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

Evaluation of therapeutic benefits of botulinum toxin for foot dystonia associated with Parkinson's disease

BACKGROUND

Foot dystonia occurs in patients with Parkinson's disease (PD) and leads to pain, malformation, and difficulty with walking. Botulinum toxin injections may be effective for foot dystonia, but the extent of improvement and effects on motor function are unclear.

METHODS

In this study, we performed botulinum toxin injections for foot dystonia in 25 patients with PD. At 3 weeks and 3 months post-infection, we assessed changes in plantar pressure distribution utilizing the Pressure Plate system; dystonia using the Modified Ashworth Spasm score; pain using the visual analog scale (VAS) score; and lower extremity function using the Calf-raise Senior (CRS) test, Timed Up and Go (TUG) test, and gait parameters (eg, stride length, step length).

RESULTS

We found improved Modified Ashworth Spasm score (p < 0.01) and VAS score (p < 0.01) post-injection. CRS test score (3 weeks, p = 0.006; 3 months, p = 0.068), stride length (3 weeks, p = 0.012; 3 months, p = 0.715), and step length (3 weeks, p = 0.011; 3 months, p = 0.803) also improved. Plantar pressure distribution improved after botulinum toxin injection (metatarsal 1, 3 weeks, p = 0.031; 3 months, p = 0.144; metatarsal 2, 3 weeks, p = 0.049; 3 months, p = 0.065; metatarsal 3, 3 weeks, p = 0.002; 3 months, p = 0.017; metatarsal 4, 3 weeks, p = 0.017; 3 months, p = 0.144; medial heel, 3 weeks, p = 0.01; 3 months, p = 0.395; lateral heel, 3 weeks, p = 0.035; 3 months, p = 0.109).

CONCLUSION

Botulinum toxin injection for foot dystonia in patients with PD can reduce spasms and pain and normalize plantar pressure distribution, which improves balance and lower extremity function.

Stroke Recovery Is a Journey: Prediction and Potentials of Motor Recovery after a Stroke from a Practical Perspective

Stroke recovery is a journey. Stroke survivors can face many consequences that may last the rest of their lives. Assessment of initial impairments allows reasonable prediction of biological spontaneous recovery at 3 to 6 months for a majority of survivors. In real-world clinical practice, stroke survivors continue to improve their motor function beyond the spontaneous recovery period, but management plans for maximal recovery are not well understood. A model within the international classification of functioning (ICF) theoretical framework is proposed to systematically identify opportunities and potential barriers to maximize and realize the potentials of functional recovery from the acute to chronic stages and to maintain their function in the chronic stages. Health conditions of individuals, medical and neurological complications can be optimized under the care of specialized physicians. This permits stroke survivors to participate in various therapeutic interventions. Sufficient doses of appropriate interventions at the right time is critical for stroke motor rehabilitation. It is important to highlight that combining interventions is likely to yield better clinical outcomes. Caregivers, including family members, can assist and facilitate targeted therapeutic exercises for these individuals and can help stroke survivors comply with medical plans (medications, visits), and provide emotional support. With health optimization, comprehensive rehabilitation, support from family and caregivers and a commitment to a healthy lifestyle, many stroke survivors can overcome barriers and achieve potentials of maximum recovery and maintain their motor function in chronic stages. This ICF recovery model is likely to provide a guidance through the journey to best achieve stroke recovery potentials.

The effect of a modified elastic band orthosis on gait and balance in stroke survivors

BACKGROUND

Gait is crucial for independent living for stroke survivors and assistive devices have been developed to support gait performance. Ankle foot orthosis (AFOs) are commonly provided to stroke survivors to prevent foot drop during walking. However, previous studies have reported limitations of AFOs including them being too heavy, creating skin irritation, and being a stigma of disability.

OBJECTIVE

The purpose was to compare the gait and balance improvement between elastic band orthosis (EBOs) and AFOs.

STUDY DESIGN

Experimental study design.

METHODS

The AFOs and EBOs were provided to 17 stroke survivors, and changes in gait and balance were assessed compared to barefoot (control). Gait spatiotemporal parameters were measured using the zebris-FDM-Rehawalk® system, and balance ability was evaluated using the time up and go test (TUG). Satisfaction with the EBOs was determined using the Quebec user evaluation of satisfaction with assistive technology (QUEST2.0) questionnaire.

