Lower limb dysfunction associated with upper motor neuron syndrome can be complex due to interaction of muscle overactivity, weakness, impaired motor control, and contracture. Treatment should be goal-directed and address the patient's passive and active functional impairments in addition to their symptoms. Therefore, a comprehensive, multidisciplinary team approach tailored to each patient's unique needs and functional goals is warranted. This article reviews the evaluation and management of issues related to lower limb muscle overactivity and how this approach was applied to 3 challenging cases.

Spasticity is a term commonly used to describe a collection of muscle overactivity patterns associated with the upper motor neuron syndrome including actual spasticity, clonus, dystonia, co-contraction, associated reactions, and flexor or extensor spasms. Gait dysfunction in the upper motor neuron syndrome can be due to a combination of paresis, impaired coordination and balance, and muscle overactivity and contracture. Treatment options include physiotherapy, assistive devices, orthotic devices, oral and intrathecal medications, intramuscular chemodenervation, neurolysis, and/or neuro-orthopaedic surgical procedures. The objective evaluation of walking and its underlying muscle activation patterns can be performed by the simultaneous collection of joint kinematics, kinetics, and dynamic electromyography (EMG) data that serve as an extension of the physical examination to better discern primary gait deviations from compensatory gait deviations as well as underlying muscle overactivity from contracture. Despite the science behind instrumented three-dimensional gait analysis, its specific contribution to clinical and surgical decision-making is not well utilized because of its associated cost, the incorrect view by some insurance companies of gait analysis being a research technique, the dearth of qualified clinical gait and motion analysis laboratories accessible to adult patients, and limited access to orthopaedic surgeons who have experience in the treatment of neurological disorders for this patient population.

Objective: To review gait alterations and evaluate the effects of OnabotulinumtoxinA on spatiotemporal walking parameters of patients with hemiparetic gait.Design: Retrospective pre- and post-intervention analysis.Setting: Gait analysis laboratory in a tertiary level rehabilitation hospital.Participants: 42 patients with hemiparesis. 19 males and 23 females, age 18-78 years were included.Intervention: Spatiotemporal parameters collected before and within 4-10 weeks after OnabotA injection to the ankle muscles. Data was recorded at self-selected velocity on a 12 m instrumented walkway. The most common muscles injected were medial and lateral gastrocnemius, soleus and tibialis posterior. Average total OnabotulinumtoxinA dose was 320 +/- 107 units.Main outcome: Spatiotemporal parameters of walking assessed before (T-0) and within 4-10 weeks post injection (T-1). Paired t-test was used to compare pre- and post-intervention data. A sequential Holm-Bonferroni procedure was used to adjust for multiple comparisons and minimize the risk of type I error. Statistical significance was set at p < 0.05.Results: Statistically significant increases were seen for walking velocity (20%) (T-0 = 0.40 +/- 0.26 m/s and T-1 = 0.48 +/- 0.29 m/s; p = 0.006), and increased cadence (T-0 = 63.48 +/- 23.93 steps/min, and T-1 = 70.88 +/- 23.65 steps/min; p = 0.006) following OnabotulinumtoxinA injections.Conclusion: This study demonstrates that injection of OnabotulinumtoxinA 320 units to ankle muscles selected with the aid of dynamic electromyography can significantly increase gait velocity and enhance functional ambulation in adults with hemiparesis due to upper motor neuron syndrome. (C) 2015 Elsevier Ltd. All rights reserved.

PM&RVolume 6, Issue 8S2 p. S112-S112 Poster Presentation No. 85 Spatiotemporal Changes in Gait Performance Due to OnabotulinumtoxinA Injection to Lower Limb Muscles in Patients With Upper Motor Neuron Syndrome Alberto Esquenazi, Alberto EsquenaziSearch for more papers by this authorPatrizio Sale MD, Patrizio Sale MDSearch for more papers by this authorDaniel Moon, Daniel MoonSearch for more papers by this authorAmanda Wikoff BS, Amanda Wikoff BSSearch for more papers by this author Alberto Esquenazi, Alberto EsquenaziSearch for more papers by this authorPatrizio Sale MD, Patrizio Sale MDSearch for more papers by this authorDaniel Moon, Daniel MoonSearch for more papers by this authorAmanda Wikoff BS, Amanda Wikoff BSSearch for more papers by this author First published: 18 September 2014 https://doi.org/10.1016/j.pmrj.2014.08.218Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume6, Issue8S28th World Congress of the International Society of Physical & Rehabilitation Medicine (ISPRM)August 2014Pages S112-S112 RelatedInformation