title: Botulinum toxin type A combined with neurodynamic mobilization for lower limb spasticity: a case report.
abstract: OBJECTIVE
  This case report describes a patient with severe lower limb spasticity treated with botulinum toxin type A (BoNT-A) and neurodynamic mobilization (NM).
  
  
  METHODS
  An 81-year-old male patient presented with a severe spastic lower limbs after total right hip replacement and severe alcoholic polyneuropathy. After the right hip replacement, he presented with generalized spasticity, crouched posture, and a large sacral pressure sore. The severe spasticity in his knees prevented walking.
  
  
  RESULTS
  The patient underwent combined treatment with BoNT-A and NM of the lower limb in 4 weekly applications. Evaluations were performed pretreatment, 4 weeks after the injection, and at a follow-up session 9 months after finishing treatment. We measured the following outcomes: pain by the Numerical Rating Scale, spasticity by the Modified Ashworth Scale for Grading Spasticity, acceptance and emotional reaction to the treatment by the Hospital Anxiety and Depression Scale, and functionality by ranges of motion. We found that the patient improved in all of the outcomes after treatment, and these results were maintained during the follow-up. After treatment, the patient was able to improve wound healing by properly positioning himself in bed or on his wheelchair and walking with help. At the follow-up evaluation, the results were maintained. The patient showed good acceptance and decreased anxiety/depression after treatment.
  
  
  CONCLUSIONS
  For this patient, the combination of NM and BoNT-A treatment decreased pain and spasticity and improved joint ranges of motion.
authors.affiliation: Physical Therapist, Department of Physical Therapy, Residenza Sanitaria Assistenziale "A. Maritano," Sangano, Italy.
authors.forename: Jorge H
authors.initials: JH
authors.lastname: Villafañe
keywords: Botulinum toxin type A; Lower limb; Physiotherapy; Spasticity