RESULTS

The EBO showed significant differences in; gait speed, cadence, stride length, stride time, step length unaffected side, stance phase and swing phase on the affected side, and pre-swing on the unaffected side, and balance performance (TUG) (p<0.05) when compared to the AFO and control conditions. The participants were quite satisfied with the EBOs with QUEST2.0 scores greater than 4 out of 5.

CONCLUSIONS

EBOs could be provided to stroke survivors given their acceptability and properties to improve gait and balance. The EBO used in this study offered clinically important improvements in gait and balance when compare to AFO and control conditions, and could mitigate against some of the limitations reported in the use of AFOs in stroke survivors.

Neuro-Rehabilitation Therapy with T-FLEX Ankle Exoskeleton and Serious Games: A Case Study

Acquired Brain Injury (ABI) causes permanent disabilities, such as foot drop. This condition affects the gait pattern, increasing the metabolic cost and risk of falling. Robotics with serious games has shown promising results in the gait rehabilitation context. This paper aims to analyze the effects of using the T-FLEX exoskeleton with (1) Automated Therapy (AT) and (2) Serious Game Therapy (SGT) in two ABI patients. Each participant completed six assisted sessions for each strategy. Results showed that AT increases the user-robot interaction torque by 10% for the first patient and 70% for the second patient, and SGT decreases by 5% for both patients. This way, SGT required the patient to generate torque to execute the ankle movement, while AT did the opposite, resulting in greater device assistance. In the functional assessment, SGT induced variations greater than 50% for the paretic ankle and knee's range of motion (ROM), indicating a potential for motor recovery. Thus, SGT led to improved ankle control and increased gait speed compared to AT. These findings suggest that SGT may be an effective rehabilitation strategy for ABI-related foot drop patients.

The effects of gastrocnemius muscle spasticity on gait symmetry and trunk control in chronic stroke patients

BACKGROUND

Although reduced gait asymmetry and trunk control are generally accepted outcomes in stroke patients after having a stroke, the number of studies examining the factors affecting gait symmetry and trunk control is limited in the literature.

RESEARCH QUESTION

What are the effects of gastrocnemius muscle spasticity on trunk control and gait symmetry in chronic stroke patients?

METHOD

The sample of the study included 29 individuals aged 40-70 who were diagnosed with stroke at least six months ago. The sociodemographic information of the patients was collected using a descriptive information form. Their gastrocnemius muscle spasticity levels were assessed using the Modified Ashworth Scale (MAS), their trunk control was assessed using the Trunk Impairment Scale (TIS), and their gait symmetry was assessed using software developed for the Kinect V2 camera.

RESULTS

There was a numerical difference between the gait symmetry results of the patients who had a MAS score lower than 2 and those who had a MAS score of 2 or higher, where MAS scores corresponded to gastrocnemius muscle spasticity levels, but this difference was not statistically significant (p > 0.05). There was a statistically significant difference between the total TIS scores and TIS coordination subscale scores of the patients who had a MAS score lower than 2 and those who had a MAS score of 2 or higher (p < 0.05). A negative significant relationship was determined between total TIS and TIS coordination subscale scores and the severity of gastrocnemius muscle spasticity.

SIGNIFICANCE

According to the results of our study, to improve trunk control and gait in stroke survivors, the management of gastrocnemius muscle spasticity should be included in rehabilitation programs. We believe that our study will be guiding for future interventional studies aiming to improve trunk control and gait in stroke patients.

Effectiveness of Repetitive Transcranial Magnetic Stimulation Combined with Visual Feedback Training in Improving Neuroplasticity and Lower Limb Function after Chronic Stroke: A Pilot Study

After a stroke, sustained gait impairment can restrict participation in the activities listed in the International Classification of Functioning, Disability, and Health model and cause poor quality of life. The present study investigated the effectiveness of repetitive transcranial magnetic stimulation (rTMS) and visual feedback training (VF) training in improving lower limb motor performance, gait, and corticospinal excitability in patients with chronic stroke. Thirty patients were randomized into three groups that received either rTMS or sham stimulation over the contralesional leg region accompanied by VF training groups in addition to the conventional rehabilitation group. All participants underwent intervention sessions three times per week for four weeks. Outcome measures included the motor-evoked potential (MEP) of the anterior tibialis muscle, Berg Balance Scale (BBS) scores, Timed Up and Go (TUG) test scores, and Fugl–Meyer Assessment of Lower Extremity scores. After the intervention, the rTMS and VF group had significantly improved in MEP latency (p = 0.011), TUG scores (p = 0.008), and BBS scores (p = 0.011). The sham rTMS and VF group had improved MEP latency (p = 0.027). The rTMS and VF training may enhance the cortical excitability and walking ability of individuals with chronic stroke. The potential benefits encourage a larger trial to determine the efficacy in stroke patients.

