Management of Lower Limb Spasticity

By Dr. Evan Friedman | July 11, 2022

“Management of Lower Limb Spasticity” is the sixth article in a series to address Myoguide Injection Guidance applications of Botulinum neurotoxin. The following article presents a short review of the Upper limb Spasticity and the application of BoNT, with a focus on the benefit of using the Myoguide™ EMG/ESTIM BoNT injection guidance system.

The following article on lower limb spasticity presents some useful information and wealth of references, specifically aimed at the management of lower limb spasticity. The information within, is simply informative and not considered to be instructive, in any way. Please have a look at the article and the appropriate reference materials for more details.

Post Stroke Spasticity

We have discussed the impact of post-stroke spasticity in previous postings.  It is estimated to affect up to 43% of stroke survivors [1,2] and results in a substantial impact on the lives of patients and their caregivers [3].

A higher degree of spasticity (modified Ashworth Scale [MAS] score ≥ 3) is more frequent in upper limb than lower limb muscles of stroke survivors.  However, the prevalence of lower and upper-limb spasticity is quite similar [2].

Lower limb spasticity can impair ambulation and gait. This has a high negative impact on the activities of daily living and basic quality of life [5,6].

Lower Limb Spasticity

Lower limb spasticity is a condition where the muscles of the legs and feet become tense and overactive. This results in limited movement and an inability to perform basic daily tasks. The condition can lead to unusual and uncontrollable muscle movements (spasms) in the leg. Lower limb spasticity can be painful. Individuals with upper limb spasticity can also experience difficulties coordinating with the movement of the lower limbs.

Lower extremity spasticity (leg & foot spasticity) is also referred to as:

  • Leg muscle spasticity
  • Flexion contractures
  • Leg spasms
  • Lower limb spasticity

Passive range of motion (PROM) is limited via:

  • Spasticity
  • Muscle overactivity
  • Contracture
  • Pain

What is Lower Limb Spasticity?

Technically, lower limb spasticity is a velocity dependent increase in tonic stretch reflexes, with increased muscle tone, and hyperexcitable tendon reflexes, occurring in the muscles of the lower limbs, hips, and pelvis. 

Lower extremity spasticity refers to increased muscle tone and hyperactive reflexes in the legs and feet. It is usually due to a problem with motor nerves in the brain (upper motor neuron syndrome (UMNS)), and can be caused by: 

  • Cerebral palsy
  • Stroke 
  • Traumatic brain injury
  • ALS (type 2)
  • MS

UMNS also leads to motor control changes in skeletal muscle following an upper motor neuron lesion.  The affected muscles can display many features, including a decreased ability to generate force.

A number of clinical assessment strategies are routinely used to evaluate the patient with residual consequences of UMNS.  The clinical expression of this motor dysfunction is influenced by:

  • Spasticity and other forms of muscle overactivity
  • Contracture
  • Impairment of motor control.

The neural component of spastic muscle comes from its stretch reflex activity, whereas the non-neural component comes from changes in physical properties intrinsic to muscle and other soft tissues. 

Lower limb spasticity can range from mild to very disabling. The affected muscles may be overactive and cause joint contractures. The most common presentations include:

  • Stiff leg, that cannot be bent or separated (extensor spasm)
  • Contracted legs that can’t be straightened out (flexor spasm)
  • There are also spasms that present as twitching or tapping of the foot.
Common Postures of Lower Limb Spasticity

Common Postures of Lower Limb Spasticity:

  • Hip flexion: hip is flexed, the body is bent forward
  • Adducted thighs: the inner parts of the thighs are pressed closely together
  • Knee extension/stiff knee: hyperextended knee joint, the lower leg is extended
  • Flexion of the knee joint, the lower leg is bent
  • Equinovarus foot: Walking with raising of the heel and inward flexion of the entire foot (Calf muscle hypertonia)
  • Striatal toe: Toe is stretched upwards

In general, the position of the weak and spastic leg, or foot, creates functional, hygienic and cosmetic issues.  Therapy, medication, and surgery are usually used together to address lower extremity spasticity.

Voluntary capacity and spastic reactivity are examined and interpreted in light of clinical and functional complaints. Symptoms that may accompany lower limb spasticity include:

  • Involuntary muscle spasms
  • Clonus
  • Scissoring of legs
  • Abnormal limb postures
  • Joint contractures.

