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Baricich A, Battaglia M, Borg MB, Loro A, Morlino P, Cosenza L, Bertoni M, Picelli A, Santamato A, Deltombe T. Multiple sclerosis and spasticity: the role of anaesthetic nerve blocks on rectus femoris muscle. When should stiff knee be treated with botulinum toxin? J Rehabil Med 2024; 56:jrm40437. [PMID: 39101677 PMCID: PMC11318643 DOI: 10.2340/jrm.v56.40437] [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: 03/27/2024] [Accepted: 07/15/2024] [Indexed: 08/06/2024] Open
Abstract
OBJECTIVE To compare the effect of rectus femoris diagnostic motor nerve blocks (DNB) with anaesthetics and rectus femoris muscle botulinum toxin (BoNT-A) injection in multiple sclerosis patients with unilateral stiff-knee gait. DESIGN Prospective observational study Subjects/Patients: Multiple sclerosis patients in stable condition. METHODS Patients underwent evaluation before and 1 hour after the anaesthetic block, and 1 month after the botulinum injection. Assessment included a 10-m walking test, a 6-minute walking test, a timed-up-and-go (TUG) test, and a Baseline Expanded Disability Status Scale (EDSS). Post-DNB and post-BoNT-A satisfaction was measured with the global assessment of efficacy scale. RESULTS Fourteen patients with unilateral stiff-knee gait due to multiple sclerosis underwent a DNB, among whom 13 received botulinum injections in the rectus femoris muscle after a satisfying test result. Positive post-DNB results correlated with significant functional improvements after BoNT-A. Higher EDSS and longer time from diagnosis correlated with poorer post-DNB and post-BoNT-A absolute outcomes. CONCLUSION DNB showed predictive value for BoNT-A outcomes, especially in the case of worse functional status. It effectively predicted endurance and walking speed improvement, while TUG showed greater improvement after botulinum. In cases of uncertain therapeutic benefit, nerve blocks may provide a valuable diagnostic support, particularly in patients with lower functional status.
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Affiliation(s)
- Alessio Baricich
- Physical and Rehabilitation Medicine, Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy; Physical and Rehabilitation Medicine, "Ospedale Maggiore della Carità" University Hospital, Novara, Italy
| | - Marco Battaglia
- Physical and Rehabilitation Medicine, Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy; Physical and Rehabilitation Medicine, "Ospedale Maggiore della Carità" University Hospital, Novara, Italy.
| | - Margherita B Borg
- Physical and Rehabilitation Medicine, Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy; Physical and Rehabilitation Medicine, "Ospedale Maggiore della Carità" University Hospital, Novara, Italy
| | - Alberto Loro
- Physical and Rehabilitation Medicine, Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy; Physical and Rehabilitation Medicine, "Ospedale Maggiore della Carità" University Hospital, Novara, Italy
| | - Paola Morlino
- Physical and Rehabilitation Medicine, "Ospedale Maggiore della Carità" University Hospital, Novara, Italy
| | - Lucia Cosenza
- Physical and Rehabilitation Medicine, "Ospedale Maggiore della Carità" University Hospital, Novara, Italy
| | - Michele Bertoni
- Physical Medicine and Rehabilitation, ASST Settelaghi, Varese, Italy
| | - Alessandro Picelli
- Neuromotor and Cognitive Rehabilitation Research Center, Department of Neurosciences, Biomedicine and Movement Sciences University of Verona Verona Italy
| | - Andrea Santamato
- Spasticity and Movement Disorders 'ReSTaRt' Unit, Physical Medicine and Rehabilitation Section, Policlinico Riuniti Hospital University of Foggia Foggia Italy
| | - Thierry Deltombe
- Department of Physical Medicine and Rehabilitation, Université de Louvain, Centre Hospitalier Universitaire de Namur, Yvoir, Belgium
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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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Li S, Winston P, Mas MF. Spasticity Treatment Beyond Botulinum Toxins. Phys Med Rehabil Clin N Am 2024; 35:399-418. [PMID: 38514226 DOI: 10.1016/j.pmr.2023.06.009] [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] [Indexed: 03/23/2024]
Abstract
Botulinum toxin (BonT) is the mainstream treatment option for post-stroke spasticity. BoNT therapy may not be adequate in those with severe spasticity. There are a number of emerging treatment options for spasticity management. In this paper, we focus on innovative and revived treatment options that can be alternative or complementary to BoNT therapy, including phenol neurolysis, cryoneurolysis, and extracorporeal shock wave 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, Houston, TX, USA; TIRR Memorial Herman.
| | - Paul Winston
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Victoria, British Columbia, Canada; Canadian Advances in Neuro-Orthopedics for Spasticity Consortium, Victoria, British Columbia, Canada
| | - Manuel F Mas
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Puerto Rico, San Juan, Puerto Rico
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Brun D, Hamel O, Montané E, Scandella M, Castel-Lacanal E, De Boissezon X, Philippe M, David G, Cormier C. Functional outcomes following surgery for spastic hip adductor muscles in ambulatory and non-ambulatory adults. J Rehabil Med 2024; 56:jrm18356. [PMID: 38528325 PMCID: PMC10985928 DOI: 10.2340/jrm.v56.18356] [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: 08/02/2023] [Accepted: 01/30/2024] [Indexed: 03/27/2024] Open
Abstract
OBJECTIVE To evaluate functional outcomes of surgery of spastic hip adductor muscles (obturator neurotomy with or without adductor longus tenotomy) in ambulatory and non-ambulatory patients, using preoperatively defined personalized goals. DESIGN Retrospective observational descriptive study. PATIENTS Twenty-three patients with adductor spasticity who underwent obturator neurotomy between May 2016 and May 2021 at the Clinique des Cèdres, Cornebarrieu, France, were included. METHODS Postoperative functional results were evaluated in accordance with the Goal Attainment Scaling method. Patients were considered "responders" if their score was ≥ 0. Secondary outcomes included spasticity, strength, hip range of motion and change in ambulatory capacity. When data were available, a comparison of pre- and postoperative 3-dimensional instrumented gait analysis was also performed. RESULTS Among the 23 patients only 3 were non-walkers. Seventeen/22 patients achieved their main goal and 14/23 patients achieved all their goals. Results were broadly similar for both walking goals (inter-knee contact, inter-feet contact, fluidity, walking perimeter, toe drag) and non-walking goals (intimacy, transfer, pain, posture, dressing). CONCLUSION Surgery of spastic hip adductor muscles results in functional improvement in ambulation, hygiene, dressing and posture and can be offered to patients with troublesome adductor overactivity. The use of a motor nerve block is recommended to define relevant goals before the surgery.
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Affiliation(s)
- Daphnée Brun
- Department of Physiological Explorations, University Hospital of Toulouse, Toulouse, France
| | - Olivier Hamel
- Neurosurgery Department, Neurosciences Pole, CAPIO, Clinique des Cèdres, Cornebarrieu
| | - Emmeline Montané
- University Hospital of Toulouse, Department of Physical and Rehabilitation Medicine, Toulouse, France
| | - Marino Scandella
- University Hospital of Toulouse, Laboratory of Gait Analysis, Toulouse, France
| | - Evelyne Castel-Lacanal
- University Hospital of Toulouse, Department of Physical and Rehabilitation Medicine, Toulouse, France
| | - Xavier De Boissezon
- University Hospital of Toulouse, Department of Physical and Rehabilitation Medicine, Toulouse, France
| | - Marque Philippe
- ToNIC (Toulouse NeuroImaging Center), Inserm, University of Toulouse 3, Toulouse, France
| | - Gasq David
- University Hospital of Toulouse, Department of Physiological Explorations, Toulouse, France
| | - Camille Cormier
- Department of Physiological Explorations, University Hospital of Toulouse, Toulouse, France.
