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A person with post-stroke lateropulsion actively pushes themselves toward their hemiplegic side, or resists moving onto their non-hemiplegic side. This study aimed to determine the association of lateropulsion severity with: • Change in function (Functional Independence Measure - FIM) and lateropulsion severity (Four-Point Pusher Score - 4PPS) during inpatient rehabilitation; • Inpatient rehabilitation length of stay (LOS); • Discharge destination from inpatient rehabilitation.Retrospective data for 1,087 participants (aged ≥65 years) admitted to a stroke rehabilitation unit (2005-2018) were analysed using multivariable regression models.Complete resolution of lateropulsion was seen in 69.4% of those with mild lateropulsion on admission (Post-stroke lateropulsion is associated with reduced functional improvement and likelihood of discharge home. However, given a longer rehabilitation duration, most stroke survivors with moderate to severe lateropulsion can achieve important functional improvement.Implications for RehabilitationWhile people with post-stroke lateropulsion can be difficult to treat and require more resources than those without lateropulsion, the majority of those affected, even in severe cases, can make meaningful recovery with appropriate rehabilitation.Although those with moderate to severe post-stroke lateropulsion may have poorer outcomes (longer LOS and reduced likelihood of discharge home) it is still important to advocate for access to rehabilitation for this patient group to give them the opportunity for optimal functional recovery.

Background: Contraversive lateropulsion is a common post-stroke impairment. Rehabilitation outcomes in stroke survivors exhibiting lateropulsion may differ from those without lateropulsion.Objectives: To systematically review evidence regarding associations between:1. Presence/severity of lateropulsion after stroke and functional outcome, rehabilitation length of stay, and discharge destination;2. Stroke-related factors and resolution of lateropulsion, functional outcome, rehabilitation length of stay, and discharge destination in affected stroke survivors.Methods: Medline, CINAHL, and Embase databases were searched. Journal articles published in English reporting on resolution of lateropulsion, length of stay, functional outcome, and/or discharge destination associated with post-stroke lateropulsion were included for review. Studies that did not include a comparison group (stroke survivors without lateropulsion, or sub-groups of participants with lateropulsion based on stroke-related factors), animal studies, and studies reporting only on ipsiversive lateropulsion and/or lateral medullary syndrome were excluded. Two authors independently assessed studies for inclusion. Included studies were evaluated using the Risk of Bias Assessment Tool for Nonrandomized Studies.Results: Screening identified 133 articles. Seven articles met inclusion criteria. People with contraversive lateropulsion after stroke can achieve similar improvements in function as those without lateropulsion, increasing likelihood of discharge home, but require longer rehabilitation durations to do so.Conclusions: The finding that longer rehabilitation durations are required for people with post-stroke lateropulsion to achieve their functional potential and increase likelihood of discharge home has implications for resourcing rehabilitation services. Given an additional three to four weeks in rehabilitation, people with post-stroke lateropulsion can achieve functional improvements function similar to those without lateropulsion.

Aim: To explore the relationship between balance deficit, falls, and activities of daily living in a cohort with Charcot-Marie-Tooth disease. Method: A cohort survey of individuals with Charcot-Marie-Tooth disease attending a neurogenetic clinic was carried out. Surveys were sent to individuals on a database of a state-wide neurogenetic service located in Perth, Australia. Results: Out of 71 surveys, 40 were returned (56%). The cohort were predominantly male (68%), the average age was 55.5 years (range 18–84) and average age at symptom onset was 23 years (range 5–65). Excluding skeletal foot changes, balance deficits (87.5%) and loss of balance confidence (90%) were the most frequently rated symptoms and those most severely affecting physical functioning (71% and 64% respectively). Ankle splinting was frequently reported in this population (65%). The majority of participants (69%) had fallen at least once in the past year and 40% of fallers reported having never seen a physiotherapist. Conclusions: Despite balance deficits and loss of balance confidence being frequently reported to impact daily activities, and falls and near-falls being common in this cohort with Charcot-Marie-Tooth disease, more than a third had not seen a physiotherapist. Future management to reduce the disease burden should investigate the effects of a timely multidisciplinary approach to manage balance dysfunction, and strategies to reduce falls in this population.