Stiff Knee Gait Disorders as Neuromechanical Consequences of Spastic Hemiplegia in Chronic Stroke

Stiff knee gait (SKG) is defined as decreased knee flexion during the swing phase. It is one of the most common gait disorders following stroke. Knee extensor spasticity is commonly accepted as the primary cause. Clinical management has focused on the reduction in knee extensor spasticity. Recent advances in understanding of post-stroke hemiplegic gait suggest that SKG can present as mechanical consequences between muscle spasticity, weakness, and their interactions with ground reactions during walking. Various underlying mechanisms are presented through sample cases in this article. They include ankle plantar flexor spasticity, knee extensor spasticity, knee flexor and extensor coactivation, and hip flexor spasticity. Careful and thorough clinical assessment is advised to determine the primary cause for each patient. Understanding of these various presentations of SKG is helpful to guide clinical assessment and select appropriate target muscles for interventions.

Prevalence and clinical predictors of spasticity after intracerebral hemorrhage

BACKGROUND

Spasticity is a common complication of intracerebral hemorrhage (ICH). However, no consensus exists on the relation between spasticity and initial clinical findings after ICH.

METHODS

This retrospective study enrolled adult patients with a history of ICH between January 2012 and October 2020. The modified Ashworth scale was used to assess spasticity. A trained image analyst traced all ICH lesions. Multivariable logistic regression was used to examine the association between ICH lesion sites and spasticity.

RESULTS

We finally analyzed 304 patients (mean age 54.86 ± 12.93 years; 72.04% men). The incidence of spasticity in patients with ICH was 30.92%. Higher National Institutes of Health stroke scale (NIHSS) scores were associated with an increased predicted probability for spasticity (odds ratio, OR = 1.153 [95% confidence interval, CI 1.093-1.216], p < .001). Logistic regression analysis revealed that lower age, higher NIHSS scores, and drinking were associated with an increased risk of moderate-to-severe spasticity (OR = 0.965 [95% CI 0.939-0.992], p = .013; OR = 1.068 [95% CI 1.008-1.130], p = .025; OR = 4.809 [95% CI 1.671-13.840], p = .004, respectively). However, smoking and ICH in the thalamus were associated with a reduced risk of moderate-to-severe spasticity (OR = 0.200 [95% CI 0.071-0.563], p = .002; OR = 0.405 [95% CI 0.140-1.174], p = .046, respectively) compared with ICH in the basal ganglia.

CONCLUSIONS

Our results suggest that ICH lesion locations are at least partly associated with post-stroke spasticity rather than the latter simply being a physiological reaction to ICH itself. The predictors for spasticity after ICH were age, NIHSS scores, past medical history, and ICH lesion sites.

Focal vibration of the plantarflexor and dorsiflexor muscles improves poststroke spasticity: a randomized single-blind controlled trial

BACKGROUND

Post-stroke spasticity is a cause of gait dysfunction and disability. Focal vibration (FV) of agonist-antagonist upper limb muscle pairs reduces flexor spasticity; however, its effects on ankle plantarflexor spasticity are uncertain.

OBJECTIVE

To assess the effects of focal vibration administered by a trained operator to the ankle plantarflexor and dorsiflexor muscles on post-stroke lower limb spasticity.

METHODS

A randomized, single-blind controlled trial of 64 participants with stroke and plantarflexor spasticity assigned to 3 groups by centralized, computer-generated randomization (1:1:1): 1) physiotherapy alone (CON), 2) physiotherapy+gastrocnemius vibration (FV_GM) and 3) physiotherapy+tibialis anterior vibration (FV_TA). Physiotherapists and assessors were blinded to group assignment. The experimental groups underwent 15, 20-min vibration sessions at 40 Hz. We performed evaluations at baseline and after the final treatment: Modified Ashworth Scale (MAS), Clonus scale, Functional Ambulation Categories (FAC), Fugl-Meyer Assessment - Lower Extremity (FMA_LE), Modified Barthel Index (MBI), and electromyography and ultrasound elastography. Primary outcome was remission rate (number and proportion of participants) of the MAS.

