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Verduzco-Gutierrez M, Raghavan P, Pruente J, Moon D, List CM, Hornyak JE, Gul F, Deshpande S, Biffl S, Al Lawati Z, Alfaro A. AAPM&R consensus guidance on spasticity assessment and management. PM R 2024; 16:864-887. [PMID: 38770827 DOI: 10.1002/pmrj.13211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 03/19/2024] [Accepted: 04/08/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND The American Academy of Physical Medicine and Rehabilitation (AAPM&R) conducted a comprehensive review in 2021 to identify opportunities for enhancing the care of adult and pediatric patients with spasticity. A technical expert panel (TEP) was convened to develop consensus-based practice recommendations aimed at addressing gaps in spasticity care. OBJECTIVE To develop consensus-based practice recommendations to identify and address gaps in spasticity care. METHODS The Spasticity TEP engaged in a 16-month virtual meeting process, focusing on formulating search terms, refining research questions, and conducting a structured evidence review. Evidence quality was assessed by the AAPM&R Evidence, Quality and Performance Committee (EQPC), and a modified Delphi process was employed to achieve consensus on recommendation statements and evidence grading. The Strength of Recommendation Taxonomy (SORT) guided the rating of individual studies and the strength of recommendations. RESULTS The TEP approved five recommendations for spasticity management and five best practices for assessment and management, with one recommendation unable to be graded due to evidence limitations. Best practices were defined as widely accepted components of care, while recommendations required structured evidence reviews and grading. The consensus guidance statement represents current best practices and evidence-based treatment options, intended for use by PM&R physicians caring for patients with spasticity. CONCLUSION This consensus guidance provides clinicians with practical recommendations for spasticity assessment and management based on the best available evidence and expert opinion. Clinical judgment should be exercised, and recommendations tailored to individual patient needs, preferences, and risk profiles. The accompanying table summarizes the best practice recommendations for spasticity assessment and management, reflecting principles with little controversy in care delivery.
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Affiliation(s)
- Monica Verduzco-Gutierrez
- Department of Rehabilitation Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Preeti Raghavan
- Department of Physical Medicine and Rehabilitation and Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jessica Pruente
- Department of Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel Moon
- Department of Physical Medicine and Rehabilitation, Jefferson Moss-Magee Rehabilitation Hospital, Elkins Park, Pennsylvania, USA
| | | | - Joseph Edward Hornyak
- Department of Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Fatma Gul
- Department of Physical Medicine and Rehabilitation Department, University of Texas, Southwestern Medical Center, Dallas, Texas, USA
| | - Supreet Deshpande
- Department of Pediatric Rehabilitation Medicine, Gillette Children's Hospital, St.Paul, Minnesota, USA
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Susan Biffl
- Division Pediatric Rehabilitation Medicine Department of Orthopedic Surgery, UCSD Rady Children's Hospital, San Diego, California, USA
| | - Zainab Al Lawati
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Abraham Alfaro
- Rehabilitation Medicine, AtlantiCare Health Services, Inc., Federally Qualified Health Center (FQHC), Atlantic City, New Jersey, USA
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Shoval HA, Ace JC, Reddy MR, Grew EC, Cheng J. Safety and effectiveness of ethanol neurolysis with and without onabotulinumtoxinA in children with cerebral palsy. PM R 2023; 15:1419-1424. [PMID: 36970949 DOI: 10.1002/pmrj.12973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 02/19/2023] [Accepted: 03/05/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND OnabotulinumtoxinA is commonly used to relieve spasticity in children with neurologic disorders. Ethanol neurolysis may be used to target more muscles but is less well studied, especially in pediatrics. OBJECTIVE To determine the safety and effectiveness of ethanol neurolysis with onabotulinumtoxinA injections compared to only onabotulinumtoxinA injections for the treatment of spasticity in children with cerebral palsy. DESIGN Prospective cohort study including patients with cerebral palsy receiving onabotulinumtoxinA and/or ethanol neurolysis from June 2020 to June 2021. SETTING Outpatient physiatry clinic. PATIENTS A total of 167 children with cerebral palsy not undergoing other treatments during injection period. INTERVENTIONS Injection with either onabotulinumtoxinA only (112 children) or a combination of ethanol and onabotulinumtoxinA injections (55 children) using both ultrasound guidance and electrical stimulation. MAIN OUTCOME MEASURES A post-procedure evaluation at 2 weeks after injection documented any adverse effects experienced by the child and perceived magnitude of improvement using an ordinal scale from 1 to 5. Multiple linear regression was used to identify and control for covariates including Gross Motor Function Classification System, gender, age, weight, ethnicity, race, and dosage. RESULTS Only weight was identified as a confounding factor. When controlled for weight, combined onabotulinumtoxinA and ethanol injections had a greater magnitude of improvement (3.78/5) compared with onabotulinumtoxinA injections alone (3.44/5), a difference of 0.34 points on the rating scale (95% confidence interval: 0.01-0.69; p = .045). However, the difference was not clinically significant. One patient in the onabotulinumtoxinA-only group and two patients in the combined onabotulinumtoxinA and ethanol group reported mild, self-limiting adverse effects. CONCLUSION Ethanol neurolysis under ultrasound and electrical stimulation guidance may be a safe and effective treatment for children with cerebral palsy that allows more spastic muscles to be treated than onabotulinumtoxinA alone.
