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Filippetti M, Tamburin S, Di Censo R, Aldegheri R, Mantovani E, Spina S, Battaglia M, Baricich A, Santamato A, Smania N, Picelli A. Do Diagnostic Nerve Blocks Affect the Starting Dose of Botulinum Neurotoxin Type A for Spasticity? A Case-Control Study. Toxins (Basel) 2024; 16:388. [PMID: 39330846 PMCID: PMC11435450 DOI: 10.3390/toxins16090388] [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: 07/19/2024] [Revised: 08/26/2024] [Accepted: 09/02/2024] [Indexed: 09/28/2024] Open
Abstract
One of the aims of diagnostic nerve blocks is to identify the overactive muscles that lead to a specific spasticity pattern. However, to date, there is no evidence on how nerve blocks may affect botulinum neurotoxin-A (BoNT-A) dose in patients with spasticity. This case-control study aims to assess the role of diagnostic nerve block in defining BoNT-A starting dose at first treatment. Patients with upper and lower limb spasticity treated for the first time with BoNT-A were retrospectively divided into two groups: Group 1 (n = 43) was evaluated with clinical assessment and diagnostic nerve block; Group 2 (n = 56) underwent clinical assessment only. Group 1 was injected with higher BoNT-A doses in some muscles (i.e., flexor digitorum profundus, soleus), and received a higher BoNT-A cumulative dose with a larger number of injected muscles for some spasticity patterns (i.e., "clenched fist", "flexed fingers", "adducted thigh"). Diagnostic nerve block may help the clinician to optimize and personalize the BoNT-A dose since the first BoNT-A treatment.
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Affiliation(s)
- Mirko Filippetti
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy
- Canadian Advances in Neuro-Orthopedics for Spasticity Consortium (CANOSC), Kingston, ON K7K 1Z6, Canada
| | - Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy
| | - Rita Di Censo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy
- Neurorehabilitation Unit, Department of Neurosciences, University Hospital of Verona, 37100 Verona, Italy
| | - Roberto Aldegheri
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy
| | - Elisa Mantovani
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy
| | - Stefania Spina
- Spasticity and Movement Disorders 'ReSTaRt' Unit, Physical Medicine and Rehabilitation Section, Policlinico Riuniti Hospital University of Foggia, 71122 Foggia, Italy
| | - Marco Battaglia
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", 28100 Novara, Italy
| | - Alessio Baricich
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
- IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Andrea Santamato
- Spasticity and Movement Disorders 'ReSTaRt' Unit, Physical Medicine and Rehabilitation Section, Policlinico Riuniti Hospital University of Foggia, 71122 Foggia, Italy
| | - Nicola Smania
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy
- Neurorehabilitation Unit, Department of Neurosciences, University Hospital of Verona, 37100 Verona, Italy
| | - Alessandro Picelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy
- Canadian Advances in Neuro-Orthopedics for Spasticity Consortium (CANOSC), Kingston, ON K7K 1Z6, Canada
- Neurorehabilitation Unit, Department of Neurosciences, University Hospital of Verona, 37100 Verona, Italy
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Filippetti M, Tamburin S, Di Censo R, Adamo M, Manera E, Ingrà J, Mantovani E, Facciorusso S, Battaglia M, Baricich A, Santamato A, Smania N, Picelli A. Role of Diagnostic Nerve Blocks in the Goal-Oriented Treatment of Spasticity with Botulinum Toxin Type A: A Case-Control Study. Toxins (Basel) 2024; 16:258. [PMID: 38922151 PMCID: PMC11209555 DOI: 10.3390/toxins16060258] [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: 04/16/2024] [Revised: 05/17/2024] [Accepted: 05/28/2024] [Indexed: 06/27/2024] Open
Abstract
The goal-setting process is pivotal in managing patients with disabling spasticity. This case-control study assessed the role of diagnostic nerve blocks in guiding the goal-setting process within goal-targeted treatment of spasticity with botulinum neurotoxin-A. In this case-control study, patients with disabling spasticity underwent either a goal-setting process based on the patient's needs and clinical evaluation (control group) or additional diagnostic nerve block procedures (case group). All enrolled patients underwent a focal treatment with botulinum neurotoxin-A injection and a 1-month follow-up evaluation during which goal achievement was quantified using the goal attainment scaling-light score system. Data showed a higher goal achievement rate in the case group (70%) than in the control group (40%). In conclusion, diagnostic nerve blocks may help guide the goal-setting process within goal-targeted treatment of spasticity with botulinum neurotoxin-A towards more realistic and achievable goals, thereby improving the outcomes of botulinum neurotoxin-A injection. Future studies should better explore the role of diagnostic nerve blocks to further personalize botulinum neurotoxin-A according to individual patients' preferences and requirements.
