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Criollo-Lamilla G, Imanilov A, Trévidic T, Trévidic P. [Forehead injections: Anatomy, technics, products]. ANN CHIR PLAST ESTH 2024:S0294-1260(24)00091-8. [PMID: 39060144 DOI: 10.1016/j.anplas.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 06/28/2024] [Indexed: 07/28/2024]
Abstract
Knowledge of anatomy not only allows optimal treatment and therefore full satisfaction of our patients, but is also fundamental in the prevention of complications. A thorough understanding of aging allows for effective treatments, as most patients demand a natural result, removing the inevitable signs of aging, which can only be understood by considering their aging. Facial aging is a natural but complex multifactorial process, particularly for the forehead. In this article, we will focus on botulinum toxin as well as fillers in aging.
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Affiliation(s)
| | - A Imanilov
- Expert2expert Group, chirurgiens plasticiens, Paris, France
| | - T Trévidic
- Expert2expert Group, chirurgiens plasticiens, Paris, France; Expert2expert Group, chirurgiens plasticiens, Budapest, Hongrie
| | - P Trévidic
- Expert2expert Group, chirurgiens plasticiens, Paris, France.
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Heslot C, Khan O, Schnitzler A, Haldane C, David R, Reebye R. Enhancing Botulinum Toxin Injection Precision: The Efficacy of a Single Cadaveric Ultrasound Training Intervention for Improved Anatomical Localization. Toxins (Basel) 2024; 16:304. [PMID: 39057944 PMCID: PMC11281316 DOI: 10.3390/toxins16070304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/25/2024] [Accepted: 06/26/2024] [Indexed: 07/28/2024] Open
Abstract
Ultrasound guidance can enhance existing landmark-based injection methods, even through a brief and single exposure during a cadaveric training course. A total of twelve participants were enrolled in this training program, comprising nine physical medicine and rehabilitation specialists, one pediatrician, and two physician assistants. For each participant, one upper-limb muscle and one lower-limb muscle were randomly chosen from the preselected muscle group. Subsequently, participants were tasked with injecting both of their chosen cadaveric muscles with 1 mL of acrylic paint using a manual needle palpation technique, relying solely on their knowledge of anatomic landmarks. Participants then underwent a personalized, one-to-one ultrasound teaching session, lasting approximately five minutes, conducted by two highly experienced instructors. Following this instructive phase, participants were tasked with a second round of injections, targeting the same two muscles in the lower and upper limbs. However, this time, the injections were performed using anatomical landmarks and ultrasound guidance. To facilitate differentiation from the initial injections, a distinct color of acrylic paint was employed. When employing the anatomical landmark-based approach, the overall success rate for injections was 67%, with 16 out of 24 targeted muscles accurately injected. With the incorporation of ultrasound guidance, the success rate was 92%, precisely targeting 22 out of the 24 muscles under examination. There was an improvement in injection accuracy achievable through the integration of ultrasound guidance, even with minimal training exposure. Our single cadaveric ultra-sound training program contributes valuable insights to the utilization of ultrasound for anatomy training to help optimize the targeting of BoNT-A.
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Affiliation(s)
- Camille Heslot
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada
- Faculty of Medicine, Paris Cité University, 75006 Paris, France
- Department of Physical Medicine and Rehabilitation, GH St Louis Lariboisière F. Widal, 75010 Paris, France
| | - Omar Khan
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada
- Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharines, ON L2T 4C2, Canada
| | - Alexis Schnitzler
- Faculty of Medicine, Paris Cité University, 75006 Paris, France
- Department of Physical Medicine and Rehabilitation, GH St Louis Lariboisière F. Widal, 75010 Paris, France
| | - Chloe Haldane
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada
| | - Romain David
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86000 Poitiers, France
- Department of Physical Medicine and Rehabilitation, Poitiers University Hospital, 86000 Poitiers, France
| | - Rajiv Reebye
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada
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He Z, Chen S, Zeng P, Dai M, Wei X, Chen J, Zhang X, Dou Z, Wen H, Li C. The effectiveness of ultrasound-guided injection of BTX-A in the management of sialorrhea in neurogenic dysphagia patients. Laryngoscope Investig Otolaryngol 2023; 8:1607-1615. [PMID: 38130251 PMCID: PMC10731496 DOI: 10.1002/lio2.1164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/08/2023] [Indexed: 12/23/2023] Open
Abstract
Objective To evaluate the effectiveness of ultrasound-guided injection of botulinum toxin type A (BTX-A) in treating sialorrhea. Methods We recruited 32 sialorrhea subjects and they received an ultrasound-guided injection of BTX-A. The extent of salivation was evaluated according to the Visual Analog Scale (VAS), Drooling Severity and Frequency Scale (DSFS), and Saliva Flow Rate (SFR). Laryngeal secretions were evaluated based on Fiberoptic Endoscopic Evaluation of Swallowing (FEES) rated according to the Murray Secretion Scale (MSS). We assessed the extent of salivation and laryngeal secretions before injection and at 1, 2, and 4 weeks after injection. Results The scores for the VAS, DSFS-S, DSFS-F, and DSFS-T decreased significantly at 1, 2, and 4 weeks after injection compared with before injection (p < .05). Based on VAS, the efficacy was substantially higher at 2 and 4 weeks after injection than at 1 week after injection (p < .05). According to DSFS-S and DSFS-T, the efficacy was significantly higher at 4 weeks than at 1 week after injection (p < .05). The SFR and MSS scores at 1 and 2 weeks after injection were superior to those before injection (p < .05). Meanwhile, the SFR score 2 weeks after injection was superior to that 1 week after injection (p < .05). Conclusion The ultrasound-guided injection of BTX-A can effectively reduce saliva secretion in patients with neurogenic dysphagia. Furthermore, it has the advantages of early onset time and lasting curative effects, which indicates that clinical promotion and application of this technique are justified. Level of Evidence Level 3.
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Affiliation(s)
- Zitong He
- Department of Rehabilitation Medicine, The Third Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Suling Chen
- Department of Rehabilitation Medicine, The Third Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Peishan Zeng
- Department of Rehabilitation Medicine, The Third Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Meng Dai
- Department of Rehabilitation Medicine, The Third Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Xiaomei Wei
- Department of Rehabilitation Medicine, The Third Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Jiemei Chen
- Department of Rehabilitation Medicine, The Third Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Xue Zhang
- Department of Rehabilitation Medicine, The Third Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Zulin Dou
- Department of Rehabilitation Medicine, The Third Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Hongmei Wen
- Department of Rehabilitation Medicine, The Third Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Chao Li
- Department of Rehabilitation Medicine, The Third Affiliated HospitalSun Yat‐sen UniversityGuangzhouChina
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Asimakidou E, Sidiropoulos C. A Bayesian Network Meta-Analysis and Systematic Review of Guidance Techniques in Botulinum Toxin Injections and Their Hierarchy in the Treatment of Limb Spasticity. Toxins (Basel) 2023; 15:toxins15040256. [PMID: 37104194 PMCID: PMC10145352 DOI: 10.3390/toxins15040256] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/22/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Accurate targeting of overactive muscles is fundamental for successful botulinum neurotoxin (BoNT) injections in the treatment of spasticity. The necessity of instrumented guidance and the superiority of one or more guidance techniques are ambiguous. Here, we sought to investigate if guided BoNT injections lead to a better clinical outcome in adults with limb spasticity compared to non-guided injections. We also aimed to elucidate the hierarchy of common guidance techniques including electromyography, electrostimulation, manual needle placement and ultrasound. To this end, we conducted a Bayesian network meta-analysis and systematic review with 245 patients using the MetaInsight software, R and the Cochrane Review Manager. Our study provided, for the first time, quantitative evidence supporting the superiority of guided BoNT injections over the non-guided ones. The hierarchy comprised ultrasound on the first level, electrostimulation on the second, electromyography on the third and manual needle placement on the last level. The difference between ultrasound and electrostimulation was minor and, thus, appropriate contextualization is essential for decision making. Taken together, guided BoNT injections based on ultrasound and electrostimulation performed by experienced practitioners lead to a better clinical outcome within the first month post-injection in adults with limb spasticity. In the present study, ultrasound performed slightly better, but large-scale trials should shed more light on which modality is superior.