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Shoval HA, Ace JC, Reddy MR, Grew EC, Cheng J. Safety and effectiveness of ethanol neurolysis with and without onabotulinumtoxinA in children with cerebral palsy. PM R 2023; 15:1419-1424. [PMID: 36970949 DOI: 10.1002/pmrj.12973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 02/19/2023] [Accepted: 03/05/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND OnabotulinumtoxinA is commonly used to relieve spasticity in children with neurologic disorders. Ethanol neurolysis may be used to target more muscles but is less well studied, especially in pediatrics. OBJECTIVE To determine the safety and effectiveness of ethanol neurolysis with onabotulinumtoxinA injections compared to only onabotulinumtoxinA injections for the treatment of spasticity in children with cerebral palsy. DESIGN Prospective cohort study including patients with cerebral palsy receiving onabotulinumtoxinA and/or ethanol neurolysis from June 2020 to June 2021. SETTING Outpatient physiatry clinic. PATIENTS A total of 167 children with cerebral palsy not undergoing other treatments during injection period. INTERVENTIONS Injection with either onabotulinumtoxinA only (112 children) or a combination of ethanol and onabotulinumtoxinA injections (55 children) using both ultrasound guidance and electrical stimulation. MAIN OUTCOME MEASURES A post-procedure evaluation at 2 weeks after injection documented any adverse effects experienced by the child and perceived magnitude of improvement using an ordinal scale from 1 to 5. Multiple linear regression was used to identify and control for covariates including Gross Motor Function Classification System, gender, age, weight, ethnicity, race, and dosage. RESULTS Only weight was identified as a confounding factor. When controlled for weight, combined onabotulinumtoxinA and ethanol injections had a greater magnitude of improvement (3.78/5) compared with onabotulinumtoxinA injections alone (3.44/5), a difference of 0.34 points on the rating scale (95% confidence interval: 0.01-0.69; p = .045). However, the difference was not clinically significant. One patient in the onabotulinumtoxinA-only group and two patients in the combined onabotulinumtoxinA and ethanol group reported mild, self-limiting adverse effects. CONCLUSION Ethanol neurolysis under ultrasound and electrical stimulation guidance may be a safe and effective treatment for children with cerebral palsy that allows more spastic muscles to be treated than onabotulinumtoxinA alone.
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Affiliation(s)
- Hannah A Shoval
- Department of Pediatric Physiatry, Atlantic Health System, Morristown, New Jersey, USA
- Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Jessica C Ace
- Department of Physical Medicine & Rehabilitation, JFK-Johnson Rehabilitation Institute, Edison, New Jersey, USA
| | - Mayuri R Reddy
- Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Emily C Grew
- Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - JenFu Cheng
- Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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Facciorusso S, Spina S, Gasperini G, Picelli A, Filippetti M, Molteni F, Santamato A. Anatomical landmarks for ultrasound-guided rectus femoris diagnostic nerve block in post-stroke spasticity. Australas J Ultrasound Med 2023; 26:236-242. [PMID: 38098618 PMCID: PMC10716569 DOI: 10.1002/ajum.12354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023] Open
Abstract
Introduction/Purpose To determine the location of the rectus femoris (RF) motor branch nerve, as well as its coordinates with reference to anatomical and ultrasound landmarks. Methods Thirty chronic stroke patients with stiff knee gait (SKG) and RF hyperactivity were included. The motor nerve branch to the RF muscle was identified medially to the vertical line from anterior superior iliac spine and the midpoint of the superior margin of the patella (line AP) and vertically to the horizontal line from the femoral pulse and its intersection point with the line AP (line F). The point of the motor branch (M) was located with ultrasound, and nerve depth and subcutaneous tissue thickness (ST) were calculated. Results The coordinates of the motor branch to the RF were 2.82 (0.47) cm medially to the line AP and 4.61 (0.83) cm vertically to the line F. Nerve depth and subcutaneous tissue thickness were 2.71 (0.62) cm and 1.12 (0.75) cm, respectively. Conclusion The use of specific coordinates may increase clinicians' confidence when performing RF motor nerve block. This could lead to better decision-making when assessing SKG in chronic stroke patients.
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Affiliation(s)
| | - Stefania Spina
- Spasticity and Movement Disorders ‘ReSTaRt’ Unit, Physical Medicine and Rehabilitation Section, Policlinico Riuniti HospitalUniversity of FoggiaFoggiaItaly
| | - Giulio Gasperini
- Villa Beretta Rehabilitation CenterValduce HospitalCosta MasnagaLeccoItaly
| | - Alessandro Picelli
- Neuromotor and Cognitive Rehabilitation Research Center, Department of Neurosciences, Biomedicine and Movement SciencesUniversity of VeronaVeronaItaly
| | - Mirko Filippetti
- Neuromotor and Cognitive Rehabilitation Research Center, Department of Neurosciences, Biomedicine and Movement SciencesUniversity of VeronaVeronaItaly
| | - Franco Molteni
- Villa Beretta Rehabilitation CenterValduce HospitalCosta MasnagaLeccoItaly
| | - Andrea Santamato
- Spasticity and Movement Disorders ‘ReSTaRt’ Unit, Physical Medicine and Rehabilitation Section, Policlinico Riuniti HospitalUniversity of FoggiaFoggiaItaly
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Winston P, Reebye R, Picelli A, David R, Boissonnault E. Recommendations for Ultrasound Guidance for Diagnostic Nerve Blocks for Spasticity. What Are the Benefits? Arch Phys Med Rehabil 2023; 104:1539-1548. [PMID: 36740138 DOI: 10.1016/j.apmr.2023.01.011] [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: 07/25/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 02/05/2023]
Abstract
The diagnostic nerve block (DNB) for spasticity is the percutaneous application of an anesthetic to an individual peripheral nerve trunk (mixed motor sensory nerve), nerve branch to a muscle or an intramuscular branch. The DNB causes a temporary paralysis to assess the contribution of muscle(s) on the spastic pattern and may unmask a fully or partially increased joint range of motion. The anesthetic literature supports the use of ultrasound (US) guidance to improve nerve blocks for sensory targets. This communication summarizes the potential advantages that support the use of US to improve DNB technique. Nerves are much smaller than muscle targets and have various known innervation patterns. US allows for rapid localization of the target before injection, particularly in complex anatomy patterns. The nerve trunks are typically found adjacent to or encapsulating blood vessels, which can be quickly identified with or without color Doppler, allowing the clinician to scan from the vessels to the target and avoid intravascular injection. Lower stimulation levels can be used as the targeted muscle(s) can be seen stimulating rather than only on the surface. A shorter needle insertion time and lower stimulation levels should cause less discomfort to the patient. Smaller volumes of anesthetic may be used as the fluid is seen reaching its target and cessation of stimulation is observed. Further study is needed to identify evidence supporting US utilization with electrical stimulation in DNBs for spasticity management, as US use during nerve blocks for perineurial anesthesia has demonstrated improved patient safety and procedural efficiency.