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Affiliation(s)
- Mirko Filippetti
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy; (M.F.); (R.D.C.); (M.A.); (E.M.); (E.M.); (N.S.); (A.P.)
| | - Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy; (M.F.); (R.D.C.); (M.A.); (E.M.); (E.M.); (N.S.); (A.P.)
| | - Rita Di Censo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy; (M.F.); (R.D.C.); (M.A.); (E.M.); (E.M.); (N.S.); (A.P.)
| | - Martina Adamo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy; (M.F.); (R.D.C.); (M.A.); (E.M.); (E.M.); (N.S.); (A.P.)
| | - Elisa Manera
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy; (M.F.); (R.D.C.); (M.A.); (E.M.); (E.M.); (N.S.); (A.P.)
| | - Jessica Ingrà
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy; (M.F.); (R.D.C.); (M.A.); (E.M.); (E.M.); (N.S.); (A.P.)
| | - Elisa Mantovani
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy; (M.F.); (R.D.C.); (M.A.); (E.M.); (E.M.); (N.S.); (A.P.)
| | - Salvatore Facciorusso
- Spasticity and Movement Disorders ‘ReSTaRt’ Unit, Physical Medicine and Rehabilitation Section, Policlinico Riuniti Hospital, University of Foggia, 71122 Foggia, Italy; (S.F.); (A.S.)
| | - Marco Battaglia
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, 28100 Novara, Italy; (M.B.); (A.B.)
| | - Alessio Baricich
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, 28100 Novara, Italy; (M.B.); (A.B.)
| | - Andrea Santamato
- Spasticity and Movement Disorders ‘ReSTaRt’ Unit, Physical Medicine and Rehabilitation Section, Policlinico Riuniti Hospital, University of Foggia, 71122 Foggia, Italy; (S.F.); (A.S.)
| | - Nicola Smania
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy; (M.F.); (R.D.C.); (M.A.); (E.M.); (E.M.); (N.S.); (A.P.)
| | - Alessandro Picelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy; (M.F.); (R.D.C.); (M.A.); (E.M.); (E.M.); (N.S.); (A.P.)
- Canadian Advances in Neuro-Orthopedics for Spasticity Consortium (CANOSC), Kingston, ON K7K 1Z6, Canada
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Wu WT, Onishi K, Mezian K, Naňka O, Wang B, Su DCJ, Ricci V, Chang KV, Özçakar L. Ultrasound imaging of the posterior lateral corner of the knee: a pictorial review of anatomy and pathologies. Insights Imaging 2024; 15:39. [PMID: 38334861 PMCID: PMC10857999 DOI: 10.1186/s13244-024-01606-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/02/2024] [Indexed: 02/10/2024] Open
Abstract
Assessment of the posterior lateral knee pain poses diagnostic challenges, requiring accurate evaluation of various structures in light of the medical history and physical examination. Despite substantial progress in the ultrasonographic diagnosis of musculoskeletal disorders, the current protocol (EURO-MUSCULUS/USPRM. Basic scanning protocols for knee) fails to conduct a comprehensive investigation into the intricate, tendons, and ligaments of the posterior lateral knee. This pictorial review aims to bridge this gap by offering a systematic approach to utilize ultrasound examination of the less-discussed structures in this specific region. Providing cadaveric and magnetic resonance images, this essay demonstrates the efficacy of ultrasound in diagnosing posterior lateral knee pain. Notably, pathologies such as ligamentous sprains and tears are clearly discernible. Moreover, the integration of ultrasound guidance plays a vital role in reducing the risk of inadvertent neurovascular injury during injection, such as the common peroneal nerve and lateral genicular artery. This comprehensive approach will enhance clinicians' understanding and equip them with effective management strategies for posterior lateral knee pain.Critical relevance statement In this visual exposition, we delve into the intricacies of the posterior lateral corner of the knee. Offering a methodical approach to employ ultrasound for visualization of the less-explored structures within this region, the authors aim to enhance the diagnosis in posterior lateral knee pain.Key points1. Ultrasound excels at revealing intricate structures in the posterior lateral knee.2. Due to proximity of vital structures, extreme caution is crucial during injections.3. Employing dynamic scan and understanding ligaments enables a comprehensive exploration of pathologies.
