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Heckert K, Biering-Sørensen B, Bäumer T, Khan O, Pagan F, Paulin M, Stitik T, Verduzco-Gutierrez M, Reebye R. Delphi Analysis: Optimizing Anatomy Teaching and Ultrasound Training for Botulinum Neurotoxin Type A Injection in Spasticity and Dystonia. Toxins (Basel) 2024; 16:371. [PMID: 39195781 PMCID: PMC11359033 DOI: 10.3390/toxins16080371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 08/16/2024] [Accepted: 08/16/2024] [Indexed: 08/29/2024] Open
Abstract
Our objective was to provide expert consensus on best practices for anatomy teaching and training on ultrasound-guided botulinum neurotoxin type A (BoNT-A) injection for specialists involved in treating spasticity and dystonia. Nine experts (three neurologists; six physical medicine and rehabilitation physicians) participated in a three-round modified Delphi process. Over three rounds, experts reached consensus on 15 of 16 statements describing best practices for anatomy and BoNT-A injection training. They unanimously agreed that knowledge of the target audience, including their needs and current competency, is crucial when designing training programs. Experts also agreed that alignment between instructors is essential to ensure consistency of approach over time and between regions, and that training programs should be simple, adaptable, and "hands-on" to enhance engagement and learning. Consensus was also reached for several other key areas of training program development. The best-practice principles identified by expert consensus could aid in the development of effective, standardized programs for anatomy teaching and BoNT-A injection training for the purposes of treating spasticity and dystonia. This will enhance the exchange of knowledge, skills, and educational approaches between global experts, allowing more specialists to treat important movement disorders and ultimately improving patient outcomes.
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Affiliation(s)
- Kimberly Heckert
- Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Bo Biering-Sørensen
- Department of Neurology, Rigshospitalet, Glostrup, DK-2600 Copenhagen, Denmark
| | - Tobias Bäumer
- Institute of System Motor Science, Center of Brain, Behavior and Metabolism, University of Lübeck, 23562 Lübeck, Germany;
| | - Omar Khan
- Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharines, ON L2T 4C2, Canada;
| | - Fernando Pagan
- Department of Neurology, Georgetown University, Washington, DC 20007, USA;
| | - Mitchell Paulin
- Rehabilitation Associates of the Main Line, Main Line Health, Paoli, PA 19301, USA;
| | - Todd Stitik
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ 07103, USA;
| | | | - Rajiv Reebye
- Department of Medicine, University of British Columbia, Vancouver, BC V5Z 2G9, Canada
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Zerbinati P, Bemporad J, Massimiani A, Bianchini E, Mazzoli D, Glorioso D, della Vecchia G, De Luca A, De Blasiis P. Lateral Pectoral Nerve Identification through Ultrasound-Guided Methylene Blue Injection during Selective Peripheral Neurectomy for Shoulder Spasticity: Proposal for a New Procedure. J Pers Med 2024; 14:116. [PMID: 38276238 PMCID: PMC10817262 DOI: 10.3390/jpm14010116] [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: 11/09/2023] [Revised: 01/12/2024] [Accepted: 01/17/2024] [Indexed: 01/27/2024] Open
Abstract
Internally rotated and adducted shoulder is a common posture in upper limb spasticity. Selective peripheral neurectomy is a useful and viable surgical technique to ameliorate spasticity, and the lateral pectoral nerve (LPN) could be a potential good target to manage shoulder spasticity presenting with internal rotation. However, there are some limitations related to this procedure, such as potential anatomical variability and the necessity of intraoperative surgical exploration to identify the target nerve requiring wide surgical incisions. This could result in higher post-surgical discomfort for the patient. Therefore, the aim of our study was to describe a modification of the traditional selective peripheral neurectomy procedure of the LPN through the perioperative ultrasound-guided marking of the target nerve with methylene blue. The details of the localization and marking procedure are described, as well as the surgical technique of peripheral selective neurectomy and the potential advantages in terms of nerve localization, surgical precision and patients' post-surgical discomfort. We suggest that the proposed modified procedure could be a valid technique to address some current limitations and move the surgical treatment of spasticity toward increasingly tailored management due to the ease of nerve identification, the possibility of handling potential anatomical variability and the resulting smaller surgical incisions.