Purpose: To explore factors influencing physical activity (PA) reported by people living in rural/semi-rural communities in the south of England post-stroke, and to understand relationships between personal, interpersonal and environmental barriers and self-reported levels of PA. Method: A survey was mailed to patients of NHS Trusts who were identified as potential participants. Self-reported PA levels, type, and frequency of reported barriers were tabulated. Spearman’s rank correlation coefficient was used to explore associations between self-reported PA level and: age, gender, level of physical function, fear of falling, beliefs regarding PA, available supports, and socioeconomic status. Results: Seventy-six of 322 questionnaires distributed were returned (24%). Only 55.2% of respondents reported undertaking PA of sufficient intensity to meet current guidelines. Personal barriers included fear of falling, stroke-related disability, pain, and fatigue. Interpersonal and environmental barriers included lack of social support, transport, and inclement weather. Significant relationships existed between self-reported PA and fear of falling, functional mobility, and beliefs relating to PA. Conclusions: Almost half of the survey cohort reported PA levels insufficient to meet current guidelines. Similar to barriers reported in previous studies in USA and other parts of the UK, numerous interlinking and overlapping personal, interpersonal, and environmental barriers to undertaking PA were identified.Implications for RehabilitationThis study found that although more than 60% of the survey population were able to ambulate >200 m, only 55.2% reported undertaking sufficient PA to meet current guidelines, putting them at increased risk of further stroke and other co-morbidities.Participants reported a number of interlinking and overlapping personal, interpersonal, and environmental barriers to undertaking PA, which may explain this discrepancy between mobility status and self reported activity levels.Rehabilitation professionals and primary care providers are well positioned to address the barriers identified in this survey, such as providing interventions to reduce fear of falling, pain, and fatigue, providing support and education about safely increasing physical activity and addressing unhelpful beliefs about PA.Behaviour change strategies, such as increasing self-efficacy, and partnering with the person with stroke to problem solve strategies to address the barriers identified by this, and related research, are likely to be more successful in increasing PA than providing information alone. This study found that although more than 60% of the survey population were able to ambulate >200 m, only 55.2% reported undertaking sufficient PA to meet current guidelines, putting them at increased risk of further stroke and other co-morbidities. Participants reported a number of interlinking and overlapping personal, interpersonal, and environmental barriers to undertaking PA, which may explain this discrepancy between mobility status and self reported activity levels. Rehabilitation professionals and primary care providers are well positioned to address the barriers identified in this survey, such as providing interventions to reduce fear of falling, pain, and fatigue, providing support and education about safely increasing physical activity and addressing unhelpful beliefs about PA. Behaviour change strategies, such as increasing self-efficacy, and partnering with the person with stroke to problem solve strategies to address the barriers identified by this, and related research, are likely to be more successful in increasing PA than providing information alone.

Background/Aims: To explore the beliefs and attitudes of potential referrers and referrees regarding the possible utilisation of early supported discharge (ESD) prior to hospital discharge. Methods: Semi-standardised one-to-one interviews were conducted with nine consultants and ten dyads, comprising inpatients and corresponding treating staff members involved in referral of these patients to ESD. Content analysis was completed to identify key themes and to group the data into categories. Results: Rehabilitation consultants reported safety and the ability to manage at home were the primary considerations in ESD referral decision making. Most patients were extremely likely to agree to referral to ESD. Four main categories were identified in the responses from the patient/staff dyads, which were summarised as: positive and negative aspects of ESD, and barriers and enablers to early discharge. Patients were only willing to return home with ESD once they were ambulant in some capacity. Staff identified considerably more potential disadvantages, and fewer benefits than patients with regard to early discharge. However, there was no indication that staff beliefs had a negative influence on patient views regarding their participation in ESD. Conclusions: Patients and staff generally approved of ESD services; however, staff may need to place greater consideration on advantages, such as the potential emotional and mental benefits that some patients associate with returning home sooner with ESD.

