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.

Bimanual motor skill learning with robotics in chronic stroke: comparison between minimally impaired and moderately impaired patients, and healthy individuals.

BACKGROUND: Most activities of daily life (ADL) require cooperative bimanual movements. A unilateral stroke may severely impair bimanual ADL. How patients with stroke (re)learn to coordinate their upper limbs (ULs) is largely unknown. The objectives are to determine whether patients with chronic supratentorial stroke could achieve bimanual motor skill learning (bim-MSkL) and to compare bim-MSkL between patients and healthy individuals (HIs). METHODS: Twenty-four patients and ten HIs trained over 3 consecutive days on an asymmetrical bimanual coordination task (CIRCUIT) implemented as a serious game in the REAplan® robot. With a common cursor controlled by coordinated movements of the ULs through robotic handles, they performed as many laps as possible (speed constraint) on the CIRCUIT while keeping the cursor within the track (accuracy constraint). The primary outcome was a bimanual speed/accuracy trade-off (biSAT), we used a bimanual coordination factor (biCO) and bimanual forces (biFOP) for the secondary outcomes. Several clinical scales were used to evaluate motor and cognitive functions. RESULTS: Overall, the patients showed improvements on biSAT and biCO. Based on biSAT progression, the HI achieved a larger bim-MSkL than the patients with mild to moderate impairment (Fugl-Meyer Assessment Upper Extremity (FMA-UE): 28-55, n = 15) but not significantly different from those with minimal motor impairment (FMA-UE: 66, n = 9). There was a significant positive correlation between biSAT evolution and the FMA-UE and Stroke Impact Scale. CONCLUSIONS: Both HI and patients with chronic stroke training on a robotic device achieved bim-MSkL, although the more impaired patients were less efficient. Bim-MSkL with REAplan® may be interesting for neurorehabilitation after stroke. TRIAL REGISTRATION: ClinicalTrial.gov identifier: NCT03974750. Registered 05 June 2019. https://clinicaltrials.gov/ct2/show/NCT03974750?cond=NCT03974750&draw=2&rank=1.

Impact of soft splints on upper limb spasticity in chronic patients with disorders of consciousness: A randomized, single-blind, controlled trial.

OBJECTIVE: To assess the effectiveness of soft splints on spasticity and hand opening in chronic patients with upper limb spasticity and disorders of consciousness (vegetative state/unresponsive wakefulness syndrome-VS/UWS and minimally conscious state-MCS). METHODS: In this prospective single-blind controlled trial, a blind evaluator assessed spasticity (Modified Ashworth Scale and Modified Tardieu Scale), range of motion (ROM) at the metacarpophalangeal, wrist and elbow joints and the patients' hand opening before and after soft splinting, manual stretching and a control condition (i.e. no treatment), as well as 60 minutes later. SUBJECTS: Seventeen patients with chronic (>3 months) disorders of consciousness were included (five VS/UWS; seven women; mean age = 42 ± 12 years; time since insult = 35 ± 31 months). Patients received either passive splinting, manual stretching treatment or no treatment. RESULTS: Thirty minutes of soft splinting or 30 minutes of manual stretching both improved spasticity of the finger flexors. An increase of hand opening ability was observed after 30 minutes of soft splinting. CONCLUSION: Thirty minutes of soft splint application reduces spasticity and improves hand opening of patients with chronic disorders of consciousness. Soft splinting is well tolerated and does not require supervision.

SurLym trial: study protocol for a multicentre pragmatic randomised controlled trial on the added value of reconstructive lymphatic surgery to decongestive lymphatic therapy for the treatment of lymphoedema.

