Thierry Deltombe

EUROPEAN CONSENSUS TABLE ON THE USE OF BOTULINUM TOXIN TYPE A IN ADULT SPASTICITY

A group of clinicians from across Europe experienced in the use of botulinum toxin type A for the treatment of spasticity following acquired brain injury gathered to develop a consensus statement on best practice in managing adults with spasticity. This consensus table summarizes the current published data, which was collated following extensive literature searches, their assessment for level of evidence and discussion among the whole group. Published information is supplemented by expert opinion based on clinical experience from 16 European countries, involving 28 clinicians, who treat an average of approximately 200 patients annually, representing many thousand spasticity treatments with botulinum toxin per year.

Acute corticosteroid myopathy in intensive care patients.

Several recent studies have attributed the occurrence of acute myopathy in intensive care unit patients to the combination of corticosteroids and neuromuscular junction blocking agents (NMBAs) used for mechanical ventilation. We present 4 patients who developed acute myopathy after administration of high doses of glucocorticoids during sedation with propofol without any NMBAs. All patients had elevated creatine kinase levels. Electrophysiological studies indicated normal motor and sensory nerve conduction velocities but reduced motor nerve response amplitudes. Needle electromyography identified abnormal spontaneous activity; motor unit potentials were polyphasic of low amplitude and short duration, characteristic of a myopathic process. Muscle biopsy demonstrated a prominent acute necrotizing myopathy in all 4 patients with a loss of thick filaments. Our observations support glucocorticoids rather than NMBAs as the main offending drug in acute corticosteroid myopathy. The predisposing factor should be the hypersensitivity of paralyzed muscles to corticosteroids regardless of the drug inducing paralysis: NMBAs or propofol.

Effect of Botulinum Toxin Injection in the Rectus Femoris on Stiff-Knee Gait in People With Stroke: A Prospective Observational Study

OBJECTIVE To study the effect of botulinum toxin type A (BTX-A) injection in the rectus femoris on the decreased knee flexion during the swing phase of gait (stiff-knee gait) in people with stroke. DESIGN Intervention study (before-after trial) with an observational design. SETTING Outpatient rehabilitation clinic and gait laboratory. PARTICIPANTS Nineteen chronic hemiparetic adults presenting with stiff-knee gait. INTERVENTION Injection of 200 U of BTX-A (Botox) into the rectus femoris. MAIN OUTCOME MEASURES Before and 2 months after BTX-A rectus femoris injection: Stroke Impairment Assessment Set (SIAS), Duncan-Ely test, and an instrumented gait analysis. RESULTS Median SIAS score improved from 53 (range, 36-65) to 57 (range, 42-70) (signed-rank test, P=.005) and the Duncan-Ely score from 3 (range, 1-3) to 1 (range, 0-3) (P<.001). In gait analysis, mean (+/- standard deviation) maximum knee flexion improved from 26 degrees +/-13 degrees to 31 degrees +/-14 degrees during the swing phase (paired t test, P<.001), knee flexion speed at toe-off improved from 82 degrees +/-63 degrees to 112 degrees +/-75 degrees/s (P=.009), and knee negative joint power (eccentric muscular contraction) improved from -.27+/-.23 to -.37+/-.26 W/kg (P<.001). The 4 patients who almost did not flex the knee (<10 degrees) before the BTX-A rectus femoris injection did not improve after the injection. The other 14 patients who flexed the knee more than 10 degrees before the BTX-A rectus femoris injection decreased the walking energy cost from 5.4+/-1.6 to 4.6+/-1.3 J x kg(-1) x m(-1) (P=.006). CONCLUSIONS BTX-A rectus femoris injection may be beneficial in patients with a stiff-knee gait after stroke, particularly in patients with some knee flexion (>10 degrees).

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.

Selective blocks of the motor nerve branches to the soleus and tibialis posterior muscles in the management of the spastic equinovarus foot

OBJECTIVE To identify the location of the motor nerve branches to the soleus and tibialis posterior muscles in relation to anatomic surface landmarks for selective motor nerve blocks in the management of the spastic equinovarus foot. DESIGN Descriptive study by computed tomography (CT) scan of 12 hemiplegic legs. SETTING Spasticity group at a university hospital. PARTICIPANTS Twelve patients with hemiplegia (6 men, 6 women) with spastic equinovarus foot. INTERVENTION Three-dimensional location of the motor nerve branches to the soleus and tibialis posterior muscles with CT scan, followed by selective motor branch blocks with anesthetics. MAIN OUTCOME MEASURES Vertical, horizontal, and deep coordinates determined by CT scan in relation to anatomic surface landmarks (upper extremity of the fibula and vertical metallic element). Soleus and tibialis posterior spasticity (Ashworth Scale), soleus H-wave maximum (Hmax)/M-wave maximum (Mmax) ratio, and sensory testing before and after the blocks. RESULTS The mean coordinates +/- standard deviation for the soleus motor branch were 10+/-5 mm (vertical), 17+/-9 mm (horizontal), and 30+/-4 mm (deep); for the tibialis posterior motor branch they were 45+/-6mm (vertical), 17+/-8mm (horizontal), and 47+/-4 mm (deep). Spasticity and Hmax/Mmax ratio decreased after the blocks, confirming their efficiency. No subjects experienced additional sensory deficit. CONCLUSION Our study determined the location of the motor nerve branches to the soleus and tibialis posterior muscles in relation to anatomic surface landmarks for selective motor branch blocks and neurolytic procedures. These coordinates allow us to perform selective motor blocks without CT scan.

