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Popescu MN, Căpeț C, Beiu C, Berteanu M. The Elias University Hospital Approach: A Visual Guide to Ultrasound-Guided Botulinum Toxin Injection in Spasticity: Part III-Proximal Lower Limb Muscles. Toxins (Basel) 2025; 17:240. [PMID: 40423325 DOI: 10.3390/toxins17050240] [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: 04/03/2025] [Revised: 05/06/2025] [Accepted: 05/08/2025] [Indexed: 05/28/2025] Open
Abstract
Ultrasound-guided botulinum toxin type A (BoNT-A) injections have become an essential tool in the management of lower limb spasticity. Following our previous work, which focused on upper limb muscles, this third part provides a detailed visual guide to the identification and injection of proximal lower limb muscles frequently involved in spastic gait and posture disorders. This guide presents the ultrasound anatomy, clinical relevance, and injection strategies for eleven key muscles: gluteusmaximus, piriformis, psoas major, rectusfemoris, sartorius, gracilis, adductorlongus, adductormagnus, semimembranosus, semitendinosus, and bicepsfemoris. For each muscle, the Elias University Hospital (EUH) model is applied, highlighting the zones of maximum thickness and motor point density to ensure precise and effective BoNT-A delivery. Enhanced with high-resolution ultrasound images and dynamic scanning techniques, this visual guide supports clinicians in performing safe, targeted injections. It serves as both an educational and practical reference for the ultrasound-guided treatment of spasticity in the proximal lower limb, completing the series and offering a standardized framework for comprehensive BoNT-A management. By promoting accurate toxin delivery, this approach is expected to improve functional mobility, reduce spasticity-related complications, and optimize patient-centered outcomes in rehabilitation settings.
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Affiliation(s)
- Marius Nicolae Popescu
- Department of Physical and Rehabilitation Medicine, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Clinic of Physical and Rehabilitation Medicine, Elias Emergency University Hospital, 011461 Bucharest, Romania
| | - Claudiu Căpeț
- Clinic of Physical and Rehabilitation Medicine, Elias Emergency University Hospital, 011461 Bucharest, Romania
| | - Cristina Beiu
- Department of Oncologic Dermatology, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Mihai Berteanu
- Department of Physical and Rehabilitation Medicine, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Clinic of Physical and Rehabilitation Medicine, Elias Emergency University Hospital, 011461 Bucharest, Romania
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Albert AM, Magimairaj HP, Lakshmanan J, Holla SJ, Prithishkumar IJ. Localizing motor entry points of adductor muscles of thigh for motor point procedures in the treatment of adductor spasticity. Anat Cell Biol 2024; 57:503-510. [PMID: 39192824 PMCID: PMC11663516 DOI: 10.5115/acb.24.065] [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: 03/05/2024] [Revised: 06/10/2024] [Accepted: 06/28/2024] [Indexed: 08/29/2024] Open
Abstract
Spasticity which is focal or segmental such as affecting a single muscle group or limb can be treated by chemical neurolysis or surgical denervation at the neurovascular hilus. This study determines the motor entry points (MEPs) of adductor muscles of the thigh in the adult Indian population and identifies precise anatomical landmarks for the successful performance motor point procedures for the relief of muscle spasticity. A total of 10 adult lower limbs were dissected, and nerve branches to adductor muscles were carefully exposed up to their MEP. The morphometry of adductor muscles, precise locations of proximal and distal MEPs, and ideal sites for motor point procedures were identified. The median number of MEPs in adductor longus was two. Most of them were located between 40% and 50% of the muscle length i.e., in the third-fifth of the total muscle length. Adductor magnus and gracilis had a median number of one and six MEPs respectively. The ideal site of motor point procedures is in the second-fifth of the muscle length for both. This preliminary study describes the location of MEPs and ideal sites of motor point procedures in the adductor muscle of the thigh. However, further cadaveric and electromyographic studies with larger samples are necessary to investigate precise locations of MEPs aiding in the treatment of spasticity.
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Affiliation(s)
- Anju Mary Albert
- Centre for Anatomical and Human Sciences, Hull York Medical School, York, United Kingdom
| | | | - Jeyaseelan Lakshmanan
- Department of Basic Sciences, College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Sunil Jonathan Holla
- Department of Anatomy, St. Matthew’s University School of Medicine, Grand Cayman, Cayman Islands
| | - Ivan James Prithishkumar
- Department of Basic Sciences, College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
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Gulcan M, Çelik S, Tomruk C, Bilge O, Uyanıkgil Y. Intramuscular nerve distribution of the sternocleidomastoid muscle for the botulinum toxin injection. Surg Radiol Anat 2024; 46:905-913. [PMID: 38684554 DOI: 10.1007/s00276-024-03367-0] [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: 02/19/2024] [Accepted: 04/03/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE The aim of this study is to define the intramuscular nerve distribution of the sternocleidomastoid muscle (SCM) and the innervation zones (IZ) to describe the optimal botulinum toxin injection sites. METHODS The cricoid cartilage (CC), laryngeal prominence (LP) and hyoid bone (HB) and angle of mandible (AM) were determined as landmarks. The length of the muscles were measured between the sternoclavicular joint and tip of the mastoid process. SCM was evaluated in two parts as anterior and posterior divided by the line where the length of the muscle was measured. Measurements were made to define the relationships of the SCM with common carotid artery, internal and external jugular veins. IZ were described according to these vessels. Afterwards, Modified Sihler's staining technique was applied to expose the intramuscular nerve distribution. RESULTS The average length of SCM was 160,1 mm. Motor entry point of the accessory nerve fibers were between the AM-HB lines, in the range of 30-40% of the muscle length, and in the posterior part of the muscles. IZ were between the HB-CC lines in the anterior and posterior part. When this interval was examined according to the vessels, the optimal injection sites were between the LP-CC lines. CONCLUSIONS This study shows the position of the intramuscular nerve fibers endings of the SCM according to the chosen landmarks and the relationship of the IZ with the vessels to prevent complications. These results can be used as a guide for safe and effective botulinum toxin injections with optimal quantities.
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Affiliation(s)
- Melisa Gulcan
- Faculty of Medicine, Department of Anatomy, Ege University, Bornova-Izmir, 35100, Turkey.
| | - Servet Çelik
- Faculty of Medicine, Department of Anatomy, Ege University, Bornova-Izmir, 35100, Turkey
- Ege University Interventional Anatomy & Plastination Research Center (EGEIAPRC), Bornova-Izmir, 35100, Turkey
- Ege University Application and Research Center of Cord Blood Cell-Tissue, Bornova, Izmir, 35100, Turkey
| | - Canberk Tomruk
- Department of Histology and Embryology, Samsun Education and Research Hospital, Ilkadim-Samsun, 55090, Turkey
| | - Okan Bilge
- Faculty of Medicine, Department of Anatomy, Ege University, Bornova-Izmir, 35100, Turkey
- Ege University Interventional Anatomy & Plastination Research Center (EGEIAPRC), Bornova-Izmir, 35100, Turkey
| | - Yigit Uyanıkgil
- Ege University Application and Research Center of Cord Blood Cell-Tissue, Bornova, Izmir, 35100, Turkey
- Faculty of Medicine, Department of Histology and Embryology, Ege University, Bornova-Izmir, 35100, Turkey
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Deschrevel J, Andries A, Maes K, De Beukelaer N, Corvelyn M, Staut L, De Houwer H, Costamagna D, Desloovere K, Van Campenhout A, Gayan-Ramirez G. Short-Term Effects of Botulinum Toxin-A Injection on the Medial Gastrocnemius Histological Features in Ambulant Children with Cerebral Palsy: A Longitudinal Pilot Study. Toxins (Basel) 2024; 16:69. [PMID: 38393147 PMCID: PMC10891867 DOI: 10.3390/toxins16020069] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/16/2024] [Accepted: 01/23/2024] [Indexed: 02/25/2024] Open
Abstract
Botulinum toxin-A (BoNT-A) injection is known to exert beneficial effects on muscle tone, joint mobility and gait in children with cerebral palsy (CP). However, recent animal and human studies have raised the concern that BoNT-A might be harmful to muscle integrity. In CP-children, the impact of BoNT-A on muscle structure has been poorly studied, and inconsistent results have been reported. This study was aimed at determining the time course effect of a single BoNT-A administration on medial gastrocnemius (MG) morphology in CP-children. MG microbiopsies from 12 ambulant and BoNT-A-naïve CP-children (age, 3.4 (2.3) years, ranging from 2.5 to 7.8 years; seven boys and five girls; GMFCS I = 5, II = 4 and III = 3) were collected before and 3 and 6 months after BoNT-A treatment to analyze the fiber cross-sectional area (fCSA) and proportion; capillarization; and satellite cell (SC) content. Compared with the baseline, the fCSA decreased at 3 months (-14%, NS) and increased at 6 months (+13%, NS). Fiber size variability was significantly higher at 3 months (type I: +56%, p = 0.032; type IIa: +37%, p = 0.032) and 6 months (type I: +69%, p = 0.04; type IIa: +121%, p = 0.032) compared with the baseline. The higher type I proportion seen at 3 months was still present and more pronounced at 6 months (type I: +17%, p = 0.04; type IIx: -65%, p = 0.032). The capillary fiber density was reduced at 3 months (type I: -43%, NS; type II: -44%, p = 0.0320) but normalized at 6 months. There was a non-significant increase in SC/100 fibers at 3 months (+75%, NS) and 6 months (+40%, NS) compared with the baseline. These preliminary data suggest that BoNT-A induced alterations in the MG of children with CP, which were still present 6 months after BoNT-A injection but with signs of muscle recovery.
