Spasticity is a complex syndrome requiring extensive and complete treatment. Injections of botulinum toxin type A decrease muscle tone in spastic muscles of the hand and improve the use of the upper limb. However, rehabilitation and different non-invasive treatments should also be considered. Shock waves are defined as a sequence of single sonic pulses characterised by high peak pressure (100 MPa), fast pressure rise (< 10 ns) and short duration (10 μs). Twenty patients, with upper limb spasticity post stroke were enrolled in the study. The patients (12 men and eight women) had a mean age of 63 years (36–76 years). An electromagnetic coil lithotriptor (Modulith SLK® by Storz Medical AG) provided with in-line ultrasound, radiographic, and computerised aiming (Lithotrack® system) was used. Flexor muscles of the forearm were treated with 1500 shots, and 3200 shots were used for interosseous muscles of the hand (800 for each muscle). The energy applied was 0.030 mj/mm. The protocol consisted of one placebo treatment session in which no shock waves were applied, followed 1 week later by one active shock wave treatment session. The Ashworth Scale was used to study the muscle tone activity in patients. No changes in the Ashworth score were noted in hand and wrist flexion after placebo stimulation. After real treatment the hand muscles and finger flexion in particular showed a marked reduction in spasticity with a change in the Ashworth scale from 3 to 0. At 1, 4, and 12 weeks, a slight increase in muscle tone was observed for all subjects. Needle EMG was performed at 4 weeks. No denervation was observed. The main finding of this preliminary study is that a single active treatment of shock wave therapy in spastic muscles in a patient affected by stroke resulted in a significant reduction in muscle tone. In contrast, no effect was noted after placebo stimulation. Nitric oxide synthesis has been suggested to be one of the most important mechanisms to explain the effectiveness of shock waves in the treatment of different soft tissue diseases. Shock wave therapy appeared to be safe, non invasive and without complications. Our findings suggest that shock wave therapy may be useful in decreasing flexor tone and functional disability in patients with spasticity of the hand, with a long-lasting effect. This therapy could open a new field of research in the treatment of spasticity. Further studies with a larger group of patients are, therefore, necessary

The objective and dynamic documentation of the knee kinematics in ambulatory children with spastic cerebral palsy and the examination of possible causes of differences when compared to normals.

17 ambulatory patients with an average age of 10,5 years (6–17 years) with cerebral palsy, spastic diplegia where examined clinically including Duncan-Ely test. They were also examined with 3-D instrumented gait analysis. The Elite system with six cameras was used and the knee kinematics in the sagittal plane was recorded.

Almost all patients (16/17) had a positive Duncan-Ely test during clinical examination. The knee kinematics in the sagittal plane showed that in 20/34 knees the range of motion was decreased compared to normal values. In 30/34 knees there was a delayed maximum knee flexion in swing phase and in 16/34 knees the amplitude of the maximum knee flexion was decreased compared to normals. Patients with severe crouch or mild rectus spasticity had almost normal knee flexion.

Foot clearance in swing phase is one of the basic prerequisites of normal gait. Patients with spastic cerebral palsy who are able to walk have an impaired foot clearance because of the pathological action of the rectus femoris.

In our study the majority of the patients with clinically confirmed rectus spasticity had decreased timing and amplitude of max. knee flexion in swing. In patients with severe co-contraction of the knee flexors and extensors max. knee flexion within normal range. Therefore it should not be considered as the only evaluation parameter in rectus femoris spasticity.

Aim: To compare the effects of botulinum toxin injection with and without electromyographic (EMG) assistance for the treatment of spastic muscles.

Methods: In a prospective comparative study, botulinum toxin was injected intramuscularly into 17 patients with spasticity due to CNS damage (CP, SCI, head injury, stroke). All patients were evaluated using the modified Ashworth scale and the score was 2–4. In 9/17 patients, group A (53%), the injection was given with EMG assistance, while in 8/17 patients, group B (47%), without, always from the same injectionist. The follow-up period ranged from 4 to 24 months.

Results: Average spasticity decreased in all injected muscles and new scores were 1–2 grades less according the modified Ashworth scale. No complications or side effects were noted. The average reduction of spasticity reached 1.66 (SD 0.5) in group A and 1.25 (SD 0.46) in group B. The average reduction of spasticity was statistically more pronounced in group A (p< 0.001).

