Frank Reiter

Botulinum toxin type A and short-term electrical stimulation in the treatment of upper limb flexor spasticity after stroke: a randomized, double-blind, placebo-controlled trial

Objective: To investigate whether the combined approach of botulinum toxin type A (BtxA) and electrical stimulation was more effective than the toxin alone in the treatment of chronic upper limb spasticity after stroke. Design: Randomized, placebo-controlled study with four treatment groups: 1000 units BtxA (Dysport®) + electrical stimulation (A), 1000 units BtxA (B), placebo + electrical stimulation (C) and placebo (D). Setting: A neurological rehabilitation clinic. Subjects: Twenty-four stroke patients with chronic upper limb spasticity after stroke, six patients in each treatment group. Interventions: Intramuscular injection of either toxin or placebo into six upper limb flexor muscles. In group A and C additional electrical stimulation of the injected muscles with surface electrodes, three times half an hour each day for three days. Main outcome measures: Muscle tone rated with the modified Ashworth score, limb position at rest and difficulties encountered during three upper limb motor tasks assessed before and 2, 6 and 12 weeks after injection. Results: Most improvements were observed in patients of group A. Cleaning the palm (p = 0.004) differed across groups. Pairwise comparison for this target variable showed that group A differed from group B and D (p <0.01), but not from C. Indicative across-group differences were obtained for elbow spasticity reduction (p = 0.011), and improvement of putting the arm through a sleeve (p = 0.020). Conclusions: The placebo-controlled trial favours the conceptthat electrical stimulation enhances the effectiveness of BtxA in the treatment of chronic upper limb flexor spasticity after stroke.

Low-dose botulinum toxin with ankle taping for the treatment of spastic equinovarus foot after stroke

OBJECTIVE To evaluate the efficacy of a combined treatment for spastic foot using selective injections of botulinum toxin (BTA) into the tibialis posterior muscle followed by ankle taping, and to compare it with current BTA treatment procedure. DESIGN Single-blind randomized control trial. Three-month follow-up after treatment. SETTING Neurorehabilitation clinic. SUBJECTS Eighteen outpatients with equinovarus foot due to severe spasticity after stroke. INTERVENTIONS (1) Injection of 190 to 320 BTA U into several calf muscles (group A); (2) injection of 100 BTA U into the tibialis posterior muscle, followed by ankle-foot taping (group B). MAIN OUTCOME MEASURES Ankle range of motion (ROM), Ashworth scale, gait velocity, and step length. RESULTS Average Ashworth scores decreased 1 point in both groups, but the benefit appeared of shorter duration in group B. Changes in both foot position at rest and passive ankle ROM were observed in all patients, without treatment-related differences, except for gain in passive dorsiflexion that appeared higher in group A. Gait velocity and step length showed similar increases in both groups. CONCLUSION The combination of selective injections of low BTA doses with ankle-foot taping is as effective as the injection of the current doses for the reduction of foot inversion with positive effects on gait parameters.

Asymmetry of gait initiation in hemiparetic stroke subjects

OBJECTIVE To investigate symmetry of gait initiation in healthy and hemiparetic subjects. DESIGN Survey. SETTING Kinematic laboratory affiliated with a hospital-based department of rehabilitation. PATIENTS OR OTHER PARTICIPANTS Ten healthy and 14 hemiparetic stroke subjects starting five times with their right and left leg, respectively. MAIN OUTCOME MEASURES Duration of defined periods, step length, center of pressure, and center of mass were recorded and calculated using two triaxial force plates, contact switches, and a video camera system. RESULTS Healthy subjects displayed a high degree of independence of kinetic and kinematic parameters of the starting limb. Hemiparetic patients showed differences with respect to the starting limb: when starting with the nonaffected leg, the swing period and step length was shorter and the center of pressure displayed a more marked medio-lateral sway with no corresponding initial movement of the center of mass; when starting with the affected leg the movement pattern of the center of pressure and center of mass was comparable to that of normal subjects. CONCLUSIONS The trajectories of the center of pressure and center of mass and the symmetry parameters are in accordance with a higher degree of uncertainty when starting with the non-affected limb in hemiparetic subjects.

