Temporospatial Parameters of Gait After Obturator Neurolysis in Patients with Spasticity

AAPM&R consensus guidance on spasticity assessment and management

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.

Functional outcomes following surgery for spastic hip adductor muscles in ambulatory and non-ambulatory adults

OBJECTIVE

To evaluate functional outcomes of surgery of spastic hip adductor muscles (obturator neurotomy with or without adductor longus tenotomy) in ambulatory and non-ambulatory patients, using preoperatively defined personalized goals.

DESIGN

Retrospective observational descriptive study.

PATIENTS

Twenty-three patients with adductor spasticity who underwent obturator neurotomy between May 2016 and May 2021 at the Clinique des Cèdres, Cornebarrieu, France, were included.

METHODS

Postoperative functional results were evaluated in accordance with the Goal Attainment Scaling method. Patients were considered "responders" if their score was ≥ 0. Secondary outcomes included spasticity, strength, hip range of motion and change in ambulatory capacity. When data were available, a comparison of pre- and postoperative 3-dimensional instrumented gait analysis was also performed.

RESULTS

Among the 23 patients only 3 were non-walkers. Seventeen/22 patients achieved their main goal and 14/23 patients achieved all their goals. Results were broadly similar for both walking goals (inter-knee contact, inter-feet contact, fluidity, walking perimeter, toe drag) and non-walking goals (intimacy, transfer, pain, posture, dressing).

CONCLUSION

Surgery of spastic hip adductor muscles results in functional improvement in ambulation, hygiene, dressing and posture and can be offered to patients with troublesome adductor overactivity. The use of a motor nerve block is recommended to define relevant goals before the surgery.

Treatment of spasticity

Spasticity is characterized by an enhanced size and reduced threshold for activation of stretch reflexes and is associated with "positive signs" such as clonus and spasms, as well as "negative features" such as paresis and a loss of automatic postural responses. Spasticity develops over time after a lesion and can be associated with reduced speed of movement, cocontraction, abnormal synergies, and pain. Spasticity is caused by a combination of damage to descending tracts, reductions in inhibitory activity within spinal cord circuits, and adaptive changes within motoneurons. Increased tone, hypertonia, can also be caused by changes in passive stiffness due to, for example, increase in connective tissue and reduction in muscle fascicle length. Understanding the cause of hypertonia is important for determining the management strategy as nonneural, passive causes of stiffness will be more amenable to physical rather than pharmacological interventions. The management of spasticity is determined by the views and goals of the patient, family, and carers, which should be integral to the multidisciplinary assessment. An assessment, and treatment, of trigger factors such as infection and skin breakdown should be made especially in people with a recent change in tone. The choice of management strategies for an individual will vary depending on the severity of spasticity, the distribution of spasticity (i.e., whether it affects multiple muscle groups or is more prominent in one or two groups), the type of lesion, and the potential for recovery. Management options include physical therapy, oral agents; focal therapies such as botulinum injections; and peripheral nerve blocks. Intrathecal baclofen can lead to a reduction in required oral antispasticity medications. When spasticity is severe intrathecal phenol may be an option. Surgical interventions, largely used in the pediatric population, include muscle transfers and lengthening and selective dorsal root rhizotomy.

Effects of dichotic listening on gait domains of healthy older adults during dual-tasking: An exploratory observational study

BACKGROUND

Identification of the cognitive mechanisms behind gait changes in aging is a prime endeavor in gerontology and geriatrics. For this reason, we have implemented a new dual-task paradigm where an auditory attentional task is performed during over-ground walking. Dichotic listening assesses spontaneous attention and voluntary attention directed to right and left-ear. The uniqueness of dichotic listening relies on its requirements that vary in difficulty and recruitment of resources from whole brain to one brain hemisphere. When used in dual-tasking, asymmetric effects on certain gait parameters have been reported.

OBJECTIVES

The present study aims to acquire a more global understanding on how dichotic listening affects gait domains. Specifically, we aimed to understand how spontaneous vs lateralized auditory attention altered the Principal Component Analysis (PCA) structure of gait in healthy older adults.

