The Effect of Botulinum Toxin Type A Injection in the Rectus Femoris in Stroke Patients Walking With a Stiff Knee Gait: A Randomized Controlled Trial.

BACKGROUND: Over activity of the rectus femoris is often cited as a main cause for stiff knee gait (SKG). Botulinum toxin (BoNT) can be used to reduce this over activity. Inconsistent results for the effect of BoNT injections were found in literature which can possibly be explained by the study design as these were uncontrolled or non-randomized studies. OBJECTIVE: To conduct a randomized controlled trial (RCT) to investigate the effect of botulinum toxin type A (BoNT-A) injections in the rectus femoris on gait kinematics and functional outcome in adult stroke patients. METHODS: Twenty-six participants were included in this triple-blind cross-over RCT. The intervention consisted of an injection with BoNT-A. Placebo is an injection with saline. Besides knee and hip kinematics, functional outcomes were measured. RESULTS: Comparison of the effect of BoNT-A injection to placebo injection showed a significant increase in peak knee flexion and knee range of motion of 6.7° and 4.8° respectively. There was no difference in hip kinematics. In functional outcomes, only the 6 Minute Walking Test showed a significant increase of 18.3 m. CONCLUSIONS: BoNT-A injections in the rectus femoris is a valuable treatment option for stroke patients walking with a SKG to improve knee kinematics. To study the effect on functional outcome more research is necessary with different functional outcome measures that can capture the effect in kinematics. It is important to use kinematic measurements to demonstrate effects in quality of movement that are not captured by commonly used functional outcome measurements post stroke.Clinical Trial Registration: https://trialsearch.who.int/Trial2.aspx?TrialID=NTR2169.

A review and evaluation of patient-reported outcome measures for spasticity in persons with spinal cord damage: Recommendations from the Ability Network - an international initiative.

Context: Patient-reported outcome measures (PROMs) are valuable for capturing the impact of spasticity on health-related quality of life (HRQoL) in persons with spinal cord damage (SCD) and evaluating the efficacy of interventions. Objective: To provide practical guidance for measuring HRQoL in persons with spasticity following SCD. Methods: Literature reviews identified measures of HRQoL and caregiver burden, utilized in studies addressing spasticity in SCD. Identified measures were evaluated for clinical relevance and practicality for use in clinical practice and research. The PRISM, SCI-SET, EQ-5D and SF-36 instruments were mapped to the International Classification of Functioning, Disability and Health (ICF). The PRISM and SCI-SET were evaluated using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist. Results: Two spasticity-specific, five generic, and four preference-based measures were identified. ICF mapping and the COSMIN checklist supported the use of the PRISM and SCI-SET in SCD. The SF-36 is considered the most useful generic measure; disability-adapted versions may be more acceptable but further studies on psychometric properties are required. The SF-36 can be converted to a preference-based measure (SF-6D), or alternatively the EQ-5D can be used. While no measures specific to caregivers of people with SCD were identified, the Caregiver Burden Scale and the Zarit Burden Interview are considered suitable. Conclusion: Recommended measures include the PRISM and SCI-SET (condition-specific), SF-36 (generic), and Caregiver Burden Scale and Zarit Burden Interview (caregiver burden). Consideration should be given to using condition-specific and generic measures in combination; the PRISM or SCI-SET combined with SF-36 is recommended.

Does clinically measured ankle plantar flexor muscle strength or weakness correlate with walking performance in healthy individuals?

