Assessment and treatment of spastic equinovarus foot after stroke: Guidance from the Mont-Godinne interdisciplinary group

Arthroscopic Releases and Hindfoot Fusion for Spastic Equinovarus Foot Deformities, An All-Inside Technique

Neurologic foot contractures pose a challenging situation for orthopaedic surgeons. These deformities are long-standing problems for patients with acute brain injuries, ultimately affecting their quality of life. We report our experience with using arthroscopic assisted, minimally invasive contracture tenotomies paired with a tibio-talo-calcaneal arthrodesis to achieve improved alignment and functional reconstruction of spastic equinovarus foot deformities.

Immediate Effects of TECAR Therapy on Gastrocnemius and Quadriceps Muscles with Spastic Hypertonia in Chronic Stroke Survivors: A Randomized Controlled Trial

BACKGROUND

The aim of this study was to assess changes in muscle properties after a single session of capacitive and resistive energetic transfer (TECAR) therapy on spastic gastrocnemius and quadriceps muscles in chronic post-stroke.

METHODS

A total of 36 chronic stroke survivors with lower limb hypertonia were enrolled in a double-blind randomized controlled trial. The experimental group (n = 18) received a single 30 min session of TECAR therapy in combination with functional massage (FM) on the gastrocnemius and quadriceps muscles. The control group (n = 18) received a sham treatment of TECAR therapy (without electrical stimulation) in combination with real FM. The primary outcome was muscle tone of the lower limb muscles assessed with the Modified Ashworth Scale (MAS). The secondary outcomes were goniometric degrees of the MAS (goniometer), neuromuscular properties of the gastrocnemius/quadriceps (myotonometer), and passive range of motion (inclinometer). All measurements were performed at baseline (T0), immediately after treatment (T1), and at 30 min post-treatment (T2) by a blinded assessor.

RESULTS

The MAS score ankle dorsiflexion significantly decreased at T0-T1 (p = 0.046), and the change was maintained at T0-T2 (p = 0.019) in the experimental group. Significant improvements were noted in the passive range of motion for knee flexion (p = 0.012) and ankle dorsiflexion (p = 0.034) at T2. In addition, knee flexion improved at T1 (p = 0.019).

CONCLUSION

A single session of Tecar therapy at the same time with FM on the gastrocnemius and rectus femoris immediately reduces muscle tone and increases the passive range of motion of both ankle and knee in chronic stroke survivors. There were no significant changes in the neuromuscular properties measured with myotonometer.

Selective Tibial Neurotomy Outcomes for Spastic Equinovarus Foot: Patient Expectations and Functional Assessment

BACKGROUND

Spastic equinovarus foot (SEF) is a common dysfunctional foot posture after stroke that impairs balance and mobility. Selective tibial neurotomy (STN) is a simple but underutilized surgical option that can effectively address critical aspects of SEF and thereby provide enduring quality of life gains. There are few studies that examine both functional outcomes and patient satisfaction with this treatment option.

OBJECTIVE

To elucidate the patient goals that motivated their decision to undergo the procedure and compare subjective and objective changes in balance and functional mobility as a consequence of surgery.

METHODS

Thirteen patients with problematic SEF who had previously failed conservative measures were treated with STN. Preoperative and postoperative (on average 6 months) assessments evaluated gait quality and functional mobility. In addition, a custom survey was conducted to investigate patient perspectives on STN intervention.

RESULTS

The survey showed that participants who opted for STN were dissatisfied with their previous spasticity management. The most common preoperative expectation for STN treatment was to improve walking, followed by improving balance, brace comfort, pain, and tone. Postoperatively, participants rated the improvement in their expectations and were, on average, 71 on a 100-point scale, indicating high satisfaction. The gait quality, assessed with the Gait Intervention and Assessment Tool, improved significantly between preoperative and postoperative assessment (M = -4.1, P = .01) with a higher average difference in stance of -3.3 than in swing -0.5. Improvement in both gait endurance (M = 36 m, P = .01) and self-selected gait speed (M = .12 m/s, P = .03) was statistically significant. Finally, static balance (M = 5.0, P = .03) and dynamic balance (M = 3.5, P = .02) were also significantly improved.

CONCLUSION

STN improved gait quality and functional mobility and was associated with high satisfaction in patients with SEF.

Selective Tibial Neurotomy for Spastic Equinovarus Foot: Operative Technique

BACKGROUND AND OBJECTIVES

Spastic equinovarus foot (SEF) is a common complication of stroke and other upper motor neuron injuries. It is characterized by a plantigrade and inverted foot, often with toe curling, causing significant disability from pain, gait, and balance difficulties. Management includes physical therapy, antispasticity drugs, orthoses, chemical neurolysis, or botulinum toxin, all of which may be insufficient, sedating, or transient. Selective tibial neurotomy (STN) provides a surgical option that is effective and long-lasting. Our goal is to provide a concise description of our technique for performing the STN for treatment of SEF. We discuss the standard posterior approach with surgical variations used by other groups and a medial approach, should the posterior approach be insufficient.

METHODS

A posterior leg approach allows access to the tibial nerve and its branches to the bilateral gastrocnemius muscles, soleus, posterior tibialis, and extrinsic toe flexors. A medial approach is used if the toe flexors cannot be accessed sufficiently from the posterior approach. Nerve branch targets identified by preoperative functional assessment are carefully exposed and fully neurolysed distally to identify all terminal branches to each muscle of interest before neurotomy.

RESULTS

The STN is a powerful tool for treating SEF, with an immediate and lasting effect. Approximately 80% of the target muscle should be denervated to ensure long-term efficacy while maintaining adequate function of the muscle through collateral innervation.

CONCLUSION

The STN is a safe and effective outpatient procedure that can be performed by an experienced nerve surgeon to improve balance and ambulation and reduce pain for patients with SEF. Large clinical trials are necessary to further establish this underutilized procedure in the United States.

