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Few studies have been published examining the prevention or treatment of spasticity or contracture using antispastic pattern positioning, range of motion exercises, stretching and/or splinting in the lower extremity. Kluding et al. (2008) reported that eight sessions of functional task practice combined with ankle joint mobilizations, provided over four weeks, resulted in increased ankle range of motion, compared with a group that received therapy only, in the chronic stage of stroke. The participants in the intervention group gained 5.7 degrees in passive ankle range of motion compared with 0.2 degree degrees in the control group (p<0.01).
The use of Botulinum toxin–type A (BTX-A) for the lower extremity is not as well-studied compared with the upper extremity. A meta-analysis (Foley et al. 2010), which included the results from 8 studies reported a moderate increase in gait speed associated with BTX-A (SMD= 0.193±0.081, 95% CI 0.033 to 0.353, p<0.018). In a recent randomized controlled trial Picelli et al. (2014) compared three different treatments among chronic stroke patients. Individuals were randomized to receive ultrasound, transcutaneous electrical stimulation, or Botox®. Picelli et al. (2014) reported that patients receiving Botox® had significantly greater improvement of spasticity (modified Ashworth Scale) compared to individuals in the other treatment groups. Dunne et al. (2012) randomized 85 stroke patients (≥ 6 weeks post stroke) to receive a single injection of 200 U (n=28), 300 U Botox ® (n=28) or saline. When the results from the two Botox ® groups were combined, there was significantly greater improvement in Ashworth Scale scores, pain, spasm frequency, and the number of patients who experienced at least a 15% increase in ankle dorsiflexion, at 12 weeks. Kaji et al. (2010) randomized 120 patients with lower limb spasticity following stroke greater than six months to receive a single treatment of 300 U Botox® or placebo. There was a significantly greater mean reduction in modified Ashworth Scale scores at weeks four, 6 and 8 in the treatment group compared with the control group; however, there were no significant differences between groups at week 10 or 12. Two pre-post studied the effect of Botox® on lower limb spasticity (modified Ashworth Scale) and found significant improvement at both 30 and 90 days post-injection (Sanamato et al. 2013a, 25-100 U; Sanamato 2013b, 250-340 U). Pittock et al. (2003) compared escalating doses of BTX-A with placebo and found that the highest dose (1,500 U Dysport ®) was associated with the greatest relief of calf spasticity compared with placebo at four, eight and 12 weeks following treatment. Lower doses (500 and 1,000 U) resulted in significant reductions in spasticity at week four only. Burbaud et al. (1996) randomized 23 adult hemiparetic stroke patients with ankle plantar flexor and foot invertor spasticity to receive a single injection of BTX-A and one of placebo in random order, at day 0 and day 90). Following active treatment, there was a significant reduction in spasticity associated with the ankle movement (extensors and invertors).
Intrathecal baclofen is popular treatment for spasticity in many populations including stroke, spinal cord injury, and cerebral palsy. Meythalar et al. (2002) performed a cross-over randomized controlled trial among individuals with chronic stroke. At one year the authors noted that spasticity had improved, as evidenced by a decline in Ashworth scores and reflex scores (p<0.01 for both); spasm frequency scores did not improve (p>0.05).