OBJECTIVE: Muscle strength is usually measured using isometric hand-held dynamometers (HHDs) in the clinic. However, during functional activities, the muscle acts more dynamically. The aim of this study was to investigate the relation between clinically measured plantar flexor (PF) muscle strength (PFMS) and laboratory measurements of peak ankle plantar flexion power generation (APFPG), peak ankle moment (PAM), peak plantar flexion velocity (PFV) and mean gait velocity in healthy participants. METHODS: The maximum PFMS on non-dominant sides in 18 able-bodied persons 23.88 (SD 3.55 years) was measured before (Pre-S) and after a stretching (Post-S) procedure (135 sec. × 13 rep. with 5 sec. rest) by using a HHD. The stretching procedure was used to generate temporary PF muscle weakness. Gait analysis was carried out for Pre-S and Post-S conditions. Normalized (by weight and height) and non-normalized HHD scores and differences for both conditions were correlated by Pearson correlation coefficient calculations (p< 0.05). RESULTS: Reduced PFMS (%23, p< 0.001) in Post-S, according to the HHD scores, has only a weak correlation with APFPG (r> 0.3, p< 0.5). Gait velocity was found to be strongly correlated with APFPG only in the Post-S condition (r= 0.68, p< 0.002). HHD scores and PAM were moderately correlated with the non-normalized Post-S condition (r= 0.44, p= 0.70) and strongly correlated with the non-normalized Pre-S condition (r= 0.62, p< 0.01). DISCUSSION: HHD scores of plantar flexor muscles give very limited information about the PF performance during walking in healthy individuals. Simple normalization did not improve the relations. Clinically measured isometric muscle strength and muscle weakness have only moderate strengths for establishing a treatment protocol and for predicting performance during walking in neurologically intact individuals.

Influence of functional electrical stimulation of the hamstrings on knee kinematics in stroke survivors walking with stiff knee gait.

OBJECTIVE: To explore whether functional electrical stimulation of the hamstrings results in improved knee kinematics in chronic stroke survivors walking with a stiff knee gait. DESIGN: Quasi-experimental. SUBJECTS: Sixteen adult chronic stroke survivors. METHODS: Survivors received functional electrical stimulation of the hamstrings, 3 times a week for 1 h during a period of 5 weeks. 3D kinematics was calculated before the training period and after 5 weeks of training. Knee kinematics of walking without stimulation before the training period was compared with walking with stimulation after 5 weeks of training. (intervention effect). In addition, knee kinematics of walking without stimulation before the training period was compared with walking without stimulation after the training period (therapeutic effect). RESULTS: The intervention effect showed a significant increase, of mean 8.7° (standard deviation (SD) 8.3, p = 0.001), in peak knee flexion. The therapeutic effect showed a significant increase in peak knee flexion, of mean 3.1° (SD 4.7, p = 0.021) Conclusion: The results of this exploratory study suggest an increase in knee kinematics in swing after functional electrical stimulation of the hamstrings in stroke survivors walking with a stiff knee gait. The largest improvement in peak knee flexion in swing was seen when participants walked with hamstring stimulation. Participants with low neurological impairment responded better to hamstring stimulation, and there are indications that the effect of hamstring stimulation can be predicted during a single session. The effect of functional electrical stimulation is comparable to that of more invasive treatment options, such as botulinum toxin or soft-tissue surgery. This makes functional electrical stimulation a feasible treatment option for daily clinical practice.

Clinical Assessment of Spasticity in People With Spinal Cord Damage: Recommendations From the Ability Network, an International Initiative.

A thorough assessment of the extent and severity of spasticity, and its effect on functioning, is central to the effective management of spasticity in persons with spinal cord damage (SCD). These individuals however do not always receive adequate assessment of their spasticity. Inadequate assessment compromises management when the effect of spasticity and/or need for intervention are not fully recognized. Assessment is also central to determining treatment efficacy. A barrier to spasticity assessment has been the lack of consensus on clinical and functional measures suitable for routine clinical practice. To extend on existing work, a working group of the Ability Network identified and consolidated information on possible measures, and then synthesized and formulated findings into practical recommendations for assessing spasticity and its effect on function in persons with SCD. Sixteen clinical and functional measures that have been used for this purpose were identified using a targeted literature review. These were mapped to the relevant domains of the International Classification of Functioning, Disability and Health to assess the breadth of their coverage; coverage of many domains was found to be lacking, suggesting a focus for future work. The advantages, disadvantages, and usefulness of the measures were assessed using a range of criteria, with a focus on usefulness and feasibility in routine clinical practice. Based on this evaluation, a selection of measures suitable for initial and follow-up assessments are recommended. The recommendations are intended to have broad applicability to a variety of health care settings where people with SCD are managed.

Weakening iliopsoas muscle in healthy adults may induce stiff knee pattern.

