Botulinum toxin type A combined with neurodynamic mobilization for lower limb spasticity: a case report

Gait analysis using three-dimensional motion and ground reaction force systems in patients with hemiplegia treated with botulinum toxin type A in ankle plantar flexors

Objective: The efficacy of botulinum toxin type A (BoNT-A) injection on spasticity has usually been measured using the range of motion (ROM) of joints and Modified Ashworth Scale (MAS); however, they only evaluate muscle tone at rest. We objectively analyzed the gait of three patients with hemiplegia using three-dimensional motion analysis and ground reaction force (GRF) systems to evaluate muscle tone during gait. Materials and Methods: We measured passive ankle dorsiflexion ROM with knee extension and the MAS score for clinical evaluation, and gait speed, stride length, single-leg support phase during the gait cycle, joint angle, joint moment, and GRFs for kinematic evaluation before and one month after BoNT-A injection. Results: All patients showed an increase in ankle dorsiflexion ROM, improvement in MAS score, and increase in stride length. Case 1 showed an increase in gait speed, prolongation of the single-leg support phase, increase in hip extension angle and moment, and improvement in the vertical and anterior-posterior components of the GRFs. Case 2 showed an increase in gait speed, improvement in double knee action, increase in ankle plantar flexion moment, and improvement in propulsion in the progressive component of the GRFs. Case 3 exhibited a laterally directed force in the GRFs. Conclusion: We evaluated the effects of BoNT-A injections in three patients with hemiplegia using three-dimensional motion analysis and GRFs. The results of the gait analysis clarified the improvements and problems in hemiplegic gait and enabled objective explanations for patients.

Acute effects of a single neurodynamic mobilization session on range of motion and H-reflex in asymptomatic young subjects: A controlled study

Neurodynamic techniques have yielded good clinical results in the treatment of various pathologies. The objective of this study is to examine the short-term effects of neurodynamic techniques of the sciatic nerve on hip ROM (range of motion) and on the amplitude and latency of the soleus H-reflex and M-waves, in young asymptomatic subjects. In a double-blind controlled trial design, 60 young asymptomatic participants were randomly assigned into six groups with different levels of manipulation of the sciatic nerve. The passive straight leg raise test was used to evaluate the hip ROM amplitude. All evaluations were performed before, 1 min after, and 30 min after intervention. For each time-point, spinal and muscle excitability were also tested. ROM increased in all groups, but none of the treatment groups had superior effects than the group with no treatment. This means that ROM testing maneuvers increased ROM amplitude, with no add-on effect of the proposed neurodynamic techniques. Neurophysiological responses changed similarly in all groups, showing that the aftereffects were not intervention-specific. We observed a significant negative association between the change in limb temperature and the change in latencies of all potentials. ROM-testing procedures performed repeatedly increase ROM amplitude. This observation should be considered when evaluating the aftereffects of therapeutic interventions on ROM amplitude. None of the explored neurodynamic techniques produced acute aftereffects on hip ROM amplitude, spinal or muscle excitability different to the induced by the ROM testing maneuver.

Effectiveness of Neurodynamic Mobilization versus Conventional Therapy on Spasticity Reduction and Upper Limb Function in Tetraplegic Patients

STUDY DESIGN

The study employed a pre- and post-test experimental design.

PURPOSE

This study was designed to assess the effect of neurodynamic mobilization of the median nerve on upper limb spasticity in tetraplegic patients.

OVERVIEW OF LITERATURE

Spasticity is a common and potentially disabling and bothersome complication in patients with spinal cord lesion; this disorder can negatively influence the quality of life by restricting the patient's ability to perform activities of daily living. Neural mobilization is currently used for reducing the spasticity in individuals with neurological disorders.