Lower Limb Spasticity Therapy

  • Therapy for spasticity includes:
  • Stretching tight muscles and joints
  • Strengthening weakened muscles
  • Using splints to improve and maintain good joint position
  • Medication can be prescribed
  • Surgery can be considered to improve mobility, self-care, hygiene, and the appearance of the affected leg. 

However, many elements of therapy are always part of a multi-tiered solution

Lower Limb Spasticity Chemodenervation

Chemodenervation using botulinum neurotoxin (BoNT) can be used to reduce spasticity, increase range of motion, and improve gait, for patients with focal symptomatically distressing spasticity [6-10].  Many of the recommendations, related to safety and efficacy, arise from studies related to research based on adults with upper limb spasticity [11-18]

Long-term observational studies on the treatment of lower limb spasticity with BoNT, has shown that spasticity management is improved.  Studies regarding lower limb spasticity have show

statistically significant reduction in muscle tone based on Modified Ashworth Scale versus placebo [4] [19-24]. 

Lower limb anatomy pertinent to spasticity
Lower limb anatomy pertinent to spasticity

The Value of EMG Guidance in The Management of Lower Limb Spasticity

There are many compelling reasons to use EMG guidance:

  • EMG ensures that the needle is located in muscle
  • Confirming that the needle is in the correct muscle (muscle activation)

Speelman and Brans showed that even the most experienced “blind” injectors were frequently inaccurate in identifying needle placement in muscles of the neck [36].

The error rate ranged from 15% in an easily palpated superficial cervical muscle, such as sternocleidomastoid, to greater than 50% in deeper muscles, such as levator scapulae and semispinalis capitis [23].

Comella and colleagues illustrated that BoNT injection for spasmodic torticollis increased magnitude of benefit with electromyographic assistance. The article involved comparing experienced investigators using EMG versus palpation and showed that EMG was superior in terms of reducing side effects and obtaining clinical benefit [35].

Recent studies showed that both expert and novice needle placements improve with guidance when compared without, even in large easily accessible muscles [37].

A recent review article by Grigoriu et al [38], showed strong evidence that instrumented guided injections (Ultrasound, EMG, STIM) were more effective than manual needle placement for the treatment of Spasmodic Torticollis, and both upper and lower limb spasticity.

These studies clearly illustrate that we all do better finding the optimal spots to locate the needles when using EMG guidance, regardless of whether the muscle is located easily on the surface, or deeper, or whether the needle insertions are being carried out by novice or experts.

The Benefits of Myoguide™ EMG/ESTIM BoNT Injection Guidance System

Myoguide™ is equipped with what is essentially a single channel EMG machine with a full featured, built in stimulator.

Myoguide™ EMG/ESTIM BoNT injection guidance system is designed to amplify EMG signals from muscle and provide audio and visual feedback to assist clinicians in locating areas of muscle activity.

Benefits include:

  • EMG visual and audio feedback (EMG GUIDANCE)
  • Integration of a well featured stimulator (STIM GUIDANCE)
  • Capable of 0.1-20mA of stimulation
  • 1.0 mA or 0.1 mA steps are available
  • Available Audio mute and Stimulation pause

STIM guidance is useful for muscle, nerve, and motor endplate location procedures provides, including stimulation location and ultrasound procedures.

Myoguide supports injection of neuromodulators, chemodenervation, neurolytic procedures, and peripheral nerve stimulation.

The Value of Electrical Stimulation (ESTIM) Guidance in the Management of Lower Limb Spasticity

Electrical stimulation (ESTIM) guidance increases the accuracy of hypodermic needle electrode placement. ESTIM is superior to simply using anatomical knowledge (AKO) placement by using muscle activation.

The potential advantage of ESTIM is that not only does it ensure that the injecting needle is in the target muscle, but that the needle is in close proximity to motor endplates and/or motor points [27]. 

Electrical stimulation is:

  • Easy to perform
  • Does not require formal training
  • Does not significantly prolong the procedure

ESTIM does require experience and practice in electrophysiological techniques, and benefits from familiarity with the relevant anatomical landmarks (standard of practice).

While it has been proven that EMG guidance does perform consistently better than AKO approaches, even in large muscles [24,25], ESTIM is useful, in particular applications, and certainly within the hand, for validation before injection of BoNT.