OBJECTIVE: The goal of the present study was to investigate the relationship between iliopsoas muscle group weakness and related hip joint velocity reduction and stiff-knee gait (SKG) during walking in healthy individuals. METHODS: A load of 5% of each individual's body weight was placed on non-dominant thigh of 15 neurologically intact, able-bodied participants (average age: 22.4 ± 0.81 years). For 33 min (135 s × 13 repetitions × 5 s rest), a passive stretch (PS) was applied with the load in place until hip flexor muscle strength dropped from 5/5 to 3+/5 according to manual muscle test. All participants underwent gait analysis before and after PS to compare sagittal plane hip, knee, and ankle kinematics and kinetics and temporo-spatial parameters. Paired t-test was used to compare pre- and post-stretch findings and Pearson correlation coefficient (r) was calculated to determine strength of correlation between SKG parameters and gait parameters of interest (p < 0.05). RESULTS: Reduced hip flexion velocity (mean: 21.5%; p = 0.005) was a contributor to SKG, decreasing peak knee flexion (PKF) (-20%; p = 0.0008), total knee range (-18.9%; p = 0.003), and range of knee flexion between toe-off and PKF (-26.7%; p = 0.001), and shortening duration between toe-off to PKF (-16.3%; p = 0.0005). CONCLUSION: These findings verify that any treatment protocol that slows hip flexion during gait by weakening iliopsoas muscle may have great potential to produce SKG pattern combined with reduced gait velocity.

Optimizing the Management of Disabling Spasticity Following Spinal Cord Damage: The Ability Network-An International Initiative.

Optimizing the treatment of disabling spasticity in persons with spinal cord damage is hampered by a lack of consensus regarding the use of acceptable definitions of spasticity and disabling spasticity, and the relative absence of decision tools such as clinical guidelines and concise algorithms to support decision-making within the broader clinical community. Many people with spinal cord damage are managed outside specialist centers, and variations in practice result in unequal access to best practice despite equal need. In order to address these issues, the Ability Network-an international panel of clinical experts-was initiated to develop management algorithms to guide and standardize the assessment, treatment, and evaluation of outcomes of persons with spinal cord damage and disabling spasticity. To achieve this, consensus was sought on common definitions through facilitated, in-person meetings. To guide patient selection, an in-depth review of the available tools was performed and expert consensus sought to develop an appropriate instrument. Literature reviews are guiding the selection and development of tools to evaluate treatment outcomes (body functions, activity, participation, quality of life) as perceived by people with spinal cord damage and disabling spasticity, and their caregivers and clinicians. Using this approach, the Ability Network aims to facilitate treatment decisions that take into account the following: the impact of disabling spasticity on health status, patient preferences, treatment goals, tolerance for adverse events, and in cases of totally dependent persons, caregiver burden.

Plantar flexor muscle weakness may cause stiff-knee gait.

AIM: The iterative simulation studies proclaim that plantar flexor (PF) muscle weakness is one of the contributors of stiff knee gait (SKG), although, whether isolated PF weakness generates SKG has not been validated in able-bodied people or individuals with neuromuscular disorders. The aim of the study was to investigate the effects of isolated PF muscle weakness on knee flexion velocity and SKG in healthy individuals. METHOD: Twenty able-bodied young adults (23±3 years) participated in this study. Passive stretch (PS) protocol was applied until the PF muscle strength dropped 33.1% according to the hand-held dynamometric measurement. Seven additional age-matched able-bodies were compared with participants' to discriminate the influence of slow-walking. All participants underwent 3D gait analysis before and after the PS. Peak knee flexion angle, range of knee flexion between toe-off and peak knee flexion, total range of knee-flexion, and time of peak knee flexion in swing were selected to describe SKG pattern. RESULTS: After PS, the reduction of plantar flexor muscle strength (33.14%) caused knee flexion velocity drop at toe-off (p=0.008) and developed SKG pattern by decreasing peak knee flexion (p=0.0001), range of knee flexion in early swing (p=0.006), and total knee flexion range (p=0.002). These parameters were significantly correlated with decreased PF velocity at toe-off (p=0.015, p=0.0001, p=0.005, respectively). The time of peak knee flexion was not significantly different between before and after stretch conditions (p=0.130). CONCLUSIONS: These findings verified that plantar flexor weakness cause SKG pattern by completing three of SKG parameters. Any treatment protocol that weakens the plantar flexor muscle might impact the SKG pattern.