METHODS

Twenty subjects with traumatic spinal cord injury (level C5-C8) and upper limb spasticity in the finger and wrist flexors were enrolled. They were randomly allocated to two different groups using a computer-generated randomization schedule: group I comprised the neurodynamic mobilization group (n=11) and group II was the conventional therapy group (n=9); the subjects were administered therapy for 5 days every week for a period of 4 weeks. Upper limb spasticity was assessed using the Modified Ashworth Scale for wrist and finger flexors; F-wave amplitude, latency, and F-wave/M-wave amplitude ratio (F/M ratio) were examined using the F-wave scores of the median nerve; and upper limb function was determined using the Capabilities of Upper Extremity (CUE) Questionnaire.

RESULTS

After 4 weeks of intervention, between-group comparisons showed a significant difference in the pre-intervention and postintervention scores on the Modified Ashworth Scale score for wrist flexors (-1.64±0.67), Modified Ashworth Scale score for finger flexors (-1.00±0.63), F-wave amplitude (-154.09±220.86), F/M ratio (-0.18±0.24), and CUE scores (17.82±13.49).

CONCLUSIONS

These results suggest that neurodynamic mobilization of the median nerve may be effective for upper limb spasticity control and upper limb functional improvement in tetraplegic patients.

Efficacy of Short-Term Robot-Assisted Rehabilitation in Patients With Hand Paralysis After Stroke: A Randomized Clinical Trial

BACKGROUND

We evaluated the effectiveness of robot-assisted motion and activity in additional to physiotherapy (PT) and occupational therapy (OT) on stroke patients with hand paralysis.

METHODS

A randomized controlled trial was conducted. Thirty-two patients, 34.4% female (mean ± SD age: 68.9 ± 11.6 years), with hand paralysis after stroke participated. The experimental group received 30 minutes of passive mobilization of the hand through the robotic device Gloreha (Brescia, Italy), and the control group received an additional 30 minutes of PT and OT for 3 consecutive weeks (3 d/wk) in addition to traditional rehabilitation. Outcomes included the National Institutes of Health Stroke Scale (NIHSS), Modified Ashworth Scale, Barthel Index (BI), Motricity Index (MI), short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), and the visual analog scale (VAS) measurements. All measures were collected at baseline and end of the intervention (3 weeks).

RESULTS

A significant effect of time interaction existed for NIHSS, BI, MI, and QuickDASH, after stroke immediately after the interventions (all, P < .001). The experimental group had a greater reduction in pain compared with the control group at the end of the intervention, a reduction of 11.3 mm compared with 3.7 mm, using the 100-mm VAS scale.

CONCLUSIONS

In the treatment of pain and spasticity in hand paralysis after stroke, robot-assisted mobilization performed in conjunction with traditional PT and OT is as effective as traditional rehabilitation.

Manual therapy and neurodynamic mobilization in a patient with peroneal nerve paralysis: a case report

OBJECTIVE

The purpose of this case report is to describe a therapeutic intervention for peroneal nerve paralysis involving the sciatic nerve.

CLINICAL FEATURES

A 24-year-old man presented with peroneal nerve paralysis with decreased sensation, severe pain in the popliteal fossa, and steppage gait, which occurred 3 days prior to the consultation. Magnetic resonance imaging and electromyography confirmed lumbar disk herniation with sciatic common peroneal nerve entrapment in the popliteal fossa.

INTERVENTION AND OUTCOME

A combined treatment protocol of spinal and fibular head manipulation and neurodynamic mobilization including soft tissue work of the psoas and hamstring muscles was performed. Outcome measures were assessed at pretreatment, 1 week posttreatment, and 3-month follow-up and included numeric pain rating scale, range of motion, pressure pain threshold, and manual muscle testing. Treatment interventions were applied for 3 sessions over a period of 1 week. Results showed reduction of the patient's subjective pain and considerable improvement in range of motion, strength, and sensation in his left foot, which was restored to full function.

CONCLUSION

A combined program of spinal and fibular head manipulation and neurodynamic mobilization reduced pain, increased range of motion and strength, and restored full function to the left leg in this patient who had severe functional impairment related to a compressed left common peroneal nerve.