Sonographic guide for botulinum toxin injections of the upper limb: EUROMUSCULUS/USPRM spasticity approach

A practical guide to botulinum neurotoxin treatment of shoulder spasticity 2: Injection techniques, outcome measurement scales, and case studies

Introduction

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, the wrist, the hand, and/or the finger muscles but less often into the shoulder muscles, despite clinical trials demonstrating improvements in pain and function after shoulder BoNT-A injection.

Methods

In part 2 of this two-part practical guide, we present an experts' consensus on the choice of outcome measurement scales and goal-setting recommendations for BoNT-A in the 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. Case studies are included as examples of approaches taken in the treatment of shoulder spasticity.

Results

Although the velocity-dependent increase in muscle tone is often a focus of patient assessment, it is only one component of spasticity and should be assessed as part of a wider range of measurements. For outcome measurement following BoNT-A injection in shoulder muscles, shoulder-specific scales are recommended. Other scales to be considered include Pain Numerical Rating and/or global functioning, as well as the quality of life and global perception of benefit scores.Goal setting is an essential part of the multidisciplinary management process for spasticity; goals should be patient-centric, realistic, and achievable; functional-focused goal statements and a mixture of short- (3-6 month) and long-term (9-18 month) goals are recommended. These can be grouped into symptomatic, passive function, active function, involuntary movement, and global mobility.Clinical evaluation tools, goal setting, and outcome expectations for the multipattern treatment of shoulder spasticity with BoNT-A should be defined by the whole multidisciplinary team, ensuring patient and caregiver involvement.

Discussion

These recommendations will be of benefit to clinicians who may not be experienced in evaluating and treating spastic shoulders.

Botulinum Toxin Injection for Painful Adductor Pollicis Contracture after Thumb Carpometacarpal Resection Arthroplasty

Pollux adductus deformity is an accompanying symptom of thumb carpometacarpal osteoarthritis. We describe a case of a patient who presented with increased muscle tone of the adductor pollicis muscle and chronic pain in the thenar musculature, i.e., recurrence of an adduction deformity. The patient reported a symptom-free period of 5.5 years after having received resection-suspension-arthroplasty for stage IV thumb carpometacarpal osteoarthritis until spasmodic pain appeared. Due to the functional impairment of this condition, we administered therapy including 100 units of Botox^® (onabotulinumtoxinA, Allergan, Dublin, Ireland) injected with a fanning technique into the adductor pollicis muscle. Thus, we observed a substantial improvement in the patient-reported outcome measures as well as pain levels compared with initial values. The current case shows the pivotal role of the adductor pollicis muscle when patients report pain at the base of the thumb, which can cause considerable impairments despite the complication-free surgical treatment of thumb CMC OA.

Robotic rehabilitation for end-effector device and botulinum toxin in upper limb rehabilitation in chronic post-stroke patients: an integrated rehabilitative approach

BACKGROUND

Determine the effects of an integrated rehabilitation protocol, including botulinum toxin and conventional rehabilitation exercise plus end-effector (EE) robotic training for functional recovery of the upper limb (UL) compared to training with the robot alone in post-chronic stroke patients with mild to severe spasticity, compared to training with the robot alone.

METHODS

In this prospective, observational case-control study, stroke patients were allocated into 2 groups: robot group (RG, patients who underwent robotic treatment with EE) and robot-toxin group (RTG, patients who in addition have carried out the injection of botulinum toxin for UL recovery). All patients were assessed by Fugl-Meyer Assessment (FMA), Motricity Index (MI), modified Ashworth scale (MAS), numeric rating scale (NRS), Box and Block Test (BBT), Frenchay Arm Test (FAT), and Barthel Index (BI) at baseline (T0), T1 (end of treatment), and T2 (3 months of follow-up).

RESULTS

Forty-four patients were included and analyzed (21RG; 23RTG). From the analysis between groups, the results suggested how there was a statistically significant difference in favor of RTG, specifically ΔT0-T1 and ΔT0-T2 for B&B p = 0.009 and p = 0.035; ΔT0-T1 and ΔT0-T2 for FAT with p = 0.016 and p = 0.031; ΔT0-T1 for MAS shoulder p = 0.016; ΔT0-T1 and ΔT0-T2 with p = 0.010 and p = 0.005 for MAS elbow; and ΔT0-T1 and ΔT0-T2 with p = 0.001 and p = 0.013 for MAS wrist.