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Affiliation(s)
- Paolo Zerbinati
- Neuro-Orthopedic Unit, Sol et Salus Hospital, 47922 Rimini, Italy (J.B.); (D.G.)
| | - Jonathan Bemporad
- Neuro-Orthopedic Unit, Sol et Salus Hospital, 47922 Rimini, Italy (J.B.); (D.G.)
| | - Andrea Massimiani
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, 00189 Rome, Italy; (A.M.); (E.B.)
| | - Edoardo Bianchini
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, 00189 Rome, Italy; (A.M.); (E.B.)
| | - Davide Mazzoli
- Gait and Motion Analysis Laboratory, Sol et Salus Hospital, 47992 Rimini, Italy;
| | - Davide Glorioso
- Neuro-Orthopedic Unit, Sol et Salus Hospital, 47922 Rimini, Italy (J.B.); (D.G.)
| | - Giuseppe della Vecchia
- Department of Women, Child, General and Specialistic Surgery, University of Campania “L. Vanvitelli”, 80138 Naples, Italy;
| | - Antonio De Luca
- Section of Human Anatomy, Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli”, Via Luciano Armanni, 5, 80138 Naples, Italy;
| | - Paolo De Blasiis
- Section of Human Anatomy, Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli”, Via Luciano Armanni, 5, 80138 Naples, Italy;
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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; 14:809. [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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Marigi EM, Iturregui JM, Werthel JD, Sperling JW, Sanchez-Sotelo J, Schoch BS. Higher rates of mortality and perioperative complications in patients undergoing primary shoulder arthroplasty and a history of previous stroke. J Shoulder Elbow Surg 2022; 32:e216-e226. [PMID: 36375747 DOI: 10.1016/j.jse.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 10/09/2022] [Accepted: 10/12/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Cerebrovascular accidents (CVAs), or strokes, are the second most common cause of mortality and third most common cause of disability worldwide. Although advances in the treatment of strokes have improved survivorship following these events, there remains a limited understanding of the effect of a prior stroke and sequelae on patients undergoing shoulder arthroplasty (SA). This study aimed to determine the outcomes of patients with a history of stroke with sequela undergoing primary SA. METHODS Over a 30-year time period (1990-2020), 205 primary SAs (32 hemiarthroplasties [HAs], 56 anatomic total shoulder arthroplasties [aTSAs], and 117 reverse shoulder arthroplasties [RSAs]) were performed in patients who sustained a previous stroke with sequela and were followed for a minimum of 2 years. This cohort was matched (1:2) according to age, sex, body mass index, implant, and year of surgery with patients who had undergone HA or aTSA for osteoarthritis or RSA for cuff tear arthropathy. Mortality after primary SA was individually calculated through a cumulative incidence analysis. Implant survivorship was analyzed with a competing risk model selecting death as the competing risk. RESULTS The stroke cohort sustained 38 (18.5%) surgical and 42 (20.5%) medical perioperative complications. Compared with the control group, the stroke cohort demonstrated higher rates of any surgical complication (18.5% vs 10.7%; P = .007), instability (6.3 % vs 1.7%; P = .002), venous thromboembolism (3.4% vs 0.5%; P = .004), pulmonary embolus (2.0% vs 0%; P = .005), postoperative stroke (2.4% vs 0%; P = .004), respiratory failure (1.0% vs 0%; P = .045), any medical complication (20.5% vs 7.3%; P < .001), and 90-day readmission (16.6% vs 4.9%; P < .001). Additionally, RSA in the stroke cohort was associated with higher reoperation (8.5% vs 2.6%; P = .011) and revision rates (6.8% vs 1.7%; P = .013) compared with the matched cohort. Subsequent cumulative incidences of death at 1, 2, 5, 10, 15, and 20 years were 4.4% vs 3.4%, 10.7% vs 5.1%, 25.6% vs 14.7%, 51.6% vs 39.3%, 74.3% vs 58.6%, and 92.6% vs 58.6% between the stroke and matched cohorts, respectively (P < .001). CONCLUSIONS A preoperative diagnosis of a stroke in patients undergoing primary SA is associated with higher rates of perioperative complications and mortality when compared to a matched cohort. This information should be considered to counsel patients and surgeons to optimize care and help mitigate risks associated with the perioperative period.
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Affiliation(s)
- Erick M Marigi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jose M Iturregui
- Department of Orthopedic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Jean-David Werthel
- Department of Orthopedic Surgery, Hopital Ambroise Paré, Boulogne-Billancourt, France
| | - John W Sperling
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Bradley S Schoch
- Department of Orthopedic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA.
