Motor branch block of the rectus femoris: its effectiveness in stiff-legged gait in spastic paresis

OBJECTIVE: To verify the efficacy of motor branch block of the rectus femoris for stiff-legged gait in spastic patients. DESIGN: Before-after treatment trial. SETTING: University hospital physical medicine and rehabilitation department outpatient clinic. PATIENTS: Thirty-one adult spastic patients with stiff-legged gait. INTERVENTION: Motor branch block of the rectus femoris with 2% lidocaine and 5% phenol. OUTCOME MEASURES: Subjective assessment of gait performance by patients themselves and objective assessment of gait speed and sagittal knee kinematics. RESULTS: Seventy-four percent (23/31) of patients felt an improvement (improved knee bending, disappeared toe dragging) after nerve block with lidocaine. Sixteen of 17 patients with an abnormal swing phase activity of the rectus femoris without that of the vastus medialis or lateralis and 20 of 23 patients with a sufficient hip flexor strength expressed an improvement subjectively. Gait analysis showed increased maximal knee flexion at swing phase and increased slope of knee flexion curve at toe off (p < .05). Phenol block was performed in 19 of 23 patients who had had a subjective improvement in their gait performance after nerve block with lidocaine. Gait speed, maximal knee flexion angle at swing phase, and slope of knee flexion curve at toe off increased significantly after phenol block (p < .05). CONCLUSION: Motor branch block of the rectus femoris can be an effective treatment in stiff-legged gait. Its effect is varied with hip flexor strength and dynamic electromyographic findings of quadriceps.     

Rectus sheath hematoma.

Two patients who developed rectus sheath hematoma while on anticoagulants are presented. Ultrasound was the definitive method of establishing the diagnosis.     

Unstable gait due to spasticity of the rectus femoris: Gait analysis and motor nerve block

We present the case of a 54 year-old man presenting with a right Brown-Séquard plus syndrome (BSPS) after a traumatic cervical spinal cord injury. After being operated on with selective tibial neurotomy and triceps surae lengthening because of a right spastic equinus foot, he developed a gait disorder at high speed. The patient complained about an instability of the right knee. Observational gait analysis exhibited an oscillating, flexion/extension motion of the right knee during stance, which was confirmed by gait analysis. Dynamic electromyographic recordings exhibited a clonus of the right rectus femoris (RF) during stance. The spastic activity of the RF and the abnormal knee motion totally reversed after a motor nerve block of the RF, as well as after botulinum toxin type A injection into the RF. We emphasize that complex, spastic gait disorders can benefit from a comprehensive assessment including gait analysis and nerve blocks.     

膝骨关节炎患者股四头肌功能水平及髋关节步态运动学特征分析

目的:观察中老年膝骨关节炎(KOA)患者股四头肌功能水平及步行过程中髋关节的运动学特征。方法:选取18例KOA患者为KOA组,8例无KOA者为对照组,2组的年龄、身高、体重和身体质量指数(BMI值)相匹配。2组受试者均进行等速肌力测试、无线表面肌电测试及步态测试,测试及比较2组股四头肌峰力矩(PT值)、股内侧肌(VM)、股外侧肌(VL)和股直肌(RF)的积分肌电值(iEMG)、均方根值(RMS)、平均功率频率(MPF)及峰值髋内收、外展角度等和步行中髋关节的运动学特征,将股四头肌肌力与髋关节运动学特征进行相关性分析。结果:KOA组股四头肌等长和等速运动时PT值较对照组显著下降(P<0.01),VL在60°/s等速收缩时表面肌电信号RMS值显著高于对照组(P<0.05),RF在180°/s等速收缩时表面肌电信号RMS值显著高于对照组(P<0.01),步行时峰值髋关节内收及外展角度显著低于对照组(P<0.05),股四头肌肌力与髋关节运动学特征无相关。结论:KOA组较对照组股四头肌肌力显著降低,活动时神经支配效率显著下降,且步行过程中峰值髋内收、外展角度显著减少,股四...     

