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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;...
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Citations
... However, because the injection in EMGguided infusion is painful, it is usually performed under general anesthesia for adults and children. The US guidance seems to be a good alternative for use in children with CP: it allows identification of the muscle to be injected and verification of the position of the needle tip in the muscle [15,16] Comprehensive rehabilitation management is required to optimize the reduction in stretch-induced by BoNT-A injection. In particular, active and passive stretching of the target muscle and strengthening of the antagonist muscle are needed after the injection [17]. ...
Objectives: To investigate the effect of botulinum toxin-A (BoNT-A) on the age groups and gross motor function classification level in children with cerebral palsy (CP).Method: In this study, 116 children with spastic CP were investigated. BoNT-A was injected into the spastic muscles of the lower limbs of all participants. All participants received physiotherapy and functional electrical stimulation for 3 months after injection. We measured the change in spasticity using the Modified Ashworth Scale and gross motor function using the GMFM-88. Spasticity was measured before injection and at 1 and 3 months after injection. Measurement of gross motor function was performed before and after the injections. Results: The effect of BoNT-A injection in combination with physiotherapy and electrical stimulation significantly improved spasticity and gross motor function. After BoNT-A injection, younger children showed reduced spasticity and improved gross motor skills compared to older children. At the gross motor level, sitting, standing, and walking improved in children with gross motor function classification levels I-III, and posture and mobility improved in children with gross motor function classification levels IV-V.Conclusions: We conclude that BoNT-A injection is effective for improving gross motor function in patients younger than 72 months of age.
... Moreover, if the needle injects beyond the glands, it might lead to hematoma and affect nerve activity at the intramuscular junction. 32 Previous studies recommended that ultrasound has more advantages than solely manual guidance (such as: visually see the injection structure, needle, blood vessels and nerves that need to be avoided, etc.), 33,34 and there was Level 1 evidence to support this. 33 In some studies, the success rate for salivary gland injection using anatomical landmarks in the parotid and submandibular glands ranges from 30% to 70%. 14 ...
... 32 Previous studies recommended that ultrasound has more advantages than solely manual guidance (such as: visually see the injection structure, needle, blood vessels and nerves that need to be avoided, etc.), 33,34 and there was Level 1 evidence to support this. 33 In some studies, the success rate for salivary gland injection using anatomical landmarks in the parotid and submandibular glands ranges from 30% to 70%. 14 ...
Objective
To evaluate the effectiveness of ultrasound‐guided injection of botulinum toxin type A (BTX‐A) in treating sialorrhea.
Methods
We recruited 32 sialorrhea subjects and they received an ultrasound‐guided injection of BTX‐A. The extent of salivation was evaluated according to the Visual Analog Scale (VAS), Drooling Severity and Frequency Scale (DSFS), and Saliva Flow Rate (SFR). Laryngeal secretions were evaluated based on Fiberoptic Endoscopic Evaluation of Swallowing (FEES) rated according to the Murray Secretion Scale (MSS). We assessed the extent of salivation and laryngeal secretions before injection and at 1, 2, and 4 weeks after injection.
Results
The scores for the VAS, DSFS‐S, DSFS‐F, and DSFS‐T decreased significantly at 1, 2, and 4 weeks after injection compared with before injection (p < .05). Based on VAS, the efficacy was substantially higher at 2 and 4 weeks after injection than at 1 week after injection (p < .05). According to DSFS‐S and DSFS‐T, the efficacy was significantly higher at 4 weeks than at 1 week after injection (p < .05). The SFR and MSS scores at 1 and 2 weeks after injection were superior to those before injection (p < .05). Meanwhile, the SFR score 2 weeks after injection was superior to that 1 week after injection (p < .05).
Conclusion
The ultrasound‐guided injection of BTX‐A can effectively reduce saliva secretion in patients with neurogenic dysphagia. Furthermore, it has the advantages of early onset time and lasting curative effects, which indicates that clinical promotion and application of this technique are justified.
Level of Evidence
Level 3.
