Impact of instrumental analysis of stiff knee gait on treatment appropriateness and associated costs in stroke patients

Andrea Merlo, Isabella Campanini

Research output: Contribution to journalArticle

Abstract

Background: Stiff Knee Gait (SKG) in stroke patients is typically treated by the inhibition of the rectus femoris (RF) with botulinum toxin (BoNT) after clinical evaluation, obtaining an average pooled recovery in knee flexion (KF) of 7 degrees. Purpose: Our hypothesis is that this limited recovery after BoNT could depend on the inadequacy in the selection of patients to be treated. The aim of this study was to assess the percentage of inappropriate treatments (PIT) that can be avoided when instrumental gait analysis (GA) is used, and to estimate the associated cost savings. Methods: We retrospectively analyzed GA data from chronic stroke patients with SKG and clinically assessed knee extensors spasticity referred to our laboratory over a five-year period. Gait kinematics and dynamic electromyography data were used. Patients were considered unsuitable for RF inhibition when: their SKG was determined by inadequate ankle push-off (APO) rather than by a brake from knee extensors, based on a previously published algorithm using gait kinematics (PITKIN); when RF was not active during KF (PITEMG); and when a proximal braking mechanism was found, if this was not due to RF activity (PITGA). Results: 160 patients, age 20–87 years, gait speed 9–77%height/s, KF peak -4–44 degrees, were included. Of these, in 119 cases poor APO was the main cause of SKG, thus leading to PITKIN = 74%. In 48 out of 107 non-obese subjects, RF spasticity was not involved in SKG, resulting in PITEMG = 45%. Finally, patients with a braking activity as the main cause and concurrent RF activity were 20/107 = 19%, resulting in PITGA = 81% Significance: When treating SKG, proper use of GA can reduce the percentage of inappropriate treatments by BoNT at the RF up to 81%. Savings are in the order of €100k/year when considering centers treating 100 or more patients/year.

Original languageEnglish
Pages (from-to)195-201
Number of pages7
JournalGait and Posture
Volume72
DOIs
Publication statusPublished - Jul 1 2019
Externally publishedYes

Fingerprint

Gait
Knee
Stroke
Quadriceps Muscle
Costs and Cost Analysis
Botulinum Toxins
Therapeutics
Biomechanical Phenomena
Ankle
Cost Savings
Electromyography
Patient Selection

Keywords

  • Botulinum toxin
  • Gait analysis
  • Spasticity
  • Stiff knee gait
  • Treatment appropriateness

ASJC Scopus subject areas

  • Biophysics
  • Orthopedics and Sports Medicine
  • Rehabilitation

Cite this

Impact of instrumental analysis of stiff knee gait on treatment appropriateness and associated costs in stroke patients. / Merlo, Andrea; Campanini, Isabella.

In: Gait and Posture, Vol. 72, 01.07.2019, p. 195-201.

Research output: Contribution to journalArticle

@article{2a3d3b4e5b9140a8b7b20918c562571e,
title = "☆Impact of instrumental analysis of stiff knee gait on treatment appropriateness and associated costs in stroke patients",
abstract = "Background: Stiff Knee Gait (SKG) in stroke patients is typically treated by the inhibition of the rectus femoris (RF) with botulinum toxin (BoNT) after clinical evaluation, obtaining an average pooled recovery in knee flexion (KF) of 7 degrees. Purpose: Our hypothesis is that this limited recovery after BoNT could depend on the inadequacy in the selection of patients to be treated. The aim of this study was to assess the percentage of inappropriate treatments (PIT) that can be avoided when instrumental gait analysis (GA) is used, and to estimate the associated cost savings. Methods: We retrospectively analyzed GA data from chronic stroke patients with SKG and clinically assessed knee extensors spasticity referred to our laboratory over a five-year period. Gait kinematics and dynamic electromyography data were used. Patients were considered unsuitable for RF inhibition when: their SKG was determined by inadequate ankle push-off (APO) rather than by a brake from knee extensors, based on a previously published algorithm using gait kinematics (PITKIN); when RF was not active during KF (PITEMG); and when a proximal braking mechanism was found, if this was not due to RF activity (PITGA). Results: 160 patients, age 20–87 years, gait speed 9–77{\%}height/s, KF peak -4–44 degrees, were included. Of these, in 119 cases poor APO was the main cause of SKG, thus leading to PITKIN = 74{\%}. In 48 out of 107 non-obese subjects, RF spasticity was not involved in SKG, resulting in PITEMG = 45{\%}. Finally, patients with a braking activity as the main cause and concurrent RF activity were 20/107 = 19{\%}, resulting in PITGA = 81{\%} Significance: When treating SKG, proper use of GA can reduce the percentage of inappropriate treatments by BoNT at the RF up to 81{\%}. Savings are in the order of €100k/year when considering centers treating 100 or more patients/year.",
keywords = "Botulinum toxin, Gait analysis, Spasticity, Stiff knee gait, Treatment appropriateness",
author = "Andrea Merlo and Isabella Campanini",
year = "2019",
month = "7",
day = "1",
doi = "10.1016/j.gaitpost.2019.06.009",
language = "English",
volume = "72",
pages = "195--201",
journal = "Gait and Posture",
issn = "0966-6362",
publisher = "Elsevier B.V.",