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Affiliation(s)
- Jorieke Deschrevel
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases and Metabolism, O&N 1bis Box 706, Herestraat 49, 3000 Leuven, Belgium; (J.D.); (A.A.); (K.M.)
| | - Anke Andries
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases and Metabolism, O&N 1bis Box 706, Herestraat 49, 3000 Leuven, Belgium; (J.D.); (A.A.); (K.M.)
| | - Karen Maes
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases and Metabolism, O&N 1bis Box 706, Herestraat 49, 3000 Leuven, Belgium; (J.D.); (A.A.); (K.M.)
| | - Nathalie De Beukelaer
- Neurorehabilitation Group, Department of Rehabilitation Sciences, Tervuursevest 101 Box 1501, 3000 Leuven, Belgium; (N.D.B.); (L.S.); (D.C.); (K.D.)
| | - Marlies Corvelyn
- Stem Cell and Developmental Biology, Department of Development and Regeneration, O&N4 Box 804, 3000 Leuven, Belgium;
| | - Lauraine Staut
- Neurorehabilitation Group, Department of Rehabilitation Sciences, Tervuursevest 101 Box 1501, 3000 Leuven, Belgium; (N.D.B.); (L.S.); (D.C.); (K.D.)
| | - Hannah De Houwer
- Pediatric Orthopedics, Department of Development and Regeneration, Herestraat 49 Box 7003, 3000 Leuven, Belgium; (H.D.H.); (A.V.C.)
| | - Domiziana Costamagna
- Neurorehabilitation Group, Department of Rehabilitation Sciences, Tervuursevest 101 Box 1501, 3000 Leuven, Belgium; (N.D.B.); (L.S.); (D.C.); (K.D.)
- Stem Cell and Developmental Biology, Department of Development and Regeneration, O&N4 Box 804, 3000 Leuven, Belgium;
- Exercise Physiology Research Group, Department of Movement Sciences, Tervuursevest 101 Box 1500, 3000 Leuven, Belgium
| | - Kaat Desloovere
- Neurorehabilitation Group, Department of Rehabilitation Sciences, Tervuursevest 101 Box 1501, 3000 Leuven, Belgium; (N.D.B.); (L.S.); (D.C.); (K.D.)
| | - Anja Van Campenhout
- Pediatric Orthopedics, Department of Development and Regeneration, Herestraat 49 Box 7003, 3000 Leuven, Belgium; (H.D.H.); (A.V.C.)
| | - Ghislaine Gayan-Ramirez
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases and Metabolism, O&N 1bis Box 706, Herestraat 49, 3000 Leuven, Belgium; (J.D.); (A.A.); (K.M.)
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Lee JH, Lee HJ, Yi KH, Lee KW, Gil YC, Kim HJ. Ideal Injection Points for Botulinum Neurotoxin for Pectoralis Minor Syndrome: A Cadaveric Study. Toxins (Basel) 2023; 15:603. [PMID: 37888634 PMCID: PMC10610843 DOI: 10.3390/toxins15100603] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/20/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023] Open
Abstract
Pectoralis Minor Syndrome (PMS) causes significant discomfort due to the compression of the neurovascular bundle within the retropectoralis minor space. Botulinum neurotoxin (BoNT) injections have emerged as a potential treatment method; however, their effectiveness depends on accurately locating the injection site. In this study, we aimed to identify optimal BoNT injection sites for PMS treatment. We used twenty-nine embalmed and eight non-embalmed human cadavers to determine the origin and intramuscular arborization of the pectoralis minor muscle (Pm) via manual dissection and Sihler's nerve staining techniques. Our findings showed the Pm's origin near an oblique line through the suprasternal notch, with most neural arborization within the proximal three-fourths of the Pm. Blind dye injections validated these results, effectively targeting the primary neural arborized area of the Pm at the oblique line's intersection with the second and third ribs. We propose BoNT injections at the arborized region within the Pm's proximal three-fourths, or the C region, for PMS treatment. These findings guide clinicians towards safer, more effective BoNT injections.
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Affiliation(s)
- Ji-Hyun Lee
- Department of Anatomy and Acupoint, College of Korean Medicine, Gachon University, 1342 Seongnam-daero, Seongnam-si 13120, Republic of Korea;
| | - Hyung-Jin Lee
- Department of Anatomy, Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University, 222 Banpo-daero, Seoul 06591, Republic of Korea;
| | - Kyu-Ho Yi
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, College of Dentistry, Yonsei University, 50-1 Yonsei-ro, Seoul 03722, Republic of Korea; (K.-H.Y.); (K.-W.L.)
| | - Kang-Woo Lee
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, College of Dentistry, Yonsei University, 50-1 Yonsei-ro, Seoul 03722, Republic of Korea; (K.-H.Y.); (K.-W.L.)
| | - Young-Chun Gil
- Department of Anatomy, College of Medicine, Chungbuk National University, 1 Chungdae-ro, Cheongju-si 28644, Republic of Korea;
| | - Hee-Jin Kim
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, College of Dentistry, Yonsei University, 50-1 Yonsei-ro, Seoul 03722, Republic of Korea; (K.-H.Y.); (K.-W.L.)
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Sapienza M, Kapoor R, Alberghina F, Maheshwari R, McCracken KL, Canavese F, Johari AN. Adverse effects following botulinum toxin A injections in children with cerebral palsy. J Pediatr Orthop B 2023; 32:435-451. [PMID: 36723611 DOI: 10.1097/bpb.0000000000001055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The study aimed to analyze the adverse events associated with botulinum toxin A (BoNT-A) injections in children with cerebral palsy (CP). The literature search was completed using the Medline, PubMed, Google Scholar, Scopus, and Cochrane Library databases from the earliest date possible up to December 2021. Search terms included 'botulinum toxin', 'cerebral palsy', 'spasticity', 'adverse effects', 'side effects', 'undesirable effects', 'complications', 'lower limb', 'upper limb', and 'children' including combinations of index and free-text terms. Fifty-five studies were included in the study. Data on 6333 pediatric patients and more than 14 080 BoNT-A injections were collected. Respiratory symptoms and respiratory tract infections were the most frequently registered adverse events (AEs). Other common AEs included procedural/focal AEs, flu-like symptoms, and asthenia. Sentinel events including four cases of death were reported. AEs were more frequent and severe in high-dose patients; however, the capacity of BoNT-A to spread systemically remains unclear. Since severe adverse events are not common, further research is needed to collect more definitive clinical and homogeneous data to support the findings of the present research and clarify the safety profile of BoNT-A, especially regarding the incidence of respiratory issues and complications in GMFCS IV or V patients.
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Affiliation(s)
- Marco Sapienza
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. 'Policlinico Gaspare Rodolico', University of Catania, Catania, Italy
- Department of Pediatric Orthopedic Surgery, Jeanne de Flandre Hospital, Lille University Centre, Lille, France
| | | | | | | | | | - Federico Canavese
- Department of Pediatric Orthopedic Surgery, Jeanne de Flandre Hospital, Lille University Centre, Lille, France
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Costamagna D, Bastianini V, Corvelyn M, Duelen R, Deschrevel J, De Beukelaer N, De Houwer H, Sampaolesi M, Gayan-Ramirez G, Campenhout AV, Desloovere K. Botulinum Toxin Treatment of Adult Muscle Stem Cells from Children with Cerebral Palsy and hiPSC-Derived Neuromuscular Junctions. Cells 2023; 12:2072. [PMID: 37626881 PMCID: PMC10453788 DOI: 10.3390/cells12162072] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/24/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Botulinum neurotoxin type-A (BoNT) injections are commonly used as spasticity treatment in cerebral palsy (CP). Despite improved clinical outcomes, concerns regarding harmful effects on muscle morphology have been raised, and the BoNT effect on muscle stem cells remains not well defined. This study aims at clarifying the impact of BoNT on growing muscles (1) by analyzing the in vitro effect of BoNT on satellite cell (SC)-derived myoblasts and fibroblasts obtained from medial gastrocnemius microbiopsies collected in young BoNT-naïve children (t0) compared to age ranged typically developing children; (2) by following the effect of in vivo BoNT administration on these cells obtained from the same children with CP at 3 (t1) and 6 (t2) months post BoNT; (3) by determining the direct effect of a single and repeated in vitro BoNT treatment on neuromuscular junctions (NMJs) differentiated from hiPSCs. In vitro BoNT did not affect myogenic differentiation or collagen production. The fusion index significantly decreased in CP at t2 compared to t0. In NMJ cocultures, BoNT treatment caused axonal swelling and fragmentation. Repeated treatments impaired the autophagic-lysosomal system. Further studies are warranted to understand the long-term and collateral effects of BoNT in the muscles of children with CP.
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Affiliation(s)
- Domiziana Costamagna
- Neurorehabilitation Group, Department of Rehabilitation Sciences, KU Leuven, 3000 Leuven, Belgium; (D.C.); (V.B.); (N.D.B.)
- Stem Cell and Developmental Biology Unit, Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium; (M.C.); (R.D.); (M.S.)
| | - Valeria Bastianini
- Neurorehabilitation Group, Department of Rehabilitation Sciences, KU Leuven, 3000 Leuven, Belgium; (D.C.); (V.B.); (N.D.B.)
| | - Marlies Corvelyn
- Stem Cell and Developmental Biology Unit, Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium; (M.C.); (R.D.); (M.S.)
| | - Robin Duelen
- Stem Cell and Developmental Biology Unit, Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium; (M.C.); (R.D.); (M.S.)
- Cardiology, Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
| | - Jorieke Deschrevel
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases and Metabolism, KU Leuven, 3000 Leuven, Belgium; (J.D.); (G.G.-R.)
| | - Nathalie De Beukelaer
- Neurorehabilitation Group, Department of Rehabilitation Sciences, KU Leuven, 3000 Leuven, Belgium; (D.C.); (V.B.); (N.D.B.)
- Willy Taillard Laboratory of Kinesiology, Geneva University Hospitals and University of Geneva, 1211 Geneva, Switzerland
| | - Hannah De Houwer
- Department of Orthopedic Surgery, University Hospitals Leuven, 3000 Leuven, Belgium; (H.D.H.); (A.V.C.)
| | - Maurilio Sampaolesi
- Stem Cell and Developmental Biology Unit, Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium; (M.C.); (R.D.); (M.S.)
| | - Ghislaine Gayan-Ramirez
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases and Metabolism, KU Leuven, 3000 Leuven, Belgium; (J.D.); (G.G.-R.)
| | - Anja Van Campenhout
- Department of Orthopedic Surgery, University Hospitals Leuven, 3000 Leuven, Belgium; (H.D.H.); (A.V.C.)
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
| | - Kaat Desloovere
- Neurorehabilitation Group, Department of Rehabilitation Sciences, KU Leuven, 3000 Leuven, Belgium; (D.C.); (V.B.); (N.D.B.)