SummaryBackground This article describes the use of an activity worksheet and questionnaire to investigate the learning experience of students on clinical placement. The worksheet measures the amount of time students spend in different learning activities, and the questionnaire explores student satisfaction and preferred learning activities. An activity worksheet and questionnaire … investigate[d] the learning experiences of students on clinical placement Methods The activity worksheet and questionnaire were used in a cohort pilot study of physiotherapy students on clinical placement. Results The activity worksheet provides details of the amount of time students engage in a range of clinical and non-clinical tasks while on placement, such as time spent treating patients, working individually, working with their peers and engaging in reflective practice. In combination with the questionnaire results, it allows clinicians to gain an understanding of the clinical learning environment experienced by their students. Discussion The data collected using these tools provide a description of the students’ activities while undertaking the clinical placement. This information may guide the refinement of the clinical experience, and offers an opportunity to individualise learning activities to match students’ needs and preferences.

Background/Aims: This study explored the applicability of the UK Bridges stroke self-management programme for use in an Australian health care context, and specifically, the need for any modification to the workbook tool. Methods: Data were collected via survey from Australian stroke professionals who had attended a 2-day Bridges training workshop and from focus groups with community-based stroke survivors across three different states. Findings: A total of 18 out of 30 workshop attendees (60%) completed the electronic survey. Most (94%) agreed that the training had advanced their practice with a stronger focus on self-management principles and that they would recommend the training to colleagues. The majority (71%) had incorporated some Bridges stroke self-management programme principles or strategies into their practice; although 81% reported a range of barriers to doing so. A total of 26 stroke survivors attended focus groups. The workbook was considered to be a useful tool to support self-management. Suggestions for change included the addition of some culturally contextualised patient stories and locally relevant stroke support resources. Conclusions: Stroke survivors and health professionals recognised the need for structured training, such as the Bridges stroke self-management programme, to develop self-management skills and knowledge post stroke. The Bridges stroke self-management programme workbook would be able to be used in Australia with minor modification.

Aim: To examine the relationship between patient/family engagement in goal planning, satisfaction with the goal setting process and associated goal attainment and functional gains during rehabilitation. Method: A prospective cohort analysis of consecutively completed episodes for patients discharged over a 1-year period (January–December 2013) in a specialist neurological rehabilitation service in the UK. Participants were adults (n=83) with neurological disabilities (mean±SD age: 42.8 ±15.0 years; programme length: 98 ± 47 days; male to female ratio: 69 : 31; diagnosis: brain injury (n=75, 90%), spinal cord injury (n=5, 6%), other neurological conditions (n=3, 4%)). The measures used were six-point visual analogue scales to rate goal engagement and goal satisfaction, Goal Attainment Scaling (GAS) and the UK Functional Assessment Measure (UK FIM+FAM). Results: Significant improvements were seen between admission and discharge for patient goal engagement (Mann-Whitney z=–2.2, p=0.027) and satisfaction (z=–...

Objective: This study investigated the inter- and intra-rater reliability of the Australian Spasticity Assessment Scale (ASAS) in adults with unilateral hypertonia following acquired brain injury. The ASAS has been shown to be superior to other clinical tools for the assessment of spasticity in children with cerebral palsy but reliability has not been previously examined in adults. Method: Four muscle groups were rated on one occasion by four assessors using the ASAS in sixteen adults with unilateral hypertonia following acquired brain injury. Twelve participants returned one week later for reassessment by the same assessors. Results: Overall inter-rater reliability of the ASAS using a quadratic weighted Kappa was moderate (Kqw 0.58) with ranges from moderate to good (Kqw 0.42 - 0.70). Agreement between raters was greatest for soleus muscle and least for wrist flexors. Overall intra-rater reliability of each of the four raters was moderate to good (Kqw 0.48 - 0.79). Agreement within raters was greatest for soleus muscle and least for biceps muscle. Conclusions: The ASAS may represent an appropriate alternative to the clinical scales currently used to assess spasticity; however inter and intra-rater reliability data from this investigation are lower than those which have previously been reported by experienced users of the ASAS in children with cerebral palsy. Further investigation with a larger sample size is warranted before any firm conclusions may be drawn about the reliability and validity of this tool to assess spasticity in adults with acquired brain injury.

