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MacRae F, Speirs A, Bursuc A, Hashemi M, Winston P. A Case Report of Cryoneurolysis for Dorsal Foot Pain and Toe Clawing in a Patient With Multiple Sclerosis. Arch Rehabil Res Clin Transl 2023; 5:100286. [PMID: 37744197 PMCID: PMC10517354 DOI: 10.1016/j.arrct.2023.100286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
Toe clawing in patients with upper motor neuron disorders is often attributed to the flexor digitorum longus (FDL) and is a common presentation among patients with multiple sclerosis (MS). This movement may be painful because of the altered pressure distribution and may increase the risk of falls, heighten energy expenditure during gait, and lower gait speed. Cryoneurolysis is a minimally invasive treatment that may be beneficial for pain and focal muscle hypertonicity. An ambulatory patient with MS was treated bilaterally with cryoneurolysis to the superficial fibular nerves for pain on the dorsum of the foot, and to the intramuscular tibial nerve motor branch to FDL for toe clawing. The patient felt that toe clawing was immediately reduced during gait and noted the ability to voluntarily spread their toes. The patient stated that the neuropathic pain on the dorsum of the foot was fully eliminated immediately post procedure. The patient reported improved confidence in their gait, maintained independence, and reduced toe clawing during a structured interview 12 weeks after treatment. The effects lasted for 5.5 months before symptoms returned. Retreatment at 6 months reproduced the benefits. The patient reported a positive experience with cryoneurolysis for toe clawing and dorsal foot pain.
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Affiliation(s)
- Fraser MacRae
- Western University, Faculty of Health Sciences, London, Canada
- Vancouver Island Health Authority, Victoria, Canada
| | - Abby Speirs
- Vancouver Island Health Authority, Victoria, Canada
| | - Andrei Bursuc
- Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Mahdis Hashemi
- Vancouver Island Health Authority, Victoria, Canada
- University of British Columbia, Vancouver, Canada
| | - Paul Winston
- Vancouver Island Health Authority, Victoria, Canada
- University of British Columbia, Vancouver, Canada
- Canadian Advances in Neuro-Orthopedics for Spasticity Consortium, Kingston, Canada
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Takekawa T, Hara T, Yamada N, Sato T, Hasegawa Y, Takagi S, Kobayashi K, Kitajima T, Abo M. Treatment outcome of local injection of botulinum toxin for claw toe: Differences between cerebral hemorrhage and infarction. Clin Neurol Neurosurg 2023; 226:107620. [PMID: 36805253 DOI: 10.1016/j.clineuro.2023.107620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/20/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Some patients with post-stroke claw toe respond well to botulinum toxin (BoNT) treatment while others do not. This study was designed to assess the impact of stroke type (cerebral hemorrhage and cerebral infarction) on the outcome of BoNT treatment for claw toe. METHODS We retrospectively examined the medical records of patients who received local BoNT (onabotulinumtoxin A) injections into the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) muscles. All patients suffered stroke-related leg paralysis and spasticity. RESULTS The study participants were 58 patients (mean age, 61.4 ± 10.3 years, ± SD) with time since stroke of 6.7 ± 4.4 years. The stroke type was cerebral hemorrhage (n = 38) and cerebral infarction (n = 20). After a total of 124 BoNT administrations with medical records entries on the subjective symptoms, the odds for symptomatic improvement was approximately 5.8 times higher in patients of the infarction group compared with the hemorrhage group (OR = 5.787, 95% CI = 2.369-14.134, p = 0. 000). Fifty-one patients (32 with cerebral hemorrhage, 19 with cerebral infarction) received the first local BoNT injection and had available medical records, analysis of which showed a significantly higher rate of symptomatic improvement in patients of the infarction group than those of the hemorrhage group (p = 0.006). After adjustment by factors known to influence treatment outcome (degree of spasticity and paralysis, BoNT dosage, and extent of FDL muscle control of toe movements), the treatment effect was predominantly higher in patients with cerebral infarction. CONCLUSION The BoNT treatment response was better for claw toes in cerebral infarction patients than in hemorrhage patients, possibly suggesting that claw toe is associated with more severe spasticity in this group of patients.
