Bò Maria Chiara [LAM – Motion Analysis Laboratory, Neuromotor and Rehabilitation Department, San Sebastiano Hospital, Azienda USL-IRCCS di Reggio Emilia, Correggio (Reggio Emilia), Italy]
Cavazzuti Lorenzo [LAM – Motion Analysis Laboratory, Neuromotor and Rehabilitation Department, San Sebastiano Hospital, Azienda USL-IRCCS di Reggio Emilia, Correggio (Reggio Emilia), Italy]
Lusuardi Mirco [Neuromotor and Rehabilitation Department, Azienda USL-IRCCS Reggio Emilia, Correggio (Reggio Emilia), Italy]
Damiano Benedetta [LAM – Motion Analysis Laboratory, Neuromotor and Rehabilitation Department, San Sebastiano Hospital, Azienda USL-IRCCS di Reggio Emilia, Correggio (Reggio Emilia), Italy]
Scaltriti Sara [LAM – Motion Analysis Laboratory, Neuromotor and Rehabilitation Department, San Sebastiano Hospital, Azienda USL-IRCCS di Reggio Emilia, Correggio (Reggio Emilia), Italy]
Guglielmini Francesco [Adjunct Professor, Department of Neurosciences, Biomedicine and Movement, University of Verona]
Merlo Andrea [LAM – Motion Analysis Laboratory, Neuromotor and Rehabilitation Department, San Sebastiano Hospital, Azienda USL-IRCCS di Reggio Emilia, Correggio (Reggio Emilia), Italy]
Campanini Isabella [LAM – Motion Analysis Laboratory, Neuromotor and Rehabilitation Department, San Sebastiano Hospital, Azienda USL-IRCCS di Reggio Emilia, Correggio (Reggio Emilia), Italy]
Equinus foot is one of the main lower limb deformities after a stroke. It results from a combination of altered motor control (e.g., triceps surae overactivity, dorsiflexor muscle paresis) and peripheral soft tissue changes (e.g., increased stiffness and viscosity, contractures) [1]. These phenomena are usually assessed at the bedside, with passive and active ankle movements [2,3]. Patients often suffer from limited walking ability both at home and in social settings, which can be assessed with specific questionnaires or functional tests [4]. It is still unclear whether and which measurements from the clinical assessment correspond to patients’ dynamic abilities. This study aims to understand the relationships between bedside ankle assessment and ambulation skills. This may help clinicians to categorise the patients within “standard” behaviour or as outliers, and refer them for further examinations, such as instrumental gait analysis with surface electromyography, if necessary.
This is a cross-sectional study. We included patients with hemiparesis due to stroke who underwent comprehensive clinical and instrumental assessment at our institution. Ankle-related measures were: passive and active dorsiflexion (aDF, pDF), dorsiflexor and plantarflexor muscle strength (dMRC, pMRC), and triceps surae spasticity, as assessed with the Modified Ashworth Scale (MAS) and the Tardieu angle. Ambulation-related measures were: Functional Ambulation Category (FAC), Walking Handicap Scale (WHS), Rivermead Mobility Index (RMI), and gait speed derived from gait analysis trials. Spearman’s rho and Kendall’s tau were used to describe correlation relationships between variables. Student’s t-test and Mann-Whitney’s U-test, along with related effect size (ES), were used to show significant differences between community and home-based walkers, as classified according to the cut-off thresholds provided by the literature. Statistical significance was set at 5%.
Thirty-three patients (27/6 M/F) aged 58.2 (12.8) and 28.2 (29.7) months post-stroke were included. Weak to strong relationships were shown between pDF, aDF, dMRC, pMRC, and the different assessments of walking ability (0.375 ≤ rho ≤ 0.705, p<0.05). MAS inversely correlated with gait speed only (rho = -0.378, p<0.05). Neither ankle- nor ambulation-related outcome measures were associated with triceps surae spasticity when measured with the Tardieu angle (rho < 0.299, p>0.05). Moreover, MAS and the Tardieu angle did not correlate (p>0.05). In general, a value of one variable could correspond to values across the entire range of the other variable, given the heterogeneity of the observations. Community walkers were significantly different from home-based walkers in terms of pDF, aDF, dMRC, pMRC (0.41 ≤ |ES| ≤ 1.61, p<0.05) (see Figure 1a, 1b) but did not differ in terms of MAS and Tardieu angle (p > 0.175) (see Figure 1c, 1d).
Associations between pDF, aDF, dMRC, pMRC and walking abilities suggest that patients with chronic stroke who maintained a fair range of motion and muscle strength are more likely to have walking abilities suitable for both safe and outdoor settings. Spasticity assessed with Tardieu Angle never correlated with walking abilities. Likely, spasticity did not occur during walking, even though it had been previously observed with passive manoeuvres at the bedside. This is probably because the patients with chronic stroke walked at very low speeds, which did not elicit a velocity-dependent phenomenon such as spasticity. Finally, MAS obtained conflicting results probably because it measures both stretch reflex activity and muscle contractures without distinguishing them [3]. Future studies should further explore the associations between these variables, highlighting possible cause-and-effect relationships that may guide tailored interventions.
[1] Gracies JM. Pathophysiology of spastic paresis. II: Emergence of muscle overactivity. Muscle Nerve. 2005;31(5):552-571. doi:10.1002/mus.20285
[2] de l’Escalopier N, Voisard C, Michaud M, et al. Evaluation methods to assess the efficacy of equinovarus foot surgery on the gait of post-stroke hemiplegic patients: A literature review. Front Neurol. 2022;13:1042667. Published 2022 Nov 9. doi:10.3389/fneur.2022.1042667
[3] Campanini I, Bò MC, Bassi MC, et al. Outcome measures for assessing the effectiveness of physiotherapy interventions on equinus foot deformity in post-stroke patients with triceps surae spasticity: A scoping review. PLoS One. 2023;18(10):e0287220. Published 2023 Oct 12. doi:10.1371/journal.pone.0287220
[4] Mudge S, Stott S. Outcome measures to assess walking ability following stroke: a systematic review of the literature. Physiotherapy. 2007;93(3):189–200. Published 2007 Sept. doi: 10.1016/j.physio.2006.12.010
