Assessment and treatment of spastic equinovarus foot after stroke: Guidance from the Mont-Godinne interdisciplinary group

Deltombe, Thierry; Wautier, Delphine; Cloedt, Philippe De; Fostier, Michèle; Gustin, Thierry

doi:10.2340/16501977-2226

Cited by 62 publications

(81 citation statements)

References 33 publications

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“…For patients with spastic equinovarus foot, DNB of the tibial nerve and its motor branches is mandatory to determine the causes of the muscle overactivity pattern and to define its management appropriately (6,8). In particular, DNB of the tibial nerve main trunk (mixed sensorimotor nerve block) is used to differentiate spastic muscle overactivity from contracture by inducing a non-selective decrease in spastic overactivity of the calf muscles (6).…”

Section: Discussionmentioning

confidence: 99%

“…On the other hand, to determine the respective role of different calf muscles (e.g. the soleus, gastrocnemii and tibialis posterior muscles) in spastic equinovarus pattern, a selective DNB of the tibial motor nerve branches is needed (6,8). From a therapeutic perspective, selective nerve blocks of the tibial nerve motor branches may be performed with neurolytic agents (i.e.…”

Section: Discussionmentioning

confidence: 99%

“…It has 4 main causes: calf muscles (soleus, gastrocnemii, tibialis posterior, flexor digitorum and flexor hallucis longus muscles) spastic overactivity; calf muscles contracture/ shortening leading to fixed deformity; drop-foot during the swing phase of gait due to muscle weakness (e.g. tibialis anterior, extensor digitorum and hallucis); imbalance between the tibialis anterior and peroneus (brevis and longus) muscles leading to hindfoot varus in the swing phase of gait (6).…”

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confidence: 99%

“…Nerve blocks involve the injection of medications near to peripheral nerves in order to obtain a (short-or long-term) reduction in, or abolition of, conduction. Selective neural blockade technique is commonly based on the use of a disposable needle for conduction anaesthesia (delivering electrical stimulation), positio-ned according to surface anatomical landmarks (6)(7)(8). The medication is usually injected when the needle tip is in close contact with the targeted motor nerve corresponding to a (clinically evident) muscular contraction of selected muscles seen at ≤ 1.0 mA intensity and 100 µs duration of stimulation (7).…”

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confidence: 99%

“…Diagnostic nerve block (DNB) allows spastic muscle overactivity to be differentiated from contracture, and the respective role of different muscles in spastic overactivity patterns to be determined (6,7). DNB consists of injecting a small dose of local anaesthetic near to the nerve (motor branches) innervating spastic muscles in order to temporarily suppress their overactivity (6). DNB may lead to a decrease in spastic muscle overactivity and clonus disappearance in the selected muscles within a few minutes.…”

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confidence: 99%

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Anatomical landmarks for tibial nerve motor branches in the management of spastic equinovarus foot after stroke: An ultrasonographic study

Picelli¹,

Chemello²,

Verzini³

et al. 2019

J Rehabil Med

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This study aimed to identify the motor nerve branches to the main calf muscles, in order to assist in the management of spastic foot. Twenty-five chronic stroke patients with spastic foot were evaluated with ultrasonography. The nerve branches to the gastrocnemii, soleus and tibialis posterior muscles were located in space (vertical, horizontal and deep), based on the position of the fibular head (proximal/distal) and a posterior line in the middle of the leg (medial/lateral). The coordinates for the gastrocnemius medialis motor branch were: 1.5 cm proximal, 1.7 cm medial, 1.1 cm deep; for the gastrocnemius lateralis motor branch: 0.9 cm proximal, 1.8 cm lateral, 1.0 cm deep; for the soleus motor branch: 1.4 cm distal, 1.6 cm lateral, 2.8 cm (SD 0.7) deep; and for the tibialis posterior motor branch: 4.3 cm distal, 1.9 cm lateral, 4.2 cm deep. These findings may help in the management of spastic foot. Objective: To identify the anatomical landmarks of tibial motor nerve branches to the gastrocnemii, soleus and tibialis posterior muscles for selective motor nerve blocks in the management of spastic equinovarus foot. Design: Observational study. Patients: Twenty-five chronic stroke patients with spastic equinovarus foot. Methods: Motor nerve branches to the gastrocnemii, soleus and tibialis posterior muscles were tracked in the affected leg, using ultrasonography, and located in the space (vertical, horizontal and deep) according to the position of the fibular head (proximal/distal) and a virtual line from the middle of the popliteal fossa to the Achilles tendon insertion (medial/lateral). Results: Mean coordinates for the gastrocnemius medialis motor branch were: 1.5 cm (standard deviation (SD) 2.7) vertical (proximal), 1.7 cm (SD 1.3) horizontal (medial), 1.1 cm (SD 0.4) deep; for the gastrocnemius lateralis motor branch: 0.9 cm (SD 2.2) vertical (proximal), 1.8 cm (SD 1.7) horizontal (lateral), 1.0 cm (SD 0.3) deep; for the soleus motor branch: 1.4 cm (SD 1.1) vertical (distal), 1.6 cm (SD 0.7) horizontal (lateral), 2.8 cm (SD 0.7) deep; and for the tibialis posterior motor branch: 4.3 cm (SD 1.5) vertical (distal), 1.9 cm (SD 0.9) horizontal (lateral), 4.2 cm (SD 0.8) deep. Conclusion: These findings may help in the identification of tibial motor nerve branches to the gastrocnemii, soleus and tibialis posterior muscles for selective motor nerve blocks in the management of spastic equinovarus foot.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Anatomical landmarks for tibial nerve motor branches in the management of spastic equinovarus foot after stroke: An ultrasonographic study