Conclusions: The effectiveness of botulinum toxin injection for the treatment of muscle spasticity in patients with CNS damage increases when used with EMG assistance and this is attributed to the appropriateness of points for injection.

Purpose of the study: Intramuscular injection of the botulinum toxin into the psoas can be proposed for permanent hip flexion due to spastic disorders. Several approaches have been described: retrograde subinguinal, anterolateral suprailiac, and posterior. Ultrasound or computed tomography can be used to guide needle position. These approaches are however limited to access to the L4 region, i.e. far from the motor points and with the risk of injury to the ureter. The purpose of this work was to determine the innervations of the psoas muscle that would be best adapted to this type of injection and thus to describe the most effective and reliable approach.

Material and methods: This anatomy study included 20 dissections to: describe vertebral insertions of the psoas major and the psoas minor and to measure their distance from the iliac crest; define the region where the ureter crosses in front of the psoas.

Results: More than 80% of the psoas muscles presented a proximal insertion on the transverse process of T12 and the body of L1; the mean length of the psoas in the adult is 27 cm above the inguinal ligament; the nerve roots collateral to the lumbar plexus are: 33% L2, 25% L3, 19% L1, 9% L4, 3% L5 and 1% T12, the remainder arising directly from the femoral nerve; the L2-L3 region is situated 4.6 cm on average above the iliac crest.

Discussion: The region facing the L2-L3 space enables access to more than 50% of the psoas nerve branches. Injection via a posterior approach situated in adults 4.6 cm above the iliac crest and identified fluoroscopically is the most reliable access. This will avoid injury to the ureter which lies lower.

Conclusion: This anatomy study described a new more effective less dangerous approach for botulinum toxin injections into the psoas muscle.

To compare the effects of botulinum toxin injection with and without electromyographic (EMG) assistance for the treatment of spastic muscles.

In a prospective comparative study, botulinum toxin was injected intramuscularly into 17 patients with spasticity due to CNS damage (CP, SCI, head injury, stroke). All patients were evaluated using the modified Ashworth scale and the score was 2–4. In 9/17 patients, group A (53%), the injection was given with EMG assistance, while in 8/17 patients, group B (47%), without, always from the same injectionist. The follow-up period ranged from 4 to 24 months.

Average spasticity decreased in all injected muscles and new scores were 1–2 grades less according the modified Ashworth scale. No complications or side effects were noted. The average reduction of spasticity reached 1.66 (SD 0.5) in group A and 1.25 (SD 0.46) in group B. The average reduction of spasticity was statistically more pronounced in group A (p< 0.001).

The effectiveness of botulinum toxin injection for the treatment of muscle spasticity in patients with CNS damage increases when used with EMG assistance and this is attributed to the appropriateness of points for injection.

Myoneural blockade is a well-established means of reducing tone in spastic muscles, thereby delaying or avoiding the need for operative intervention. The recent interest in botulinum A toxin has tended to obscure the fact that other agents such as alcohol have been used for many years to achieve a similar effect.

Eighty-two children between the ages of 2 and 16 years with cerebral palsy underwent myoneural blocks using 45% ethanol for dynamic contracture of the hamstrings and/or gastrocnemius. The injections were performed under a light general anaesthetic, using a nerve stimulator to localise the myoneural junction. A total of 153 muscle groups were injected.

Hamstring tightness improved as a result of ethanol injection, the popliteal angle reducing from a mean of 73° (range 40° – 90°) to 43° (range 10° – 70°). Gastrocnemius tightness also improved, the ankle dorsiflexion with knee extended improving from a mean of −7° to +3°.

The maximal effect was achieved in a mean of 12 weeks and was maintained for a further 12 weeks before starting to deteriorate. The time from injection to the next intervention ranged from 13 weeks to over 2 years. There were no complications or adverse effects.

The effect of any one therapy in cerebral palsy is difficult to establish, given that there are often several different modalities of treatment operating concurrently. However, the results from this series indicate that myoneural blockade with ethanol is a useful and safe adjunct to other therapies in the child with lower limb spasticity.

Objective: The aim of this study was to delineate parents’ and professional caretakers’ satisfaction after spinal fusion in children with spasticity, and to determine differences in their perceptions.

