An effective approach for botulinum toxin injection in patients with stroke for focal spasticity: dual guidance

Abstract

Objective: This study has aimed to compare the efficacy of botulinum toxin (BTX) injections, applied to the upper limb muscles of the stroke patients in our clinic who have being diagnosed with focal spasticity, that are performed via ultrasonography and ultrasonography + electrical muscle (EM) stimulator guidance. Literature didn’t include detailed crosscheck of ultrasound guided BTX and EM treatment applications for upper limb focal spasticity patients Materials and Methods: Electronic data on 62 hemiplegic stroke patients with grade 2 and 3 focal spasticity who had received botulinum toxin injections into their upper limb muscles by the same physician, who used similar protocol and recorded the results, were scanned retrospectively. The spasticity of the patients in both groups was assessed with the Modified Ashworth Scale at the end of two weeks and three months. Results: A statistically significant difference was found between the Modified Ashworth Scale values of both groups in terms of all muscles, compared to the values seen in the pre-treatment period (p<0.05). The Modified Ashworth Scale values at 3 months posttreatment in ultrasonography + electrical muscle stimulator group were not statistically different from those at 2 weeks posttreatment, with respect to wrist flexion and finger flexion. In intergroup comparison, there was no statistically significant difference between the Modified Ashworth Scale values of at pretreatment and 2 weeks posttreatment. However, statistically significant difference in all muscle groups was found in favor of the ultrasonography + electrical muscle stimulator group at 3 months posttreatment controls (p<0.05). Conclusion: Upper limb spasticity due to stroke can be substantially recovered with botulinum toxin injections that are applied via only ultrasonography guidance or via ultrasonography + electrical muscle stimulator guidance.. According to data from the assessment at 3 months posttreatment, the botulinum toxin injection performed via ultrasonography + electrical muscle stimulator guidance had more positive effects .

Keywords

• stroke,muscle spasticity,botulinum toxin,injections,electrical muscle stimulation

References

1. 1. Yersal O. Clinical outcome of patients with glioblastoma multiforme: 1. Hankey GJ, Stroke. How large a public health problem and how can the neurologist help? Arch Neurol. 1999;56(6):748-54.
2. 2. Ozcakir S, Sivrioglu K. Botulinum Toxin in Poststroke Spasticity, Clin Med Res. 2007;5(2):132-8.
3. 3. Thompson AJ, Jarrett L, Lockley L, Marsden J, Stevenson VL. Clinical management of spasticity. J Neurol Neurosurg Psychiatry. 2005;76(4):459-63.
4. 4. Karataş GK. Bölüm 168, İnme, Fiziksel Tıp ve Rehabilitasyon, 2. Baskı. (Ed: Beyazova M, Kutsal YG), Güneş Tıp Kitabevleri. 2011; 2761-88.
5. 5. Simpson D.M. Clinical trials of botulinum toxin in the treatment of spasticity: Etiology, Evaluation, Management and the Role of Botulinum Toxin, chapter 10. 2002; 125-30.
6. 6. Çeliker R. Bölüm 58, Spastisite Tedavisinde Kullanılan İlaçlar, Fiziksel Tıp ve Rehabilitasyon, 2. Baskı, (Ed: Beyazova M, Kutsal YG), Güneş Tıp Kitabevleri. 2011; 901-17.
7. 7. Picelli A, Lobba D, Midiri A, Prandi P, Melotti C, Baldessarelli S,et al. Botulinum toxin injection into the forearm muscles for wrist and fingers spastic overactivity in adults with chronic stroke: a randomized controlled trial comparing three inject. Clin Rehabil. 2014;28(3):232-42.
8. 8. Chin TY, Nattrass GR, Selber P, Graham HK. Accuracy of intramuscular injection of botulinum toxin A in juvenile cerebral palsy: a comparison between manual needle placement and placement guided by electrical stimulation. J Pediatr Orthop. 2005;25(3):286-91.

9. 9. Kwon JY, Hwang JH, Kim JS. Botulinum toxin a injection into calf muscles for treatment of spastic equinus in cerebral palsy: a controlled trial comparing sonography and electric stimulation-guided injection techniques: a preliminary report. Am J Phys Med Rehabil. 2010;89(4):279-86.
10. 10. Yang EJ, Rha DW, Yoo JK, Park ES. Accuracy of manual needle placement for gastrocnemius muscle in children with cerebral palsy checked against ultrasonography. Arch Phys Med Rehabil.2009 May;90(5):741-4.
11. 11. G. Sheean, N. A. Lanninb, L. Turner-Stokes, B. Rawickid and B. J. Snowe. Botulinum toxin assessment, intervention and after-care for upper limb hypertonicity in adults: international consensus statement, European Journal of Neurology. 2010; (Suppl., 17).
12. 12. Picelli A, Tamburin S, Bonetti P, Fontana C, Barausse M, Dambruoso F, Gajofatto F, Santilli V, Smania N. Botulinum toxin type A injection into the gastrocnemius muscle for spastic equinus in adults with stroke: a randomized controlled trial comparing. Am J Phys Med Rehabil. 2012;91(11):957-64.
13. 13. Wissel J, Ward AB, Erztgaard P, Bensmail D, Hecht MJ, Lejeune TM,et al. European consensus table on the use of botulinum toxin type A in adult spasticity. J Rehabil Med. 2009;41(1):13-25.
14. 14. Lapatki BG, van Dijk JP, van de Warrenburg BP, Zwarts MJ. Botulinum toxin has an increased effect when targeted toward the muscle’s endplate zone: A high-density surface EMG guided study. Clin Neurophysiol. 2011;122:1611-16.
15. 15. Van Campenhout A, Molenaers G. Localization of the motor endplate zone in human skeletal muscles of the lower limb: Anatomical guidelines for injection with botulinum toxin. Dev Med Child Neurol. 2011;53:108-19.