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Affiliation(s)
- Paul Winston
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Canada; Canadian Advances in Neuro-Orthopedics for Spasticity Consortium, Kingston, Canada.
| | - Rajiv Reebye
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Canada; Canadian Advances in Neuro-Orthopedics for Spasticity Consortium, Kingston, Canada
| | - Alessandro Picelli
- Canadian Advances in Neuro-Orthopedics for Spasticity Consortium, Kingston, Canada; Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, Neuromotor and Cognitive Rehabilitation Research Center, University of Verona, Verona, Italy
| | - Romain David
- Physical Medicine and Rehabilitation Unit, Poitiers University, Poitiers, France
| | - Eve Boissonnault
- Canadian Advances in Neuro-Orthopedics for Spasticity Consortium, Kingston, Canada; Division of Physical Medicine and Rehabilitation, University of Montreal, Canada
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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: 0] [Impact Index Per Article: 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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PICELLI A, CENSO RD, ZADRA A, FACCIOLI S, SMANIA N, FILIPPETTI M. Management Of Spastic Equinovarus Foot in Children with Cerebral Palsy: An Evaluation of Anatomical Landmarks for Selective Nerve Blocks of the Tibial Nerve Motor Branches. J Rehabil Med 2023; 55:jrm00370. [PMID: 36807992 PMCID: PMC9972165 DOI: 10.2340/jrm.v55.4538] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 12/13/2022] [Indexed: 02/23/2023] Open
Abstract
OBJECTIVE To define the anatomical landmarks of tibial motor nerve branches for selective motor nerve blocks of the gastrocnemii, soleus and tibialis posterior muscles in the management of spastic equinovarus foot. DESIGN Observational study. PATIENTS Twenty-four children with cerebral palsy with spastic equinovarus foot. METHODS Considering the affected leg length, motor nerve branches to the gastrocnemii, soleus and tibialis posterior muscles were tracked using ultrasonography, and located in the space (vertical, horizontal, deep) according to the position of fibular head (proximal/distal) and a virtual line from the middle of popliteal fossa to the Achilles tendon insertion (medial/lateral). RESULTS Location of motor branches was defined as percentage of the affected leg length. Mean coordinates were: for the gastrocnemius medialis 2.5 ± 1.2% vertical (proximal), 1.0 ± 0.7% horizontal (medial), 1.5 ± 0.4% deep; for the gastrocnemius lateralis 2.3 ± 1.4% vertical (proximal), 1.1 ± 0.9% horizontal (lateral), 1.6 ± 0.4% deep; for the soleus 2.1 ± 0.9% vertical (distal), 0.9 ± 0.7% horizontal (lateral), 2.2 ± 0.6% deep; for the tibialis posterior 2.6 ± 1.2% vertical (distal), 1.3 ± 1.1% horizontal (lateral), 3.0 ± 0.7% deep. CONCLUSION These findings may help the identification of tibial motor nerve branches to perform selective nerve blocks in patients with cerebral palsy with spastic equinovarus foot.
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Affiliation(s)
- Alessandro PICELLI
- Neuromotor and Cognitive Rehabilitation Research Centre, Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy,Neurorehabilitation Unit, University Hospital of Verona, Verona, Italy,Canadian Advances in Neuro-Orthopaedics for Spasticity Congress (CANOSC), Kingston, ON, Canada
| | - Rita Di CENSO
- Neuromotor and Cognitive Rehabilitation Research Centre, Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Alessandro ZADRA
- Neuromotor and Cognitive Rehabilitation Research Centre, Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Silvia FACCIOLI
- AUSL IRCCS di Reggio Emilia, Reggio Emilia, Italy,Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola SMANIA
- Neuromotor and Cognitive Rehabilitation Research Centre, Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy,Neurorehabilitation Unit, University Hospital of Verona, Verona, Italy
| | - Mirko FILIPPETTI
- Neuromotor and Cognitive Rehabilitation Research Centre, Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy,Neurorehabilitation Unit, University Hospital of Verona, Verona, Italy
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Struyf P, Triccas LT, Schillebeeckx F, Struyf F. The Place of Botulinum Toxin in Spastic Hemiplegic Shoulder Pain after Stroke: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2797. [PMID: 36833493 PMCID: PMC9957016 DOI: 10.3390/ijerph20042797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 01/19/2023] [Accepted: 02/02/2023] [Indexed: 06/18/2023]
Abstract
Stroke is a common pathology worldwide, with an age-standardized global rate of new strokes of 150.5 per 100,000 population in 2017. Stroke causes upper motor neuron impairment leading to a spectrum of muscle weakness around the shoulder joint, changes in muscle tone, and subsequent soft tissue changes. Hemiplegic shoulder pain (HSP) is the most common pain condition in stroke patients and one of the four most common medical complications after stroke. The importance of the appropriate positioning and handling of the hemiplegic shoulder for prevention of HSP is therefore of high clinical relevance. Nevertheless, HSP remains a frequent and disabling problem after stroke, with a 1-year prevalence rate up to 39%. Furthermore, the severity of the motor impairment is one of the most important identified risk factors for HSP in literature. Spasticity is one of these motor impairments that is likely to be modifiable. After ruling out or treating other shoulder pathologies, spasticity must be assessed and treated because it could lead to a cascade of unwanted complications, including spastic HSP. In clinical practice, Botulinum toxin A (BTA) is regarded as the first-choice treatment of focal spasticity in the upper limb, as it gives the opportunity to target specifically selected muscles. It thereby provides the possibility of a unique patient tailored focal and reversible treatment for post stroke spasticity. This scoping review aims to summarize the current evidence of BTA treatment for spastic HSP. First, the clinical manifestation and outcome measures of spastic HSP will be addressed, and second the current evidence of BTA treatment of spastic HSP will be reviewed. We also go in-depth into the elements of BTA application that may optimize the therapeutic effect of BTA. Finally, future considerations for the use of BTA for spastic HSP in clinical practice and research settings will be discussed.
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Affiliation(s)
- Pieter Struyf
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, B-2610 Wilrijk, Belgium
- Department of Rehabilitation Medicine, Research School Caphri, Maastricht University Medical Center, 6200 MD Maastricht, The Netherlands
- Adelante Zorggroep, 6229 HX Maastricht, The Netherlands
| | - Lisa Tedesco Triccas
- REVAL, Faculty of Rehabilitation Sciences, Universiteit Hasselt, B-3590 Diepenbeek, Belgium
- Department of Clinical and Movement Neuroscience, Institute of Neurology, University College London, London WC1N 3BG, UK
| | - Fabienne Schillebeeckx
- Department of Physical Medicine and Rehabilitation, University Hospital Leuven, B-3000 Leuven, Belgium
| | - Filip Struyf
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, B-2610 Wilrijk, Belgium
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Korupolu R, Malik A, Pemberton E, Stampas A, Li S. Phenol neurolysis in people with spinal cord injury: a descriptive study. Spinal Cord Ser Cases 2022; 8:90. [PMID: 36481543 PMCID: PMC9732339 DOI: 10.1038/s41394-022-00556-0] [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: 04/01/2022] [Revised: 10/12/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022] Open
Abstract
STUDY DESIGN Descriptive study. OBJECTIVES The study's main objective was to describe the common targets of phenol neurolysis and review the safety and efficacy of the dose used for this spasticity management procedure in people with spinal cord injury (SCI). SETTING An acute rehabilitation hospital. METHODS Data from people with SCI who underwent phenol neurolysis procedures for spasticity management between April 2017 and August 2018 were included in this study. We collected demographics and phenol neurolysis procedure-related information. RESULTS A total of 66 people with SCI and spasticity underwent phenol neurolysis of 303 nerves over 102 encounters. During these encounters, 97% of procedures were performed using both electrical stimulation and ultrasound guidance. The median (IQR) total volume of 6% aqueous phenol used per encounter was 4.0 (2.0-6.0) ml with a median (IQR) of 1.5 (1.0-2.3) ml per nerve. The most frequent target was the obturator nerve (33%), followed by the pectoral nerves (23%). Immediate post-phenol neurolysis improvement or reduction in spasticity was reported for 92% of all documented encounters. There was no documentation of any post-procedure-related adverse events in this cohort during this specified time frame. CONCLUSIONS Our findings suggest that phenol neurolysis can be safely used to manage spasticity in people with SCI under combined electrical stimulation and ultrasound guidance. Further research is required to assess the procedure's safety, efficacy, and cost-effectiveness on patient-reported outcomes compared to other spasticity interventions.
