Corinne Bleyenheuft

Treatment of genu recurvatum in hemiparetic adult patients: A systematic literature review

INTRODUCTION AND METHODS We carried out a systematic review of the literature on treatment of genu recurvatum in hemiparetic adult patients by searching the PubMed, Pedro, Trip Database and Science Direct databases. The following keywords were used: (recurvatum or hyperextension or knee) and (hemiplegia or hemiparesis). RESULTS Nine articles met our selection criteria. Four assessed retraining methods (functional electric stimulation or electrogoniometric feedback), two assessed orthopaedic or neurosurgical treatments and three articles focused on orthoses. DISCUSSION AND CONCLUSION Even though all the various treatments produced encouraging results, most of the reviewed studies presented methodological limitations. Moreover, none of the selected articles suggested a treatment strategy which takes account of the various aetiologies in genu recurvatum. On the basis of some of the reviewed articles and our own clinical experience, we propose an aetiology-specific treatment strategy for genu recurvatum patients. In a broad patient population, this categorization could form the basis for testing the specificity of each treatment method as a function of the cause of genu recurvatum. This approach could help confirm the clinical indications and identify the most appropriate treatment for each patient.

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.

The effect of botulinum toxin injections on gait control in spastic stroke patients presenting with a stiff-knee gait.

INTRODUCTION Botulinum toxin type A (BoNT-A) injections are known to improve walking impairments and activity in spastic hemiparetic stroke patients presenting with a stiff-knee gait [Caty GD, Detrembleur C, Bleyenheuft C, Deltombe T, Lejeune TM. 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. Stroke 2008;39(October (10)):2803-8]. The aim of the present study was to understand how the improvement of mechanical variables during gait is controlled by the central nervous system after BoNT-A injections. Therefore, we used Kinematic Segmental Coordination (KSC), i.e. the kinematic covariation law of elevation angles between lower limb segments, to assess their effect on gait control. As far as we know, this has never been studied before. METHODS Twenty chronic hemiparetic stroke patients presenting with a stiff-knee gait performed an instrumented gait analysis at the same walking speed before and 2 months after BoNT-A injection in several spastic muscles. We used the kinematic recordings previously obtained by Caty et al. [Caty GD, Detrembleur C, Bleyenheuft C, Deltombe T, Lejeune TM. 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. Stroke 2008;39(October (10)):2803-8] and computed KSC following Borgheses methodology. The treatment effect was tested using a repeated measures ANOVA. RESULTS BoNT-A injections allowed a statistically significant improvement in KSC of both lower limbs (p=0.004). Moreover, the unaffected side KSC reached normal values after BoNT-A injections. CONCLUSION AND DISCUSSION BoNT-A allowed an improvement in KSC of the affected lower limb and a normalization of KSC of the unaffected limb. This improvement could either be due to a mechanical effect or a central effect of BoNT-A via the spinal central pattern generators (CPGs).

Reliability of lower limb kinematics, mechanics and energetics during gait in patients after stroke.

OBJECTIVE To assess the reliability of kinematic, mechanical and energetic gait variables at short (1 day) and medium (1 month) intervals in adult patients after stroke. DESIGN Prospective study. SUBJECTS Ten patients with chronic post-stroke (mean age 53.5 years; age range 25-80 years). METHODS Three-dimensional gait analysis was performed 3 times in these subjects: at baseline (T0), after 1 day (T1) and after 1 month (T2). The reliability of the gait analysis was tested by comparing gait variables measured at T1 and T0 (1 day interval), at T2 and T0 (1 month interval). The inter-session reliability of kinematic, mechanical and energetic variables was calculated by intra-class correlation coefficient (ICC). RESULTS The reliability of kinematic variables ranged from excellent to moderate (ICC >or= 0.51), except for the ankle position at heel strike (ICC = 0.44). The reliability of mechanical and energetic variables ranged from excellent to good (ICC >or= 0.71). The most reliable variable was external mechanical work (ICC = 0.96). The kinematic, mechanical and energetic variables did not change significantly between T0, T1 and T2 (repeated-measures analysis of variance). CONCLUSION Kinematic, mechanical and energetic gait variables present good reliability when measured at 1 day and 1 month intervals in adult patients after stroke.

