knee flexion angle at toeoff and peak knee flexion angle. We also analyzed gait speed and step length of the non-paretic limb. All variables were obtained with and without the orthosis. Kinematic data were acquired using a motion capture system (ELITE). Subjects wearing an AFO showed significant improvements in gait speed (0.62m/s (0.08 SD) vs. 0.47m/s (0.13 SD) (p=0.007)), step length of the non-paretic limb (42cm (5.9 SD) vs. 33.5cm (6.6 SD) (p=0.005)) and peak knee flexion angle during the swing phase: 30.7° (14.1° SD) vs. 26.3° (11.7° SD) p=0.005. No significant differences were obtained in the knee flexion angle at toeoff between no AFO and AFO conditions.We described benefits with AFO/footwear use in the kinematics of the knee, the step length of the non-paretic limb, and the gait velocity in hemiplegic subjects after mild to moderate stroke. We conclude that the use of an AFO can improve the gait pattern and increase velocity in these subjects.

Neurorehabilitation with versus without resistance training after botulinum toxin treatment in children with cerebral palsy: A randomized pilot study

To compare the effects of physical rehabilitation with (PRT) and without (CON) progressive resistance training following treatment of spastic plantarflexors with botulinum toxin type A (BoNT) in children with cerebral palsy (CP). Fourteen children with CP performed supervised PRT (n=7) or CON (n=7) two times per week for 12 weeks, following the BoNT-treatment. Outcome measurements were performed at baseline (pre BoNT), and 4 and 12 weeks post BoNT. They consisted of: ankle muscle function (maximal torque and submaximal torque steadiness of isometric ankle dorsi- and plantarflexion and associated ankle muscle [EMG] activity), gait function (3-dimensional gait analysis), balance function (sway analysis), gross motor function (GMFM-66), and spasticity (modified Ashworth). Submaximal torque control (torque steadiness) of isometric dorsiflexion improved similarly in the two groups, and the improvement was related to the reduction in antagonist (soleus) co-activity (P< 0.05). Maximal plantarflexion torque increased after PRT, whereas a reduction was seen after CON (P< 0.05). No changes in function were observed. Both types of physical rehabilitation in combination with BoNT-treatment improved antagonist (ankle dorsiflexion) torque-control to the same extent - which was related to the reduction in antagonist co-activity - but only rehabilitation with PRT increased maximal plantarflexion torque.

Contribution of Ankle Dorsiflexor Strength to Walking Endurance in People With Spastic Hemiplegia After Stroke

Ng SS, Hui-Chan CW. Contribution of ankle dorsiflexor strength to walking endurance in people with spastic hemiplegia after stroke. Objectives(1) To determine the relationships of ankle dorsiflexor strength, ankle plantarflexor strength, and spasticity of the ankle plantarflexors with walking endurance; (2) to determine whether affected ankle dorsiflexor strength makes an independent contribution to walking endurance; and (3) to quantify its relative contribution to the walking endurance of people with spastic hemiplegia after stroke. DesignA cross-sectional study. SettingUniversity-based rehabilitation center. ParticipantsSubjects (N=62) with spastic hemiplegia. InterventionsNot applicable. Main Outcome MeasuresWalking endurance was measured by the distance covered in the six-minute walk test (6MWT). Ankle dorsiflexor and plantarflexor strength were measured using a load-cell mounted on a custom-built foot support. Plantarflexor spasticity was measured using the Composite Spasticity Scale. ResultsThe six-minute walk distances showed stronger positive correlation with affected dorsiflexor strength (r=.793, P≤.000) when compared with affected plantarflexor strength (r=.349, P=.005). Results of the regression model showed that after adjusting for basic demographic and stroke-related impairments, affected ankle dorsiflexor strength remained independently associated with six-minute walk distance, accounting for 48.8% of the variance. ConclusionsThis is the first study, to our knowledge, to document the importance of ankle dorsiflexor strength as an independent determinant of walking endurance in stroke survivors with spastic plantarflexors. Our findings suggest that stroke rehabilitation programs aiming to improve walking endurance should include strengthening exercises for the ankle dorsiflexors.