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Lungu C, Nmashie A, George MC, Karp BI, Alter K, Shin S, Tse W, Frucht SJ, Wu T, Koo V, Considine E, Norato G, Hallett M, Simpson DM. Comparison of Ultrasound and Electrical Stimulation Guidance for Onabotulinum Toxin-A Injections: A Randomized Crossover Study. Mov Disord Clin Pract 2022; 9:1055-1061. [PMID: 36523503 PMCID: PMC9631842 DOI: 10.1002/mdc3.13546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 07/11/2022] [Accepted: 07/24/2022] [Indexed: 09/09/2023] Open
Abstract
Background Botulinum neurotoxin (BoNT) injection is an established therapy for limb spasticity and focal limb dystonia. Comparative benefits of injection guidance procedures have not been rigorously studied. Objectives We compared 2 targeting techniques for onabotulinumtoxin-A (onabotA) injection for the treatment of focal hand dystonia and upper limb spasticity: electrophysiologic guidance using electrical stimulation (E-stim) and ultrasound (US). Methods This was a 2-center, randomized, crossover, assessor-blinded trial. Participants with focal hand dystonia or upper limb spasticity, on stable onabotA therapy for at least 2 previous injection cycles, were randomly assigned to either E-stim or US with crossover at 3 months. The primary outcome was improvement in dystonia or spasticity severity on a visual analog scale (VAS; 0-100) measured 1 month after each injection. The secondary outcome was participant discomfort assessed on a VAS. Repeated-measures analysis of covariance was used with linear mixed-model covariate selection. Results A total of 19 participants (13 men) completed the study, 10 with upper limb spasticity and 9 with dystonia. Benefit was equivalent between the 2 techniques (VAS least-square mean [LSmean] 51.5 mm with US and 53.1 with E-stim). E-stim was perceived as more uncomfortable by participants (VAS LSmean 34.5 vs. 19.9 for E-stim and US, respectively). Procedure duration was similar with the 2 procedures. There were no serious adverse events related to either approach. Conclusions US and E-Stim localization guidance techniques provide equivalent efficacy in onabotA injections for spasticity and dystonia. US guidance injections are more comfortable for participants. Both techniques are effective guidance methods, with US potentially preferable based on participant comfort.
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Affiliation(s)
- Codrin Lungu
- Division of Clinical Research, National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMarylandUSA
| | - Alexandra Nmashie
- Department of PediatricsNew York Medical College/NYCHealth Hospitals/MetropolitanNew YorkNew YorkUSA
| | | | - Barbara I. Karp
- Division of Clinical Research, National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMarylandUSA
| | - Katharine Alter
- Department of Rehabilitation MedicineClinical Center, National Institutes of HealthBethesdaMarylandUSA
| | - Susan Shin
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Winona Tse
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Steven J. Frucht
- Department of NeurologyNew York University Grossman School of MedicineNew YorkNew YorkUSA
| | - Tianxia Wu
- Clinical Trials UnitNational Institute of Neurological Disorders and Stroke, National Institutes of HealthBethesdaMarylandUSA
| | - Vivian Koo
- Human Motor Control SectionNational Institute of Neurological Disorders and Stroke, National Institutes of HealthBethesdaMarylandUSA
| | - Elaine Considine
- Human Motor Control SectionNational Institute of Neurological Disorders and Stroke, National Institutes of HealthBethesdaMarylandUSA
| | - Gina Norato
- Clinical Trials UnitNational Institute of Neurological Disorders and Stroke, National Institutes of HealthBethesdaMarylandUSA
| | - Mark Hallett
- Human Motor Control SectionNational Institute of Neurological Disorders and Stroke, National Institutes of HealthBethesdaMarylandUSA
| | - David M. Simpson
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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6
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Chong Y, Li Z, Zhang D, Jin L, Chen C, Yu N, Long X. Ultrasonographic analysis of the calves for efficient botulinum toxin type A injection. J Cosmet Dermatol 2022; 21:4301-4306. [PMID: 35894831 DOI: 10.1111/jocd.15279] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/28/2022] [Accepted: 07/25/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Large calves are considered unattractive. Botulinum toxin type A (BoNT-A), acting as a neurotoxin that reduces muscle contraction, is widely used in calf contouring. However, there lacks detailed anatomical data to guide clinical injection. OBJECTIVES This study aims to use ultrasonography to provide depth information of the calf muscles and determine the morphological types of the gastrocnemius muscle. METHODS Ultrasound scanning was performed at six sites on 40 Chinese adults. A real-time ultrasound scannerwas used to detect the depth of the gastrocnemius muscle and the soleus muscle. RESULTS The thickness of the gastrocnemius muscle and the soleus muscle was measured. The depth from the skin to the surface, the middle, and the bottom of the gastrocnemius muscle was measured. The morphology of gastrocnemius muscle was classified into four different types under ultrasound according to the muscle bulge pattern. CONCLUSION This study took ultrasonic measurements of Asian calves to guide accurate and effective BoNT-A injection in real clinical practice.
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Affiliation(s)
- Yuming Chong
- Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhijin Li
- Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Dingyue Zhang
- Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lin Jin
- Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Cheng Chen
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Nanze Yu
- Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiao Long
- Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Li Z, Yang Y, Yu N, Zhou W, Li Z, Chong Y, Zhang Y, Wang HC, Chen C, Long X, Wang X. The "Visible" Muscles on Ultrasound Imaging Make Botulinum Toxin Injection More Precise: A Systematic Review. Aesthetic Plast Surg 2022; 46:406-418. [PMID: 34341856 DOI: 10.1007/s00266-021-02493-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 07/18/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Botulinum toxin (BoNT) injection is the most commonly performed procedure in cosmetic surgery. However, blind injection is unable to take individual anatomical variations into consideration, which is the main contributing factor to complications. Ultrasound (US) imaging was introduced to reduce complications and improve effects. This article will review uses of US in aesthetic BoNT injection. METHOD A systematic electronic search was performed using the PubMed, MEDLINE, Web of science. Search terms were set to focus on aesthetic BoNT injection. Two independent reviewers subsequently reviewed the resultant articles based on strict inclusion and exclusion criteria. Selected manuscripts were analysed and grouped by procedure categories. Clinical cases were all performed by one plastic surgeon in our department. RESULTS The search finally retained 24 articles. Five procedural categories were identified, including masseter (n = 16), frontalis (n = 2), glabella complex (n = 2), trapezius (n=1), and gastrocnemius (n = 3). US imaging is practical and instructive for pre-operative assessments as in needle-type selection, injection point localization and depth setting, as well as post-operative follow-ups regarding injection feedback (for instance, the extent of muscle volume decreases). What's more, ultrasound-guided injection makes needle trajectory visualized so as for the needle to reach the target muscle in avoidance of potential damage to neurovascular bundle, gland or adjacent muscle. CONCLUSION Muscles, such as masseter, frontalis, glabella complex, trapezius and gastrocnemius, and their adjacent structures can be well visualized using US, and as such, US can be a useful tool for a variety of pre-operative, intra-operative and post-operative procedures. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Zhijin Li
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Dongcheng District, Beijing, 100730, China
| | - Yanlong Yang
- The Seventh Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Nanze Yu
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Dongcheng District, Beijing, 100730, China.
| | - Wenzhe Zhou
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zirong Li
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Dongcheng District, Beijing, 100730, China
| | - Yuming Chong
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuwei Zhang
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hayson Chenyu Wang
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Dongcheng District, Beijing, 100730, China
| | - Cheng Chen
- Department of Ultrasound, Peking Union Medical College Hospital, Beijing, China
| | - Xiao Long
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Dongcheng District, Beijing, 100730, China
| | - Xiaojun Wang
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Dongcheng District, Beijing, 100730, China.