A Case Report of Cryoneurolysis for Dorsal Foot Pain and Toe Clawing in a Patient With Multiple Sclerosis

Toe clawing in patients with upper motor neuron disorders is often attributed to the flexor digitorum longus (FDL) and is a common presentation among patients with multiple sclerosis (MS). This movement may be painful because of the altered pressure distribution and may increase the risk of falls, heighten energy expenditure during gait, and lower gait speed. Cryoneurolysis is a minimally invasive treatment that may be beneficial for pain and focal muscle hypertonicity. An ambulatory patient with MS was treated bilaterally with cryoneurolysis to the superficial fibular nerves for pain on the dorsum of the foot, and to the intramuscular tibial nerve motor branch to FDL for toe clawing. The patient felt that toe clawing was immediately reduced during gait and noted the ability to voluntarily spread their toes. The patient stated that the neuropathic pain on the dorsum of the foot was fully eliminated immediately post procedure. The patient reported improved confidence in their gait, maintained independence, and reduced toe clawing during a structured interview 12 weeks after treatment. The effects lasted for 5.5 months before symptoms returned. Retreatment at 6 months reproduced the benefits. The patient reported a positive experience with cryoneurolysis for toe clawing and dorsal foot pain.

Recommendations for Ultrasound Guidance for Diagnostic Nerve Blocks for Spasticity. What Are the Benefits?

The diagnostic nerve block (DNB) for spasticity is the percutaneous application of an anesthetic to an individual peripheral nerve trunk (mixed motor sensory nerve), nerve branch to a muscle or an intramuscular branch. The DNB causes a temporary paralysis to assess the contribution of muscle(s) on the spastic pattern and may unmask a fully or partially increased joint range of motion. The anesthetic literature supports the use of ultrasound (US) guidance to improve nerve blocks for sensory targets. This communication summarizes the potential advantages that support the use of US to improve DNB technique. Nerves are much smaller than muscle targets and have various known innervation patterns. US allows for rapid localization of the target before injection, particularly in complex anatomy patterns. The nerve trunks are typically found adjacent to or encapsulating blood vessels, which can be quickly identified with or without color Doppler, allowing the clinician to scan from the vessels to the target and avoid intravascular injection. Lower stimulation levels can be used as the targeted muscle(s) can be seen stimulating rather than only on the surface. A shorter needle insertion time and lower stimulation levels should cause less discomfort to the patient. Smaller volumes of anesthetic may be used as the fluid is seen reaching its target and cessation of stimulation is observed. Further study is needed to identify evidence supporting US utilization with electrical stimulation in DNBs for spasticity management, as US use during nerve blocks for perineurial anesthesia has demonstrated improved patient safety and procedural efficiency.

Treatment of adult spasticity with Botox (onabotulinumtoxinA): Development, insights, and impact

Upper and lower limb spasticity (ULS, LLS) often occur following a stroke or in patients with other neurological disorders, leading to difficulties in mobility and daily living and decreased quality of life. Prior to the use of onabotulinumtoxinA, antispastic medications had limited efficacy and often caused sedation. Phenol injections were difficult for physicians to perform, painful, and led to tissue destruction. The success of onabotulinumtoxinA in treating cervical dystonia led to its use in spasticity. However, many challenges characterized the development of onabotulinumtoxinA for adult spasticity. The wide variability in the presentation of spasticity among patients rendered it difficult to determine which muscles to inject and how to measure improvement. Another challenge was the initial refusal of the Food and Drug Administration to accept the Ashworth Scale as a primary endpoint. Additional scales were designed to incorporate a goal-oriented, patient-centered approach that also accounted for the variability of spasticity presentations. Several randomized, double-blind, placebo-controlled trials of post-stroke spasticity of the elbow, wrist, and/or fingers showed significantly greater improvements in the modified Ashworth Scale and patient treatment goals and led to the approval of onabotulinumtoxinA for the treatment of ULS in adult patients. Lessons learned from the successful ULS trials were applied to design an LLS trial that led to approval for the latter indication. Additional observational trials mimicking real-world treatment have shown continued effectiveness and patient satisfaction. The use of onabotulinumtoxinA for spasticity has ushered in a more patient-centered treatment approach that has vastly improved patients' quality of life.

Evaluation of Selective Tibial Neurotomy for the Spastic Foot Treatment Using a Personal Goal-Centered Approach: A 1-Year Cohort Study

BACKGROUND

Selective tibial neurotomy (STN) has already demonstrated its effectiveness to reduce foot deformities and spasticity, but assessment according to a goal-centered approach is missing.

OBJECTIVE

To evaluate the effectiveness of STN associated with a postoperative rehabilitation program for the treatment of the spastic foot, according to a goal-centered approach.

METHODS

Interventional study (before-after STN and rehabilitation program) with observational design including consecutive adult patients with spastic foot, who received STN followed by a rehabilitation program, was performed. The primary outcome measure was the achievement of individual goals at the 1-year follow-up using the Goal Attainment Scaling methodology (with T-score). The secondary outcomes measures were the Modified Ashworth Scale and the modified Rankin Score.

RESULTS

A total of 104 patients were included. At the 1-year follow-up, 228/252 (90.5%) goals were achieved: 62/252 (24.6%) were achieved as initially expected, 86/252 (34.1%) were achieved better than initially expected, and 80 (31.7%) were achieved much better than initially expected. The mean T-score was significantly increased at the 1-year follow-up (61.5 ± 10.5) compared with the preoperative period (38.1 ± 2.9, P < .00001), and 95/104 (91.3%) patients had a T-score ≥50, meaning that these patients have achieved their goals. At follow-up, spastic deformities were all significantly decreased ( P < .0001), the Modified Ashworth Scale was significantly lower for each muscle targeted ( P < .0001), and the modified Rankin Score was significantly decreased ( P < .0001) allowing the patient population to improve from a moderate to a slight disability status.

CONCLUSION

This study showed that STN, associated with a postoperative rehabilitation program, successfully achieve personal goals in patients with spastic foot.

International Recommendations to Manage Poststroke Equinovarus Foot Deformity Validated by a Panel of Experts Using Delphi

OBJECTIVE

To establish international recommendations for the management of spastic equinovarus foot deformity.

DESIGN

Delphi method.