INTRODUCTION: Lymphoedema is a chronic condition caused by lymphatic insufficiency. It leads to swelling of the limb/midline region and an increased risk of infection. Lymphoedema is often associated with mental and physical problems limiting quality of life. The first choice of treatment is a conservative treatment, consisting of exercises, skin care, lymph drainage and compression. Reconstructive lymphatic surgery is also often performed, that is, lymphovenous anastomoses, lymph node transfer or a combination. However, robust evidence on the effectiveness of reconstructive lymphatic surgery is missing. Therefore, the objective of this trial is to investigate the added value of reconstructive lymphatic surgery to the conservative treatment in patients with lymphoedema. METHODS AND ANALYSIS: A multicentre randomised controlled and pragmatic trial was started in March 2022 in three Belgian university hospitals. 90 patients with arm lymphoedema and 90 patients with leg lymphoedema will be included. All patients are randomised between conservative treatment alone (control group) or conservative treatment with reconstructive lymphatic surgery (intervention group). Assessments are performed at baseline and at 1, 3, 6, 12, 18, 24 and 36 months. The primary outcome is lymphoedema-specific quality of life at 18 months. Key secondary outcomes are limb volume and duration of wearing the compression garment at 18 months. The approach of reconstructive lymphatic surgery is based on presurgical investigations including clinical examination, lymphofluoroscopy, lymphoscintigraphy, lymph MRI or CT angiography (if needed). All patients receive conservative treatment during 36 months, which is applied by the patient's own physical therapist and by the patient self. From months 7 to 12, the hours a day of wearing the compression garment are gradually decreased. ETHICS AND DISSEMINATION: The study has been approved by the ethical committees of University Hospitals Leuven, Ghent University Hospital and CHU UCL Namur. Results will be disseminated via peer-reviewed journals and presentations. TRIAL REGISTRATION NUMBER: NCT05064176.

Case Study of Intrathecal Baclofen Pump Motor Shutdown Secondary to the Effect of the Magnetic Field Created by a Personal Digital Tablet and Magnetic Cover.

ABSTRACT: We present the case of a posttraumatic C6 AIS A tetraplegic patient with spasticity treated with an intrathecal baclofen pump, who noticed a transient increase in his spasticity each time he used a digital tablet (Ipad) protected by a magnetic shell placed on his abdomen. Telemetry confirmed transient motor shutdown responsible for withdrawal symptoms each time the tablet was used. Symptoms resolved after the removal of the protective shell. Effects of magnetic fields like magnetic resonance imaging are known to stall the pump rotor, which recover at the end of magnetic resonance imaging. Other sources of magnetic fields like laptops or new smartphones with magnet charging technology may also interfere with implanted devices. We therefore recommend patients to avoid close contact of magnetic devices with the intrathecal baclofen pump. More robust studies are warranted to assess the effect of the new magnetic technologies on the function of intrathecal pumps.

Effects of Diagnostic Tibial Nerve Block and Selective Tibial Nerve Neurotomy on Spasticity and Spastic co-contractions: A Retrospective Observational Study.

OBJECTIVE: To assess the effects of diagnostic nerve block and selective tibial neurotomy on spasticity and co-contractions in patients with spastic equinovarus foot. METHODS: Among 317 patients who underwent a tibial neurotomy between 1997 and 2019, 46 patients who met the inclusion criteria were retrospectively screened. Clinical assessment was made before and after diagnostic nerve block and within 6 months after neurotomy. A total of 24 patients underwent a second assessment beyond 6 months after surgery. Muscle strength, spasticity, angle of catch (XV3), passive (XV1) and active (XVA) ankle range of motion were measured. The spasticity angle X (XV1-XV3) and paresis angle Z (XV1-XVA) were calculated with the knee in flexed and extended positions. RESULTS: Tibialis anterior and triceps surae strength remained unchanged, while both Ashworth and Tardieu scores were highly reduced after nerve block and neurotomy at all measurement times. XV3 and XVA increased significantly after block and neurotomy. XV1 increased slightly after neurotomy. Consequently, spasticity angle X and paresis angle Z decreased after nerve block and neurotomy. CONCLUSION: Tibial nerve block and neurotomy improve active ankle dorsiflexion, probably by reducing spastic co-contractions. The results also confirmed a long-lasting decrease in spasticity after neurotomy and the predictive value of nerve blocks.

Selecting Goals and Target Muscles for Botulinum Toxin A Injection Using the Goal Oriented Facilitated Approach to Spasticity Treatment (GO-FAST) Tool.