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Reebye R, Balbert A, Bensmail D, Walker H, Wissel J, Deltombe T, Francisco G. Module 2: Nonsurgical management of Spasticity. THE JOURNAL OF THE INTERNATIONAL SOCIETY OF PHYSICAL AND REHABILITATION MEDICINE 2022. [DOI: 10.4103/2349-7904.347808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Bäcker HC, Freibott CE, Swart E, Perka C, Jobin CM, Rosenwasser MP. A novel treatment for prevention of post-traumatic elbow stiffness using onaBotulinum toxin type A: a prospective placebo controlled randomized trial. Acta Orthop Belg 2021. [DOI: 10.52628/87.3.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Approximately 30% of all upper extremity fractures are elbow fractures which may result elbow stiffness. This study aimed to investigate the efficacy of onaBotulinum Toxin type A injection to prevent post-traumatic pain and elbow-stiffness. All patients were included who presented to a single surgeon with supracondylar/ intraarticular distal humerus fractures, proximal ulna and radius fractures. The study was developed in a randomized placebo controlled study between 2003-2007. The Disabilities of the Arm, Shoulder, and Hand (DASH) score as well as the arc-of-motion (AOM) were assessed after three, six, twelve-months and final follow up for evaluation. Of the 31-patients included, 15-patients (48.4%) received Botox injections. In all patients no complication was observed when injecting a dosage 100-units for the brachialis and biceps brachii muscles. Furthermore, it was an effective method to prevent post-traumatic elbow stiffness, lasting six- months. Significant differences in DASH, VAS-score and ROM after three-months between the Botox and control group (DASH 21.6±11.0 vs. 55.3±11.0 ; VAS 1.2±5.2 vs. 5.7±21.9 ; ROM 103±7.6 vs. 73±6.3 ; p>0.05) were identified in the prospective group. Botulinum toxin is a safe, reliable and effective treatment to prevent post-traumatic elbow stiffness.
Our study demonstrates improved early range-of- motion (p<0.05), better extension after 6 weeks and improved functional outcome including VAS and DASH score (p<0.05).
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Vova JA, Green MM, Brandenburg JE, Davidson L, Paulson A, Deshpande S, Oleszek JL, Inanoglu D, McLaughlin MJ. A consensus statement on the use of botulinum toxin in pediatric patients. PM R 2021; 14:1116-1142. [PMID: 34558213 DOI: 10.1002/pmrj.12713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 08/12/2021] [Accepted: 09/10/2021] [Indexed: 11/10/2022]
Abstract
Botulinum toxin has been used in medicine for the past 30 years. However, there continues to be controversy about the appropriate uses and dosing, especially in the pediatric population. A panel of nine pediatric physiatrists from different regions and previous training programs in the United States were nominated based on institutional reputation and botulinum toxin (BoNT) experience. Based on a review of the current literature, the goal was to provide the rationale for recommendations on the administration of BoNT in the pediatric population. The goal was not only to review safety, dosing, and injection techniques but also to develop a consensus on the appropriate uses in the pediatric population. In addition to upper and lower limb spasticity, the consensus also provides recommendations for congenital muscular torticollis, cervical dystonia, sialorrhea, and brachial plexus palsies.
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Affiliation(s)
- Joshua A Vova
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael M Green
- University of Utah/Primary Children's Hospital, Salt Lake City, Utah, USA
| | | | - Loren Davidson
- University of California Davis, Sacramento, California, USA
| | - Andrea Paulson
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Gillette Children's Specialty Healthcare, Minneapolis, Minnesota, USA
| | - Supreet Deshpande
- Gillette Children's Specialty Healthcare, Minneapolis, Minnesota, USA
| | | | - Didem Inanoglu
- Children's Health Specialty Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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11
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Nonnekes J, Geurts A. Letter to the Editor: Randomized Trial of Botulinum Toxin Type A in Hereditary Spastic Paraplegia-The SPASTOX Trial. Mov Disord 2021; 36:1733. [PMID: 34302383 PMCID: PMC8361968 DOI: 10.1002/mds.28659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jorik Nonnekes
- Donders Institute for Brain, Cognition and Behaviour, Department of Rehabilitation, Radboud University Medical Centre, Center of Expertise for Parkinson & Movement Disorders, Nijmegen, the Netherlands
| | - Alexander Geurts
- Donders Institute for Brain, Cognition and Behaviour, Department of Rehabilitation, Radboud University Medical Centre, Center of Expertise for Parkinson & Movement Disorders, Nijmegen, the Netherlands
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12
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Zhang C, Chen YT, Liu Y, Magat E, Gutierrez-Verduzco M, Francisco GE, Zhou P, Li S, Zhang Y. Improving Botulinum Toxin Efficiency in Treating Post-Stroke Spasticity Using 3D Innervation Zone Imaging. Int J Neural Syst 2021; 31:2150007. [PMID: 33438529 DOI: 10.1142/s0129065721500076] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Spasticity is a common post-stroke syndrome that imposes significant adverse impacts on patients and caregivers. This study aims to improve the efficiency of botulinum toxin (BoNT) in managing spasticity, by utilizing a three-dimensional innervation zone imaging (3DIZI) technique based on high-density surface electromyography (HD-sEMG) recordings. Stroke subjects were randomly assigned to two groups: the control group ([Formula: see text]) which received standard ultrasound-guided injections, and the experimental group ([Formula: see text]) which received 3DIZI-guided injections. The amount of BoNT given was consistent for all subjects. The Modified Ashworth Scale (MAS), compound muscle action potential (CMAP) and muscle activation volume (MAV) from bilateral biceps brachii muscles were obtained at the baseline, 3 weeks, and 3 months after injection. Intra-group and inter-group comparisons of MAS, CMAP amplitude and MAV were performed. An overall improvement in MAS of spastic elbow flexors was observed during the 3-week visit ([Formula: see text]), yet no statistically significant difference found with intra-group or inter-group analysis. Compared to the baseline, a significant reduction of CMAP amplitude and MAV were observed in the spastic biceps muscles of both groups at 3-week post-injection, and returned to approximate baseline value at 12-week post injection. A significantly higher reduction was found in CMAP amplitude ([Formula: see text]% versus [Formula: see text]%, [Formula: see text]) and MAV ([Formula: see text]% versus [Formula: see text]%, [Formula: see text]) in the experimental group compared to the control group. The study has demonstrated preliminary evidence that precisely directing BoNT to the innervation zones (IZs) localized by 3DIZI leads to a significantly higher treatment efficiency improvement in spasticity management. Results have also shown the feasibility of developing a personalized BoNT injection technique for the optimization of clinical treatment for post-stroke spasticity using proposed 3DIZI technique.