METHODS

Seventy-eight healthy older adults (mean age: 71.1 years; 44 women and 34 men) underwent the Bergen dichotic listening test while walking. As this study only focuses on the effects of the cognitive task on gait, only dual-task costs for gait were calculated and entered into the PCA analyses. We explored the PCA structure for the effects on bilateral gait parameters (i.e., both limbs together) as well as on lateralized gait parameters (i.e, separate parameters by limb). We first established gait domains during single-task walking. Then, dual-task cost scores for gait were entered in a series of PCAs.

RESULTS

Results from the PCAs for bilateral gait parameters showed limited alterations on gait structure. In contrast, PCAs for lateralized data demonstrated modifications of the gait structure during dichotic listening. The PCAs corresponding for all dichotic listening conditions showed different factor solutions ranging between 4 and 6 factors that explained between 73.8% to 80% of the total variance. As a whole, all conditions had an impact on "pace", "pace variability" and "base of support variability" domains. In the spontaneous attention condition, a six-factor solution explaining 78.3% of the variance showed asymmetrical disruptions on the PCA structure. When attention was focused to right-ear, a five-factor solution explaining 89% of the variance and similar to baseline was found. When attention was directed to left-ear, a four-factor solution explaining 73.8% of the variance was found with symmetrical impact on all factors.

CONCLUSIONS

These findings demonstrate for the first time that specific facets of attentional control affects gait domains both symmetrically and asymmetrically in healthy older adults.

Efficacy and Safety of AbobotulinumtoxinA for the Treatment of Hemiparesis in Adults with Lower Limb Spasticity Previously Treated With Other Botulinum Toxins: A Secondary Analysis of a Randomized Controlled Trial

Objective

To examine the safety and efficacy of abobotulinumtoxinA in patients previously treated with botulinum toxin type A (BoNT‐A) products other than abobotulinumtoxinA.

Design

Secondary analysis from a phase 3, double‐blind, single‐cycle, randomized, placebo‐controlled study.

Setting

Fifty‐two centers (11 countries).

Patients

Adults with spastic hemiparesis were randomized (1:1:1) to receive abobotulinumtoxinA 1000 U, 1500 U, or placebo in their affected lower limb.

Main Outcome Measurements

Muscle tone (6‐point Modified Ashworth Scale [MAS], 0‐5) for the gastrocnemius‐soleus complex (GSC); proportion of MAS responders (≥1‐point improvement); angle of catch (X_V3) and spasticity grade (Y) for the GSC and soleus. Assessments were at weeks 1, 4, and 12 post‐injection. Only descriptive statistics are presented.

Results

Of 388 patients, 84 received previous BoNT‐A treatment (abobotulinumtoxinA 1000 U: N = 30; abobotulinumtoxinA 1500 U: N = 28; placebo: N = 26). At week 4, mean (SD) changes in MAS score in the GSC were − 0.8 (1.1), −0.9 (1.0), and − 0.4 (0.7) for abobotulinumtoxinA 1000 U, 1500 U, and placebo, respectively. Greater MAS responder rates were observed for abobotulinumtoxinA versus placebo at all time points. Mean (SD) changes (week 4) for abobotulinumtoxinA 1000 U, 1500 U, and placebo for X_V3 were: GSC, 8° (21), 6° (10) and 1° (7); soleus, 11° (21), 5° (9) and 0° (8), respectively; for Y: GSC, −0.4 (0.7), −0.6 (0.8) and − 0.0 (0.9); soleus, −0.5 (0.7), −0.5 (0.7) and − 0.1 (0.6), respectively. Safety data and adverse events were consistent with the overall known profile of abobotulinumtoxinA.

Conclusions

Patients previously treated with other BoNT‐As showed improved muscle tone and spasticity at week 4 following abobotulinumtoxinA injection versus placebo. These findings suggest that abobotulinumtoxinA, at the recommended doses, has a good safety and efficacy profile in adults with lower limb spasticity who were previously treated with other BoNT‐A products.