CONCLUSION

Our results suggest, in line with the literature, a good efficacy in the reduction of spasticity and in the improvement of the function of the UL, with the reduction of pain, adopting a rehabilitation protocol integrated with BoTN, robot-assisted training, and traditional physiotherapy.

An Evaluation of Musculoskeletal Interventional Ultrasound Training in Canadian Physical Medicine and Rehabilitation Residency Programs

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.

Rectus Femoris Characteristics in Post Stroke Spasticity: Clinical Implications from Ultrasonographic Evaluation

In stroke survivors, rectus femoris (RF) spasticity is often implicated in gait pattern alterations such as stiff knee gait (SKG). Botulinum toxin type A (BoNT-A) is considered the gold standard for focal spasticity treatment. However—even if the accuracy of injection is crucial for BoNT-A efficacy—instrumented guidance for BoNT-A injection is not routinely applied in clinical settings. In order to investigate the possible implications of an inadequate BoNT-A injection on patients’ clinical outcome, we evaluated the ultrasound-derived RF characteristics (muscle depth, muscle thickness, cross-sectional area and mean echo intensity) in 47 stroke survivors. In our sample, we observed wide variability of RF depth in both hemiparetic and unaffected side of included patients (0.44 and 3.54 cm and between 0.25 and 3.16 cm, respectively). Moreover, our analysis did not show significant differences between treated and non-treated RF in stroke survivors. These results suggest that considering the inter-individual variability in RF muscle depth and thickness, injection guidance should be considered for BoNT-A treatment in order to optimize the clinical outcome of treated patients. In particular, ultrasound guidance may help the clinicians in the long-term follow-up of muscle quality.

A pragmatic approach to Botulinum Toxin safety

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.

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

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.

Evaluating the functional outcomes of ultrasound-guided botulinum toxin type A injections using the Euro-musculus approach for upper limb spasticity treatment in post-stroke patients: an observational study

BACKGROUND

Ultrasound-guided botulinum toxin type A injection is an effective treatment for spasticity. Euro-musculus spasticity approach is a new method for administering injections to the correct point of the correct muscle. The clinical outcomes of this practical approach are not yet available in the literature.

AIM

The purpose of this study was to evaluate the effects on spasticity and the functional outcomes of ultrasound guided botulinum toxin type A injections via the Euro-musculus spasticity approach to treat upper limb spasticity in post-stroke patients.

DESIGN

Observational study.

SETTING

Inpatient post-stroke patients.

POPULATION

Twenty-five post-stroke patients with post-stroke upper limb spasticity were recruited.

METHODS

The ultrasound-guided botulinum toxin type A injections were administered into the spastic target muscles using the Euro-musculus spasticity approach, and all of the patients were enrolled in rehabilitation programs after the injections. This research included the innervation zone and injection site figures and ultrasound images of each muscle in the upper limb. The degree of spasticity was assessed via the Modified Ashworth Scale and the upper limb motor function via the Fugl Meyer Upper Extremity Scale at the baseline and 4 and 12 weeks after the botulinum toxin type A injection.

RESULTS

Significant decreases in the Modified Ashworth Scale scores of the upper limb flexor muscle tone measured 4 and 12 weeks after the botulinum toxin type A injection were found when compared to the baseline scores (P<0.025). When compared with the baseline Fugl Meyer Upper Extremity subgroup scores, the sitting position, wrist and total scores at 4 and 12 weeks were significantly improved (P<0.025). However, only the Fugl Meyer Upper Extremity hand scores were significantly improved 12 weeks after the injection (P<0.025).

CONCLUSIONS

Ultrasound-guided botulinum toxin type A injection via the Euro-musculus spasticity approach is a practical and effective method for administering injections to the correct point of the correct muscle. Ultrasound-guided botulinum toxin type A injections combined with rehabilitation programs decrease spasticity and improve the upper extremity motor functions in stroke patients.

CLINICAL REHABILITATION IMPACT

This new approach for ultrasound-guided botulinum toxin type A injection is very practical and effective method for upper extremity spasticity.