Treatment Of Spastic Equinus Foot Research Articles

Randomized Controlled Trial on Effectiveness of Intermittent Serial Casting on Spastic Equinus Foot in Children with Cerebral Palsy After Botulinum Toxin-A Treatment.

Physical therapy (PT) and botulinum toxin-A (BTX-A) injections are widely used in the treatment of spastic equinus foot due to cerebral palsy. The aim of this study was to show effects of intermittent serial casting (SC) in addition to standard treatment on spasticity, passive range of motion (PROM), and gait. Fifty-one ambulatory patients, treated by BTX-A to plantar flexor muscles, were randomly assigned to casting or control groups in a 2:1 ratio. Both groups received PT for 3 weeks. Casting group additionally received intermittent SC during 3 consecutive weekends. Assessments included Modified Ashworth Scale (MAS), Tardieu Scale, Observational Gait Scale (OGS), and Physician Global Assessment at baseline and posttreatment weeks 4 and 12. Significant improvements in PROM, MAS, Tardieu Scale, and OGS were recorded in both groups (P < 0.001 for all). Average changes in MAS, PROM, angle of catch, spasticity angle, and OGS of the casting group were significantly higher than those of the controls at week 4 (P = 0.006, P = 0.002, P < 0.001, P = 0.005, P = 0.011), and 12 (P = 0.013, P < 0.001, P < 0.001, P = 0.011, P < 0.001). Follow-up Physician Global Assessment also favored casting group (P < 0.001 for both). Combining intermittent SC with BTX-A injections and PT might provide additional benefits for spastic equinus foot. Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) identify treatment options for spastic equinus goot in children with cerebral palsy; (2) explain different approaches of serial casting with an additional model of intermittent casting; and (3) describe the potential benefits of combined treatment modalities, including intermittent serial casting, for spastic equinus foot in children with cerebral palsy. Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Long Term Follow-up of Subcutaneous Achilles Tendon Lengthening in the Treatment of Spastic Equinus Foot in Patients with Cerebral Palsy.

Spastic equinus foot is among the most common deformities in patients with cerebral palsy. The optimal therapy of this condition is yet to be determined. Despite a considerable volume of literature concerned with the subject of cerebral palsy, there is still a need for studies focusing on long-term follow-up after corrective procedures. The study aimed to evaluate the long-term effects of subcutaneous Achilles tendon lengthening in the treatment of spastic equinus foot. A total of 100 patients after Hooke's or White's isolated subcutaneous lengthening of the Achilles tendon were invited to participate in the retrospective assessment. Of the above number, 53 patients reported for an examination (76 feet). The average follow-up time was 10.09 years. To enable a more accurate determination of the risk of recurrence, the patients were divided into two groups according to whether they had been operated before or after reaching the age of 8 years. All patients were able to walk and suffered from the spastic type of cerebral palsy. The average age of patients at the time of the Achilles tendon lengthening procedure was 7 years. The follow-up time ranged from 3 to 17 years (an average of 10.09 years). The degree of equinus foot contracture before the surgery was from -5 to -60 degrees (an average of -17.53 degrees). Recurrence of the deformity was reported in 43.42% of the patients. Recurrences were more common in those with hemiplegic cerebral palsy. 1. Subcutaneous Achilles tendon lengthening is not associated with a risk of serious complications, while providing good long-term therapeutic outcomes as well as very good cosmetic and functional effects. 2. Subcutaneous Achilles tendon lengthening minimises the costs and time of patients' hospitalisation and uses a relatively simple operative technique.

