Combined Effects of Isokinetic Training and Botulinum Toxin Type A on Spastic Equinus Foot in Patients with Chronic Stroke: A Pilot, Single-blind, Randomized Controlled Trial

Abstract

Botulinum toxin A (BoNT-A) has been shown effective for poststroke lower limb spasticity. Following injections, a wide range of multidisciplinary approach has been previously provided. The purpose of this pilot, single-blind, randomized controlled trial was to determine whether BoNT-A combined with a regime of a four-week ankle isokinetic treatment has a positive effect on function and spasticity, compared with BoNT-A alone. Secondly, the validity of the use of an isokinetic dynamometer to measure the stretch reflex at the ankle joint and residual strength has been investigated. Twenty-five chronic stroke patients were randomized to receive combined treatment (n = 12; experimental group) or BoNT-A alone (n = 13; control group). Outcome measures were based on the International Classification of Functioning, Disability and Health. An isokinetic dynamometer was also used for stretch reflex and strength assessment. Patients were evaluated at baseline (t0), after five (t1) and eight weeks after the injection (t2). The experimental group reported significantly greater improvements on lower limb spasticity, especially after eight weeks from baseline. Gait speed (10-m walk test) and walking capacity (6-min walking test) revealed statistically significantly better improvement in the experimental than in control group. Peak resistive ankle torque during growing angular velocities showed a significant reduction at the higher velocities after BoNT-A injections in the experimental group. Peak dorsiflexor torque was significantly increased in the experimental group and peak plantarflexor torque was significantly decreased in control group. Alternative rehabilitation strategies that combine BoNT-A and an intense ankle isokinetic treatment are effective in reducing tone and improving residual strength and motor function in patients with chronic hemiparesis.

Reasons and Determinants of BoNT-A Treatment Discontinuation in Patients Living with Spasticity: A 10-Year Retrospective Analysis

“…Latino et al observed a similar trend in patients with MS [ 22 ]. This finding is consistent with existing literature showing that the maximum benefit of BoNT-A treatment in the management of spasticity is the association with multi-modal rehabilitation [ 57 , 58 , 59 ]. The underlying mechanism is that physiotherapy in combination with BoNT-A injections can improve the overall response to toxins, likewise by enhancing its diffusion and leading to more effective uptake by the target muscles [ 60 ].…”

Association of Lower Limb Focal Spasticity With Kinematic Variables During Walking in Traumatic Brain Injury

“…Multiple international focal spasticity guidelines state that “focal spasticity does not always require pharmacological treatment,”55 so the challenge in clinical decision-making is to determine the contribution of factors including focal muscle spasticity, muscle paresis, and reduced motor control that need to be prioritized for treatment. It may be possible that previous studies that failed to make clinically significant improvements in kinematic variables or walking speed following BoNT-A injection had injected muscles with focal spasticity that were not the primary cause of the targeted variable 19–24…”

“…It may be possible that previous studies that failed to make clinically significant improvements in kinematic variables or walking speed following BoNT-A injection had injected muscles with focal spasticity that were not the primary cause of the targeted variable. [19][20][21][22][23][24] The calf muscles are the most commonly injected with BoNT-A for focal muscle spasticity in the lower limb, 54 and were the most commonly affected in this current cohort. It is somewhat surprising that although more than half of the participants with TBI had focal calf muscle spasticity, there were no significant differences between those with calf spasticity, those without, and the HC cohort for ankle dorsiflexion at initial contact and during swing (Tables 1 and 3).…”

“…However, the relationship of focal lower limb muscle spasticity with walking remains unclear. While it is well established that interventions such as botulinum neurotoxin (BoNT-A) are effective at reducing focal muscle spasticity, there has been limited effect on walking outcomes 19–23…”

OrthoRehab: Development of a New Methodology for the Comparison Study Between Different Types of Ankle–Foot Orthoses in Foot Dysfunction

“…Taking the total number of adult stroke patients into account, 10-20% have equinus foot as a severe consequence and >90% of patients with RA have reported foot complaints during the course of the disease such as hallux valgus (65%), longitudinal arch (42%) flattening, and claw toe (39%) (3)(4)(5)(6)(7). This is one of the most dysfunctional deformities with a significant impact on gait and quality of life of individuals who have suffered from stroke or RA (5,6,(8)(9)(10)(11)(12). The possible treatment for these dysfunctions/deformities is the use of ankle-foot orthoses (AFOs) or, in severe cases, surgical intervention.…”