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.
Dynamic Spasticity in TA, adductors of hip, pectorals,
pronators (Mm ext.hallucis long & tib ant and/or Peronei ?) , rectus
- Are you familiar with R1 (1st catch) and R2 (full PROM) measurements
as well as MAS ratings ? Would be interesting to know these for all of
the affected ms actually
Tightness currently seen in pronators, pectoral.
Hams(mild) (Earlier there was tightness in TA, hip adductor, rectus femoris,
mild amount in hip flexors, hams
- Tightness or shortening (tightness in my opinion is a mix of both
increased tone and lack of passive extensibility) of pectorals ??? Now
Duncan-Ely negative (R-fem)?
Deformities-rocker bottom, left external tibial torsion,
Increased progression angle Lt see below, how did you examine the ext tib.
Torsion Lt ? LLD of I cm in?
- Might have a short Rt leg, hard to tell just from the video ==>
Subluxation of left hip (??????)
- Radiological confirmation ???? Tape-measures are basically guess-work
MMT-all muscles are above grade 3 except hip abductors,
hip extensors, which is around grade 2
- If you are rating with the Oxford scale then 3 means act. mvmt only
against gravity, no extra load (e.g. body weight) and 2 inability to lift
distal part of joint against gravity… you seem to use a totally different
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
She has strong extensor synergy when she walks,
- Would not really say so
Walk with stiff leg for
- For ??? Well, again I do not really see a pronounced rectus spasticity
interfering here… but actually hard to say without a lateral view
For clearance of lower extremity she extends her
back and clears it (due to rectus femoris Spasticity associated with extension
- Again hard to say without a lateral view but not obvious on the views
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
increase of challenges. Have you tried quadripods or fore-arm crutches
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
- Scissoring or even narrow base not observed, however, hoe DOES she
walk without the AFO’s (and the again extremely bulky shoes ?) With such
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
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
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
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 ?
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
2-8-2, Blk. 2, Bukit OUG Condo, Jalan 3/155, OUG, 58200 Kuala Lumpur,
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
otherwise.now 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.
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