RESULTS

MAS remission rate was higher in FV_GM and FV_TA than CON groups (CON vs. FV_GM: p=0.009, odds ratio 0.15 [95% confidence interval 0.03-0.67]; CON vs. FV_TA: p=0.002, 0.12 [0.03-0.51]). Remission rate was higher in the experimental than CON groups for the Clonus scale (CON vs. FV_GM: p<0.001, OR 0.07 [95% CI 0.01-0.31]; CON vs. FV_TA: p=0.006, 0.14 [95% CI 0.03-0.61]). FAC remission rate was higher in the FV_TA than the CON (p=0.009, 0.18 [0.05-0.68]) and FV_GM (p=0.014, 0.27 [0.07-0.99]) groups. Ultrasound variables of the paretic medial gastrocnemius decreased more in FV_GM than CON and FV_TA groups (shear modulus: p=0.006; shear wave velocity: p=0.008).

CONCLUSIONS

Focal vibration reduced post-stroke spasticity of the plantarflexor muscles. Vibration of the tibialis anterior improved ambulation more than vibration of the gastrocnemius or physiotherapy alone. Gastrocnemius vibration may reduce spasticity by changing muscle stiffness.

Aging after stroke: how to define post-stroke sarcopenia and what are its risk factors?

BACKGROUND

Sarcopenia, generally described as "aging-related loss of skeletal muscle mass and function", can occur secondary to a systemic disease.

AIM

This project aimed to study the prevalence of sarcopenia in chronic ambulatory stroke survivors and its associated risk factors using the two most recent diagnostic criteria.

DESIGN

A cross-sectional observational study.

SETTING

A scientific laboratory.

POPULATION

Chronic stroke.

METHODS

Twenty-eight ambulatory chronic stroke survivors (12 females; mean age=57.8±11.8 years; time after stroke=76±45 months), hand-grip strength, gait speed, and appendicular skeletal muscle mass (ASM) were measured to define sarcopenia. Risk factors, including motor impairment and spasticity, were identified using regression analysis.

RESULTS

The prevalence of sarcopenia varied between 18% and 25% depending on the diagnostic criteria used. A significant difference was seen in the prevalence of low hand grip strength on the affected side (96%) when compared to the contralateral side (25%). The prevalence of slow gait speed was 86% while low ASM was present in 89% of the subjects. Low ASM was marginally negatively correlated with time since stroke and gait speed, but no correlation was observed with age, motor impairment, or spasticity. ASM loss, bone loss and fat deposition were significantly greater in the affected upper limb than in the affected lower limb. Regression analyses showed that time since stroke was a factor associated with bone and muscle loss in the affected upper limb, spasticity had a protective role for muscle loss in the affected lower limb, and walking had a protective role for bone loss in the lower limb.

CONCLUSIONS

The prevalence of sarcopenia in stroke survivors is high and is a multifactorial process that is not age-related. Different risk factors contribute to muscle loss in the upper and lower limbs after stroke.

CLINICAL REHABILITATION IMPACT

Clinicians need to be aware of high prevalence of sarcopenia in chronic stroke survivors. Sarcopenia is more evident in the upper than lower limbs. Clinicians also need to understand potential protective roles of some factors, such as spasticity and walking for the muscles in the lower limb.

Effect of Dry Needling Treatment on Tibial Musculature in Combination with Neurorehabilitation Treatment in Stroke Patients: Randomized Clinical Study