Spread of Botulinum Neurotoxin Type A at Standard Doses Is Inherent to the Successful Treatment of Spastic Equinus Foot in Cerebral Palsy

To evaluate whether botulinum toxin type A at standard doses spreads to antagonist leg muscles in dynamic equinus foot, we studied 18 ambulatory children with hemiplegic cerebral palsy. The gastrocnemius muscle on the affected side was injected with botulinum toxin type A (Dysport) (mean ± standard deviation, 14.3 ± 0.9 U/kg). Compound muscle action potential areas were assessed in the lateral gastrocnemius and tibialis anterior muscles on the treated and untreated sides before botulinum toxin type A injections and on days 10 and 30 after injections. In all patients, compound muscle action potential areas recorded from both the muscles on the treated side decreased from preinjection values at day 10 (P < .05) and 30 (P < .002). After injection, ankle spasticity had diminished (P < .05), equinus foot excursion increased (P < .05), and functional gait improved (P < .05). This study shows that botulinum toxin type A spreads from foot flexors to antagonist extensors and suggests that spread may be partly responsible for improving gait in children with cerebral palsy.

The Effect and Complication of Botulinum Toxin Type A Injection with Serial Casting for the Treatment of Spastic Equinus Foot

ObjectiveTo identify the effect of serial casting combined with Botulinum toxin type A (BTX-A) injection on spastic equinus foot.MethodTwenty-nine children with cerebral palsy who had equinus foot were recruited from the outpatient clinic of Rehabilitation Medicine. The children were divided into 2 groups, one of which received serial casting after BTX-A injection, and the other which only received BTX-A injection. Serial casting started 3 weeks after the BTX-A injection, and was changed weekly for 3 times. Spasticity of the ankle joint was evaluated using the modified Ashworth scale (MAS), and the modified Tardieu scale (MTS). Gait pattern was measured using the physician's rating scale (PRS).ResultsThe degree of ankle dorsiflexion and the MAS improved significantly until 12 weeks following the BTX-A injection in the serial casting group (p<0.001), while the BTX-A injection-only group improved until 6 weeks following injection (p<0.05). The combined group showed a significantly greater increase in the degree of dorsiflexion compared to the BTX-A injection-only group at post-injection weeks 6 and 12 (p<0.05). Three children (11.5%) suffered from foot ulcers as a complication caused by the serial casting.ConclusionOur study demonstrated that the effect of BTX-A injection with serial casting was superior and lasted longer than the effect of BTX-A injection only in patients with spastic equinus foot. We therefore recommend BTX-A injection with serial casting for the treatment of equinus foot. However, physicians must also consider the possible complications associated with serial casting.

Botulinum Toxin Type A for the Treatment of the Spastic Equinus Foot in Cerebral Palsy

Muscle overactivity, one of the cardinal features of spasticity, is a common sequel of cerebral palsy. In this group of patients spasticity is responsible for several limitations that interfere with gait, causing variable functional disability. Drugs such as baclofen, tizanidine, or benzodiazepines, or even definitive treatments such as orthopedics or neurosurgeries are generally prescribed with uncertain results. The use of botulinum toxin type A has been frequently suggested for the treatment of spastic equinus foot in cerebral palsy, but few studies with adequate methodology support this idea. The present paper reviews and summarizes the data of published double-blind, randomized clinical trials to assess, with a meta-analysis, if botulinum toxin type A is an adequate treatment for spasticity caused by cerebral palsy. The results reveal a statistical superiority of botulinum toxin type A over placebo on gait improvement, tested using the Physician Rating Scale and Video Gait Analysis (Peto odds ratio = 3.99, 95% confidence interval = 2.20-7.22) in patients with spastic equinus foot. The botulinum toxin group also presented better results in the subjective assessment than the placebo group (Peto odds ratio = 3.49, 95% confidence interval = 1.50-8.12). Adverse events were more frequently observed after the use of botulinum toxin type A, but they were considered mild and self-limited.

