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Review of electrical stimulation, botulinum toxin, and their combination for spastic drop foot

Review of electrical stimulation, botulinum toxin, and their combination for spastic drop foot. Ari Jacob Levi Wilkenfeld, MD, PhD. Aim Review pathophysiology of spastic drop foot and its treatment options.

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Review of electrical stimulation, botulinum toxin, and their combination for spastic drop foot

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  1. Review of electrical stimulation, botulinum toxin, and their combination for spastic drop foot Ari Jacob Levi Wilkenfeld, MD, PhD

  2. 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.

  3. 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.

  4. 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.

  5. 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.

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