Contributors of stiff knee gait pattern for able bodies: Hip and knee velocity reduction and tiptoe gait.

UNLABELLED: Stiff-knee gait (SKG) is commonly encountered in clinic; many other gait abnormalities are seen together with this pathology. Simulation studies revealed that diminished knee flexion (KF) velocity and increased knee extension moments are strongly related with SKG. This study aimed to determine whether tiptoe walking and hip-knee flexion velocity reduction causes SKG pattern in healthy participants. METHODS: Fourteen able-bodied adults' (Av. age: 23.0±2.4) heel-toe (N), tiptoe (T), and walking with 5% body weight on both shanks (W) were analyzed using 3D gait analysis by controlling cadence (90step/min). Repeated measures analysis of variance was used followed by Bonferroni correction (p<0.05). RESULTS: Walking velocity and cadence were similar for all conditions (p>0.1). Maximum hip flexion velocity was reduced (15%) significantly as well as the KF velocity (10%) in the W condition. The peak knee flexion (PKF) (8.3% for T, 8.6% for W) and total knee range (10.9% for T, 13% for W) were reduced for both conditions (p<0.05). The knee range in early swing and the duration between toe-off and PKF were reduced only in the weighted-leg condition (p<0.05). CONCLUSIONS: Slow hip and knee flexion diminished all SKG parameters except timing of PKF. Tiptoe gait itself generated a borderline SKG pattern by reducing the PKF and total knee range. By considering that tiptoe gait and SKG commonly seen together, some of the SKG contributors can be treated by normalizing the ankle motion in the stance and increasing the hip-knee flexion velocity by rigorously planned muscle lengthening procedures and effective strengthening exercises.

Fine-wire electromyography response to neuromuscular electrical stimulation in the triceps surae.

Neuromuscular electrical stimulation (NMES) has previously been used to enhance venous return from the lower leg. By artificially activating lower leg muscles, venous blood may be effectively ejected from the muscle and adjacent veins. It could easily be assumed that combined NMES of the gastrocnemius and soleus would be the most effective single-channel application in this regard, as these muscles represent the largest muscular bulk in the lower leg. However, we have previously reported that soleus stimulation in isolation is substantially more effective. To understand why this is the case, we recorded fine-wire electromyography during NMES of the gastrocnemius and soleus muscles. We found that gastrocnemius and soleus stimulation are effective in eliciting selective stimulation of these muscles. However, combined stimulation of these muscles using a single set of electrodes was only capable in generating ∼ 50% of the response in each muscle, insufficient to generate their theoretical maximum venous return.

Effect of chemodenervation of the rectus femoris muscle in adults with a stiff knee gait due to spastic paresis: a systematic review with a meta-analysis in patients with stroke.

OBJECTIVE: To determine the effect of motor branch block (MBB) or neuromuscular block (NMB) of the rectus femoris on knee kinematics during swing, functional outcome, and energy cost in adults with spastic paresis presenting a stiff knee gait. DATA SOURCES: PubMed, Embase, CINAHL, and Cochrane Library were searched. Studies were collected up to February 26, 2013. Reference lists were additionally scrutinized. STUDY SELECTION: No restrictions were applied regarding study design. Patients were adults suffering from a central neurological disorder. Interventions had to include MBB or NMB. Outcome measures had to include knee kinematics during the swing phase. Study selection was independently performed by 2 reviewers. DATA EXTRACTION: Two reviewers independently assessed the methodological quality of included studies. Data on kinematics, functional outcome, and energy cost from patients with stroke were extracted from the total population and when possible pooled. DATA SYNTHESIS: A total of 9 articles describing 12 different studies were included. Knee kinematics (peak knee flexion or knee range) during swing improved significantly in all the included studies. The average increase in peak knee flexion varied from 1.9° to 15.4°. Data pooling of peak knee flexion in patients with stroke showed a significant improvement of 7.37° (P=.000) in NMB studies and of 9.35° (P=.002) in MBB studies. Data pooling of knee velocity at toe-off showed a significant improvement of 53.01°/s in NMB studies. In MBB studies, this improvement was not significant. Data pooling of knee range of motion, functional outcomes, and energy cost showed no significant difference. CONCLUSIONS: According to this review, chemodenervation of the rectus femoris shows a significant improvement in peak knee flexion during swing. The effect on functional outcomes and energy cost is still unclear.