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Affiliation(s)
- Toru Takekawa
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan.
| | - Takatoshi Hara
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan; Department of Rehabilitation Medicine, National Center of Neurology and Psychiatry, Kodaira, Tokyo 187-8551, Japan.
| | - Naoki Yamada
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan.
| | - Tomoharu Sato
- Motoyama Rehabilitation Hospital, Kobe, Hyogo 658-0015, Japan.
| | - Yuki Hasegawa
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan; Department of Rehabilitation Medicine, Tokyo General Hospital, Tokyo 165-0022, Japan.
| | - Satoshi Takagi
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan; Shinagawa Rehabilitation Hospital, Tokyo 141-0001, Japan.
| | - Kazushige Kobayashi
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan.
| | - Tomohide Kitajima
- Department of Cerebrospinal Surgery, Narita Hospital, Narita, Chiba 286-0845, Japan.
| | - Masahiro Abo
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan.
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Takekawa T, Kobayashi K, Yamada N, Takagi S, Hara T, Kitajima T, Sato T, Sugihara H, Kinoshita K, Abo M. Effects of Flexor Digitorum Longus Muscle Anatomical Structure on the Response to Botulinum Toxin Treatment in Patients with Post-Stroke Claw Foot Deformity. Toxins (Basel) 2022; 14:toxins14100666. [PMID: 36287935 PMCID: PMC9610091 DOI: 10.3390/toxins14100666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/13/2022] [Accepted: 09/19/2022] [Indexed: 11/21/2022] Open
Abstract
(1) Background: The purpose of this retrospective case-control study was to determine the relationship between the control of toe movements by flexor hallucis longus (FHL) and flexor digitorum longus (FDL) muscles and the response to treatment with botulinum toxin (BoNT) in post-stroke patients with claw toe. (2) Methods: Subjects with stroke-related leg paralysis/spasticity and claw toes received multiple injections of BoNT (onabotulinumtoxin A) into the FHL or FDL muscles. We investigated the relationship between the mode of transmission of FHL and FDL muscle tension to each toe (MCT) and treatment outcome using the data of 53 patients who received 124 injections with clinically recorded treatment outcome. We also dissected the potential variables that could determine the treatment outcome. (3) Results: The effectiveness of BoNT treatment was significantly altered by FDL-MCT (OR = 0.400, 95% CI = 0.162–0.987, p = 0.047). Analysis of the response to the first BoNT injection showed an odds ratio of FDL-MCT of approximately 6.0 times (OR = 0.168, 95% CI = 0.033–0.857, p = 0.032). The more tibial the influence of the FDL muscle on each toe, the better the treatment outcome on the claw toe. (4) Conclusions: The anatomic relation between FDL muscle and each toe seems to affect the response to treatment with BoNT in post-stroke patients with claw toes.
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Affiliation(s)
- Toru Takekawa
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan
- Correspondence: ; Tel.: +81-3-3433-1111
| | - Kazushige Kobayashi
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan
| | - Naoki Yamada
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan
| | - Satoshi Takagi
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan
- Shinagawa Rehabilitation Hospital, Tokyo 141-0001, Japan
| | - Takatoshi Hara
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan
- National Center of Neurology and Psychiatry, Tokyo 187-8551, Japan
| | - Tomohide Kitajima
- Department of Cerebrospinal Surgery, Medical Center Narita Hospital, Narita, Chiba 286-0845, Japan
| | - Tomoharu Sato
- Motoyama Rehabilitation Hospital, Kobe 658-0015, Hyogo, Japan
| | - Hiroshi Sugihara
- Department of Neurology, Kita-Kashiwa Rehabilitation General Hospital, Kashiwa, Chiba 277-0004, Japan
| | | | - Masahiro Abo
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan
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Vova JA, Green MM, Brandenburg JE, Davidson L, Paulson A, Deshpande S, Oleszek JL, Inanoglu D, McLaughlin MJ. A consensus statement on the use of botulinum toxin in pediatric patients. PM R 2021; 14:1116-1142. [PMID: 34558213 DOI: 10.1002/pmrj.12713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 08/12/2021] [Accepted: 09/10/2021] [Indexed: 11/10/2022]
Abstract
Botulinum toxin has been used in medicine for the past 30 years. However, there continues to be controversy about the appropriate uses and dosing, especially in the pediatric population. A panel of nine pediatric physiatrists from different regions and previous training programs in the United States were nominated based on institutional reputation and botulinum toxin (BoNT) experience. Based on a review of the current literature, the goal was to provide the rationale for recommendations on the administration of BoNT in the pediatric population. The goal was not only to review safety, dosing, and injection techniques but also to develop a consensus on the appropriate uses in the pediatric population. In addition to upper and lower limb spasticity, the consensus also provides recommendations for congenital muscular torticollis, cervical dystonia, sialorrhea, and brachial plexus palsies.