Functional electrical stimulation of dorsiflexor muscle: Effects on dorsiflexor strength, plantarflexor spasticity, and motor recovery in stroke patients

To evaluate the therapeutic effects of Functional Electrical Stimulation (FES) of the tibialis anterior muscle on plantarflexor spasticity, dorsiflexor strength, voluntary ankle dorsiflexion, and lower extremity motor recovery with stroke survivors. We conducted a prospective interventional study. Rehabilitation ward, physiotherapy unit and gait analysis laboratory. Fifty-one patients with foot drop resulting from stroke. The functional electrical stimulation (FES) group (n=27) received 20-30 minutes of electrical stimulation to the peroneal nerve and anterior tibial muscle of the paretic limb along with conventional rehabilitation program (CRP). The control group (n=24) treated with CRP only. The subjects were treated 1 hr per day, 5 days a week, for 12 weeks. Plantarflexor spasticity measured by modified ashworth scale (MAS), dorsiflexion strength measured by manual muscle test (MMT), active/passive ankle joint dorsiflexion range of motion, and lower-extremity motor recovery by Fugl-Meyer assessment (FMA) scale. After 12 weeks of treatment, there was a significant reduction in a plantarflexor spasticity by 38.3% in the FES group and 21.2% in control group (P< 0.05), between the beginning and end of the trial. Dorsiflexor muscle strength was increased significantly by 56.6% and 27.7% in the FES group and control group, respectively. Similarly, voluntary ankle dorsiflexion and lower-extremity motor function improved significantly in both the groups. No significant differences were found in the baseline measurements among groups. When compared with control group, a significant improvement (p< 0.05) was measured in all assessed parameters in the FES group at post-treatment assessment, thus FES therapy has better effect on recovery process in post-stroke rehabilitation. Therapy combining FES and conventional rehabilitation program was superior to a conventional rehabilitation program alone, in terms of reducing spasticity, improving dorsiflexor strength and lower extremity motor recovery in stroke patients.

장기간 고빈도 경피신경전기자극이 뇌졸중 환자의 하지 경직 및 균형에 미치는 영향

본 연구는 장기간의 고빈도 경피신경전기자극이 뇌졸중 환자의 하지 경직 및 균형 개선에 미치는 효과를 알아보고자 하였다. 하지에 경직이 유발된 26명의 대상자를 기본적인 재활을 수행하는 상태에서 무작위로 TENS군(14명)과 속임 TENS군(12명)으로 배정하였다. 경피신경전기자극은 4주간 주 5회, 1회당 30분씩 경직이 유발된 양측 비복근에 적용하였다. MAS와 도수근력계를 이용하여 발목 족저굴곡근의 경직을 측정하였다. 균형의 측정은 힘판을 이용하여 세 가지 자세(눈을 뜬 상태의 기립자세, 눈을 감은 상태의 기립자세, 불안정한 면에서 눈을 뜬 상태의 기립자세)에서 누적된 자세동요의 이동거리를 측정하였다. 4 주간의 치료 후 양측 군 모두 경직과 균형의 유의한 개선을 나타냈다(p 【The purpose of this study was to investigate effects of the long-term high-frequency transcutaneous electrical nerve stimulation(TENS) on the spasticity and the balance in chronic stroke patients. Twenty-six subjects with spasticity over lower limbs were allocated randomly into two groups under standard rehabilitation: (1) TENS group, (2) placebo-TENS group. TENS stimulation was applied on the both the gastrocnemius for 30 minutes, 5 days a week for 4 weeks(100 Hz, 0.25 ms, 2 times sensory threshold). The Modified Ashworth Scale(MAS) and Hand-held manual muscle tester were used to assess the ankle plantarflexor spasticity. Balance function under three conditions was measured by using force-plate and the amount of postural sway was assessed; in (1) the condition of standing with eyes opened, (2) with eyes closed and (3) the condition of standing on unstable surface with eyes opened. Both groups showed significant improvement in spasticity and balance function after treatment for 4 weeks(p】

Intra-rater reliability of the modified Tardieu scale to quantify spasticity in elbow flexors and ankle plantar flexors in adult stroke subjects

Objectives:The purpose of this study was to investigate Iintra-rater reliability of the Modified Tardieu Scale (MTS) in elbow flexors and ankle plantar flexors in adult subjects with stroke.Materials and Methods:A total of 91 subjects with stroke participated in this test-retest study. Intra-rater reliability of the MTS was investigated by a qualified and trained physiotherapist for elbow flexors and ankle plantar flexors in two sessions. A rater was one who performed the procedure and an observer only records the angles so that the rater was blinded to findings. Outcome measures in this study were measurable components of MTS, which are angle of muscle reaction (R1), passive range of motion (R2), dynamic component (R2-R1), and quality of muscle reaction (grade 0 – 4) termed as MTS score.Results:Intra-rater reliability of MTS was very good for R1, R2, R2-R1, and MTS score (ICC > 0.85, P<0.0001) across two sessions in elbow flexors and ankle plantar flexors.Conclusion:MTS is a reliable clinical tool for measurement of spasticity in the elbow flexors and ankle plantar flexors in adult subjects with stroke.