SETTING

International study.

PARTICIPANTS

A total of 24 international experts (N=24) in neuro-orthopedic deformities, from different specialties (Physical and Rehabilitation Medicine physicians, neurologists, geriatricians, orthopedic surgeons, neurosurgeons, plastic surgeons).

INTERVENTIONS

Experts answered 3 rounds of questions related to important aspects of diagnosis, assessment, and treatment of spastic equinovarus foot deformity.

MAIN OUTCOME MEASURES

A consensus was established when at least 80% of experts agreed on a statement RESULTS: A total of 52 items reached consensus. Experts recommend assessing effect of the deformity on functional activities before treatment. Before treatment, it is crucial to differentiate spastic muscle overactivity from soft tissue contractures, identify which muscles are involved in the deformity, and evaluate the activity of antagonist muscles. Motor nerve blocks, 2-dimensional video analysis, and radiologic examinations are often required to complement a clinical examination. The treatment of equinovarus foot depends on the correctability of the deformity and the patient's ability to stand or walk. The preoperative assessment should include an interdisciplinary consultation that must finalize a formal agreement between physicians and the patient, which will define personalized attainable goals before surgery.

CONCLUSION

The establishment of guidelines on managing equinovarus foot will help physicians and surgeons, specialists, and nonspecialists to diagnoses and assess the deformity and direct patients to a network of experts to optimize patient functional recovery and improve their autonomy.

Management Of Spastic Equinovarus Foot in Children with Cerebral Palsy: An Evaluation of Anatomical Landmarks for Selective Nerve Blocks of the Tibial Nerve Motor Branches

OBJECTIVE

To define the anatomical landmarks of tibial motor nerve branches for selective motor nerve blocks of the gastrocnemii,  soleus and tibialis posterior muscles in the management of spastic equinovarus foot.

DESIGN

Observational study.

PATIENTS

Twenty-four children with cerebral palsy with spastic equinovarus foot.

METHODS

Considering the affected leg length, motor nerve branches to the gastrocnemii, soleus and tibialis posterior muscles were tracked using ultrasonography, and located in the space (vertical, horizontal, deep) according to the position of fibular head (proximal/distal) and a virtual line from the middle of popliteal fossa to the Achilles tendon insertion (medial/lateral).

RESULTS

Location of motor branches was defined as percentage of the affected leg length. Mean coordinates were: for the gastrocnemius medialis 2.5 ± 1.2% vertical (proximal), 1.0 ± 0.7% horizontal (medial), 1.5 ± 0.4% deep; for the gastrocnemius lateralis 2.3 ± 1.4% vertical (proximal), 1.1 ± 0.9% horizontal (lateral), 1.6 ± 0.4% deep; for the soleus 2.1 ± 0.9% vertical (distal), 0.9 ± 0.7% horizontal (lateral), 2.2 ± 0.6% deep; for the tibialis posterior 2.6 ± 1.2% vertical (distal), 1.3 ± 1.1% horizontal (lateral), 3.0 ± 0.7% deep.

CONCLUSION

These findings may help the identification of tibial motor nerve branches to perform selective nerve blocks in patients with cerebral palsy with spastic equinovarus foot.

Bilateral ankle deformities affects gait kinematics in chronic stroke patients

Objectives

Stroke patients suffer from ankle joint deformities due to spastic ankle muscles. This study evaluated the viability of using 3D scanned surface images of the feet of stroke victims to visually assess the deformities of a hemiparetic foot and investigated the influences of deformed ankle joints on gait kinematics.

Methods

A total of 30 subjects with stroke-induced hemiparesis and 11 age-matched healthy controls completed the clinical assessments. We analyzed their feet's morphometric characteristics using a 3D scanner, identified convenient anthropometric measurements, and conducted gait trials on even and uneven terrains. The 3D foot morphometric characteristics were evaluated using the geometric morphometrics method (GMM).

Results

Results showed that there were significant differences in bilateral foot shapes between the chronic stroke patients and healthy controls and between the paretic and non-paretic sides in the chronic stroke patients. In stroke patients, those with the smaller medial malleoli's vertical tilt angles showed significantly different ankle ranges of motion of dorsi-/plantar flexion during gaits on uneven terrains (p = 0.009). In addition, those with the greater medial malleoli's vertical tilt angles showed significantly different ankle ranges of motion of inversion/eversion during gaits on even and uneven terrains (p < 0.05).

Conclusion

Using 3D scanning technology, bilateral morphometric changes in the feet of chronic stroke patients were shown by GMM and the simple anthropometric measurements identified its shape deformities in the feet. Their possible effects on gait kinematics while walking on uneven terrains were investigated. Current methodology can be potentially useful in applying conventional productions of clinically manufactured, patient-fitted ankle-foot-orthosis in orthotics and prosthetics, and in detecting various unidentified pathological deformities in the feet.

Respective Contributions of Instrumented 3D Gait Analysis Data and Tibial Motor Nerve Block on Presurgical Spastic Equinus Foot Assessment: A Retrospective Study of 40 Adults

Spastic equinus foot is a common deformity in neurologic patients who compromise walking ability. It is related to the imbalance between weak dorsiflexion and overactive plantar flexor muscles. To achieve the best functional results after surgical management, the challenge is to identify the relevant components involved in the deformity using several methods, namely, examination in the supine position, motor nerve blocks allowing transient anesthesia of suspected overactive muscles, and kinematic and electromyographic data collected during an instrumented 3D gait analysis. The procedure is not standardized; its use varies from one team to another. Access to gait analysis laboratories is limited, and some teams do not perform motor nerve blocks. When both examinations are available, instrumental data from the instrumented 3D gait analysis can be used to specify muscle targets for motor blocks, but data collected from both examinations are sometimes considered redundant. This retrospective cohort analysis compared examination in the supine position, temporary motor nerve blocks, and instrumented 3D gait analysis data in 40 adults after brain or spinal cord injuries. Clinical data collected before motor nerve block was not associated with instrumental data to assess calf muscle's overactivity and tibialis anterior function. Improvement of ankle dorsiflexion in the swing phase after tibial motor nerve block was associated with soleus spastic co-contraction during this phase corroborating its involvement in ankle dorsiflexion defects. This study showed the relevance of tibial motor nerve block to remove spastic calf dystonia and facilitate the assessment of calf contracture. It also underlined the need for complementary and specific analyses of the tibialis anterior abnormal activation pattern after motor nerve block to confirm or deny their pathological nature.

