Multiple sclerosis and spasticity: the role of anaesthetic nerve blocks on rectus femoris muscle. When should stiff knee be treated with botulinum toxin?

OBJECTIVE: To compare the effect of rectus femoris diagnostic motor nerve blocks (DNB) with anaesthetics and rectus femoris muscle botulinum toxin (BoNT-A) injection in multiple sclerosis patients with unilateral stiff-knee gait. DESIGN: Prospective observational study Subjects/Patients: Multiple sclerosis patients in stable condition. METHODS: Patients underwent evaluation before and 1 hour after the anaesthetic block, and 1 month after the botulinum injection. Assessment included a 10-m walking test, a 6-minute walking test, a timed-up-and-go (TUG) test, and a Baseline Expanded Disability Status Scale (EDSS). Post-DNB and post-BoNT-A satisfaction was measured with the global assessment of efficacy scale. RESULTS: Fourteen patients with unilateral stiff-knee gait due to multiple sclerosis underwent a DNB, among whom 13 received botulinum injections in the rectus femoris muscle after a satisfying test result. Positive post-DNB results correlated with significant functional improvements after BoNT-A. Higher EDSS and longer time from diagnosis correlated with poorer post-DNB and post-BoNT-A absolute outcomes. CONCLUSION: DNB showed predictive value for BoNT-A outcomes, especially in the case of worse functional status. It effectively predicted endurance and walking speed improvement, while TUG showed greater improvement after botulinum. In cases of uncertain therapeutic benefit, nerve blocks may provide a valuable diagnostic support, particularly in patients with lower functional status.

Gait abnormalities of COPD are not directly related to respiratory function.

STUDY OBJECTIVE: To assess whether gait abnormalities in COPD depend on mere impairment of respiratory function. METHODS: In 40 patients with COPD at different GOLD stages and 28 controls, we evaluated: forced expiratory volume in 1s (FEV1); partial pressure of oxygen; Mini-Mental State Examination (MMSE); dynamic balance through the Mini-BESTest (MBT); Timed Up and Go (TUG) test without and with dual task counting aloud back by three; 6-min walk test (6MWT); body sway during quiet stance (stabilometry); spatial-temporal variables of gait by a 4-m long sensorized walkway (baropodometry). Lower-limb muscle strength, tendon reflexes, and sensation were also clinically evaluated. RESULTS: Muscle strength of proximal but not distal muscles was slightly reduced in patients, whereas reflexes and sensation were unaffected. FEV1, partial pressure of oxygen, MMSE, MBT, stabilometry, as well as baropodometry, were abnormal and unrelated to muscle weakness. The time taken to perform the TUG test was increased, and to a larger extent with than without dual task. At baropodometry, variability of step length was increased; abnormalities of gait variables were associated with larger body sway but not with FEV1 or hypoxemia. Gait speed at 6MWT was correlated with MBT score and with FEV1 as well as hypoxemia. CONCLUSIONS: 6MWT findings give a measure of gait disability linked to endurance-related respiratory failure. Gait at baropodometry is associated with impairment of balance, cognitive status and abnormal dual task performance. We suggest that central nervous lesions, presumably of vascular origin, are detrimental to balance and gait in COPD.

Early rehabilitative treatment after infrainguinal lower limb bypass surgery.

BACKGROUND AND AIM OF THE WORK: Functional activity may remain limited in patients affected by critical limb ischemia, despite successful infrainguinal lower limb bypass surgery (ILLBS). The aim of the work was to evaluate the impact of a rehabilitative intervention on postoperative ambulatory status and pain. METHODS: In an observational study, data were collected on 34 patients undergoing ILLBS for critical limb ischemia or end-stage peripheral arterial disease. All patients underwent a postoperative rehabilitation program aimed at recovering gait autonomy. Information was collected on pre-operative comorbidities, ambulatory status (on admission to and discharge from hospital) and pain in the affected lower limb (on the first physiotherapy session and at discharge). RESULTS: Before ILLBS, 61.8% of the patients walked independently without aids or assistance. The rehabilitative program started on average 5.7 (SD: 2.1) days after surgery. At discharge, 50% of the patients walked independently, 41.2% walked with aids and/or assistance and 8.8% were not able to walk. Overall, 76.5% of the sample recovered their pre-operative ambulatory status. Although pain tended to decrease, the difference at the first (1.5; SD: 2.6) and at the last treatment session (0.8; SD= 1.3) was not statistically significant. CONCLUSION: Our exercise protocol resulted to be easy to perform during hospital stay, with an overall favourable outcome for ambulatory status. Our results are in line with those reported in literature about the rates of postoperative dependence in walking, but appear to be slightly better in regards to the percentage of patients who recovered pre-operative ambulatory status.