Gait & Posture 39 (2014) 761–766
Contents lists available at ScienceDirect
Gait & Posture journal homepage: www.elsevier.com/locate/gaitpost
Does the rectus femoris nerve block improve knee recurvatum in adult stroke patients? A kinematic and electromyographic study R. Gross a,*, L. Delporte b,c,d,e, L. Arsenault b, P. Revol b,c,d,e, M. Lefevre f, D. Clevenot f, D. Boisson b,c,d,e, P. Mertens e,g, Y. Rossetti b,c,d,e, J. Luaute´ b,c,d,e a Service de me´decine physique et de re´adaptation neurologique, centre hospitalier universitaire de Nantes, hoˆpital Saint Jacques, 85 rue Saint Jacques, 44093 Nantes cedex, France b Poˆle d’activite´ me´dicale de Re´e´ducation et Re´adaptation, Hoˆpital Henry Gabrielle, Plateforme Mouvement et Handicap, Hospices Civils de Lyon, F-69230 Lyon, France c Centre de Recherche en Neurosciences de Lyon, Lyon Neuroscience Research Center, INSERM U1028, ImpAct, 16 avenue Le´pine, 69676 Bron, France d Centre de Recherche en Neurosciences de Lyon, Lyon Neuroscience Research Center, CNRS, UMR5292, ImpAct, 16 avenue Le´pine, 69676 Bron, France e Universite´ Lyon 1, F-69000 Lyon, France f Service Anesthe´sie-Re´animations me´dicale et chirurgicale, Centre hospitalier Lyon Sud, Hospices Civils de Lyon, Chemin du Grand Revoyet, 69495 Pierre-Be´nite, France g De´partement de Neurochirurgie, hoˆpital neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 27 June 2012 Received in revised form 7 October 2013 Accepted 12 October 2013
Knee recurvatum (KR) during gait is common in hemiplegic patients. Quadriceps spasticity has been postulated as a cause of KR in this population. The aim of this study was to assess the role of rectus femoris spasticity in KR by using selective motor nerve blocks of the rectus femoris nerve in hemiparetic stroke patients. The data from six adult, post-stroke hemiplegic patients who underwent a rectus femoris nerve block for a stiff-knee gait were retrospectively analyzed. An extensive clinical and functional evaluation was performed and gait was assessed by motion analysis (kinematic, kinetic and electromyographic parameters) before and during the block realized using 2% lidocaine injected under a neurostimulation and ultrasonographic targeting procedure. The main outcome measures were the peak knee extension in stance and peak knee extensor moment obtained during gait analysis. No serious adverse effect of the nerve block was observed. The block allowed a reduction of rectus femoris overactivity in all patients. Peak knee extension and extensor moment in stance did not improve in any patient, but peak knee flexion during the swing phase was significantly higher after block (mean: 31.28 post, 26.4 pre, p < 0.05). Our results provide arguments against the hypothesis that the spasticity of the rectus femoris contributes to KR. ß 2013 Elsevier B.V. All rights reserved.
Keywords: Rectus femoris Knee recurvatum Spasticity Hemiplegia Nerve block
1. Introduction Knee recurvatum (KR) during gait is defined by a knee reaching full extension (08) or more during the stance phase. It is a common abnormality in adult hemiplegic patients, affecting 30–50% of walking stroke patients [1,2]. It is assumed to be caused by various pathological mechanisms depending on the patient’s pathology but is the consequence of an excessive knee extensor moment creating an acceleration of this joint towards extension [3,4]. Several factors involved in KR, contributing to an excessive knee extensor moment, have been already described. They include
* Corresponding author at: Raphae¨l Gross, Service de me´decine physique et de re´adaptation neurologique, CHU de Nantes, 85 rue Saint Jacques, 44093 Nantes cedex, France. E-mail addresses: [email protected], [email protected] (R. Gross). 0966-6362/$ – see front matter ß 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.gaitpost.2013.10.008
quadriceps weakness, quadriceps spasticity, calf muscles spasticity or contracture, buttock muscles or hamstrings weakness, and proprioceptive disorders [3,4]. In spastic hemiplegic patients, the best-known mechanism is spasticity and/or contracture of the calf muscles that limit ankle dorsiflexion and prevent the tibia and the knee from moving forward [3,5]. In adult hemiplegic patients, this mechanism has been successfully demonstrated using various treatments: ankle-foot orthoses [6,7], selective neurotomies of the nervus tibialis branches [8], or orthopaedic surgery to lengthen the Achilles tendon [9]. Quadriceps spasticity has been proposed to be another potential mechanism for KR [3,5]. Spastic, hyperactive knee extensors might cause overextension of the knee during the stance phase by an excessive contraction following the stretchreflex elicited by foot–ground contact. This hypothesis was first put forward by Perry [3]. Motor nerve blocks can be used to assess the potential role of muscle overactivity in abnormal movements [10]. Depending on
762
R. Gross et al. / Gait & Posture 39 (2014) 761–766