... Before the first BoNT course, electrophysiological activity of the following muscles on both sides were assessed by needle electromyography (Medtronic Keypoint portable 4-channel electromyography) under the guidance of ultrasonography (US, Alpinion E-Cube 8) [33]: longissimus, iliocostalis (at lumbar and thoracic levels adjusted for each patient according to the fulcrum of spine curvatures), internal and external abdominal oblique muscles. Muscles were evaluated with patients under different testing conditions: (i) while sitting without any upper limb or trunk support (with the patient's trunk maintained in a relaxed position); (ii) during a trunk passive mobilization (recording the muscle activity with the trunk maintained in an upright straight position by an operator); and (iii) during self-realignment of the trunk, with a specific maneuver normally activating the muscle under evaluation. ...
Lateral trunk flexion (LTF) and its severe form, called Pisa syndrome (PS), are highly invalidating axial postural abnormalities associated with Parkinson’s disease (PD). Management strategies for LTF lack strong scientific evidence. We present a real-life, longitudinal study evaluating long-term efficacy of botulinum toxin (BoNT) injections in axial muscles to reduce LTF and PS in PD. A total of 13 PD patients with LTF > 5° received ultrasound- and electromyography-guided BoNT injections every 4 months. Seven untreated matched PD patients with LTF served as controls and their changes in posture after 18 months were compared with those of seven patients continuing BoNT over 12 months. 53.8% of patients continued the BoNT injections for at least 12 months. Various individual LTF responses were observed. Overall, BoNT-treated patients obtained a not statistically significant improvement of LTF of 17 ± 41% (p = 0.237). In comparison, the seven untreated PD patients suffered a deterioration in LTF over 12 months by 36 ± 45% (p = 0.116), showing a significantly different trajectory of posture change (p = 0.026). In conclusion, repeated BoNT injections in axial muscles showed varying effects in managing PD-associated LTF, suggesting that: (a) a relevant number of patients with LTF can benefit from BoNT; (b) long-term treatment could prevent LTF worsening; (c) an instrumented, personalized approach is important; and (d) there is a need for prospective, long-term studies.
... In fact, there are reports suggesting an equivalence of the guided and non-guided approach, while expert opinions vary based on personal experiences in clinical practice [26][27][28][29]. Precedent reviews attempted to compare the effect of guided and non-guided injections on clinical outcome [30][31][32][33]. However, these reviews addressed this issue in the form of a critical appraisal and were restricted to a qualitative analysis, leading to less robust conclusions. ...
... The advantage of guided against non-guided BoNT injections is often taken as a given, because it is intuitive to expect a better therapeutic efficacy by introducing an imaging or electrophysiological adjunct to traditional anatomical localization. To date, this has been supported solely by qualitative evidence synthesis methodologies [30][31][32][33]. Our study proves for the first time the superiority of guided BoNT injections by implementing a network meta-analysis and quantifies these effects for limb spasticity in adults. ...
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.
... In fact, there are reports suggesting an equivalence of the guided and non-guided approach, while expert opinions vary based on personal experiences in clinical practice [26][27][28][29]. Precedent reviews attempted to compare the effect of guided and non-guided injections on clinical outcome [30][31][32][33]. However, these reviews addressed this issue in the form of a critical appraisal and were restricted to a qualitative analysis, leading to less robust conclusions. ...
... The advantage of guided against non-guided BoNT injections is often taken as a given, because it is intuitive to expect a better therapeutic efficacy by introducing an imaging or electrophysiological adjunct to traditional anatomical localization. To date, this has been supported solely by qualitative evidence synthesis methodologies [30][31][32][33]. Our study proves for the first time the superiority of guided BoNT injections by implementing a network meta-analysis and quantifies these effects for limb spasticity in adults. ...
... Alter and Karp opined that the addition of US alone or combined with traditional techniques is recommended by many clinical experts, however, head-to-head trials are needed to determine the benefits of improved accuracy with US guidance. 6 Accurate targeting has further importance in DNBs, as nerves are bundled with vascular structures, and thus there is more risk of puncturing the adjacent or encapsulated blood vessels. 7 Nerves are much smaller than muscles and as DNBs may target both the larger peripheral nerve trunks and/or their branches, visualization of the nerves and surrounding structures becomes more critical. ...