Foot and ankle deformities in stroke: relationship with ambulation, balance, and daily living activities: a cross-sectional study

BACKGROUND

Ankle-foot deformities play a critical role in functional capacity and therefore activities of daily living in stroke patients.

AIM

This is the first study to evaluate all foot deformities in stroke patients together. The primary aim of this study is to determine the frequency of ankle-foot deformities in stroke patients. The secondary aim is to investigate the relationships between ankle-foot deformities and ambulation, postural control, balance, spasticity, and activities of daily living.

MATERIAL AND METHODS

The Functional Ambulation Classification was used to assess ambulation status, Postural Assessment Scale for Stroke Patients was used to assess postural control and balance. Lower extremity spasticity was evaluated with Modified Ashworth Scale. Activities of daily living were evaluated with Barthel Index.

RESULTS

Ankle-foot deformity was detected in 77 (42%) of 184 cases. The incidence of pes equinovarus was 48%, pes equinus was seen in 22%, claw toe in 19.5%, and pes varus in 10.4%. Pes equinovarus and claw toe were seen together in 8 cases. In the group with ankle-foot deformity, the disease duration was longer and the rate of spasticity in the lower extremity was statistically higher (p = 0.29, p = 0.023). There was no difference in Functional Ambulation Classification, Barthel Index, and Postural Assessment Scale for Stroke Patients scores between patients with or without ankle-foot deformity (p = 0.811, 0.321, 0.385).

CONCLUSION

It is important to detect ankle-foot deformities in stroke patients. Ankle-foot deformities are associated with spasticity in patients with stroke and are an important factor to be considered when determining the rehabilitation program.

Neuro-Orthopedic Surgery for Equinovarus Foot Deformity in Adults: A Narrative Review

Neuro-orthopedic surgery is an alternative to the conservative treatment of spastic equinovarus foot (SEF) in adults. The objective of the present narrative review was to summarize current practice with regard to patient assessment, the choice of treatment, the various neuro-orthopedic procedures, and the latter's outcomes. We searched literature databases (MEDLINE, EMBASE, Cochrane) for original articles or opinion papers on surgical treatment of spastic equinovarus foot in adults. Neuro-orthopedic approaches require a careful analysis of the patient's and/or his/her caregiver needs and thus relevant treatment goals. Surgical planning requires detailed knowledge of impairments involved in the spastic equinovarus foot deformity based on a careful clinical examination and additional information from diagnostic nerve blocks and/or a quantitative gait analysis. Procedures mainly target nerves (neurotomy) and tendons (lengthening, transfer, tenotomy). These procedures reduce impairments (spasticity, range of motion, and foot position), improve gait and walking function, but their impact on participation and personalized treatment goals remains to be demonstrated. Neuro-orthopedic surgery is an effective treatment option for spastic equinovarus foot in adults. However, practice is still very heterogeneous and there is no consensus on the medical strategies to be applied before, during and after surgery (particularly the type of anesthesia, the need for immobilization, rehabilitation procedures).

Effects of Subtalar Joint Mobilization with Movement on Muscle Strength, Balance, Functional Performance, and Gait Parameters in Patients with Chronic Stroke: A Single-Blind Randomized Controlled Study

BACKGROUND

Losses in muscle strength, balance, and gait are common in patients with chronic stroke (CS). Ankle joint movements play a key role in this population to maintain a sufficient level of functional activity. The aim of this study was to investigate the effects of the subtalar joint (STJ) mobilization with movement (MWM) technique on muscle strength, balance, functional performance, and gait speed (GS) in patients with CS.

METHODS

Twenty-eight patients with CS were randomly divided into the control group (n = 14) and the STJ MWM group (n = 14). A 30-min neurodevelopmental treatment program and talocrural joint MWM were applied to both groups. Also, STJ MWM was applied to the STJ MWM group. The patients were treated 3 days a week for 4 weeks. Ankle dorsiflexion and plantarflexion muscle strength, Berg Balance Scale, Timed Up and Go test, and GS were evaluated before and after treatment.

RESULTS

Berg Balance Scale and Timed Up and Go test scores, dorsiflexion and plantarflexion muscle strength, and GS improved in both groups after the treatment sessions (P < .05), but the improvements were greater in the STJ MWM group compared with the control group (P < .05).

CONCLUSIONS

According to these results, STJ MWM together with neurodevelopmental treatment and talocrural joint MWM can increase ankle muscle strength, balance, functional performance, and GS on the affected leg in patients with CS.

Triceps Surae Muscle Characteristics in Spastic Hemiparetic Stroke Survivors Treated with Botulinum Toxin Type A: Clinical Implications from Ultrasonographic Evaluation

Equinovarus foot is one of the most commonly spasticity related conditions in stroke survivors, leading to an impaired gait and poor functional performances. Notably, spastic muscles undergo a dynamic evolution following typical pathophysiological patterns. Botulinum Neurotoxin Type A (BoNT-A) is the gold standard for focal spasticity treatment, and ultrasound (US) imaging is widely recommended to guide injections and monitor muscle evolution. The role of BoNT-A in influencing muscle fibroadipose degeneration is still unclear. In this study, we analyzed medial gastrocnemius (MG) and soleus (SOL) US characteristics (cross-sectional area, muscle thickness, pennation angle, and mean echo intensity) in 53 patients. MG and SOL alterations, compared to the unaffected side, depend on the spasticity only and not on the BoNT-A treatment. In functionally preserved patients (functional ambulation classification, FAC > 3; modified Ashworth scale, MAS ≤ 2), the ultrasonographic changes of MG compared to ipsilateral SOL observed in the paretic limb alone seems to be due to histological, anatomical, pathophysiological, and biomechanical differences between the two muscles. In subjects with poor walking capability and more severe spasticity, such ipsilateral difference was found in both calves. In conclusion, BoNT-A does not seem to influence muscle degeneration. Similar muscles undergo different evolution depending on the grade of walking deficit and spasticity.