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Affiliation(s)
- Wei-Ting Wu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, No. 87, Nei-Jiang Rd., Wan-Hwa District, Taipei, Taiwan
- Department of Physical Medicine and Rehabilitation, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kentaro Onishi
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kamal Mezian
- Department of Rehabilitation Medicine, First Faculty of Medicine and General University Hospital in Prague, Charles University, Prague, Czech Republic
| | - Ondřej Naňka
- Institute of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Bow Wang
- Department of Medical Imaging, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Daniel Chiung-Jui Su
- Department of Physical Medicine and Rehabilitation, Chi-Mei Medical Center, Tainan, Taiwan
| | - Vincenzo Ricci
- Physical and Rehabilitation Medicine Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, No. 87, Nei-Jiang Rd., Wan-Hwa District, Taipei, Taiwan.
- Department of Physical Medicine and Rehabilitation, National Taiwan University College of Medicine, Taipei, Taiwan.
- Center for Regional Anesthesia and Pain Medicine, Wang-Fang Hospital, Taipei Medical University, Taipei, Taiwan.
| | - Levent Özçakar
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
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Laure Inghilleri M, Alonso S, Moron H, Ruiz H, Bastide S, Coudray S. The value of ultrasound-guidance of nerves and muscles for patient tolerance and parameters electrodiagnostic studies. Clin Neurophysiol Pract 2024; 9:78-84. [PMID: 38357416 PMCID: PMC10864755 DOI: 10.1016/j.cnp.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/05/2024] [Accepted: 01/09/2024] [Indexed: 02/16/2024] Open
Abstract
Objective To assess impact of ultrasound guidance (USG) on patient's perception of nerve conduction studies (NCS). Methods In this single-center, randomized, sham-controlled, parallel, single-blind trial, we evaluated ultrasound (US) in identifying NCS stimulation site. Consecutive adults (18-80 old) without neuropathy referred for NCS were electronically randomized 1:1 to USG or Sham US. The primary outcome was sensory supramaximal intensity (SSMI) for each site/nerve; motor supramaximal intensity (MSMI), amplitudes, number of non-routine muscle punctured, Visual Analogue Scale (VAS), satisfaction were secondary outcomes. Results 290 participants were randomized, with 145 in the USG and 144 Sham US groups, respectively. No difference in SSMI, CMAP or SNAP, VAS, satisfaction was recorded. With USG, the median at the elbow and fibular MMSI were lower (p = 0.04; p = 0.02). With normal NCS or overweight and obese subgroups patients had lower median SSMI (p = 0.05/ p = 0.02), higher median and sural SNAP with normal NCS (p = 0.04; p = 0.007) and the sural SNAP for the expert US subgroup (p = 0.02). Conclusions USG is useful for nerves, that are anatomically variable or in obesity. The sural SNAP gain with US in the normal NCS subgroup could facilitate routine NCS. Significance In standard NCS the USG does not modify the patient's tolerance.Trial Registration: clinicaltrials.gov (NCT03868189).
