Post-TBI Gait Rehabilitation

By BUCK WILLIS, MBBS, PHD | July 1, 2007

BUCK WILLIS, MBBS, PHD, is clinical research director for Dynasplint Systems and Landmark Medical Systems in Severna Park, Maryland. He is also affiliated with the Department of Health, Physical Education, and Recreation at Texas State University in San Marcos.

Hypertonicity in plantar flexion is a frequent complication of traumatic brain injury (TBI), which affects more than 1.5 million persons in the United States.¹

If not addressed, hypertonicity can develop into contracture.² Infarction or other damage to upper motor neurons, resulting in decreased inhibition, is thought to cause hypertonicity.³ Hypertonicity, contracture, and the resulting footdrop all have adverse effects on the gait pattern and the core activities of daily living.

Footdrop is hypertonicity in plantar flexion, causing contracture of any combination of the following muscles: gastrocnemius, soleus, flexor digitorum longus, flexor hallicus longus, and Achilles tendon. Hypertonicity-associated contracture causes an exaggerated flexion of the hip and knee that prevents the toes from catching on the ground during the swing phase of gait. Tone must first be treated before gait rehabilitation can be achieved.

TREATMENT OPTIONS
Methods commonly used for treating hypertonicity include botulinum toxin type A (Botox) injections, tibial nerve block, serial casting, and dynamic splinting.

Botulinum toxin type A. A double- blind controlled study performed by Pittock and colleagues⁴ showed that a formulation of botulinum toxin type A (Dysport, pending FDA approval in the United States) was useful in reducing hypertonicity and pain in patients recovering from cerebrovascular accident (CVA). The study measured the effect that different doses of the agent had on tone in 234 patients with CVA-associated gastrocnemius hypertonicity that affected their gait pattern.

Patients randomly received either placebo or 500, 1000, or 1500 U of botulinum toxin type A. Although the highest dose yielded the most significant benefit in reducing hypertonicity, limb pain, and need for walking aids, significant improvement also was seen in patients receiving 1000 U of the agent and some benefits were seen in patients receiving 500 U as well.

Sixty-eight patients reported a total of 130 adverse events (infection, seizures, lack of coordination, and injection site pain or stinging). However, the study authors concluded that the drug was relatively safe and may be useful in the treatment of poststroke rehabilitation for gait complications.

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Post-TBI Gait Rehabilitation

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