Short-term reduction of ankle spasticity after surgical lengthening of the triceps surae in chronic post-stroke patients: a retrospective cohort study.

Introduction: In post-stroke patients with equinovarus foot deformity (EVFD), soft tissue rearrangements may contribute to muscle overactivity when a muscle is stretched or tension is applied. Therefore, we investigated the effects of surgically restoring the triceps surae (TS) length and lengthening ability on TS spasticity. Methods: This retrospective study included chronic post-stroke patients who underwent neuro-orthopedic surgery inclusive of TS lengthening. TS spasticity was measured using the Modified Tardieu Scale (MTS) before and 1 month after surgery, both with the knee extended (KE) and flexed (KF). MTS variations were analyzed using the Wilcoxon test. The time from stroke onset was compared between patients with and without post-surgical spasticity using the t-test. Statistical significance was set at 5%. Results: A total of 120 patients with EVFD, aged 57 (12) years, ranging from 1 to 36 years from stroke, were included in the study. The median MTS_KE score significantly decreased from 3 (range 0-4) to 2 (0-4) (p < 0.001) after surgery. The MTS score decreased by ≥1 point in more than half of the sample. Notably, 19 and 32 patients were completely relieved from spasticity (MTS = 0) in the KE and KF conditions, respectively. Post-surgical spasticity did not depend on the time since stroke onset (p = 0.560). Discussion: TS lengthening led to a short-term reduction of spasticity in 41% and 63% of chronic post-stroke patients in the gastro-soleus complex and soleus, respectively, with complete relief observed in 21% and 30% of the sample. Surgical lengthening can be considered an effective treatment that not only restores joint range of motion but also may reduce spasticity, even in chronic patients.

Short-term effects of foot surgery on walking-related pain, function, and satisfaction in patients with Charcot-Marie-Tooth disease: a prospective cohort study.

Introduction: Patients with Charcot-Marie-Tooth disease (CMT) often suffer from walking-related pain (WRP), muscle weakness, foot deformities, and reduced ankle dorsiflexion (DF), which affects their ability to walk and daily activities. Functional surgery (FS) can restore foot deviations, affecting the loading ability during gait. We assessed the short-term effects of FS in patients with CMT on WRP, foot and ankle structure, and function, along with patients' perceived improvement. Methods: This is a prospective cohort study on CMT patients who had undergone FS and rehabilitation. We analyzed the changes after 1 month, focusing on WRP, DF, the center of pressure progression (COPP) during walking, and measures of walking ability. The non-parametric Wilcoxon test was used. Results: Ten patients were included. One month after FS, WRP reduced from 5.5 (IQR = 3.5) to 2 (IQR = 3.5), p = 0.063, with an effect size of 0.615. The highest decrease was found in patients with very high pre-surgical pain levels. DF almost reached 10° for both active and passive movements (p < 0.05), and COPP improved from 44 to 60% (p = 0.009) of foot length. Gait speed, lower limb functioning, and balance did not change. More than half of the sample felt improved or much improved after FS. Conclusion: FS can be effective in reducing WRP and restoring foot posture in CMT patients in the short-term, which allows them to wear shoes, and leads to a perceived improvement and satisfaction. Lack of improvement in functional skills may be due to muscle weakness typical of CMT. Studies with longer follow-ups may confirm these hypotheses.

Surgical quadriceps lengthening can reduce quadriceps spasticity in chronic stroke patients. A case-control study.

Background: Muscle overactivity is one of the positive signs of upper motor neuron lesions. In these patients, the loss of muscle length and extensibility resulting from soft tissue rearrangement has been suggested as a contributing cause of muscle overactivity in response to stretching. Objective: To assess the effects of surgical lengthening of the quadriceps femoris (QF) muscle-tendon unit by aponeurectomy on muscle spasticity. Methods: This is a case-control study on chronic stroke patients with hemiparesis that have undergone lower limb functional surgery over a 8-year period. CASEs underwent corrective surgery for both the foot and knee deviations, inclusive of a QF aponeurectomy. Controls (CTRLs) underwent corrective surgery for foot deviations only. QF spasticity was assessed with the Modified Tardieu Scale (MTS) before and 1 month after surgery. The Wilcoxon test was used to assess MTS variations over time and the Mann-Whitney test was used to verify the presence of group differences at the 1 month mark. Results: Ninety-three patients were included: 57 cases (30F, 1-34 years from lesion) and 36 controls (12F, 1-35 years from lesion). Before surgery, both CASEs and CTRLs had similar MTS scores (median MTS = 3) and functional characteristics. One month after surgery, QF spasticity was significantly lower in the CASEs compared to CTRLs (p = 0.033) due to a significant reduction of the median MTS score from 3 to 0 in the CASE group (p < 0.001) and no variations in the CTRL group (p = 0.468). About half of the cases attained clinically significant MTS reductions and complete symptom relief even many years from the stroke. Conclusions: Functional surgery inclusive of QF aponeurectomy can be effective in reducing or suppressing spasticity in chronic stroke patients. This is possibly a result of the reduction in neuromuscular spindle activation due to a decrease in muscle shortening, passive tension, and stiffness.