The objective of this article is to introduce the GO-FAST Tool (developed by the Toxnet group) to clinicians working in the field of neurological rehabilitation, specifically post-stroke spasticity management. The concepts utilized in the Tool and described in this article can be broadly grouped into five topics: the principles of patient-centred goal-setting; an algorithm for setting SMART (specific, measurable, attainable, realistic, and timed) treatment goals; goal-related target muscles and botulinum toxin type A dose determinants; goal attainment follow-up, scoring, and interpretation; and the multimodal approach to spasticity management. The Tool can enhance clinical practice by providing guided assistance with goal-setting and target muscle selection for botulinum toxin type A treatment. It also provides support with the follow-up evaluation of goal attainment and calculation of treatment success. The Tool is designed to be used by clinicians with varying levels of expertise in the field of neurological rehabilitation and post-stroke spasticity management, from those who are new to the field to those with many years of experience. A case study is presented in the Results Section of the article to illustrate the utility of the Tool in setting SMART treatment goals in the management of patients with post-stroke spasticity.

Spontaneous non-traumatic hip dislocation in patients with stroke.

This is a unique clinical case of a spontaneous non-traumatic hip dislocation in a patient with stroke with a hip and knee flexion pattern. This case highlights the role of spasticity as a cause of hip dislocation and the need to combine focal spasticity treatment and surgery to restore ambulation.

Worldwide Survey of Clinician Practice on use of Adjunctive Therapies Following Botulinum Toxin Injection for Spasticity.

OBJECTIVE: Non-pharmacological adjunctive therapies can be used alongside botulinum toxin injection to enhance its efficacy. The objective of this global study was to determine the current practice and perception among clinicians of the use of adjunctive therapies after botulinum toxin injections for the treatment of limb spasticity. METHODS: A questionnaire with 22 questions on clinical practice demographics, self-reported use and clinician opinion on barriers to the use of complementary therapies, and priorities for future research was translated into 7 languages and distributed worldwide through national and international professional associations concerning (neuro)rehabilitation. RESULTS: A total of 527 clinicians from 52 countries responded to the survey. Most commonly used physical interventions were: active exercise programmes at home (81%), stretching programmes at home (81%), and splinting (70%), followed by active movement exercises (65%) and within 30 min of botulinum toxin injection and constraint induced movement therapy (63%). The main barriers reported by clinicians to provision of these interventions were clinicians' lack of time, limited financial resources, and lack of evidence. Future research should focus primarily on immediate active movement exercises and passive stretching. CONCLUSION: Worldwide, clinicians often recommend adjunctive therapies after a botulinum toxin injection to reduce spasticity. The most commonly used physical interventions among clinicians were active exercises at home, stretching at home, and splinting. Lack of evidence, time and financial constraints were identified as barriers to providing these interventions.

Botulinum Toxin Services for Neurorehabiliation: Recommendations for Challenges and Opportunities during the COVID-19 Pandemic.

The COVID-19 pandemic severely impacted the function of medical facilities and rehabilitation services worldwide, including toxin services delivering Botulinum toxin treatments for neuromuscular conditions such as spasticity, dystonia, and sialorrhea. The aim of this paper is to understand how toxin services have dealt with the situation and what strategies have been adopted to continue services. The recommendations are based on a virtual round table held with toxin services experts from different European countries who shared their experiences and discussed the best practices. The challenges for toxin services were reviewed based on the experts' experiences and on relevant literature from 2020 and 2021. A set of recommendations and best practices were compiled, focusing firstly on guidance for clinical practice, including assessing patients' health and risk status and the urgency of their treatment. Secondly, it was discussed how patients on botulinum toxin therapy can be cared for and supported during the pandemic, and how modern technology and tele-medicine platforms can be generally used to optimize effectiveness and safety of toxin treatments. The technological advances prompted by the COVID-19 crisis can result in better and more modern patient care in the future.

Cross-cultural validation of the French version of the Lymphedema Functioning, Disability and Health Questionnaire for Upper Limb Lymphedema (Lymph-ICF-UL).