Improving walking capacity by surgical correction of equinovarus foot deformity in adult patients with stroke or traumatic brain injury: a systematic review.

OBJECTIVE: Equinovarus foot deformity following stroke or traumatic brain injury compromises walking capacity, interfering with activities of daily living. In soft-tissue surgery the imbalanced muscles responsible for the deviant position of the ankle and foot are lengthened, released and/or transferred. However, knowledge about the effectiveness of surgical correction is limited. The aim of the present study was to carry out a systematic review of the literature to assess the effects of surgical correction of equinovarus foot deformity in patients with stroke or traumatic brain injury. METHODS: A systematic search of full-length articles in the English, German or Dutch languages published from 1965 to March 2011 was performed in PubMed, EMBASE, CINAHL, Cochrane and CIRRIE. The identified studies were analysed following the International Classification of Functioning, Disability and Health criteria. RESULTS: A total of 15 case series, case control and historically controlled studies (CEBM level 4) were identified, suggesting that surgical correction of equinovarus foot deformity is a safe procedure that is effective in terms of re-obtaining a balanced foot position, improving walking capacity and diminishing the need for orthotic use. DISCUSSION: Further validation of surgical correction of equinovarus foot deformity following stroke or traumatic brain injury is required, using higher level study designs with validated assessment tools. Comparing surgical techniques with other interventions is necessary to generate evidence upon which treatment algorithms could be based.

Gait analysis of the lower limb in patients with rheumatoid arthritis: a systematic review.

INTRODUCTION: In rheumatoid arthritis (RA), signs and symptoms of feet and ankle are common. To evaluate the dynamic function of feet and ankles, namely walking, a variety of gait studies have been published. In this systematic review, we provide a systematic overview of the available gait studies in RA, give a clinimetrical assignment, and review the general conclusions regarding gait in RA. METHODS: A systematic literature search within the databases PubMed, CINAHL, sportdiscus, Embase, and Scopus was described and performed and delivered 78 original gait studies that were included for further data extraction. RESULTS: The clinimetrical quality of the 78 included RA gait studies measured according a tailored QUADAS item list and proposed clinimetrical criteria by Terwee and coworkers are moderate. General conclusions regarding the walking abnormalities of RA patients point to a slower walk, longer double support time, and avoidance of extreme positions. Frequently found static features in RA are hallux valgus, pes planovalgus, and hind foot abnormalities. CONCLUSIONS: Gait studies in RA patients show moderate clinimetrical properties, but are a challenging way of expressing walking disability. Future gait research should focus on more uniformity in methodology. When this need is satisfied, more clinical applicable conclusions can be drawn.

Influence of gravity compensation on kinematics and muscle activation patterns during reach and retrieval in subjects with cervical spinal cord injury: an explorative study.

Many interventions in upper-limb rehabilitation after cervical spinal cord injury (CSCI) use arm support (gravity compensation); however, its specific effects on kinematics and muscle activation characteristics in subjects with a CSCI are largely unknown. We conducted a cross-sectional explorative study to study these effects. Nine subjects with a CSCI performed two goal-directed arm movements (maximal reach, reach and retrieval) with and without gravity compensation. Angles at elbow and shoulder joints and muscle activation were measured and compared. Seven subjects reduced elbow extension (range 1.8°-4.5°) during the maximal reaching task with gravity compensation. In the reach and retrieval task with gravity compensation, all subjects decreased elbow extension (range 0.1°-11.0°). Eight subjects executed movement closer to the body. Regarding muscle activation, gravity compensation did not influence timing; however, the amplitude of activation decreased, especially in antigravity muscles, namely mean change +/- standard deviation of descending part of trapezius (18.2% +/- 37.5%), anterior part of deltoid (37.7% +/- 16.7%), posterior part of deltoid (32.0% +/- 13.9%), and long head biceps (49.6% +/- 20.0%). Clinical implications for the use of gravity compensation in rehabilitation (during activities of daily living or exercise therapy) should be further investigated with a larger population.

The effect of FES of the tibial nerve on physiological activation of leg muscles during gait.