Ultrasonographic Evaluation of Three Approaches for Botulinum Toxin Injection into Tibialis Posterior Muscle in Chronic Stroke Patients with Equinovarus Foot: An Observational Study

Spastic equinovarus (SEV) foot deformity is commonly observed in patients with post-stroke spasticity. Tibialis posterior (TP) is a common target for botulinum toxin type-A (BoNT-A) injection, as a first-line treatment in non-fixed SEV deformity. For this deep muscle, ultrasonographic guidance is crucial to achieving maximum accuracy for the BoNT-A injection. In current clinical practice, there are three approaches to target the TP: an anterior, a posteromedial, and a posterior. To date, previous studies have failed to identify the best approach for needle insertion into TP. To explore the ultrasonographic characteristics of these approaches, we investigated affected and unaffected legs of 25 stroke patients with SEV treated with BoNT-A. We evaluated the qualitative (echo intensity) and quantitative (muscle depth, muscle thickness, overlying muscle, subcutaneous tissue, cross-sectional area) ultrasound characteristics of the three approaches for TP injection. In our sample, we observed significant differences among almost all the parameters of the three approaches, except for the safety window. Moreover, our analysis showed significant differences in cross-sectional area between treated and untreated. Advantages and disadvantages of each approach were investigated. Our findings can thus provide a suitable reference for clinical settings, especially for novice operators.

Real-World Adherence to OnabotulinumtoxinA Treatment for Spasticity: Insights From the ASPIRE Study

OBJECTIVE

To identify baseline characteristics and treatment-related variables that affect adherence to onabotulinumtoxinA treatment from the Adult Spasticity International Registry (ASPIRE) study.

DESIGN

Prospective, observational registry (NCT01930786).

SETTING

International clinical sites.

PARTICIPANTS

Adults with spasticity (N=730).

INTERVENTIONS

OnabotulinumtoxinA at clinician's discretion.

MAIN OUTCOME MEASURES

Clinically meaningful thresholds used for treatment adherent (≥3 treatment sessions during 2-year study) and nonadherent (≤2 sessions). Data analyzed using logistic regression and presented as odds ratios (ORs) with 95% confidence intervals (CIs). Treatment-related variables assessed at sessions 1 and 2 only.

RESULTS

Of the total population, 523 patients (71.6%) were treatment adherent with 5.3±1.6 sessions and 207 (28.4%) were nonadherent with 1.5±0.5 sessions. In the final model (n=626/730), 522 patients (83.4%) were treatment adherent and 104 (16.6%) were nonadherent. Baseline characteristics associated with adherence: treated in Europe (OR=1.84; CI, 1.06-3.21; P=.030) and use of orthotics (OR=1.88; CI, 1.15-3.08; P=.012). Baseline characteristics associated with nonadherence: history of diplopia (OR=0.28; CI, 0.09-0.89; P=.031) and use of assistive devices (OR=0.51; CI, 0.29-0.90; P=.021). Treatment-related variables associated with nonadherence: treatment interval ≥15 weeks (OR=0.43; CI, 0.26-0.72; P=.001) and clinician dissatisfaction with onabotulinumtoxinA to manage pain (OR=0.18; CI, 0.05-0.69; P=.012). Of the population with stroke (n=411), 288 patients (70.1%) were treatment adherent with 5.3±1.6 sessions and 123 (29.9%) were nonadherent with 1.5±0.5 session. In the final stroke model (n=346/411), 288 patients (83.2%) were treatment adherent and 58 (16.8%) were nonadherent. Baseline characteristics associated with adherence: treated in Europe (OR=2.99; CI, 1.39-6.44; P=.005) and use of orthotics (OR=3.18; CI, 1.57-6.45; P=.001). Treatment-related variables associated with nonadherence: treatment interval ≥15 weeks (OR=0.42; CI, 0.21-0.83; P=.013) and moderate/severe disability on upper limb Disability Assessment Scale pain subscale (OR=0.40; CI, 0.19-0.83; P=.015).

CONCLUSIONS

These ASPIRE analyses demonstrate real-world patient and clinical variables that affect adherence to onabotulinumtoxinA and provide insights to help optimize management strategies to improve patient care.

Effects of orthopedic insoles on postural balance in patients with chronic stroke: A randomized crossover study

BACKGROUND

Orthopedic insoles (OIs) with medial arch support and heel cushion are widely used to manage lower extremity injuries, but their effects on postural balance in patients with chronic stroke have not been adequately explored.

METHODS

Design: Double-blinded, sham-controlled, randomized crossover trial.

PARTICIPANTS

A total of 32 ambulatory patients (20 men and 12 women, aged between 30 and 76 years) with more than 6 months since stroke onset.

INTERVENTIONS

All participants received one assessment session wearing OIs and one session wearing sham insole (SI) in a random order with a 1-day interval.

OUTCOMES

Our primary outcome was the Berg Balance Scale score. Secondary outcomes included the Functional Reach Test, Timed Up and Go test, and computerized posturography. All were performed in both sessions. Subgroup analyses regarding demographic and functional variables were conducted to identify potential responders.

RESULTS

Significant between-insole differences favoring OIs were seen in all clinical tests (P < 0.05), but were seen only in the static medial-lateral sway in computerized posturography assessment (P = 0.04). An approximate 2-point difference in the BBS score favoring OIs was observed in all subgroups, not reaching the minimal clinically important difference.

CONCLUSION

The use of OIs generated small but significant positive effects on improving postural balance among patients with chronic stroke. Additional biomechanical and clinical studies are required to evaluate their potential for routine clinical use.

TRIAL REGISTRATION

NCT03194282.