Influence of body weight support on normal human gait: development of a gait retraining strategy

The recovery of locomotion, following interactive training with graded weight support, in the adult spinal cat has led to the proposal that removal of body weight may be a therapeutic tool in human gait retraining. There would be benefits, however, in knowing normal responses of humans to partial weight bearing before applying this strategy to patients. In this study, 10 nondisabled male subjects walked on a treadmill while 0%, 30%, 50%, and 70% of their body weight was supported by a modified climbing harness. To dissociate the changes attributable to walking speed from those attributable to body weight, each subject walked at the specified body-weight-support (BWS) levels and at full weight bearing (FWB) at the same speed. Simultaneously, electromyographic data from the right leg muscles, footswitch signals, and video recording of joint motion were collected. The FWB and BWS gaits appeared similar, except at the highest level of BWS studied (ie, 70% of BWS). Significant differences among other BWS and FWB trials at comparable speeds included decreases in percentage of stance, percentage of total double-limb support time, and maximum hip and knee flexor swing angle. Other adaptations to BWS were a reduction in the mean burst amplitude of the muscles that are active during stance and an increase in the mean burst amplitude of the tibialis anterior muscle. The possible implications of this new gait retraining strategy for patients with neurological impairment are discussed. [Finch L, Barbeau H, Arsenault B. Influence of body weight support on normal human gait: development of a gait retraining strategy.     

步态康复机器人评价正常老年人步态的性别差异

背景：在国内采用步态康复机器人对正常老年人的步态进行评定的研究较少,且无明确结论。目的：采用步态康复机器人对正常老年人的肌力、关节活动度、痉挛状态等指标进行评定,了解老年人步态的特点。方法：选取健康老年人30名,男15名,女15名,年龄（62.40±1.58）岁。利用步态康复机器人的评估工具L-FORCE,L-STIFF和L-ROM测试受试者的肌力、痉挛状态和关节活动度。结果与结论：老年人L-FORCE测试结果显示,双侧髋屈肌力和双侧膝屈伸肌力在健康老年人不同性别间差异有显著性意义（P〈0.05）。老年人L-STIFF测试结果显示,60（°）/s左髋伸、120（°）/s左髋屈伸痉挛状态在不同性别间差异有显著性意义（P〈0.05）。老年人L-ROM测试结果显示,健康老年人行走时关节活动度不存在性别差异（P〉0.05）。提示老年男性下肢肌力大于女性;老年男性L-STIFF测试结果高于老年女性,提示治疗师在对患者进行L-STIFF评价时要考虑性别因素;健康老年人关节活动度不存在性别差异。     

Effect of botulinum toxin injection in the rectus femoris on stiff-knee gait in people with stroke: a prospective observational study

Stoquart GG, Detrembleur C, Palumbo S, Deltombe T, Lejeune TM. Effect of botulinum toxin injection in the rectus femoris on stiff-knee gait in people with stroke: a prospective observational study.

Objective

To study the effect of botulinum toxin type A (BTX-A) injection in the rectus femoris on the decreased knee flexion during the swing phase of gait (stiff-knee gait) in people with stroke.

Design

Intervention study (before-after trial) with an observational design.

Setting

Outpatient rehabilitation clinic and gait laboratory.

Participants

Nineteen chronic hemiparetic adults presenting with stiff-knee gait.

Intervention

Injection of 200U of BTX-A (Botox) into the rectus femoris.

Main Outcome Measures

Before and 2 months after BTX-A rectus femoris injection: Stroke Impairment Assessment Set (SIAS), Duncan-Ely test, and an instrumented gait analysis.

Results

Median SIAS score improved from 53 (range, 36−65) to 57 (range, 42−70) (signed-rank test, P=.005) and the Duncan-Ely score from 3 (range, 1−3) to 1 (range, 0−3) (P<.001). In gait analysis, mean (± standard deviation) maximum knee flexion improved from 26°±13° to 31°±14° during the swing phase (paired t test, P<.001), knee flexion speed at toe-off improved from 82°±63° to 112°±75°/s (P=.009), and knee negative joint power (eccentric muscular contraction) improved from −.27±.23 to −.37±.26W/kg (P<.001). The 4 patients who almost did not flex the knee (<10°) before the BTX-A rectus femoris injection did not improve after the injection. The other 14 patients who flexed the knee more than 10° before the BTX-A rectus femoris injection decreased the walking energy cost from 5.4±1.6 to 4.6±1.3J·kg⁻¹·m⁻¹ (P=.006).