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Affiliation(s)
- Marie Laure Inghilleri
- Neuromuscular Disorder Unit, Department of Neurophysiology, CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Sandrine Alonso
- Department of Biostatistics, Clinical Epidemiology, Public Health and Innovation in Methodology (BESPIM), CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Hélène Moron
- Neuromuscular Disorder Unit, Department of Neurophysiology, CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Hector Ruiz
- Neuromuscular Disorder Unit, Department of Neurophysiology, CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Sophie Bastide
- Department of Biostatistics, Clinical Epidemiology, Public Health and Innovation in Methodology (BESPIM), CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Sarah Coudray
- Neuromuscular Disorder Unit, Department of Neurophysiology, CHU Nîmes, Univ Montpellier, Nîmes, France
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Spina S, Facciorusso S, Botticelli C, Intiso D, Ranieri M, Colamaria A, Fiore P, Ciritella C, Genêt F, Santamato A. Ultrasonographic Evaluation of Three Approaches for Botulinum Toxin Injection into Tibialis Posterior Muscle in Chronic Stroke Patients with Equinovarus Foot: An Observational Study. Toxins (Basel) 2021; 13:829. [PMID: 34822612 PMCID: PMC8622442 DOI: 10.3390/toxins13110829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/11/2021] [Accepted: 11/19/2021] [Indexed: 02/04/2023] Open
Abstract
Spastic equinovarus (SEV) foot deformity is commonly observed in patients with post-stroke spasticity. Tibialis posterior (TP) is a common target for botulinum toxin type-A (BoNT-A) injection, as a first-line treatment in non-fixed SEV deformity. For this deep muscle, ultrasonographic guidance is crucial to achieving maximum accuracy for the BoNT-A injection. In current clinical practice, there are three approaches to target the TP: an anterior, a posteromedial, and a posterior. To date, previous studies have failed to identify the best approach for needle insertion into TP. To explore the ultrasonographic characteristics of these approaches, we investigated affected and unaffected legs of 25 stroke patients with SEV treated with BoNT-A. We evaluated the qualitative (echo intensity) and quantitative (muscle depth, muscle thickness, overlying muscle, subcutaneous tissue, cross-sectional area) ultrasound characteristics of the three approaches for TP injection. In our sample, we observed significant differences among almost all the parameters of the three approaches, except for the safety window. Moreover, our analysis showed significant differences in cross-sectional area between treated and untreated. Advantages and disadvantages of each approach were investigated. Our findings can thus provide a suitable reference for clinical settings, especially for novice operators.
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Affiliation(s)
- Stefania Spina
- Spasticity and Movement Disorders “ReSTaRt” Unit, Physical Medicine and Rehabilitation Section, Policlinico Riuniti Hospital, University of Foggia, 71122 Foggia, Italy; (C.B.); (C.C.)
| | - Salvatore Facciorusso
- Villa Beretta Rehabilitation Center, Valduce Hospital, Costa Masnaga, 23845 Lecco, Italy;
| | - Chiara Botticelli
- Spasticity and Movement Disorders “ReSTaRt” Unit, Physical Medicine and Rehabilitation Section, Policlinico Riuniti Hospital, University of Foggia, 71122 Foggia, Italy; (C.B.); (C.C.)
| | - Domenico Intiso
- Unit of Neuro-Rehabilitation, and Rehabilitation Medicine, IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, 71013 Foggia, Italy;
| | - Maurizio Ranieri
- Department of Basic Sciences, Neuroscience and Sense Organs, Aldo Moro University, 70124 Bari, Italy;
| | - Antonio Colamaria
- Department of Neurosurgery, University of Foggia, 71122 Foggia, Italy;
| | - Pietro Fiore
- Neurorehabilitation Unit, IRCCS Maugeri, 70124 Bari, Italy;
| | - Chiara Ciritella
- Spasticity and Movement Disorders “ReSTaRt” Unit, Physical Medicine and Rehabilitation Section, Policlinico Riuniti Hospital, University of Foggia, 71122 Foggia, Italy; (C.B.); (C.C.)
| | - François Genêt
- UPOH (Unité Péri Opératoire du Handicap, Perioperative Disability Unit), Physical Medicine and Rehabilitathion Department, Raymond-Poincaré Hospital, GHU APHP-Université PARIS SACLAY, 92380 Garches, France;
| | - Andrea Santamato
- Spasticity and Movement Disorders “ReSTaRt” Unit, Physical Medicine and Rehabilitation Section, Policlinico Riuniti Hospital, University of Foggia, 71122 Foggia, Italy; (C.B.); (C.C.)