the pharmacological agent used, the temporary effect of a nerve block reverses within 1–12 h. Selective lower limb nerve blocks are particularly useful to assess the role of spasticity of specific muscle groups in pathological gait. For instance, the rectus femoris nerve block (RFNB) is routinely used to investigate spastic stiff-knee gait (SKG), which is assumed to result from rectus femoris (RF) overactivity during the swing phase of gait. Up to now, three studies have shown positive results within that context. Sung and Bang [11] were the first to describe the results of a RFNB on SKG, assessed by motion analysis, in 31 patients. They reported an increase of the peak knee flexion in swing angle of 15.48 on average with block. This positive effect was later confirmed (peak knee flexion in swing with block = +48) in 6 patients by Chantraine et al. [12], and in 10 patients by Robertson et al. (+10.88) [13]. Stoquart et al. [14] reported the effect of a botulinum toxin injection in the RF in post-stroke hemiplegic patients, with positive effects on SKG. None of these studies reported data about the effect of the nerve block on knee flexion/extension during stance, and thus on knee recurvatum. Recently, we described in a case report the positive effect of a RFNB and of a botulinum toxin injection on an abnormal knee flexion/extension oscillating movement, caused by a clonus of the quadriceps, in a patient presenting with a Brown-Se´quardplus syndrome [15]. The purpose of the present study was to assess the involvement of RF spasticity in KR in adult hemiplegic patients using a nerve block of the RF. We hypothesized that the nerve block of the RF would reduce KR in these patients. If confirmed, the implication of the rectus femoris could lead to prospects for effective treatments of KR using botulinum toxin or selective femoral neurotomies in order to improve knee stability and pain in hemiplegic patients. 2. Patients and methods 2.1. Subjects This observational retrospective analysis involved adult hemiplegic patients with a KR who underwent a RFNB for a stiff-knee gait associated with quadriceps spasticity and whose gait had been assessed by a motion analysis system. The inclusion criteria were: (i) quadriceps spasticity assessed by a modified Ashworth score of at least 1 [16]; (ii) more than a year delay since stroke (clinical stability); (iii) ability to walk at least 20 m without aid; (iv) presence of a KR during self-selected speed gait on gait analysis: K3 0 using the K3 parameter (maximal knee extension in stance phase) obtained using the data reduction method by Benedetti et al. [17]. Exclusion criteria were: (i) evidence of ankle plantar flexor muscles shortening (dorsiflexion of the ankle with the knee extended
Contents lists available at ScienceDirect
Gait & Posture journal homepage: www.elsevier.com/locate/gaitpost
Does the rectus femoris nerve block improve knee recurvatum in adult stroke patients? A kinematic and electromyographic study R. Gross a,*, L. Delporte b,c,d,e, L. Arsenault b, P. Revol b,c,d,e, M. Lefevre f, D. Clevenot f, D. Boisson b,c,d,e, P. Mertens e,g, Y. Rossetti b,c,d,e, J. Luaute´ b,c,d,e a Service de me´decine physique et de re´adaptation neurologique, centre hospitalier universitaire de Nantes, hoˆpital Saint Jacques, 85 rue Saint Jacques, 44093 Nantes cedex, France b Poˆle d’activite´ me´dicale de Re´e´ducation et Re´adaptation, Hoˆpital Henry Gabrielle, Plateforme Mouvement et Handicap, Hospices Civils de Lyon, F-69230 Lyon, France c Centre de Recherche en Neurosciences de Lyon, Lyon Neuroscience Research Center, INSERM U1028, ImpAct, 16 avenue Le´pine, 69676 Bron, France d Centre de Recherche en Neurosciences de Lyon, Lyon Neuroscience Research Center, CNRS, UMR5292, ImpAct, 16 avenue Le´pine, 69676 Bron, France e Universite´ Lyon 1, F-69000 Lyon, France f Service Anesthe´sie-Re´animations me´dicale et chirurgicale, Centre hospitalier Lyon Sud, Hospices Civils de Lyon, Chemin du Grand Revoyet, 69495 Pierre-Be´nite, France g De´partement de Neurochirurgie, hoˆpital neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 27 June 2012 Received in revised form 7 October 2013 Accepted 12 October 2013
Knee recurvatum (KR) during gait is common in hemiplegic patients. Quadriceps spasticity has been postulated as a cause of KR in this population. The aim of this study was to assess the role of rectus femoris spasticity in KR by using selective motor nerve blocks of the rectus femoris nerve in hemiparetic stroke patients. The data from six adult, post-stroke hemiplegic patients who underwent a rectus femoris nerve block for a stiff-knee gait were retrospectively analyzed. An extensive clinical and functional evaluation was performed and gait was assessed by motion analysis (kinematic, kinetic and electromyographic parameters) before and during the block realized using 2% lidocaine injected under a neurostimulation and ultrasonographic targeting procedure. The main outcome measures were the peak knee extension in stance and peak knee extensor moment obtained during gait analysis. No serious adverse effect of the nerve block was observed. The block allowed a reduction of rectus femoris overactivity in all patients. Peak knee extension and extensor moment in stance did not improve in any patient, but peak knee flexion during the swing phase was significantly higher after block (mean: 31.28 post, 26.4 pre, p < 0.05). Our results provide arguments against the hypothesis that the spasticity of the rectus femoris contributes to KR. ß 2013 Elsevier B.V. All rights reserved.