ESTIM provides a simple way to double check whether EMG is actually coming from the expected muscle. This is helpful where the target muscle is surrounded by multiple smaller muscles packed into the vicinity (e.g. hand and foot).  

Myoguide’s stimulator presents:

  • 5 stimulation frequency choices
  • 4 pulse width choices
  • 0.1- 20 mA of stimulation current available i
  • 1.0 mA and 0.1 mA stimulation steps are available.
  • Stimulation pause feature to streamline STIM guidance procedures

0.1 mA steps are helpful and necessary for nerve location procedures allow evoking responses at lower, more comfortable stimulation levels.  

Pulse widths of up to 500 microseconds allow evoking muscle twitches at lower currents, yielding a more comfortable clinical experience for patients undergoing stimulation location procedures.

Wider stimulation choices allow evoking twitch at lower, more comfortable stimulation levels. 

Myoguide has an exclusive feature, “Stimulation Pause” which allows clinicians to easily halt the stimulation process. Muscle twitch confirmation can be used to assess whether the operator must reposition the injection needle electrode, to effect results.

Stimulation can easily be returned to the pre-paused current level with the touch of any button.

The goal is to validate that the needle tip location is within the correct muscle, by being able to witness the muscle twitch in the correct location.  The needle can easily be partially withdrawn and repositioned should a correction be needed.

Myoguide™ EMG/ESTIM BoNT injection guidance system is designed to amplify EMG signals from muscle and provide audio and visual feedback to assist clinicians in locating areas of muscle activity.

Myoguide on a table

Myoguide also has an integrated and well featured stimulator, capable of stimulation in either 1.0 mA or 0.1 mA steps, for muscle, nerve, and motor endplate location procedures.

Myoguide supports injection of neuromodulators and both chemodenervation and neurolytic procedures, as well as, peripheral nerve stimulation. Learn more about how to use Myoguide

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References

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  4. R. Kaji, Y. Osako, K. Suyama, T. Maeda, Y. Uechi, M. Iwasaki.   Botulinum toxin type A in post-stroke lower limb spasticity: a multicenter, double-blind, placebo-controlled trial  J Neurol, 257 (2010), pp. 1330-1337
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  33. Dashtipour K, Chen JJ, Walker HW, Lee MY.  Systematic Literature Review of AbobotulinumtoxinA in Clinical Trials for Lower Limb Spasticity. Medicine (Baltimore) 2016 Jan;95(2): e2468. doi: 10.1097/MD.0000000000002468. PMID: 26765447
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References Divided into Categories

Diagnosis

  • Cabanas-Valdés R, Calvo-Sanz J, Urrùtia G, Serra-Llobet P, Pérez-Bellmunt A, Germán-Romero A.  The effectiveness of extracorporeal shock wave therapy to reduce lower limb spasticity in stroke patients: a systematic review and meta-analysis. Top Stroke Rehabil 2020 Mar;27(2):137-157. Epub 2019 Nov 11 doi: 10.1080/10749357.2019.1654242. PMID: 31710277
  • Esquenazi A, Alfaro A, Ayyoub Z, Charles D, Dashtipour K, Graham GD, McGuire JR, Odderson IR, Patel AT, Simpson DM. OnabotulinumtoxinA for Lower Limb Spasticity: Guidance From a Delphi Panel Approach. PM R. 2017 Oct;9(10):960-968. doi: 10.1016/j.pmrj.2017.02.014. Epub 2017 Mar 7. PMID: 28286053.
  • Esquenazi A, Alfaro A, Ayyoub Z, Charles D, Dashtipour K, Graham GD, McGuire JR, Odderson IR, Patel AT, Simpson DM. Systematic Literature Review of AbobotulinumtoxinA in Clinical Trials for Lower Limb Spasticity.  PM R 2017 Oct;9(10):960-968. Epub 2017 Mar 7 doi: 10.1016/j.pmrj.2017.02.014. PMID: 28286053
  • Williams G, Banky M, Olver J.  Distribution of Lower Limb Spasticity Does Not Influence Mobility Outcome Following Traumatic Brain Injury: An Observational Study. J Head Trauma Rehabil 2015 Sep-Oct;30(5):E49-57. doi: 10.1097/HTR.0000000000000094.  PMID: 25310296
  • Singer JC, Mansfield A, Danells CJ, McIlroy WE, Mochizuki G.  The effect of post-stroke lower-limb spasticity on the control of standing balance: Inter-limb spatial and temporal synchronisation of centres of pressure. Clin Biomech (Bristol, Avon) 2013 Oct;28(8):921-6. Epub 2013 Jul 25 doi: 10.1016/j.clinbiomech.2013.07.010. PMID: 23938181

