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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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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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Alter KE, Karp BI. Ultrasound Guidance for Botulinum Neurotoxin Chemodenervation Procedures. Toxins (Basel) 2017; 10:toxins10010018. [PMID: 29283397 PMCID: PMC5793105 DOI: 10.3390/toxins10010018] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/12/2017] [Accepted: 12/21/2017] [Indexed: 12/28/2022] Open
Abstract
Injections of botulinum neurotoxins (BoNTs) are prescribed by clinicians for a variety of disorders that cause over-activity of muscles; glands; pain and other structures. Accurately targeting the structure for injection is one of the principle goals when performing BoNTs procedures. Traditionally; injections have been guided by anatomic landmarks; palpation; range of motion; electromyography or electrical stimulation. Ultrasound (US) based imaging based guidance overcomes some of the limitations of traditional techniques. US and/or US combined with traditional guidance techniques is utilized and or recommended by many expert clinicians; authors and in practice guidelines by professional academies. This article reviews the advantages and disadvantages of available guidance techniques including US as well as technical aspects of US guidance and a focused literature review related to US guidance for chemodenervation procedures including BoNTs injection.
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Affiliation(s)
- Katharine E Alter
- Functional and Applied Biomechanics Section, Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892-1604, USA.
| | - Barbara I Karp
- Combined Neurosciences IRB, National Institutes of Health, Bethesda, MD 20892-1604, USA.
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Oliveira JB, Evêncio-Neto J, Baratella-Evêncio L. Histological and immunohistochemical findings of the action of botulinum toxin in salivary gland: systematic review. BRAZ J BIOL 2017; 77:251-259. [PMID: 27599097 DOI: 10.1590/1519-6984.11115] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 02/15/2016] [Indexed: 11/21/2022] Open
Abstract
The treatment of sialorrhea is necessary for the constant risks posed by hypersalivation. A new therapeutic option comes up with the application of botulinum toxin in salivary glands. However, little is known about its mechanism of action in glandular tissue. Based on the above, this work had the objective to systematically review the literature about the action of botulinum toxin on submandibular and parotid salivary glands tissues. Electronic search was performed in databases of great relevance for this study (PubMed, SciELO, HighWire, Crossref, Scopus, Science Direct, MEDLINE, OLDMEDLINE, Serials Database, NLM Catalog, LILACS and IBECS). Inclusion and exclusion criteria for articles were established, and a total number of 14 articles were selected and used. There are few publications that clarify how the salivary gland acini behave with application of botulinum toxin. Although, the immunohistochemical findings were consistent among authors, showing weak immunoreactivity in glands treated with botulinum toxin. Histometric data are divergent, requiring more detailed studies to answer the questions about the efficacy and safety of botulinum toxin in salivary glands.
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Affiliation(s)
- J B Oliveira
- Department of Anatomy, Biological Sciences Center - CCB, Universidade Federal de Pernambuco - UFPE, Av. Prof. Moraes Rego, 1235, Cidade Universitária, CEP 50670-901, Recife, PE, Brazil
- Post-graduate Program in Bioscience Animal - PPGBA, Universidade Federal Rural de Pernambuco - UFRPE, Rua Dom Manoel de Medeiros, s/n, Dois Irmãos, CEP 52171-900, Recife, PE, Brazil
| | - J Evêncio-Neto
- Post-graduate Program in Bioscience Animal - PPGBA, Universidade Federal Rural de Pernambuco - UFRPE, Rua Dom Manoel de Medeiros, s/n, Dois Irmãos, CEP 52171-900, Recife, PE, Brazil
- Department of Animal Morphology and Physiology, Universidade Federal Rural de Pernambuco - UFRPE, Rua Dom Manoel de Medeiros, s/n, Dois Irmãos, CEP 52171-900, Recife, PE, Brazil
| | - L Baratella-Evêncio
- Department of Histology and Embryology, Biological Sciences Center - CCB, Universidade Federal de Pernambuco - UFPE, Av. Prof. Moraes Rego, 1235, Cidade Universitária, CEP 50670-901, Recife, PE, Brazil
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McGuire J, Heath K, O'Dell MW. Should Ultrasound Be Used Routinely to Guide Botulinum Toxin Injections for Spasticity? PM R 2016; 8:1004-1010. [PMID: 27769363 DOI: 10.1016/j.pmrj.2016.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 09/15/2016] [Indexed: 11/19/2022]
Affiliation(s)
- John McGuire
- Associate Professor PM&R, Medical Director of Comprehensive Spasticity Management, Medical Director for Stroke Rehabilitation, Medical College of Wisconsin, Froedtert Memorial Lutheran Hospital, Milwaukee, WI
| | - Kelly Heath
- Assistant Professor, Neurorehabilitation, Department of Physical Medicine & Rehabilitation, Hospital of the University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Michael W O'Dell
- Division of Rehabilitation Medicine, Weill Cornell Medicine, 525 E. 68th Street, 16th FL, New York, NY 10065
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Li TY, Chang CY, Chou YC, Chen LC, Chu HY, Chiang SL, Chang ST, Wu YT. Effect of Radial Shock Wave Therapy on Spasticity of the Upper Limb in Patients With Chronic Stroke: A Prospective, Randomized, Single Blind, Controlled Trial. Medicine (Baltimore) 2016; 95:e3544. [PMID: 27149465 PMCID: PMC4863782 DOI: 10.1097/md.0000000000003544] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Recently, studies have reported that extracorporeal shock wave therapy (ESWT) is a safe, noninvasive, alternative treatment for spasticity. However, the effect of ESWT on spasticity cannot be determined, because most studies to date have enrolled small patient numbers and have lacked placebo-controlled groups and/or long-term follow-up. In addition, whether varying the number of ESWT sessions would affect the duration of the therapeutic effect has not been investigated in a single study. Hence, we performed a prospective, randomized, single blind, placebo-controlled study to investigate the long-term effect of radial ESWT (rESWT) in patients with poststroke spasticity and surveyed the outcome of functional activity.Sixty patients were randomized into 3 groups. Group A patients received 1 session of rESWT per week for 3 consecutive weeks; group B patients received a single session of rESWT; group C patients received one session of sham rESWT per week for 3 consecutive weeks. The primary outcome was Modified Ashworth Scale of hand and wrist, whereas the secondary outcomes were Fugl-Meyer Assessment of hand function and wrist control. Evaluations were performed before the first rESWT treatment and immediately 1, 4, 8, 12, and 16 weeks after the last session of rESWT.Compared to the control group, the significant reduction in spasticity of hand and wrist lasted at least 16 and 8 weeks in group A and B, respectively. Three sessions of rESWT had a longer-lasting effect than one session. Furthermore, the reduction in spasticity after 3 sessions of rESWT may be beneficial for hand function and wrist control and the effect was maintained for 16 and 12 weeks, respectively.rESWT may be valuable in decreasing spasticity of the hand and wrist with accompanying enhancement of wrist control and hand function in chronic stroke patients.