Keywords: Rectus femoris Knee recurvatum Spasticity Hemiplegia Nerve block
1. Introduction Knee recurvatum (KR) during gait is defined by a knee reaching full extension (08) or more during the stance phase. It is a common abnormality in adult hemiplegic patients, affecting 30–50% of walking stroke patients [1,2]. It is assumed to be caused by various pathological mechanisms depending on the patient’s pathology but is the consequence of an excessive knee extensor moment creating an acceleration of this joint towards extension [3,4]. Several factors involved in KR, contributing to an excessive knee extensor moment, have been already described. They include
* Corresponding author at: Raphae¨l Gross, Service de me´decine physique et de re´adaptation neurologique, CHU de Nantes, 85 rue Saint Jacques, 44093 Nantes cedex, France. E-mail addresses: [email protected], [email protected] (R. Gross). 0966-6362/$ – see front matter ß 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.gaitpost.2013.10.008
quadriceps weakness, quadriceps spasticity, calf muscles spasticity or contracture, buttock muscles or hamstrings weakness, and proprioceptive disorders [3,4]. In spastic hemiplegic patients, the best-known mechanism is spasticity and/or contracture of the calf muscles that limit ankle dorsiflexion and prevent the tibia and the knee from moving forward [3,5]. In adult hemiplegic patients, this mechanism has been successfully demonstrated using various treatments: ankle-foot orthoses [6,7], selective neurotomies of the nervus tibialis branches [8], or orthopaedic surgery to lengthen the Achilles tendon [9]. Quadriceps spasticity has been proposed to be another potential mechanism for KR [3,5]. Spastic, hyperactive knee extensors might cause overextension of the knee during the stance phase by an excessive contraction following the stretchreflex elicited by foot–ground contact. This hypothesis was first put forward by Perry [3]. Motor nerve blocks can be used to assess the potential role of muscle overactivity in abnormal movements [10]. Depending on
762
R. Gross et al. / Gait & Posture 39 (2014) 761–766
the pharmacological agent used, the temporary effect of a nerve block reverses within 1–12 h. Selective lower limb nerve blocks are particularly useful to assess the role of spasticity of specific muscle groups in pathological gait. For instance, the rectus femoris nerve block (RFNB) is routinely used to investigate spastic stiff-knee gait (SKG), which is assumed to result from rectus femoris (RF) overactivity during the swing phase of gait. Up to now, three studies have shown positive results within that context. Sung and Bang [11] were the first to describe the results of a RFNB on SKG, assessed by motion analysis, in 31 patients. They reported an increase of the peak knee flexion in swing angle of 15.48 on average with block. This positive effect was later confirmed (peak knee flexion in swing with block = +48) in 6 patients by Chantraine et al. [12], and in 10 patients by Robertson et al. (+10.88) [13]. Stoquart et al. [14] reported the effect of a botulinum toxin injection in the RF in post-stroke hemiplegic patients, with positive effects on SKG. None of these studies reported data about the effect of the nerve block on knee flexion/extension during stance, and thus on knee recurvatum. Recently, we described in a case report the positive effect of a RFNB and of a botulinum toxin injection on an abnormal knee flexion/extension oscillating movement, caused by a clonus of the quadriceps, in a patient presenting with a Brown-Se´quardplus syndrome [15]. The purpose of the present study was to assess the involvement of RF spasticity in KR in adult hemiplegic patients using a nerve block of the RF. We hypothesized that the nerve block of the RF would reduce KR in these patients. If confirmed, the implication of the rectus femoris could lead to prospects for effective treatments of KR using botulinum toxin or selective femoral neurotomies in order to improve knee stability and pain in hemiplegic patients. 2. Patients and methods 2.1. Subjects This observational retrospective analysis involved adult hemiplegic patients with a KR who underwent a RFNB for a stiff-knee gait associated with quadriceps spasticity and whose gait had been assessed by a motion analysis system. The inclusion criteria were: (i) quadriceps spasticity assessed by a modified Ashworth score of at least 1 [16]; (ii) more than a year delay since stroke (clinical stability); (iii) ability to walk at least 20 m without aid; (iv) presence of a KR during self-selected speed gait on gait analysis: K3 0 using the K3 parameter (maximal knee extension in stance phase) obtained using the data reduction method by Benedetti et al. [17]. Exclusion criteria were: (i) evidence of ankle plantar flexor muscles shortening (dorsiflexion of the ankle with the knee extended