Spasticity and Electrophysiologic Changes after Extracorporeal Shock Wave Therapy on Gastrocnemius

ObjectiveTo evaluate the spasticity and electrophysiologic effects of applying extracorporeal shock wave therapy (ESWT) to the gastrocnemius by studying F wave and H-reflex.MethodTen healthy adults and 10 hemiplegic stroke patients with ankle plantarflexor spasticity received one session of ESWT on the medial head of the gastrocnemius. The modified Ashworth scale (MAS), tibial nerve conduction, F wave, and H-reflex results were measured before and immediately after the treatment. The Visual Analogue Scale (VAS) was used during ESWT to measure the side effects, such as pain.ResultsThere were no significant effects of ESWT on the conduction velocity, distal latency and amplitude of tibial nerve conduction, minimal latency of tibial nerve F wave, latency, or H-M ratio of H-reflex in either the healthy or stroke group. However, the MAS of plantarflexor was significantly reduced from 2.67±1.15 to 1.22±1.03 (p<0.05) after applying ESWT in the stroke group.ConclusionAfter applying ESWT on the gastrocnemius in stroke patients, the spasticity of the ankle plantarflexor was significantly improved, with no changes of F wave or H-reflex parameters. Further studies are needed to evaluate the mechanisms of the antispastic effect of ESWT.

Transcutaneous Electrical Stimulation on Acupoints Combined With Task-Related Training to Improve Motor Function and Walking Performance in an Individual 7 Years Poststroke

Impaired walking function and spasticity are common sequelae of stroke. Prior studies have shown that a rehabilitation program combining transcutaneous electrical stimulation (TES) with task-related training (TRT) improves motor function in individuals with stroke. However, it is unclear if this approach is beneficial for individuals with long-standing stroke. The subject of this case study was a 61-year-old man who was 7 years poststroke. He exhibited limitations of walking function, impaired strength of the ankle muscles, and severe plantarflexor spasticity. For 4 weeks, the patient performed a 5-day/wk home program consisting of 60 minutes of TES (below motor threshold) to the acupoints in the affected lower leg, followed by 60 minutes of TRT. He documented his daily home program activities in a log, and 3 times a week he received a call from the therapist to verify his adherence. The patient also had 8 clinic visits, which focused on instruction to ensure adherence to the (TES + TRT) protocol and progression of the program. After the 4-week program, plantarflexor spasticity decreased and ankle dorsi- and plantarflexor strength improved. More important, there were notable improvements in gait velocity, walking endurance, and functional mobility. These gains were maintained at 4 weeks posttreatment. This accessible home program was safe and effective for decreasing impairment and improving function in an individual with long-term, chronic stroke. The gains were maintained 4 weeks posttreatment. Details are provided for developing a home program integrating somatosensory TES and TRT.

The effect of NDT and BTX-A injection on muscle spasticity

The aim of this study was to compare the effect of neuro-development treatment (NDT) technique and NDT plus botulinum toxin type A (BTX-A) injection on the reduction of spasticity and improvement of the quality of movement patterns of lower limb in hemiplegic patients. For this purpose, 15 hemiplegic (8 female and 7 male cases) with an age range of 27-70 years participated in this study. The patients were in spastic phase and able to walk with or without assisting device. The severity of spasticity was measured by the original Ashworth scale (OAS) and was assigned from 1 to 3. Five patients were treated using NDT method (Group A) and ten patients were treated using combination method (NDT plus BTX-A injection, Group B). BTX-A injection was performed in gastrocnemius, soleus and tibialis posterior muscles. NDT technique was performed in both groups for 10 sessions. Baseline assessments consisted of measuring the severity of spasticity in plantar flexors according to OAS, active and passive range of motion of ankle joint and the quality of movement patterns of lower limb in the standing position according to NDT. In both groups, reduced spasticity, increased active and passive range of motion and improved quality of movement patterns were observed, while the mean changes of these parameters was significantly (P