(1) Background: Introducing ultrasound-guided dry needling to neurorehabilitation treatments increases the beneficial effects of therapy. The aim of this study was to compare the effects of including an ultrasound-guided dry needling session in neurorehabilitation treatment on spasticity and gait-balance quality versus neurorehabilitation treatment in subjects who had suffered a stroke. (2) Methods: A single-blind, randomized clinical trial was conducted. Thirty-six patients who had suffered a stroke in the right middle cerebral artery signed the informed consent for participation in the study. Twenty patients finally participated and were randomly assigned to the control group (neurorehabilitation treatment) or experimental group (neurorehabilitation treatment plus ultrasound-guided dry needling). Pre-treatment and post-treatment data were collected on the same day. The experimental group (n = 10) first underwent an ultrasound-guided dry needling intervention on the tibialis anterior and tibialis posterior musculature, followed by neurorehabilitation treatment; the control group (n = 10) underwent their corresponding neurorehabilitation without the invasive technique. Pre-treatment and post-treatment measurements were taken on the same day, assessing the quality of balance-gait using the "Up and Go" test and the degree of spasticity using the Modified Modified Ashworth Scale. (3) Results: The patients who received neurorehabilitation treatment plus ultrasound-guided dry needling showed a greater decrease in spasticity in the tibial musculature after the neurorehabilitation treatment session (p < 0.001), improving balance and gait (p < 0.001). (4) Conclusions: An ultrasound-guided dry needling session combined with neurorehabilitation treatment reduced spasticity and improved balance and gait in stroke patients.

Effects of Extensor Digitorum Longus and Tibialis Anterior Taping on Balance and Gait Performance in Patients Post Stroke

The purpose of this study was to investigate the effects of extensor digitorum longus taping (EDLT) and tibialis anterior taping (TAT) on balance and gait performance in patients post-stroke. The study included 40 stroke patients randomly assigned to two intervention groups: the EDLT group and the TAT group. Therapeutic taping was applied to the extensor digitorum in the EDLT group and applied to the tibialis anterior in the TAT group. Balance variables were measured using BioRescue equipment, and gait variables were measured using G-walk equipment. Balance and gait variables were significantly increased in both the EDLT and TAT groups after the intervention, but there were no significant differences between the two groups. Therefore, we concluded that eversion (EDLT) or inversion (TAT) through taping did not affect the outcome. Only dorsiflexion affects gait speed increase post-stroke. As a result of this study, extensor digitorum longus taping and tibialis anterior taping were taping methods with no difference in the improvement of balance ability and gait performance.

Efficacy of Overground Robotic Gait Training on Balance in Stroke Survivors: A Systematic Review and Meta-Analysis

Strokes often lead to a deficit in motor control that contributes to a reduced balance function. Impairments in the balance function severely limit the activities of daily living (ADL) in stroke survivors. The present systematic review and meta-analysis primarily aims to explore the efficacy of overground robot-assisted gait training (o-RAGT) on balance recovery in individuals with stroke. In addition, the efficacy on ADL is also investigated. This systematic review identified nine articles investigating the effects of o-RAGT on balance, four of which also assessed ADL. The results of the meta-analysis suggest that o-RAGT does not increase balance and ADL outcomes more than conventional therapy in individuals after stroke. The data should not be overestimated due to the low number of studies included in the meta-analysis and the wide confidence intervals. Subgroup analyses to investigate the influence of participant’s characteristics and training dosage were not performed due to lack of data availability. Further well-designed randomized controlled trials are needed to investigate the efficacy of o-RAGT on balance in individuals with stroke.

Is the Outcome of Diagnostic Nerve Block Related to Spastic Muscle Echo Intensity? A Retrospective Observational Study on Patients with Spastic Equinovarus Foot

OBJECTIVE

To investigate the relationship between spastic calf muscles echo intensity and the outcome of tibial nerve motor branches selective block in patients with spastic equinovarus foot.

DESIGN

Retrospective observational study.

PATIENTS

Forty-eight patients with spastic equinovarus foot.

METHODS

Each patient was given selective diagnostic nerve block (lidocaine 2% perineural injection) of the tibial nerve motor branches. All patients were evaluated before and after block. Outcomes were: spastic calf muscles echo intensity measured with the Heckmatt scale; affected ankle dorsiflexion passive range of motion; calf muscles spasticity measured with the modified Ashworth scale and the Tardieu scale (grade and angle).

RESULTS

Regarding the outcome of tibial nerve selective diagnostic block (difference between pre- and post-block condition), Spearman's correlation showed a significant inverse association of the spastic calf muscles echo intensity with the affected ankle dorsiflexion passive range of motion (p = 0.045; ρ = 00-0.269), modified Ashworth scale score (p = 0.014; ρ = -0.327), Tardieu grade (p = 0.008; ρ = -0.352) and Tardieu angle (p = 0.043; ρ = -0.306).