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Asimakidou E, Sidiropoulos C. A Bayesian Network Meta-Analysis and Systematic Review of Guidance Techniques in Botulinum Toxin Injections and Their Hierarchy in the Treatment of Limb Spasticity. Toxins (Basel) 2023; 15:toxins15040256. [PMID: 37104194 PMCID: PMC10145352 DOI: 10.3390/toxins15040256] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/22/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
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.
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Huang C, Lu Z, Chen M, Klein CS, Zhang Y, Li S, Zhou P. Muscle innervation zone estimation from monopolar high-density M-waves using principal component analysis and radon transform. Front Physiol 2023; 14:1137146. [PMID: 37008017 PMCID: PMC10050562 DOI: 10.3389/fphys.2023.1137146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 02/27/2023] [Indexed: 03/17/2023] Open
Abstract
This study examined methods for estimating the innervation zone (IZ) of a muscle using recorded monopolar high density M waves. Two IZ estimation methods based on principal component analysis (PCA) and Radon transform (RT) were examined. Experimental M waves, acquired from the biceps brachii muscles of nine healthy subjects were used as testing data sets. The performance of the two methods was evaluated by comparing their IZ estimations with manual IZ detection by experienced human operators. Compared with manual detection, the agreement rate of the estimated IZs was 83% and 63% for PCA and RT based methods, respectively, both using monopolar high density M waves. In contrast, the agreement rate was 56% for cross correlation analysis using bipolar high density M waves. The mean difference in estimated IZ location between manual detection and the tested method was 0.12 ± 0.28 inter-electrode-distance (IED) for PCA, 0.33 ± 0.41 IED for RT and 0.39 ± 0.74 IED for cross correlation-based methods. The results indicate that the PCA based method was able to automatically detect muscle IZs from monopolar M waves. Thus, PCA provides an alternative approach to estimate IZ location of voluntary or electrically-evoked muscle contractions, and may have particular value for IZ detection in patients with impaired voluntary muscle activation.
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Affiliation(s)
- Chengjun Huang
- Department of Neuroscience, Baylor College of Medicine, Houston, TX, United States
| | - Zhiyuan Lu
- School of Rehabilitation Science and Engineering, University of Health and Rehabilitation Sciences, Qingdao, Shandong, China
- *Correspondence: Zhiyuan Lu, ; Ping Zhou,
| | - Maoqi Chen
- School of Rehabilitation Science and Engineering, University of Health and Rehabilitation Sciences, Qingdao, Shandong, China
| | - Cliff S. Klein
- Guangdong Work Injury Rehabilitation Center, Guangzhou, Guangdong, China
| | - Yingchun Zhang
- Department of Biomedical Engineering, University of Houston, Houston, TX, United States
| | - Sheng Li
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston, Houston, TX, United States
- TIRR Memorial Hermann Hospital, Houston, TX, United States
| | - Ping Zhou
- School of Rehabilitation Science and Engineering, University of Health and Rehabilitation Sciences, Qingdao, Shandong, China
- *Correspondence: Zhiyuan Lu, ; Ping Zhou,
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Peeters N, Papageorgiou E, Hanssen B, De Beukelaer N, Staut L, Degelaen M, Van den Broeck C, Calders P, Feys H, Van Campenhout A, Desloovere K. The Short-Term Impact of Botulinum Neurotoxin-A on Muscle Morphology and Gait in Children with Spastic Cerebral Palsy. Toxins (Basel) 2022; 14:676. [PMID: 36287944 PMCID: PMC9607504 DOI: 10.3390/toxins14100676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 08/27/2023] Open
Abstract
Children with spastic cerebral palsy (SCP) are often treated with intramuscular Botulinum Neurotoxin type-A (BoNT-A). Recent studies demonstrated BoNT-A-induced muscle atrophy and variable effects on gait pathology. This group-matched controlled study in children with SCP compared changes in muscle morphology 8-10 weeks post-BoNT-A treatment (n = 25, median age 6.4 years, GMFCS level I/II/III (14/9/2)) to morphological changes of an untreated control group (n = 20, median age 7.6 years, GMFCS level I/II/III (14/5/1)). Additionally, the effects on gait and spasticity were assessed in all treated children and a subgroup (n = 14), respectively. BoNT-A treatment was applied following an established integrated approach. Gastrocnemius and semitendinosus volume and echogenicity intensity were assessed by 3D-freehand ultrasound, spasticity was quantified through electromyography during passive muscle stretches at different velocities. Ankle and knee kinematics were evaluated by 3D-gait analysis. Medial gastrocnemius (p = 0.018, -5.2%) and semitendinosus muscle volume (p = 0.030, -16.2%) reduced post-BoNT-A, but not in the untreated control group, while echogenicity intensity did not change. Spasticity reduced and ankle gait kinematics significantly improved, combined with limited effects on knee kinematics. This study demonstrated that BoNT-A reduces spasticity and partly improves pathological gait but reduces muscle volume 8-10 weeks post-injections. Close post-BoNT-A follow-up and well-considered treatment selection is advised before BoNT-A application in SCP.
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Affiliation(s)
- Nicky Peeters
- Department of Rehabilitation Sciences, KU Leuven, 3001 Leuven, Belgium
- Department of Rehabilitation Sciences, Ghent University, 9000 Ghent, Belgium
| | | | - Britta Hanssen
- Department of Rehabilitation Sciences, KU Leuven, 3001 Leuven, Belgium
- Department of Rehabilitation Sciences, Ghent University, 9000 Ghent, Belgium
| | | | - Lauraine Staut
- Department of Rehabilitation Sciences, KU Leuven, 3001 Leuven, Belgium
| | - Marc Degelaen
- Inkendaal Rehabilitation Hospital, 1602 Vlezenbeek, Belgium
- Rehabilitation Research Group, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | | | - Patrick Calders
- Department of Rehabilitation Sciences, Ghent University, 9000 Ghent, Belgium
| | - Hilde Feys
- Department of Rehabilitation Sciences, KU Leuven, 3001 Leuven, Belgium
| | - Anja Van Campenhout
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
- Department of Orthopedic Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Kaat Desloovere
- Department of Rehabilitation Sciences, KU Leuven, 3001 Leuven, Belgium
- Clinical Motion Analysis Laboratory, University Hospitals Leuven, Pellenberg, 3212 Leuven, Belgium
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11
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Green MM, Kim H, Gauden R, Scheinberg A, Schroeder AS, Heinen F, Berweck S, Hong BY, Gormley M. Needlepoints: Clinical approach to child living with cerebral palsy. J Pediatr Rehabil Med 2022; 15:91-106. [PMID: 35275576 DOI: 10.3233/prm-220006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
| | - Heakyung Kim
- NewYork-Presbyterian Hospital, New York, NY, USA
| | - Ruth Gauden
- The Royal Children's Hospital Melbourne, Parkville, Australia
| | - Adam Scheinberg
- The Royal Children's Hospital Melbourne, Parkville, Australia.,Murdoch Children's Research Institute, Parkville, Australia
| | | | | | | | - Bo Young Hong
- St. Vincent's Hospital, Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Mark Gormley
- Gillette Children's Specialty Healthcare, St.Paul, MN, USA
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12
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Xu J, Xuan A, Liu Z, Li Y, Zhu J, Yao Y, Yu T, Zhu D. An Approach to Maximize Retrograde Transport Based on the Spatial Distribution of Motor Endplates in Mouse Hindlimb Muscles. Front Cell Neurosci 2021; 15:707982. [PMID: 34456685 PMCID: PMC8385196 DOI: 10.3389/fncel.2021.707982] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/16/2021] [Indexed: 11/13/2022] Open
Abstract
Knowledge regarding the relationship between muscles and the corresponding motor neurons would allow therapeutic genes to transport into specific spinal cord segments. Retrograde tracing technique by targeting the motor endplate (MEP), a highly specialized structure that offers direct access to the spinal motor neurons, has been used to elucidate the connectivity between skeletal muscles and the innervating motor neuron pools. However, current injection strategies mainly based on blind injection or the local MEP region might lead to an underestimation of the motor neuron number due to the uneven distribution of MEP in skeletal muscles. In this work, we proposed a novel intramuscular injection strategy based on the 3D distribution of the MEPs in skeletal muscles, applied the 3D intramuscular injection to the gastrocnemius and tibialis anterior for retrograde tracing of the corresponding motor neurons, and compared this with the existing injection strategy. The intramuscular diffusion of the tracer demonstrated that 3D injection could maximize the retrograde transport by ensuring a greater uptake of the tracer by the MEP region. In combination with optical clearing and imaging, we performed 3D mapping and quantification of the labeled motor neurons and confirmed that 3D injection could label more motor neurons than the current injection method. It is expected that 3D intramuscular injection strategy will help elucidate the connective relationship between muscles and motor neurons faithfully and becomes a promising tool in the development of gene therapy strategies for motor neuron diseases.
