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To examine long-term outcomes of Botulinum toxin type A (BoNT-A) injection to vastus lateralis (VL) for refractory anterior knee pain (AKP).Two cohorts (private clinic referrals and previous research participants) injected with BoNT-A for AKP by one neurologist were surveyed retrospectively. Primary outcomes were self-reported benefit, duration of symptom relief, and knee surgery post-injection. Secondary outcomes were changes in utilization of medication/physiotherapy treatment, AKP symptoms and activity limitation.Overall, average symptom duration was 76 months (SD 98). Responses were available from 46 of 53 private patients. Thirty-eight reported benefit from injection, which was ongoing in 29. Average benefit was 25 months (SD 21). Nine individuals reported symptom recurrence after an average of 14 months (SD 21). Ten had knee surgery post-injection; six of whom had not benefitted from BoNT-A injection. Nineteen of 23 previous research participants were contactable. Initially, all responded favorably to injection. Symptomatic benefit, with an average duration of 44 months (SD 20), persisted in 15. Two subjects proceeded to surgical intervention.A single BoNT-A treatment to VL led initially to improved function and relief of knee-related symptoms in 57 of 65 individuals. Improvements were sustained at follow-up, with an average benefit of 34 months (SD 25) post-injection, in 44 of 57 cases.

To assess the reliability and validity of the Neck Pain and Disability Scale (NPAD) translated into Hindi.Following a pilot study to ascertain uncertainties with existing terminology in the NPAD scale, a cervical radiculopathy patient cohort (n = 63) was assessed with the translated NPAD. Reliability was assessed by regression analysis for test-retest and by item-factor and factor-total score correlations. Face validity was compared in a cross-sectional design study with an asymptomatic group (n = 38). Convergent and divergent validity were investigated by correlating the NPAD scores with the Numerical Pain Rating Scale (NPRS) for neck and arm pain, and 10 cm long VAS Activity and VAS Depression scales.ICC values for test-retest NPAD total and factor scores were0.92 and R2 values0.912. Pearson product moment correlation of item vs. factor scores varied from 0.17 - 0.91 and for factor vs. total scores 0.72 - 0.91. Differences in NPAD scores between the patient and the asymptomatic group were significant (t = 30.90, p0.05). Convergent validity was explained when Factor 2 (minus item 20) was correlated (r = 0.67) with NPRS maximum value scores. Divergent validity was illustrated by low correlation with VAS Activity (r = 0.15) and negative correlation with VAS Depression (r = -0.80) scores.Based on the results of this study, the Hindi version of the NPAD is a reliable and valid instrument for the assessment of pain and disability in cervical radiculopathy patients.

To examine the effect of intramuscular injection of botulinum toxin type A [Dysport] to reduce relative overactivity of the vastus lateralis [VL] muscle, in conjunction with re-training of vastus medialis [VM] muscle as an adjunct to rehabilitation for chronic anterior knee pain.Eight females with chronic (6 months) history of anterior knee pain, who had failed conservative management, were studied in this open label pilot study. Intramuscular Dysport injection [300 - 500 units] to the distal third of VL muscle was followed by a 12-week customized home exercise programme to improve recruitment of VM muscle and functional knee control. VL and VM muscle cross sectional area from a standardized spiral CT sequence, isometric quadriceps strength (dynamometry), timed stair task, self-reported pain and disability were assessed.Subjects reported reduced knee pain and brace dependency and increased participation in sporting and daily living activities. Isometric quadriceps muscle strength was maintained or improved despite significant atrophy, evident on CT, of the distal component of VL in the treated limb. Time taken to ascend and descend a flight of stairs improved in all subjects. Subjective and objective improvements were maintained at 24-week follow-up.These pilot data provide preliminary support for the role of Dysport as an adjunct to non-surgical management of individuals with chronic anterior knee pain. Larger double blind, randomized, placebo-injection controlled studies of this novel approach to improving patellofemoral mechanics are needed to establish the efficacy of this intervention.

