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This article and any supplementary material should be cited as follows: Wilkenfeld AJ. Review of electrical stimulation, botulinum toxin, and their combination for spastic drop foot. J Rehabil Res Dev. 2013;50(3): Slideshow Project DOI: /JRRD JSP Background Spastic drop foot – Weak ankle dorsiflexors and spastic ankle plantar flexors predispose ankle to stay pathologically plantar flexed. Functional ES – Uses electric current to activate muscles and nerves that are weak/paralyzed but still have intact lower motor neurons and musculature. BTX – Prevents acetylcholine release at presynaptic terminal, thus impairing neuromuscular transmission and inducing weakness.
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This article and any supplementary material should be cited as follows: Wilkenfeld AJ. Review of electrical stimulation, botulinum toxin, and their combination for spastic drop foot. J Rehabil Res Dev. 2013;50(3):315-26. http://dx.doi.org/10.1682/JRRD.2012.03.0044
Slideshow ProjectDOI:10.1682/JRRD.2012.03.0044JSP
Review of electrical stimulation, botulinum toxin, and their
combination for spastic drop foot
Ari Jacob Levi Wilkenfeld, MD, PhD
This article and any supplementary material should be cited as follows: Wilkenfeld AJ. Review of electrical stimulation, botulinum toxin, and their combination for spastic drop foot. J Rehabil Res Dev. 2013;50(3):315-26. http://dx.doi.org/10.1682/JRRD.2012.03.0044
Slideshow ProjectDOI:10.1682/JRRD.2012.03.0044JSP
• Aim– Review pathophysiology of spastic drop foot and its
treatment options. – Present theoretical reasons why functional electrical
stimulation (ES) and botulinum toxin (BTX) injections could work synergistically.
• Relevance– There are reasons to think functional ES and BTX
injections might work effectively in combination, but no clear consensus exists in literature.
This article and any supplementary material should be cited as follows: Wilkenfeld AJ. Review of electrical stimulation, botulinum toxin, and their combination for spastic drop foot. J Rehabil Res Dev. 2013;50(3):315-26. http://dx.doi.org/10.1682/JRRD.2012.03.0044
Slideshow ProjectDOI:10.1682/JRRD.2012.03.0044JSP
Background• Spastic drop foot– Weak ankle dorsiflexors and spastic ankle plantar flexors
predispose ankle to stay pathologically plantar flexed.• Functional ES– Uses electric current to activate muscles and nerves that
are weak/paralyzed but still have intact lower motor neurons and musculature.
• BTX– Prevents acetylcholine release at presynaptic terminal,
thus impairing neuromuscular transmission and inducing weakness.
This article and any supplementary material should be cited as follows: Wilkenfeld AJ. Review of electrical stimulation, botulinum toxin, and their combination for spastic drop foot. J Rehabil Res Dev. 2013;50(3):315-26. http://dx.doi.org/10.1682/JRRD.2012.03.0044
Slideshow ProjectDOI:10.1682/JRRD.2012.03.0044JSP
Treatment• 4 mechanisms by which ES might increase
antispasticity effect of BTX. – Animal experiments: BTX’s paralytic effect starts earlier
when toxin uptake is increased with ES.
– Moving muscle through flexion/extension cycles could help mechanically spread toxin.
– Direct effects of ES on tone reduction.
– Simultaneously addressing positive and negative components of upper motor neuron syndrome could lead to increased functional gains in gait.
This article and any supplementary material should be cited as follows: Wilkenfeld AJ. Review of electrical stimulation, botulinum toxin, and their combination for spastic drop foot. J Rehabil Res Dev. 2013;50(3):315-26. http://dx.doi.org/10.1682/JRRD.2012.03.0044
Slideshow ProjectDOI:10.1682/JRRD.2012.03.0044JSP
Conclusions• For ES: Evidence of decreased spasticity.– But, e.g., whether stimulation should be over spastic muscle
or its antagonist, how long effect lasts, and whether it works during gait must be clarified.
• For BTX: Evidence of decreased tone. – But evidence lacking for improved gait.
• ES+BTX: Evidence that ES of muscle may increase efficacy of BTX. – However, large controlled studies examining relative effects
are lacking.