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Affiliation(s)
- Jianyi Xu
- Britton Chance Center for Biomedical Photonics, Wuhan National Laboratory for Optoelectronics, Huazhong University of Science and Technology, Wuhan, China.,MoE Key Laboratory for Biomedical Photonics, School of Engineering Sciences, Huazhong University of Science and Technology, Wuhan, China
| | - Ang Xuan
- Britton Chance Center for Biomedical Photonics, Wuhan National Laboratory for Optoelectronics, Huazhong University of Science and Technology, Wuhan, China.,MoE Key Laboratory for Biomedical Photonics, School of Engineering Sciences, Huazhong University of Science and Technology, Wuhan, China
| | - Zhang Liu
- Britton Chance Center for Biomedical Photonics, Wuhan National Laboratory for Optoelectronics, Huazhong University of Science and Technology, Wuhan, China.,MoE Key Laboratory for Biomedical Photonics, School of Engineering Sciences, Huazhong University of Science and Technology, Wuhan, China
| | - Yusha Li
- Britton Chance Center for Biomedical Photonics, Wuhan National Laboratory for Optoelectronics, Huazhong University of Science and Technology, Wuhan, China.,MoE Key Laboratory for Biomedical Photonics, School of Engineering Sciences, Huazhong University of Science and Technology, Wuhan, China
| | - Jingtan Zhu
- Britton Chance Center for Biomedical Photonics, Wuhan National Laboratory for Optoelectronics, Huazhong University of Science and Technology, Wuhan, China.,MoE Key Laboratory for Biomedical Photonics, School of Engineering Sciences, Huazhong University of Science and Technology, Wuhan, China
| | - Yingtao Yao
- Britton Chance Center for Biomedical Photonics, Wuhan National Laboratory for Optoelectronics, Huazhong University of Science and Technology, Wuhan, China.,MoE Key Laboratory for Biomedical Photonics, School of Engineering Sciences, Huazhong University of Science and Technology, Wuhan, China
| | - Tingting Yu
- Britton Chance Center for Biomedical Photonics, Wuhan National Laboratory for Optoelectronics, Huazhong University of Science and Technology, Wuhan, China.,MoE Key Laboratory for Biomedical Photonics, School of Engineering Sciences, Huazhong University of Science and Technology, Wuhan, China
| | - Dan Zhu
- Britton Chance Center for Biomedical Photonics, Wuhan National Laboratory for Optoelectronics, Huazhong University of Science and Technology, Wuhan, China.,MoE Key Laboratory for Biomedical Photonics, School of Engineering Sciences, Huazhong University of Science and Technology, Wuhan, China
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13
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Krasavina DA, Chemeris AV, Orlova OR, Ivanov YI. [Botulinum therapy of spastic forms of cerebral palsy in various locomotor patterns]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:119-123. [PMID: 34283541 DOI: 10.17116/jnevro2021121061119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Spasticity in patients with cerebral palsy (CP) is the main impediment to normal locomotion. The function of the Central Pattern Generator (CPG), i.e. a group of neural chains in the spinal cord, stands at the core of any rhythmical movement. CPG can generate locomotion patterns without supraspinal control, which can have both positive and negative impact on the ability to move. Performing the motor tasks such as walking, running and swimming, creates the consistent rhythmical movement of legs and arms through interaction between CPGs of upper and lower extremities. This interaction can cause the activation of pathological movement patterns in lower extremities in response to upper limb spasticity. Thus, neural chains in the spinal cord become the generator of pathologically increased excitation which has developed as a result of a focal lesion in the CNS. All the statements described above show the importance of introducing the upper limb injections of bFotulinum toxin A in the protocol in order to develop normal locomotion. The PUL study approved the optimal level of efficacy and favourable safety profile of botulinum toxin A in children with CP and upper limb muscle spasticity.
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Affiliation(s)
- D A Krasavina
- Saint-Petersburg Institute for Advanced Training of Medical Experts, St. Petersburg, Russia
| | - A V Chemeris
- Kazakhstan Medical University of Continuing Education, Almaty, Kazakhstan
| | - O R Orlova
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - Y I Ivanov
- Saint-Petersburg Institute for Advanced Training of Medical Experts, St. Petersburg, Russia
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14
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Weidensteiner C, Madoerin P, Deligianni X, Haas T, Bieri O, Akinci D'Antonoli T, Bracht-Schweizer K, Romkes J, De Pieri E, Santini F, Rutz E, Brunner R, Garcia M. Quantification and Monitoring of the Effect of Botulinum Toxin A on Paretic Calf Muscles of Children With Cerebral Palsy With MRI: A Preliminary Study. Front Neurol 2021; 12:630435. [PMID: 33935939 PMCID: PMC8085320 DOI: 10.3389/fneur.2021.630435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/01/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Muscles from patients with cerebral palsy (CP) are often spastic and form contractures that limit the range of motion. Injections of botulinum toxin A (BTX) into the calf muscles are an important treatment for functional equinus; however, improvement in gait function is not always achieved. BTX is also used to test muscle weakening for risk evaluation of muscle lengthening surgery. Our aim was to assess the effect of BTX over time on calf muscle properties in pediatric CP patients with MRI. Material and Methods: Six toe-walking CP patients (mean age 11.6 years) with indication for lengthening surgery were prospectively enrolled and received BTX injections into the gastrocnemius and soleus muscles. MRI scans at 3T of the lower legs and clinical examinations were performed pre-BTX, 6 weeks (6w), and 12 weeks (12w) post-BTX. A fat-suppressed 2D multi-spin-echo sequence was used to acquire T2 maps and for segmentation. Fat fraction maps were calculated from 3D multi-echo Dixon images. Diffusion tensor imaging (DTI) with a 2D echo-planar imaging (EPI) sequence yielded maps of the mean apparent diffusion coefficient (ADC) and of the fractional anisotropy (FA). Hyperintense regions of interest (ROIs) on the T2-weighted (T2w) images at 6w were segmented in treated muscles. Mean values of T2, fat fraction, ADC, and FA were calculated in hyperintense ROIs and in reference ROIs in non-treated muscles. Results: Hyperintensity on T2w scans and increased T2 (group mean ± standard deviation: 35 ± 1 ms pre-BTX, 45 ± 2 ms at 6w, and 44 ± 2 ms at 12w) were observed in all patients at the injection sites. The T2 increase was spatially limited to parts of the injected muscles. FA increased (0.30 ± 0.03 pre-BTX, 0.34 ± 0.02 at 6w, and 0.36 ± 0.03 at 12w) while ADC did not change in hyperintense ROIs, indicating a BTX-induced increase in extracellular space and a simultaneous decrease of muscle fiber diameter. Fat fraction showed a trend for increase at 12w. Mean values in reference ROIs remained unchanged. Conclusion: MRI showed limited spatial distribution of the BTX-induced effects in pediatric CP patients. It could be a promising non-invasive tool for future studies to test BTX treatment protocols.
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Affiliation(s)
- Claudia Weidensteiner
- Division of Radiological Physics, Department of Radiology, University Hospital of Basel, Basel, Switzerland.,Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Philipp Madoerin
- Division of Radiological Physics, Department of Radiology, University Hospital of Basel, Basel, Switzerland
| | - Xeni Deligianni
- Division of Radiological Physics, Department of Radiology, University Hospital of Basel, Basel, Switzerland.,Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Tanja Haas
- Division of Radiological Physics, Department of Radiology, University Hospital of Basel, Basel, Switzerland
| | - Oliver Bieri
- Division of Radiological Physics, Department of Radiology, University Hospital of Basel, Basel, Switzerland.,Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Tugba Akinci D'Antonoli
- Department of Radiology, University Hospital of Basel, Basel, Switzerland.,Department of Radiology, University Children's Hospital Basel, Basel, Switzerland
| | | | - Jacqueline Romkes
- Laboratory for Movement Analysis, University Children's Hospital Basel, Basel, Switzerland
| | - Enrico De Pieri
- Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland.,Laboratory for Movement Analysis, University Children's Hospital Basel, Basel, Switzerland
| | - Francesco Santini
- Division of Radiological Physics, Department of Radiology, University Hospital of Basel, Basel, Switzerland.,Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Erich Rutz
- Murdoch Children's Research Insitute, The University of Melbourne, Pediatric Orthopedic Department, The Royal Children's Hospital, Parkville, VIC, Australia.,Faculty of Medicine, The University of Basel, Basel, Switzerland
| | - Reinald Brunner
- Laboratory for Movement Analysis, University Children's Hospital Basel, Basel, Switzerland.,Department of Orthopedic Surgery, University Children's Hospital Basel, Basel, Switzerland
| | - Meritxell Garcia
- Department of Radiology, Division of Neuroradiology, University Hospital of Basel, Basel, Switzerland
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15
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Zhang C, Chen YT, Liu Y, Magat E, Gutierrez-Verduzco M, Francisco GE, Zhou P, Li S, Zhang Y. Improving Botulinum Toxin Efficiency in Treating Post-Stroke Spasticity Using 3D Innervation Zone Imaging. Int J Neural Syst 2021; 31:2150007. [PMID: 33438529 DOI: 10.1142/s0129065721500076] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Spasticity is a common post-stroke syndrome that imposes significant adverse impacts on patients and caregivers. This study aims to improve the efficiency of botulinum toxin (BoNT) in managing spasticity, by utilizing a three-dimensional innervation zone imaging (3DIZI) technique based on high-density surface electromyography (HD-sEMG) recordings. Stroke subjects were randomly assigned to two groups: the control group ([Formula: see text]) which received standard ultrasound-guided injections, and the experimental group ([Formula: see text]) which received 3DIZI-guided injections. The amount of BoNT given was consistent for all subjects. The Modified Ashworth Scale (MAS), compound muscle action potential (CMAP) and muscle activation volume (MAV) from bilateral biceps brachii muscles were obtained at the baseline, 3 weeks, and 3 months after injection. Intra-group and inter-group comparisons of MAS, CMAP amplitude and MAV were performed. An overall improvement in MAS of spastic elbow flexors was observed during the 3-week visit ([Formula: see text]), yet no statistically significant difference found with intra-group or inter-group analysis. Compared to the baseline, a significant reduction of CMAP amplitude and MAV were observed in the spastic biceps muscles of both groups at 3-week post-injection, and returned to approximate baseline value at 12-week post injection. A significantly higher reduction was found in CMAP amplitude ([Formula: see text]% versus [Formula: see text]%, [Formula: see text]) and MAV ([Formula: see text]% versus [Formula: see text]%, [Formula: see text]) in the experimental group compared to the control group. The study has demonstrated preliminary evidence that precisely directing BoNT to the innervation zones (IZs) localized by 3DIZI leads to a significantly higher treatment efficiency improvement in spasticity management. Results have also shown the feasibility of developing a personalized BoNT injection technique for the optimization of clinical treatment for post-stroke spasticity using proposed 3DIZI technique.