Conclusions

BTX-A rectus femoris injection may be beneficial in patients with a stiff-knee gait after stroke, particularly in patients with some knee flexion (>10°).     

Quadriceps femoris muscle angle: normal values and relationships with gender and selected skeletal measures

The quadriceps femoris angle ("Q angle") has been implicated as a source of several knee disorders, but values for normal knees have not been adequately documented in the literature. This study was designed to provide clinicians with normal values and information regarding the relationships between Q angle, gender, and selected anatomical measurements. The Q angles of 100 individuals (50 men, 50 women), who had no history of knee disorders, were measured goniometrically. The hip widths and femur lengths of all subjects were measured with calipers. The mean Q angle for women was 15.8 +/- 4.5 degrees and for men was 11.2 +/- 3.0 degrees. Using a point biserial correlation, we found a relationship between gender and Q angle (r = -.517) that remained significant (p less than .01) when the effects of femur length and hip width were controlled. The relationships identified between Q angle and the anatomical measurements were no longer significant when the effect of gender was eliminated. The results substantiate the belief that women have larger Q angles than men, but they fail to provide clinicians with an anatomical explanation or new predictor of Q angle.     

Effect of botulinum toxin injection on length and lengthening velocity of rectus femoris during gait in hemiparetic patients

Background

In hemiparetic patients, rectus femoris spasticity is one of the main causes of reduced knee flexion in swing phase, known as stiff knee gait. Botulinum toxin is often used to reduce rectus femoris spasticity and to increase knee flexion during swing phase. However, the mechanisms behind these improvements remain poorly understood. The aim of this study was (1) to quantify maximal rectus femoris length and lengthening velocity during gait in ten adult hemiparetic subjects with rectus femoris spasticity and stiff knee gait and to compare these parameters with those of ten healthy subjects and (2) to study the effect of botulinum toxin injection in the rectus femoris muscle on the same parameters.

Methods

10 patients with stiff knee gait and rectus femoris spasticity underwent 3D gait analysis before and one month after botulinum toxin injection of the rectus femoris (200 U Botox®, Allergan Inc., Markham, Ontario, CANADA). Rectus femoris length and lengthening velocity were quantified using a musculoskeletal model (SIMM®, MusculoGraphics, Inc., Santa Rosa, California, USA).

Findings

Maximal length and lengthening velocity of the rectus femoris were significantly reduced on the paretic side. There was a significant increase in muscle length as well as lengthening velocity during gait following botulinum toxin injection.

Interpretation

This study showed that botulinum toxin injection in the spastic rectus femoris of hemiparetic patients improves muscle kinematics during gait. However maximal rectus femoris length did not reach normal values following injection, suggesting that other mechanisms are likely involved.     

Restoring normal gait after limb salvage procedures in malignant bone tumours of the knee.

Eleven patients exhibiting decreased strength of knee extension following wide resection and prosthetic reconstruction for malignant bone tumors of the knee performed gait exercises with compensatory muscle training. Two patients whose knee extension strength was assessed as manual muscle test (MMT) grade 4 were able to develop a gait with double knee action and to maneuver stairs, step-by-step, due to compensation by the gluteus maximus, biceps femoris, and gastrocnemius muscles. Four patients whose knee extension strength was less than MMT grade 4, and whose ankle dorsal and plantar flexion was MMT grade 4 or higher, acquired the ability to go up and down stairs step-by-step, although their gait pattern was a knee-extended gait. Electromyographic studies demonstrated continuous discharges of the gluteus maximus, biceps femoris, and gastrocnemius muscles during the stance phase as compensation for decreased strength in knee extension.