05/21/2013 // Concord, CA, USA // LifeCare123 // Greg Vigna, MD, JD, Joe Motta, JD // (press release)
Foot and ankle deformity is one of the most frequently seen consequences that result from traumatic brain injury. It is part of the ‘upper motor neuron syndrome’ that results in increased tone and increase spasticity seen in this patient population. Tone is the resistance to passive stretch. Spasticity is a velocity dependent increase in tone. This means that the faster a patient attempts to move the more resistance to that movement occur.
The foot and ankle deformity most commonly encountered in the brain-injured patient is called the equinus deformity, which produces inversion of the foot and flexion at the ankle. This deformity causes significant dysfunction during gait. During gait, or walking, there is a swing phase, an initial contact phase, and a stance phase. Normally initial contact occurs with the heel causing the knee to bend forward. In the brain-injured patient with an equinus deformity, initial contact occurs not with the heel but with the forefoot causing the knee to bend backward. This causes and abnormal, inefficient gait pattern, which increases energy requirements for ambulation, decreases speed, and over time leads to knee instability, back pain, and degenerative joint disease.
The goal with treatment of the equinus deformity is to improve the position of the foot and ankle to allow heel strike at the initial contact phase of gait. Treatment for equinus deformity consists of any of or all of the following interventions: 1) Physical therapy, 2) Oral medications, 3) Local injections including both motor point blocks, and Botox.
Physical therapy is an essential component in the evaluation and treatment of the equinus deformity. Therapeutic interventions that are utilized include stretching the Achilles tendon, the muscles of the calf and strengthen the muscles of the hip, thigh, and muscles at the front of the shin. Physical therapy is often required to improve the speed and stability of gait. Often there is a fixed contracture at the ankle and foot and serial casting over a period of 2-6 weeks may be necessary to stretch the Achilles tendon. Physical therapist will work with an orthotist to have the patient fitted with an ankle foot orthosis (AFO), which will allow for heel strike at initial contact and normalized the gait abnormality.
Oral medications are generally effective to some degree in controlling generalized spasticity. These include baclofen, valium, and zanaflex. These medications will need to be titrated or adjusted over time to find the most effective dose without causing problematic side effects. Unfortunately, these medications are often not useful in controlling the equinus deformity, which is a localized deformity caused by spasticity and requires local treatments.
Local injection therapy includes motor point blocks and Botox. Motor point blocks involve the use of phenol, which is a neurotoxic substance. A motor point is the location where the peripheral nerve innervates the muscle to signal the muscle to contract. By isolating a motor point by way of EMG guidance and injecting phenol there will be a decrease in innervation causing a decrease in motor contraction. In the case of the equinus deformity injecting the tibial nerve at its innervation at the gastrocnemius muscle and the posterior tibialis muscle this deformity will be decreased. This procedure requires a patient to lay motionless, allowing for the clinician to locate the motor point with a needle. Pediatric traumatic brain injured patients often have trouble with this procedure. Complications include persistent pain in the region of the injection.
Botulinum toxin type A (Botox) has become recognized as the most effective medication used for focal spasticity. It is safe, has a duration of action that last 3-4 months, and is very effective. The medical community may perceive this intervention as very expensive, but to the patient it is perceived as a good value. From my experience Botox has been very useful in normalizing gait in both patients with stroke and traumatic brain injury with equinus deformity at the ankle and foot. By utilizing EMG guidance 200-300 units injected in divided doses in the gastrosoleus complex (the calf) and into the posterior tibialis muscle adequately decreases the tone and spasticity of the effected muscles that allows for improved speed and quality of ambulation. Botox injections are most effective when used in conjunction with a skill physical therapist and orthotist.
My clinical experience with Botox in the management of equinus deformity related to brain injury has been quite gratifying. When used in appropriate adult and pediatric traumatic brain injured patients, used in conjunction with physical therapy there is a meaningful improvement in gait.
Life Care Planning Perspective:
A life care planner must consider all life-long medical interventions necessary and appropriate to prevent complications and improve the overall psychosocial health of a patient who has suffered a brain injury. Interventions that improve the speed, safety, and quality of ambulation will be included in a life care plan. Interventions including Botox, physical therapy, and ongoing physical conditioning at an appropriate gym would be included. Botox has become the standard of care for focal spasticity and most physiatrist are trained in this intervention. Patients with an inadequate response should be referred to a center of excellence, which often has spasticity clinics, which are comprised of physicians, physical, and occupational therapist, and orthotist that collaborate on the best treatment plan to achieve the therapeutic goal.
Personal Injury Attorney Perspective:
Spasticity is another common complication associated with traumatic brain injury, and requires an attorney who can describe the negative effects on a patient. An attorney will need to provide the jury with all anticipated future medical costs for the traumatic brain injury that the negligence (carelessness) or wrongful act a defendant proximately caused (substantial factor). Spasticity treatments would be one of the included costs for past and future economic (medical costs) and noneconomic (pain and suffering) damages over the projected lifetime of the client. This may be a substantial amount. An underfunded settlement may preclude adequate treatment for spasticity causing impairment in gait, lost of independence, and other complications.
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