Case of the Week 25/2/05: What people said...

Couldn’t resist after all to download the huge video files, view and now comment on them. Gait She has been receiving therapy past 1 and half yr and she has started walking with walker within 6 months. For the past one yr her motor status is static
as she is today .

- Such a plateau after initial upright mobility is rather the rule than the exception I’d say. Progress comes with hours of daily practice and carefully graded
increase of challenges. Have you tried quadripods or fore-arm crutches yet?

We are unable to wean her off walker
- Again: the monster of a walker in the video is hers ? How many hours of daily up-time does she have ? Does she have a standing frame ?
 due to the dynamic adductor spasticity that comes in her stepping with AFO

- Scissoring or even narrow base not observed, however, hoe DOES she walk without the AFO’s (and the again extremely bulky shoes ?) With such an
appliance on my legs (in proportion) I would have a pretty abnormal gait as well, as hard I’d try…

- The lateral rotation of the shanks in swing is probably just (an actually very functional) mechanism to cope with this kind of foot-wear which surely makes
toe-clearance pretty difficult.

- Isn’t there a way to reduce shoe size or even just glue rubber-soles on and to increase fore-foot flexibility of the AFO ?
and of course TA spasticity also without AFO.

Our concerns are

     Whether botox given to her adductor,
     - To reduce that bit of lack of abduction in swing on the Lt which is probably just due to gluteal weakness ???
     rectus femoris can help her along with stabilization of the rocker bottom
     - We have so far never injected the rectus femoris in order not to interfere with antigravity function of the quads, also consider spill-over effect /
     diffusion. Reduction in tone initially might first lead to crouch even inability to walk and then to compensatory increase in spasticity

     Whether muscle release is a better option.
     - At this age ??? If you want to have that on your conscience…

     Whether there is instability at the hip
     - That is indeed somewhat obvious I’d say

In short:

I’d just play it cool, reassure the mother she’s doing well, try to minimize the footwear in favor of a lighter and more functional version of an AFO &
footwear allowing some degree of to flexibility (if no toe-clawing, then might try a toe-raise sparing the hallux) and get her an appropriate walker. That with maximizing uptime, maybe with a standing frame, encouraging spontaneous use of the walker & cruising as well as balance in standing. Then stairs fwd and sideways for hip strengthening. Maybe progress to quad-canes / fore-arm crutches (Rotan?).

I would not mess around with either BTX-A or surgery at this stage as I see no severe enough functional impairment to warrant any such invasive

On the contrary, she seems to be doing very well.

I have attached our “Objective measurement” form for your perusal.

Hope not to be left without any feedback from your side again,

Thanks for sharing,



PS: Instead of 2 anterior and posterior view one each plus a lateral view would have been a lot more informative and probably faster to download…

PPS: Prof. Kirtley - any comments on the above ? Would you inject or operate on her ?

Henner Wenkhausen
Physiotherapist, Consultant for Neuro-pediatric Rehab @ HUKM

Phone-lines: ++60 for Malaysia, mobile: 012 9029722,
Office: 03 91733333, ext: 8192, FAX: 9173 8945
New home phone: 0060 +3 7781184
Home addr:
2-8-2, Blk. 2, Bukit OUG Condo, Jalan 3/155, OUG, 58200 Kuala Lumpur, Malaysia

Dear Mr. Amitesh and Mrs. Jovial Lewis,
                 I guess we need to cut a long story short here a bit.
                 Your main reply was this:
How useful is serial casting in a spastic muscle with no passive limitation .we try a technique of muscle lenthening called myofacial release.we do get the full rom over a period of time if there is no contracture.we have managed to maintain a full prom in her, but it reverses back due to spastcity.spasticity does come down over a perod of time with active intervention form our side with regular treatment at home also.sometimes spacticity is very dominant in certain muslces which prevent us form getiing an indepedant gait without and orthosis.she may improve beyond this if done the same  for few yrs or we have to intervene we don’t know whch of the other intervention can help her as our experience with surgery managed cases is very limited.we would not want to make a mistake .but b-tox may help to reduce spascticity .we have realised serial casting may help in early cases of tighteness with spasticity ,but in a muscle with pure spasticity???? We had tried serial castng with similar type of cases but it was a failure.

                 The main question is how to remedy her supposed gastroc/soleus spasticity and/or shortening (dynamic/ static contractures).
                 Till now it is not clear from your mixed information which one applies. From the measurements supplied as quoted below it is pretty clearly a
                 shortening / statis contracture and not primarily spasticity.
Rt/Lt >
T angle
T angle
10 DF

15 DF


4/4 (3?)
10 DF
25 DF
8 DF

30 DF


                 Compared to a normal R2 of 45-50 degrees of Dorsi-flexion (DF) there is a significant loss of PROM in DF.
                 The Tardieu angle is relatively small, suggesting a relatively small contribution of spasticity to the restrictions of DF.
                 MAS gastrocnemius can't be 4 as otherwise there would be no ROM (RIGID in flex/ext by definition for MAS 4), but probably a 3.
                 As there is still may be confusion and uncertainty here about what means what let me explain in brief:
                 R1: The angle at which the joint is when the corresponding muscle is subjected to a quick ! stretch. This needs to be done a couple of times
                 with the child being quiet and not struggling with the therapist or otherwise excited, etc. to get a usefull value. It is important NOT to push any
                 further than EXACTLY where you do get this point of initial resistance !
                 R2: The classic PROM assessed with sustained slow stretch.
                 Tardieu angle = R2 - R1. This derived value indicates the how much spasticity there is REALLY or whether it is not "just" a static contracture.
                 I our clinical practice the cut-off point is roughly about 20-30 degrees; less than that > Static contracture, more than that > Dynamic
                 Important note: Goniometry is not very accurate by default in this population. A variance of 5 degrees is NORMAL (inter- & intra tester).
                 We try to increase accuracy by orientating the prox. lever of the gonio with the frontline of the tibia (not an imaginary longitudinal midline)
                 because it is relatively easy to align the gonio with it.
                 The distal one from lateral with the plantar edge OF THE REARFOOT ONLY (till proximal head of metatarsal V) to avoid erronously
                 interpreting a mid-footbreak (rockerbottom) as DF. Care also needs to be taken to align the rearfoot in neutral as deviations in pronation/
                 eversion are common and lead to false postive measurements.
                 I hope this helps to verify your measurements.
                 Without a change in these basic values as provided above all of my previous comments & suggestions apply.
                 Thanks & Regards,
                 PS: Regarding effectives (not to mention cost-effectiveness) of BTX-A and serial casting you might want to have a look at the following

                 Efficacy of botulinum toxin type A, serial casting, and combined treatment: A retrospective analysis.

                 A Glanzman, H Kim, T Beck, K Swaminathan

                 BTX-A is less effective than serial casting for increasing the range of motion at the ankle, and does not improve
                 results versus casting alone, according to this retrospective study. Of 86 legs treated for spasticity in 55 patients,
                 37 received BTX-A, 17 received serial casting, and 32 received a combination. Average dose of BTX-A was 2.5 U
                 Botox/kg. An average of 2.8 casts were applied for 1 week each. Mean improvement in range of motion was 5.1
                 degrees for BTX-A alone, versus 14.9 degrees for casting alone (p=0.0001), and 17.5 degrees for combination
                 treatment (p=0.0002). The difference between casting alone and combination treatment was not significant.
                 Of course there are (lots more) other studies suggesting otherwise, of course...

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