PURPOSE: Upper limb lymphedema is a vexing morbidity that can occur after the treatment for breast cancer. The Lymphedema Functioning, Disability and Health Questionnaire for Upper Limb Lymphedema (Lymph-ICF-UL) is a valid and reliable tool assessing problems in functioning in patients with breast cancer-related lymphedema. Until now, a French-language version was lacking. The aim of this study was to perform a cross-cultural validation of the French version of the Lymph-ICF-UL questionnaire. METHODS: A forward-backward translation process between the original language (Dutch) and the target language (French) was performed. Psychometric properties of this final French version were examined in 50 participants. RESULTS: Intraclass correlation coefficients for test-retest reliability ranged from 0.66 to 0.95. Cronbach's alpha coefficients for internal consistency were higher than 0.77. Face and content validity were very good because the scoring system was clear for all participants (100%), questions were understandable (100%), and all complaints due to BCRL were mentioned by 78% of the participants. Construct validity was moderate. Convergent validity was established since 3 out of 5 expected domains of the Lymph-ICF-UL showed a moderate correlation with expected domains of the 36-item Short-Form Health Survey. There was satisfactory divergent validity as 6 out of 9 hypotheses assessing divergent validity were accepted. CONCLUSION: The French version of the Lymph-ICF-UL is a reliable and valid questionnaire and ready for use in clinical as well as in scientific practice.Implications for rehabilitationSince the introduction of more effective treatment modalities increasing the number of breast cancer survivors, the amount of patients dealing with lymphedema is rising likewise up to a pooled incidence rate of more than 16% of the women treated for breast cancer.The French version of the Lymph-ICF-UL is a reliable and valid questionnaire for assessing problems in functioning of patients with breast cancer-related lymphedema of the arm and/or hand.As the questionnaire provides patient information in the different domains of the International Classification of Functioning, Disability and Health, it facilitates evaluating the impact of breast cancer-related lymphedema on daily functioning.Based on the outcomes of the Lymph-ICF-UL treatment goals can be set, where after the questionnaire can be used to monitor long-term results of this treatment and self-care.

The Effect of Repeated abobotulinumtoxinA (Dysport®) Injections on Walking Velocity in Persons with Spastic Hemiparesis Caused by Stroke or Traumatic Brain Injury.

BACKGROUND: Botulinum toxin (BoNT) injections were shown to improve muscle tone of limbs in patients with spasticity. However, limited data are available regarding the effects of repeated BoNT injections on walking ability. OBJECTIVE: To assess changes in walking velocity (WV), step length, and cadence under different test conditions after repeated treatment with abobotulinumtoxinA (aboBoNT-A; Dysport) in spastic lower limb muscles. DESIGN: Secondary analysis of an open-label, multiple-cycle extension (National Clinical Trials number NCT01251367) to a phase III, double-blind, randomized, placebo-controlled, single-treatment cycle study, in adults with chronic hemiparesis (NCT01249404). SETTING: Fifty-two centers across Australia, Belgium, the Czech Republic, France, Hungary, Italy, Poland, Portugal, Russia, Slovakia, and the United States. PATIENTS: 352 Ambulatory adults (18-80 years) with spastic hemiparesis and gait dysfunction caused by stroke or traumatic brain injury, with a comfortable barefoot WV of 0.1 to 0.8 m/s. INTERVENTIONS: Up to four aboBoNT-A treatment cycles, administered to spastic lower limb muscles. MAIN OUTCOME MEASUREMENTS: Changes from baseline in comfortable and maximal barefoot and with shoes WV (m/s), step length (m/step), and cadence (steps/minutes). RESULTS: At Week 12 after four injections, WV improved by 0.08 to 0.10 m/s, step length by 0.03 to 0.04 m/step, and cadence by 3.9 to 6.2 steps/minutes depending on test condition (all P < .0001 to .0003 vs baseline). More patients (7% to 17%) became unlimited community ambulators (WV ≥0.8 m/s) across test conditions compared with baseline, with 39% of 151 patients classified as unlimited community ambulators in at least one test condition and 17% in all four test conditions. CONCLUSIONS: Clinically meaningful and statistically significant improvements in WV, step length, and cadence under all four test conditions were observed in patients with spastic hemiparesis after each aboBoNT-A treatment cycle.

A practical guide to optimizing the benefits of post-stroke spasticity interventions with botulinum toxin A: An international group consensus.