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Comments on "Clinical utility of ultrasonography imaging in musculoskeletal conditions: a systematic review and meta-analysis". J Med Ultrason (2001) 2021; 49:117-118. [PMID: 34402026 DOI: 10.1007/s10396-021-01125-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 07/09/2021] [Indexed: 10/20/2022]
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Park JH, Rhyu IJ, Lim HK, Cha JH, Shin GJ, Rhim HC, Kim DH. Which Approach Is Most Optimal for Needle Electromyographic Examination of the Biceps Femoris Short Head: Medial or Lateral? Ann Rehabil Med 2021; 45:42-48. [PMID: 33557485 PMCID: PMC7960956 DOI: 10.5535/arm.20092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/06/2020] [Indexed: 11/29/2022] Open
Abstract
Objective To investigate the anatomical characteristics of the biceps femoris short head (BS) and determine the optimal needle placement for BS examination. Methods Twenty-one lower limbs were dissected. The distances from the medial and lateral margins of the biceps femoris long head (BL) tendon to the common fibular nerve (CFN) (M_CFN_VD and L_CFN_VD, respectively) and the distance from the lateral margin of the BL tendon to the lateral margin of the BS (L_BS_HD) were measured 5 cm proximal to the tip of the fibular head (P1), four fingerbreadths proximal to the tip of the fibular head (P2), and at the upper apex of the popliteal fossa (P3). Results The BS was located lateral to the BL tendon. The CFN was located along the medial margin of the BL tendon. The median values were 2.0 (P1), 3.0 (P2), and 0 mm (P3) for M_CFN_VD; and 17.4 (P1), 20.2 (P2), and 21.8 mm (P3) for L_CFN_VD; and 8.1 (P1), 8.8 (P2), and 13.0 mm (P3) for L_BS_VD. Conclusion The lateral approach to the BL tendon was safer than the medial approach for examining the BS. Amore proximal insertion site around the upper apex of the popliteal fossa was more accurate than the distal insertion site. In this study, we propose a safer and more accurate approach for electromyography of the BS.
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Affiliation(s)
- Jong Heon Park
- Department of Dermatology, Korea University Ansan Hospital, Ansan, Korea
| | - Im Joo Rhyu
- Department of Anatomy, Korea University College of Medicine, Seoul, Korea.,Division of Brain Korea 21 Plus Program for Biomedical Science, Korea University College of Medicine, Seoul, Korea
| | - Ha Kyoung Lim
- Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Jae Hyun Cha
- Department of Laboratory Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Gi Jun Shin
- Department of Orthopedic Surgery, Korea University Ansan Hospital, Ansan, Korea
| | - Hye Chang Rhim
- Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Seoul, Korea
| | - Dong Hwee Kim
- Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Seoul, Korea
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Amatto MD, Rambaransingh B, Yu JC. An Evaluation of Musculoskeletal Interventional Ultrasound Training in Canadian Physical Medicine and Rehabilitation Residency Programs. PM R 2020; 13:1148-1156. [PMID: 33247549 DOI: 10.1002/pmrj.12527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/16/2020] [Accepted: 11/16/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND Ultrasound is a rapidly evolving field of medicine with strong utility in musculoskeletal practices. In Canadian physical medicine and rehabilitation (PM&R) residency programs there are no national standards for objectives of training in this area. This possible disconnection between demand and availability could lead to gaps in education. OBJECTIVE (1) To determine the current state of interventional musculoskeletal ultrasound (MSUS) training in Canadian PM&R residency programs, as perceived by both residents and program directors; (2) to evaluate the perspectives of experts in the field on current and future MSUS curriculum inclusion. DESIGN This study was a cross-sectional cohort study using an explanatory sequential mixed methods design. SETTING This project included anonymous online surveys and targeted telephone/in-person semistructured interviews. PARTICIPANTS Participants were Canadian PM&R residents or clinicians. Survey responses included 71 residents and nine program directors. Interviews were conducted with nine MSUS experts. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Outcome measures included residents' level of interest, amount of exposure, and barriers to training. Themes regarding resident exposure and future directions for MSUS training were obtained based on expert interviews. RESULTS The vast majority (97%) of current PM&R residents are interested in using ultrasound clinically, with 73% reporting having had "none" to "limited exposure" in MSUS. Expert interviews revealed four major themes: (1) appropriate training is dependent on access, (2) MSUS represents an emerging standard of care, (3) a minimal baseline level of competence should be expected, and (4) various strategies may be used to integrate basic MSUS into existing residency curriculums. CONCLUSIONS The use of ultrasound as a clinical tool is rapidly increasing. Current PM&R residents have a desire to incorporate this skill into their future practices. Although barriers exist to implementing this training on a national level, the future looks promising with multiple strategies outlined to assist the process.
