Stroke Clinical Trial
Official title:
Study of the Efficacy and Safety of the Neuro-orthopaedic Surgery in the Treatment of the Spastic Equinovarus Foot With ICF Assessment
Spastic equinovarus foot (SEF) is a major cause of disability in stroke patients. Treatments
may include physical therapy, orthosis, botulinum toxin (BTX) injections, selective tibial
neurotomy and tendon lengthening and/or transfer.
Until now, no study has been conducted to assess the result of neuro-orthopaedic surgery in
the treatment of SEF.
The aim of this study is to evaluate the benefit of neuro-orthopaedic surgery (selective
neurotomy and/or Achilles tendon lengthening and/or tibialis anterior transfer) in case of
SEF according to the 3 domains of the International Classification of Functioning,
Disability and Health (ICF)of the World Health organisation (WHO)
INTRODUCTION
Stroke is the third cause of death and the leading cause of handicap among industrialized
countries (1). Spasticity following stroke is responsible for spastic equinovarus foot (SEF)
in 18% of cases (2). Spastic equinovarus foot is due to spasticity (muscle hypertonia) of
the calf muscles (soleus, gastrocnemius and tibialis posterior), often complicated by
contracture and by the weakness of peroneus longus and peroneus brevis muscles (3).
Therefore, stroke patients walk slowly, and often require assistive device as orthosis or
canes. This disability limits their social participation and their quality of life.
Spastic equinovarus foot treatments include oral medications, physical therapy, orthosis,
chemical denervations (botulinum toxin, alcohol or phenol injections), selective neurotomy
and orthopedic surgery (3). Selective neurotomy is a neurosurgical procedure consisting in
partially and selectively cutting motor branches innervating the spastic muscles providing a
permanent treatment of the spasticity (3). Orthopaedic surgery consists in Achilles tendon
lengthening and tibialis anterior transfer (3). The efficacy of mixed neur-orthopaedic
surgery has never been prospectively assess according to the ICF classification.
OBJECTIVES
The aim of the present project is to study the effectiveness of neuro-orthopaedic surgery
(neurotomy and tendon surgery) in the treatment of SEF.
The functional assessment will explore the three ICF domains.
METHODS
The investigators will recruit 50 chronic spastic patients presenting with SEF. The surgical
treatment will be decided according to the improvement obtained by an anaesthetic diagnostic
tibial motor nerve branches block (5) followed by an interdisciplinary discussion.
Patients will be assessed before treatment, 2 months, 1 year and 2 years after treatment
among the 3 ICF domains. Impairments will be assessed by the Stoke Impairment Assessment Set
(SIAS), the Ashworth and Tardieu scales (spasticity) and the MRC scale (muscle strength).
Gait disorders will be evaluated by a video analysis. Disability will be evaluated by the
ABILOCO scale (6) and the participation (quality of life) by the SATIS-Stroke questionnaire
(7) and the SF-36 questionnaire.
The patients selection, the lidocaine hyperselective diagnostic blocks, the selective
neurotomy and the tendon surgery will be achieved by the medical doctors participants to the
spasticity group. The functional assessment will be achieved by the physical therapists of
the PMR department (blinded assessor).
PERSPECTIVE
The investigators hope to demonstrate the benefit of neuro-orthopaedic surgery in case of
SEF according to the 3 domains of the ICF (8)
;
Observational Model: Case-Only, Time Perspective: Prospective
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