The Role of Kinesiotaping Combined With Botulinum Toxin to Reduce Plantar Flexors Spasticity After Stroke

Purpose: To evaluate the effect of kinesiotaping as an adjuvant therapy to botulinum toxin A (BTX-A) injection in lower extremity spasticity. Methods: This is a single-center, randomized, and double-blind study. Twenty hemiplegic patients with spastic equinus foot were enrolled into the study and randomized into 2 groups. The first group (n=10) received BTX-A injection and kinesiotaping, and the second group (n=10) received BTX-A injection and sham-taping. Clinical assessment was done before injection and at 2 weeks and 1, 3, and 6 months. Outcome measures were modified Ashworth scale (MAS), passive ankle dorsiflexion, gait velocity, and step length. Results: Improvement was recorded in both kinesiotaping and sham groups for all outcome variables. No significant difference was found between groups other than passive range of motion (ROM), which was found to have increased more in the kinesiotaping group at 2 weeks. Conclusion: There is no clear benefit in adjuvant kinesiotaping application with botulinum toxin for correction of spastic equinus in stroke.

Effects of Combining Electric Stimulation With Active Ankle Dorsiflexion While Standing on a Rocker Board: A Pilot Study for Subjects With Spastic Foot After Stroke

Cheng J-S, Yang Y-R, Cheng S-J, Lin P-Y, Wang R-Y. Effects of combining electric stimulation with active ankle dorsiflexion while standing on a rocker board: a pilot study for subjects with spastic foot after stroke. Objective To investigate the therapeutic effects of combining electric stimulation (ES) with active ankle dorsiflexion while standing on a rocker board in subjects with plantarflexor spasticity after stroke. Design Randomized controlled trial. Setting A rehabilitation medical center. Participants Subjects (N=15) with spastic foot after stroke. Interventions Subjects were randomly assigned to an experimental or a control group. The experimental group received ES of ankle dorsiflexors in concert with a motor training paradigm that required the subject to dorsiflex the ankles in response to a cue while standing on a rocker board. After 30 minutes of this exercise, subjects received ambulation training focusing on ankle control for 15 minutes. The control group received general range of motion and strength exercises for 30 minutes, followed by 15 minutes of ambulation training focusing on ankle control. Sessions occurred 3 times a week for 4 weeks. Main Outcome Measures Dynamic spasticity of plantarflexors, dorsiflexor muscle strength, balance performance, gait kinematics, and functional gait performance as assessed by the Emory Functional Ambulation Profile (EFAP) were used as outcome measurements. Results The experimental group demonstrated a greater decrease in dynamic ankle spasticity at a comfortable gait speed ( P=.049), a greater improvement in spatial gait symmetry ( P=.015), and a greater improvement in functional gait ability as indicated by the EFAP ( P=.015) than the control group. Conclusions Our results suggest that repeated ES with volitional ankle movements can decrease dynamic ankle spasticity in subjects with stroke. Furthermore, such improvement parallels better gait symmetry and functional gait performance.

Comparing normal walking and compensated walking: Their stability and perturbation resistance. A simulation study

People usually develop different kinds of compensated gait in response to local function deficits, such as muscle weakness, spasticity in specific muscle groups, or joint stiffness, in order to overcome the falling risk factors. Compensated walking has been analysed empirically in the impaired gait analysis area. However, the compensation could be identified spatially and temporally. The stability and perturbation resistance of compensated walking have not been analysed quantitatively. In this research, a biomimetic human walking simulator was employed to model one individual paraplegic subject with plantarflexor spasticity. The pes equinus was expressed by biasing the outputs of plantarflexor neurons corresponding to the spastic muscles. Then, the compensatory mechanism was explored by adjusting the outputs of the other muscles. It was shown that this approach can be used for quantitative analysis of the spastic gait and compensated walking. Thus, this research can improve the understanding of the behaviour of compensated walking, bringing insights not only for building useful walking assist systems with high safety but also for designing effective rehabilitation interventions.