Spastic equinovarus deformity of the ankle in adults with acquired brain injury can severely limit the achievement of rehabilitation goals. This study examined changes in triceps surae muscle extensibility, passive resistive torque and soleus stretch reflex responses in 10 adult brain injured subjects undergoing serial casting to correct ankle equinovarus deformity.Goniometric measurement of maximal passive dorsiflexion was used to evaluate extensibility of the triceps surae muscles. Computer controlled ankle dynamometry and surface electromyography were used to identify passive resistive torque and soleus stretch reflex onset angle in response to stretches at two velocities.The mean casting period was 5 weeks. Casting was discontinued in one subject due to failure to achieve measurable gain in ankle range over three consecutive cast changes. Median improvements in maximal ankle dorsiflexion, with the knee flexed or extended, of 30 degrees and 15 degrees, respectively, were achieved in the remaining nine subjects (p0.0001). The median passive ankle range in response to a displacing torque of 10 Nm increased 4.3 degrees over the intervention period (p0.0001). Consistent soleus reflex activity in response to passive stretches at 25 degrees x s(-1) was elicited in only four subjects. A trend for the stretch reflex onset to move further into the available range was demonstrated in these subjects.In the present study, serial casting contributed to significant change in triceps surae extensibility and passive resistive torque, corresponding with improved maximal passive ankle dorsiflexion range and an increase in the angle achieved with a displacing torque of 10 N.m. Increased stretch reflex threshold was observed in some subjects. The use of pre-determined outcome criteria and careful measurement of responses to this intervention were important to prevent premature discontinuation of casting when gains were slower than expected.

The ability to transfer in tetraplegia is a focal point of rehabilitation. Many factors have been associated with independence in transferring, yet the majority of these are anecdotal reports. The purpose of this paper is to report preliminary findings of the study of movement strategies of individuals with spinal cord injury attempting a long sitting transfer. Analyses were made from the lateral and posterior views. Pattern recognition techniques show two distinct movement strategies in both views. These were a lift and forward flexion technique from the lateral perspective and a translatory and rotatory technique when viewed from behind. It would seem that the posterior view provides more discriminative information. It is recommended that intervention techniques, such as Functional Electrical Stimulation or orthotic devices be developed within fundamental motion analysis constructs to optimize functional outcome.

This special issue of Disability and Rehabilitation reports contemporary applications of Botulinum toxin for managing muscle overactivity and associated muscle imbalance. Clostridium botulinum, a gram-positive anaerobic bacterium, produces a potent poison, Botulinum toxin, which, when ingested, can induce transient muscle weakness, which in severe cases can be life-threatening. Despite this potential risk, minute doses of the purified neurotoxin confer an option for efficacious treatment of painful muscle spasms, focal muscle overactivity, and muscle imbalance of neurological and musculoskeletal origin. Intramuscular injection with therapeutic preparations of Botulinum toxin decreases contractile activity by blocking acetylcholine release at the neuromuscular junction, rendering the muscle relatively weakened for a variable period until the nerve terminal has recovered. In many conditions treated using Botulinum toxin injection, the main goal is to achieve a balance between the activity of a tight/short/overactive agonist and a weak/lengthened/inhibited antagonist, with synergistic muscles often contributing in a variety of complex ways. This special issue addresses a range of conditions where the main goal of treatment is to achieve a better balance of muscle function and, as a consequence, better movement control. In the preface to this material, Dr Alan Scott, describes the development of the therapeutic application of this toxin based upon pioneering studies using Botulinum toxin type A in monkeys and subsequently in humans to treat strabismus. From these fundamental origins, clinical applications have broadened extensively and continue to expand. Some of these applications are highlighted in sections within this issue and give insights into indications, efficacy and future issues for the therapeutic use of Botulinum toxin. The pharmacological basis for Botulinum toxin is reviewed by Dressler and Benecke who describe the versatility of its applications; including the potential to block cholinergic neuromuscular innervation of intraand extrafusal muscle fibres as well as cholinergic autonomic innervation of sweat, lacrimal, and salival glands and smooth muscles. In general it would appear that long-term clinical application does not produce additive adverse effects, although the potential for autoimmunity remains a problem in some applications. The development of commercial preparations of Botulinum toxin type B has offered options for individuals with auto-resistance and there is some evidence that this serotype may be more efficacious in the treatment of autonomic disorders. The role of Botulinum toxin injection in the management of axial and cervical dystonia is reviewed by Benecke and Dressler. Intramuscular injection of Botulinum toxin has revolutionalized the treatment of this group of conditions. Precise identification of dystonic muscles and careful quantification of their involvement is necessary to optimize patient outcomes. Sheean reports on the pathophysiology of the excessive and inappropriate muscle contractions which occur during fine motor tasks in individuals with focal task specific hand dystonia; and the efficacy of Botulinum toxin therapy, at least in the short term, in conjunction with other therapeutic approaches for this cohort. Gracies and colleagues provide an overview of the role of Botulinum toxin therapy in the management of muscle imbalance in the lower limb in adult onset central nervous system injury/dysfunction. These authors point to the key interactions between muscle overactivity, adaptive shortening and loss of strength