Spastic Equinus Foot: Multicenter Study of the Long-term Results of Tibial Neurotomy

Tibial neurotomy is a surgical technique widely used for the treatment of spastic equinus foot, but it has rarely been evaluated. The primary objective of this prospective study was to provide an objective quantification of the long-term results of tibial neurotomy. This multicenter prospective study was conducted from 1999 to 2003. Fifty-five patients with spastic equinus foot were treated in five neurosurgical centers. Preoperative and postoperative clinical evaluation comprised description of the foot deformity, study of stretch reflexes, evaluation of the repercussions of the deformity, and gait analysis. Selective neurotomy was performed in all patients. No postoperative complications were observed. The mean postoperative follow-up was 10 months. Tibial neurotomy improved the appearance of the foot (equinus and varus deformities, claw toes); the equinus score decreased from 1.54 to 0.273 after the operation. Stretch reflex scores were decreased significantly and for a long term after surgery; the mean triceps surae stretch reflex score decreased from 2.46 to 0.47. The angle of passive dorsiflexion of the ankle increased significantly (from -0.56 degrees to +6.85 degrees). Gait analysis demonstrated a statistically significant increase in the speed of the patient's gait after surgical treatment; the time taken by the patient to walk 10 m at a normal speed in shoes decreased from a mean of 55 seconds to 35.16 seconds. Postoperatively, 92.7% of preoperative objectives had been achieved. Tibial neurotomy ensures long-term functional improvement of patients with spastic equinus foot. It provides a lasting response for these patients compared with other, more transient treatments.

Long term course of the H reflex after selective tibial neurotomy

Objectives: This study was conducted to evaluate the long term clinical and electrophysiological outcome by recording the H reflex in a consecutive series of six patients treated by selective tibial...

Repeated Botulinum Toxin A Injections in the Treatment of Spastic Equinus Foot

Equinus foot disorder is a common problem for patients with cerebral palsy who are able to ambulate. Botulinum toxin A is a recommended method of treatment for temporary reduction of muscle tone. The efficacy of repeated botulinum toxin A injections in the calf muscles was evaluated in a clinical trial involving 21 children with cerebral palsy and dynamic equinus foot deformity who were able to ambulate. The mean age of the children was 5.7 years. All patients received at least two injections, six patients received at least three injections, and three patients received four injections. The outcome was evaluated using observational and three-dimensional instrumented gait analysis. Significant improvements of the gait parameters were observed at 6 and 18 weeks after the first and second injections. Botulinum toxin A injections in gastrocnemius and soleus muscles may change the natural history of equinus foot deformity in patients with spastic diplegia. Orthopaedic surgery may be postponed or avoided.

Soleus neurotomy for treatment of the spastic equinus foot. Groupe d'Evaluation et de Traitement de la Spasticité et de la Dystonie.

This prospective, nonrandomized, noncontrolled study was performed to evaluate the results of a new type of neurotomy, namely the soleus neurotomy, for treatment of the spastic equinus foot. Between May 1996 and March 1998, 46 patients were treated for a spastic equinus foot. Clinical status, spasticity (Ashworth Scale score), and kinematic parameters of the gait were determined before and after surgery. The neurotomy was performed on the upper nerve of the soleus in all cases and was associated with other neurotomies (lower nerve of the soleus, 21 patients; gastrocnemius, 9 patients, tibialis posterior, 18 patients; flexor hallucis longus, 16 patients; and flexor digitorum longus, 17 patients). The mean follow-up period was 15 months (range, 8-28 mo). The equinus deformity disappeared clinically in all patients. Before the operation, all patients had an Ashworth Scale score of 2, with an inexhaustible clonus present on knee extension and persisting with knee flexion (Tardieu Scale score, 4), which was abolished in 95% of the patients after surgery. Two patients still had some clonus on knee extension; this did not interfere with their clinical improvement. Knee recurvatum disappeared in eight patients. Analysis of kinematic parameters demonstrated a statistically significant increase in joint motion of the second rocker (P = 0.0026) of the ankle during stance. The duration of the stance or swing phase, length of the walking cycle, and velocity or rate of spontaneous walking were not significantly modified. The study demonstrated that soleus neurotomy is effective for the treatment of spastic equinus foot, leading to abolition of spasticity and improvement in the range of ankle motion during the stance phase of gait.