... The guidelines were created to establish a standard for the procedure as the experts noted that the literature for DNBs in spasticity "is very poor and does not allow for an opinion" on efficacy or outcomes. Similar to the use of US in chemodenervation for spasticity, 6 the French guidelines state that both e-stim and/or US can be used while noting that "there is no demonstrated superiority of one over the Ultrasound Guided Nerve Blocks other" and that "Recommendations for the tracking mode for nerve blocks can be extrapolated from chemical neurolysis." However, they acknowledge that when performing nerve blocks for the "specific indications" of their practice, the French Society of Anesthesia & Intensive Care ...
... At the intramuscular branch or end plate to potentially avoid targeting downstream muscles or sensory branches. 6 Picelli et al. wrote "In daily practice, ultrasound should be coupled with needle electrical stimulation in order to maximize precise identification." 12 An experienced injector can rapidly identify the nerves using the known anatomic landmarks from the spasticity literature. ...
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 e-stimulation in DNBs for spasticity management, as US use during nerve blocks for perineurial anesthesia has demonstrated improved patient safety and procedural efficiency.
... Beyond preliminary demonstrations of non-invasive optogenetics and brain imaging, these systemically delivered nanoscopic light sources can also be applied to other biological systems, such as light-controlled geneediting. Although existing demonstrations of these internal light sources have been limited to rodents, which have small organ sizes, we envision that they also have great application potential in humans with larger organs, as their penetration depth can readily reach the level of 10 cm due to the use of tissue-penetrant ultrasound and the endogenous circulatory system that covers the entire body [47]. ...
... Indeed, in a previous study of post-stroke survivors from Brazil, increased adductor tone was a frequent finding [30], also noted in patients with spastic hemiplegia [21,22]. Consistent with clinical practice in Brazil [26], anatomic palpation was used to guide injection in most patients; however, it is important to acknowledge that this may not be routine practice in other countries where electrical stimulation or ultrasound may be more widely available and, therefore, more commonly used to guide injections [31,32]. ...
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.
... In addition, the ultrasound-guided injection was useful for injecting Botulinum toxin in the muscle, which was related to a previous study reporting that instrumental guidance was found to be superior to a manual needle injection. [35] conclusIons Botulinum toxin type A is the treatment of choice for trapezius hypertrophy and trapezius myalgia. The ultrasound-guided along injection technique in this study and 30-unit dosage were recommended for practical trapezius contouring because no serious side effects were found, and this contributed to the satisfactory outcomes for all patients. ...
Context:
Based on various Botulinum toxin A products, reports of the lower efficacy of Incobotulinum toxin A compared with Onabotulinum toxin A for muscle contouring were observed. In addition, complications of trapezius myalgia and shoulder contouring treatment from malpractice have been reported.
Aims:
The study aimed at comparing the efficacy between Incobotulinum toxin A and Onabotulinum toxin A; research was conducted on a safe treatment technique for trapezius hypertrophy and trapezius myalgia.
Materials and methods:
A split-shoulder, double-blind, randomized controlled trial was performed. Twenty volunteers with trapezius hypertrophy and trapezius myalgia were randomly injected with 30 units of Incobotulinum toxin A and Onabotulinum toxin A in each trapezius muscle guided by ultrasound.
Results:
The trapezius thickness among those receiving treatment with Onabotulinum toxin A and Incobotulinum toxin A on day 60 was 7.35 ± 1.11 and 7.33 ± 1.21 mm, respectively, which did not portray a significant difference (P = 0.991). Compared with the muscle size from day 60 to one year, the size of the trapezius muscle that had been treated by Onabotulinum toxin type A regained a significantly larger size compared with that treated by Incobotulinum toxin A (P = 0.027). On comparing the size of the trapezius muscle treated by Incobotulinum toxin A between one year and day 0, it was observed that the trapezius thickness at one year had significantly decreased (P < 0.001). On comparing the pain score from day 60 to day 0, it was observed that the pain scores of trapezius myalgia treated by Onabotulinum toxin A and Incobotulinum toxin A significantly differed (P = 0.003).
Conclusions:
Incobotulinum toxin A had the same efficacy but a longer lasting effect for the trapezius size contouring and a higher efficacy for trapezius myalgia treatment compared with Onabotulinum toxin A.
... Current practices now include ultrasound guidance which is the preferred practice in our center. This allows the proceduralist to have direct and continuous visualization of the target, surrounding structures and the procedural needle [6]. ...