The effects of surface functional electrical stimulation (FES) of the tibial nerve of healthy subjects were evaluated. The FES was applied at three different times during gait: early, mid and late stances. The purpose of this work is to understand the effect of unilateral stimulation on the bilateral activation patterns of leg muscles, because FES is used in practice to improve gait, while associated neuromuscular change is not often measured. The experimental protocol presented here will be transferred to stroke subjects, who could benefit from improved push-off during gait. Results show that FES of the tibial nerve changes the offset timing of the tibialis anterior muscle on the stimulated side and the on- and offset timings of the tibialis anterior muscle of the leg contralateral to stimulation. Additionally, activity levels of the semitendinosus ipsilateral and tibialis anterior contralateral to the stimulated leg significantly decreased, with respect to the non-stimulated condition. For the semitendinosus, this was a difference of 6-7microV, with p<0.05. For the tibialis anterior, this was a difference of 7-15microV, with a significance of p=0.00, respectively. This information is important for future applications of stimulation as it means that stimulation not only affects the stimulated muscle but also the physiological motor control by the CNS.

Recovery of gait after stroke: what changes?

BACKGROUND: Little is known about whether changes in coordination patterns of muscle activation after stroke are related to functional recovery of walking. OBJECTIVE: The present study investigated the longitudinal relationship between changes in neuromuscular activation patterns of paretic muscles in hemiplegic gait and improvement in walking ability after stroke. METHODS: Thirteen patients diagnosed with a first unilateral ischemic stroke had their recovery of walking measured by the Rivermead Mobility Index, Functional Ambulation Categories, Barthel Index, Trunk Control Test, Motricity Index, and comfortable walking speed. Surface electromyography (SEMG) of the erector spinae, gluteus maximus, gluteus medius, rectus femoris, vastus lateralis, semitendinosus, gastrocnemius, and tibialis anterior muscles of both legs was used to quantify coordination patterns in comfortable walking mode. All clinical and electromyography-related measurements were taken at 3, 6, 9, 12, and 24 weeks poststroke. Timing parameters of the SEMG patterns were calculated, using an objective burst detection algorithm, and analyzed with the measures of functional recovery. RESULTS: All functional measures, except Trunk Control Test, showed statistically significant improvement over time, whereas SEMG patterns did not change significantly over time. CONCLUSION: The lack of significant change in SEMG patterns over time suggests that functional gait improvements may be more related to compensatory strategies in muscle activation of the unaffected leg and biomechanical changes than by restitution of muscle coordination patterns in the affected leg.

Therapeutic effect of an implantable peroneal nerve stimulator in subjects with chronic stroke and footdrop: a randomized controlled trial.

BACKGROUND AND PURPOSE: Footdrop, characterized by a person's inability to raise the foot at the ankle, is a common problem in patients with stroke. A randomized controlled trial was performed to determine the therapeutic effect of using a new implantable, 2-channel peroneal nerve stimulator for 6 months versus an ankle-foot orthosis (AFO). SUBJECTS: Twenty-nine patients with chronic stroke and footdrop participated in the study. The mean time from stroke was 7.3 years (SD=7.3), and all subjects were community ambulators. METHODS: The study used a randomized controlled trial design. The functional electrical stimulation (FES) group received the implantable stimulation system for correction of their footdrop. The control group continued using their conventional walking device (ie, AFO, orthopedic shoes, or no walking device). All subjects were measured at baseline and at weeks 4, 8, 12, and 26 in the gait laboratory. The therapeutic effect of FES on the maximum value of the root mean square (RMSmax) of the tibialis anterior (TA) muscle with both flexed and extended knees and walking speed were selected as the primary outcome measures. The RMSmax of the peroneus longus (PL), gastrocnemius (GS), and soleus (SL) muscles with both flexed and extended knees and muscle activity of the TA muscle of the affected leg during the swing phase of gait were selected as secondary outcome measures. RESULTS: A significantly higher RMSmax of the TA muscle with extended knee was found after using FES. No change in walking speed was found when the stimulator was not switched on. A significantly increased RMSmax of the GS muscle with both flexed and extended knees was found after using FES. DISCUSSION AND CONCLUSION: Functionally, no therapeutic effect of implantable peroneal nerve stimulation was found. However, the significantly increased voluntary muscle output of the TA and GS muscles after the use of FES suggests that there was a certain extent of plasticity in the subjects in this study.