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Jacinto J, Camões-Barbosa A, Carda S, Hoad D, Wissel J. A practical guide to botulinum neurotoxin treatment of shoulder spasticity 1: Anatomy, physiology, and goal setting. Front Neurol 2022; 13:1004629. [PMID: 36324373 PMCID: PMC9618862 DOI: 10.3389/fneur.2022.1004629] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/28/2022] [Indexed: 09/26/2023] Open
Abstract
Botulinum neurotoxin type A (BoNT-A) is a first-line treatment option for post-stroke spasticity, reducing pain and involuntary movements and helping to restore function. BoNT-A is frequently injected into the arm, wrist, hand and/or finger muscles, but less often into the shoulder muscles, despite clinical trials demonstrating improvements in pain and function after shoulder BoNT-A injection. In part 1 of this two-part practical guide, we present an experts' consensus on the use of BoNT-A injections in the multi-pattern treatment of shoulder spasticity to increase awareness of shoulder muscle injection with BoNT-A, alongside the more commonly injected upper limb muscles. Expert consensus was obtained from five European experts with a cumulative experience of more than 100 years of BoNT-A use in post-stroke spasticity. A patient-centered approach was proposed by the expert consensus: to identify which activities are limited by the spastic shoulder and consider treating the muscles that are involved in hindering those activities. Two patterns of shoulder spasticity were identified: for Pattern A (adduction, elevation, flexion and internal rotation of the shoulder), the expert panel recommended injecting the pectoralis major, teres major and subscapularis muscles; in most cases injecting only the pectoralis major and the teres major is sufficient for the first injection cycle; for Pattern B (abduction or adduction, extension and internal rotation of the shoulder), the panel recommended injecting the posterior part of the deltoid, the teres major and the latissimus dorsi in most cases. It is important to consider the local guidelines and product labels, as well as discussions within the multidisciplinary, multiprofessional team when deciding to inject shoulder muscles with BoNT-A. The choice of shoulder muscles for BoNT-A injection can be based on spastic pattern, but ideally should also firstly consider the functional limitation and patient expectations in order to establish better patient-centered treatment goals. These recommendations will be of benefit for clinicians who may not be experienced in evaluating and treating spastic shoulders.
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Affiliation(s)
- Jorge Jacinto
- Centro de Medicina de Reabilitação de Alcoitão, Serviço de Reabilitação de Adultos 3, Alcabideche, Portugal
| | | | - Stefano Carda
- Centre Hospitalier Universitaire Vaudois (CHUV), Neuropsychology and Neurorehabilitation, Lausanne, Switzerland
| | - Damon Hoad
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Jörg Wissel
- Department of Neurorehabilitation and Physical Therapy, Vivantes Hospital Spandau, Berlin, Germany
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Wissel J, Camões-Barbosa A, Comes G, Althaus M, Scheschonka A, Simpson DM. Pain Reduction in Adults with Limb Spasticity Following Treatment with IncobotulinumtoxinA: A Pooled Analysis. Toxins (Basel) 2021; 13:887. [PMID: 34941725 PMCID: PMC8704318 DOI: 10.3390/toxins13120887] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 11/17/2022] Open
Abstract
Some studies have shown that incobotulinumtoxinA reduces spasticity-associated pain, but further evidence is needed. This exploratory analysis pooled pain-relief data from six Phase 2 or 3 studies of incobotulinumtoxinA (four placebo-controlled studies) for treating upper limb spasticity in adults. Spasticity-associated pain was assessed at baseline and 4 weeks post incobotulinumtoxinA injection using the disability assessment scale (DAS) for pain. Only data for patients with pain at baseline were analysed. Overall, 544 (incobotulinumtoxinA, N = 415; placebo, N = 129) of 937 patients (58.1%) experienced pain at baseline. At Week 4, a significantly greater proportion of incobotulinumtoxinA- (52.1%) than placebo-treated patients (28.7%; Chi-square p < 0.0001) showed a response (≥1-point improvement in DAS pain score). In logistic regression analysis, incobotulinumtoxinA-treated patients were 2.6 times more likely to achieve this endpoint than placebo-treated patients. A significant difference between incobotulinumtoxinA and placebo was observed regardless of baseline pain severity. Additionally, 27.1% of incobotulinumtoxinA- versus 12.4% of placebo-treated patients reported complete pain relief at Week 4 (p = 0.0006). Pain relief increased with multiple injection cycles. To achieve patient-centred care, pain relief may be considered a treatment goal in adults with spasticity-associated pain regardless of pain severity. This study contributes to understanding the benefits of incobotulinumtoxinA in treating limb spasticity-associated pain.