Therapy

  • Esquenazi A, Bavikatte G, Bandari DS, Jost WH, Munin MC, Tang SFT, Largent J, Adams AM, Zuzek A, Francisco GE.  Long-Term Observational Results from the ASPIRE Study: OnabotulinumtoxinA Treatment for Adult Lower Limb Spasticity. PM R 2021 Oct;13(10):1079-1093. Epub 2021 Jan 11 doi: 10.1002/pmrj.12517. PMID: 33151636
  • Chen S, Lv C, Wu J, Zhou C, Shui X, Wang Y.  Effectiveness of a home-based exercise program among patients with lower limb spasticity post-stroke: A randomized controlled trial.  Chen S, Lv C, Wu J, Zhou C, Shui X, Wang Y Asian Nurs Res (Korean Soc Nurs Sci) 2021 Feb;15(1):1-7. Epub 2020 Sep 2 doi: 10.1016/j.anr.2020.08.007. PMID: 32890770
  • Fheodoroff K, Rekand T, Medeiros L, Koßmehl P, Wissel J, Bensmail D, Scheschonka A, Flatau-Baqué B, Simon O, Dressler D, Simpson DM.  Quality of life in subjects with upper- and lower-limb spasticity treated with incobotulinumtoxinA. Health Qual Life Outcomes 2020 Mar 4;18(1):51. doi: 10.1186/s12955-020-01304-4. PMID: 32131842
  • Esquenazi A, Wein TH, Ward AB, Geis C, Liu C, Dimitrova R.  Optimal Muscle Selection for OnabotulinumtoxinA Injections in Poststroke Lower-Limb Spasticity: A Randomized Trial.  Am J Phys Med Rehabil 2019 May;98(5):360-368. doi: 10.1097/PHM.0000000000001101. PMID: 31003229
  • Dashtipour K, Chen JJ, Walker HW, Lee MY.  Systematic Literature Review of AbobotulinumtoxinA in Clinical Trials for Lower Limb Spasticity. Medicine (Baltimore) 2016 Jan;95(2):e2468. doi: 10.1097/MD.0000000000002468. PMID: 26765447Free PMC Article

Prognosis

  • Mudge AJ, Sangeux M, Wojciechowski EA, Louey MG, McKay MJ, Baldwin JN, Dwan LN, Axt MW, Burns J. Can pedobarography predict the occurrence of heel rocker in children with lower limb spasticity? Clin Biomech (Bristol, Avon) 2020 Jan;71:208-213. Epub 2019 Oct 23 doi: 10.1016/j.clinbiomech.2019.10.022. PMID: 31783269
  • López de Munain L, Valls-Solé J, Garcia Pascual I, Maisonobe P.  Botulinum Toxin Type A Improves Function According to Goal Attainment in Adults with Poststroke Lower Limb Spasticity in Real Life Practice. On behalf of the VALGAS investigators group. Eur Neurol 2019;82(1-3):1-8. Epub 2019 Nov 14 doi: 10.1159/000503172. PMID: 31726452
  • Santamato A, Panza F, Intiso D, Baricich A, Picelli A, Smania N, Fortunato F, Seripa D, Fiore P, Ranieri M.  Long-term safety of repeated high doses of incobotulinumtoxinA injections for the treatment of upper and lower limb spasticity after stroke. J Neurol Sci 2017 Jul 15;378: 182-186. Epub 2017 May 1 doi: 10.1016/j.jns.2017.04.052. PMID: 28566161
  • Dashtipour K, Chen JJ, Walker HW, Lee MY.  Systematic Literature Review of AbobotulinumtoxinA in Clinical Trials for Lower Limb Spasticity. Medicine (Baltimore) 2016 Jan;95(2):e2468. doi: 10.1097/MD.0000000000002468. PMID: 26765447
  • Williams G, Banky M, Olver J.  Distribution of Lower Limb Spasticity Does Not Influence Mobility Outcome Following Traumatic Brain Injury: An Observational Study. J Head Trauma Rehabil 2015 Sep-Oct;30(5):E49-57. doi: 10.1097/HTR.0000000000000094. PMID: 25310296