Clinical and anatomical approach using Sihler's staining technique (whole mount nerve stain)

Sihler's staining allows visualization of the nerve distribution within soft tissues without extensive dissection and does not require slide preparation, unlike traditional approaches. This technique can be applied to the mucosa, muscle, and organs that contain myelinated nerve fibers. In particular, Sihler's technique may be considered the best tool for observing nerve distribution within skeletal muscles. The intramuscular distribution pattern of nerves is difficult to observe through manual manipulation due to the gradual tapering of nerves toward the terminal end of muscles, so it should be accompanied by histological studies to establish the finer branches therein. This method provides useful information not only for anatomists but also for physiologists and clinicians. Advanced knowledge of the nerve distribution patterns will be useful for developing guidelines for clinicians who perform operations such as muscle resection, tendon transplantation, and botulinum toxin injection. Furthermore, it is a useful technique to develop neurosurgical techniques and perform electrophysiological experiments. In this review, Sihler's staining technique is described in detail, covering its history, staining protocol, advantages, disadvantages, and possible applications. The application of this technique for determining the arterial distribution pattern is also described additionally in this study.

Withdrawal reflexes in adductor muscles elicited by electrical and magnetic stimulation of the obturator nerve

The withdrawal reflex in the short head of the biceps femoris muscle after electrical stimulation of the sural nerve at the ankle has been investigated in numerous studies. These studies have described two distinct responses: early (R-II) and late (R-III). However, withdrawal reflex activity of the adductor muscles in the legs has not been studied systematically. Adductor muscle reflex activity is important because it can produce serious clinical problems, such as adductor spasticity and spasms, during bladder surgery. The present study examined withdrawal reflex features of adductor muscles obtained by electrical and magnetic stimulation of the obturator nerve (ON) in 34 normal healthy subjects. Early adductor muscle withdrawal reflex responses were elicited by ipsilateral ON electrical stimulation with a mean latency of 45.7+/-2.0 ms (responses in 94% of subjects). Reflex responses were also obtained using magnetic stimulation at a similar incidence rate. Contralateral ON electrical stimulation resulted in a similar reflex, but with a lower incidence. ON and femoral nerve electrical and magnetic coil stimulation produced similar low-incidence responses in the vastus medialis. These findings indicate that short latency adductor withdrawal reflexes are easily obtained on both sides following electrical or magnetic stimulation of the ON, and they can be elicited by both nociceptive and nonnociceptive stimuli. These reflexes prepare the body for a proper response to incoming signals and likely serve to protect the pelvic floor and pelvic organs.

Adductor release and chemodenervation in children with cerebral palsy: a pilot study in 16 children

PURPOSE

A pilot study with short-term outcomes of a combined surgical and medical intervention for management of generalized lower limb spasticity, hip displacement and contractures of adductors in children with bilateral spastic cerebral palsy.

METHODS

A prospective cohort study of 16 children (9 boys and 7 girls) aged 2-6 years with bilateral spastic cerebral palsy was performed. At entry, 5 were classified as level III and 11 as level IV, according to the Gross Motor Function Classification System (GMFCS). The intervention consisted of surgical lengthening of adductor longus and gracilis combined with the phenolization of the anterior branch of the obturator nerve, using 1 ml of 6% phenol, applied under direct vision at the time of lengthening of adductor longus. The hamstring and calf muscles were each injected with Botulinum neurotoxin A at a dose of 4 U/kg/muscle. Serial clinical (hip, knee, ankle joint range of motion), radiographic (migration percentage) and functional data-taken from a functional mobility scale (FMS) or GMFCS-were collected at 3, 6, 12 and 24 months post-operatively.

RESULTS

There was a significant increase in hip abduction, knee extension (popliteal angle) and ankle dorsiflexion, maintained for 24 months; mean hip migration percentage decreased from 29 to 21% (P < 0.001). Using a validated mobility scale, significant improvements were noted in gross motor function. There were no complications related to the intervention.

CONCLUSIONS

The combined surgical-medical intervention resulted in a reduction of spastic hip subluxation and improvements in gross motor function, as determined by the FMS. The combined intervention is, thus, useful as a temporizing measure, before definitive decisions are made considering such interventions as dorsal rhizotomy, intrathecal baclofen and single-event, multilevel surgery.

Clinical factors that affect walking level and performance in chronic spinal cord lesion patients

STUDY DESIGN

Observational Study.