CONCLUSION

These findings support the hypothesis that patients with spastic equinovarus foot with higher spastic calf muscles echo intensity have a poor response to selective nerve block of the tibial nerve motor branches.

Development of a New Ankle Joint Hybrid Assistive Limb

Foot and ankle disabilities (foot drop) due to common peroneal nerve palsy and stroke negatively affect patients’ ambulation and activities of daily living. We developed a novel robotics ankle hybrid assistive limb (HAL) for patients with foot drop due to common peroneal nerve palsy or stroke. The ankle HAL is a wearable exoskeleton-type robot that is used to train plantar and dorsiflexion and for voluntary assistive training of the ankle joint of patients with palsy using an actuator, which is placed on the lateral side of the ankle joint and detects bioelectrical signals from the tibialis anterior (TA) and gastrocnemius muscles. Voluntary ankle dorsiflexion training using the new ankle HAL was implemented in a patient with foot drop due to peroneal nerve palsy after lumbar surgery. The time required for ankle HAL training (from wearing to the end of training) was approximately 30 min per session. The muscle activities of the TA on the right were lower than those on the left before and after ankle HAL training. The electromyographic wave of muscle activities of the TA on the right was slightly clearer than that before ankle HAL training in the resting position immediately after ankle dorsiflexion. Voluntary ankle dorsiflexion training using the novel robotics ankle HAL was safe and had no adverse effect in a patient with foot drop due to peroneal nerve palsy.

Inter-rater reliability of the Australian Spasticity Assessment Scale in poststroke spasticity

To investigate the inter-rater reliability of the Australian Spasticity Assessment Scale (ASAS) in adult stroke patients with spasticity, two experienced clinicians rated the elbow flexor, wrist flexor, and ankle plantar flexor spasticity by using the ASAS in 85 persons with stroke. Unweighted and weighted (linear and quadratic) kappa statistics were used to calculate the inter-rater reliability for each muscle group. Unweighted kappa coefficients for elbow flexors (n = 83), wrist flexors (n = 80), and ankle plantar flexors (n = 77) were 0.67, 0.60, and 0.55, respectively. Linear and quadratic weighted kappa coefficients, respectively, were 0.77 and 0.87 for elbow flexors, 0.72 and 0.82 for wrist flexors, and 0.72 and 0.85 for ankle plantar flexors. The raters never disagreed by more than a single score in the rating of elbow flexors. On the contrary, the raters disagreed by more than a single score in three patients in the rating of ankle plantar flexors and in one patient in the rating of wrist flexors. The results suggested that inter-rater reliability of the ASAS differed according to the spastic muscle group assessed and the statistical method used. The strength of the agreement on the ASAS, an ordinal scale, ranged from good to very good when the weighted kappa values were considered.

Ankle dorsiflexion training with a newly developed Hybrid Assistive Limb for a patient with foot drop caused by common peroneal nerve palsy: a case report

[Purpose] An ankle disorder (foot drop) caused by common peroneal nerve palsy or cerebrovascular accident (stroke) interferes with patients’ ability to walk and hinders in activities of daily living. A new robotic ankle, the Hybrid Assistive Limb, has been developed for the treatment of foot drop caused by common peroneal nerve palsy or sequelae of stroke. The purpose in this study was to report and examine the efficacy and feasibility of a case who was treated with voluntary ankle dorsiflexion training with the ankle Hybrid Assistive Limb. [Participant and Method] A 60-year-old man with foot drop due to peroneal nerve palsy that occurred without a contributory cause was treated via ankle dorsiflexion training with the use of a new robotic ankle, the “Ankle Hybrid Assistive Limb”. [Results] Following total ankle rehabilitation training with the Ankle Hybrid Assistive Limb, improvements in ankle dorsiflexor strength, gait, and sensory function of the lower leg and foot were observed. [Conclusion] The newly developed ankle Hybrid Assistive Limb could be an effective training tool for foot drop caused by common peroneal nerve palsy.