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Affiliation(s)
- Hannah A Shoval
- Department of Pediatric Physiatry, Atlantic Health System, Morristown, New Jersey, USA
- Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Jessica C Ace
- Department of Physical Medicine & Rehabilitation, JFK-Johnson Rehabilitation Institute, Edison, New Jersey, USA
| | - Mayuri R Reddy
- Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Emily C Grew
- Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - JenFu Cheng
- Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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Tomaras MC, Simmons SF, Schnelle JF, Charles D, Hacker ML. The Minimum Data Set: An Opportunity to Improve Spasticity Screening. J Am Med Dir Assoc 2020; 22:608-612. [PMID: 32893138 DOI: 10.1016/j.jamda.2020.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/29/2020] [Accepted: 07/03/2020] [Indexed: 10/23/2022]
Abstract
Spasticity is a common movement disorder that arises from trauma or disease affecting the central nervous system. Untreated spasticity can result in limitations in completing activities of daily living, painful limb contractures, and other conditions associated with loss of mobility. In the long-term care setting, this treatable condition is prevalent, yet often unrecognized likely because of a lack of spasticity-trained practitioners. A recently published spasticity referral tool holds promise for addressing the underdiagnosis of spasticity in the long-term care population. The Minimum Data Set (MDS) would be an ideal mechanism for increasing the diagnosis and treatment of spasticity because it is a government-directed comprehensive screening tool that informs care plans for all residents residing in federally funded long-term care facilities. The MDS could easily integrate the published referral assessment to record the presence of spastic postures and muscle rigidity. We propose expanding the MDS to include 3 questions related to spasticity to improve the recognition and treatment of this prevalent and treatable condition.
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Affiliation(s)
- Miranda C Tomaras
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN.
| | | | | | - David Charles
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN
| | - Mallory L Hacker
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN; Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
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Gonnade N, Lokhande V, Ajij M, Gaur A, Shukla K. Phenol Versus Botulinum Toxin A Injection in Ambulatory Cerebral Palsy Spastic Diplegia: A Comparative Study. J Pediatr Neurosci 2017; 12:338-343. [PMID: 29675072 PMCID: PMC5890553 DOI: 10.4103/jpn.jpn_123_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The aim of this study is to compare the treatment effectiveness of botulinum toxin type A (BTX-A) and phenol blocks in the management of lower limb spasticity and to measure improvement in gross motor functional outcome in children with cerebral palsy (CP). This is a hospital-based prospective, noncontrolled randomized study that took place in a tertiary care center. A total of 61 ambulatory children with CP spastic diplegia, aged from 4 to 10 years, were randomly divided into two groups and included in this study. Twenty-eight children with CP received BTX-A injections and 33 received phenol motor point blocks. The measures performed were as follows: outcome assessment spasticity by the Modified Ashworth scale (MAS), active range of motion (AROM) of lower limb joint by goniometer, and functional improvement by Gross Motor Function Measures (GMFM). Postinjection follow-up done at 2, 6, 12, 24, and 48 weeks. Significant improvement in reduction of spasticity, increased AROM of all joints of lower limbs, and improvement in functional outcome were observed in CP with spastic diplegia after BTX-A injections as compared with the phenol motor point block group. There was no significant side effect after BTX-A injections as compared with phenol injections. BTX-A injections showed superior treatment effects in the reduction of spasticity and improvement in AROM and functional outcome measures with spastic diplegia as compared with phenol blocks. BTX-A injections also revealed fewer clinical side effects and were well tolerated by children with CP.
