Botulinum Toxin Injections by Ultrasounds Guidance and Stretching Exercise in Spastic Toe Clawing

The investigators will enroll 50 hemiplegic stroke patients met the inclusion criteria(onset more than 6 month, lower extremity Brunnstrome stage more than stage IV, walking without assistance devices and pain during walking due to claw toe. The investigators will focus and inject BTX-A with ultrasonographyic guidance on flexor digitorum longus and brevis(both 50 unit). If patients combine ankle plantar flexors spasticity, the investigators will inject another 50 unit on both the medial and lateral head of gastrocnemius . Every patients will receive regular stretching exercise in hospital and do self stretching exercise at home for 3 months after injection. Patients will be evaluated at 2 weeks, 4 weeks and 12 weeks, 24 weeks and 1 year after injection. Outcome measure include severity of spasticity and pain, sensory and motor function, range of motion, functional assessment of lower extremity and analyze pressure under foot.

Inclusion criteria

• Patient with spasticity toe clawing(metatarsophalange jointextension, proximal and distal phalange joint flexion)
• MAS scale of metatarsophalange joint and interphalangeal joint more than 2
• Pain during walking, abnormal gait patterns and can't wear shoess due to claw toe
• Haven't received botox or phenol or alcohol injections before

Exclusion criteria

• Lower extremities joint contrature, bone deformity
• Had received botox injections or phenol injections or before due to lower extremities spasticity
• Combine other neuromuscular system disease
• Severe cognition disorder or aphasia after stroke
• Significant atrophy of flexor digitorum longus and brevis
• Allergy to botox
• Infection on injection site
• Have systemic infection
• Now accept aminioglycoside or other medicine will affect neuromusclar transition