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Affiliation(s)
- Michael D Amatto
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Brian Rambaransingh
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Jaime C Yu
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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Vova JA, Leung E. A pragmatic approach to Botulinum Toxin safety. J Pediatr Rehabil Med 2020; 13:195-199. [PMID: 32568125 DOI: 10.3233/prm-200716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Botulinum Toxin (BoNT) is widely used to treat hypertonia in pediatric patients. Although serious adverse events (AEs) occur infrequently, they can lead to significant patient morbidity and mortality. This paper will discuss potential safety risks that may affect outcomes, medical comorbidities, medication dosing, targeting techniques, and muscle morphology. It is the responsibility of the physician to discuss risks and benefits regarding the use of BoNT and mitigate risks of AEs while maximizing the effectiveness of the medication.
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Kaymak B, Malas FÜ, Kara M, On AY, Özçakar L. Comment on Ultrasound Guidance for Botulinum Neurotoxin Chemodenervation Procedures. Toxins 2017, 10, 18-Quintessential Use of Ultrasound Guidance for Botulinum Toxin Injections-Muscle Innervation Zone Targeting Revisited. Toxins (Basel) 2018; 10:toxins10100396. [PMID: 30274173 PMCID: PMC6215312 DOI: 10.3390/toxins10100396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 06/14/2018] [Indexed: 12/26/2022] Open
Abstract
Recently, the importance of targeting structures during botulinum neurotoxin applications has been discussed in a variety of disorders, including spasticity and dystonia. In this respect, the advantages of ultrasound imaging to traditional techniques have been emphasized. We would like underscore the importance of ultrasound guidance, with targeting innervation zone(s) of the over-active muscles to achieve effective clinical outcomes. Additionally, we also clarify the difference between the terms—innervation zone (motor end plate) and motor point—which have been used by the authors as if they were the same. Further, we disagree with the authors about the intramuscular botulinum neurotoxin application techniques i.e., in-plane vs. out-of-plane whereby the former is, for sure, superior.
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Affiliation(s)
- Bayram Kaymak
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara 06100, Turkey.
| | - Fevziye Ünsal Malas
- Ankara Physical Medicine and Rehabilitation Training and Research Center, Ankara 06100, Turkey.
| | - Murat Kara
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara 06100, Turkey.
| | - Arzu Yağız On
- Department of Physical and Rehabilitation Medicine, Ege University Medical School, İzmir 35100, Turkey.
| | - Levent Özçakar
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara 06100, Turkey.
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Reply to Comment on Ultrasound Guidance for Botulinum Neurotoxin Chemodenervation Procedures. Toxins 2018, 10, 18-Quintessential Use of Ultrasound Guidance for Botulinum Toxin Injections. Toxins (Basel) 2018; 10:toxins10100400. [PMID: 30274231 PMCID: PMC6215238 DOI: 10.3390/toxins10100400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 09/25/2018] [Indexed: 11/16/2022] Open
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Effects of ultrasound-guided botulinum toxin type-A injections with a specific approach in spastic cerebral palsy. Acta Neurol Belg 2018; 118:429-433. [PMID: 29694645 DOI: 10.1007/s13760-018-0929-5] [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: 02/24/2018] [Accepted: 04/17/2018] [Indexed: 10/17/2022]
Abstract
The aim of this study was to detect effects of ultrasound-guided botulinum toxin type-A (US-guided BoNT-A) injections prepared according to lower extremity innervation zones on spasticity and motor function in 3-16 years children with diplegic and hemiplegic spastic cerebral palsy. This study included 25 patients between 3 and 16 years of age who admitted to our clinic in 2017, were being followed in our clinic with a diagnosis of cerebral palsy, had BoNT-A injections due to lower extremity spasticity. The US-guided BoNT-A injections were administered into the spastic muscles using a specific approach according to innervation zones of muscle. Modified Ashworth Scale (MAS) and Gross Motor Functional Classification System (GMFCS) were assessed at the baseline, and 4 and 12 weeks after the BoNT-A injections. Minimum and maximum ages of the patients were 45 and 192 months, and gender distribution was 8 females and 17 males. Significant decreases in the MAS scores of the knee and ankle tones were measured 4 and 12 weeks after the BoNT-A injection when compared to the baseline scores (p < 0.025). Hip muscle tonus only decreased 12 weeks after the injection (p < 0.025). In parallel with a reduction in spasticity GMFCS improved from 3 to 2 in the 4th and 12th weeks. US-guided BoNT-A injections with Euro-musculus approach is a practical and effective method to perform injections into proper points of proper muscles in children with spastic cerebral palsy.
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