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Affiliation(s)
- Chuan Zhang
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
| | - Yen-Ting Chen
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston and TIRR, Memorial Hermann Hospital, Houston, TX, USA
| | - Yang Liu
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
| | - Elaine Magat
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston and TIRR, Memorial Hermann Hospital, Houston, TX, USA
| | - Monica Gutierrez-Verduzco
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston and TIRR, Memorial Hermann Hospital, Houston, TX, USA
| | - Gerard E Francisco
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston and TIRR, Memorial Hermann Hospital, Houston, TX, USA
| | - Ping Zhou
- Institute of Rehabilitation Engineering, The University of Rehabilitation, Qingdao, P. R. China
| | - Sheng Li
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston and TIRR, Memorial Hermann Hospital, Houston, TX, USA
| | - Yingchun Zhang
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
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16
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Use of the Posterior Lumbar Approach for Psoas Major Injection in Hip Flexor Spasticity. Can J Neurol Sci 2020; 48:267-272. [PMID: 32713400 DOI: 10.1017/cjn.2020.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Hip flexor spasticity in patients with upper motor neuron syndrome of multiple etiologies has been managed with botulinum neurotoxin injections mainly targeting the "iliopsoas" muscle. A lumbar approach to target psoas major (PM) has been described; however, it has not been incorporated into clinical practice due to perceived risk of injury to surrounding structures. This study will investigate the feasibility and accuracy of ultrasound-guided (UG)-PM injection using a lumbar approach by assessing the intra/extramuscular injectate spread in cadaveric specimens. METHODS In eight lightly embalmed specimens, toluidine blue dye/saline was injected into PM using a UG-posterior lumbar approach. The posterior abdominal wall was exposed, and dye spread and surrounding structures digitized and modeled in 3D. The area and vertebral level of dye spread, distance of dye to the inferior vena cava (IVC), and abdominal aorta (AA) and dye spread to adjacent organs were quantified. RESULTS The models enabled visualization of the dye spread in 3D. Mean area of dye spread was 24.4 ± 2.8 cm2; most commonly between L2 and L4 vertebral levels. Mean distance of the dye to AA was 3.2 ± 1.2 cm and to IVC was 1.8 ± 0.4 cm. Dye spread remained intramuscular in all but one specimen. No dye spread occurred to any adjacent organs. CONCLUSIONS The injection of PM using the UG-posterior lumbar approach was consistent and without spread to surrounding structures. This technique alone or in addition to the anterior approach is expected to have better clinical outcomes in the treatment of hip flexor spasticity. Further clinical studies are required.
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17
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Sätilä H. Over 25 Years of Pediatric Botulinum Toxin Treatments: What Have We Learned from Injection Techniques, Doses, Dilutions, and Recovery of Repeated Injections? Toxins (Basel) 2020; 12:toxins12070440. [PMID: 32640636 PMCID: PMC7404978 DOI: 10.3390/toxins12070440] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 12/20/2022] Open
Abstract
Botulinum toxin type A (BTXA) has been used for over 25 years in the management of pediatric lower and upper limb hypertonia, with the first reports in 1993. The most common indication is the injection of the triceps surae muscle for the correction of spastic equinus gait in children with cerebral palsy. The upper limb injection goals include improvements in function, better positioning of the arm, and facilitating the ease of care. Neurotoxin type A is the most widely used serotype in the pediatric population. After being injected into muscle, the release of acetylcholine at cholinergic nerve endings is blocked, and a temporary denervation and atrophy ensues. Targeting the correct muscle close to the neuromuscular junctions is considered essential and localization techniques have developed over time. However, each technique has its own limitations. The role of BTXA is flexible, but limited by the temporary mode of action as a focal spasticity treatment and the restrictions on the total dose deliverable per visit. As a mode of treatment, repeated BTXA injections are needed. This literature reviewed BTXA injection techniques, doses and dilutions, the recovery of muscles and the impact of repeated injections, with a focus on the pediatric population. Suggestions for future studies are also discussed.
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Affiliation(s)
- Heli Sätilä
- Department of Neuropediatrics, Päijät-Häme Central Hospital, Lahti, Finland, Keskussairaalankatu 7, 15850 Lahti, Finland
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18
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Bar-On L, Aertbeliën E, Van Campenhout A, Molenaers G, Desloovere K. Treatment Response to Botulinum Neurotoxin-A in Children With Cerebral Palsy Categorized by the Type of Stretch Reflex Muscle Activation. Front Neurol 2020; 11:378. [PMID: 32581991 PMCID: PMC7280486 DOI: 10.3389/fneur.2020.00378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 04/14/2020] [Indexed: 11/13/2022] Open
Abstract
While Botulinum NeuroToxin-A (BoNT-A) injections are frequently used to reduce the effects of hyperactive stretch reflexes in children with cerebral palsy (CP), the effects of this treatment vary strongly. Previous research, combining electromyography (EMG) with motion analysis, defined different patterns of stretch reflex muscle activation in muscles, those that reacted more to a change in velocity (velocity dependent -VD), and those that reacted more to a change in length (length dependent -LD). The aim of this study was to investigate the relation between the types of stretch reflex muscle activation in the semitendinosus with post-BoNT-A outcome as assessed passively and with 3D gait analysis in children with spastic CP. Eighteen children with spastic CP (10 bilaterally involved) between the ages of 12 and 18 years were assessed before and on average, 8 weeks post-treatment. EMG and motion analysis were used to assess the degree and type of muscle activation dependency in the semitendinosus during passive knee extensions performed at different joint angular velocities. Three-dimensional gait analysis was used to assess knee gait kinematics as a measure of functional outcome. Pre-treatment, 9 muscles were classified as VD and 9 as LD, but no differences between the groups were evident in the baseline knee gait kinematics. Post-treatment, stretch reflex muscle activation decreased significantly in both groups but the reduction was more pronounced in those muscles classified pre-treatment as VD (-72% vs. -50%, p = 0.005). In the VD group, these changes were accompanied by greater knee extension at initial contact and during the swing phase of gait. In the LD group, there was significantly increased post-treatment knee hyperextension in late stance. Although results vary between patients, the reduction of stretch reflex muscle activation in the semitendinosus generally translated to an improved functional outcome, as assessed with 3D gait analysis. However, results were less positive for those muscles with pre-treatment length-dependent type of stretch reflex muscle activation. The study demonstrates the relevance of categorizing the type of stretch reflex muscle activation as a possible predictor of treatment response.
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Affiliation(s)
- Lynn Bar-On
- Department of Rehabilitation Medicine, Amsterdam UMC, Amsterdam Movement Sciences, Amsterdam, Netherlands.,Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Erwin Aertbeliën
- Department of Mechanical Engineering, KU Leuven, Leuven, Belgium.,ROB Core Lab, Flanders Make, Leuven, Belgium
| | - Anja Van Campenhout
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Clinical Motion Analysis Laboratory, University Hospital Leuven, Leuven, Belgium
| | - Guy Molenaers
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Clinical Motion Analysis Laboratory, University Hospital Leuven, Leuven, Belgium
| | - Kaat Desloovere
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium.,Clinical Motion Analysis Laboratory, University Hospital Leuven, Leuven, Belgium
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19
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Shi W, Zhu L, Wang T, Zhang G, Lian J. Classification of Hypertrophic Gastrocnemius Muscle and Its Treatment with Botulinum Toxin A. Aesthetic Plast Surg 2019; 43:1588-1594. [PMID: 31555873 DOI: 10.1007/s00266-019-01455-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/02/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Treatments including selective neurectomy, muscle resections and botulinum toxin A (BTX) injections have been used to improve the stocky appearance of calves. BTX injection has the advantages of high efficiency and is almost noninvasive. However, criterion standards of injection are still missing. OBJECTIVE We aimed to establish a method to classify the hypertrophic calf for a personalized treatment and set up an injection protocol based on the findings. METHODS Three-dimensional CT reconstruction was used to measure the thickness and cross-sectional area of the triceps surae. B-mode ultrasound and palpation were used to evaluate the muscle thickness and determine the dosage. Patients were followed 3 and 6 months after the treatment. RESULTS A total of 112 legs were classified into three degrees of thickness (< 15 mm, 15-25 mm and > 25 mm). Twenty-seven subjects were treated with an individualized BTX (100-300 U). Maximal circumference decreased 0.33 ± 0.00 cm after 3 month (p < 0.05) and 0.67 ± 0.11 cm after 6 months (p < 0.01). The angulated calf contour was improved. No severe side effects were reported. CONCLUSIONS Localizing and dosage are the key points when applying BTX. Dosage should be decided by muscle thickness instead of circumference. BTX treatment improves the prominent contour of the calf rather than reducing the volume. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
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Affiliation(s)
- Wenjun Shi
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, No. 610 Rm, No.833 L, ZhiZaoju Rd, Huangpu Distr, Shanghai, China
| | - Lian Zhu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, No. 610 Rm, No.833 L, ZhiZaoju Rd, Huangpu Distr, Shanghai, China.
| | - Tingliang Wang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, No. 610 Rm, No.833 L, ZhiZaoju Rd, Huangpu Distr, Shanghai, China
| | - Guoyou Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, No. 610 Rm, No.833 L, ZhiZaoju Rd, Huangpu Distr, Shanghai, China
| | - Jie Lian
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, No. 610 Rm, No.833 L, ZhiZaoju Rd, Huangpu Distr, Shanghai, China
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Anatomy of proximal attachment, course, and innervation of hamstring muscles: a pictorial essay. Knee Surg Sports Traumatol Arthrosc 2019; 27:673-684. [PMID: 30374579 DOI: 10.1007/s00167-018-5265-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 10/23/2018] [Indexed: 01/12/2023]
Abstract
Hamstring injuries are very common in sports medicine. Knowing their anatomy, morphology, innervation, and function is important to provide a proper diagnosis, treatment as well as appropriate prevention strategies. In this pictorial essay, based on anatomical dissection, the detailed anatomy of muscle-tendon complex is reviewed, including their proximal attachment, muscle course, and innervation. To illustrate hamstrings' role in the rotational control of the tibia, the essay also includes the analysis of their biomechanical function.Level of evidence V (expert opinion based on laboratory study).
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21
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Motor unit innervation zone localization based on robust linear regression analysis. Comput Biol Med 2019; 106:65-70. [PMID: 30684784 DOI: 10.1016/j.compbiomed.2019.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 01/13/2019] [Accepted: 01/13/2019] [Indexed: 11/23/2022]
Abstract
With the aim of developing a flexible and reliable procedure for superficial muscle innervation zone (IZ) localization, we proposed a method to estimate IZ location using surface electromyogram (EMG) based on robust linear regression. Regression lines were used to model the bidirectional propagation pattern of a single motor unit action potential (MUAP) and visualize the trajectory of the MUAP propagation. IZ localization was performed by identifying the origin of the bidirectional MUAP propagation. Robust linear regression and MUAP peak detection, combined with propagation phase reversal identification, may provide an efficient way to estimate IZ location. Our method offers high resolution in locating IZs based on simulation studies and experimental tests. Furthermore, our method is flexible and may also be applied using a relatively small number of EMG channels. A comparative study of the proposed method with the cross-correlation method for IZ localization was conducted. The results obtained with simulated MUAPs and measured spontaneous MUAPs in the biceps brachii muscle in six subjects (four males and two females, 57 ± 10 years old) with amyotrophic lateral sclerosis (ALS). Our method achieved estimation performance comparable to that obtained by using the cross-correlation method but with higher resolution. This study provides an accurate and practical method to estimate IZ location.