Adequate folate and iron intake during pregnancy is critical for maternal and fetal health. No previous studies to our knowledge have reported dietary supplement use and folate status among pregnant women sampled in NHANES, a nationally representative, cross-sectional survey. We analyzed data on 1296 pregnant women who participated in NHANES from 1999 to 2006 to characterize overall supplement use, iron and folic acid use, and RBC folate status. The majority of pregnant women (77%) reported use of a supplement in the previous 30 d, most frequently a multivitamin/-mineral containing folic acid (mean 817 μg/d) and iron (48 mg/d). Approximately 55–60% of women in their first trimester reported taking a folic acid- or iron-containing supplement compared with 76–78% in their second trimester and 89% in their third trimester. RBC folate was lowest in the first trimester and differed by supplement use across all trimesters. Median RBC folate was 1628 nmol/L among users and 1041 nmol/L among nonusers. Among all pregnant women, median RBC folate increased with trimester (1256 nmol/L in the first, 1527 nmol/L in the second, and 1773 nmol/L in the third). Given the role of folic acid in the prevention of neural tube defects, it is notable that supplement use and median RBC folate was lowest in the first trimester of pregnancy, with 55% of women taking a supplement containing folic acid. Future research is needed to determine the reasons for low compliance with supplement recommendations, particularly folic acid, in early pregnancy.

PURPOSE: We examined the feasibility and outcome of electromyographically triggered electrical muscle stimulation (EMG-ES) plus unilateral or bilateral task specific practice on arm function in chronic stroke survivors with moderate-severe hemiplegia. Transcranial magnetic stimulation was used to examine inter-hemispheric inhibition (IHI) acting on the stroke-affected hemisphere in a subset of eight participants. METHODS: Twenty-one stroke survivors (14 males; mean time post stroke 57.9 months) participated in this pilot investigation. Participants underwent a six-week program of daily EMG-ES training with random assignment to concurrent task practice using the stroke-affected hand only or both hands. The upper-extremity subscale of the Fugl-Meyer (FMUE) and the Arm Motor Ability Test (AMAT) were completed at baseline, 0-, 1-, and 3-months post-intervention. RESULTS: Following the intervention, FMUE (F(3, 57) = 3.89, p = .01, etap2 = .17) and AMAT (F(3, 57) = 12.6, p = .01, etap2 = .39) scores improved, and remained better than baseline at three months re-assessment. The difference between groups was not significant. A non-significant decrease in IHI was observed post-intervention. CONCLUSIONS: An intensive program of EMG-ES assisted functional training is feasible, well tolerated, and leads to improvements in moderate-severe deficits of arm function post stroke. Larger placebo controlled studies are needed to explore any advantage of bilateral over unilateral EMG-ES assisted training.

The Centre for MusculoskeletalStudies, School of Surgery, The University of Western Australia, Western Australia, AustraliaBackground: Recently, the European Journal of Neu-rology published international consensus statements forthe assessment, treatment and aftercare associated withthe use of botulinum neurotoxin type A. This surveyexamined current allied health practice in relation to botu-linum neurotoxin type A use in Australia in the light ofthese guidelines.Methods: An electronic questionnaire was distributed tomembers of neurology groups of the Australian Physio-therapy Association and Occupational Therapy Australia.The questionnaire explored assessment processes used,familiarity with pharmaceutical benefits schemeindications for botulinum neurotoxin type A use, goalsetting and outcome measurement, follow-up therapy andaccess to spasticity management services.Results: The 123 survey respondents (81 from the Aus-tralian Physiotherapy Association – response rate 16.2%,42 from Occupational Therapy Australia – response rate6.4%) reported that focal spasticity was a major problemfor which botulinum neurotoxin type A was a primaryintervention. The Tardieu scale was more frequently usedthan the modified Ashworth scale (82% vs. 48%). Mosttherapists (76.3%) reported being confident diagnosingspasticity and its functional implications (84.2%), butfewer were confident discussing referral for botulinumneurotoxin type A with doctors (56.1%). Goals were setin conjunction with the client (93.6%). Barriers to injec-tion and adjunctive therapy (motor training etc.) includedwaiting times for botulinum neurotoxin type A injection,access to specialist adjunctive therapists and referral fortreatment.Conclusions: Allied health practitioners in Australiareport clinical practice to be closely aligned with interna-tional guidelines for the use of botulinum neurotoxin typeA in adult spasticity. Therapist confidence in advocatingfor botulinum neurotoxin type A injection, consistent useof objective measures of spasticity and treatment outcomesand barriers to providing adjunctive therapy need to beaddressed.KEY WORDS botulinum toxins, muscle hypertonia, mus-cle spasticity, physical therapy modalities, rehabilitation.