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Affiliation(s)
- Chuan Zhang
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
| | - Yen-Ting Chen
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston and TIRR, Memorial Hermann Hospital, Houston, TX, USA
| | - Yang Liu
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
| | - Elaine Magat
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston and TIRR, Memorial Hermann Hospital, Houston, TX, USA
| | - Monica Gutierrez-Verduzco
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston and TIRR, Memorial Hermann Hospital, Houston, TX, USA
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston and TIRR, Memorial Hermann Hospital, Houston, TX, USA
| | - Ping Zhou
- Institute of Rehabilitation Engineering, The University of Rehabilitation, Qingdao, P. R. China
| | - Sheng Li
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston and TIRR, Memorial Hermann Hospital, Houston, TX, USA
| | - Yingchun Zhang
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
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Kreisler A, Gerrebout C, Defebvre L, Demondion X. Accuracy of non-guided versus ultrasound-guided injections in cervical muscles: a cadaver study. J Neurol 2021; 268:1894-1902. [PMID: 33399965 DOI: 10.1007/s00415-020-10365-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/09/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The col-cap concept encouraged neurologists to inject a large group of muscles in the treatment of cervical dystonia. This includes deep muscles such as the obliquus capitis inferior or the semispinalis capitis, and muscles close to vascular or neurological structures such as scalene muscles. Our aim was to determine the accuracy of injections in cervical muscles using ultrasonography (US) or palpation of anatomical landmarks. METHODS A mix of paint, gelatin and iodized contrast agent was injected in nine pairs of cervical muscles of human cadavers, according to two injection techniques: US-guided and non-guided. The dye was localized on 1 cm-thick, frozen slices. RESULTS A total of 102 muscles was injected in the US-guided group (n = 8). The global accuracy was 88.2%. The lowest accuracy was in the OCI (41.7%); trying to avoid the vertebral artery, injections were too medial. A total of 54 muscles was injected in the non-guided group (n = 3). The global accuracy was 48.0%; moreover, some dye was found in four blood vessels. The embalming process produced texture changes, making difficult the palpation of bony landmarks. CONCLUSIONS Our results indicate that US-guided injections are more accurate than non-guided injections in most cervical muscles.
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Affiliation(s)
- Alexandre Kreisler
- CHU Lille, Neurologie et Pathologie du Mouvement, F-59000, Lille, France.
| | - Camille Gerrebout
- CHU Lille, Neurologie et Pathologie du Mouvement, F-59000, Lille, France
| | - Luc Defebvre
- CHU Lille, Neurologie et Pathologie du Mouvement, F-59000, Lille, France
| | - Xavier Demondion
- CHU Lille, Radiologie et Imagerie Musculo-squelettique, F-59000, Lille, France
- Department of Anatomy and Organogenesis, Univ. Lille, F-59045, Lille, France
- CHU Lille, ULR 7367 - UTML&A - Unité de Taphonomie Médico-Légale et d'Anatomie, Univ. Lille, F-59000, Lille, France
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Abstract
Spasticity is one component of the upper motor neuron (UMN) syndrome resulting from a multitude of neurologic conditions, such as stroke, brain injury, spinal cord injury, multiple sclerosis, and cerebral palsy. It is clinically recognized as a phenomenon of velocity-dependent increase in resistance, i.e., hypertonia. Recent advances in the pathophysiology of spasticity improve our understanding of mechanisms underlying this complex phenomenon and its relations to other components of UMN syndrome (weakness and disordered motor control), as well as the resultant clinical problems. This theoretical framework provides a foundation to set up treatment goals and to guide goal-oriented clinical assessment and treatment. Among a spectrum of treatment options, botulinum toxin (BoNT) therapy is the preferred treatment for focal spasticity. The evidence is very robust that BoNT therapy effectively reduces spasticity; however, it does not improve voluntary movement. In this chapter, we highlight a few issues on how to achieve the best clinical outcomes of BoNT therapy, such as dosing, dilution, guidance techniques, adjunctive therapies, early treatment, repeated injections, and central effects, as well as the ways to improve motor function in selected subgroups of patients with spasticity. We also discuss the reasons of poor responses to BoNT therapy and when not to use BoNT therapy.
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Affiliation(s)
- Sheng Li
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center Houston (UTHealth), Houston, TX, USA.
- TIRR Memorial Hermann Hospital, Houston, TX, USA.
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center Houston (UTHealth), Houston, TX, USA
- TIRR Memorial Hermann Hospital, Houston, TX, USA
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Ko YD, Yun SI, Ryoo D, Chung ME, Park J. Accuracy of Ultrasound-Guided and Non-guided Botulinum Toxin Injection Into Neck Muscles Involved in Cervical Dystonia: A Cadaveric Study. Ann Rehabil Med 2020; 44:370-377. [PMID: 32986942 PMCID: PMC7655231 DOI: 10.5535/arm.19211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 03/03/2020] [Indexed: 12/12/2022] Open
Abstract
Objective To compare the accuracy of ultrasound-guided and non-guided botulinum toxin injections into the neck muscles involved in cervical dystonia. Methods Two physicians examined six muscles (sternocleidomastoid, upper trapezius, levator scapulae, splenius capitis, scalenus anterior, and scalenus medius) from six fresh cadavers. Each physician injected ultrasound-guided and non-guided injections to each side of the cadaver’s neck muscles, respectively. Each physician then dissected the other physician’s injected muscle to identify the injection results. For each injection technique, different colored dyes were used. Dissection was performed to identify the results of the injections. The muscles were divided into two groups based on the difficulty of access: sternocleidomastoid and upper trapezius muscles (group A) and the levator scapulae, splenius capitis, scalenus anterior, and scalenus medius muscles (group B). Results The ultrasound-guided and non-guided injection accuracies of the group B muscles were 95.8% and 54.2%, respectively (p<0.001), while the ultrasound-guided and non-guided injection accuracies of the group A muscles were 100% and 79.2%, respectively (p<0.05). Conclusion Ultrasound-guided botulinum toxin injections into inaccessible neck muscles provide a higher degree of accuracy than non-guided injections. It may also be desirable to consider performing ultrasound-guided injections into accessible neck muscles.
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Affiliation(s)
- Yun Dam Ko
- Department of Rehabilitation Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soo In Yun
- Department of Rehabilitation Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dahye Ryoo
- Department of Rehabilitation Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Myung Eun Chung
- Department of Rehabilitation Medicine, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jihye Park
- Department of Rehabilitation Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Dias N, Zhang C, Smith CP, Lai HH, Zhang Y. High-density surface electromyographic assessment of pelvic floor hypertonicity in IC/BPS patients: a pilot study. Int Urogynecol J 2020; 32:1221-1228. [PMID: 32761375 DOI: 10.1007/s00192-020-04467-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 07/23/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION AND HYPOTHESIS To assess the feasibility of objectively assessing pelvic floor hypertonicity (PFH) in women with interstitial cystitis/bladder pain syndrome (IC/BPS) using an intra-vaginal high-density surface electromyography (HD-sEMG) probe. METHODS Seven female subjects (mean age 44 ± 13 years) with a prior diagnosis of IC/BPS were recruited. A full digital pelvic examination was administered to identify hypertonic muscles. Intra-vaginal HD-sEMG was acquired during rest. Root-mean-squared (RMS) amplitude during rest was calculated for each channel to define a hypertonicity index and hypertonic zone. Innervation zones (IZs) were identified from the bipolar mapping of decomposed HD-sEMG signals and summarized into an IZ distribution mapping. RESULTS Of the seven subjects recruited, five had normal pelvic floor muscle tone and two exhibited hypertonicity upon muscle palpation. Subjects with PFH demonstrated a higher hypertonicity index (12.6 ± 3.5 vs. 4.5 ± 1.2) in sessions 1 and 2. The hypertonic zone defined by the 64-channel RMS mapping coincided with the digital pelvic examination findings. The corresponding IZs were localized for each motor unit. The hypertonicity indices between two consecutive sessions were well correlated (CC = 0.95). CONCLUSIONS This study represents the first effort to employ intra-vaginal HD-sEMG to assess PFH in women with IC/BPS. Our results demonstrate the feasibility of HD-sEMG to provide a quantitative diagnosis of PFH and the precise localization of hypertonic muscles and IZs. The proposed HD-sEMG-based techniques provide promising tools for clinical diagnosis and treatment of PFH, such as the personalized guidance of BoNT injections.