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Affiliation(s)
- Radha Korupolu
- grid.267308.80000 0000 9206 2401Department of Physical Medicine and Rehabilitation, The University of Texas Health Sciences Center at Houston, Houston, TX USA ,grid.414053.70000 0004 0434 8100TIRR Memorial Hermann, Houston, TX USA
| | - Aila Malik
- grid.267308.80000 0000 9206 2401Department of Physical Medicine and Rehabilitation, The University of Texas Health Sciences Center at Houston, Houston, TX USA
| | - Erin Pemberton
- grid.267308.80000 0000 9206 2401Department of Physical Medicine and Rehabilitation, The University of Texas Health Sciences Center at Houston, Houston, TX USA
| | - Argyrios Stampas
- grid.267308.80000 0000 9206 2401Department of Physical Medicine and Rehabilitation, The University of Texas Health Sciences Center at Houston, Houston, TX USA ,grid.414053.70000 0004 0434 8100TIRR Memorial Hermann, Houston, TX USA
| | - Sheng Li
- grid.267308.80000 0000 9206 2401Department of Physical Medicine and Rehabilitation, The University of Texas Health Sciences Center at Houston, Houston, TX USA ,grid.414053.70000 0004 0434 8100TIRR Memorial Hermann, Houston, TX USA
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12
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Riberto M, Frances JA, Chueire R, Amorim ACFG, Xerez D, Chung TM, Mercuri LHC, Lianza S, Rocha ECDM, Maisonobe P, Cuperman-Pohl T, Khan P. Post Hoc Subgroup Analysis of the BCause Study Assessing the Effect of AbobotulinumtoxinA on Post-Stroke Shoulder Pain in Adults. Toxins (Basel) 2022; 14:toxins14110809. [PMID: 36422983 PMCID: PMC9692702 DOI: 10.3390/toxins14110809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/30/2022] [Accepted: 10/25/2022] [Indexed: 11/22/2022] Open
Abstract
Botulinum toxin type A is approved for the focal treatment of spasticity; however, the effectiveness of abobotulinumtoxinA (aboBoNT-A) in patients with shoulder pain who have set reduced pain as a treatment goal is understudied. In addition, some patients encounter delays in accessing treatment programs; therefore, the suitability of aboBoNT-A for pain reduction in this population requires investigation. These factors were assessed in aboBoNT-A-naive Brazilian patients in a post hoc analysis of data from BCause, an observational, multicenter, prospective study (NCT02390206). Patients (N = 49, n = 25 female; mean (standard deviation) age of 60.3 (9.1) years; median (range) time since onset of spasticity of 16.1 (0-193) months) received aboBoNT-A injections to shoulder muscles in one or two treatment cycles (n = 47). Using goal attainment scaling (GAS), most patients achieved their goal of shoulder pain reduction after one treatment cycle (72.1%; 95% confidence interval: 57.2-83.4%). Improvements in GAS T-score from baseline, clinically meaningful reductions in pain score at movement, and clinically meaningful increases in passive shoulder abduction angle further improved with repeated treatment more than 4 months later, despite treatment starting at a median of 16.1 months after the onset of spasticity. These findings support the further investigation of aboBoNT-A injections in chronic post-stroke shoulder pain.
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Affiliation(s)
- Marcelo Riberto
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, São Paulo 14049-900, Brazil
| | - João Amaury Frances
- Hospital Bettina Ferro de Souza, Campus IV da Universidade Federal do Pará, Belém 66075-110, Brazil
| | - Regina Chueire
- Faculdade de Medicina de São José do Rio Preto, Autarquia Estadual 15090-000, Brazil
| | | | - Denise Xerez
- Serviço de Medicina Física e Reabilitação, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-590, Brazil
| | - Tae Mo Chung
- Complexo Hospital das Clinicas, Instituto de Medicina Fisica e Reabilitação, São Paulo 04116-030, Brazil
| | | | - Sérgio Lianza
- Hospital Alemão Oswaldo Cruz, São Paulo 01323-020, Brazil
| | | | | | | | - Patricia Khan
- Centro Catarinense de Reabilitação, Florianópolis, Santa Catarina 88025-301, Brazil
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13
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Samitier Pastor CB, Climent Barbera JM, Cutillas Ruiz R, Formigo Couceiro J, Vázquez Doce A. [Clinical practice guideline for the treatment of spasticity: Consensus and algorithms]. Rehabilitacion (Madr) 2022; 56:204-214. [PMID: 35428487 DOI: 10.1016/j.rh.2021.11.004] [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: 05/10/2021] [Revised: 09/23/2021] [Accepted: 11/04/2021] [Indexed: 06/14/2023]
Abstract
Spasticity is a complex phenomenon of extremely variable clinical expression, a dynamic and evolutionary process that can condition the activity and treatment of the patient. The current recommendation for early treatment aims to avoid progression and complications, and involves an individualized approach based on a wide range of pharmacological and non-pharmacological measures. This guide results from a forum of expert specialists who faced some frequent uncertainties in the assessment process and therapeutic approach of the spastic patient such as the suitability of initiating treatment, considerations for initiating, continuing and ceasing treatment with botulinum toxin, adjuvant treatments, pain or follow-up. The result is one algorithm of decision for the therapeutic approach of spasticity. Both scientific progress and the exchange of clinical experience on which this guide is based, can support decision-making on some areas of gloom that we find in daily practice.
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Affiliation(s)
- C B Samitier Pastor
- Servicio de Rehabilitación, Hospital Asepeyo, Sant Cugat, Sant Cugat del Vallés, Barcelona, España.
| | - J M Climent Barbera
- Servicio de Rehabilitación, Hospital General Universitario de Alicante, Alicante, España
| | - R Cutillas Ruiz
- Servicio de Rehabilitación, Hospital Universitario Fundación Jiménez Díaz, Madrid, España
| | - J Formigo Couceiro
- Servicio de Rehabilitación, Complexo Hospitalario Universitario A Coruña, A Coruña, España
| | - A Vázquez Doce
- Servicio de Medicina Física y Rehabilitación, Hospital Universitario de La Princesa, Madrid, España
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14
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Ko EJ, Kim DY. Pharmacological management of muscle spasticity. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2022. [DOI: 10.5124/jkma.2022.65.2.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Muscle spasticity is a neurologic disorder, which is considered one of the positive signs of upper motor neuron diseases. Spasticity is common after brain or spinal cord injury. Since spasticity results in tendon retraction, muscle weakness, pain, ankylosis, and disability in activities of daily living, treatment is warranted.Current Concepts: Spasticity is usually assessed using the Modified Ashworth Scale or Modified Tardieu Scale. It is treated with various methods, including physical therapy, occupational therapy, orthosis, medication, and surgery. Pharmacological management should be selected according to the location and severity of the symptom and includes oral medications, chemical nerve block, and intrathecal baclofen pump insertion. Oral medications include baclofen, benzodiazepine, dantrolene, and tizanidine. Chemoneurolysis of spasticity is done with botulinum toxin or a mixture of phenol and alcohol.Discussion and Conclusion: Since muscle spasticity affects motor function and activities of daily living, understanding of this symptom and choosing an optimal treatment are necessary. Pharmacologic treatments should be administered with caution especially with the side effects. Optimal treatment of spasticity will bring the best neurological outcome for the patients.
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15
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Koh M, Leng TY. Alcohol Motor Blocks: Case Series and a Narrative Review. Cureus 2022; 14:e21575. [PMID: 35228934 PMCID: PMC8867019 DOI: 10.7759/cureus.21575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2022] [Indexed: 11/29/2022] Open
Abstract
Alcohol neurolysis and intramuscular blocks are interventions for spasticity management. Here, we illustrate two clinical cases with spasticity impeding ease of care and pain which required selective alcohol intramuscular blocks with alcohol neurolysis. Post-interventions, both cases demonstrated improvement in pain and joint range of motion which facilitated better positioning and reduced caregiver burden. Pertinent learning points from alcohol neurolysis with intramuscular blocks are discussed concerning therapeutic effectiveness and intervention safety.