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.

Botulinum neurotoxin (BoNT) is most commonly used to reduce focal over-activity in skeletal muscle, although newer indications such as management of drooling, pain and tremor are emerging. Treatment of spasticity incorporating BoNT is usually part of an integrated multidisciplinary rehabilitation programme. Prior to initiating this therapy, specific functional limitations, goals and expected outcomes of treatment should be discussed with the patient/carers. Muscle selection and the order/priority of treatment should be agreed. Treatment goals may involve increasing active or passive function or the avoidance of secondary complications or impairment progression. This paper describes the basic science mechanisms of the action of BoNT and subsequent nerve recovery and introduces a supplement comprising the best available evidence and expert opinion from international panels on questions of assessment, indications, BoNT regimen, adjunctive therapy, expected outcomes and recommended monitoring. Speciality areas reviewed include Paediatric Lower Limb Hypertonicity, Paediatric Upper Limb Hypertonicity, Adult Lower Limb Hypertonicity, Adult Upper Limb Hypertonicity, Cervical Dystonia, Drooling and Pain and Niche Indications. There is good quality scientific evidence to support the efficacy of BoNT to reduce muscle over-activity in the limbs secondary to central nervous system disorders in adults and children, to address primary or secondary cervical dystonia, to reduce saliva flow and to treat some pain syndromes. There is emergent evidence for the efficacy of BoNT to reduce focal tremor, to treat other types of pain including neuropathic pain and also to improve function following treatment of focal muscle over-activity.

Objectives This randomised controlled crossover trial examined the efficacy of botulinum toxin type A (BoNT-A) injection, plus an exercise programme, to remediate chronic anterior knee pain (AKP) associated with quadriceps muscle imbalance. Methods 24 individuals with refractory AKP received either BoNT-A (500 U Dysport) or the same volume saline injection to the vastus lateralis (VL) muscle and performed home exercises focusing on re-training the vastus medialis (VM) muscle. All subjects were offered open-label injection at 12 weeks. Knee-related disability (anterior knee pain scale; AKPS) and activity-induced pain (10 cm visual analogue scale) at 12 weeks were the primary outcomes. Peak isometric extensor force was recorded and normalised VL:VM ratios were derived from simultaneous surface electromyography. Selfreported pain and disability measures were collected at six time points to a mean of 20±8 months. Results 14 subjects received BoNT-A and 10 placebo injection. Improvement at 12 weeks was significantly greater for BoNT-A compared with placebo-injected subjects for the AKPS (p

Intramuscular injection of botulinum toxin (BoNT) produces reversible blockade of neuromuscular transmission. In animal experimental models, recovery begins within four weeks and is usually complete by twelve weeks. We present evidence of prolonged denervation following BoNT injection of the vastus lateralis (VL) muscle to correct quadriceps muscle imbalance in patients with chronic anterior knee pain. Needle electromyography data were obtained from 10 subjects who had received a single BoNT treatment 5 to 19 months earlier as part of a clinical trial. Insertional and spontaneous activity, recruitment, and motor unit action potentials were examined. Clear differences between the injected and non-injected VL muscles, which correlated with the time since injection, were identified in all subjects. All 10 subjects studied with needle EMG showed evidence of persisting denervation in the BoNT-A injected VL muscle beyond the period of neuromotor recovery expected from animal experimental studies.