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Affiliation(s)
- Nicholas Dias
- Department of Biomedical Engineering, University of Houston, Houston, TX, 77204, USA
| | - Chuan Zhang
- Department of Biomedical Engineering, University of Houston, Houston, TX, 77204, USA
| | | | - H Henry Lai
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Yingchun Zhang
- Department of Biomedical Engineering, University of Houston, Houston, TX, 77204, USA.
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Rectus Femoris Characteristics in Post Stroke Spasticity: Clinical Implications from Ultrasonographic Evaluation. Toxins (Basel) 2020; 12:toxins12080490. [PMID: 32751934 PMCID: PMC7472004 DOI: 10.3390/toxins12080490] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/26/2020] [Accepted: 07/29/2020] [Indexed: 11/21/2022] Open
Abstract
In stroke survivors, rectus femoris (RF) spasticity is often implicated in gait pattern alterations such as stiff knee gait (SKG). Botulinum toxin type A (BoNT-A) is considered the gold standard for focal spasticity treatment. However—even if the accuracy of injection is crucial for BoNT-A efficacy—instrumented guidance for BoNT-A injection is not routinely applied in clinical settings. In order to investigate the possible implications of an inadequate BoNT-A injection on patients’ clinical outcome, we evaluated the ultrasound-derived RF characteristics (muscle depth, muscle thickness, cross-sectional area and mean echo intensity) in 47 stroke survivors. In our sample, we observed wide variability of RF depth in both hemiparetic and unaffected side of included patients (0.44 and 3.54 cm and between 0.25 and 3.16 cm, respectively). Moreover, our analysis did not show significant differences between treated and non-treated RF in stroke survivors. These results suggest that considering the inter-individual variability in RF muscle depth and thickness, injection guidance should be considered for BoNT-A treatment in order to optimize the clinical outcome of treated patients. In particular, ultrasound guidance may help the clinicians in the long-term follow-up of muscle quality.
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Kreisler A, Simonin C, Degardin A, Mutez E, Defebvre L. Anatomy-guided injections of botulinum neurotoxin in neck muscles: how accurate is needle placement? Eur J Neurol 2020; 27:2142-2146. [PMID: 32579789 DOI: 10.1111/ene.14415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 06/17/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE In cervical dystonia, the accuracy of botulinum neurotoxin (BoNT) injections may influence the response to the treatment. METHODS We used ultrasound to evaluate the accuracy of anatomy-guided injections of BoNT in the neck muscles. RESULTS A total of 56 consecutive patients and 332 injections were evaluated. The overall accuracy was 76.6%. The lowest accuracy (67.9%) was observed for the splenius capitis muscle. CONCLUSIONS Anatomic guidance of BoNT injections in the neck muscles is often inaccurate. Imaging guidance may improve the accuracy of BoNT injections in cervical dystonia.
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Affiliation(s)
- A Kreisler
- Service de Neurologie et Pathologie du Mouvement, CHU Lille, Lille, France
| | - C Simonin
- Service de Neurologie et Pathologie du Mouvement, CHU Lille, Lille, France
| | - A Degardin
- Service de Neurologie et Pathologie du Mouvement, CHU Lille, Lille, France
| | - E Mutez
- Service de Neurologie et Pathologie du Mouvement, CHU Lille, Lille, France
| | - L Defebvre
- Service de Neurologie et Pathologie du Mouvement, CHU Lille, Lille, France
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Sätilä H. Over 25 Years of Pediatric Botulinum Toxin Treatments: What Have We Learned from Injection Techniques, Doses, Dilutions, and Recovery of Repeated Injections? Toxins (Basel) 2020; 12:toxins12070440. [PMID: 32640636 PMCID: PMC7404978 DOI: 10.3390/toxins12070440] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 12/20/2022] Open
Abstract
Botulinum toxin type A (BTXA) has been used for over 25 years in the management of pediatric lower and upper limb hypertonia, with the first reports in 1993. The most common indication is the injection of the triceps surae muscle for the correction of spastic equinus gait in children with cerebral palsy. The upper limb injection goals include improvements in function, better positioning of the arm, and facilitating the ease of care. Neurotoxin type A is the most widely used serotype in the pediatric population. After being injected into muscle, the release of acetylcholine at cholinergic nerve endings is blocked, and a temporary denervation and atrophy ensues. Targeting the correct muscle close to the neuromuscular junctions is considered essential and localization techniques have developed over time. However, each technique has its own limitations. The role of BTXA is flexible, but limited by the temporary mode of action as a focal spasticity treatment and the restrictions on the total dose deliverable per visit. As a mode of treatment, repeated BTXA injections are needed. This literature reviewed BTXA injection techniques, doses and dilutions, the recovery of muscles and the impact of repeated injections, with a focus on the pediatric population. Suggestions for future studies are also discussed.
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Affiliation(s)
- Heli Sätilä
- Department of Neuropediatrics, Päijät-Häme Central Hospital, Lahti, Finland, Keskussairaalankatu 7, 15850 Lahti, Finland
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Loram I, Siddique A, Sanchez MB, Harding P, Silverdale M, Kobylecki C, Cunningham R. Objective Analysis of Neck Muscle Boundaries for Cervical Dystonia Using Ultrasound Imaging and Deep Learning. IEEE J Biomed Health Inform 2020; 24:1016-1027. [PMID: 31940567 DOI: 10.1109/jbhi.2020.2964098] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To provide objective visualization and pattern analysis of neck muscle boundaries to inform and monitor treatment of cervical dystonia. METHODS We recorded transverse cervical ultrasound (US) images and whole-body motion analysis of sixty-one standing participants (35 cervical dystonia, 26 age matched controls). We manually annotated 3,272 US images sampling posture and the functional range of pitch, yaw, and roll head movements. Using previously validated methods, we used 60-fold cross validation to train, validate and test a deep neural network (U-net) to classify pixels to 13 categories (five paired neck muscles, skin, ligamentum nuchae, vertebra). For all participants for their normal standing posture, we segmented US images and classified condition (Dystonia/Control), sex and age (higher/lower) from segment boundaries. We performed an explanatory, visualization analysis of dystonia muscle-boundaries. RESULTS For all segments, agreement with manual labels was Dice Coefficient (64 ± 21%) and Hausdorff Distance (5.7 ± 4 mm). For deep muscle layers, boundaries predicted central injection sites with average precision 94 ± 3%. Using leave-one-out cross-validation, a support-vector-machine classified condition, sex, and age from predicted muscle boundaries at accuracy 70.5%, 67.2%, 52.4% respectively, exceeding classification by manual labels. From muscle boundaries, Dystonia clustered optimally into three sub-groups. These sub-groups are visualized and explained by three eigen-patterns which correlate significantly with truncal and head posture. CONCLUSION Using US, neck muscle shape alone discriminates dystonia from healthy controls. SIGNIFICANCE Using deep learning, US imaging allows online, automated visualization, and diagnostic analysis of cervical dystonia and segmentation of individual muscles for targeted injection.
