Gracies UM chemodenervation of LE

Cofemer
DES MPR / SNC et MPR
Septembre 2008
Chemodenervation in the Lower
Extremity – Gait Analysis
DES : Médecine physique et de réadaptation
DIU : Médecine de rééducation
Module : Système nerveux central et MPR
Lyon: Septembre 2008
Coordonnateurs : Pr Isabelle RICHARD & Pr Gilles RODE
Titre :
CHEMODENERVATION IN THELOWER EXTREMITY
GAIT ANALYSIS
Marinesco, 1903
Auteur : Pr Jean-Michel GRACIES
Jean-Michel Gracies, MD, PhD
CHU Henri Mondor, Créteil, France
© Cofemer et lʼauteur
Different types of muscle overactivity
Muscle Overactivity in Spastic Paresis
Disabling Quantifiable
at bedside
1. Stretch-sensitive
Stretch-sensitive
- Spasticity
=
Phasic stretch, at rest
- Spastic Dystonia
=
Tonic stretch, at rest
- Spastic Co-contraction =
Voluntary command
+ tonic stretch
Spasticity
Spastic Co-contraction
Spastic Dystonia
2. Non Stretch-sensitive
+
++
+
Non stretch-sensitive
- Extrasegmental co-contraction (synkinesia)
- Cutaneous and nociceptive reflexes
- Other
Extrasegmental co-contraction
Cutaneous, nociceptive reflexes
Other
+/+
+/-
Gracies, 2001
Gracies et al, 2001
Function
Passive
Improving Motor Function
In Spastic Paralysis
- Soft tissue contracture
- Spastic dystonia
Active
- Soft tissue contracture
- Spastic dystonia
- Motor weakness
- Spastic cocontraction
◊ To modify these factors, local or systemic treatment?
Mayer et al, 2001; Gracies et al, 2002
Chemodenervation MI
1
Jean-Michel Graciès
Cofemer
DES MPR / SNC et MPR
Walking
Baclofen
IT Baclofen
Diazepam
Clorazepate
Ketazolam
Clonazepam
Tetrazepam
Piracetam
Progabide
Gabapentin
Tiagabine
Carisoprodol
Dantrolene
Lamotrigine
Riluzole
Phenytoin
Tizanidine
Clonidine
IT Clonidine
Thymoxamine
Propanolol
Cyproheptadine
Orphenadrine
Chlorpromazine
Cyclobenzaprine
Cannabis
Threonine,Glycine
IT midazolam
IT morphine
worse
26c,25nc
no change 67,68c
worse
408c
worse
26c,94c,93nc
better
no change
no change
155c
164c
171c
no change
254,256,269c
worse
462c
no change
308c
Active upper limb tasks
no change
better
no change
369,391,402c
155c
164c
Septembre 2008
Motor power
decreased
24c,65c
decreased
decreased
decreased
370,405,408c
94c
124c
no change
162c
199-202,
201,204,206c
no change
201,202,206,207c
decreased
no change
254,258,263,264c
decreased
256c
decreased
306,307c
Less overactive
More overactive
+ shortened
Gracies et al, 2002
Gracies, 2003
Three problems around each joint
1. Motor weakness
(Spatial hypoactivity)
FOCAL TREATMENT
2. Muscle overactivity
(Temporal hyperactivity)
=
3. Muscle Shortening
Stepwise, joint by joint approach
◊ Focal motor training / surgical
◊ Focal chemical weakening /
surgical
◊ Focal physical lengthening /
(Muscle stretch)
surgical
2 and 3 > 1 in antigravific/shortened muscles:
◊ FOCAL TREATMENT
Gracies, 2003
Gracies, 2001
Three problems around each joint
Posturing
1. Motor weakness
(Spatial hypoactivity)
2. Muscle overactivity
(Temporal hyperactivity)
3. Muscle Shortening
◊ Focal motor training / surgical
◊ Focal chemical weakening /
surgical
◊ Focal physical lengthening /
(Muscle stretch)
surgical
2 and 3 > 1 in antigravific/shortened muscles:
◊ FOCAL TREATMENT
Gracies, 2001
Chemodenervation MI
2
Jean-Michel Graciès
Cofemer
DES MPR / SNC et MPR
Septembre 2008
Jocelyne 57 yo
Therapeutic Weakening
of Rectus Femoris in Hemiparesis
• PMH depression, EtOH + tobacco consumption
• Aug 16, 2006 : headache, left hemiplegia, coma
CGS 8.
• Right parietal + intraventricular hemorrhage
• ◊ surgical evacuation + external derivation
Disease History
Evolution
• Gradual recovery from coma but initial persistence
of complete left hemiplegia
• BoNT injection to treat equinovarus deformity
in left leg in Jan 07..
• On admission in PM&R, sept 06 :
- Left SM complete hemiplegia + hemineglect
- Begins to stand up on right leg nov 06.
Chemodenervation MI
3
Jean-Michel Graciès
Cofemer
DES MPR / SNC et MPR
Neuro-orthopedic treatment distally
Septembre 2008
Evolution (cont)
• May 07 (M9):
• Begins to walk w quad cane on cast ablation July 07
(M11).
• Systemic treatment :
- Neurotomy of superior soleus nerve
- Gastrocnemius lengthening
- Double arthrodesis at ankle, astragale-scaphoïd et
calcaneum-cuboïd
- SPLATT (tibialis anterior to 5th meta head)
- Tenotomy at base of external flexors
- Percutaneous Tenotomy on Adductor I.