Clinical prediction guides

  • Heinen F, Kanovský P, Schroeder AS, Chambers HG, Dabrowski E, Geister TL, Hanschmann A, Martinez-Torres FJ, Pulte I, Banach M, Gaebler-Spira D.  IncobotulinumtoxinA for the treatment of lower-limb spasticity in children and adolescents with cerebral palsy: A phase 3 study.   J Pediatr Rehabil Med 2021;14(2):183-197. doi: 10.3233/PRM-210040. PMID: 34092664
  • Esquenazi A, Bavikatte G, Bandari DS, Jost WH, Munin MC, Tang SFT, Largent J, Adams AM, Zuzek A, Francisco GE.  Long-Term Observational Results from the ASPIRE Study: OnabotulinumtoxinA Treatment for Adult Lower Limb Spasticity. PM R 2021 Oct;13(10):1079-1093. Epub 2021 Jan 11 doi: 10.1002/pmrj.12517. PMID: 33151636
  • Fheodoroff K, Rekand T, Medeiros L, Koßmehl P, Wissel J, Bensmail D, Scheschonka A, Flatau-Baqué B, Simon O, Dressler D, Simpson DM.  Quality of life in subjects with upper- and lower-limb spasticity treated with incobotulinumtoxinA.  Health Qual Life Outcomes. 2020 Mar 4;18(1):51. doi: 10.1186/s12955-020-01304-4. PMID: 32131842
  • Esquenazi A, Wein TH, Ward AB, Geis C, Liu C, Dimitrova R.  Optimal Muscle Selection for OnabotulinumtoxinA Injections in Poststroke Lower-Limb Spasticity: A Randomized Trial.  Am J Phys Med Rehabil 2019 May;98(5):360-368. doi: 10.1097/PHM.0000000000001101. PMID: 31003229
  • Banky M, Clark RA, Pua YH, Mentiplay BF, Olver JH, Williams G.  Inter- and intra-rater variability of testing velocity when assessing lower limb spasticity.  J Rehabil Med 2019 Jan 1;51(1):54-60. doi: 10.2340/16501977-2496. PMID: 30483723