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Affiliation(s)
- Joshua A Vova
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael M Green
- University of Utah/Primary Children's Hospital, Salt Lake City, Utah, USA
| | | | - Loren Davidson
- University of California Davis, Sacramento, California, USA
| | - Andrea Paulson
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Gillette Children's Specialty Healthcare, Minneapolis, Minnesota, USA
| | - Supreet Deshpande
- Gillette Children's Specialty Healthcare, Minneapolis, Minnesota, USA
| | | | - Didem Inanoglu
- Children's Health Specialty Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Abstract
BACKGROUND Poor response to injection of botulinum toxin (BoNT) into the flexor digitorum longus (FDL) muscle has been reported especially in patients with claw foot deformity. We previously advocated BoNT injection into the flexor hallucis longus (FHL) muscle in such patients. Here, we determined the functional and anatomical relationships between FHL and FDL. METHODS Toe flexion pattern was observed during electrical stimulation of FHL and FDL muscles in 31 post-stroke patients with claw-foot deformity treated with BoNT. The FHL and FDL tendon arrangement was also studied in five limbs of three cadavers. RESULTS Electrical stimulation of the FHL muscle elicited big toe flexion in all 28 cases examined and second toe in 25, but the response was limited to the big toe in 3. FDL muscle stimulation in 29 patients elicited weak big toe flexion in 1 and flexion of four toes (2nd to 5th) in 16 patients. Cadaver studies showed division of the FHL tendon with branches fusing with the FDL tendon in all five limbs examined; none of the tendons was inserted only in the first toe. No branches of the FDL tendon merged with the FHL tendon. CONCLUSION Our results showed coupling of FHL and FDL tendons in most subjects. Movements of the second and third toes are controlled by both the FDL and FHL muscles. The findings highlight the need for BoNT injection in both the FDL and FHL muscles for the treatment of claw-toe deformity.
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Palazón-García R, Alcobendas-Maestro M, Esclarin-de Ruz A, Benavente-Valdepeñas AM. Treatment of spasticity in spinal cord injury with botulinum toxin. J Spinal Cord Med 2019; 42:281-287. [PMID: 29869974 PMCID: PMC6522928 DOI: 10.1080/10790268.2018.1479053] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
CONTEXT Spasticity is one of the most frequent complications in spinal cord injury (SCI), and is routinely managed with oral pharmacologic therapy. Botulinum toxin (BT) is not accepted as a treatment for spasticity in SCI in Spain but may be used in certain cases of focal distribution. OBJECTIVE To report the results with BT for treatment of spasticity in SCI. DESIGN AND SETTING Descriptive retrospective study conducted at a specialist SCI rehabilitation center in Spain, covering patients first treated from 2012 through 2014, and successfully followed up for a minimum of 1 year. Data were collected on the following variables: demographic and SCI characteristics (level and grade); nature of spasticity, e.g. tone, distribution, spasms, articular involvement and pain; function; application of BT; tolerance and adverse reactions. RESULTS The study covered 90 patients, predominantly male with incomplete injuries. Improvement in tone as measured by the modified Ashworth scale was a mean of 1.17 points. Goniometric improvement was achieved in 65.6% and improvement in pain in 38.9% of cases. There were no adverse side-effects. Patients with focal spasticity showed a significantly greater improvement in tone (P < 0.0001). The earlier the BT injection, the greater the improvement in goniometric performance (P < 0.006) and pain (P < 0.033), with the best results being obtained within the first 6 months of clinical course. ASIA D injuries showed a greater improvement in tone (P < 0.0001). CONCLUSIONS BT can be both an effective treatment for focal spasticity in SCI and a good coadjuvant for oral treatments in generalized spasticity.
