EFFECT OF TREATING ELBOW FLEXOR SPASTICITY WITH BOTULINUM TOXIN INJECTION AND ADJUNCTIVE CASTING ON HEMIPARETIC GAIT PARAMETERS: A PROSPECTIVE CASE SERIES
Supun Kotteduwa Jayawarden, BSc, Ryan Sandarage, BSc, Jordan Farag, MD, Carl Ganzert, MSc, Paul Winston, MD, Patricia Mills, MD, MHSc and Rajiv Reebye, MD
On the recovery pathway for acquired brain injury patients, the application of a stretching cast to the elbow, following a Botulinum toxin injection can be a powerful tool to manage spasticity. This technique has been shown to help improve symmetry, prevent contractures, improve hygiene and reduce the difficulty of dressing. What casting is not known for however, is the improvement and retraining of patient gait patterns. Therefore we were pleasantly surprised to hear from Mr. L that after his casting cycle he was, “Not tripping anymore and finally making it across the street before the light changed.”
A follow up analysis of Mr L’s gait video showed improvements in numerous parameters of gait. We designed a case series protocol to shed light whether or not this treatment would improve gait in other patients of a similar presentation and if so, what aspects of gait were most influenced.
Objective: To investigate changes in hemiparetic gait parameters after treatment of elbow flexor spasticity with botulinum neurotoxin (BoNT) injection and adjunctive casting.
Design: Prospective case series.
Subjects: Ten participants with spasticity secondary to acquired brain injury (8 stroke, 2 traumatic brain injury).
Interventions: Participants received BoNT injections for their spastic elbow flexors under ultrasound guid-ance. Two weeks post-injection, an elbow stretching cast was applied for 1 week.
Outcome measures: Assessments using the Modified Ashworth Scale (MAS), Tardieu scale V1 angle of arrest at slow speed and V3 angle of catch at fast speed, 2-min walk test (2MWT), Edinburgh Gait Score scale (EGS) and video gait analysis for step-length symmetry were conducted pre-BoNT injection (t0) and at cast removal (t1). Goal attainment scale (GAS) was used to assess changes in spasticity and gait 3 months post-injection (t2).
Results: At t1, participants showed a mean increase of 16.7° (p < 0.01) on the Tardieu Scale V3 and a mean reduction of 0.5 points on the MAS (p < 0.05). There was also a mean reduction on EGS of 2.7 points (p < 0.05), and a mean increase on 2MWT of 3.1 m (p < 0.05). On the GAS, all participants report-ed impro-ved gait at t2 and 80% reported a decrease in spasticity.
Conclusion: Combining BoNT injection with casting for treatment of elbow flexor spasticity without treat-ing the lower limb may improve hemiparetic gait parameters.
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