Singer BJ, Jegasothy GM, Singer KP, Allison GT, Dunne JW. Incidence of ankle contracture after moderate to severe acquired brain injury. Arch Phys Med Rehabil 2004;85:1465–9. Objective To examine an adult population undergoing rehabilitation after brain injury to determine the incidence of ankle contracture and factors contributing to the development of this deformity. Design Descriptive study Setting Specialist inpatient neurosurgical rehabilitation unit in Australia. Participants Patients (N=105) admitted with a new diagnosis of moderate to severe brain injury over a 12-month period. Interventions Not applicable. Main outcome measures Maximal ankle dorsiflexion range and the presence of abnormal muscle tone affecting the lower limb(s) were evaluated at weekly intervals. Ankle contracture was defined as maximal passive range of less than 0° dorsiflexion with the knee in extension. Patients were grouped into 3 muscle tone categories: normal, predominantly spastic, or predominantly dystonic. Age, sex, mechanism and severity of brain injury, time to onset of ankle contracture, total length of hospital stay, and discharge mobility status data were also recorded. Results Muscle tone was designated as normal in 68 (64.7%), as spastic in 14 (13.3%), and as dystonic in 23 (21.9%) patients. The incidence of ankle contracture was 16.2% (17/105 cases). Ankle deformity correlated closely with muscle tone category. Of 23 cases with dystonic muscle overactivity, 17 developed contracture at some point between 1 and 16 weeks after brain injury, although no subject with normal tone or spasticity developed the deformity. There was a weak association between the severity of brain injury and development of ankle contracture. Conclusions The incidence of ankle contracture was much lower than previously reported. Dystonic overactivity of the plantarflexor and invertor muscles is a major predisposing factor to ankle contracture.

Hypertonia of the triceps surae muscles is a common consequence of acquired brain injury. The increased resistance to passive lengthening results from rheologic changes within the musculotendinous unit, in addition to altered descending facilitatory influences on the alpha motor-neurone pool. Hypertonia can contribute to abnormal ankle joint biomechanics during the performance of functional tasks. In order to achieve effective outcomes, therapeutic interventions need to be based on accurate measurement and analysis of the various components of hypertonia. Some options for the clinical evaluation of hypertonia at the ankle joint are discussed in this paper. Reflex hyper-excitability and rheologic changes within the musculotendinous unit are inextricably linked. Serial evaluation of passive range of motion and muscle stiffness in patients with hypertonia provides useful information for treatment planning. In addition to measurement of the available passive range of motion when maximal force is appli...

Prevalence and correlates of HIV testing were examined in a sample of 957 unmarried recent college students in the United States. Participants were asked about HIV testing, past-six-months sexual activities, lifetime treatment for sexually transmitted infections (STI), past-year health service utilization, and DSM-IV criteria for alcohol and other drug (AOD) dependence during the 2008–2009 academic year. Two in five (41.9% wt ) were ever tested for HIV. Holding constant demographics, HIV testing was positively related to AOD dependence, frequency of unprotected sex, number of sex partners, having a physical exam by a medical professional, number of visits to a health provider for physical health problems, and lifetime STI treatment. Women were more likely than men to be tested for HIV despite similar levels of risky sex. Results demonstrate the feasibility of achieving high HIV testing rates in a college population. Human Immunodeficiency Virus (HIV) remains a major public health challenge worldwide and a persistent risk to young people. One-third of all new HIV infections occur among people under age 30 (Prejean, Song, An, & Hall, 2008), and the number of new infections annually has changed little since the late 1990s (Hall et al., 2008). Of major concern is that, of the 1.1 million individuals living with HIV in the United States, one in five does not know they are infected (Campsmith, Rhodes, Hall, & Green, 2008). HIV testing can increase the proportion of HIV-infected individuals who are aware of their serostatus, and thus remains an important preventive measure in reducing HIV transmission. To that end, in 2006 the Centers for Disease Control and Prevention (CDC) revised its HIV testing guidelines to recommend universal opt-out testing for all adults visiting a health care setting, while still targeting

