Usefulness of a Qualitative Ultrasound Evaluation of the Gastrocnemius-Soleus Complex with the Heckmatt Scale for Clinical Practice in Cerebral Palsy

Assessing muscle architecture with ultrasound: implications for spasticity

Botulinum Neurotoxin Type A (BoNT-A) injections using Ultrasound (US) guidance have led to research evaluating changes in muscle architecture. Controversy remains as to what constitutes increased Echo-Intensity (EI) in spastic muscles and whether this may affect outcomes. We aim to provide a narrative review of US muscle architecture changes following Central Nervous System (CNS) lesions and explore their relationship to spasticity. Medline, CINAHL, and Embase databases were searched with keywords: ultrasonography, hypertonia, spasticity, fibrosis, and Heckmatt. Three physicians reviewed the results of the search to select relevant papers. Reviews identified in the search were used as a resource to identify additional studies. A total of 68 papers were included. Four themes were identified, including histopathological changes in spastic muscle, effects of BoNT-A on the muscle structure, available US modalities to assess the muscle, and utility of US assessment in clinical spasticity. Histopathological studies revealed atrophic and fibro-fatty changes after CNS lesions. Several papers described BoNT-A injections contributing to those modifications. These changes translated to increased EI. The exact significance of increased muscle EI remains unclear. The Modified Heckmatt Scale (MHS) is a validated tool for grading muscle EI in spasticity. The use of the US may be an important tool to assess muscle architecture changes in spasticity and improve spasticity management. Treatment algorithms may be developed based on the degree of EI. Further research is needed to determine the incidence and impact of these EI changes in spastic muscles.

The Relationship of Gastrocnemius-Soleus Muscle Architecture with Balance and Functional Strength in Acute Stroke Patients

Balance and functional impairment could occur due to the weakness of the gastrocsoleus muscles in acute stroke patients. This study was planned to determine the muscle architecture and its relationship to balance and functional strength functional ability in patients with acute stroke. A cross-sectional analysis of 22 stroke patients (68.59 ± 8.16) was performed in this study. Gastrocnemius muscle thickness and cross-sectional area were significantly greater on the non-paretic than on the paretic sides (p = 0.004, p = 0.005, respectively). Partial correlation analysis showed that soleus muscle thickness and cross-sectional area was significantly correlated with Berg Balance Scale, Single Leg Stance Test, Five Times Sit to Stand Test and Tandem test results in the paretic side (r = 0.49-0.77, p < 0.05). The gastrocnemius muscle thickness of the non-paretic side had a significant relationship with balance (r = 0.45-0.65, p < 0.05). The muscle thickness and cross-sectional area of the soleus muscle on the paretic sides was significantly related with the functional strength and balance after stroke. It may be beneficial to develop clinical assessment and intervention programs focusing on distal plantar flexor muscle groups in order to improve the functional status and balance.

Quantitative assessment of spasticity: a narrative review of novel approaches and technologies

Spasticity is a complex neurological disorder, causing significant physical disabilities and affecting patients' independence and quality of daily lives. Current spasticity assessment methods are questioned for their non-standardized measurement protocols, limited reliabilities, and capabilities in distinguishing neuron or non-neuron factors in upper motor neuron lesion. A series of new approaches are developed for improving the effectiveness of current clinical used spasticity assessment methods with the developing technology in biosensors, robotics, medical imaging, biomechanics, telemedicine, and artificial intelligence. We investigated the reliabilities and effectiveness of current spasticity measures employed in clinical environments and the newly developed approaches, published from 2016 to date, which have the potential to be used in clinical environments. The new spasticity scales, taking advantage of quantified information such as torque, or echo intensity, the velocity-dependent feature and patients' self-reported information, grade spasticity semi-quantitatively, have competitive or better reliability than previous spasticity scales. Medical imaging technologies, including near-infrared spectroscopy, magnetic resonance imaging, ultrasound and thermography, can measure muscle hemodynamics and metabolism, muscle tissue properties, or temperature of tissue. Medical imaging-based methods are feasible to provide quantitative information in assessing and monitoring muscle spasticity. Portable devices, robotic based equipment or myotonometry, using information from angular, inertial, torque or surface EMG sensors, can quantify spasticity with the help of machine learning algorithms. However, spasticity measures using those devices are normally not physiological sound. Repetitive peripheral magnetic stimulation can assess patients with severe spasticity, which lost voluntary contractions. Neuromusculoskeletal modeling evaluates the neural and non-neural properties and may gain insights into the underlying pathology of spasticity muscles. Telemedicine technology enables outpatient spasticity assessment. The newly developed spasticity methods aim to standardize experimental protocols and outcome measures and enable quantified, accurate, and intelligent assessment. However, more work is needed to investigate and improve the effectiveness and accuracy of spasticity assessment.