Gait Changes Following Botulinum Toxin A Treatment in Stroke

Purpose: To characterize the effects of botulinum toxin A treatment of spastic plantar flexors in stroke on joint mobility and gait kinematics and kinetics. Method: Nine patients with hemiparetic stroke presenting with ankle hypertonicity participated in this exploratory open-label case series study. Comprehensive gait analysis provided bilateral kinematic and kinetic information for the ankle, knee, and hip joints throughout the stance phase. Data were obtained at baseline, 2 weeks, and 10 weeks post botulinum toxin injection of the spastic plantar flexors. Results: Passive ankle range of motion increased post injection (p < .05). The amount of plantarflexion in late stance was significantly reduced (p < .05) while the maximum dorsiflexion increased in midstance at 10 weeks post treatment. The angular displacement profiles for the knee revealed that patients tended to display less hyperextension following treatment (p = .053). No significant changes in kinetic measures were found; however, case-by-case observations suggested that most patients experienced improvements in positive work production. Conclusions: The findings indicate that botulinum toxin treatment results in improved joint mobility and ankle kinematics and, in some patients, increases in positive work, suggesting better gait performance.

A randomized controlled trial to compare two botulinum toxin injection techniques on the functional improvement of the leg of children with cerebral palsy

Objective: To compare the efficacy of botulinum toxin type A injection guided by different localizing techniques, electrical stimulation and palpation, to treat spasticity of the ankle plantar flexors. Design: Randomized controlled trial. Setting: Hospital neurology and rehabilitation department. Participants: Sixty-five children with spastic hemiplegic or diplegic cerebral palsy. Interventions: Botulinum toxin injection guided by electrical stimulation or palpation, and two weeks of physiotherapy. Main outcome measures: Passive range of movement (ROM), modified Ashworth Scale, Composite Spasticity Scale, D and E dimensions of the Gross Motor Function Measure, walking velocity. Results: Three groups improved significantly (P<50.05). The mean improvements between baseline and the end of follow-up were respectively 20, 16.2 and 11.9 degrees for passive ROM, —1.9, —1.4 and —0.7 for modified Ashworth Scale scores, —5.8, —4.2 and —2.3 for Composite Spasticity Scale scores, 18.6, 11.3 and 6.9 for Gross Motor Function Measure scores, and 0.2, 0.1 and 0.1 m/s for walking velocity in the botulinum toxin group guided by electrical stimulation injection plus physiotherapy, the botulinum toxin group guided by palpation injection plus physiotherapy, and the physiotherapy only group. The botulinum toxin injection guided by electrical stimulation group showed greater improvement in passive ROM (P<50.05), modified Ashworth Scale scores (P<50.05), Composite Spasticity Scale scores (P<50.05), and Gross Motor Function Measure scores (P<50.05) than the other two groups after treatment for three months. Conclusions: Botulinum toxin injection guided by electrical stimulation plus physiotherapy is likely to be best in improving spasticity and functional performance in children with cerebral palsy.

Transcutaneous electrical stimulation on acupuncture points improves muscle function in subjects after acute stroke: A randomized controlled trial

To investigate whether transcutaneous electrical stimulation, when applied to acupuncture points in patients after acute stroke, decreases spasticity and/or increases muscle strength more effectively than placebo stimulation and standard rehabilitation. Randomized control trial. Sixty-two patients aged 70.0 (standard deviation 7.4) years and 9.2 (standard deviation 3.4) days post-stroke. The patients were randomly assigned to 3 groups receiving transcutaneous electrical stimulation, placebo stimulation, or standard rehabilitation alone. Stimulation was applied to 4 acupuncture points in the affected lower leg for 60 min, 5 days a week for 3 weeks. Plantarflexor spasticity, ankle muscle strength, and functional mobility were measured before treatment, weekly during treatment, and at follow-up at week 8 post-stroke. No significant difference was found in the outcome measures among groups before treatment. When compared with standard rehabilitation or placebo stimulation, transcutaneous electrical stimulation to acupuncture points significantly increased the percentage of patients with normal tone, increased ankle dorsiflexor strength, and decreased antagonist co-contraction ratio (p < 0.05). The patients in the transcutaneous electrical stimulation group also tended to walk 2-4 days earlier than the patients in the other 2 groups. Three weeks of transcutaneous electrical stimulation to lower leg acupuncture points, given 5 times a week within 10 days post-stroke, significantly decreased ankle plantarflexor spasticity, and increased dorsiflexor strength concomitant with a decrease in antagonist co-contraction.