Foot Assessment Clinical Scales in Charcot-Marie-Tooth Patients: A Scoping Review.

Introduction: Charcot-Marie-Tooth disease (CMT) is a slow and progressive peripheral motor sensory neuropathy frequently associated with the cavo-varus foot deformity. We conducted a scoping review on the clinical scales used to assess foot deviations in CMT patients and analyzed their metric properties. Evidence Acquisition: A first search was conducted to retrieve all scales used to assess foot characteristics in CMT patients from the Medline, Web of Science, Google Scholar, Cochrane, and PEDro databases. A second search was conducted to include all studies that evaluated the metric properties of such identified scales from the same databases. We followed the methodologic guidelines specific for scoping reviews and used the PICO framework to set the eligibility criteria. Two independent investigators screened all papers. Evidence Synthesis: The first search found 724 papers. Of these, 41 were included, using six different scales: "Foot Posture Index" (FPI), "Foot Function Index", "Maryland Foot Score", "American Orthopedic Foot & Ankle Society's Hindfoot Evaluation Scale", "Foot Health Status Questionnaire", Wicart-Seringe grade. The second search produced 259 papers. Of these, 49 regarding the metric properties of these scales were included. We presented and analyzed the properties of all identified scales in terms of developmental history, clinical characteristics (domains, items, scores), metric characteristics (uni-dimensionality, inter- and intra-rater reliability, concurrent validity, responsiveness), and operational characteristics (normative values, manual availability, learning time and assessors' characteristics). Conclusions: Our results suggested the adoption of the six-item version of the FPI scale (FPI-6) for foot assessment in the CMT population, with scoring provided by Rasch Analysis. This scale has demonstrated high applicability in different cohorts after a short training period for clinicians, along with good psychometric properties. FPI-6 can help health professionals to assess foot deformity in CMT patients over the years.

Indices of Loading and Propulsive Ability in the Gait of Patients With Chronic Stroke With Equinus Foot Deviation: A Correlation Study.

In literature, indices of overall walking ability that are based on ground reaction forces have been proposed because of their ease of administration with patients. In this study, we analyzed the correlation between the indices of dynamic loading and propulsion ability of 40 chronic hemiparetic post-stroke patients with equinus foot deviation and a set of clinical assessments of ankle joint deviations and walking ability. Ankle passive and active range of motion (ROM) and triceps surae spasticity were considered, along with walking speed and three complementary scales of walking ability focusing respectively on the need for assistance on functional mobility, including balance and transfers, and the limitation in social participation. The correlation between the ground reaction force-based indices and both clinical and functional variables was carried out using the non-parametric Spearman correlation coefficient. Both indices were correlated to 8 of the 10 investigated variables, thus supporting their use. In particular, the dynamic propulsive ability was correlated with all functional scales (rho = 0.5, p < 0.01), and has the advantage of being a continuous variable. Among clinical assessments, limited ankle ROM affected walking ability the most, while spasticity did not. Since the acquisition of ground reaction forces does not require any patient prepping, the derived indices can be used during the rehabilitation period to quickly detect small improvements that, over time, might lead to the broad changes detectable by clinical scales, as well as to immediately highlight the lack of these improvements, thus suggesting adjustments to the ongoing rehabilitation approach.

Long-term effects on body functions, activity and participation of hemiplegic patients in equino varus foot deformity surgical correction followed by immediate rehabilitation. A prospective observational study.

Background: Functional surgery is an effective approach in the treatment of the rigid equinovarus foot deformity (EVFD). This must be associated with early rehabilitation treatments (ERTs) to prevent muscle rearrangements due to immobilization. Objectives: To assess the effects of EVFD surgical correction in adult stroke patients, when assessed according to the ICF domains. Methods: Variables from 24 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 were analyzed. Body function domain: pain (NPRS), walking speed, clinical global impression of change (cGIC). Activity domain: Rivermead Mobility Index (RMI), FAC, and 6 min walking test (6MWT). Participation domain: Walking Handicap Scale (WHS). Patients were assessed before (T0), one (T1), three (T2) and twelve (T3) months after surgery by a single assessor. Results: All variables but the 6MWT significantly improved (Wilcoxon test, p < .05) at T1 or T2 and this remained until the 12-months mark. Since T1, all patients reached and maintained a supervised independent walking (FAC≥3) and all those wearing an AFO stopped using it. The median cGCI was "much improved" at T1, with a "further minimal improvement" at T3. This was not associated with the improvement measured by both FAC, and WHS (Chi-square test, p = .20 and p = .36, respectively). Conclusions: Functional surgery combined with ERT is effective in improving the patients' condition according to all ICF domains. Both subjective and objective assessments have to be used when assessing these patients.