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Fujita K1, Miaki H2, Hori H1, Kobayashi Y3, Nakagawa T2
1Fukui Health Science University, Department of Rehabilitation Physical Therapy, Faculty of Health Science, Fukui, Japan, 2Kanazawa University, Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa, Japan, 3Fukui General Hospital, Department of Rehabilitation Medicine, Fukui, Japan
Background: Administration of botulinum neurotoxin A (BoNT-A) to the ankle plantar flexors in patients with hemiplegia reduces the strength of knee extension, which may decrease their walking ability. Studies have reported improvements in walking ability with physical therapy following BoNT-A administration. However, no previous studies have evaluated from an exercise physiology perspective the efficacy of physical therapy after BoNT-A administration for adult patients with hemiplegia.
Purpose: To investigate the effects of physical therapy following BoNT-A administration on gait electromyography for patients with hemiparesis secondary to stroke.
Methods: Thirty-five patients with chronic stroke with spasticity were non-randomly assigned to BoNT-A monotherapy (n=18) or BoNT-A plus physical therapy (PT) (n=17). On the paralyzed side of the body, 300 single doses of BoNT-A were administered intramuscularly to the ankle plantar flexors. Physical therapy was performed for 2 weeks, starting from the day after administration. The same physical therapy program was followed for each patient. It included the following: stretching of the ankle plantar flexors, leg resistance exercises, low-frequency electrical stimulation of the ankle dorsiflexors, electromyographic feedback for ankle dorsiflexion exercises and body weight support treadmill exercises. The evaluations were performed immediately before and 2 weeks after BoNT-A administration. The primary outcome assessment included electromyography and determination of spatiotemporal parameters during gait. Relative muscle activity, co-activation indices, and walking time/distance were calculated for each gait phases. The secondary outcome assessment included determination of the spasticity of ankle plantar flexors.
Results: No significant differences in any of the pre-intervention data between the treatment groups were found. For both treatment groups, modified Ashworth scale and clonus scores decreased after the intervention (p 0.05). For patients who received BoNT-A monotherapy, soleus activity during the loading response decreased after the intervention (p 0.01), and no changes in the spatiotemporal parameters were observed. For those who received BoNT-A+PT, biceps femoris activity and knee co-activation index during the loading response and tibialis anterior activity during the pre-swing phases increased, whereas soleus and rectus femoris activities during the swing phase decreased after the intervention (p 0.05). These rates of change were significantly greater than those for patients who received BoNT-A monotherapy (p 0.05). For those who received BoNT-A+PT, changes in spatiotemporal gait parameters were observed; almost all subjects showed improvements in walking speed (p 0.01).
Conclusion(s): Following BoNT-A monotherapy, soleus activity during the stance phase decreased and walking ability either remained unchanged or deteriorated. Following BoNT-A+PT, muscle activity and knee joint stability increased during the stance phase, and abnormal muscle activity during the swing phase was suppressed.
Implications: If botulinum treatment of the ankle plantar flexors in stroke patients is targeted to those with low knee extension strength, or if it aims to improve leg swing on the paralyzed side of the body, then physical therapy following BoNT-A administration could be an essential part of the treatment strategy.
Keywords: Botulinum, Electromyography, Gait
Funding acknowledgements: None
Purpose: To investigate the effects of physical therapy following BoNT-A administration on gait electromyography for patients with hemiparesis secondary to stroke.
Methods: Thirty-five patients with chronic stroke with spasticity were non-randomly assigned to BoNT-A monotherapy (n=18) or BoNT-A plus physical therapy (PT) (n=17). On the paralyzed side of the body, 300 single doses of BoNT-A were administered intramuscularly to the ankle plantar flexors. Physical therapy was performed for 2 weeks, starting from the day after administration. The same physical therapy program was followed for each patient. It included the following: stretching of the ankle plantar flexors, leg resistance exercises, low-frequency electrical stimulation of the ankle dorsiflexors, electromyographic feedback for ankle dorsiflexion exercises and body weight support treadmill exercises. The evaluations were performed immediately before and 2 weeks after BoNT-A administration. The primary outcome assessment included electromyography and determination of spatiotemporal parameters during gait. Relative muscle activity, co-activation indices, and walking time/distance were calculated for each gait phases. The secondary outcome assessment included determination of the spasticity of ankle plantar flexors.
Results: No significant differences in any of the pre-intervention data between the treatment groups were found. For both treatment groups, modified Ashworth scale and clonus scores decreased after the intervention (p 0.05). For patients who received BoNT-A monotherapy, soleus activity during the loading response decreased after the intervention (p 0.01), and no changes in the spatiotemporal parameters were observed. For those who received BoNT-A+PT, biceps femoris activity and knee co-activation index during the loading response and tibialis anterior activity during the pre-swing phases increased, whereas soleus and rectus femoris activities during the swing phase decreased after the intervention (p 0.05). These rates of change were significantly greater than those for patients who received BoNT-A monotherapy (p 0.05). For those who received BoNT-A+PT, changes in spatiotemporal gait parameters were observed; almost all subjects showed improvements in walking speed (p 0.01).
Conclusion(s): Following BoNT-A monotherapy, soleus activity during the stance phase decreased and walking ability either remained unchanged or deteriorated. Following BoNT-A+PT, muscle activity and knee joint stability increased during the stance phase, and abnormal muscle activity during the swing phase was suppressed.
Implications: If botulinum treatment of the ankle plantar flexors in stroke patients is targeted to those with low knee extension strength, or if it aims to improve leg swing on the paralyzed side of the body, then physical therapy following BoNT-A administration could be an essential part of the treatment strategy.
Keywords: Botulinum, Electromyography, Gait
Funding acknowledgements: None
Topic: Neurology: stroke
Ethics approval required: Yes
Institution: Nittazuka medical welfare center
Ethics committee: Nittazuka Ethics
Ethics number: 44677
All authors, affiliations and abstracts have been published as submitted.