Effect of functional electrical stimulation on postural control in children with hemiplegic cerebral palsy: a randomized controlled trial

Background

Children with cerebral palsy have impairments of postural control during static and dynamic activities. Improving postural control is one of the primary objectives of rehabilitation for children with cerebral palsy. Therefore, the objective of this study was to study the effect of functional electric stimulation on postural control in children with hemiplegic cerebral palsy. A randomized controlled study was conducted on 30 children with hemiplegic cerebral palsy (18 boys and 12 girls) between the ages of 8 and 12 years. The children were distributed in two equal groups. The experimental group received functional electrical stimulation (pulse width 300 μs, frequency 33 Hz, 2 h/day, 3 days/week, / 3 consecutive months) in addition to the traditional physical therapy program. While the control group received the traditional physiotherapy program only for the same duration. The outcomes included postural stability indices that were measured at baseline and following 3 months of intervention using the Biodex balance system.

Results

A significant improvement was found in the postural stability indices of children in both groups, comparing their mean values before and after treatment. Furthermore, the results revealed a greater improvement in the postural stability of the experimental group (P < 0.001).

Conclusion

Functional electrical stimulation may be a useful tool to enhance the postural stability of children with hemiplegic cerebral palsy.

Clinical trial registration

This study was registered in the ClinicalTrial.gov PRS (NCT04269798). https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0009LHP&selectaction=Edit&uid=U0003GAI&ts=4&cx=74k74l

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.

Neurologic Conditions Associated with Cavus Foot Deformity

The cavus foot deformity is an often less understood deformity within the spectrum of foot and ankle conditions. The hallmark concern is the possibility of an underlying neurologic or neuromuscular disorder. Although a proportion of these deformities are idiopathic, a significant majority do correlate with an underlying disorder. The appropriate evaluation of this deformity, in coordination within the multidisciplinary scope of health care, allows for a timely diagnosis and understanding of the patient's condition. We provide an abbreviated survey of possible underlying etiologies for the patient with the cavus foot deformity as a reference to the foot and ankle surgeon.

A New Definition of Poststroke Spasticity and the Interference of Spasticity With Motor Recovery From Acute to Chronic Stages

The relationship of poststroke spasticity and motor recovery can be confusing. "True" motor recovery refers to return of motor behaviors to prestroke state with the same end-effectors and temporo-spatial pattern. This requires neural recovery and repair, and presumably occurs mainly in the acute and subacute stages. However, according to the International Classification of Functioning, Disability and Health, motor recovery after stroke is also defined as "improvement in performance of functional tasks," i.e., functional recovery, which is mainly mediated by compensatory mechanisms. Therefore, stroke survivors can execute motor tasks in spite of disordered motor control and the presence of spasticity. Spasticity interferes with execution of normal motor behaviors ("true" motor recovery), throughout the evolution of stroke from acute to chronic stages. Spasticity reduction does not affect functional recovery in the acute and subacute stages; however, appropriate management of spasticity could lead to improvement of motor function, that is, functional recovery, during the chronic stage of stroke. We assert that spasticity results from upregulation of medial cortico-reticulo-spinal pathways that are disinhibited due to damage of the motor cortex or corticobulbar pathways. Spasticity emerges as a manifestation of maladaptive plasticity in the early stages of recovery and can persist into the chronic stage. It coexists and shares similar pathophysiological processes with related motor impairments, such as abnormal force control, muscle coactivation and motor synergies, and diffuse interlimb muscle activation. Accordingly, we propose a new definition of spasticity to better account for its pathophysiology and the complex nuances of different definitions of motor recovery.

Real-world analysis of botulinum toxin (BoNT) injections in post-stroke spasticity: Higher doses of BoNT and longer intervals in the early-start group