Study Design-Methods: A questionnaire assessing patients’ functional improvement after spinal arthrodesis for correcting scoliosis was addressed to 190 parents. An expanded questionnaire was also addressed to 122 educators and therapists working exclusively in the care of children with cerebral palsy.

Results: The vast majority of parents and caregivers reported a very positive impact of the surgery on patients’ overall function, quality of life, and ease of care. Caretakers did not recognize effects of the scoliotic deformity on patients’ head control, hand use, and feeding ability. Parents had more appreciation of the benefits in the children’s appearance, while educators and therapists acknowledged more improvement in gross and oral motor function. Most parents (95.8%) and caretakers (84.3%) would recommend spinal surgery, considering that the benefits from scoliosis correction clearly outweigh the increased risk of surgical complications in this group of severely involved patients.

Conclusions: Correction of spinal deformity in children with cerebral palsy is associated with a very high parents’ and caretakers’ satisfaction rate, with both groups reporting excellent improvement in appearance, comfort, ease of care, and some functional gains. The answers received during the survey demonstrated clearly that the vast majority of parents and caretakers consider the surgical outcome of the spinal fusion very beneficial for the patients’ overall function and level of care. There were documented differences in the perceived positive impact of spine surgery in children with cerebral palsy between the two groups. Parents stated more consistent benefits from correcting scoliosis in the patients’ appearance, whereas therapists and educators delineated the improvement in the gross and oral motor function. However, both groups considered that the benefits from correcting scoliotic deformity undoubtedly offset the potential risks from surgery, and would have no hesitation in recommending this procedure for children with cerebral palsy who develop significant scoliosis interfering with their level of function and their overall quality of life.

Spasticity used to be considered a contraindication for total hip replacement (THR) procedures. Due to the development of implants as well as surgical skills, THR became an option for the treatment of painful dislocation of the hip joint in patients with spastic plegia. The aim of this study was an evaluation of mid-term results of THR in spastic CP adolescent patients with painful hips with hip joint subluxation or dislocation. In 2014–2022, 18 pts (19 hips) with CP aged 16 to 20 years underwent THR in our department. The mean follow-up was 4 years (range: 1 – 9 years). Results were evaluated using the Gross Motor Function Scale, VAS scale in accordance with the Ashworth scale, types of implants used (dual mobility cup and not dual mobility cup), and radiological assessment (Crowe scale). Complications have been thoroughly analyzed. In 10 pts there has been an improvement in the GMFSC scale average from 1 to 2 points observed after the surgery. All pts have improved in the VAS scale average of 8 points (from 10 to 7). According to the Crowe scale repositioning of preoperative dislocation to primary acetabulum was achieved in all cases. Complications occurred in 4 cases: dislocations of 2 THR with dual mobility cup and 2 THR with non-dual mobility cup requiring revision surgery with good final result. No statistical significance was noted according to the type of cup (Mann-Whitney U Test). The most important risk factor for complications is severe spasticity. We believe, that CP pts with painful hips should be treated using THR. We didn't observe any significant differences between the types of implants. These findings may serve as a basis for the prediction of outcomes of THR treatment in this specific group of pts. Level of evidence: Case-control or retrospective comparative study-Level III

Intramuscular injections of botulinum neuro toxin A (BoNT-A) have been a cornerstone in the treatment of spasticity for the last two decades. In India, the treatment is now offered to children with spastic cerebral palsy (CP). However, despite its use, the evidence for its functional effects is limited and inconclusive. The objective of this study is to determine whether BoNT-A makes walking easier in children with CP. We hypothesize that injections with BoNT-A will not reduce energy cost during walking, improve walking capacity, reduce pain or improve self-perceived performance and satisfaction. Between the period of 2012 and 2014, 35 children with spastic CP less than 10 years of age were included. The patients were classified according to their gross motor function classification system (GMFCS) and their pre-and post-injection gait analysis were performed. Spasticity assessed by Modified Ashworth Score [MAS]. Trained parents were utilised for the post injection physiotherapy as these children will be more complaint to them. GMFCS and MAS scoring done every three months till one year follow up. Therapeutically, effect was found in 90% of the patients, an average duration of the medical effect was 6–12 months. The improvement in GMFC functional score in serial measurements was seen in these patients though some deterioration in spasticity scores at one year. Despite mild recurrence in spasticity, majority maintained independent (42%) or assisted ambulation (48%) at one year. No major side effects occurred. Botox may prove a useful adjuvant in conservative management of the spasticity of cerebral palsy. Apart from being very cost effective in these financially deprived populations, successful management with these injections may allow delay of surgical intervention until the child is older and at less risk of possible complications, including the need for repeated surgical procedures