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Paulson A, Zigler CK, Houtrow A, Pruitt D. Botulinum Toxin: Techniques Within Pediatric Physiatry. PM R 2019; 11:38-44. [DOI: 10.1016/j.pmrj.2018.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 06/15/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Andrea Paulson
- Department of Pediatrics; University of Cincinnati College of Medicine; Cincinnati OH 45267; Division of Pediatric Rehabilitation Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Christina K. Zigler
- Department of Physical Medicine and Rehabilitation; University of Pittsburgh; Pittsburgh PA
| | - Amy Houtrow
- Department of Physical Medicine and Rehabilitation; University of Pittsburgh; Pittsburgh PA
| | - David Pruitt
- Department of Pediatrics; University of Cincinnati College of Medicine; Cincinnati OH; Division of Pediatric Rehabilitation Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Genêt F, Denormandie P, Keenan MA. Orthopaedic surgery for patients with central nervous system lesions: Concepts and techniques. Ann Phys Rehabil Med 2018; 62:225-233. [PMID: 30290282 DOI: 10.1016/j.rehab.2018.09.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 09/09/2018] [Accepted: 09/09/2018] [Indexed: 12/26/2022]
Abstract
Since ancient times, the aim of orthopedic surgery has been to correct limb and joint deformities, including those resulting from central nervous system lesions. Recent developments in the treatment of spasticity have led to changes in concepts and management strategies. The increase in life expectancy has increased the functional needs of patients. Orthopedic surgery, along with treatments for spasticity, improves the functional capacity of patients with neuro-orthopaedic disorders, improving their autonomy. In this paper, we describe key moments in the history of orthopedic surgery regarding the treatment of patients with central nervous system lesions, from poliomyelitis to stroke-related hemiplegia, from the limbs to the spine, and from contractures to heterotopic ossification. A synthesis of the current surgical techniques is then provided, and the importance of multidisciplinary evaluation and management is highlighted, along with indications for medical, rehabilitation and surgical treatments and their combinations. We explain why it is essential to consider patients' expectations and to set achievable goals, particularly before surgery, which is by nature irreversible. More recently, specialized surgical teams have begun to favor the use of soft-tissue techniques over bony and joint procedures, except for spinal disorders. We highlight that orthopedic surgery is no longer the end-point of treatment. For example, lengthening a contractured muscle improves the balance around a joint, improving mobility and stability but may be only part of the problem. Further medical treatment and rehabilitation, or additional surgery, are often necessary to continue to improve the function of the limb. Despite the recognized effectiveness of orthopedic surgery for neuro-orthopedic disorders, few studies have formally evaluated them. Hence, there is a need for research to provide evidence to support orthopedic surgery for treating neuro-orthopedic disorders.
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Affiliation(s)
- F Genêt
- Service de médecine physique et de réadaptation, hôpital Raymond Poincaré, Assistance publique-Hôpitaux de Paris, CIC-IT 1429, 92380 Garches, France; End:icap" U1179 Inserm, service de université Versailles Saint Quentin en Yvelines, UFR des Sciences de la Santé-Simone Veil, 2, avenue de la source de bièvres, 78170 Montigny le Bretonneux, France.
| | - P Denormandie
- End:icap" U1179 Inserm, service de université Versailles Saint Quentin en Yvelines, UFR des Sciences de la Santé-Simone Veil, 2, avenue de la source de bièvres, 78170 Montigny le Bretonneux, France; Chirurgie orthopédique et traumatologique, hôpital Raymond Poincaré, Assistance publique-Hôpitaux de Paris, CIC-IT 1429, 92380 Garches, France
| | - M A Keenan
- Penn Neuro-Orthopaedics Service, University of Pennsylvania, Philadelphia, PA, USA
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Schramm A, Huber D, Möbius C, Münchau A, Kohl Z, Bäumer T. Involvement of obliquus capitis inferior muscle in dystonic head tremor. Parkinsonism Relat Disord 2017; 44:119-123. [PMID: 28802760 DOI: 10.1016/j.parkreldis.2017.07.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 07/20/2017] [Accepted: 07/31/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Head tremor is a common feature in cervical dystonia (CD) and often less responsive to botulinum neurotoxin (BoNT) treatment than dystonic posturing. Ultrasound allows accurate targeting of deeper neck muscles. METHODS In 35 CD patients with dystonic head tremor the depth and thickness of the splenius capitis (SPL), semispinalis capitis and obliquus capitis inferior muscles (OCI) were assessed using ultrasound. Ultrasound guided EMG recordings were performed from the SPL and OCI. RESULTS Burst-like tremor activity was present in both OCI in 25 and in one in 10 patients. In 18 patients, tremor activity was present in one SPL and in 2 in both SPL. Depth and thickness of OCI, SPL and semispinalis capitis muscles were very variable. CONCLUSION Muscular activity underlying tremulous CD is most commonly present in OCI. Due to the variability of muscle thickness, we suggest ultrasound guided BoNT injections into OCI.
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Affiliation(s)
- A Schramm
- Department of Neurology, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nürnberg, Schwabachanlage 6, 91054 Erlangen, Germany
| | - D Huber
- Department of Neurology, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nürnberg, Schwabachanlage 6, 91054 Erlangen, Germany
| | - C Möbius
- Department of Neurology, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nürnberg, Schwabachanlage 6, 91054 Erlangen, Germany
| | - A Münchau
- Institute of Neurogenetics, Center for Brain, Behavior and Metabolism (CBBM), Marie-Curie-Strasse 66, 23538 Lübeck, Germany
| | - Z Kohl
- Department of Molecular Neurology, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nürnberg, Schwabachanlage 6, 91054 Erlangen, Germany
| | - T Bäumer
- Institute of Neurogenetics, Center for Brain, Behavior and Metabolism (CBBM), Marie-Curie-Strasse 66, 23538 Lübeck, Germany.
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Botulinum Toxin Injection-Site Selection for a Smooth Shoulder Line: An Anatomical Study. BIOMED RESEARCH INTERNATIONAL 2017; 2017:3092720. [PMID: 28246594 PMCID: PMC5299158 DOI: 10.1155/2017/3092720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 10/03/2016] [Indexed: 12/02/2022]
Abstract
Introduction. This study aimed to improve the accuracy of manual needle placement into the trapezius (TM) for smooth shoulder line. Methods. For macroscopic study 12 TMs and for microscopic study 4 cadavers were detached and then sampled, 1⁎1 cm at the four points from the origin to insertion site (0% at the most lateral point of external occipital protuberance and 100% at the most lateral point of acromion). Results. Most of the nerve endings observed during macroscopic investigations were concentrated in the 60–80% region, and the second most distributed region was the 40–60% region. The microscopic results revealed that the 60–80% region on the reference line had the most dense neuromuscular junction area, while the 40–60% and 80–100% areas were similar in their neuromuscular junction densities. Discussion. These anatomical results will be useful in clinical settings especially for cosmetic surgeons.
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Schramm A, Bäumer T, Fietzek U, Heitmann S, Walter U, Jost WH. Relevance of sonography for botulinum toxin treatment of cervical dystonia: an expert statement. J Neural Transm (Vienna) 2015; 122:1457-63. [PMID: 25547861 PMCID: PMC4591194 DOI: 10.1007/s00702-014-1356-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Accepted: 12/20/2014] [Indexed: 11/26/2022]
Abstract
Botulinum neurotoxin A (BoNT A) is the first-line treatment for cervical dystonia. However, although BoNT A has a favorable safety profile and is effective in the majority of patients, in some cases the treatment outcome is disappointing or side effects occur when higher doses are used. It is likely that in such cases either the target muscles were not injected accurately or unintended weakness of non-target muscles occurred. It has been demonstrated in clinical trials for spastic movement disorders that sonography-guided BoNT A injections could improve treatment outcome. As the published evidence for a benefit of sonography-guided BoNT injection in patients with cervical dystonia is scarce, it is the aim of this review to discuss the relevance of sonography in this indication and provide a statement from clinical experts for its use. The clear advantage of sonography-guided injections is non-invasive, real-time visualization of the targeted muscle, thus improving the precision of injections and potentially the treatment outcomes as well as avoiding adverse effects. Other imaging techniques are of limited value due to high costs, radiation exposure or non-availability in clinical routine. In the hands of a trained injector, sonography is a quick and non-invasive imaging technique. Novel treatment concepts of cervical dystonia considering the differential contributions of distinct cranial and cervical muscles can reliably be implemented only by use of imaging-guided injection protocols.