OBJECTIVE

To evaluate the effects of neurologic and non-neurologic factors on walking level and performance in chronic spinal cord lesion (SCL) patients.

SUMMARY OF BACKGROUND DATA

Walking is one of the primary goals of patients after a SCL. Several studies have demonstrated that different neurologic and non-neurologic factors can affect walking level and performance. However, in SCL age and muscle strength have always been considered the major determinants of walking.

METHODS

Sixty-five patients with chronic SCL were included. Their demographic, neurologic status (ASIA standards), balance, and spasticity were recorded. Pearson and Spearman correlations were adopted to quantify the association between patients' characteristics and walking ability. The relationship between functional walking measures, Timed Up and Go, Six Minutes Walking Test (SMWT), Ten Meters Walking Test, and Walking Index for Spinal Cord Injury, and demographic and neurologic factors were measured by regression analyses.

RESULTS

Strength, balance, spasticity, and age were strictly correlated with walking level and walking performance. They also were the best predictors of walking features.

CONCLUSION

Results confirm the recognized importance of age and upper and lower extremity strengths for walking after a SCL. They also highlight the role of 2 other factors, i.e., balance and spasticity, seldom considered as thoroughly in SCL.

Effects of Botulinum Toxin-A on Gait Velocity, Step Length, and Base of Support of Patients with Dynamic Equinovarus Foot

OBJECTIVE

The aim of this study was to identify if botulinum toxin type A is a drug able to modify walking velocity, step length, and width of the base of support of adult patients with dynamic equinovarus foot deformity resulting from upper motor neuron syndrome.

DESIGN

This retrospective study analyzed data from 20 patients' files selected from 448 consecutive charts. The main inclusion criteria were the presence of dynamic equinovarus foot deformity due to upper motor neuron syndrome, age between 20 and 80 yrs, evaluation of temporospatial parameters of gait by the Gait Mat II before and 4 wks after botulinum toxin type A injection to the calf muscles, and the ability to walk barefoot, unassisted, and without braces. For data analysis, based on walking velocity, we divided the patients into two groups, slow walking velocity (0.18-0.49 m/sec) and medium walking velocity (0.50-0.99 m/sec).

RESULTS

Width of the base of support was significantly reduced after botulinum toxin type A treatment, both for the affected (P < 0.005) and the unaffected limbs (P < 0.002), in the group of subjects walking at medium velocity. Walking velocity or step length of either group of patients was not significantly modified by botulinum toxin type A treatment.

CONCLUSIONS

Based on this study, a significant effect of botulinum toxin type A on width of the base of support is evident and seems to be the result of a better position of the affected foot during the stance phase of locomotion leading to increased body stability and consequent reduction of width of the base of support of the unaffected limb. No change was evident in step length or walking velocity for this patient population.

Plantar feedback contributes to the regulation of leg stiffness

BACKGROUND

Running and hopping involve moving in a bouncing fashion during which the limbs behave as springs. The ability to alter the stiffness of these leg springs is essential to maintaining an efficient gait. Since the plantar surface of the foot is the only part of the body to encounter the ground during bipedal locomotion, it would seem logical that some aspect of the neurological functioning of the foot is responsible for transmission of information about the surface characteristics to the central nervous system, resulting in changes in leg stiffness.

METHODS

Ten subjects (9 males, 1 female) participated in this experiment. Lidocaine was injected inferior and posterior to the lateral malleolus in order to achieve tibial nerve block at the level of the ankle. Subjects hopped at 2.2 Hz on a force plate while data were collected at 1000 Hz. Data were analyzed for peak force and leg stiffness and compared using a repeated measures ANOVA.

FINDINGS

Tactile sensation, deep pressure sensation, and abductor hallucis activity displayed significant decreases following the injection, as did postural stability. Subjects demonstrated a significantly decreased leg stiffness after the nerve block (P<.01).

INTERPRETATION

Plantar sensation has an effect on regulating leg mechanics in hopping. A loss of sensation in this region can exert a significant impact on the properties of the leg in gait, and future research should determine the specific pathways by which plantar feedback exerts this effect.