This consensus paper is derived from a meeting of an international group of 19 neurological rehabilitation specialists with a combined experience of more than 250 years (range 4-25 years; mean 14.1 years) in treating post-stroke spasticity with botulinum toxin A. The group undertook critical assessments of some recurring practical challenges, not yet addressed in guidelines, through an exten-sive literature search. They then discussed the results in the light of their individual clinical experience and developed consensus statements to present to the wider community who treat such patients. The analysis provides a comprehensive overview of treatment with botulinum toxin A, including the use of adjunctive therapies, within a multidisciplinary context, and is aimed at practicing clinicians who treat patients with post-stroke spasticity and require further practical guidance on the use of botulinum toxin A. This paper does not replicate information published elsewhere, but instead aims to provide practical advice to help optimize the use of botulinum toxin A and maximize clinical outcomes. The recommendations for each topic are summarized in a series of statements. Where published high-quality evidence exists, the recommendations reflect this. However, where evidence is not yet conclusive, the group members issued statements and, in some cas-es, made recommendations based on their clinical experience.

Selective tibial neurotomy in the treatment of spastic equinovarus foot in hemiplegic patients: a 2-year longitudinal follow-up of 30 cases.

OBJECTIVE: To assess the long-term efficacy of selective tibial neurotomy in the treatment of spastic equinovarus foot in hemiplegic patients. DESIGN: Intervention study (before-after trial) with an observational design and 2-year follow-up. SETTING: Spasticity group in a university hospital. PARTICIPANTS: Hemiplegic patients (N=30) with spastic equinovarus foot. INTERVENTION: A selective neurotomy was performed at the level of the motor nerve branches of the tibial nerve. MAIN OUTCOME MEASURES: Spasticity (Ashworth scale), muscle strength (Medical Research Council scale), passive ankle dorsiflexion, gait parameters (6 min walking test), and gait kinematics (video assessment) were assessed before and at 2 months, 1 year, and 2 years after selective tibial neurotomy. RESULTS: Compared with preoperative values, there was a statistically significant decrease in triceps surae spasticity, an increase in gait speed, and a reduction in equinus and varus in swing and stance phases at 2 months postoperatively. This improvement persisted at 1 and 2 years after selective tibial neurotomy. Selective tibial neurotomy does not induce permanent triceps muscle weakness or triceps surae-Achilles' tendon complex shortening. CONCLUSION: This study confirms the long-lasting beneficial effect of selective tibial neurotomy on spasticity, gait speed, and equinovarus deformity in the treatment of spastic equinovarus foot in hemiplegic patients.

Serotonin Syndrome Mimicking Intrathecal Baclofen Withdrawal in a Patient with Hereditary Spastic Paraparesis.

CONTEXT: Serotonin syndrome is a drug-induced condition related to an increased level of serotonin in the brain, which may induce neuromuscular, autonomic and mental symptoms. CASE REPORT: A 40-year-old woman with hereditary spastic paraparesis (Strumpell-Lorrain disease) with an implanted intrathecal baclofen pump for severe spasticity. Two days after starting a medication known to inhibit serotonin re-uptake (paroxetine), she developed a sudden increase in lower limb spasticity with continuous spasms, fever, tachycardia and hypertension. Intrathecal baclofen withdrawal was excluded, confirming serotonin syndrome. CONCLUSION: Medications that inhibit serotonin reuptake may induce serotonin syndrome, resulting in increased spasticity in patients with spinal cord lesions, and should be prescribed with caution.

Gait improvement in adults with hemiparesis using a rolling cane: A cross-over trial.

OBJECTIVE: To assess the changes in gait parameters in adults with hemiparesis using a rolling cane (quadripod cane with small wheels; Wheeleo®) compared with a classical quadripod cane. DESIGN: A prospective, multicentric, cross-over randomized trial. PARTICIPANTS: Thirty-two ambulatory adults with hemiparesis. METHODS: Participants were assessed using a quadripod cane and a rolling cane. Outcome measures were changes in: walking speed during a 10-m walk test and a 6-min walk test; frequency of 2-step gait; physiological cost index; number of therapist interventions to control the balance; perceived exertion; and participant satisfaction. RESULTS: The following outcomes were improved with the use of a rolling cane: walking speed during a 10-m walk test at comfortable (+22%: p<0.001) and maximal (+30: p<0.001) speeds; walking speed (+50%: p<0.001) and distance (+49%: p

COVID-19 pandemic. What should Physical and Rehabilitation Medicine specialists do? A clinician's perspective.