Botulinum toxin type A for spasticity in cerebral palsy patients: Which impact on popliteal angle to hamstring length? A proof-of-concept study

BACKGROUND

Cerebral palsy (CP) is the most common physical disability in childhood. It is a heterogeneous condition in terms of etiology, motor type and severity of impairments. Clinical impairments, such as increased muscle tone (spasticity), muscle weakness and joint stiffness contribute to the abnormal development of functional activities, including gait.

OBJECTIVE

The objective of this study was to investigate the popliteal angle to hamstring length after ultrasound guided Incobotulinum toxin A injections for spasticity in CP patients.

METHODS

In this proof-of-concept study, we included outpatients with CP and crouch gait correlated to hamstrings spasticity referred to the Pediatric Rehabilitation outpatient clinic of Umberto I University Hospital, Sapienza University of Rome, in the period between February and October 2018.

METHODS

Modified Ashworth Scale (MAS) of hamstring muscles, Popliteal Angle and Modified Popliteal Angle, Passive Knee Extension and 10 Meter Walk Test (10MWT) were assessed at baseline (T0) and three weeks after ultrasound guided injection (T1) of Incobotulinum Toxin A (dose weight and site dependent).

RESULTS

Thirteen patients (5 male and 8 female), mean aged 9.91 ± 3.59, were included. The clinical evaluation at T0 showed hamstring muscles spasticity, with MAS of 2.4 ± 0.6, popliteal angle -51.7∘± 11.0∘, modified popliteal angle of -39.5∘± 11.0∘, passive knee extension of -14.0∘± 8.7∘ and 10MWT of 14.3 ± 4.6 seconds. At T1, hamstring muscles MAS mean value was 1.7 ± 0.6 (p< 0.01), popliteal angle 41.3∘± 7.0∘ (p< 0.001), modified popliteal angle -32.9∘± 10.4∘ (p< 0.001), passive knee extension -4.0∘± 4.2∘ (p< 0.05) and 10MWT 12.6 ± 4.8 seconds (p< 0.05). None of the treated patients reported any adverse event related to Incobotulinum Toxin A injection.

CONCLUSION

Incobotulinum toxin A treatment has been proven to be safe and effective for hamstring muscles spasticity management in CP patients. Further studies with larger samples and longer follow-up are warranted to assess the efficacy of this treatment on the popliteal angle.

Muscle architecture and its relationship with lower extremity muscle strength in multiple sclerosis

This study was planned to determine the muscle architecture (pennation angle, muscle fiber length, and muscle thickness) and its relationship to lower extremity muscle strength in patients with Multiple Sclerosis (pwMS). The muscle architecture (pennation angle, muscle fiber length, and muscle thickness) and lower extremity muscle strength were assessed in 33 pwMS [13 Relapsing-Remitting MS (RRMS), 5 Primary Progressive MS (PPMS), 5 Secondary Progressive MS (SPMS), and 11 matched healthy controls (HC)]. Muscle architecture features were assessed with ultrasonography and muscle strength were assessed with a digital hand-held dynamometer. The rectus femoris muscle thickness and pennation angle, gastrocnemius muscle thickness, and the tibialis anterior pennation angle were significantly lower in pwMS compared to HC (p < 0.05). The strength of hip flexors, hip extensors, knee extensors, foot plantar, and foot dorsi flexors were lower in pwMS. In PPMS group, muscle strength of hip flexors was lower than RRMS and SPMS groups, and muscle strength of foot dorsi flexors was lower than RRMS (p < 0.05). In pwMS, positive correlations were found, between knee flexor strength and biceps femoris pennation angle. Also knee extensor strength and rectus femoris fiber length and muscle thickness were correlated positively (p < 0.05). According to our results the muscle architecture is affected in MS. The determination of architectural changes of lower extremity muscles may guide the arrangement of optimal strength exercises in functional rehabilitation programs.ClinicalTrials: NCT03766698.

Predicting the surgical reparability of large-to-massive rotator cuff tears by B-mode ultrasonography: a cross-sectional study

PURPOSE

This study aimed to compare the ability of B-mode ultrasonography and magnetic resonance imaging (MRI) to predict the repairability of large-to-massive rotator cuff tears (RCTs).