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Affiliation(s)
- Nitesh Gonnade
- Assistant Professor in Physical Medicine and Rehabilitation, All India Institute of Medical sciences, Jodhpur, Rajasthan, India
| | - Vaibhav Lokhande
- Senior resident in Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Mohammed Ajij
- Department of Paediatrics, Sawai Mansingh Medical college, Jaipur, Rajasthan, India
| | - Anil Gaur
- Director of All India Institute of Physical Medicine and Rehabilitation, Mumbai, India
| | - Kamalakant Shukla
- Assistant Professor, Departments of Biochemistry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Hu S, Zhuo L, Zhang X, Yang S. Localization of nerve entry points as targets to block spasticity of the deep posterior compartment muscles of the leg. Clin Anat 2017; 30:855-860. [PMID: 28459126 DOI: 10.1002/ca.22893] [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: 03/10/2017] [Accepted: 04/21/2017] [Indexed: 11/11/2022]
Abstract
To identify the optimal body surface puncture locations and the depths of nerve entry points (NEPs) in the deep posterior compartment muscles of the leg, 60 lower limbs of thirty adult cadavers were dissected in prone position. A curved line on the skin surface joining the lateral to the medial epicondyles of the femur was taken as a horizontal reference line (H). Another curved line joining the lateral epicondyle of the femur to the lateral malleolus was designated the longitudinal reference line (L). Following dissection, the NEPs were labeled with barium sulfate and then subjected to spiral computed tomography scanning. The projection point of the NEP on the posterior skin surface of the leg was designated P, and the projection in the opposite direction across the transverse plane was designated P'. The intersections of P on H and L were identified as PH and PL , and their positions and the depth of the NEP on PP' were measured using the Syngo system and expressed as percentages of H, L, and PP'. The PH points of the tibial posterior, flexor hallucis longus and flexor digitorum longus muscles were located at 38.10, 46.20, and 55.21% of H, respectively. The PL points were located at 25.35, 41.30, and 45.39% of L, respectively. The depths of the NEPs were 49.11, 54.64, and 55.95% of PP', respectively. The accurate location of these NEPs should improve the efficacy and efficiency of chemical neurolysis for treating spasticity of the deep posterior compartment muscles of the leg. Clin. Anat. 30:855-860, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Shuaiyu Hu
- Department of Anatomy, Zunyi Medical College, Zunyi, Guizhou, China
| | - Lifan Zhuo
- Department of Anatomy, Zunyi Medical College, Zunyi, Guizhou, China
| | - Xiaoming Zhang
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas
| | - Shengbo Yang
- Department of Anatomy, Zunyi Medical College, Zunyi, Guizhou, China
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Zhong S, Li G, Yang L, Yan Q, Wang Y, Zhao G, Li Y. Anatomic and Ultrasonic Study Based on Selective Tibial Neurotomy. World Neurosurg 2017; 99:214-225. [DOI: 10.1016/j.wneu.2016.11.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/02/2016] [Accepted: 11/03/2016] [Indexed: 10/20/2022]
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The Dose and Volume-Response Relationship of an Ethanol-Induced Tibial Nerve Block in a Rabbit Model. Am J Phys Med Rehabil 2014; 93:138-45. [DOI: 10.1097/phm.0b013e3182a92b57] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Park ES, Rha DW, Lee WC, Sim EG. The effect of obturator nerve block on hip lateralization in low functioning children with spastic cerebral palsy. Yonsei Med J 2014; 55:191-6. [PMID: 24339306 PMCID: PMC3874912 DOI: 10.3349/ymj.2014.55.1.191] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Hip adductor spasticity has a great impact on developing hip displacement in children with cerebral palsy (CP). Obturator nerve (ON) block is less invasive intervention rather than soft tissue surgery for reduction of hip adductor spasticity. The aim of this study is to investigate the effect of ON block on hip lateralization in low functioning children with spastic CP. MATERIALS AND METHODS The study was performed by retrospective investigation of the clinical and radiographic follow-up data of low functioning children [gross motor function classification system (GMFCS) level III to V] with spastic cerebral palsy whose hip was subluxated. Migration percentage (MP) was measured on hip radiographs and its annual change was calculated. In intervention group, ON block was done with 50% ethyl alcohol under the guidance of electrical stimulation. RESULTS The data of 49 legs of 25 children for intervention group and the data of 41 legs of 23 children for nonintervention group were collected. In intervention group, the MP were significantly reduced at 1st follow-up and the MPs at 2nd and last follow-up did not show significant differences from initial MP. Whereas in nonintervention group, the MPs at 1st, 2nd and last follow-up were all significantly increased compared to initial MPs. CONCLUSION ON block with ethyl alcohol is useful as an early effective procedure against progressive hip displacement in these children with spastic CP.