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Affiliation(s)
- Axel Schramm
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Tobias Bäumer
- Department of Movement Disorders and Neuropsychiatry, University of Lübeck, Lübeck, Germany
| | - Urban Fietzek
- Department of Neurology and Clinical Neurophysiology, Schön Klinik München Schwabing, Munich, Germany
| | - Susanne Heitmann
- Department of Neurology, Deutsche Klinik für Diagnostik, Wiesbaden, Germany
| | - Uwe Walter
- Department of Neurology, University of Rostock, Rostock, Germany
| | - Wolfgang H Jost
- Department of Neurology, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
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De Bruijn E, Nijmeijer S, Forbes P, Koelman J, van der Helm F, Tijssen M, Happee R. Improved identification of dystonic cervical muscles via abnormal muscle activity during isometric contractions. J Neurol Sci 2015; 354:10-6. [DOI: 10.1016/j.jns.2015.03.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 02/11/2015] [Accepted: 03/30/2015] [Indexed: 11/16/2022]
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Grigoriu AI, Dinomais M, Rémy-Néris O, Brochard S. Impact of Injection-Guiding Techniques on the Effectiveness of Botulinum Toxin for the Treatment of Focal Spasticity and Dystonia: A Systematic Review. Arch Phys Med Rehabil 2015; 96:2067-78.e1. [PMID: 25982240 DOI: 10.1016/j.apmr.2015.05.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 04/16/2015] [Accepted: 05/04/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To conduct a systematic review of the impact of different injection-guiding techniques on the effectiveness of botulinum toxin type A (BoNT-A) for the treatment of focal spasticity and dystonia. DATA SOURCES MEDLINE via PubMed, Academic Search Premier, PASCAL, The Cochrane Library, Scopus, SpringerLink, Web of Science, EM Premium, and PsycINFO. STUDY SELECTION Two reviewers independently selected studies based on predetermined inclusion criteria. DATA EXTRACTION Data relating to the aim were extracted. Methodological quality was graded independently by 2 reviewers using the Physiotherapy Evidence Database assessment scale for randomized controlled trials (RCTs) and the Downs and Black evaluation tool for non-RCTs. Level of evidence was determined using the modified Sackett scale. DATA SYNTHESIS Ten studies were included. Seven were randomized. There was strong evidence (level 1) that instrumented guiding (ultrasonography [US], electrical stimulation [ES], electromyogram [EMG]) was more effective than manual needle placement for the treatment of spasmodic torticollis, upper limb spasticity, and spastic equinus in patients with stroke, and spastic equinus in children with cerebral palsy. Three studies provided strong evidence (level 1) of similar effectiveness of US and ES for upper and lower limb spasticity in patients with stroke, and spastic equinus in children with cerebral palsy, but there was poor evidence or no available evidence for EMG or other instrumented techniques. CONCLUSIONS These results strongly recommend instrumented guidance of BoNT-A injection for the treatment of spasticity in adults and children (ES or US), and of focal dystonia such as spasmodic torticollis (EMG). No specific recommendations can be made regarding the choice of instrumented guiding technique, except that US appears to be more effective than ES for spastic equinus in adults with stroke.
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Affiliation(s)
| | - Mickael Dinomais
- LUNAM, University of Angers, University Hospital of Angers, Rehabilitation Department, Angers, France; LUNAM, University of Angers, Angers Laboratory for Research in Engineering Systems (LARIS)-UPRES EA, Angers, France
| | - Olivier Rémy-Néris
- University Hospital of Brest, Rehabilitation Department, Brest, France; Western Brittany University, Brest, France; National Institute of Health and Medical Research (INSERM) UMR 1101, Medical Data Treatment (LaTIM), Brest, France
| | - Sylvain Brochard
- University Hospital of Brest, Rehabilitation Department, Brest, France; Western Brittany University, Brest, France; National Institute of Health and Medical Research (INSERM) UMR 1101, Medical Data Treatment (LaTIM), Brest, France
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Yun JS, Chung MJ, Kim HR, So JI, Park JE, Oh HM, Lee JI. Accuracy of needle placement in cadavers: non-guided versus ultrasound-guided. Ann Rehabil Med 2015; 39:163-9. [PMID: 25932411 PMCID: PMC4414961 DOI: 10.5535/arm.2015.39.2.163] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 10/08/2014] [Indexed: 11/14/2022] Open
Abstract
Objective To compare the accuracy rates of non-guided vs. ultrasound-guided needle placement in four lower limb muscles (tibialis posterior, peroneus longus, and short and long heads of the biceps femoris). Methods Two electromyographers examined the four muscles in each of eight lower limbs from four fresh frozen cadavers. Each electromyographer injected an assigned dye into each targeted muscle in a lower limb twice (once without guidance, another under ultrasound guidance). Therefore, four injections were done in each muscle of one lower limb. All injections were performed by two electromyographers using 18 gauge 1.5 inch or 24 gauge 2.4 inch needles to place 0.5 mL of colored acryl solution into the target muscles. The third person was blinded to the injection technique and dissected the lower limbs and determined injection accuracy. Results A 71.9% accuracy rate was achieved by blind needle placement vs. 96.9% accuracy with ultrasound-guided needle placement (p=0.001). Blind needle placement accuracy ranged from 50% to 93.8%. Conclusion Ultrasound guidance produced superior accuracy compared with that of blind needle placement in most muscles. Clinicians should consider ultrasound guidance to optimize needle placement in these muscles, particularly the tibialis posterior.
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Affiliation(s)
- Jae Sung Yun
- Department of Rehabilitation Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Min Jae Chung
- Department of Rehabilitation Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hae Rim Kim
- Department of Rehabilitation Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jae In So
- Department of Rehabilitation Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jung Eun Park
- Department of Rehabilitation Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hyun Mi Oh
- Department of Rehabilitation Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jong In Lee
- Department of Rehabilitation Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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Jourdan C, Bévalot J, Denormandie P, Dionnet A, Parratte B. Training evaluation for a practice in spasticity-related techniques. Ann Phys Rehabil Med 2015; 58:114-5. [PMID: 25770006 DOI: 10.1016/j.rehab.2014.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 10/16/2014] [Indexed: 11/27/2022]
Affiliation(s)
- C Jourdan
- AP-HP, hôpital Raymond-Poincaré, service de médecine physique et de réadaptation, 104, boulevard Raymond-Poincaré, 92380 Garches, France; EA 4047 ECIPSY, université de Versailles Saint-Quentin UFR des sciences de la santé Simone Veil, 2 avenue de la Source-de-la-Bièvre, 78180 Montigny-Le-Bretonneux, France.
| | - J Bévalot
- Centre de rééducation et de réadaptation fonctionnelle des Salins de Brégille, 7, chemin Monts-de-Bregille-Haut, 25000 Besançon, France
| | - P Denormandie
- AP-HP, hôpital Raymond-Poincaré, service de chirurgie orthopédique, 104, boulevard Raymond-Poincaré, 92380 Garches, France
| | - A Dionnet
- École européenne de chirurgie, 45, rue des Saint-Pères, 75006 Paris, France
| | - B Parratte
- CHU de Besançon, service de médecine physique et de réadaptation, 2, place Saint-Jacques, 25000 Besançon, France; Université Franche Comté, laboratoire d'anatomie, UFR sciences médicales et pharmaceutiques, 19, rue Ambroise-Paré, 25030 Besançon cedex, France
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Walker HW, Lee MY, Bahroo LB, Hedera P, Charles D. Botulinum Toxin Injection Techniques for the Management of Adult Spasticity. PM R 2014; 7:417-27. [DOI: 10.1016/j.pmrj.2014.09.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 09/26/2014] [Accepted: 09/28/2014] [Indexed: 12/31/2022]
Affiliation(s)
- Heather W. Walker
- Department of Physical Medicine and Rehabilitation, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC
| | - Michael Y. Lee
- Department of Physical Medicine and Rehabilitation, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC
| | | | - Peter Hedera
- Department of Neurology, Vanderbilt University, Nashville, TN
| | - David Charles
- Department of Neurology, Vanderbilt University, Nashville, TN
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Intramuscular distribution of botulinum toxin—Visualized by MRI. J Neurol Sci 2014; 344:76-9. [DOI: 10.1016/j.jns.2014.06.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 06/08/2014] [Accepted: 06/13/2014] [Indexed: 11/22/2022]
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Walter U, Dressler D. Ultrasound-guided botulinum toxin injections in neurology: technique, indications and future perspectives. Expert Rev Neurother 2014; 14:923-36. [PMID: 25046267 DOI: 10.1586/14737175.2014.936387] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Botulinum toxin (BT) therapy is used in neurology to treat muscle hyperactivity disorders including dystonia, spasticity, cerebral palsy, hemifacial spasms and re-innervation synkinesias as well as exocrine gland hyperactivity disorders. To increase its therapeutic effect and to decrease adverse effects in adjacent tissues, exact BT placement is important. Ultrasonography (US) allows non-invasive, real-time imaging of muscular and glandular tissues and their surrounding structures. It can visualize, guide, and standardize the entire procedure of BT application. Small randomized studies suggest that US-guidance can improve therapeutic efficacy and reduce adverse effects of BT therapy when compared to conventional placement. US-guidance should be used in forearm muscles when functionality is important, and in selected leg muscles. It may be used for targeting distinct neck muscles in cervical dystonia. It is helpful for targeting the salivary glands. Here we review the technique, indications and future developments of US-guidance for BT injection in neurological disorders.