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16
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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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17
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Lagnau P, Lo A, Sandarage R, Alter K, Picelli A, Wissel J, Verduzco-Gutierrez M, Suputtitada A, Munin MC, Carda S, Khan O, Koçer S, Reebye R. Ergonomic Recommendations in Ultrasound-Guided Botulinum Neurotoxin Chemodenervation for Spasticity: An International Expert Group Opinion. Toxins (Basel) 2021; 13:249. [PMID: 33807196 PMCID: PMC8067138 DOI: 10.3390/toxins13040249] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 02/06/2023] Open
Abstract
Ultrasound (US)-guided botulinum neurotoxin (BoNT) injections are becoming a mainstay in the treatment of muscle spasticity in upper motor neuron syndromes. As a result, there has been a commensurate increase in US-guided BoNT injection for spasticity training courses. However, many of these courses do not emphasize the importance of ergonomics. This paper aims to highlight the importance of ultrasound ergonomics and presents ergonomic recommendations to optimize US-guided BoNT injection techniques in spasticity management. Expert consensus opinion of 11 physicians (4 different continents; representing 8 countries, with an average of 12.6 years of practice using US guidance for BoNT chemodenervation (range 3 to 22 years)). A search using PubMed, College of Physicians and Surgeons of British Columbia database, EMbase was conducted and found no publications relating the importance of ergonomics in US-guided chemodenervation. Therefore, recommendations and consensus discussions were generated from the distribution of a 20-question survey to a panel of 11 ultrasound experts. All 11 surveyed physicians considered ergonomics to be important in reducing physician injury. There was complete agreement that physician positioning was important; 91% agreement that patient positioning was important; and 82% that ultrasound machine positioning was important. Factors that did not reach our 80% threshold for consensus were further discussed. Four categories were identified as being important when implementing ultrasound ergonomics for BoNT chemodenervation for spasticity; workstation, physician, patient and visual ergonomics. Optimizing ergonomics is paramount when performing US-guided BoNT chemodenervation for spasticity management. This includes proper preparation of the workspace and allowing for sufficient pre-injection time to optimally position both the patient and the physician. Lack of awareness of ergonomics for US-guided BoNT chemodenervation for spasticity may lead to suboptimal patient outcomes, increase work-related injuries, and patient discomfort. We propose key elements for optimal positioning of physicians and patients, as well as the optimal setup of the workspace and provide clinical pearls in visual identification of spastic muscles for chemodenervation.
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Affiliation(s)
- Philippe Lagnau
- GF Strong Rehabilitation Centre, Vancouver, BC V5Z 2G9, Canada;
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada; (A.L.); (R.S.); (A.S.); (S.C.); (O.K.)
| | - Alto Lo
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada; (A.L.); (R.S.); (A.S.); (S.C.); (O.K.)
- Division of Physical Medicine and Rehabilitation, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Ryan Sandarage
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada; (A.L.); (R.S.); (A.S.); (S.C.); (O.K.)
- Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
| | - Katharine Alter
- Functional and Applied Biomechanics Section, Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA;
| | - Alessandro Picelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy;
| | - Jorg Wissel
- Neurological Rehabilitation & Physical Therapy, Department of Neurology with Stroke Unit, Vivantes Hospital Spandau, 13585 Berlin, Germany;
| | - Monica Verduzco-Gutierrez
- Department of Rehabilitation Medicine, Joe-R.-and-Teresa-Lozano Long School of Medicine, UT Health San Antonio, San Antonio, TX 78229, USA;
| | - Areerat Suputtitada
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada; (A.L.); (R.S.); (A.S.); (S.C.); (O.K.)
- Department of Rehabilitation Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | - Michael C. Munin
- Physical Medicine and Rehabilitation School of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA;
| | - Stefano Carda
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada; (A.L.); (R.S.); (A.S.); (S.C.); (O.K.)
- Neuropsychology and Neurorehabilitation Service, Department of Clinical Neuroscience, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Omar Khan
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada; (A.L.); (R.S.); (A.S.); (S.C.); (O.K.)
- Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharines, ON L2T 4C2, Canada
| | - Serdar Koçer
- Centre de Rééducation Hôpital du Jura, 2900 Porrentruy, Switzerland;
| | - Rajiv Reebye
- GF Strong Rehabilitation Centre, Vancouver, BC V5Z 2G9, Canada;
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada; (A.L.); (R.S.); (A.S.); (S.C.); (O.K.)
- Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
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18
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Ince B, Uyanik O, Oltulu P, Ismayilzade M, Dadaci M, Savaci N. Ethyl Alcohol Versus Botulinum Toxin A: A Comparative Study of the Visual and Histopathological Outcomes in the Rabbit Anterior Auricular Muscle Model. Dermatol Surg 2021; 46:1661-1666. [PMID: 32852430 DOI: 10.1097/dss.0000000000002600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Botulinum toxin has long been known for its paralytic effects at the neuromuscular junction. Although it has been widely used for vascular and nervous tissues, there has been no study of the aesthetic effects of the application of ethanol to muscle tissues to date. OBJECTIVE The authors aimed to demonstrate the effects of the application of ethanol to muscle tissues after an intramuscular injection and to compare the effects of botulinum toxin A (BTA) and ethanol. METHODS AND MATERIALS A total of 28 rabbits were divided into 4 groups (n = 7 each). Botulinum toxin A (5 units) and different concentrations of ethanol (5 cc) were injected into the left and right anterior auricular muscles of all rabbits, respectively. Ear ptosis was assessed, and histopathological examination was performed after all rabbits were euthanized in the eighth week. RESULTS Muscle function was affected earlier in ethanol-treated ears than in botulinum-treated ears; however, the ptotic effect lasted for a significantly shorter duration in ethanol-injected ears than in BTA-applied ears. CONCLUSION Ethanol can block muscle function reversibly and can serve as an alternative to BTA, particularly when rapid results are desirable.
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Affiliation(s)
- Bilsev Ince
- Departments of Plastic and Reconstructive and Aesthetic Surgery, and
| | - Orkun Uyanik
- Departments of Plastic and Reconstructive and Aesthetic Surgery, and
| | - Pembe Oltulu
- Pathology, Faculty of Meram Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Majid Ismayilzade
- Departments of Plastic and Reconstructive and Aesthetic Surgery, and
| | - Mehmet Dadaci
- Departments of Plastic and Reconstructive and Aesthetic Surgery, and
| | - Nedim Savaci
- Departments of Plastic and Reconstructive and Aesthetic Surgery, and
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Laffont I. 2019 Sidney Licht lecture: Spasticity and related neuro-orthopedic deformities: A core topic in physical and rehabilitation medicine. THE JOURNAL OF THE INTERNATIONAL SOCIETY OF PHYSICAL AND REHABILITATION MEDICINE 2021. [DOI: 10.4103/jisprm-000080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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20
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Farrell M, Karp BI, Kassavetis P, Berrigan W, Yonter S, Ehrlich D, Alter KE. Management of Anterocapitis and Anterocollis: A Novel Ultrasound Guided Approach Combined with Electromyography for Botulinum Toxin Injection of Longus Colli and Longus Capitis. Toxins (Basel) 2020; 12:toxins12100626. [PMID: 33008043 PMCID: PMC7650774 DOI: 10.3390/toxins12100626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 09/24/2020] [Accepted: 09/27/2020] [Indexed: 11/16/2022] Open
Abstract
Chemodenervation of cervical musculature using botulinum neurotoxin (BoNT) is established as the gold standard or treatment of choice for management of Cervical Dystonia (CD). The success of BoNT procedures is measured by improved symptomology while minimizing side effects and is dependent upon many factors including: clinical pattern recognition, identifying contributory muscles, BoNT dosage, and locating and safely injecting target muscles. In patients with CD, treatment of anterocollis (forward flexion of the neck) and anterocaput (anterocapitis) (forward flexion of the head) are inarguably challenging. The longus Colli (LoCol) and longus capitis (LoCap) muscles, two deep cervical spine and head flexor muscles, frequently contribute to these patterns. Localizing and safely injecting these muscles is particularly challenging owing to their deep location and the complex regional anatomy which includes critical neurovascular and other structures. Ultrasound (US) guidance provides direct visualization of the LoCol, LoCap, other cervical muscles and adjacent structures reducing the risks and side effects while improving the clinical outcome of BoNT for these conditions. The addition of electromyography (EMG) provides confirmation of muscle activity within the target muscle. Within this manuscript, we present a technical description of a novel US guided approach (combined with EMG) for BoNT injection into the LoCol and LoCap muscles for the management of anterocollis and anterocaput in patients with CD.