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Aydil S, Akpinar FM, Akpinar E, Beng K, Yagmurlu MF. Effectiveness of Multilevel Botulinum Toxin A Injection with Integrated Treatment Program on Spasticity Reduction in Non-Ambulatory Young Children with Cerebral Palsy. Med Princ Pract 2019; 28:309-314. [PMID: 30840957 PMCID: PMC6639572 DOI: 10.1159/000499369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 03/05/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The aim of the present study was to evaluate the effectiveness of multilevel Botulinum Toxin A (BTX-A) injection, as part of an integrated approach, for the treatment of spasticity in non-ambulatory young children with diplegic cerebral palsy (CP). SUBJECTS AND METHODS Seventeen non-ambulatory patients aged 4-8 years with diplegic CP (Gross Motor Function Classification System [GMFCS] level IV) were evaluated before and at 1st, 3rd, and 6th months after BTX-A injection. The effect of BTX-A on spasticity of gastrocnemius and hamstring muscles was assessed using the Modified Ashworth Scale (MAS) and Modified Tardieu Scale (MTS). The velocity-dependent properties of spastic muscle as both slow (R2) and fast (R1) stretches were evaluated in MTS. RESULTS A statistically significant improvement was observed in R1 angles of gastrocnemius and hamstring muscles at 1st and 3rd months after BTX-A injection in non-ambulatory young children with CP. Statistically significant improvement was found in MAS of gastrocnemius and hamstring muscles and R2 angles of knee and ankle joint after 1st month of BTX-A injection. CONCLUSION Multilevel BTX-A injection, as part of an integrated approach, can be used for focal treatment of spasticity, especially of hamstring and gastrocnemius muscles, in non-ambulatory young children with CP GMFCS level IV.
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Affiliation(s)
- Sebahat Aydil
- Physical Therapy and Rehabilitation, Gait Analysis Laboratory, Metin Sabanci Baltalimani Bone Diseases Education and Research Hospital, Istanbul, Turkey,
| | - Fatma Merih Akpinar
- Physical Therapy and Rehabilitation, Gait Analysis Laboratory, Metin Sabanci Baltalimani Bone Diseases Education and Research Hospital, Istanbul, Turkey
| | - Evren Akpinar
- Metin Sabanci Baltalimani Bone Diseases Education and Research Hospital, Pediatric Orthopaedics, Istanbul, Turkey
| | - Kubilay Beng
- Metin Sabanci Baltalimani Bone Diseases Education and Research Hospital, Pediatric Orthopaedics, Istanbul, Turkey
| | - Mehmet Firat Yagmurlu
- Metin Sabanci Baltalimani Bone Diseases Education and Research Hospital, Pediatric Orthopaedics, Istanbul, Turkey
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23
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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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Sánchez-Mila Z, Salom-Moreno J, Fernández-de-Las-Peñas C. Effects of dry needling on post-stroke spasticity, motor function and stability limits: a randomised clinical trial. Acupunct Med 2018; 36:358-366. [PMID: 29986902 DOI: 10.1136/acupmed-2017-011568] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the effects of inclusion of deep dry needling into a treatment session following the Bobath concept on spasticity, motor function and postural control after a stroke. METHODS 26 patients who had suffered a stroke were randomly assigned to one of two treatment groups: Bobath only, or Bobath plus dry needling. Both groups received a session including strengthening, stretching and reconditioning exercises following the principles of the Bobath concept. Patients in the Bobath plus dry needling group also received a single session of ultrasound-guided dry needling of the tibialis posterior. Spasticity (Modified Modified Ashworth Scale), function (Fugl-Meyer Scale) and stability limits (computerised dynamic posturography using the SMART EquiTest System) were collected before and 10 min after treatment by a blinded assessor. The parameters of the stability limits included movement velocity (MVL), maximum excursion (MXE), end-point excursion (EPE) and directional control (DCL). RESULTS A greater number of individuals receiving Bobath plus dry needling exhibited a decrease in spasticity after treatment (P<0.001). Analysis of covariance (ANCOVA) showed that patients receiving Bobath plus dry needling exhibited greater improvements in the balance (0.8, 95% CI 0.2 to 1.4), sensory (1.7, 95% CI 0.7 to 2.7) and range of motion (3.2, 95% CI 2.0 to 4.4) domains of the Fugl-Meyer Scale than those receiving Bobath only. ANCOVA also found that subjects receiving dry needling showed a greater increase in MVL non-affected forward direction, EPE non-affected direction, MXE backward and MXE affected/non-affected, DCL backward and DCL affected backward direction, than those who did not receive it. CONCLUSIONS The inclusion of deep dry needling into a treatment session following the Bobath concept was effective at decreasing spasticity and improving balance, range of motion and the accuracy of maintaining stability in patients who had experienced a stroke. TRIAL REGISTRATION NUMBER NCT02579291.
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Affiliation(s)
- Zacarías Sánchez-Mila
- Alumno de Doctorado, Escuela Internacional de Doctorado, Universidad Rey Juan Carlos, Alcorcon, Spain
| | - Jaime Salom-Moreno
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcon, Spain.,Cátedra de Investigación y Docencia en Fisioterapia: Terapia Manual y Punción Seca, Universidad Rey Juan Carlos, Alcorcón, Spain
| | - César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcon, Spain.,Cátedra de Investigación y Docencia en Fisioterapia: Terapia Manual y Punción Seca, Universidad Rey Juan Carlos, Alcorcón, Spain
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25
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Alter KE, Karp BI. Ultrasound Guidance for Botulinum Neurotoxin Chemodenervation Procedures. Toxins (Basel) 2017; 10:toxins10010018. [PMID: 29283397 PMCID: PMC5793105 DOI: 10.3390/toxins10010018] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/12/2017] [Accepted: 12/21/2017] [Indexed: 12/28/2022] Open
Abstract
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; palpation; range of motion; electromyography or electrical stimulation. Ultrasound (US) based imaging based guidance overcomes some of the limitations of traditional techniques. US and/or US combined with traditional guidance techniques is utilized and or recommended by many expert clinicians; authors and in practice guidelines by professional academies. This article reviews the advantages and disadvantages of available guidance techniques including US as well as technical aspects of US guidance and a focused literature review related to US guidance for chemodenervation procedures including BoNTs injection.
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Affiliation(s)
- Katharine E Alter
- Functional and Applied Biomechanics Section, Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892-1604, USA.
| | - Barbara I Karp
- Combined Neurosciences IRB, National Institutes of Health, Bethesda, MD 20892-1604, USA.
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Abstract
PURPOSE OF REVIEW The goal of this review is to summarize the unique regenerative milieu within mature mammalian extraocular muscles (EOMs). This will aid in understanding disease propensity for and sparing of EOMs in skeletal muscle diseases as well as the recalcitrance of the EOM to injury. RECENT FINDINGS The EOMs continually remodel throughout life and contain an extremely enriched number of myogenic precursor cells that differ in number and functional characteristics from those in limb skeletal muscle. The EOMs also contain a large population of Pitx2-positive myogenic precursor cells that provide the EOMs with many of their unusual biological characteristics, such as myofiber remodeling and skeletal muscle disease sparing. This environment provides for rapid and efficient remodeling and regeneration after various types of injury. In addition, the EOMs show a remarkable ability to respond to perturbations of single muscles with coordinated changes in the other EOMs that move in the same plane. SUMMARY These data will inform Ophthalmologists as they work toward developing new treatments for eye movement disorders, new approaches for repair after nerve or direct EOMs injury, as well as suggest potential explanations for the unusual disease propensity and disease sparing characteristics of human EOM.
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Affiliation(s)
- Mayank Verma
- Stem Cell Institute, University of Minnesota, Minneapolis, Minnesota
| | - Krysta Fitzpatrick
- Stem Cell Institute, University of Minnesota, Minneapolis, Minnesota
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, Minnesota
| | - Linda K McLoon
- Stem Cell Institute, University of Minnesota, Minneapolis, Minnesota
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, Minnesota
- Department of Neuroscience, University of Minnesota, Minneapolis, Minnesota
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27
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Park SJ, Yoon KB, Yoon DM, Kim SH. Botulinum Toxin Treatment for Nocturnal Calf Cramps in Patients With Lumbar Spinal Stenosis: A Randomized Clinical Trial. Arch Phys Med Rehabil 2017; 98:957-963. [DOI: 10.1016/j.apmr.2017.01.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 11/17/2016] [Accepted: 01/12/2017] [Indexed: 11/26/2022]
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OnabotulinumtoxinA for Lower Limb Spasticity: Guidance From a Delphi Panel Approach. PM R 2017; 9:960-968. [DOI: 10.1016/j.pmrj.2017.02.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 02/11/2017] [Accepted: 02/17/2017] [Indexed: 11/24/2022]
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Botulinum Toxin Injection-Site Selection for a Smooth Shoulder Line: An Anatomical Study. BIOMED RESEARCH INTERNATIONAL 2017; 2017:3092720. [PMID: 28246594 PMCID: PMC5299158 DOI: 10.1155/2017/3092720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 10/03/2016] [Indexed: 12/02/2022]
Abstract
Introduction. This study aimed to improve the accuracy of manual needle placement into the trapezius (TM) for smooth shoulder line. Methods. For macroscopic study 12 TMs and for microscopic study 4 cadavers were detached and then sampled, 1⁎1 cm at the four points from the origin to insertion site (0% at the most lateral point of external occipital protuberance and 100% at the most lateral point of acromion). Results. Most of the nerve endings observed during macroscopic investigations were concentrated in the 60–80% region, and the second most distributed region was the 40–60% region. The microscopic results revealed that the 60–80% region on the reference line had the most dense neuromuscular junction area, while the 40–60% and 80–100% areas were similar in their neuromuscular junction densities. Discussion. These anatomical results will be useful in clinical settings especially for cosmetic surgeons.