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Affiliation(s)
- Ramiro Palazón-García
- Department of Physical Medicine and Rehabilitation, National Hospital for Paraplegics, Toledo, Spain
| | - Mónica Alcobendas-Maestro
- Department of Physical Medicine and Rehabilitation, National Hospital for Paraplegics, Toledo, Spain
| | - Ana Esclarin-de Ruz
- Department of Physical Medicine and Rehabilitation, National Hospital for Paraplegics, Toledo, Spain
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Kim KT, Chung ME. Musculoskeletal Problems in Lower Extremity after Stroke. BRAIN & NEUROREHABILITATION 2016. [DOI: 10.12786/bn.2016.9.1.13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Keon-tae Kim
- Department of Rehabilitation Medicine, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Korea
| | - Myung Eun Chung
- Department of Rehabilitation Medicine, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Korea
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Kim HG, Chung ME, Song DH, Kim JY, Sul BM, Oh CH, Park NS. Determination of injection site in flexor digitorum longus for effective and safe botulinum toxin injection. Ann Rehabil Med 2015; 39:32-8. [PMID: 25750869 PMCID: PMC4351492 DOI: 10.5535/arm.2015.39.1.32] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 09/02/2014] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To determine the optimal injection site in the flexor digitorum longus (FDL) muscle for effective botulinum toxin injection. METHODS Fourteen specimens from eight adult Korean cadavers were used in this study. The most proximal medial point of the tibia plateau was defined as the proximal reference point; the most distal tip of the medial malleolus was defined as the distal reference point. The distance of a line connecting the proximal and distal reference points was defined as the reference length. The X-coordinate was the distance from the proximal reference point to the intramuscular motor endpoint (IME), or motor entry point (MEP) on the reference line, and the Y-coordinate was the distance from the nearest point from MEP on the medial border of the tibia to the MEP. IME and MEP distances from the proximal reference point were evaluated using the raw value and the X-coordinate to reference length ratio was determined as a percentage. RESULTS The majority of IMEs were located within 30%-60% of the reference length from the proximal reference point. The majority of the MEPs were located within 40%-60% of the reference length from the proximal reference point. CONCLUSION We recommend the anatomical site for a botulinum toxin injection in the FDL to be within a region 30%-60% of the reference length from the proximal reference point.
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Affiliation(s)
- Hong Geum Kim
- Department of Rehabilitation Medicine, St. Paul's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Myung Eun Chung
- Department of Rehabilitation Medicine, St. Paul's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Dae Heon Song
- Department of Rehabilitation Medicine, St. Paul's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Ju Yong Kim
- Department of Rehabilitation Medicine, St. Paul's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Bo Mi Sul
- Department of Rehabilitation Medicine, St. Paul's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Chang Hoon Oh
- Department of Rehabilitation Medicine, St. Paul's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Nam Su Park
- Department of Rehabilitation Medicine, St. Paul's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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Chemodenervation for treatment of limb spasticity following spinal cord injury: a systematic review. Spinal Cord 2015; 53:252-64. [PMID: 25582713 DOI: 10.1038/sc.2014.241] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 11/28/2014] [Accepted: 12/03/2014] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVES To systematically review the literature on chemodenervation with botulinum toxin (BoNT) or phenol/alcohol for treatment of limb spasticity following spinal cord injury (SCI). SETTING British Columbia, Canada. METHODS EMBASE, MEDLINE, CINAHL, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials were searched for English language studies published up until March 2014. Studies were assessed for eligibility and quality by two independent reviewers. RESULTS No controlled trials were identified. A total of 19 studies were included: 9 involving BoNT and 10 involving phenol/alcohol. Owing to the clinically diverse nature of the studies, meta-analysis was deemed inappropriate. The studies produced level 4 and level 5 evidence that chemodenervation with BoNT or alcohol/phenol can lead to improvement in outcome measurements classified in the body structure and function, as well as activity domains of the International Classification of Functioning, Disability and Health framework. The Modified Ashworth Scale (MAS) was the most commonly used outcome measure. All six studies on BoNT and three of the four studies on phenol/alcohol measuring MAS reported a decrease in at least one point. An improvement in MAS was not always associated with improvement in function. The effect of phenol/alcohol has the potential to last beyond 6 months; study follow-up did not occur beyond this time point. CONCLUSION Chemodenervation with BoNT or phenol/alcohol may improve spasticity and function in individuals with SCI. However, there is a lack of high-quality evidence and further research is needed to confirm the efficacy of these interventions.