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Affiliation(s)
- Michael Farrell
- MedStar/Georgetown University National Rehabilitation Hospital, Washington, DC 20010, USA;
| | - Barbara I. Karp
- National Institutes of Neurological Disorders and Stroke, Bethesda, MD 20892 USA; (B.I.K.); (P.K.); (D.E.)
| | - Panagiotis Kassavetis
- National Institutes of Neurological Disorders and Stroke, Bethesda, MD 20892 USA; (B.I.K.); (P.K.); (D.E.)
| | - William Berrigan
- Emory School of Medicine, Emory University, Atlanta, GA 30322, USA;
| | - Simge Yonter
- Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892-1604, USA;
| | - Debra Ehrlich
- National Institutes of Neurological Disorders and Stroke, Bethesda, MD 20892 USA; (B.I.K.); (P.K.); (D.E.)
| | - Katharine E. Alter
- Functional and Applied Biomechanics Section, Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892-1604, USA
- Correspondence:
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21
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Tan YL, Wee TC. Botulinum Toxin Injection and Electromyography in Patients Receiving Anticoagulants: A Systematic Review. PM R 2020; 13:880-889. [PMID: 32896110 DOI: 10.1002/pmrj.12486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 08/29/2020] [Accepted: 08/31/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To identify the different practice patterns of botulinum toxin injection (BTX) and electromyography (EMG) in patients receiving anticoagulation and to evaluate the incidence, reporting, and management of bleeding complications and compartment syndrome from BTX and EMG. LITERATURE SURVEY Systematic review of relevant clinical studies in PubMed/Medline and Embase databases using key terms from inception to 31 May 2020. All publications in the English language were included without demographic limits. METHODOLOGY A comprehensive search was performed to identify all studies addressing BTX and EMG in patients receiving anticoagulants. Two reviewers independently screened the titles, abstracts, and full texts and extracted data based on a set of predefined inclusion and exclusion criteria. All studies that met the inclusion criteria were assigned their respective levels of evidence using the Joanne Briggs Institute (JBI) Level of Evidence for Effectiveness. SYNTHESIS Eighteen studies were included in this review of which there were nine studies each on BTX and EMG. The results indicated heterogeneity in the practice patterns of BTX and EMG in patients taking anticoagulants. These included the decision for continuation of anticoagulant, international normalized ratio (INR) results acceptable to practitioners, the modality for procedure guidance, and surveillance of bleeding complications. In addition, there were variations in the description of targeted muscles and description of needle sizes. The overall incidence of bleeding complications and compartment syndrome rates were low. CONCLUSIONS Despite the varied practice in anticoagulated patients undergoing BTX or EMG, practitioners should allow periprocedural continuation of anticoagulants, targeting an INR of 2 to 3 while using the smallest needle (25 gauge or smaller) of appropriate length. Some of the evidence on procedural guidance and complication surveillance were weak and more research in these areas is required.
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Affiliation(s)
- Yeow Leng Tan
- Department of Rehabilitation Medicine, Singapore General Hospital, Singapore
| | - Tze Chao Wee
- Department of Rehabilitation Medicine, Changi General Hospital, Singapore
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Formigo-Couceiro J, Otero-Villaverde S, Alonso-Bidegain M. [Proposal for approach to selective tibial nerve block in spastic patient. A propos of a case]. Rehabilitacion (Madr) 2020; 55:71-74. [PMID: 32741573 DOI: 10.1016/j.rh.2020.06.006] [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: 03/05/2020] [Revised: 06/14/2020] [Accepted: 06/18/2020] [Indexed: 10/23/2022]
Abstract
The most frequent pattern of spasticity in the lower limb is equinovarus foot. Patients with central nervous system injury and severe spasticity, conservative treatment and botulinum toxin type A often have a limited effect. In these cases, nerve blocks can be very useful in deciding our therapeutic action. We present a clinical case as an example of a new ultrasound-guided approach to tibial nerve block, as this is the main nerve involved in equinovarus foot pattern, specific for spastic patients and its usefulness for the clinical management of spasticity.
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Affiliation(s)
- J Formigo-Couceiro
- Servicio de Medicina Física y Rehabilitación, Complexo Hospitalario Universitario de A Coruña, A Coruña, Galicia, España.
| | - S Otero-Villaverde
- Servicio de Medicina Física y Rehabilitación, Complexo Hospitalario Universitario de A Coruña, A Coruña, Galicia, España
| | - M Alonso-Bidegain
- Servicio de Medicina Física y Rehabilitación, Complexo Hospitalario Universitario de A Coruña, A Coruña, Galicia, España
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Hon AJ, Kraus P. Spasticity Management After Spinal Cord Injury. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-020-00280-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abstract
Identifying the subtypes of hypertonia is becoming increasingly important. Treatment strategies, including tone-modulating surgical interventions, medication type and dosing, and chemodenervation, may differ depending on the type of hypertonia present. It is important to delineate how hypertonia interferes with function and quality of life so that the appropriate intervention can be selected at the right time. Outcomes of treatment depend heavily on clear communication of goals. Botulinum toxin should not be used in isolation but as an adjunct to rehabilitation modalities.
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Affiliation(s)
- Rochelle Dy
- PM&R, Texas Children's Hospital, 6701 Fannin Street, Suite D1280, Houston, TX 77030, USA.
| | - Desiree Roge
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
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25
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Moon DK, Johnson AMF. Lower Extremity Problem-Solving: Challenging Cases. Phys Med Rehabil Clin N Am 2019; 29:619-631. [PMID: 30626518 DOI: 10.1016/j.pmr.2018.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Lower limb dysfunction associated with upper motor neuron syndrome can be complex due to interaction of muscle overactivity, weakness, impaired motor control, and contracture. Treatment should be goal-directed and address the patient's passive and active functional impairments in addition to their symptoms. Therefore, a comprehensive, multidisciplinary team approach tailored to each patient's unique needs and functional goals is warranted. This article reviews the evaluation and management of issues related to lower limb muscle overactivity and how this approach was applied to 3 challenging cases.
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Affiliation(s)
- Daniel K Moon
- The Sheerr Gait and Motion Analysis Laboratory, The Motor Control Analysis Laboratory, Department of Physical Medicine and Rehabilitation, MossRehab, Einstein Healthcare Network, 60 Township Line Road, Elkins Park, PA 19027, USA.
| | - Ashley M F Johnson
- Department of Physical Medicine and Rehabilitation, Temple University Hospital, 3401 North Broad Street, Philadelphia, PA 19140, USA
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Abstract
Intrathecal baclofen therapy is a well-established technique for spasticity management. This article briefly reviews the pharmacology of intrathecal baclofen as well as customary approach for utilization of this targeted drug delivery concept. Following these descriptions, four unusual presentations will be described, including the need for initial trialing, patient-directed boluses during chronic intrathecal baclofen therapy, use of medications other than baclofen for intrathecal therapy in spastic patients, and intraventricular baclofen delivery. These hypothetical cases are provided in an effort to expand the use of targeted drug delivery to larger population of spastic patients.
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Affiliation(s)
- Michael Saulino
- MossRehab, 60 Township Line Road, Elkins Park, PA 19027, USA; Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, PA, USA.