A Novel Approach to New-Onset Hemiplegic Shoulder Pain With Decreased Range of Motion Using Targeted Diagnostic Nerve Blocks: The ViVe Algorithm

Introduction: Hemiplegic shoulder pain (HSP) is the most common pain disorder after stroke with incidence estimates of 30–70% and associated with reductions in function, interference with rehabilitation, and a reduced quality of life. Onset may occur as soon as a week after stroke in 17% of patients. Management of HSP represents a complex treatment pathway with a lack of evidence to support one treatment. The pain has heterogeneous causes. In the acute setting, decreased range of motion in the shoulder can be due to early-onset spasticity, capsular pattern stiffness, glenohumeral pathology, or complex regional pain syndrome (CRPS). As contracture can form in up to 50% of patients after stroke, effective management of the painful shoulder and upper limb with decreased range of motion requires assessment of each possible contributor for effective treatment. The anesthetic diagnostic nerve block (DNB) is known to differentiate spasticity from contracture and other disorders of immobility and can be useful in determining an appropriate treatment pathway.

Objective: To create a diagnostic algorithm to differentiate between the causes of HSP in the stiff, painful shoulder in the subacute setting using diagnostic techniques including the Budapest Criteria for CRPS and DNB for spasticity and pain generators.

Results: Examination of each joint in the upper extremity with HSP may differentiate each diagnosis with the use of an algorithm. Pain and stiffness isolated to the shoulder may be differentiated as primary shoulder pathology; sensory suprascapular DNB or intra-articular/subacromial injection can assist in differentiating adhesive capsulitis, arthritis, or rotator cuff injury. CRPS may affect the shoulder, elbow, wrist, and hand and can be evaluated with the Budapest Criteria. Spasticity can be differentiated with the use of motor DNB. A combination of these disorders may cause HSP, and the proposed treatment algorithm may offer assistance in selecting a systematic treatment pathway.

Kinesio taping techniques for ankle stabilisation in patients with stroke: a single-blinded randomised controlled study

Background/Aims

Ankle proprioception and neuromuscular feedback from this region provides the sensory input needed for balance. The aim of this study was to investigate the effects of repeated correction taping applied on the ankle and peroneus longus and peroneus brevis muscles on balance and gait in patients with stroke.

Methods

A total of 61 patients with stroke with a mean age of 62.25 ± 7.04 years were included in this study. The patients were randomly divided into two groups. The control group (n=30) received 1 hour of rehabilitation, which took place during weekdays over the course of 2 weeks. The intervention group (n=31) received 1 hour of daily rehabilitation as well as having kinesio tape applied to their ankle. Both groups were assessed with the Balance Evaluating Systems Test, Timed Up and Go Test, Functional Reach Test, Tetrax Balance System and Barthel Index. Clinical assessments were performed at baseline, immediately after the first application, 1 week and 2 weeks later, following the first taping.

Results

There was a significant improvement in the Balance Evaluating Systems and Functional Reach Tests scores between the first and last measurements in favour of the intervention group (P<0.05). There were no significant changes between baseline and immediately after assessment for all measurements (P>0.05). There was no significant difference in Tetrax scores, Timed Up and Go Test and Barthel Index scores (P>0.05).

Conclusions

In this study, it was found that dynamic balance was improved by taping the peroneus longus and peroneus brevis muscles, but the static balance did not change. One week of kinesio taping would be beneficial; however, prolonged use would not provide further improvement.

Does Botulinum Toxin Treatment Affect the Ultrasonographic Characteristics of Post-Stroke Spastic Equinus? A Retrospective Pilot Study

Equinovarus/equinus foot is a pattern most commonly treated with botulinum toxin type A in patients with post-stroke spasticity involving the lower limbs; the gastrocnemius is the muscle most frequently injected. Spastic equinovarus/equinus can present a mixture of conditions, including spasticity, muscle/tendon shortening, muscle weakness and imbalance. In this study, we wanted to determine whether botulinum toxin treatment affects the ultrasonographic characteristics of post-stroke spastic equinus. The same dose of AbobotulinumtoxinA was injected into the gastrocnemius medialis and lateralis of 21 chronic stroke patients with spastic equinus. Clinical (Ashworth scale and ankle range of motion) and ultrasound (conventional and sonoelastography) evaluation of the treated leg was carried out before and 4 weeks after injection. No significant effects of botulinum toxin treatment on the ultrasonographic characteristics of spastic equinus were observed. As expected, there were significant improvements in ankle passive dorsiflexion range of motion and calf muscle spasticity at 1 month after treatment. There was a direct association between Achilles tendon elasticity and calf muscle spasticity at baseline evaluation. Larger studies with a long-term timeline of serial evaluations are needed to further investigate the possible effects of botulinum toxin injection on spastic muscle characteristics in patients with post-stroke spasticity.

Peri-operative Botulinum Neurotoxin injection to improve outcomes of surgeries on spastic limbs: A systematic review

Our objective was to systematically review literature regarding the rationale and current evidence for peri-operative Botulinum Neurotoxin (BoNT) injection to improve outcomes of surgeries on spastic limbs. We conducted a systematic search of databases MEDLINE, EMBASE, and Cochrane Central Register of Controlled until March 2020, using the PRISMA guidelines. After assessing all titles and abstracts against inclusion criteria, full texts were reviewed for studies of potential interest. The inclusion criteria were studies on humans with any study design, published in all languages. Participants had to have underlying limb spasticity and be scheduled to undergo surgery on one or more spastic limb(s). BoNT had to be administered peri-operatively to improve surgical outcomes and not solely for the purpose of alleviating spasticity. The risk of bias was evaluated using the Physiotherapy Evidence Database (PEDro) scoring system for randomized controlled trials (RCTs) and the Downs and Black tool for RCTs and non-randomized trials. Further, the level of evidence was evaluated using a five-level scale (simplified form of Sackett). Five studies met our inclusion criteria comprising a total of 90 participants, of both pediatric and adult age groups, with underlying limb spasticity, who received BoNT perioperatively to improve outcomes of the surgeries performed on spastic limbs. Interventions were intramuscular BoNT injection prior to, at the time of, or after surgery on a spastic limb for the purpose of improving surgical outcomes, and not solely for alleviating muscle spasticity. Outcome measures were surgical success/failure, post-operative pain and analgesic use, sleep quality, adverse events, spasticity control e.g. Modified Ashworth Scale. Our literature search yielded 5 articles that met the inclusion criteria. Current evidence supports peri-operative injection of BoNT to improve outcomes of surgeries performed on spastic limbs. There is level 1 evidence that BoNT administered pre-operatively is effective for reducing pain, spasticity, and analgesic use in pediatric patients with cerebral palsy (CP). This is supported by level 4 evidence from a retrospective case series. Level 5 evidence from case reports highlights the potential for the use of BONT in the peri-operative period. There is level 1 evidence that BoNT administered intra-operatively is not effective for reducing pain and analgesic use in pediatric patients with CP. This lack of benefit may reflect sub-optimal timing of injections, different methods of injection, different timing of the primary outcome measure, and/or differences in adjunctive therapies, but further research is required.