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Affiliation(s)
- Uwe Walter
- Department of Neurology, University of Rostock, Gehlsheimer Str. 20, D-18147, Rostock, Germany
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Nieto J, Juanes JA, Alonso P, Curto B, Hernández F, Moreno V, Ruisoto P. Computerized-Aid Medical Training. JOURNAL OF INFORMATION TECHNOLOGY RESEARCH 2014. [DOI: 10.4018/jitr.2014040104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The application of new technologies in training environments allows the development of new teaching modalities that enable knowledge and ability acquisition in healthcare professionals. Simulation has proven to be an effective method to favor and improve learning as well as to attain the necessary skills to perform a specific technique with greater reliability and security for the patient. We present a new tool or technological development in medical training, through an ultrasound simulator, valid for the knowledge and necessary ability acquisition in the proper infiltration of botulinum toxin guided by ultrasound. This tool benefits from the advantages that new technologies bring when applied in medical training, offering a virtual setting, comfortable and accessible, that does not require the user to move or have access to an ultrasound machine, allowing ultrasound explorations without the existence of a real patient.
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Affiliation(s)
- Javier Nieto
- Department of Rehabilitation, Universitary Hospital Salamanca, Salamanca, Spain
| | - Juan A Juanes
- VisualMed System Research Group, University of Salamanca, Salamanca, Spain
| | - Pablo Alonso
- Department of Anesthesia, Universitary Hospital Salamanca, Salamanca, Spain
| | - Belén Curto
- Department of Computer Science and Automatic, University of Salamanca, Salamanca, Spain
| | - Felipe Hernández
- Department of Anesthesia, Universitary Hospital Salamanca, Salamanca, Spain
| | - Vidal Moreno
- Department of Computer Science and Automatic, Universitary Hospital Salamanca, Salamanca, Spain
| | - Pablo Ruisoto
- VisualMed System Research Group, University of Salamanca, Salamanca, Spain
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Baxter M, Uddin N, Raghav S, Leong P, Low K, Hamza K, Holmes PW, Hamilton G, Thyagarajan D, Lau K, Bardin PG. Abnormal vocal cord movement treated with botulinum toxin in patients with asthma resistant to optimised management. Respirology 2014; 19:531-7. [PMID: 24655302 DOI: 10.1111/resp.12271] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 01/01/2014] [Accepted: 01/07/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Abnormal vocal cord movement may coexist with asthma and cause additional upper/middle airway obstruction. The condition may be a form of muscular dystonia that could contribute to asthma resistant to optimised treatments. Botulinum toxin causes temporary paralysis of muscle and may be an effective local treatment that improves asthma control. METHODS In an observational study, we evaluated the benefits of unilateral vocal cord injection with botulinum toxin in 11 patients (total 24 injections). Subjects had asthma resistant to optimised treatment and abnormal vocal cord movement. Responses after botulinum toxin treatment were assessed using asthma control test (ACT) scores, vocal cord narrowing quantified by computerised tomography (CT) of the larynx and spirometry. Side-effects were recorded. RESULTS ACT scores improved overall (9.1 ± 2.4 before and 13.5 ± 4.5 after treatment; difference 4.4 ± 4.2; P < 0.001). There was also an improvement in airway size on CT larynx (time below lower limit of normal at baseline 39.4 ± 37.63% and improved to 17.6 ± 25.6% after injection; P = 0.032). Spirometry was not altered. One patient experienced an asthma exacerbation but overall side-effects were moderate, chiefly dysphonia and dysphagia. CONCLUSIONS Although a placebo effect cannot be ruled out, local injection of botulinum toxin may be an effective treatment for intractable asthma associated with abnormal vocal cord movement. Further mechanistic studies and a double-blind randomised controlled trial of botulinum toxin treatment are merited.
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Affiliation(s)
- Malcolm Baxter
- Ear, Nose and Throat Surgery, Monash Medical Centre and Monash Institute of Medical Research (MIMR), Monash University, Melbourne, Victoria, Australia
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Isoyama H, Takeuchi N. Overview of botulinum toxin as a treatment for spasticity in stroke patients. World J Neurol 2013; 3:133-137. [DOI: 10.5316/wjn.v3.i4.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 10/03/2013] [Accepted: 11/05/2013] [Indexed: 02/06/2023] Open
Abstract
Spasticity after the occurrence of stroke induces limb deformity, functional disability and/or pain in patients, which limits their activities of daily living and deteriorates their quality of life. Botulinum toxin (BTX) has recently been reported as an efficacious therapeutic agent for the treatment of spasticity. Systematic review and meta-analysis studies have demonstrated that BTX therapy after stroke reduces spasticity and increases physical activity capacity and performance levels. Moreover, BTX can be used as an adjuvant in physiotherapy. Several studies have confirmed that the combination of BTX therapy and physiotherapy improves motor recovery. However, to date, only a few such combination studies have been conducted and their findings are considered preliminary and controversial. Therefore, future studies are required to determine the appropriate combination of treatment methods that will aid motor recovery.
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Peña E. Treatment with botulinum toxin: An update. World J Neurol 2013; 3:29-41. [DOI: 10.5316/wjn.v3.i3.29] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/10/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023] Open
Abstract
Botulinum neurotoxin (BoNT) is a potent toxin produced by the anaerobic bacterium clostridium botulinum. It causes flaccid, long-lasting, local and reversible paralysis. In addition, BoNT inhibits the secretion of the exocrine glands and could have properties in the control of pain. Thus, BoNT is useful in the treatment of many neuromuscular conditions where an increase of muscle tone is associated with the pathogenic mechanism. Furthermore, BoNT is recommended in the treatment of some hypersecretion disorders of the exocrine gland and could play a role in the treatment of migraine and other chronic pain conditions. In the BoNT therapy adverse effects are usually mild and reversible. However, repeated injections of BoNT can lead to the development of neutralizing antibodies that can subsequently inhibit the biological activity of the toxin. In this sense, many factors can influence the immunogenicity of the BoNT, such as product-related factors, the dose of BoNT used, the frequency of injection and the previous exposure to the toxin. In this review, we are going to discuss the current clinical applications of BoNT with a special focus on evidence, doses, injection technique and adverse effects for those applications more frequently used in neurology, namely spasticity, blepharospasm, hemifacial spasm, cervical dystonia and other focal dystonias, as well as chronic migraine, tremor, sialorrhea, facial palsy, neurogenic bladder and many other neurological condition.
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