Our primary objective was to compare early-start vs. late-start Botulinum toxin (BoNT) injections in post-stroke spasticity management. This is an IRB approved retrospective chart review of patients who were admitted for inpatient rehabilitation within 6 months after first-ever stroke between January 2014 and December 2018 and received BoNT injections within 15 months. The total dose and interval between consecutive injections were used as objective outcomes. 2367 stroke admissions were reviewed. 189 patients metinclusion criteria. 68 out of 189 patients received BoNT injections within 12 weeks after stroke (EARLY group). 20 patients in the EARLY group who received at least three cycles were included for analysis. Out of 189 patients, 47 patients were categorized into the Early- and Late-start subgroups each by time from stroke onset to first BoNT injection (1st and 4th quartiles of time distribution) for comparisons. In the EARLY group, the first interval (Mean (M) = 7.6 weeks, standard deviation (SD) = 2.14) was significantly shorter than the second interval (M = 23.7, SD = 10.41) and the third interval (M = 20.0, SD = 11.23; p < 0.05). The dose at the first cycle (M = 492 units, SD = 201.5) was significantly lower than the dose at the third cycle (M = 605, SD = 82.6). In comparison between the Early- and Late-start subgroups, the time to first BoNT injection was 6.4 weeks (range: 4.7-8.6) after stroke for the Early-start subgroup and 49.6 weeks (range: 27.4-62.3) after stroke for the Late-start subgroup. The subsequent intervals after the first injection were significantly longer in the Early-start subgroup (M = 23.1 weeks) than in the Late-start subgroup (M = 14.6 weeks) (p = 0.008). The average total dose of BoNT was significantly higher in the Early-start subgroup (M = 561.9 units, SD = 143.1) than the Late-start subgroup (M = 470.0, SD = 164.8) (p = 0.012). The findings showed that higher doses of BoNT were used in the Early-start group, and often resulted in longer intervals between subsequent injections than in the Late-start group.

Prevalence and Risk Factors for Spasticity After Stroke: A Systematic Review and Meta-Analysis

Background: Spasticity is a common sequela of stroke. The incidence of poststroke spasticity (PSS) has not been systematically reviewed in recent years, and some risk factors remain debated. This systematic review and meta-analysis was conducted to determine the prevalence and risk factors for PSS. Methods: We searched electronic databases (PubMed, Embase, Cochrane Library, CNKI, WANFANG and CBM) inception to May 12, 2020. Observational studies summarizing the incidence or risk factors for PSS were included. Only cohort studies were enrolled in meta-analysis. For risk factors examined in at least three different studies, we combined effects into odds ratios (OR) and 95% confidence intervals (CI). Results: One thousand four hundred sixty-seven studies were retrieved and 23 were involved in meta-analysis. The pooled prevalence of spasticity after stroke was 25.3% and that after the first-ever stroke was 26.7%. The incidence of spasticity after the first-ever stroke with paresis was 39.5%. The prevalence of disabling or severe spasticity (MAS ≥ 3) in stroke patients with paresis was 9.4% (95% CI 0.056-0.133), and severe spasticity was 10.3% (95% CI 0.058-0.149). Moderate to severe paresis (OR = 6.573, 95% CI 2.579-16.755, I ² = 0.0%), hemorrhagic stroke (OR = 1.879, 95% CI 1.418-2.490, I ² = 27.3%) and sensory disorder were risk factors for PSS. Conclusions: The incidence of PSS was significantly higher in stroke patients with paresis. Patients with moderate to severe paresis and sensory disorder should be closely followed up. The role of hemorrhagic stroke in predicting PSS remains to be further explored.

Role of Spasticity Severity in the Balance of Post-stroke Patients

Background: Lower limb spasticity after stroke is common that can affect the balance, increase the risk of falling, and reduces the quality of life. Objective: First, evaluate the effects of spasticity severity of ankle plantar flexors on balance of patients after stroke. Second, to determine the relationship between the spasticity severity with ankle proprioception, passive ankle dorsiflexion range of motion (ROM), and balance confidence. Methods: Twenty-eight patients with stroke based on the Modified Modified Ashworth Scale (MMAS) were divided into two groups: High Spasticity Group (HSG) (MMAS > 2) (n = 14) or a Low Spasticity Group (LSG) (MMAS ≤ 2) (n = 14). The MMAS scores, Activities-Specific Balance Confidence Questionnaire, postural sway of both affected and non-affected limbs under the eyes open and eyes closed conditions, timed up and go (TUG) test, passive ankle dorsiflexion ROM, and ankle joint proprioception were measured. Results: The ankle joint proprioception was significantly better in the LSG compared to the HSG (p = 0.01). No significant differences were found between the LSG and HSG on all other outcome measures. There were no significant relationships between the spasticity severity and passive ankle dorsiflexion ROM, and balance confidence. Conclusion: The severity of ankle plantar flexor spasticity had no effects on balance of patients with stroke. However, the ankle joint proprioception was better in patients with low spasticity. Our findings suggest that the balance is affected regardless of the severity of the ankle plantar flexor spasticity in this group of participants with stroke.

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.