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.

External iliac artery endofibrosis: a new possible predisposing factor

External iliac artery endofibrosis (EIAE) is an uncommon disease that affects a large number of athletes. The pathogenesis of EIAE is unclear. We offer an additional possible cause, with a direct relationship between EIAE and psoas muscle hypertrophy.

The influence of skin temperature on latency and amplitude of the sympathetic skin response in normal subjects.

The influence of skin temperature on latency and amplitude of the sympathetic skin response (SSR) was studied in 10 normal subjects. SSRs were elicited in all four limbs of each subject by electrical stimulation after cooling of the right arm and after cooling of the right hand only. At low skin temperature, the latency was prolonged and the amplitude decreased. Latency and amplitude were linearly correlated with skin temperature of the right arm. There were no changes in the left arm and the legs, which basically excludes involvement of central pathways in these response parameters. With regard to the skin temperature of the arm, a temperature correction factor of 0.088 s/°C was calculated for latency. With regard to the skin temperature of the hand, latency prolongation was significantly greater after cooling of the whole arm. This suggests that not only the neuroglandular junction, but also the postganglionic sympathetic C fibers were responsible for latency modifications. In contrast, amplitude was reduced similarly after cooling of the whole arm and the hand only, suggesting that mainly the neuroglandular junction is responsible for amplitude modifications. We conclude that skin temperature is a mandatory measurement in the study of the SSR.

Selective tibial neurotomy in the treatment of spastic equinovarus foot: a 2-year follow-up of three cases.

Deltombe T, Detrembleur C, Hanson P, Gustin T: Selective tibial neurotomy in the treatment of spastic equinovarus foot: A 2-year follow-up of three cases. Am J Phys Med Rehabil 2006;85:82–88. Objective:To objectively assess the decrease in spasticity and the improvement in gait after tibial nerve neurotomy performed to treat spastic equinovarus foot. Design:Before–after trial with a 2-yr follow-up. Three hemiplegic patients with spastic equinovarus foot were treated with a selective peripheral neurotomy of the tibial motor nerve branches (soleus, lateral and medial gastrocnemius and tibialis posterior nerves). Evaluation included clinical assessment of spasticity (Ashworth scale), maximal Hoffmann reflex (Hmax)/compound muscle action potential (Mmax) ratio measurement, gait analysis, and muscle stiffness evaluation performed before and 2 mos, 1 yr, and 2 yrs after the neurotomy. Results:Spasticity, muscle stiffness, and Hmax/Mmax ratio decreased after neurotomy. The kinematic (ankle dorsal flexion and knee recurvatum) and kinetic variables (maximum ankle muscle moment and external work) of the gait were permanently improved after neurotomy. Interestingly, kinetic variables seemed to gradually improve with time after the neurotomy. Conclusion:Tibial neurotomy is an effective and durable treatment for spastic equinovarus foot.

A Randomized Controlled Trial of Selective Neurotomy Versus Botulinum Toxin for Spastic Equinovarus Foot After Stroke

Background. Selective neurotomy is a permanent treatment of focal spasticity, and its effectiveness in treating spastic equinovarus of the foot (SEF) was previously suggested by a few nonrandomized and uncontrolled case-series studies. Objectives. This study is the first assessor-blinded, randomized, controlled trial evaluating the effects of this treatment. Methods. Sixteen chronic stroke patients presenting with SEF were randomized into 2 groups: 8 patients underwent a tibial neurotomy and the remaining 8 received botulinum toxin (BTX) injections. The soleus was treated in all patients, and the tibialis posterior and flexor hallucis longus were treated in about half of patients. The primary outcome was the quantitative measurement of ankle stiffness (L-path), an objective measurement directly related to spasticity. Participants were assessed by a blind assessor before their intervention and at 2 and 6 months after treatment. Evaluations were based on the 3 domains of the International Classification of Functioning, Disability and Health (ICF). Results. Compared with BTX, tibial neurotomy induced a higher reduction in ankle stiffness. Both treatments induced a comparable improvement of ankle kinematics during gait, whereas neither induced muscle weakening. Activity, participation, and quality of life were not significantly modified in either group. Conclusions. This study demonstrates that the tibial nerve neurotomy is an effective treatment of SEF, reducing the impairments observed in chronic stroke patients. Future studies should be conducted to confirm the long-term efficacy based on the ICF domains.