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Affiliation(s)
- Eun Sook Park
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea.
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Byun SD, Park DH, Choi WD, Hong YH, Lee ZI, Kim CH. Obturator Nerve Block Using Ultrasound-guided Intraneural Alcohol Injection in Patient with Hip Adductor Spasticity. BRAIN & NEUROREHABILITATION 2012. [DOI: 10.12786/bn.2012.5.2.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Seung Deuk Byun
- Department of Rehabilitation Medicine, Daegu Fatima Hospital, Korea
| | - Dong Hwi Park
- Department of Rehabilitation Medicine, Daegu Fatima Hospital, Korea
| | - Won Duck Choi
- Department of Rehabilitation Medicine, Daegu Fatima Hospital, Korea
| | - Yong Ho Hong
- Department of Rehabilitation Medicine, Daegu Fatima Hospital, Korea
| | - Zee Ihn Lee
- Department of Rehabilitation Medicine, Daegu Fatima Hospital, Korea
| | - Chul Hyun Kim
- Department of Rehabilitation Medicine, Kyungpook National University College of Medicine, Korea
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Affiliation(s)
- Wael Fouad
- Alexandria Faculty of Medicine, Neurosurgery Department, Sultan Hussein Street, Azarita, Alexandria Egypt
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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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Williams G, Morris ME, Schache A, McCrory PR. Incidence of Gait Abnormalities After Traumatic Brain Injury. Arch Phys Med Rehabil 2009; 90:587-93. [DOI: 10.1016/j.apmr.2008.10.013] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Revised: 09/26/2008] [Accepted: 10/01/2008] [Indexed: 11/15/2022]
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Observational gait analysis in traumatic brain injury: accuracy of clinical judgment. Gait Posture 2009; 29:454-9. [PMID: 19109020 DOI: 10.1016/j.gaitpost.2008.11.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Revised: 11/03/2008] [Accepted: 11/09/2008] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the accuracy of clinicians' visual observations of gait disorders following traumatic brain injury (TBI). METHODS 30 ambulant participants (sample of convenience) receiving physiotherapy for mobility limitations following TBI and 25 age, height, weight and sex matched healthy unimpaired controls (HC) were recruited. Kinematic and ground reaction force data during gait were captured and video recordings were concurrently collected. Participants with TBI walked at self-selected speed whilst HCs walked at preferred speed as well as the mean TBI speed for comparison. 40 doctors, experienced physiotherapists, new graduate physiotherapists and novices were observers. Each viewed and rated 36 gait variables for a randomized sub-sample of 10 participants with TBI. Observer inaccuracy was calculated for each gait variable. RESULTS Overall the accuracy of observational gait analysis was low and there was considerable variability in observations between clinicians. For most kinematic variables, observer inaccuracy ranged from 30% to 50%. Although experienced observers were generally more accurate, average inter-item correlations were low, indicating that experience did not consistently improve the accuracy of visual observations. Observational plane, gait variable type, the joint or the segment had little effect on accuracy of observations. CONCLUSIONS Observational gait analysis for adults with TBI has relatively low accuracy. Some of the gait abnormalities evident from quantitative gait analysis were not detected by observational gait analysis.
