Hiroki Tanikawa

Efficacy of Botulinum Toxin A Treatment for Pes Varus during Gait.

BACKGROUND The efficacy of botulinum toxin A (BoNTA) injection on spasticity is usually measured using Modified Ashworth Scale (MAS), but this only evaluates muscle tone at rest and has poor reliability. There are no reports that quantitatively evaluate pes varus during walking after botulinum treatment. The purpose of this study was to evaluate the efficacy of BoNTA injection on pes varus during gait using 3-dimensional motion analysis. METHODS Twenty-four hemiplegic patients with spastic pes varus deformity during gait received BoNTA injection into lower limb muscles. MAS score, comfortable overground gait velocity, and pes varus angle during treadmill walking were evaluated before, 2, 6, and 12 weeks after the injection. Five healthy subjects were also recruited to develop the pes varus/valgus angle as a normal reference. RESULTS The median MAS scores were significantly lower at 2 and 6 weeks after the injection. The maximum pes varus angle during the swing phase was significantly lower at 2, 6, and 12 weeks after the injection. It was significantly lower at 6 weeks after the injection during stance phase. The comfortable overground gait velocity was also improved after the injection. However, 2 patients experienced pain during gait and their pes varus angle increased during the follow-up period. CONCLUSIONS BoNTA injection improved pes varus angle during gait. Evaluating motion in addition to spasticity at rest is recommended because improvements in limb function do not always parallel improvements in spasticity at rest.

Quantitative assessment of retropulsion of the hip, excessive hip external rotation, and excessive lateral shift of the trunk over the unaffected side in hemiplegia using three-dimensional treadmill gait analysis

Background: Gait assessment is important to determine the most effective strategy to regain gait function during stroke rehabilitation. To understand the mechanisms that cause abnormal gait patterns, it is useful to objectively identify and quantify the abnormal gait patterns. Objective assessment also helps evaluate the efficacy of treatments and can be used to provide suggestions for treatment. Objective: To evaluate the validity of quantitative indices for retropulsion of the hip, excessive hip external rotation, and excessive lateral shift of the trunk over the unaffected side in hemiplegic patients. Methods: Forty-six healthy control subjects and 112 hemiplegic patients participated. From the 112 patients, 50 patients were selected into each abnormal gait pattern with some overlap. Participants were instructed to walk on a treadmill and were recorded using a three-dimensional motion analysis system. An index to quantify each of the three abnormal gait patterns was calculated from the three-dimensional coordinate data. The index values of patients were compared with those of healthy subjects and with the results of observational gait assessment by three physical therapists with expertise in gait analysis. Results: Strong correlation was observed between the index value and the median observational rating for all three abnormal gait patterns (−0.56 to −0.74). Most of the patients with an abnormal gait pattern had a higher index value than the healthy subjects. Conclusions: The proposed indices are useful for clinical gait analysis. Our results encourage a more detailed analysis of hemiplegic gait using a motion analysis system.

Biomechanical factors behind toe clearance during the swing phase in hemiparetic patients

Background: The toe clearance of a paretic limb in the swing phase of gait is related to tripping, which is considered a major cause of falls. The biomechanical factors for obtaining toe clearance are more complicated in hemiparetic gait than that in normal gait because of the compensatory movements during swing phase. Understanding the biomechanical factors should help in targeting the point for rehabilitative interventions. Objective: To clarify the biomechanical factors behind toe clearance during swing phase in hemiparetic gait. Methods: Fifty patients with hemiparesis after a stroke participated in this study. Three-dimensional motion analysis was used for the kinematic analysis of the hemiparetic gait. The correlation coefficients between limb shortening and angle changes and between limb shortening and hip elevation and foot lateral shift were calculated. Limb shortening was defined as the shortening of the hip–toe distance. The significant factors that determine toe clearance were examined by multiple regression analysis. Independent variables were limb shortening, hip elevation, and foot lateral shift. Results: Limb shortening was negatively correlated with hip elevation (r = −0.75) and foot lateral shift (r = −0.41). Multiple regression analysis showed a significant contribution of limb shortening and hip elevation to toe clearance. The coefficient of determination was 0.95. Conclusions: Toe clearance was mainly determined by limb shortening and hip elevation, which were found to be in a trade-off relationship. These results warrant further investigation into the use of three-dimensional motion analysis in the rehabilitation clinic to facilitate targeted rehabilitative training to restore gait ability.

Quantitative assessment of knee extensor thrust, flexed-knee gait, insufficient knee flexion during the swing phase, and medial whip in hemiplegia using three-dimensional treadmill gait analysis

ABSTRACT Background: Most people with hemiplegia experience gait changes after a stroke. Abnormal gait patterns in stroke patients vary across subjects and this make it difficult to assess the cause of gait abnormalities. Therefore, it is necessary to quantitatively evaluate abnormal gait patterns through gait analysis for stroke patients. Objective: To develop and evaluate the validity of quantitative assessments of the degree of knee extensor thrust, flexed-knee gait, insufficient knee flexion during the swing phase, and medial whip. Methods: Forty-six healthy control subjects and 112 people with hemiplegia participated. From the 112 patients, 50 patients were selected into each abnormal gait pattern (knee extensor thrust, flexed-knee gait, insufficient knee flexion during the swing phase, and medial whip) with some overlap. Participants were instructed to walk on a treadmill and were recorded using a three-dimensional motion analysis system. An index to quantify each of the four abnormal gait patterns exhibited by the patients was calculated from the three-dimensional coordinate data. The indices were developed based on the definition of the abnormal gait patterns. The index values for the patients were compared with those of healthy subjects as well as with the results of observational gait assessment by three physical therapists with expertise in gait analysis. Results: Strong correlation was observed between the index value and the median observational rating for all four abnormal gait patterns (−0.64 to −0.86). Most of the patients with an abnormal gait pattern had a higher index value than the healthy subjects. Conclusions: The use of these indices in gait analysis of people with hemiplegia can help to diagnose severity of gait disorder, determine the appropriate treatment, and evaluate the effectiveness of the treatment.

Quantitative assessment for flexed-elbow deformity during gait following botulinum toxin A treatment

BACKGROUND The effect of botulinum toxin A (BoNTA) injection on flexed-elbow deformity is usually evaluated using the Modified Ashworth Scale (MAS), but only with the muscle tone at rest. Some patients show the flexed-elbow deformity during gait despite low muscle tone at rest. OBJECTIVE This study aimed to evaluate the effect of BoNTA injection on flexed-elbow deformity during gait using a three-dimensional motion analysis system. METHODS Twenty stroke patients with spastic flexed-elbow deformity during gait received BoNTA injections into the upper limb muscles. The MAS score of the elbow flexors, passive elbow range of motion, comfortable overground gait velocity, and elbow flexion angle during treadmill gait were evaluated just before and 2, 6, and 12 weeks after the injection. Twenty-five healthy subjects were also recruited to provide a normal reference of the elbow flexion angle. RESULTS The MAS scores at 2, 6 and 12 weeks after the injection were significantly lower than that before the injection. Some patients showed no spasticity at rest but an obviously flexed elbow during gait. The elbow flexion angles during gait at 2 and 6 weeks after the injection were significantly lower than that before the injection. CONCLUSIONS BoNTA injections to the upper limb muscles reduced muscle tone at rest and flexed-elbow deformity during gait. However, the elbow flexion angle during gait returned to its pre-injection level sooner than the muscle tone at rest. We strongly recommend evaluating muscle tone during motion and at rest, preferably using three-dimensional motion analysis since it can objectively detect small changes.