Objective: To examine the safety and efficacy of onabotulinumtoxinA (Botox) for plantarflexor overactivity following stroke. Design: Double-blind randomized controlled trial, open-label extension phase. Setting: Neurology rehabilitation facilities. Subjects: Eighty-five subjects with lower limb hypertonia received 200 U ( n = 28) or 300 U ( n = 28) of onabotulinumtoxinA or saline ( n = 29) injection. Primary measures: Plantarflexor Ashworth scores at 12 weeks post injection and adverse events. Secondary measures: self-reported spasm frequency and pain, physician rating of hypertonia severity, gait quality and active dorsiflexion. Results: Differences were not seen between onabotulinumtoxinA groups; hence data were pooled. Incidence of adverse events was not different between groups ( P = 0.61). Reduction in hypertonia was not different between groups at 12 weeks ( P = 0.53); however for subjects with Ashworth scores of >3 at baseline, 14/31 in the onabotulinumtoxinA group demonstrated a reduction of >1 grade versus 1/17 receiving placebo injection ( P = 0.01). Overall, onabotulinumtoxinA-injected subjects demonstrated significantly greater improvement in spasm frequency (22/54 versus 4/29, P = 0.01), pain reduction (8/54 versus 1/29, P = 0.02), active dorsiflexion (8/54 versus 1/29 P = 0.03) and gait quality (17/54 versus 6/29, P = 0.02) than controls. In the open-label phase, a second onabotulinumtoxinA injection was associated with greater hypertonia reduction ( P = 0.005) and gait quality ( P = 0.002) compared with single injection. Conclusions: OnabotulinumtoxinA injection for ankle flexor overactivity after stroke was safe and well tolerated but did not alter local spasticity at 12 weeks; it did reduce spasms and improve gait quality. There were no detectable differences between higher and lower doses. A second injection may be associated with greater change.

Intramuscular injection of botulinum toxin (BoNT) produces reversible blockade of neuromuscular transmission. In animal experimental models, recovery begins within four weeks and is usually complete by twelve weeks. We present evidence of prolonged denervation following BoNT injection of the vastus lateralis (VL) muscle to correct quadriceps muscle imbalance in patients with chronic anterior knee pain. Needle electromyography data were obtained from 10 subjects who had received a single BoNT treatment 5 to 19 months earlier as part of a clinical trial. Insertional and spontaneous activity, recruitment, and motor unit action potentials were examined. Clear differences between the injected and non-injected VL muscles, which correlated with the time since injection, were identified in all subjects. All 10 subjects studied with needle EMG showed evidence of persisting denervation in the BoNT-A injected VL muscle beyond the period of neuromotor recovery expected from animal experimental studies.

Muscle overactivity is common in patients with adult onset central nervous system damage. It can produce significant disablement in conjunction with other impairments such as adaptive soft tissue shortening and loss of muscle strength. Muscle overactivity is not evenly distributed throughout the body; across joints there is frequently imbalance between agonist and antagonist, producing abnormal joint postures and movement patterns. Due to the asymmetric nature of the abnormal activity across joints, in general we recommend local treatment targeting the more overactive of the two agonists, rather than systemic treatment. Considerable experience with the use of botulinum toxin, both serotypes A and B, in the treatment of muscle overactivity has been accumulated in the last two decades through pragmatic clinical practice and open label studies, supported by an increasing number of randomized controlled trials. In most cases, it is important to use botulinum toxin injection for treatment of muscle overactivity in the setting of wider rehabilitation goals and interventions. Focal and partial blocks with botulinum toxin should be used as a component of a general neurorehabilitation programme rather than as an alternative to other treatments. We review the evidence supporting the use of botulinum toxin to treat muscle overactivity in the lower limb, present practical guidelines on when and how to use botulinum toxin and provide direction for future research.

