Treatment strategies for Genu recurvatum in adult patients with hemiparesis: a case series

No idea on Genu recurvatum, that is what your doctor and therapists are supposed to know more about than you.
http://www.pmrjournal.org/article/S1934-1482%2814%2901474-9/abstract

Malathy Appasamy, MD^∗

,

Michelle E. De Witt^∗2

,

Nisha Patel, MD^∗1

,

Nancy Yeh, MD^∗2

,

Ona Bloom, Ph.D³

,

Anthony Oreste, MD^∗2

^∗Address where study conducted: Department of Physical Medicine and Rehabilitation The Hofstra North Shore Long Island Jewish health system 1554 Northern Blvd, 4th Floor Manhasset, New York 11030 TEL: 516-627-8470 FAX: 516-365-8941

¹Current institutional affiliation: Adventist rehab hospital 9909 Medical center drive Rockville MD 20850

²Department of Physical Medicine and Rehabilitation The Hofstra North Shore Long Island Jewish health system 1554 Northern Blvd, 4th Floor Manhasset, New York 11030 TEL: 516-627-8470 FAX: 516-365-8941

³Assistant Investigator, The Feinstein Institute for Medical Research Assistant Professor, Dept. of Physical Medicine and Rehabilitation; Molecular Medicine The Hofstra North Shore-LIJ School of Medicine 350 Community Drive, Fl 2352 Manhasset, NY 11030 Tel: #516-562-3839

Received: December 18, 2012; Received in revised form: October 3, 2014; Accepted: October 12, 2014; Published Online: November 13, 2014

DOI: http://dx.doi.org/10.1016/j.pmrj.2014.10.015

Publication stage: In Press Accepted Manuscript

Abstract

Objective

To report our clinical experience and propose a biomechanical factor-based treatment strategy for improvement of genu recurvatum (GR), in order to reduce the need for knee-ankle-foot orthosis (KAFO) or surgical treatment.

Design

Case series.

Setting

Outpatient clinic of a Department of Physical Medicine and Rehabilitation in an academic medical center.

Subjects and interventions

Adult subjects (n=22) with hemiparesis and GR who received Botulinium injections alone or in combination with multiple types of orthotic interventions that included solid AFO ± heel lift, hinged AFO with an adjustable posterior stop (APS) ± heel lift, AFO with dual-channel ankle joint ± heel lift or a knee AFO (KAFO) with offset knee joint. Biomechanical factors reviewed included muscle strength, modified Ashworth score (MAS) for spasticity, presence of clonus, posterior capsule laxity, sensory deficits and proprioception.

Outcome Measurements

Outcome factors were improvement or elimination of GR based on subjective assessment before and after the interventions by the same experienced clinician.

Results

More than one biomechanical factor contributed to GR in all patients. Botulinium toxin A injection was used in patients who had significant plantar flexor spasticity and/or clonus. Four types of orthotic interventions were used based on the biomechanical factor : solid AFO in patients with severe ankle dorsiflexion and plantar flexion weakness or clonus; hinged ankle joint with APS with less severe ankle dorsiflexion weakness in the absence of clonus; AFO with a dual-channel ankle joint for quadriceps weakness or severe proprioceptive deficits; KAFO with offset knee joints in Achilles tendon contracture or severe proprioceptive deficits. Adjunctive options included addition of heel lifts and to toe plate modifications. Combinatorial interventions of Botulinium injection, modified AFOs, and heel lifts improved or eliminated GR and avoided need for cumbersome orthotics or surgical interventions.

Conclusions

GR in hemiparesis is multifactorial and can be successfully controlled by a using a conservative biomechanical factor-based approach and using combined medical and orthotic interventions. A algorithmic approach and a prospective study design is proposed to determine a combination of effective interventions to correct GR.