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30
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Li J, Zhang R, Cui BL, Zhang YX, Bai GT, Gao SS, Li WJ. Therapeutic efficacy and safety of various botulinum toxin A doses and concentrations in spastic foot after stroke: a randomized controlled trial. Neural Regen Res 2017; 12:1451-1457. [PMID: 29089990 PMCID: PMC5649465 DOI: 10.4103/1673-5374.215257] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
No recommended guidelines currently exist for the therapeutic concentration or dose of botulinum toxin type A (BTXA) injected into the muscle to treat limb spasticity. Therefore, in this randomized controlled trial, we explored the safety and efficacy of two concentrations and two doses of BTXA in the treatment of spastic foot after stroke to optimize this treatment in these patients. Eligible patients (n = 104) were randomized into four groups. The triceps surae and tibialis posterior on the affected side were injected with BTXA at one of two doses (200 U or 400 U) and two concentrations (50 U/mL or 100 U/mL). The following assessments were conducted before as well as 4 days and 1, 2, 4, and 12 weeks after treatment: spasticity, assessed using the modified Ashworth scale; basic functional mobility, assessed using a timed up and go test; pace, assessed using a 10-meter timed walking test; and the ability to walk, assessed using Holden's graded scale and a visual analog scale. The reported results are based on the 89 patients that completed the study. We found significant differences for the two doses and concentrations of BTXA to improve the ability of patients to walk independently, with the high-dose/low-concentration combination providing the best effect. Onset and duration of the ameliorating effects of BTXA were 4–7 days and 12 weeks, respectively. Thus, BTXA effectively treated foot spasms after stroke at an optimal dose of 400 U and concentration of 50 U/mL.
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Affiliation(s)
- Jiang Li
- Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Ru Zhang
- Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Bo-Li Cui
- Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Yong-Xiang Zhang
- Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Guang-Tao Bai
- Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Si-Shan Gao
- Department of Neurology, Traditional Medicine Hospital of Huangdao District, Qingdao, Shandong Province, China
| | - Wen-Jian Li
- Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
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31
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Haberfehlner H, Jaspers RT, Rutz E, Becher JG, Harlaar J, van der Sluijs JA, Witbreuk MM, Romkes J, Freslier M, Brunner R, Maas H, Buizer AI. Knee Moment-Angle Characteristics and Semitendinosus Muscle Morphology in Children with Spastic Paresis Selected for Medial Hamstring Lengthening. PLoS One 2016; 11:e0166401. [PMID: 27861523 PMCID: PMC5115739 DOI: 10.1371/journal.pone.0166401] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 10/30/2016] [Indexed: 11/18/2022] Open
Abstract
To increase knee range of motion and improve gait in children with spastic paresis (SP), the semitendinosus muscle (ST) amongst other hamstring muscles is frequently lengthened by surgery, but with variable success. Little is known about how the pre-surgical mechanical and morphological characteristics of ST muscle differ between children with SP and typically developing children (TD). The aims of this study were to assess (1) how knee moment-angle characteristics and ST morphology in children with SP selected for medial hamstring lengthening differ from TD children, as well as (2) how knee moment-angle characteristics and ST morphology are related. In nine SP and nine TD children, passive knee moment-angle characteristics and morphology of ST (i.e. fascicle length, muscle belly length, tendon length, physiological cross-sectional area, and volume) were assessed by hand-held dynamometry and freehand 3D ultrasound, respectively. At net knee flexion moments above 0.5 Nm, more flexed knee angles were found for SP compared to TD children. The measured knee angle range between 0 and 4 Nm was 30% smaller in children with SP. Muscle volume, physiological cross-sectional area, and fascicle length normalized to femur length were smaller in SP compared to TD children (62%, 48%, and 18%, respectively). Sixty percent of the variation in knee angles at 4 Nm net knee moment was explained by ST fascicle length. Altered knee moment-angle characteristics indicate an increased ST stiffness in SP children. Morphological observations indicate that in SP children planned for medial hamstring lengthening, the longitudinal and cross-sectional growth of ST muscle fibers is reduced. The reduced fascicle length can partly explain the increased ST stiffness and, hence, a more flexed knee joint in these SP children.
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Affiliation(s)
- Helga Haberfehlner
- Laboratory for Myology, Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands
- Department of Rehabilitation Medicine, VU University Medical Center, Amsterdam, The Netherlands
- MOVE Research Institute Amsterdam, The Netherlands
| | - Richard T. Jaspers
- Laboratory for Myology, Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands
- MOVE Research Institute Amsterdam, The Netherlands
- * E-mail:
| | - Erich Rutz
- Pediatric Orthopaedic Department, University Children’s Hospital Basle (UKBB), Basle, Switzerland
- Laboratory for Movement Analysis, University Children's Hospital Basle (UKBB), Basle, Switzerland
| | - Jules G. Becher
- Department of Rehabilitation Medicine, VU University Medical Center, Amsterdam, The Netherlands
- MOVE Research Institute Amsterdam, The Netherlands
| | - Jaap Harlaar
- Department of Rehabilitation Medicine, VU University Medical Center, Amsterdam, The Netherlands
- MOVE Research Institute Amsterdam, The Netherlands
| | - Johannes A. van der Sluijs
- MOVE Research Institute Amsterdam, The Netherlands
- Department of Orthopaedic Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Melinda M. Witbreuk
- MOVE Research Institute Amsterdam, The Netherlands
- Department of Orthopaedic Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Jacqueline Romkes
- Laboratory for Movement Analysis, University Children's Hospital Basle (UKBB), Basle, Switzerland
| | - Marie Freslier
- Laboratory for Movement Analysis, University Children's Hospital Basle (UKBB), Basle, Switzerland
| | - Reinald Brunner
- Pediatric Orthopaedic Department, University Children’s Hospital Basle (UKBB), Basle, Switzerland
- Laboratory for Movement Analysis, University Children's Hospital Basle (UKBB), Basle, Switzerland
| | - Huub Maas
- Laboratory for Myology, Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands
- MOVE Research Institute Amsterdam, The Netherlands
| | - Annemieke I. Buizer
- Department of Rehabilitation Medicine, VU University Medical Center, Amsterdam, The Netherlands
- MOVE Research Institute Amsterdam, The Netherlands
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McGuire J, Heath K, O'Dell MW. Should Ultrasound Be Used Routinely to Guide Botulinum Toxin Injections for Spasticity? PM R 2016; 8:1004-1010. [PMID: 27769363 DOI: 10.1016/j.pmrj.2016.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 09/15/2016] [Indexed: 11/19/2022]
Affiliation(s)
- John McGuire
- Associate Professor PM&R, Medical Director of Comprehensive Spasticity Management, Medical Director for Stroke Rehabilitation, Medical College of Wisconsin, Froedtert Memorial Lutheran Hospital, Milwaukee, WI
| | - Kelly Heath
- Assistant Professor, Neurorehabilitation, Department of Physical Medicine & Rehabilitation, Hospital of the University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Michael W O'Dell
- Division of Rehabilitation Medicine, Weill Cornell Medicine, 525 E. 68th Street, 16th FL, New York, NY 10065
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33
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Attias M, Bonnefoy-Mazure A, De Coulon G, Cheze L, Armand S. Feasibility and reliability of using an exoskeleton to emulate muscle contractures during walking. Gait Posture 2016; 50:239-245. [PMID: 27665088 DOI: 10.1016/j.gaitpost.2016.09.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 09/16/2016] [Accepted: 09/18/2016] [Indexed: 02/02/2023]
Abstract
Contracture is a permanent shortening of the muscle-tendon-ligament complex that limits joint mobility. Contracture is involved in many diseases (cerebral palsy, stroke, etc.) and can impair walking and other activities of daily living. The purpose of this study was to quantify the reliability of an exoskeleton designed to emulate lower limb muscle contractures unilaterally and bilaterally during walking. An exoskeleton was built according to the following design criteria: adjustable to different morphologies; respect of the principal lines of muscular actions; placement of reflective markers on anatomical landmarks; and the ability to replicate the contractures of eight muscles of the lower limb unilaterally and bilaterally (psoas, rectus femoris, hamstring, hip adductors, gastrocnemius, soleus, tibialis posterior, and peroneus). Sixteen combinations of contractures were emulated on the unilateral and bilateral muscles of nine healthy participants. Two sessions of gait analysis were performed at weekly intervals to assess the reliability of the emulated contractures. Discrete variables were extracted from the kinematics to analyse the reliability. The exoskeleton did not affect normal walking when contractures were not emulated. Kinematic reliability varied from poor to excellent depending on the targeted muscle. Reliability was good for the bilateral and unilateral gastrocnemius, soleus, and tibialis posterior as well as the bilateral hamstring and unilateral hip adductors. The exoskeleton can be used to replicate contracture on healthy participants. The exoskeleton will allow us to differentiate primary and compensatory effects of muscle contractures on gait kinematics.
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Affiliation(s)
- M Attias
- Willy Taillard Laboratory of Kinesiology, Geneva University Hospitals and Geneva University, Switzerland; HES-SO University of Applied Sciences and Arts Western Switzerland, School of Health Sciences, Geneva, Switzerland; Univ Lyon, Université Lyon 1, IFSTTAR, LBMC UMR_T9406, F69622, Lyon, France.
| | - A Bonnefoy-Mazure
- Willy Taillard Laboratory of Kinesiology, Geneva University Hospitals and Geneva University, Switzerland
| | - G De Coulon
- Pediatric Orthopaedic Service, Department of Child and Adolescent, Geneva University Hospitals and Geneva University, Geneva, Switzerland
| | - L Cheze
- Univ Lyon, Université Lyon 1, IFSTTAR, LBMC UMR_T9406, F69622, Lyon, France
| | - S Armand
- Willy Taillard Laboratory of Kinesiology, Geneva University Hospitals and Geneva University, Switzerland
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Valentine J, Stannage K, Fabian V, Ellis K, Reid S, Pitcher C, Elliott C. Muscle histopathology in children with spastic cerebral palsy receiving botulinum toxin type A. Muscle Nerve 2016; 53:407-14. [PMID: 26154631 DOI: 10.1002/mus.24763] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 06/19/2015] [Accepted: 07/06/2015] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Botulinum toxin A (BoNTA) is routine treatment for hypertonicity in children with cerebral palsy (CP). METHODS This single-blind, prospective, cross-sectional study of 10 participants (mean age 11 years 7 months) was done to determine the relationship between muscle histopathology and BoNTA in treated medial gastrocnemius muscle of children with CP. Open muscle biopsies were taken from medial gastrocnemius muscle and vastus lateralis (control) during orthopedic surgery. RESULTS Neurogenic atrophy in the medial gastrocnemius was seen in 6 participants between 4 months and 3 years post-BoNTA. Type 1 fiber loss with type 2 fiber predominance was significantly related to the number of BoNTA injections (r = 0.89, P < 0.001). CONCLUSIONS The impact of these changes in muscle morphology on muscle function in CP is not clear. It is important to consider rotating muscle selection or injection sites within the muscle or allowing longer time between injections.