Intramuscular injection of Botulinum toxin to produce reduction of focal muscle overactivity, and localized muscle spasm, has been utilized therapeutically for almost two decades. Muscle overactivity in neurologically normal muscle, where an imbalance exists between a relatively overactive muscle and its less active synergist or antagonist, can inhibit control of the antagonist producing a functional muscle imbalance. This brief review provides an overview of the role of muscle imbalance in sports-related pain and dysfunction, and outlines the potential for intramuscular injection of Botulinum toxin to be used as an adjunct to specific muscle re-education and functional rehabilitation in this patient group. A comprehensive understanding of normal movement and the requirements of the sporting activity are essential to allow accurate diagnosis of abnormal motor patterns and to re-educate more appropriate movement strategies. Therapeutic management of co-impairments may include stretching of tight soft tissues, specific re-education aimed at isolation of the non-dominant weak muscles and improvement in their activation, 'unlearning' of faulty motor patterns, and eventual progression onto functional exercises to anticipate gradual return to sporting activity. Intramuscular injection of Botulinum toxin, in carefully selected cases, provides short term reduction of focal muscle overactivity, and may facilitate activation of relatively 'inhibited' muscles and assist the restoration of more appropriate motor patterns.

To examine an adult population undergoing rehabilitation after brain injury to determine the incidence of ankle contracture and factors contributing to the development of this deformity.Descriptive studySpecialist inpatient neurosurgical rehabilitation unit in Australia.Patients (N=105) admitted with a new diagnosis of moderate to severe brain injury over a 12-month period.Not applicable.Maximal ankle dorsiflexion range and the presence of abnormal muscle tone affecting the lower limb(s) were evaluated at weekly intervals. Ankle contracture was defined as maximal passive range of less than 0 degrees dorsiflexion with the knee in extension. Patients were grouped into 3 muscle tone categories: normal, predominantly spastic, or predominantly dystonic. Age, sex, mechanism and severity of brain injury, time to onset of ankle contracture, total length of hospital stay, and discharge mobility status data were also recorded.Muscle tone was designated as normal in 68 (64.7%), as spastic in 14 (13.3%), and as dystonic in 23 (21.9%) patients. The incidence of ankle contracture was 16.2% (17/105 cases). Ankle deformity correlated closely with muscle tone category. Of 23 cases with dystonic muscle overactivity, 17 developed contracture at some point between 1 and 16 weeks after brain injury, although no subject with normal tone or spasticity developed the deformity. There was a weak association between the severity of brain injury and development of ankle contracture.The incidence of ankle contracture was much lower than previously reported. Dystonic overactivity of the plantarflexor and invertor muscles is a major predisposing factor to ankle contracture.

Singer BJ, Jegasothy GM, Singer KP, Allison GT. Evaluation of serial casting to correct equinovarus deformity of the ankle after acquired brain injury in adults. Arch Phys Med Rehabil 2003;84:483-91. Objective: To determine the potential short-term benefit of serial plaster casting in the management of equinovarus defor- mity associated with acquired brain injury. Design: Prospective uncontrolled interventional trial. Setting: Inpatient rehabilitation facility in Australia. Participants: Sixteen patients (19 limbs) with equinovarus deformity or deteriorating ankle range of motion associated with severe plantarflexor and invertor muscle overactivity un- derwent serial plaster casting over an 18-month period. Interventions: Below-knee plaster casts were reapplied weekly to increase joint range and muscle extensibility. Main Outcome Measures: Precasting goniometric mea- sures of maximal ankle dorsiflexion range (in knee extension and flexion) were compared with 4 subsequent test occasions (after initial cast, midpoint of casting, after final cast, 1wk after removal). The amount and type of assistance required to per- form a standardized wheelchair-to-bed transfer before and 3 months from commencement of casting were also compared. Results: Subjects who underwent the serial casting regimen had significantly improved ankle range (knee flexed mean, 18°; knee extended mean, 16°; P.0001); 13 subjects reduced their need for transfer assistance (P.0015). Conclusion: Serial casting appears to be effective, at least in the short term, in reducing the equinovarus deformity that occurs after acquired brain injury. Greater ankle mobility was associated with improved transfer independence in the majority of subjects.