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Anatomical bases of tibial neurotomy for treatment of spastic foot. Surg Radiol Anat 2008; 30:503-8. [DOI: 10.1007/s00276-008-0359-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2007] [Accepted: 04/28/2008] [Indexed: 10/22/2022]
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Viel EJ. Neurophysiological approach in the peripheral anesthetic blocks as a diagnosis and prognosis tool for spasticity. Clin Neurophysiol 2005; 116:1491-2. [PMID: 15936985 DOI: 10.1016/j.clinph.2005.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2005] [Revised: 03/01/2005] [Accepted: 03/10/2005] [Indexed: 10/25/2022]
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Buffenoir K, Decq P, Lefaucheur JP. Interest of peripheral anesthetic blocks as a diagnosis and prognosis tool in patients with spastic equinus foot: A clinical and electrophysiological study of the effects of block of nerve branches to the triceps surae muscle. Clin Neurophysiol 2005; 116:1596-600. [PMID: 15905125 DOI: 10.1016/j.clinph.2004.11.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2004] [Revised: 11/02/2004] [Accepted: 11/02/2004] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate clinically and electrophysiologically the effects of selective anesthetic blocks of motor nerve branches to the triceps surae muscle on lower limb stretch reflex in patients with spastic equinus foot. METHODS Eleven patients were assessed before and after selective anesthetic block of the superior soleus nerve or the gastrocnemius nerves, performed by lidocaine injection. The stretch reflex (SR) of the ankle with the knee flexed or extended and the Achilles tendon reflex (TR) were scored clinically. Additionally, the direct M response and the H reflex to tibial nerve stimulation were recorded on the three heads of the triceps surae muscle. The ratio of H reflex to M response of maximal amplitudes (H(max)/M(max)) was calculated. RESULTS The SR and TR mean scores were significantly reduced after soleus nerve block but not after gastrocnemius nerve block. Electrophysiologically, H(max) and H(max)/M(max) ratios were significantly reduced for the soleus muscle after soleus nerve block and for the lateral (but not medial) gastrocnemius muscle after gastrocnemius nerve block. CONCLUSIONS Soleus nerve block appeared more appropriate than gastrocnemius nerve block to relieve spasticity clinically. In addition, the decrease in H(max)/M(max) ratio suggested that lidocaine preferentially blocked proprioceptive Ia fibers rather than A-alpha motor fibers. SIGNIFICANCE Selective anesthetic blocks of nerve branches to the triceps surae muscle are useful in the assessment of lower limb spasticity and can benefit from H reflex investigation. H reflex recordings showed a preferential susceptibility of muscle spindle afferents to local anesthetics and supported the hypothesis of a prominent role of the soleus muscle in spastic ankle. The clinical and electrophysiological effects induced by anesthetic blocks may help to guide therapeutic interventions, such as neurotomy, neurolysis or botulinum toxin injection.
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Affiliation(s)
- Kevin Buffenoir
- Service de Neurochirurgie, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
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Jang SH, Ahn SH, Park SM, Kim SH, Lee KH, Lee ZI. Alcohol neurolysis of tibial nerve motor branches to the gastrocnemius muscle to treat ankle spasticity in patients with hemiplegic stroke. Arch Phys Med Rehabil 2004; 85:506-8. [PMID: 15031842 DOI: 10.1016/s0003-9993(03)00468-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of alcohol neurolysis of tibial nerve motor branches to the gastrocnemius muscle for the treatment of ankle plantarflexor spasticity in patients with hemiplegic stroke. DESIGN Case series. SETTING Inpatient and outpatient clinics in the rehabilitation department of a university hospital. PARTICIPANTS Twenty-two patients with hemiplegic stroke (mean age, 48y). INTERVENTIONS Motor branch block (MBB) of the tibial nerve to the gastrocnemius muscle with 50% ethyl alcohol in cases of spastic ankle. MAIN OUTCOME MEASURES The severity of spasticity was assessed using the Modified Ashworth Scale (MAS) score of ankle plantarflexor, clonus score of the ankle, and the passive range of motion (PROM) of ankle dorsiflexion. RESULTS The MAS score was reduced in 17 (77%) of 22 patients during the 6-month follow-up, and spasticity reappeared at the level of the pre-MBB state in 5 patients (23%). The mean values of all parameters were significantly improved. The changes of mean values from the pre-MBB to the 6-month post-MBB stage were as follows: MAS score, 3.3+/-0.7 versus 1.7+/-1.1; clonus score, 1.6+/-0.7 versus 0.4+/-0.8; and PROM, 17.1 degrees +/-13.0 degrees versus 28.6 degrees +/-4.7 degrees. No serious complications were observed during the 6-month follow-up period. CONCLUSIONS MBB of the tibial nerve to the gastrocnemius muscle is an effective and safe procedure for relieving localized spasticity of the ankle plantarflexors.
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Affiliation(s)
- Sung Ho Jang
- Department of Physical Medicine & Rehabilitation, Yeungnam University School of Medicine, Taegu, South Korea.
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