Interaction of artificial and physiological activation of the gastrocnemius during gait.

Objectives. The purpose of this research was to understand the effects of surface functional electrical stimulation (FES) of the tibial nerve on the activation of the gastrocnemius medialis of the stimulated side. Methods. FES was carried out on six healthy subjects, initiated at three different times during gait: early, mid, and late stance. Each stimulation burst consisted of 15 pulses, applied for 300 msec, at 50 Hz stimulation frequency. Mixed model statistical analysis was carried out on the median onset and offset times of the gastrocnemius medialis and the root mean square of the interpulse interval responses. Results. Results indicate that the electromyography response to FES is dependent on the time of application. The most prominent effects found in the intervals between the stimulation pulses (interpulse intervals) were found when stimulation was applied early in the stance phase. This study revealed that the only statistically significant effect on burst timing was a delay in offset timing due to mid-timed stimulation. Conclusions. We conclude that additional activation may have been compensated, at least in part, by blocking of the physiological activation during the stimulation burst.

Flexor Hallucis Longus tendon rupture in RA-patients is associated with MTP 1 damage and pes planus.

BACKGROUND: To assess the prevalence of and relation between rupture or tenosynovitis of the Flexor Hallucis Longus (FHL) tendon and range of motion, deformities and joint damage of the forefoot in RA patients with foot complaints. METHODS: Thirty RA patients with painful feet were analysed, their feet were examined clinically for the presence of pes planus and range of motion (ROM), radiographs were scored looking for the presence of forefoot damage, and ultrasound examination was performed, examining the presence of tenosyovitis or rupture of the FHL at the level of the medial malleolus. The correlation between the presence or absence of the FHL and ROM, forefoot damage and pes planus was calculated. RESULTS: In 11/60(18%) of the feet, a rupture of the FHL was found. This was associated with a limited motion of the MTP1-joint, measured on the JAM (chi2 = 10.4, p = 0.034), a higher prevalence of pes planus (chi2 = 5.77, p = 0.016) and a higher prevalence of erosions proximal at the MTP-1 joint (chi2 = 12.3, p = 0.016), and joint space narrowing of the MTP1 joint (chi2 = 12.7, p = 0.013). CONCLUSION: Rupture of the flexor hallucis longus tendon in RA-patients is associated with limited range of hallux motion, more erosions and joint space narrowing of the MTP-1-joint, as well as with pes planus.

A randomized controlled trial of an implantable 2-channel peroneal nerve stimulator on walking speed and activity in poststroke hemiplegia.

OBJECTIVE: To determine the effect of a new implantable 2-channel peroneal nerve stimulator on walking speed and daily activities, in comparison with the usual treatment in chronic stroke survivors with a drop foot. DESIGN: Randomized controlled trial. SETTING: All subjects were measured 5 times in the gait laboratory. PARTICIPANTS: Twenty-nine stroke survivors with chronic hemiplegia with drop foot who fulfill the predefined inclusion and exclusion criteria were included in the study. INTERVENTION: The intervention group received an implantable 2-channel peroneal nerve stimulator for correction of their drop foot. The control group continued using their conventional walking device, consisting of an ankle-foot orthosis, orthopedic shoes, or no device. MAIN OUTCOME MEASURES: Walking speed, assessed both by a six-minute walk test (6MWT) and by using a 10-m walkway, was selected as primary outcome measure and activity monitoring data, consisting of percentage time spent on stepping, standing, and sitting/lying were selected as secondary outcome measure. RESULTS: Functional electric stimulation (FES) resulted in a 23% improvement of walking speed measured with the 6MWT, whereas the improvement in the control group was only 3% (P=.010). Comfortable walking speed measured on a 10-m walkway was also significantly improved in favor of FES (P=.038). The percentage time spent on stepping deteriorated with 3% in the intervention and 0.8% in control group, which was not statistically significant between both groups (P=.13). CONCLUSIONS: The present study shows a clinically relevant effect of the implantable 2-channel peroneal nerve stimulator on walking speed in the sample of stroke survivors included in our study.