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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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Ateş F, Yucesoy CA. Botulinum toxin type-A affects mechanics of non-injected antagonistic rat muscles. J Mech Behav Biomed Mater 2018; 84:208-216. [DOI: 10.1016/j.jmbbm.2018.05.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/18/2018] [Accepted: 05/16/2018] [Indexed: 11/27/2022]
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29
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Intrathecal Baclofen Therapy for the Control of Spasticity. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00072-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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30
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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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Hu S, Zhuo L, Zhang X, Yang S. Localization of nerve entry points as targets to block spasticity of the deep posterior compartment muscles of the leg. Clin Anat 2017; 30:855-860. [PMID: 28459126 DOI: 10.1002/ca.22893] [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: 03/10/2017] [Accepted: 04/21/2017] [Indexed: 11/11/2022]
Abstract
To identify the optimal body surface puncture locations and the depths of nerve entry points (NEPs) in the deep posterior compartment muscles of the leg, 60 lower limbs of thirty adult cadavers were dissected in prone position. A curved line on the skin surface joining the lateral to the medial epicondyles of the femur was taken as a horizontal reference line (H). Another curved line joining the lateral epicondyle of the femur to the lateral malleolus was designated the longitudinal reference line (L). Following dissection, the NEPs were labeled with barium sulfate and then subjected to spiral computed tomography scanning. The projection point of the NEP on the posterior skin surface of the leg was designated P, and the projection in the opposite direction across the transverse plane was designated P'. The intersections of P on H and L were identified as PH and PL , and their positions and the depth of the NEP on PP' were measured using the Syngo system and expressed as percentages of H, L, and PP'. The PH points of the tibial posterior, flexor hallucis longus and flexor digitorum longus muscles were located at 38.10, 46.20, and 55.21% of H, respectively. The PL points were located at 25.35, 41.30, and 45.39% of L, respectively. The depths of the NEPs were 49.11, 54.64, and 55.95% of PP', respectively. The accurate location of these NEPs should improve the efficacy and efficiency of chemical neurolysis for treating spasticity of the deep posterior compartment muscles of the leg. Clin. Anat. 30:855-860, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Shuaiyu Hu
- Department of Anatomy, Zunyi Medical College, Zunyi, Guizhou, China
| | - Lifan Zhuo
- Department of Anatomy, Zunyi Medical College, Zunyi, Guizhou, China
| | - Xiaoming Zhang
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas
| | - Shengbo Yang
- Department of Anatomy, Zunyi Medical College, Zunyi, Guizhou, China
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32
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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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33
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Genet F, Schnitzler A, Droz-Bartholet F, Salga M, Tatu L, Debaud C, Denormandie P, Parratte B. Successive motor nerve blocks to identify the muscles causing a spasticity pattern: example of the arm flexion pattern. J Anat 2016; 230:106-116. [PMID: 27595994 DOI: 10.1111/joa.12538] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2016] [Indexed: 11/30/2022] Open
Abstract
Botulinum Toxin A has been the main treatment for spasticity since the beginning of the 1990s. Surprisingly, there is still no consensus regarding injection parameters or, importantly, how to determine which muscles to target to improve specific functions. The aim of this study was to develop a systematic approach to determine this, using the example of the arm flexion pattern. We first determined anatomical landmarks for selective motor block of the brachialis nerve, using 20 forearms from 10 fresh cadavers in Ecole Européenne de Chirurgie and a university-based dissection centre, Paris, France. We then carried out selective blocks of the motor nerves to the brachialis, brachioradialis and biceps brachii in patients with stroke with an arm flexion pattern, in a University Rehabilitation Hospital, Garches, France. We measured: the resting angle of the elbow angle in standing (manual goniometer), active and passive range of extension, and spasticity using the Held and Tardieu and the Modified Ashworth scales. Range of passive elbow extension was also measured with the shoulder in 90° of flexion. The resting angle of the elbow in standing decreased by 35.0° (from 87.6 ± 23.7 to 52.6 ± 24.2°) with inhibition of brachialis, by a further 3.9° (from 52.6 ± 24.2 to 48.7 ± 23.7°) with inhibition of brachioradialis and a further 14.5° (from 48.7 ± 23.7to 34.2 ± 20.7°) with inhibition of biceps brachii. These results were consistent with the clinical evaluation of passive elbow range of motion with the shoulder at 90°. Sequential blocking of the nerves to the three main elbow flexors revealed that the muscle that limited elbow extension the most, was brachialis. This muscle should be the main target to improve the arm flexion pattern. These results show that it is important not simply to inject the most superficial or powerful muscles to treat a spastic deformity. A comprehensive assessment is required. The strategy proposed in this paper should increase the effectiveness of botulinum toxin injections by ensuring that the relevant muscles are targeted.
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Affiliation(s)
- F Genet
- Service de Médecine Physique et de Réadaptation, Hôpital Raymond Poincaré, Garches, France.,'End:icap' U1179 INSERM, UFR des Sciences de la Santé - Simone Veil, Université Versailles Saint Quentin en Yvelines, Montigny le Bretonneux, France.,Ecole Européenne de Chirurgie (EEC), Paris, France
| | - A Schnitzler
- Service de Médecine Physique et de Réadaptation, Hôpital Raymond Poincaré, Garches, France.,Ecole Européenne de Chirurgie (EEC), Paris, France
| | - F Droz-Bartholet
- Service de Médecine Physique et de Réadaptation, CHRU Besançon, Besançon Cedex, France
| | - M Salga
- Service de Médecine Physique et de Réadaptation, Hôpital Raymond Poincaré, Garches, France.,'End:icap' U1179 INSERM, UFR des Sciences de la Santé - Simone Veil, Université Versailles Saint Quentin en Yvelines, Montigny le Bretonneux, France
| | - L Tatu
- Laboratoire d'anatomie UFR SMP, Université Bourgogne/Franche-Comté, Besançon Cedex, France.,Service d'Explorations et Pathologies Neuro-musculaires, CHRU Besançon, Besançon Cedex, France
| | - C Debaud
- 'End:icap' U1179 INSERM, UFR des Sciences de la Santé - Simone Veil, Université Versailles Saint Quentin en Yvelines, Montigny le Bretonneux, France.,Service de Chirurgie Orthopédique, Hôpital Européen Georges Pompidou, Paris, France
| | - P Denormandie
- 'End:icap' U1179 INSERM, UFR des Sciences de la Santé - Simone Veil, Université Versailles Saint Quentin en Yvelines, Montigny le Bretonneux, France.,Ecole Européenne de Chirurgie (EEC), Paris, France.,Service de Chirurgie Orthopédique, Hôpital Raymond Poincaré, Garches, France
| | - B Parratte
- Ecole Européenne de Chirurgie (EEC), Paris, France.,Service de Médecine Physique et de Réadaptation, CHRU Besançon, Besançon Cedex, France.,Laboratoire d'anatomie UFR SMP, Université Bourgogne/Franche-Comté, Besançon Cedex, France
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34
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Saulino M, Ivanhoe CB, McGuire JR, Ridley B, Shilt JS, Boster AL. Best Practices for Intrathecal Baclofen Therapy: Patient Selection. Neuromodulation 2016; 19:607-15. [DOI: 10.1111/ner.12447] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 02/23/2016] [Accepted: 04/02/2016] [Indexed: 11/27/2022]
Affiliation(s)
| | - Cindy B. Ivanhoe
- Baylor College of Medicine; Houston TX USA
- Mentis Neuro Health Brain Injury and Stroke Program at TIRR-Memorial Hermann; Houston TX USA
| | - John R. McGuire
- Physical Medicine and Rehabilitation, Medical College of Wisconsin; Milwaukee WI USA
| | - Barbara Ridley
- Spasticity Management Program, Alta Bates Summit Medical Center; Berkeley CA USA
| | - Jeffrey S. Shilt
- Department of Orthopedic and Scoliosis Surgery, Baylor College of Medicine and Texas Children's Hospital; Houston TX USA
| | - Aaron L. Boster
- Systems Medical Chief, Neuroimmunology, OhioHealth Multiple Sclerosis Program; Columbus OH USA
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35
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Kim DD, Asif A, Kataria S. Presentation of Neurolytic Effect of 10% Lidocaine after Perineural Ultrasound Guided Injection of a Canine Sciatic Nerve: A Pilot Study. Korean J Pain 2016; 29:158-63. [PMID: 27413480 PMCID: PMC4942643 DOI: 10.3344/kjp.2016.29.3.158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 05/17/2016] [Accepted: 06/01/2016] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Phenol and alcohol have been used to ablate nerves to treat pain but are not specific for nerves and can damage surrounding soft tissue. Lidocaine at concentrations > 8% injected intrathecal in the animal model has been shown to be neurotoxic. Tests the hypothesis that 10% lidocaine is neurolytic after a peri-neural blockade in an ex vivo experiment on the canine sciatic nerve. METHODS Under ultrasound, one canine sciatic nerve was injected peri-neurally with 10 cc saline and another with 10 cc of 10% lidocaine. After 20 minutes, the sciatic nerve was dissected with gross inspection. A 3 cm segment was excised and preserved in 10% buffered formalin fixative solution. Both samples underwent progressive dehydration and infusion of paraffin after which they were placed on paraffin blocks. The sections were cut at 4 µm and stained with hemoxylin and eosin. Microscopic review was performed by a pathologist from Henry Ford Hospital who was blinded to which experimental group each sample was in. RESULTS The lidocaine injected nerve demonstrated loss of gross architecture on visual inspection while the saline injected nerve did not. No gross changes were seen in the surrounding soft tissue seen in either group. The lidocaine injected sample showed basophilic degeneration with marked cytoplasmic vacuolation in the nerve fibers with separation of individual fibers and endoneurial edema. The saline injected sample showed normal neural tissue. CONCLUSIONS Ten percent lidocaine causes rapid neurolytic changes with ultrasound guided peri-neural injection. The study was limited by only a single nerve being tested with acute exposure.