Ankle and Foot Spasticity Patterns in Chronic Stroke Survivors with Abnormal Gait

Chronic stroke survivors with spastic hemiplegia have various clinical presentations of ankle and foot muscle spasticity patterns. They are mechanical consequences of interactions between spasticity and weakness of surrounding muscles during walking. Four common ankle and foot spasticity patterns are described and discussed through sample cases. The patterns discussed are equinus, varus, equinovarus, and striatal toe deformities. Spasticity of the primary muscle(s) for each deformity is identified. However, it is emphasized that clinical presentation depends on the severity of spasticity and weakness of these muscles and their interactions. Careful and thorough clinical assessment of the ankle and foot deformities is needed to determine the primary cause of each deformity. An understanding of common ankle and foot spasticity patterns can help guide clinical assessment and selection of target spastic muscles for botulinum toxin injection or nerve block.

Equinovarus foot in stroke survivors with spasticity: a narrative review of muscle–tendon morphology and force production adaptation

Background/Aims

Spastic paresis is the most common motor disorder in stroke survivors and can cause various types of muscle overactivity. This can lead to the development of spastic equinovarus foot, producing an inadequate base of support that limits locomotion and weight transfers. Physical therapists require better knowledge of the effects of spastic equinovarus foot in order to administer effective clinical treatment. Therefore, the aim of the present review was to describe changes in the muscle morphology and force production of stroke survivors with spastic equinovarus foot in relation to gait performance.

Methods

A narrative review of research into the effects of spastic paresis and equinovarus foot in stroke survivors was undertaken.

Results

There were a total of 20 identified studies that observed muscle-tendon morphology and force production in stroke survivors. All studies included in the present review reported several changes in muscle and tendon biomechanical properties as results of the spastic muscle overactivity.

Conclusions

Stroke survivors with spastic equinovarus foot experience muscle and tendon morphology that result in decreased force production, muscle power and gait performance.

Botulinum Toxin Type A for the Treatment of Lower Limb Spasticity after Stroke

Post-stroke lower limb spasticity impairs balance and gait leading to reduced walking speed, often increasing wheelchair use and caregiver burden. Several studies have shown that appropriate treatments for lower limb spasticity after stroke include injections of botulinum toxin type A (BoNT-A), phenol or alcohol, surgical correction and a rehabilitation program. In the present article, we review the safety and effectiveness of BoNT-A for the treatment of lower limb spasticity after stroke, with a focus on higher doses of BoNT-A. The cumulative body of evidence coming from the randomized clinical trials and open-label studies selected in the article suggest BoNT-A to be safe and efficacious in reducing lower limb spasticity after stroke. Studies of high doses of BoNT-A also showed a greater reduction of severe post-stroke spasticity. In stroke survivors with spasticity of the ankle plantar-flexor muscles, a combined approach between surgery and BoNT-A can be indicated. However, controversy remains about improvement in motor function relative to post-stroke spasticity reduction after BoNT-A treatment.

Simple semi-permanent blockade against rigid varus foot in a case with spasticity: possible practical benefits in ambulatory adults

A 55-year-old ambulatory woman with hemiplegia and varus foot deformity had several problems in her daily life, including load pain and stance instability in the affected foot, easy fatigue of the non-paralysed leg, low back pain, neck stiffness and rapid shoe-rubber wear on the deformed side. We began repeated focal blockades using botulinum toxin to the tibialis posterior muscle to control varus spasticity. Distant influences presenting in the whole body were relieved soon after the first blockade, and shoe wear also stopped. Although, neither the deformed appearance nor foot contact pattern on walking changed in the initial period after beginning the blockade, the foot contact pattern revealed gradual improvement over several years. Generally, surgical correction is indicated for the treatment of deformed feet. The present case suggests that, in case of varus-deformed foot with some spastic elements, trial of focal blockade for varus spasticity may be worthwhile.

Combined Effects of Isokinetic Training and Botulinum Toxin Type A on Spastic Equinus Foot in Patients with Chronic Stroke: A Pilot, Single-blind, Randomized Controlled Trial

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.

Orthopaedic surgery for patients with central nervous system lesions: Concepts and techniques

Since ancient times, the aim of orthopedic surgery has been to correct limb and joint deformities, including those resulting from central nervous system lesions. Recent developments in the treatment of spasticity have led to changes in concepts and management strategies. The increase in life expectancy has increased the functional needs of patients. Orthopedic surgery, along with treatments for spasticity, improves the functional capacity of patients with neuro-orthopaedic disorders, improving their autonomy. In this paper, we describe key moments in the history of orthopedic surgery regarding the treatment of patients with central nervous system lesions, from poliomyelitis to stroke-related hemiplegia, from the limbs to the spine, and from contractures to heterotopic ossification. A synthesis of the current surgical techniques is then provided, and the importance of multidisciplinary evaluation and management is highlighted, along with indications for medical, rehabilitation and surgical treatments and their combinations. We explain why it is essential to consider patients' expectations and to set achievable goals, particularly before surgery, which is by nature irreversible. More recently, specialized surgical teams have begun to favor the use of soft-tissue techniques over bony and joint procedures, except for spinal disorders. We highlight that orthopedic surgery is no longer the end-point of treatment. For example, lengthening a contractured muscle improves the balance around a joint, improving mobility and stability but may be only part of the problem. Further medical treatment and rehabilitation, or additional surgery, are often necessary to continue to improve the function of the limb. Despite the recognized effectiveness of orthopedic surgery for neuro-orthopedic disorders, few studies have formally evaluated them. Hence, there is a need for research to provide evidence to support orthopedic surgery for treating neuro-orthopedic disorders.