Recent systematic reviews

  • Cabanas-Valdés R, Calvo-Sanz J, Urrùtia G, Serra-Llobet P, Pérez-Bellmunt A, Germán-Romero A.  The effectiveness of extracorporeal shock wave therapy to reduce lower limb spasticity in stroke patients: a systematic review and meta-analysis. Top Stroke Rehabil 2020 Mar;27(2):137-157. Epub 2019 Nov 11 doi: 10.1080/10749357.2019.1654242. PMID: 31710277
  • Guyot P, Kalyvas C, Mamane C, Danchenko N.  Botulinum Toxins Type A (Bont-A) in the Management of Lower Limb Spasticity in Children: A Systematic Literature Review and Bayesian Network Meta-analysis.  J Child Neurol 2019 Jun;34(7):371-381. Epub 2019 Feb 25 doi: 10.1177/0883073819830579. PMID: 30803305
  • Gupta AD, Chu WH, Howell S, Chakraborty S, Koblar S, Visvanathan R, Cameron I, Wilson D.  A systematic review: efficacy of botulinum toxin in walking and quality of life in post-stroke lower limb spasticity.  Syst Rev 2018 Jan 5;7(1):1. doi: 10.1186/s13643-017-0670-9. PMID: 29304876
  • Dashtipour K, Chen JJ, Walker HW, Lee MY.  Systematic Literature Review of AbobotulinumtoxinA in Clinical Trials for Lower Limb Spasticity. Medicine (Baltimore) 2016 Jan;95(2):e2468. doi: 10.1097/MD.0000000000002468. PMID: 26765447
  • Ade-Hall RA, Moore AP.  Botulinum toxin type A in the treatment of lower limb spasticity in cerebral palsy. Cochrane Database Syst Rev 2000;(2):CD001408. doi: 10.1002/14651858.CD001408. PMID: 10796784
  • Mahmood A, Veluswamy SK, Hombali A, Mullick A, N M, Solomon JM.Arch Phys Med . Effect of Transcutaneous Electrical Nerve Stimulation on Spasticity in Adults With Stroke: A Systematic Review and Meta-analysis.  Rehabil. 2019 Apr;100(4):751-768. doi: 10.1016/j.apmr.2018.10.016. Epub 2018 Nov 16.PMID: 30452892
  • Gupta AD, Chu WH, Howell S, Chakraborty S, Koblar S, Visvanathan R, Cameron I, Wilson, Dashtipour K, Chen JJ, Walker HW, Lee MY.  Systematic Literature Review of Abobotulinumtoxin-A in Clinical Trials for Lower Limb Spasticity. Medicine (Baltimore). 2016 Jan;95(2):e2468. doi:10.1097/MD.0000000000002468.PMID: 26765447 
  • Cabanas-Valdés R, Calvo-Sanz J, Urrùtia G, Serra-Llobet P, Pérez-Bellmunt A, Germán-Romero.   The effectiveness of extracorporeal shock wave therapy to reduce lower limb spasticity in stroke patients: a systematic review and meta-analysis.  A.Top Stroke Rehabil. 2020 Mar;27(2):137-157. doi: 10.1080/10749357.2019.1654242. Epub 2019 Nov 11.PMID: 31710277
  • Guyot P, Kalyvas C, Mamane C, Danchenko N.J Child Neurol. Botulinum Toxins Type A (Bont-A) in the Management of Lower Limb Spasticity in Children: A Systematic Literature Review and Bayesian Network Meta-analysis. 2019 Jun;34(7):371-381. doi: 10.1177/0883073819830579. Epub 2019 Feb 25.PMID: 30803305
  • Banky M, Ryan HK, Clark R, Olver J, Williams G.  Do clinical tests of spasticity accurately reflect muscle function during walking: A systematic review. Brain Inj. 2017;31(4):440-455. doi: 10.1080/02699052.2016.1271455. Epub 2017 Mar 7.PMID: 28267368 
  • Rosales RL, Chua-Yap AS.  Evidence-based systematic review on the efficacy and safety of botulinum toxin-A therapy in post-stroke spasticity.  J Neural Transm (Vienna). 2008;115(4):617-23. doi: 10.1007/s00702-007-0869-3. Epub 2008 Mar 6.PMID: 18322637 
  • McIntyre A, Lee T, Janzen S, Mays R, Mehta S, Teasell R.  Systematic review of the effectiveness of pharmacological interventions in the treatment of spasticity of the hemiparetic lower extremity more than six months post stroke. Top Stroke Rehabil. 2012 Nov-Dec;19(6):479-90. doi: 10.1310/tsr1906-479.PMID: 2319271
  • Grigoriu AI, Dinomais M, Rémy-Néris O, Brochard S.  Impact of Injection-Guiding Techniques on the Effectiveness of Botulinum Toxin for the Treatment of Focal Spasticity and Dystonia: A Systematic Review. Arch Phys Med Rehabil. 2015 Nov;96(11):2067-78.e1. doi: 10.1016/j.apmr.2015.05.002. Epub 2015 May 14.PMID: 25982240 
  • Cabanas-Valdés R, Calvo-Sanz J, Serra-Llobet P, Alcoba-Kait J, González-Rueda V, Rodríguez-Rubio PR. The Effectiveness of Massage Therapy for Improving Sequelae in Post-Stroke Survivors. A Systematic Review and Meta-Analysis.  Int J Environ Res Public Health. 2021 Apr 21;18(9):4424. doi: 10.3390/ijerph18094424.PMID: 33919371 
  • Ade-Hall RA, Moore AP.  Botulinum toxin type A in the treatment of lower limb spasticity in cerebral palsy.  Cochrane Database Syst Rev. 2000;(2):CD001408. doi: 10.1002/14651858.CD001408.PMID: 10796784 
  • Demetrios M, Khan F, Turner-Stokes L, Brand C, McSweeney S.  Multidisciplinary rehabilitation following botulinum toxin and other focal intramuscular treatment for post-stroke spasticity.  Cochrane Database Syst Rev. 2013 Jun 5;(6):CD009689. doi: 10.1002/14651858.CD009689.pub2.PMID: 23740539