◊ Cast 2 months
–
–
–
–
–
Baclofen
Clonazepam at night
Zolpidem
Citalopram
Paracetamol
Spastic Co-contraction RF
Gracies,, 2008
Gracies, 2008
Self-rehabilitation
Rectus Femoris
• Calf stretch in unipodal
stance on scales 10
min/day
• Rapid alternating
movements of hip flexion
• Barefoot walking on
specific distance counting
nb of steps
Two consecutive injections :
• 75 U BoNT A, Nov 2007.
• 5000 U BoNT B, Feb 08.
• Shoulder adductor and
elbow flexor stretching
posture
Chemodenervation MI
4
Jean-Michel Graciès
Cofemer
DES MPR / SNC et MPR
Septembre 2008
Monnier, 2007
Monnier, 2007
Injection RF
Subjective Results
• Better ease in passive opening of left hand..
• However, no good sensation at left leg.
Objective Results
• 10 m walking speed increased by 20% at
comfortable walking et 25% at fast walking,
barefoot and with shoes
Post BoNT
Pre BoNT
◊ RF 5000 U FHL 5000 U
Gracies, 2008
Chemodenervation MI
5
Jean-Michel Graciès
Cofemer
DES MPR / SNC et MPR
Septembre 2008
Marche - Mme Z
BTX -B 5000U
0,60
0,50
Lgr pas confortable (m)
Vit confortable (m/sec)
Lgr pas rapide (m)
Vit rapide (m/sec)
BTX -A 75U
0,40
0,30
0,20
0,10
août -07
sept -07
oct -07
nov -07
déc-07
janv -08
févr-08
mars -08
avr -08
A1 post AVC
Al Kandari,
2008
Al Kandari
2008
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.
Arch Phys Med Rehabil. 2008 Jan;89(1):56-61.
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 degrees +/-13
degrees to 31 degrees +/-14 degrees during the swing phase (paired t test, P<.001),
knee flexion speed at toe-off improved from 82 degrees +/-63 degrees to 112
degrees +/-75 degrees/s (P=.009), and knee negative joint power (eccentric
muscular contraction) improved from -.27+/-.23 to -.37+/-.26 W/kg (P<.001). The
4 patients who almost did not flex the knee (<10 degrees) before the BTX-A rectus
femoris injection did not improve after the injection. The other 14 patients who
flexed the knee more than 10 degrees before the BTX-A rectus femoris injection
decreased the walking energy cost from 5.4+/-1.6 to 4.6+/-1.3 J x kg(-1) x 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 degrees).
Raquel 30 years old
Hemorrhage from AVM age 20
2nd AVM treated by radiation therapy
Bobath therapy for 10 years
Status March 05
Gracies, 20035
Chemodenervation MI
Gracies, 20035
6
Jean-Michel Graciès
Cofemer
DES MPR / SNC et MPR
Septembre 2008
March 05
Overactive PFxrs+HS
◊ Soleus 200 U
PFxrs cocontraction
Pre injection
SL = 26 cm
SP = 0.34 m/sec
Next:
Soleus
FDB
TP ++
Pre injection
SL = 26 cm
SP = 0.34 m/sec
Gracies, 2006
Gracies, 2006
TP medial access
FHL injection
Branch tib nerve
TP external access
4 weeks post injection
32 cm (+23% SL)
0.4 m/sec (+18% SP)
200 U
50 U
100 U
Gracies, 2006
Gracies, 2006
Aug 05: After 2 inj
43 cm (+65%)
0.59 m/sec (+73%)
Soleus 200 U - 200 U
FDB 100 U - 50 U
TP
0 U - 100 U
ST
100 U - 0U
Chemodenervation MI
Soleus targeting
FDB 100 U ST 100 U
Gluteus Maximus
Gracies, 2006
Gracies, 2005
7
Jean-Michel Graciès
Cofemer
DES MPR / SNC et MPR
Septembre 2008
Pre injection
SL = 26 cm
SP = 0.34 m/sec
Soleus
Glut Max
TP
FDB
ST
FHL/FDL
GM injection
Gracies, 2005
Mar 05: Pre injection
May 06: After 5 inj
SL = 26 cm
SP = 0.34 m/sec
Soleus
Glut Max
Glut Med (med fibers)
TP
FDB
HS
FHL/FDL
200 U
150 U
250 U
150U
50 U
50U
50 U
300U
50U
200 U
0U
100 U
100 U 50 U
100 U 0U
150 U
250 U
50 U
50 U
Gracies, 2006
March 07: After 8 inj
SL = 26 cm
SP = 0.34 m/sec
59 cm (+127%)
0.91 m/sec (+168%)
Side
views
200U
100U
100 U
100 U 50 U
100 U
200 U
Mar 05: Pre injection
50 cm (+92%)
0.77 m/sec (+126%)
200 U
Dec 05: After 3 inj
48 cm (+83%)
0.62 m/sec (+84%)
Gracies, 2006
Gracies, 2007
Raquel's walking
1.00
Inj Inj
Step length fast (m)
Speed fast (m/sec)
Inj
Inj
Inj
0.80
Side view pre
Inj
Side view post inj 5
0.60
Inj
Inj
0.40
0.20
Toe clawing pre
2/17/2005 5/28/2005
Toe clawing post inj 5
Gracies, 2006
Chemodenervation MI
9/5/2005 12/14/2005 3/24/2006
7/2/2006
10/10/2006 1/18/2007
4/28/2007
Gracies, 2007
8
Jean-Michel Graciès