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Affiliation(s)
- Tsung-Ying Li
- From the Department of Physical Medicine and Rehabilitation (T-YL, C-YC, L-CC, H-YC, S-LC, S-TC, Y-TW), Tri-Service General Hospital, School of Medicine; School of Public Health, National Defense Medical Center (Y-CC), Neihu District, Taipei; Department of Physical Medicine and Rehabilitation (L-CC), Hualien Armed Forces General Hospital, Hualien County; and Department of Rehabilitation (S-TC), Taichung Veterans General Hospital, Taiwan Boulevard, Taichung, Taiwan, Republic of China
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Kurenkov AL, Klochkova OA, Zmanovskaya VA, Falkovskiy IV, Kenis VM, Vladykina LN, Krasavina DA, Nosko AS, Rychkova LV, Karimova KM, Bursagova BI, Namazova-baranova LS, Mamedyarov AM, Kuzenkova LM, Dontzov OG, Ryzhenkov MA, Butorina MN, Pavlova OL, Harlamova NN, Dankov DM, Levitina EV, Popkov DA, Ryabykh SO, Medvedeva SN, Gubina EB, Agranovich OV, Kiseleva TI, Vasileva ON, Zykov VP, Mihnovich VI, Belogorova ТА. The First Russian Consensus on the Multilevel Abobotulinumtoxin A Injections in Spastic Forms of Cerebral Palsy. Zh Nevrol Psikhiatr Im S S Korsakova 2016; 116:121-130. [DOI: 10.17116/jnevro2016116111121-130] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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8
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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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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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Abstract
Aside from its prompt use in musculoskeletal injuries (sports lesions, degenerative/inflammatory joint disorders, and peripheral nerve pathologies), ultrasonographic imaging can be used quite conveniently in various types of rehabilitation conditions as well. If used in a rehabilitation setting, ultrasound can significantly contribute to the diagnostic/therapeutic algorithm of rehabilitation patients. Accordingly, in this article, the authors focus on the diagnostic/interventional utility of ultrasound particularly for shoulder problems, overuse injuries of wheelchair users, heterotopic ossification, amputee follow-up, peripheral nerve and botulinum toxin injections, and diaphragm imaging/electromyography.
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Musculoskeletal Ultrasound in Physical Medicine and Rehabilitation. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2013. [DOI: 10.1007/s40141-012-0003-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Lim ECH, Quek AML, Seet RCS. Accurate targeting of botulinum toxin injections: how to and why. Parkinsonism Relat Disord 2012; 17 Suppl 1:S34-9. [PMID: 21999895 DOI: 10.1016/j.parkreldis.2011.06.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Botulinum toxin (BTX), the exotoxin of the obligate anaerobe, Clostridium botulinum, is used to ameliorate pain and treat conditions associated with glandular, smooth and skeletal muscle overactivity. The benefits derived from the injection of BTX may be negated by unintended weakness of uninjected muscles. Performance of BTX injections may be facile, requiring only surface marking or clinical-localisation techniques but may be more technically demanding, necessitating the use of equipment, such as electromyography (EMG) or ultrasonography (U/S). Less often, endoscopic, fluoroscopic or computed tomographic (CT) guidance may be required. Despite evidence to support the efficacy of BTX injections in treating many conditions, there is no evidence to support the superiority of any one injection technique over needle localisation using surface anatomy. This is possibly due to the lack of well-designed controlled studies, that is, current studies are hampered by small patient numbers, lack of consistency of injection technique and the application of different rating scales. Intuitively, certain injection techniques are more suited to injection of specific muscles or conditions, for example, U/S or passive-monitoring EMG should be used to treat cervical dystonia, active-monitoring EMG applied for strabismus injections, whereas either active-monitoring EMG or endoscopy is indicated when giving BTX for spasmodic dysphonia. Finally, electrical-stimulation EMG or U/S (or a combination of both) would be most suitable when injecting the forearm muscles for spasticity or writer's cramps.
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Affiliation(s)
- Erle C H Lim
- Division of Neurology, National University Hospital, National University Health System, National University of Singapore, Singapore.
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