Post-stroke spasticity management with repeated botulinum toxin injections in the upper limb.

OBJECTIVE Although the botulinum toxin A (BTX-A) treatment has proved effective in spasticity management, no information is available with regard to the effects of repeated injections over time. DESIGN To evaluate the effects of BTX-A on moderate or severe upper limb spasticity, an exploratory investigation was performed on 28 stroke patients treated for 2 yr or longer and observed for 3 yr. Every 3 to 5 mo, each patient received BTX-A injections in upper limb muscles. The assessment, performed before and 1 mo after each injection for a median of 28 mo, included technical and functional objectives and the burden of care. The former were evaluated by using the modified Ashworth Scale for spasticity and the goniometric measurement of rest position and range of motion; functional objectives were evaluated by means of the Frenchay Arm Test and a patient/caregiver goals assessment scale. RESULTS BTX-A treatment was followed by an improvement in all technical outcome measures. Motor dexterity scores improved in only 8 of 28 patients, vs. daily living activities, which increased in all subjects. Although the average dosage injected per session did not change, intervals between injections became longer. No relationship between either spasticity onset or residual motoricity and response to treatment could be found. CONCLUSIONS This investigation is relevant clinically because repeated BTX-A injections show unchanging effectiveness in the management of focal spasticity after stroke.

Immediate effects of therapeutic facilitation on the gait of hemiparetic patients as compared with walking with and without a cane

OBJECTIVES Although the neurodevelopmental technique (Bobath) is the most widely used approach in the gait rehabilitation of hemiparetic subjects in Europe, there is little neurophysiological evidence for its presumed effects on gait symmetry and facilitation of paretic muscles during the therapeutic intervention. The study, therefore, investigated the immediate effects of gait entrainment by a physical therapist on the gait of hemiparetic subjects. METHODS Cycle parameters, gait symmetry, hip joint movement and the electromyographic activity of several lower limb muscles were assessed in 22 patients during a classic intervention by five Bobath therapists and while walking with and without a cane. RESULTS Multivariate statistics revealed that, while being assisted by the therapist, patients walked faster (P = 0.022), with a longer relative stance period of the affected leg (P = 0.005), a higher symmetry (P = 0.002), larger hip extension (P = 0.001) and more activation (P = 0.026) of the Mm. triceps surae, vastus lateralis, biceps femoris and gluteus medius as compared to walking with and without a cane. Extensor spasticity of the plantar-flexor tended to increase (n.s.). In five subjects, no after-effect could be documented 1 h after a gait training of 30 min. CONCLUSIONS The study confirmed a more balanced walking pattern in conjunction with facilitation of various weight bearing muscles during the therapeutic intervention. A prolonged single stance period of the affected leg, an unobstructed hip movement, enhanced weight acceptance and a faster gait seemed to be responsible for the observed immediate effects of the therapeutic intervention.

Entwicklung eines Gangtrainers mit geregeltem Servoantrieb zur Rehabilitation gehunfähiger Patienten - Development of a Servo-controlled Gait Trainer for the Rehabilitation of Non-ambulatory Patients

The aim of the present study was to develop a new gait trainer for the rehabilitation of non-ambulatory patients. For the simulation of the gait phases, we used a commercially available fitness trainer (Fast Track) with two foot plates moving in an alternating fashion and connected to a servo-controlled propulsion system providing the necessary support for the movement depending on the patients impairment level. To compensate deficient equilibrium reflexes, the patient was suspended in a harness capable of supporting some of his/her weight. Video analysis of gait and the kinesiological EMG were used to assess the pattern of movement and the corresponding muscle activity, which were then evaluated in healthy subjects, spinal cord injured and stroke patients and compared with walking on the flat or on a treadmill. Walking on the gait trainer was characterised by a symmetrical, sinusoidal movement of lower amplitude than in normal gait. The EMG showed a low activity of the tibialis anterior muscle, while the antigravity muscles were clearly activated by the gait trainer during the stance phase. In summary, the new gait trainer generates a symmetrical gait-like movement, promoting weight acceptance in the stance phase, which is important for the restoration of walking ability.