Capturing neuroplastic changes after bimanual intensive rehabilitation in children with unilateral spastic cerebral palsy: A combined DTI, TMS and fMRI pilot study

Intensive rehabilitation interventions have been shown to be efficacious in improving upper extremity function in children with unilateral spastic cerebral palsy (USCP). These interventions are based on motor learning principles and engage children in skillful movements. Improvements in upper extremity function are believed to be associated with neuroplastic changes. However, these neuroplastic changes have not been well-described in children with cerebral palsy, likely due to challenges in defining and implementing the optimal tools and tests in children. Here we documented the implementation of three different neurological assessments (diffusion tensor imaging-DTI, transcranial magnetic stimulation-TMS and functional magnetic resonance imaging-fMRI) before and after a bimanual intensive treatment (HABIT-ILE) in two children with USCP presenting differential corticospinal developmental reorganization (ipsilateral and contralateral). The aim of the study was to capture neurophysiological changes and to document the complementary relationship between these measures, the potential measurable changes and the feasibility of applying these techniques in children with USCP. Independent of cortical reorganization, both children showed increases in activation and size of the motor areas controlling the affected hand, quantified with different techniques. In addition, fMRI provided additional unexpected changes in the reward circuit while using the affected hand.

Quantitative assessment of anaesthetic nerve block and neurotomy in spastic equinus foot : a review of two cases

OBJECTIVE To quantitatively evaluate the effect of motor nerve branch block and neurotomy of the soleus nerve on triceps surae spasticity, reviewing 2 cases. METHODS Beside clinical assessment, we carried out a quantitative measurement of the stiffness of the ankle flexor muscles. The path length of the phase diagram between elastic and viscous stiffness quantifies the reflex response to movement and reflects the importance of the spasticity. The assessments were carried out before and 30 min after motor nerve branch block of the upper soleus nerve and more than 7 months after neurotomy. RESULTS Both patients presented with pronounced ankle plantar flexor spasticity: their path lengths were more than 6 times greater than normal values at baseline (#1: 354 N m rad(-1); #2: 409 N m rad(-1)). Motor nerve branch block and neurotomy allowed a near-normalization of elastic and viscous stiffness of ankle plantar flexor muscles in the 2 patients. Their path length was almost similarly improved by motor nerve branch block (#1: 127 N m rad(-1); #2: 231 N m rad(-1)) and neurotomy (#1: 60 N m rad(-1); #2: 162 N m rad(-1)). CONCLUSION These case reports highlight the fundamental role of the soleus muscle in triceps surae spasticity in our patients, the predictivity of motor nerve branch block in the preoperative assessment, and the effectiveness of soleus neurotomy in spastic equinus foot.

Comparison between tibial nerve block with anaesthetics and neurotomy in hemiplegic adults with spastic equinovarus foot.

OBJECTIVE The aim of the study was to compare the effect of diagnostic motor nerve block with anaesthetics and of selective tibial neurotomy in the treatment of spastic equinovarus foot in hemiplegic adults. METHODS In this prospective observational study, 30 hemiplegic adults with spastic equinovarus foot benefited from a diagnostic nerve block with anaesthetics followed by a selective tibial neurotomy performed at the level of the same motor nerve branches of the tibial nerve. Spasticity (Ashworth scale), muscle strength (Medical Research Council scale), passive ankle dorsiflexion (ROM), gait parameters (10 meters walking test) and gait kinematics (video assessment) were assessed before and after the nerve block and two months and two years after selective tibial neurotomy. RESULTS The decrease in spasticity and the improvement in gait kinematics were similar after the diagnostic nerve block and two months and two years after neurotomy. The diagnostic nerve block did not revealed the slight increase in gait speed and in tibialis anterior muscle strength that was observed two years after neurotomy. CONCLUSION This study suggests that diagnostic nerve block with anaesthetics and selective neurotomy equally reduce spasticity and improve gait in case of spastic equinovarus foot in hemiplegic adults. Diagnostic nerve block can be used as a valuable screening tool before neurotomy.

Influence of ankle-foot orthoses on kinematic segmental covariation among stroke patients.

OBJECTIVES To evaluate the effect of ankle-foot orthosis on lower limbs kinematic segmental covariation (KSC) among stroke patients. METHODS Ten chronic hemiparetic spastic stroke patients presenting with a lack of ankle dorsiflexion were assessed with instrumented gait analysis under three conditions: wearing a shoe, with a prefabricated ankle-foot orthosis (AFO), and with a dynamic AFO. Kinematic parameters were recorded and computed KSC was calculated according to Borgheses methodology. RESULTS Contrary to the prefabricated AFO, the dynamic AFO improved KSC of the paretic side. We observed a high correlation between the external mechanical work and the affected sides KSC. In the unaffected side, KSC was globally unchanged. CONCLUSION In stroke patients, wearing a dynamic AFO improves KSC of the paretic lower limb only.