Purpose of the study: Spasticity of the rectus femoris (RF) in cerebral palsy patients is considered to be the main cause of stiff knee gait. The kinematics of this muscle, variations in length and speed of lengthening, are altered. Research is however lacking on changes in this parameter after surgery. Our objective was to study its effect on the quality of gait and on the kinematics of the RF in order to identify kinetic behaviour with diagnostic value. Material and methods: Twenty-six transfers were performed during multiple level interventions. A uniform technique was applied: wide separation of the RF from the vastus muscles and supra-patellar tenotomy, suture of the RF tendon to the gracilis tendon tunnelled through the medial intermuscular partition. Intramuscular lengthening of the hamstrings (n=20) was associated with patella lowering procedures (n=4). The Gait-Deviation-Index (GDI) and the Goldberg score were determined pre- and postoperatively to quantify gait quality and search for stiff knee. A musculoskeletal model (virtual RF) was developed to simulate the trajectory of the RF during gait. Results: The quality of gait improved (+18±12 GDI) with a negative interaction between the preoperative GDI and its improvement. For the Goldberg score, surgery yielded 88% improvement. Surgery had a significant effect on normalising the timing of RF lengthening and the maximal lengthening speed. Improvement in stiff knee was correlated with a normalisation of the timing of maximal length. Discussion: Improvement in gait quality was greater when the preoperative quality is low; there is a risk of no improvement if the GDI is > 75. Normalisation of the timing of the maximal length of the RF is correlated with improvement in knee oscillation. Early timing signals a postoperative improvement in stiff knee. Early peak in the speed of lengthening of the RF can be explained by early triggering of spasticity during weight bearing which would limit the lengthening of the RF. Conclusion: Global improvement of gait quality and stiff knee has been demonstrated. Certain muscular kinematic parameters are normalised, demonstrating the effect of transfer during oscillation but also during weight-bearing. Early peak in RF lengthening is a prognostic factor of successful surgery

Purpose: We report a retrospective consecutive series of 57 hemiplegic patients (32 men and 25 women) who underwent surgery between 1995 and 2000 for spastic talipes equinovarus associating fascicular neurotomy of the tibial nerve and tendon release in order to recover sole to floor walking capacity. Material and methods: Mean patient age was 47 years (16–75). The hemiplegia resulted from stroke (n=41), trauma (n=8), and other causes (n=8). All patients had spastic talipes equinovarus and 46 required a walking aid. Triceps force and spasticity were scored 2.1 (MRC) and 3.66 (Ashworth) respectively. Pedial hypoaesthesia was present in 23 patients. The mean functional ambulation classification (FAC) score was 3.3, with severe disability (FAC 1 or 2) in 13 patients. Surgery was performed three years (average) after the causal event. After identification by electrical stimulation, we performed microsurgical section of 4/5 nerve fibres of the terminal branches of the tibial nerve in 55 patients. After physical exploration of musculotendon retraction (triceps and toes flexors) and dorsiflesion palsy, we released tendons as needed. The Achilles tendon was lengthened percutaneously in 13 patients, Bardot tenodesis or transfer of the anterior hemi-tibial anterior tendon was performed in 29, and tenotomy of the toe flexors in 12. Results: Mean follow-up was three years (1–6). Triceps force and foot sensitivity were not modified by the surgery. Spasticity was scored 1.08 and 1.19 (Ashworth) postoperatively and at last follow-up respectively. The FAC walking score was 4.13 and 4.15 postoperatively and at last follow-up respectively. The walking aid was no longer necessary or was improved in 52 patients. Tibiotalal arthrodesis was necessary for recurrent spasticity in three patients. Discussion: The preoperative assessment of foot deformity and gait is an essential element. Correct preoperative assessment enables microsurgery for fascicular neurotomy of the posterior tibial nerve and tendon lengthening or tenodesis during the same operation. These procedures are indicated for severe deformity and should be used as the first intention treatment before arthrodesis which involves greater morbidity