METHODS

This cross-sectional study included participants with large-to-massive RCTs who underwent arthroscopic repair. B-mode ultrasonography and MRI were conducted prior to arthroscopic repair. B-mode ultrasonography was used to evaluate the echogenicity of the rotator cuff muscle using the Heckmatt scale. Intra-rater and inter-rater reliabilities were examined for two independent physicians. MRI was used to evaluate the degrees of tendon retraction, fatty infiltration of rotator cuff muscles, and muscle atrophy. Finally, two experienced orthopedic surgeons performed surgery and decided whether the torn stump could be completely repaired intraoperatively.

RESULTS

Fifty participants were included, and 32 complete repairs and 18 partial repairs were performed. B-mode ultrasonography showed good intra-rater reliability and inter-rater reliability for assessment of the muscle echogenicity of the supraspinatus and infraspinatus muscles. The correlation coefficients between B-mode ultrasound findings and MRI findings showed medium to large effect sizes (r=0.4-0.8). The Goutallier classification of the infraspinatus muscles was the MRI predictor with the best discriminative power for surgical reparability (area under the curve [AUC], 0.89; 95% confidence interval [CI], 0.81 to 0.98), while the Heckmatt scale for infraspinatus muscles was the most accurate ultrasound predictor (AUC, 0.85; 95% CI, 0.74 to 0.96). No significant differences in AUCs among the MRI and ultrasound predictors were found.

CONCLUSION

B-mode ultrasonography was a reliable examination tool and had a similar ability to predict surgical reparability to that of MRI among patients with large-to-massive RCTs.

Effect of performing daily activities while standing on the quantity and quality of the thigh muscles in adults with severe cerebral palsy: a cross-sectional study

[Purpose] To observe the effect of daily standing, as indicated by gross motor function, on the quantity and quality of the thigh muscles in adults with severe cerebral palsy and to obtain data to determine an appropriate intervention that will improve their quality of life. [Participants and Methods] Thirty-three adults with severe cerebral palsy participated in the study. We assessed the gross motor function using the GMFM-66-IS. We then evaluated the quadriceps muscle thickness and the rectus femoris muscle echo intensity using ultrasonography. We divided the participants into the standing and non-standing groups and then examined the correlations of the GMFM-66-IS score to muscle thickness and echo intensity. We calculated the difference in mean muscle thickness and echo intensity between the two groups using an independent t-test. [Results] Significant positive correlations were found between the GMFM-66-IS score and muscle thickness and echo intensity. In the group-specific analysis, no significant correlation was found between echo intensity and the GMFM-66-IS score in either group. Muscle thickness and echo intensity were greater in the participants of the standing group. [Conclusion] Daily standing, as indicated by gross motor function, affected muscle thickness and echo intensity. Quantitative and qualitative data might need to be evaluated when assessing the muscles of adults with severe cerebral palsy using ultrasonography.

Reliability and Validity of the Modified Heckmatt Scale in Evaluating Muscle Changes With Ultrasound in Spasticity

Objectives

To determine the reliability and validity of the Modified Heckmatt scale in assessing muscle echotexture in spasticity.

Design

Prospective, observational, 2-center study. Two residents and 2 ultrasound experienced staff physicians each rated 100 ultrasound images that were also analyzed using quantitative gray-scale.

Setting

Academic ambulatory spasticity clinic.

Participants

Participants (N=50) included 45 patients with upper or lower extremity spasticity and 5 healthy references.

Interventions

Not applicable.

Main Outcome Measures

Modified Heckmatt scale ratings and quantitative gray-scale scores

Results

Inter- and intra-rater intraclass correlation coefficients were 0.76 and 0.81, respectively (P<.001), indicating good to excellent reliability. A significant relationship was found between Modified Heckmatt scores and quantitative gray-scale scores (r=0.829; P<.001).

Conclusions

The Modified Heckmatt scale demonstrated good reliability and validity to assess the pathologic muscle changes that occur in patients with spasticity.

•

Spasticity can alter muscle architecture as viewed with ultrasound.

•

Spastic muscles can show increased echointensity (EI).

•

Spastic muscles with increased EI may respond less favorably to botulinum toxin.

•

Muscle EI can be quantified using the Modified Heckmatt scale.

•

The Modified Heckmatt scale demonstrated good reliability and validity.