Safety and long-term effects on gait of hemiplegic patients in equinovarus foot deformity surgical correction followed by immediate rehabilitation: a prospective observational study

BACKGROUND

Equinovarus foot deformity (EVFD) is the most common lower limb deformity in stroke patients. Immobilization following EVFD surgical correction is known to have a negative impact on muscle rearrangement with possible loss of walking ability in stroke patients. In a previous study, safe and positive effects at one-month follow-up after surgery were obtained with an early rehabilitation treatment (ERT) characterized by immediate walking and training.

AIM

To determine long-term safety and efficacy of functional surgery followed by early rehabilitation (FSER).

DESIGN

A 12 months prospective observational study.

SETTING

Outpatients clinic, Gait and Motion Laboratory, Sol et Salus Hospital, Rimini, Italy.

POPULATION

Twenty-four adult chronic stroke survivors with EVFD surgical correction followed by ERT, age 55±13 years, affected side 12L/12R, time from lesion 5±4 years.

METHODS

Patients received clinical and instrumental evaluation by gait analysis (GA) before (T0), one, three and twelve months after surgery. Safety was defined as the absence of any complication consequent to FSER. Efficacy was assessed by the recovery in ankle kinematics, walking speed and space-time parameters.

RESULTS

No clinical complication (thrombosis, surgical wound infection, muscle or tendon injury, muscle hematoma) arose in the sample during the follow-up year. Variables relating to ankle kinematics improved towards their normal values at one month after surgery. These were maintained at 3 and 12 months, with a significant difference between follow-ups and pre-surgical values (Durbin-Conover Test, P<0.01). Gait speed, cadence, anterior step length and stride length of the affected side showed a statistical improvement at 3 and 12 months (Wilcoxon test, P=0.012 and P=0.001, respectively). Stride width decreased at 1 month after surgery and showed a further stable reduction at 3 months (P=0.008).

CONCLUSIONS

The ERT protocol with immediate rehabilitation starting on the first day after surgical correction was safe and effective in providing a long-term correction of EVFD. Ankle dorsiflexion improved both in stance and swing, allowing for a significative improvement in walking speed.

CLINICAL REHABILITATION IMPACT

FSER can be considered an encouraging approach in the management of EVFD, with durable results.

Botulinum toxin type A or selective neurotomy for treating focal spastic muscle overactivity?

OBJECTIVE

To discuss the effectiveness, indications, limitations and side effects of botulinum toxin type A and selective neurotomy for treating focal spastic muscle overactivity to help clinicians choose the most appropriate treatment.

METHODS

Expert opinion based on scientific evidence and personal experience.

RESULTS

Botulinum toxin type A can decrease muscle tone in different types of spastic muscle overactivity, which allows for treating a large variety of spastic patterns with several etiologies. The toxin effect is sometimes insufficient to improve functional outcome and is transient, thereby requiring repeated injections. Selective neurotomy is a permanent surgical treatment of the reflex component of the spastic muscle overactivity (spasticity) that is effective for spastic equinovarus foot. The neurotomy provides a greater and more constant reduction in spasticity. However, the long-lasting effect on the non-reflex muscle overactivity, especially dystonia, is doubted. The effectiveness, clinical indications, advantages, side effects and limitations of both techniques are discussed.

CONCLUSION

Botulinum toxin type A has the highest level of evidence and the largest range of indications. However, the botulinum toxin effect is reversible and seems less effective, which supports a permanent surgical treatment such as selective neurotomy, especially for the spastic foot. Further research is needed to compare the effect of botulinum toxin type A and selective neurotomy for the different types of spastic muscle overactivity and clinical patterns.

Effect of the neuro-orthopedic surgery for spastic equinovarus foot after stroke: a prospective longitudinal study based on a goal-centered approach

BACKGROUND

Neuro-orthopedic surgery is recognized as an effective treatment to improve walking capacity in case of spastic equinovarus foot. However, the effect of surgery on the 3 domains of the International Classification of Functioning, Disability and Health (ICF) has never been studied.

AIM

The aim of this study was to assess the efficacy of the neuro-orthopedic surgery for spastic equinovarus foot after stroke based on a goal-centered approach and on the 3 domains of the International Classification of Functioning, Disability and Health (ICF).

DESIGN

Prospective, single blind, case-series, intervention study (before-after trial) with a 1-year follow-up.

SETTING

University Hospital of Mont-Godinne.

POPULATION

Eighteen hemiplegic patients with spastic equinovarus foot.

METHODS

A selective tibial neurotomy and/or an Achille tendon lengthening, and/or a tibialis anterior tendon transfer were performed to correct a disabling SEF. The primary outcome measure was the goal attainment scale. The secondary outcome measures included body function and structure (spasticity, strength, range of motion, pain, gait speed, ankle kinematics), activities (walking aids, functional ambulation category, functional walking category, ABILOCO) and social participation and quality of life (Satispart-Stroke, SF-36) assessment before and 2 months and 1 year after surgery.

RESULTS

An increase in the goal attainment scale score, in the body function and activity/participation domains of the ICF, a decrease in triceps spasticity and pain, an increase in ankle range of motion and gait speed, an improvement in equinus and a reduction in walking aids were observed.

CONCLUSIONS

This study confirms the efficacy of the neuro-orthopedic surgical treatment of spastic equinovarus foot after stroke to improve walking capacities and to achieve personal goals in the body function and activity/participation domains of the ICF.

CLINICAL REHABILITATION IMPACT

In case of post-stroke spastic foot, a personalized neuro-orthopedic surgical program including neurotomy, tendon lengthening and/or transfer improves patient-centered goals in the different domains of the ICF.