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Walker HW, Lee MY, Bahroo LB, Hedera P, Charles D. Botulinum Toxin Injection Techniques for the Management of Adult Spasticity. PM R 2014; 7:417-27. [DOI: 10.1016/j.pmrj.2014.09.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 09/26/2014] [Accepted: 09/28/2014] [Indexed: 12/31/2022]
Affiliation(s)
- Heather W. Walker
- Department of Physical Medicine and Rehabilitation, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC
| | - Michael Y. Lee
- Department of Physical Medicine and Rehabilitation, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC
| | | | - Peter Hedera
- Department of Neurology, Vanderbilt University, Nashville, TN
| | - David Charles
- Department of Neurology, Vanderbilt University, Nashville, TN
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Nalysnyk L, Papapetropoulos S, Rotella P, Simeone JC, Alter KE, Esquenazi A. OnabotulinumtoxinA muscle injection patterns in adult spasticity: a systematic literature review. BMC Neurol 2013; 13:118. [PMID: 24011236 PMCID: PMC3848723 DOI: 10.1186/1471-2377-13-118] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 09/03/2013] [Indexed: 01/22/2023] Open
Abstract
Background OnabotulinumtoxinA has demonstrated significant benefit in adult focal spasticity. This study reviews the injection patterns (i.e., muscle distribution, dosing) of onabotulinumtoxinA for treatment of adult spasticity, as reported in published studies. Methods A systematic review of clinical trials and observational studies published between 1990 and 2011 reporting data on muscles injected with onabotulinumtoxinA in adult patients treated for any cause of spasticity. Results 28 randomized, 5 nonrandomized, and 37 single-arm studies evaluating 2,163 adult patients were included. The most frequently injected upper-limb muscles were flexor carpi radialis (64.0% of patients), flexor carpi ulnaris (59.1%), flexor digitorum superficialis (57.2%), flexor digitorum profundus (52.5%), and biceps brachii (38.8%). The most frequently injected lower-limb muscles were the gastrocnemius (66.1% of patients), soleus (54.7%), and tibialis posterior (50.5%). The overall dose range reported was 5–200 U for upper-limb muscles and 10–400 U for lower-limb muscles. Conclusions The reviewed evidence indicates that the muscles most frequently injected with onabotulinumtoxinA in adults with spasticity were the wrist, elbow, and finger flexors and the ankle plantar flexors. OnabotulinumtoxinA was injected over a broad range of doses per muscle among the studies included in this review, but individual practitioners should be mindful of local regulatory approvals and regulations.
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Affiliation(s)
- Luba Nalysnyk
- Epidemiology & Database Analytics, United BioSource Corporation, Lexington, MA, USA.
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Chiong Y, Tay SS, Lim PAC, Tan DML. The effects of toe spreader in people with overactive toe flexors post stroke: a randomized controlled pilot study. Clin Rehabil 2012; 27:90-5. [PMID: 22643727 DOI: 10.1177/0269215512446157] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To investigate the long-term effects of the toe spreader on gait characteristics, pain, activity level and balance in individuals with chronic stroke who exhibited tonic toe flexion reflex. The secondary objectives were to determine the sample size for future studies and to assess compliance to the use of the toe spreader. DESIGN Single-blind, randomized controlled pilot trial. SETTING Outpatient clinic of a tertiary hospital in Singapore. SUBJECTS Nine ambulatory participants with tonic toe flexion reflex more than six months post stroke. INTERVENTION Control or customized toe spreader groups for six months. The toe spreader was made of Rolyan Ezemix elastomer putty and worn with sport sandals during ambulation. MAIN MEASURES Gait speed and plantar surface contact area, pain visual analogue scale (VAS), Berg Balance Scale, Modified Ashworth Scale, activity level measured on pedometer and compliance via logbook. RESULTS There were no significant differences between the groups. Both groups showed non-significant improvements in gait speed (toe spreader 0.34 (0.26) versus 0.37 (0.29) m/s; control 0.40 (0.27) versus 0.50 (0.17) m/s), activity level, step length of the hemiplegic leg and stride length at six months. All participants in the intervention group used the toe spreader less than 50% of the days, indicating suboptimal compliance. CONCLUSION The use of the toe spreader did not result in significant improvements in any outcomes. Studies with sample sizes of at least 56 participants and strategies to increase compliance to the use of the toe spreader are recommended.
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Affiliation(s)
- Yi Chiong
- Department of Rehabilitation Medicine, Singapore General Hospital, Singapore.