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Affiliation(s)
- Jörg Wissel
- Department of Neurorehabilitation and Physical Therapy, Vivantes Hospital Spandau, 13585 Berlin, Germany
| | | | - Georg Comes
- Merz Pharmaceuticals GmbH, D-60318 Frankfurt am Main, Germany; (G.C.); (M.A.); (A.S.)
| | - Michael Althaus
- Merz Pharmaceuticals GmbH, D-60318 Frankfurt am Main, Germany; (G.C.); (M.A.); (A.S.)
| | - Astrid Scheschonka
- Merz Pharmaceuticals GmbH, D-60318 Frankfurt am Main, Germany; (G.C.); (M.A.); (A.S.)
| | - David M. Simpson
- Icahn School of Medicine at Mount Sinai, Department of Neurology, New York, NY 10029, USA;
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de Sire A, Moggio L, Demeco A, Fortunato F, Spanò R, Aiello V, Marotta N, Ammendolia A. Efficacy of rehabilitative techniques in reducing hemiplegic shoulder pain in stroke: Systematic review and meta-analysis. Ann Phys Rehabil Med 2021; 65:101602. [PMID: 34757009 DOI: 10.1016/j.rehab.2021.101602] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 09/10/2021] [Accepted: 09/13/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hemiplegic shoulder pain (HSP) is a disabling complication affecting stroke survivors. In this context, rehabilitation might play a key role in its clinical management. Recent systematic reviews of the impact of rehabilitative approaches on pain reduction in patients with HSP are lacking. OBJECTIVE This systematic review of randomized controlled trials (RCTs) with meta-analysis aimed to investigate the efficacy of rehabilitative techniques in reducing HSP in stroke survivors. METHODS PubMed, Scopus, and Web of Science were searched from inception to March 8, 2021 to identify RCTs of stroke survivors with HSP undergoing specific rehabilitative techniques combined with conventional therapy to reduce pain intensity. A network meta-analysis and meta-analysis of the Bayesian network of random effects were performed. The risk of bias of studies was assessed with Version 2 of the Cochrane Risk of Bias tool for randomized trials. RESULTS Of 1139 articles identified, 12 were included in the final synthesis. We analyzed data for 723 stroke survivors, reporting a significant overall decrease in pain intensity after a rehabilitative approach by the Bayesian meta-analysis (standardized mean difference 2.78, 95% confidence interval 0.89;-4.59; p = 0.003). We report a significant reduction in HSP with botulinum toxin type A injection (p = 0.001), suprascapular nerve pulsed radiofrequency (p = 0.030), suprascapular nerve block (p = 0.020), and trigger-point dry needling (p = 0.005) as compared with conventional rehabilitation. Concerning the effect size, we identified a Bayesian factor10 of 97.2, with very strong evidence of superiority of rehabilitative techniques. CONCLUSIONS The present systematic review and meta-analysis showed that adding other rehabilitative techniques to conventional rehabilitation was significantly more effective than conventional rehabilitation alone in the complex management of patients affected by HSP.
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Affiliation(s)
- Alessandro de Sire
- Physical and Rehabilitative Medicine, Department of Medical and Surgical Sciences, University of Catanzaro "Magna Graecia", 88100 Catanzaro, Italy.
| | - Lucrezia Moggio
- Physical and Rehabilitative Medicine, Department of Medical and Surgical Sciences, University of Catanzaro "Magna Graecia", 88100 Catanzaro, Italy
| | - Andrea Demeco
- Physical and Rehabilitative Medicine, Department of Medical and Surgical Sciences, University of Catanzaro "Magna Graecia", 88100 Catanzaro, Italy
| | - Francesco Fortunato
- Neurology Institute, Department of Medical and Surgical Sciences, University of Catanzaro "Magna Graecia", 88100 Catanzaro, Italy
| | - Riccardo Spanò
- Physical and Rehabilitative Medicine, Department of Medical and Surgical Sciences, University of Catanzaro "Magna Graecia", 88100 Catanzaro, Italy
| | - Vincenzo Aiello
- Rheumatology Unit, Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
| | - Nicola Marotta
- Physical and Rehabilitative Medicine, Department of Medical and Surgical Sciences, University of Catanzaro "Magna Graecia", 88100 Catanzaro, Italy
| | - Antonio Ammendolia
- Physical and Rehabilitative Medicine, Department of Medical and Surgical Sciences, University of Catanzaro "Magna Graecia", 88100 Catanzaro, Italy
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