Picelli¹,

Chemello²,

Verzini³

et al. 2019

J Rehabil Med

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Management of Gait Impairments in Chronic Unilateral Upper Motor Neuron Lesions

et al. 2018

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Importance: A variety of neurological disorders can damage the corticospinal tract in the supratentorial region of the brain. Gait impairments are common in patients with chronic supratentorial upper motor neuron lesions, and are a source of great disability. Clinical management aimed at improving the gait pattern in these patients is generally perceived as a challenging task, as many possible abnormalities may interact. Moreover, a multitude of treatment options exist-ranging from assistive devices and muscle stretching to pharmacological and surgical interventions-but evidence is inconclusive for most approaches and there is a lack of clear treatment guidelines. Observations: To improve management, we here show that gait deviations in adults with a chronic supratentorial upper motor neuron lesion can roughly be reduced to three groups of primary deficits: (1) imbalance of muscle strength, length and activity around the ankle and tarsal joints leading to pes equino(varus), (2) calf muscle weakness, and (3) overactivity of proximal leg muscles.

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Clinical Outcome Assessments for Spasticity: Review, Critique, and Recommendations

Gal,

Baude,

Deltombe

et al. 2024

Movement Disorders

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BackgroundSpasticity is a common feature in patients with disruptions in corticospinal pathways. However, the term is used ambiguously. Here, spasticity is defined as enhanced velocity‐dependent stretch reflexes and placed within the context of deforming spastic paresis encompassing other forms of muscle overactivity.ObjectiveThis scoping review aims at evaluating the clinimetric quality of clinical outcome assessments (COAs) for spasticity across different pathologies and to make recommendations for their use.MethodsA literature search was conducted to identify COAs used to assess spasticity. An international expert panel evaluated the measurement properties in the included COAs. Recommendations were based on the MDS‐COA program methodology based on three criteria: if the COA was (1) applied to patients with spastic paresis, (2) used by others beyond the developers, and (3) determined to be reliable, valid, and sensitive to change in patients with spasticity.ResultsWe identified 72 COAs of which 17 clinician‐reported outcomes (ClinROs) and 6 patient‐reported outcomes (PROs) were reviewed. The Tardieu Scale was the only ClinRO recommended for assessing spasticity. One ClinRO—Composite Spasticity Index—and two PROs—Spasticity 0–10 Numeric Rating Scale and 88‐Item Multiple Sclerosis Spasticity Scale—were recommended with caveats. The Ashworth‐derived COAs were excluded after evaluation due to their focus on muscle tone rather than spasticity, as defined in this review.ConclusionsThe Tardieu Scale is recommended for assessing spasticity, and two PROs are recommended with caveats. Consistent terminology about the various types of muscle overactivity is necessary to facilitate their assessment and treatment. © 2024 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

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Assessment and treatment of spastic equinovarus foot after stroke: Guidance from the Mont-Godinne interdisciplinary group

Abstract: Based on 20 years of interdisciplinary expertise of management of the spastic foot, guidance was established to clarify a complex problem in order to help clinicians treat spastic equinovarus foot. This work should be the first step in a more global international consensus.

Cited by 62 publications

References 33 publications

Anatomical landmarks for tibial nerve motor branches in the management of spastic equinovarus foot after stroke: An ultrasonographic study

Anatomical landmarks for tibial nerve motor branches in the management of spastic equinovarus foot after stroke: An ultrasonographic study

Management of Gait Impairments in Chronic Unilateral Upper Motor Neuron Lesions

Clinical Outcome Assessments for Spasticity: Review, Critique, and Recommendations

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