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Olver J, Esquenazi A, Fung VSC, Singer BJ, Ward AB. Botulinum toxin assessment, intervention and aftercare for lower limb disorders of movement and muscle tone in adults: international consensus statement. Eur J Neurol 2010; 17 Suppl 2:57-73. [DOI: 10.1111/j.1468-1331.2010.03128.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Pek CH, Seet RC, Yik JH, Lim EC. Orofacial dystonia triggered by mouth closure. Clin Neurol Neurosurg 2010; 112:79-81. [DOI: 10.1016/j.clineuro.2009.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2008] [Revised: 07/09/2009] [Accepted: 09/23/2009] [Indexed: 10/20/2022]
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Elovic EP, Esquenazi A, Alter KE, Lin JL, Alfaro A, Kaelin DL. Chemodenervation and Nerve Blocks in the Diagnosis and Management of Spasticity and Muscle Overactivity. PM R 2009; 1:842-51. [DOI: 10.1016/j.pmrj.2009.08.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Accepted: 08/06/2009] [Indexed: 01/04/2023]
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Mendicino RW, Kim C, Kabazie AJ, Catanzariti AR. Correction of severe foot and ankle contracture due to CRPS using external fixation and pain management: report of a pediatric case. J Foot Ankle Surg 2008; 47:434-40. [PMID: 18725124 DOI: 10.1053/j.jfas.2008.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2007] [Indexed: 02/03/2023]
Abstract
UNLABELLED Complex regional pain syndrome-induced dystonia is a severe deformity that can affect the lower extremities and hinder ambulation. Although a number of conservative treatments have been described for this condition, we are not aware of any publications describing the use of surgical intervention for the treatment of this condition. In this report, we describe the case of a pediatric patient with a severe lower extremity deformity in conjunction with chronic pain syndrome. A concerted, interdisciplinary treatment approach was undertaken for the management of this patient, and this included contributions from a foot and ankle surgeon, a pain specialist, an internist, a physical therapist, and a psychiatrist. The primary goal of the treatment strategy was to recreate a plantigrade, weight-bearing lower extremity, while controlling pain. To this end, gradual correction of deformity was achieved using an external fixator and, by 6 months after the surgery, the patient was for the first time in years ambulating on the realigned lower extremity. After 3 years of follow-up, she maintained an activity level that was equal to that which she enjoyed before the injury. LEVEL OF CLINICAL EVIDENCE 4.
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Affiliation(s)
- Robert W Mendicino
- Department of Foot & Ankle Surgery, The Western Pennsylvania Hospital, Pittsburgh, PA 15224, USA.
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Lim ECH, Seet RCS. Botulinum toxin: description of injection techniques and examination of controversies surrounding toxin diffusion. Acta Neurol Scand 2008; 117:73-84. [PMID: 17850405 DOI: 10.1111/j.1600-0404.2007.00931.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The benefits derived from botulinum toxin (BTX) injections may be negated by unintentional weakness of adjacent uninjected muscles. Such weakness may be the result of inaccurate targeting, or diffusion of BTX to surrounding muscles. Several techniques, using electromyographic, endoscopic or imaging guidance are purported to increase the accuracy of targeting. Diffusion of BTX is thought to be influenced by factors such as dose, concentration, injectate volume, number of injections, site and rate of injection, needle gauge, muscle size, muscular fascia, distance of needle tip from the neuromuscular junction, and protein content of the BTX formulation. This article describes techniques that aim to increase the accuracy of BTX injections and examines the controversies surrounding diffusion of BTX following injection.
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Affiliation(s)
- E C-H Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, and National University Hospital, Singapore.
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Lim ECH, Oh VMS, Ong BKC, Chow AWL, Seet RCS. Where has all the botox gone? (How) will we ever learn… Using monoclonal antibodies to track botulinum toxin. Med Hypotheses 2006; 67:440-6. [PMID: 16678355 DOI: 10.1016/j.mehy.2006.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2006] [Accepted: 03/13/2006] [Indexed: 11/26/2022]
Abstract
Botulinum toxin (BTX) is an important therapeutic tool in the treatment of overactive skeletal and smooth muscles, as well as hypersecretory and painful disorders. Despite advances in our understanding of how BTX works, much remains to be elucidated, such as how BTX ameliorates pain, how it produces weakness remote from the site of injection and the fate of the heavy and light chain components of the BTX molecule following endocytosis into the presynaptic membrane. BTX, conjugated to radionuclides, allows investigators to track the molecule both in vitro and in vivo. However, altering the BTX molecule may cause structural changes or pharmacokinetic and pharmacodynamic alterations, and disrupt its normal action. We propose instead to bind the biomarkers (appropriate dyes, radionuclides or MRI contrast agents) to monoclonal antibodies directed against either heavy or light chain components of BTX, thus allowing administration of native (i.e. unaltered) BTX.
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Affiliation(s)
- Erle C-H Lim
- Division of Neurology, Yong Loo Lin School of Medicine, National University of Singapore/National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore.
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