}

TY - JOUR

T1 - ☆Impact of instrumental analysis of stiff knee gait on treatment appropriateness and associated costs in stroke patients

AU - Merlo, Andrea

AU - Campanini, Isabella

PY - 2019/7/1

Y1 - 2019/7/1

N2 - Background: Stiff Knee Gait (SKG) in stroke patients is typically treated by the inhibition of the rectus femoris (RF) with botulinum toxin (BoNT) after clinical evaluation, obtaining an average pooled recovery in knee flexion (KF) of 7 degrees. Purpose: Our hypothesis is that this limited recovery after BoNT could depend on the inadequacy in the selection of patients to be treated. The aim of this study was to assess the percentage of inappropriate treatments (PIT) that can be avoided when instrumental gait analysis (GA) is used, and to estimate the associated cost savings. Methods: We retrospectively analyzed GA data from chronic stroke patients with SKG and clinically assessed knee extensors spasticity referred to our laboratory over a five-year period. Gait kinematics and dynamic electromyography data were used. Patients were considered unsuitable for RF inhibition when: their SKG was determined by inadequate ankle push-off (APO) rather than by a brake from knee extensors, based on a previously published algorithm using gait kinematics (PITKIN); when RF was not active during KF (PITEMG); and when a proximal braking mechanism was found, if this was not due to RF activity (PITGA). Results: 160 patients, age 20–87 years, gait speed 9–77%height/s, KF peak -4–44 degrees, were included. Of these, in 119 cases poor APO was the main cause of SKG, thus leading to PITKIN = 74%. In 48 out of 107 non-obese subjects, RF spasticity was not involved in SKG, resulting in PITEMG = 45%. Finally, patients with a braking activity as the main cause and concurrent RF activity were 20/107 = 19%, resulting in PITGA = 81% Significance: When treating SKG, proper use of GA can reduce the percentage of inappropriate treatments by BoNT at the RF up to 81%. Savings are in the order of €100k/year when considering centers treating 100 or more patients/year.

AB - Background: Stiff Knee Gait (SKG) in stroke patients is typically treated by the inhibition of the rectus femoris (RF) with botulinum toxin (BoNT) after clinical evaluation, obtaining an average pooled recovery in knee flexion (KF) of 7 degrees. Purpose: Our hypothesis is that this limited recovery after BoNT could depend on the inadequacy in the selection of patients to be treated. The aim of this study was to assess the percentage of inappropriate treatments (PIT) that can be avoided when instrumental gait analysis (GA) is used, and to estimate the associated cost savings. Methods: We retrospectively analyzed GA data from chronic stroke patients with SKG and clinically assessed knee extensors spasticity referred to our laboratory over a five-year period. Gait kinematics and dynamic electromyography data were used. Patients were considered unsuitable for RF inhibition when: their SKG was determined by inadequate ankle push-off (APO) rather than by a brake from knee extensors, based on a previously published algorithm using gait kinematics (PITKIN); when RF was not active during KF (PITEMG); and when a proximal braking mechanism was found, if this was not due to RF activity (PITGA). Results: 160 patients, age 20–87 years, gait speed 9–77%height/s, KF peak -4–44 degrees, were included. Of these, in 119 cases poor APO was the main cause of SKG, thus leading to PITKIN = 74%. In 48 out of 107 non-obese subjects, RF spasticity was not involved in SKG, resulting in PITEMG = 45%. Finally, patients with a braking activity as the main cause and concurrent RF activity were 20/107 = 19%, resulting in PITGA = 81% Significance: When treating SKG, proper use of GA can reduce the percentage of inappropriate treatments by BoNT at the RF up to 81%. Savings are in the order of €100k/year when considering centers treating 100 or more patients/year.

KW - Botulinum toxin

KW - Gait analysis

KW - Spasticity

KW - Stiff knee gait

KW - Treatment appropriateness

UR - http://www.scopus.com/inward/record.url?scp=85067389963&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85067389963&partnerID=8YFLogxK

U2 - 10.1016/j.gaitpost.2019.06.009

DO - 10.1016/j.gaitpost.2019.06.009

M3 - Article

VL - 72

SP - 195

EP - 201

JO - Gait and Posture

JF - Gait and Posture

SN - 0966-6362

ER -