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Affiliation(s)
- David D Kim
- Department of Anesthesiology, Henry Ford Hospital, Detroit, MI, USA
| | - Asma Asif
- Department of Anesthesiology, Henry Ford Hospital, Detroit, MI, USA
| | - Sandeep Kataria
- Department of Anesthesiology, Henry Ford Hospital, Detroit, MI, USA
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36
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Ploypetch T, Kwon JY, Armstrong HF, Kim H. A Retrospective Review of Unintended Effects After Single-Event Multi-Level Chemoneurolysis With Botulinum Toxin-A and Phenol in Children With Cerebral Palsy. PM R 2015; 7:1073-1080. [DOI: 10.1016/j.pmrj.2015.05.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 05/18/2015] [Accepted: 05/22/2015] [Indexed: 11/16/2022]
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Chemodenervation for treatment of limb spasticity following spinal cord injury: a systematic review. Spinal Cord 2015; 53:252-64. [PMID: 25582713 DOI: 10.1038/sc.2014.241] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 11/28/2014] [Accepted: 12/03/2014] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVES To systematically review the literature on chemodenervation with botulinum toxin (BoNT) or phenol/alcohol for treatment of limb spasticity following spinal cord injury (SCI). SETTING British Columbia, Canada. METHODS EMBASE, MEDLINE, CINAHL, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials were searched for English language studies published up until March 2014. Studies were assessed for eligibility and quality by two independent reviewers. RESULTS No controlled trials were identified. A total of 19 studies were included: 9 involving BoNT and 10 involving phenol/alcohol. Owing to the clinically diverse nature of the studies, meta-analysis was deemed inappropriate. The studies produced level 4 and level 5 evidence that chemodenervation with BoNT or alcohol/phenol can lead to improvement in outcome measurements classified in the body structure and function, as well as activity domains of the International Classification of Functioning, Disability and Health framework. The Modified Ashworth Scale (MAS) was the most commonly used outcome measure. All six studies on BoNT and three of the four studies on phenol/alcohol measuring MAS reported a decrease in at least one point. An improvement in MAS was not always associated with improvement in function. The effect of phenol/alcohol has the potential to last beyond 6 months; study follow-up did not occur beyond this time point. CONCLUSION Chemodenervation with BoNT or phenol/alcohol may improve spasticity and function in individuals with SCI. However, there is a lack of high-quality evidence and further research is needed to confirm the efficacy of these interventions.
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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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Ravid E, Prochazka A. Controlled nerve ablation with direct current: parameters and mechanisms. IEEE Trans Neural Syst Rehabil Eng 2014; 22:1172-85. [PMID: 24760938 DOI: 10.1109/tnsre.2014.2307756] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Spastic hypertonus (muscle over-activity) often develops after spinal cord injury or stroke. Chemodenervating agents such as Botulinum toxin A (BtA) and phenol are often used to treat this condition. We have previously shown that the use of direct current (DC) to create controlled lesions of peripheral nerves may provide a means of reducing spastic hypertonus. Here, we explored a range of stimulation parameters that could be used clinically. Nerves were lesioned with DC in chronically implanted animals and the outcome was tracked over many months. In addition, we used DC to ablate nerves in animals with decerebrate rigidity (an animal model of spastic hypertonus) and we explored the possible mechanisms of DC nerve ablation. We found that nerve ablation with DC was effective in reducing hypertonus. Some stimulation paradigms were more likely to be clinically acceptable than others. Furthermore we showed that nerve regeneration occurs in the months following DC nerve ablation and we demonstrated that the ablation procedure is repeatable, much like BtA treatment. Regarding mechanism, our results did not support the hypothesis that DC caused nerve damage by overactivating sodium channels. Rather, the mechanism of damage seems to be related to changes in pH.
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41
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Shilt JS, Seibert PS, Kadyan V. Optimal management for people with severe spasticity. Degener Neurol Neuromuscul Dis 2012; 2:133-140. [PMID: 30890884 DOI: 10.2147/dnnd.s16630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Spasticity is characterized by velocity-dependent increase in tonic stretch reflexes and tendon jerks. Many people affected by spasticity receive late treatment, or no treatment, which greatly reduces the potential to regain full motor control and restore function. There is much to consider before determining treatment for people with spasticity. Treatment of pediatric patients increases the complexity, because of the substantial difference between adult and pediatric spasticity. Proper patient evaluation, utilization of scales and measures, and obtaining patient and caregiver history is vital in determining optimal spasticity treatment. Further, taking into consideration the limitations and desires of individuals serve as a guide to best management. We have grouped contributing factors into the IDAHO Criteria to elucidate a multidisciplinary approach, which considers a person's complete field of experience. This model is applied to goal setting, and recognizes the importance of a spasticity management team, comprising the treatment subject, his/her family, the environment, and a supportive, well-informed medical staff. The criteria take into account the complexity associated with diagnosing and treating spasticity, with the ultimate goal of improved function.
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Affiliation(s)
- Jeffrey S Shilt
- Idaho Spasticity Program, Saint Alphonsus Health Systems, Boise, ID
| | - Pennie S Seibert
- Department of Psychology, Boise State University, Boise, ID, USA,
| | - Vivek Kadyan
- Idaho Spasticity Program, Saint Alphonsus Health Systems, Boise, ID
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42
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Watanabe TK. Role of oral medications in spasticity management. PM R 2009; 1:839-41. [PMID: 19769918 DOI: 10.1016/j.pmrj.2009.07.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2009] [Accepted: 07/30/2009] [Indexed: 10/20/2022]
Abstract
Oral medications are frequently used to manage spasticity. Some clinicians may believe that oral medications are a more conservative or "first-line" strategy to treat this condition. However, their use may lead to significant adverse events. Additionally, efficacy has not been well-established, in particular the ability of these medications to enhance functional outcome. The decision regarding the use of oral medications is further complicated by the fact that a number of different agents have been used for many different diagnoses. The relative dearth of well-controlled studies makes the choice of medications for a given clinical condition even more difficult. This article reviews the mechanisms of action of some of the medications that are more commonly used to treat spasticity and identifies some studies that may suggest efficacy, or lack thereof, for certain diagnoses. Because questions remain regarding the benefit of oral medications, potential side effects also are emphasized to help the reader consider both potential risks and benefits. The article is intended as a broad overview, rather than comprehensive review of the literature.
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