COVID-19 pandemic is rapidly spreading all over the world, creating the risk for a healthcare collapse. While acute care and intensive care units are the main pillars of the early response to the disease, rehabilitative medicine should play an important part in allowing COVID-19 survivors to reduce disability and optimize the function of acute hospital setting. The aim of this study was to share the experience and the international perspective of different rehabilitation centers, treating COVID-19 survivors. A group of Physical Medicine and Rehabilitation specialists from eleven different countries in Europe and North America have shared their clinical experience in dealing with COVID-19 survivors and how they have managed the re-organization of rehabilitation services. In our experience the most important sequelae of severe and critical forms of COVID-19 are: 1) respiratory; 2) cognitive, central and peripheral nervous system; 3) deconditioning; 4) critical illness related myopathy and neuropathy; 5) dysphagia; 6) joint stiffness and pain; 7) psychiatric. We analyze all these consequences and propose some practical treatment options, based on current evidence and clinical experience, as well as several suggestions for management of rehabilitation services and patients with suspected or confirmed infection by SARS-CoV-2. COVID-19 survivors have some specific rehabilitation needs. Experience from other centers may help colleagues in organizing their services and providing better care to their patients.

Effect of upper limb botulinum toxin injections on impairment, activity, participation, and quality of life among stroke patients.

BACKGROUND AND PURPOSE: The purpose of this study was to study the effect of Botulinum toxin type A (BoNT-A) injections in spastic upper limb muscles on impairment, activity, participation and quality of life in chronic stroke patients. METHODS: BoNT-A (Dysport) was injected into several upper limb spastic muscles in a group of 20 patients. Neurological impairment (muscle tone and strength, dexterity, SIAS), activity (ABILHAND), participation (SATIS-Stroke), and quality of life (SF36) were assessed before and 2 months after the injections. RESULTS: BoNT-A injections improved muscle tone, but had no impact on dexterity, manual ability, social participation, and quality of life. CONCLUSIONS: In this study, BoNT-A injections in spastic upper limbs significantly reduced neurological impairments, but had no functional impact.

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 simultaneous botulinum toxin injections into several muscles on impairment, activity, participation, and quality of life among stroke patients presenting with a stiff knee gait.

BACKGROUND AND PURPOSE: Walking is an essential activity for daily life and social participation, and it is frequently limited after stroke. A lack of knee flexion during the swing phase (stiff knee) is one of the impairments that restrict walking ability among patients with hemiparetic spasticity. Our purpose was to study the effect of Botulinum toxin type A (BoNT A) injections in several spastic muscles on the impairment, activity, participation, and quality of life of patients with chronic stroke presenting with a stiff knee gait. METHODS: Twenty chronic hemiparetic poststroke patients with stiff knee gait and ability to walk on a treadmill were recruited. BoNT A was injected into several spastic muscles: the rectus femoris (200 U), semitendinosus (100 U) and triceps surae (200 U). Patients' neurological impairments (Ashworth scale, Duncan-Ely test, Stroke Impairment Assessment Set, and instrumented gait analysis), activity (ABILOCO and 10-m walking test), and participation (SATISPART-Stroke and 36-item Short-Form Health Survey) were assessed before and 2 months after the injection. RESULTS: BoNT A injection reduced the impairments. It improved Stroke Impairment Assessment Set (56.5 [48-63] to 56.5 [52.5 to 63]; P<0.001), reduced rectus femoris muscle tone (2 [1 to 2.5] to 0 [0 to 1]; P<0.001), and reduced semitendinosus muscle tone (1 [1 to 1.5] to 1 [0 to 1]; P<0.001). Gait analysis demonstrated increased knee flexion during the swing phase (22+/-19 degrees to 27+/-16 degrees ; P=0.03), decreased external mechanical work (0.66+/-0.38 to 0.59+/-0.25 J kg(-1) m(-1); P=0.04), and demonstrated a lower energy cost (5.8+/-1.9 to 4.9+/-1.9 J kg(-1) m(-1); P=0.03). The patients' locomotion ability was improved (2.2+/-1.9 to 3.2+/-2.1 logits; P=0.03). The participation and quality of life remained unchanged. CONCLUSIONS: BoNT A injections in several muscles improved the stiff knee gait and the locomotion ability in adult stroke patients.