Administration of botulinum neurotoxin A (BoNT-A) to the ankle plantar flexors in patients with hemiplegia reduces the strength of knee extension, which may decrease their walking ability. Studies have reported improvements in walking ability with physical therapy following BoNT-A administration. However, no previous studies have evaluated from an exercise physiology perspective the efficacy of physical therapy after BoNT-A administration for adult patients with hemiplegia. To investigate the effects of physical therapy following BoNT-A administration on gait electromyography for patients with hemiparesis secondary to stroke. Non-randomized controlled trial. Single center. Thirty-five patients with chronic stroke with spasticity were assigned to BoNT-A monotherapy (N.=18) or BoNT-A plus physical therapy (PT) (N.=17). On the paralyzed side of the body, 300 single doses of BoNT-A were administered intramuscularly to the ankle plantar flexors. Physical therapy was performed for 2 weeks, starting from the day after administration. Gait electromyography was performed and gait parameters were measured immediately before and 2 weeks after BoNT-A administration. Relative muscle activity, coactivation indices, and walking time/distance were calculated for each phase. For patients who received BoNT-A monotherapy, soleus activity during the loading response decreased 2 weeks after the intervention (P<0.01). For those who received BoNT-A+PT, biceps femoris activity and knee coactivation index during the loading response and tibialis anterior activity during the pre-swing phases increased, whereas soleus and rectus femoris activities during the swing phase decreased 2 weeks after the intervention (P<0.05). These rates of change were significantly greater than those for patients who received BoNT-A monotherapy (P<0.05). Following BoNT-A monotherapy, soleus activity during the stance phase decreased and walking ability either remained unchanged or deteriorated. Following BoNT-A+PT, muscle activity and knee joint stability increased during the stance phase, and abnormal muscle activity during the swing phase was suppressed. If botulinum treatment of the ankle plantar flexors in stroke patients is targeted to those with low knee extension strength, or if it aims to improve leg swing on the paralyzed side of the body, then physical therapy following BoNT-A administration could be an essential part of the treatment strategy.

Background: Although randomized controlled trials (RCTs) have shown that calcitonin gene-related peptide (CGRP)-targeted monoclonal antibodies (CGRP mAbs) are an efficacious and safe therapeutic modality for migraine prevention, their clinical benefits have not been well validated in Japanese patients in the real-world setting. The present study aimed to evaluate the real-world efficacy and safety of galcanezumab, fremanezumab, and erenumab in Japanese patients with migraine. Methods: This observational retrospective cohort study was conducted at two headache centers in Japan. Patients with migraine who had experienced treatment failure with at least one traditional oral migraine preventive agent were treated with a CGRP mAb de novo. The primary efficacy endpoints were the changes from baseline in monthly migraine days (MMDs) and Headache Impact Test-6 (HIT-6) score after 3 dosing intervals (V3). We explored whether demographic and clinical characteristics predicted therapeutic outcomes at V3. Results: Sixty-eight patients who completed three doses of a CGRP mAb (85.3% female [58/68], mean age: 46.2 ± 13.1 years) were included in the analysis. There were 19 patients with chronic migraine. The baseline MMDs were 13.4 ± 6.0. After 3 doses, the MMDs significantly decreased to 7.4 ± 5.5 (p < 0.0001), and the 50% response rate was 50.0%. HIT-6 score was significantly reduced from 66.7 ± 5.4 to 56.2 ± 8.7 after 3 doses (P = 0.0001). There was a positive correlation between the changes in MMDs and HIT-6 score from baseline after 2 doses (p = 0.0189). Those who achieved a ≥ 50% therapeutic response after the first and second doses were significantly more likely to do so at V3 (crude odds ratio: 3.474 [95% CI: 1.037 to 10.4], p = 0.0467). The most frequent adverse event was constipation (7.4%). None of the adverse events were serious, and there was no need for treatment discontinuation. Conclusions: This real-world study demonstrated that CGRP mAbs conferred Japanese patients with efficacious and safe migraine prevention, and an initial positive therapeutic response was predictive of subsequent favorable outcomes. Concomitant measurement of MMDs and HIT-6 score was useful in evaluating the efficacy of CGRP mAbs in migraine prevention.

Abnormal gait, particularly in patients with stroke, causes neuromuscular fatigue. We aimed to clarify temporal changes in gait performance and lower limb muscle activity during extended walking in people with stroke hemiplegia. Twelve adults with stroke and eleven healthy controls performed an extended trial involving 20-min continuous walk at a comfortable speed. The primary outcome was electromyography amplitude during the trial and secondary outcomes were walking performance and the instantaneous mean frequency of electromyography during the trial. Data at 1, 6, 12, and 18 min after initiating walking were compared. Performance during extended walking in people with stroke was maintained over time. The electromyography amplitude decreased in the tibialis anterior during the pre-swing phase and increased in the rectus femoris during the single-support phase over time; these changes were similar on the paretic and nonparetic sides. Instantaneous mean frequency decreased over time on the nonparetic side in the tibialis anterior and on the paretic side in the rectus femoris. Healthy subjects did not show any changes over time. The changes in muscle activity in patients with stroke differed between the paretic and nonparetic sides, muscle type, and gait phase; walking performance was maintained despite being affected by neuromuscular fatigue.

Stiff knee gait (SKG) occurrence after a stroke is associated with various abnormal muscle activities; however, the interactions among these muscles are unclear. This study aimed to elucidate the muscle synergy characteristics during walking in patients with SKG after a stroke. This cross-sectional study included 20 patients with poststroke SKG (SKG group), 16 patients without poststroke SKG (non-SKG group), and 15 healthy adults (control group). Participants walked a 10-m distance at a comfortable speed, and electromyographic data were recorded from six lower-limb muscles. Non-negative matrix factorization was employed to derive time-varying activity (C), muscle weights (W), and the percentage of total variance accounted for (tVAF) for muscle synergies. The SKG group showed a higher tVAF than the control group. The initial stance module (including knee extensors) showed increased activity during the swing phase. The initial swing module (including hip flexors and ankle dorsiflexors) exhibited a higher activity during the single-support phase but a lower activity during the swing phase. The synergy structure in patients with SKG after stroke was simplified, with specific abnormalities in synergy activities. SKG may arise from several synergy alterations involving multiple muscles, indicating that approaches focused on controlling individual muscle activities are unsuitable.