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Affiliation(s)
- Jane Valentine
- Department of Paediatric Rehabilitation, Princess Margaret Hospital, Perth, Western Australia, Australia.,School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
| | - Katherine Stannage
- Department of Orthopedic Surgery, Princess Margaret Hospital, Perth, Western Australia, Australia
| | - Vicki Fabian
- Neuropathology Section, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Kevin Ellis
- Neuropathology Section, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Siobhan Reid
- School of Sport Science, Exercise & Health, University of Western Australia, Perth, Western Australia, Australia
| | - Christian Pitcher
- School of Sport Science, Exercise & Health, University of Western Australia, Perth, Western Australia, Australia
| | - Catherine Elliott
- Department of Paediatric Rehabilitation, Princess Margaret Hospital, Perth, Western Australia, Australia.,Faculty of Health Science, Curtin University, Perth, Western Australia, Australia
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Mohan R, Tosolini AP, Morris R. Intramuscular Injections Along the Motor End Plates: A Minimally Invasive Approach to Shuttle Tracers Directly into Motor Neurons. J Vis Exp 2015. [PMID: 26273739 DOI: 10.3791/52846 (2015)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Diseases affecting the integrity of spinal cord motor neurons are amongst the most debilitating neurological conditions. Over the last decades, the development of several animal models of these neuromuscular disorders has provided the scientific community with different therapeutic scenarios aimed at delaying or reversing the progression of these conditions. By taking advantage of the retrograde machinery of neurons, one of these approaches has been to target skeletal muscles in order to shuttle therapeutic genes into corresponding spinal cord motor neurons. Although once promising, the success of such gene delivery approach has been hampered by the sub-optimal number of transduced motor neurons it has so far shown to yield. Motor end plates (MEPs) are highly specialized regions on the skeletal musculature that are in direct synaptic contact to the spinal cord α motor neurons. In this regard, it is important to note that, so far, the efforts to retrogradely transfer genes into motor neurons were made without reference to the location of the MEP region in the targeted muscles. Here, we describe a simple protocol 1) to reveal the exact location of the MEPs on the surface of skeletal muscles and 2) to use this information to guide the intramuscular delivery and subsequent optimal retrograde transport of retrograde tracers into motor neurons. We hope to utilize the results from these tracing experiments in further studies into investigating retrograde transport of therapeutic genes to spinal cord motor neurons through the targeting of MEPs.
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Affiliation(s)
- Rahul Mohan
- Translational Neuroscience Facility, School of Medical Sciences, University of New South Wales
| | - Andrew P Tosolini
- Translational Neuroscience Facility, School of Medical Sciences, University of New South Wales
| | - Renée Morris
- Translational Neuroscience Facility, School of Medical Sciences, University of New South Wales;
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Mohan R, Tosolini AP, Morris R. Intramuscular Injections Along the Motor End Plates: A Minimally Invasive Approach to Shuttle Tracers Directly into Motor Neurons. J Vis Exp 2015:e52846. [PMID: 26273739 DOI: 10.3791/52846] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Diseases affecting the integrity of spinal cord motor neurons are amongst the most debilitating neurological conditions. Over the last decades, the development of several animal models of these neuromuscular disorders has provided the scientific community with different therapeutic scenarios aimed at delaying or reversing the progression of these conditions. By taking advantage of the retrograde machinery of neurons, one of these approaches has been to target skeletal muscles in order to shuttle therapeutic genes into corresponding spinal cord motor neurons. Although once promising, the success of such gene delivery approach has been hampered by the sub-optimal number of transduced motor neurons it has so far shown to yield. Motor end plates (MEPs) are highly specialized regions on the skeletal musculature that are in direct synaptic contact to the spinal cord α motor neurons. In this regard, it is important to note that, so far, the efforts to retrogradely transfer genes into motor neurons were made without reference to the location of the MEP region in the targeted muscles. Here, we describe a simple protocol 1) to reveal the exact location of the MEPs on the surface of skeletal muscles and 2) to use this information to guide the intramuscular delivery and subsequent optimal retrograde transport of retrograde tracers into motor neurons. We hope to utilize the results from these tracing experiments in further studies into investigating retrograde transport of therapeutic genes to spinal cord motor neurons through the targeting of MEPs.
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Affiliation(s)
- Rahul Mohan
- Translational Neuroscience Facility, School of Medical Sciences, University of New South Wales
| | - Andrew P Tosolini
- Translational Neuroscience Facility, School of Medical Sciences, University of New South Wales
| | - Renée Morris
- Translational Neuroscience Facility, School of Medical Sciences, University of New South Wales;
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Mohan R, Tosolini AP, Morris R. Intramuscular Injections Along the Motor End Plates: A Minimally Invasive Approach to Shuttle Tracers Directly into Motor Neurons. JOURNAL OF VISUALIZED EXPERIMENTS : JOVE 2015. [PMID: 26273739 DOI: 10.3791/52846+(2015)] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Diseases affecting the integrity of spinal cord motor neurons are amongst the most debilitating neurological conditions. Over the last decades, the development of several animal models of these neuromuscular disorders has provided the scientific community with different therapeutic scenarios aimed at delaying or reversing the progression of these conditions. By taking advantage of the retrograde machinery of neurons, one of these approaches has been to target skeletal muscles in order to shuttle therapeutic genes into corresponding spinal cord motor neurons. Although once promising, the success of such gene delivery approach has been hampered by the sub-optimal number of transduced motor neurons it has so far shown to yield. Motor end plates (MEPs) are highly specialized regions on the skeletal musculature that are in direct synaptic contact to the spinal cord α motor neurons. In this regard, it is important to note that, so far, the efforts to retrogradely transfer genes into motor neurons were made without reference to the location of the MEP region in the targeted muscles. Here, we describe a simple protocol 1) to reveal the exact location of the MEPs on the surface of skeletal muscles and 2) to use this information to guide the intramuscular delivery and subsequent optimal retrograde transport of retrograde tracers into motor neurons. We hope to utilize the results from these tracing experiments in further studies into investigating retrograde transport of therapeutic genes to spinal cord motor neurons through the targeting of MEPs.
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Affiliation(s)
- Rahul Mohan
- Translational Neuroscience Facility, School of Medical Sciences, University of New South Wales
| | - Andrew P Tosolini
- Translational Neuroscience Facility, School of Medical Sciences, University of New South Wales
| | - Renée Morris
- Translational Neuroscience Facility, School of Medical Sciences, University of New South Wales;
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Van Campenhout A, Bar-On L, Desloovere K, Huenaerts C, Molenaers G. Motor endplate-targeted botulinum toxin injections of the gracilis muscle in children with cerebral palsy. Dev Med Child Neurol 2015; 57:476-83. [PMID: 25557985 DOI: 10.1111/dmcn.12667] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2014] [Indexed: 11/30/2022]
Abstract
AIM Intramuscular botulinum toxin-A (BoNT-A) injections reduce spasticity by blocking neurotransmission at the motor endplate (MEP). The goal of this study was to assess the reduction in spasticity achieved by injecting BoNT-A at different sites of the gracilis muscle. METHOD Thirty-four gracilis muscles, in 27 children (10 females and 17 males, mean age of 8.6y [SD 2.5y]) with spastic cerebral palsy (unilateral and bilateral, Gross Motor Function Classification System [GMFCS] levels I-IV), were randomly assigned to one of two groups. In one group BoNT-A was injected proximally (at a site 25% of the distance from the pubic tubercle and the medial epicondyle) and in the other it was injected at the MEP zones (half of the dose was administered at 30% of this distance and half at 60%). Spasticity was assessed before and after BoNT-A injection using simultaneous measurements of surface electromyography (sEMG) and angular velocity during passive muscle stretch applied at different velocities. The primary outcome measure included the velocity-dependent change in average root mean square electromyography (RMS-EMG). Secondary outcome was assessed with the Modified Ashworth Scale (MAS) and Modified Tardieu Scale (MTS). RESULTS Spasticity decreased more in MEP-targeted muscles than in proximally injected muscles, as demonstrated by a larger reduction in average RMS-EMG values (p=0.04), though this difference was not found with the MAS or MTS. INTERPRETATION The results suggest that BoNT-A injection of the gracilis at sites with a high concentration of MEPs is effective at reducing spasticity. These preliminary findings should be confirmed by larger studies. In the case of long muscles, such as the gracilis, the injection site is important.
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Affiliation(s)
- Anja Van Campenhout
- Department of Orthopaedics, University Hospital Leuven, Leuven, Belgium; KU Leuven Department of Development and Regeneration, Leuven, Belgium
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Kim HG, Chung ME, Song DH, Kim JY, Sul BM, Oh CH, Park NS. Determination of injection site in flexor digitorum longus for effective and safe botulinum toxin injection. Ann Rehabil Med 2015; 39:32-8. [PMID: 25750869 PMCID: PMC4351492 DOI: 10.5535/arm.2015.39.1.32] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 09/02/2014] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To determine the optimal injection site in the flexor digitorum longus (FDL) muscle for effective botulinum toxin injection. METHODS Fourteen specimens from eight adult Korean cadavers were used in this study. The most proximal medial point of the tibia plateau was defined as the proximal reference point; the most distal tip of the medial malleolus was defined as the distal reference point. The distance of a line connecting the proximal and distal reference points was defined as the reference length. The X-coordinate was the distance from the proximal reference point to the intramuscular motor endpoint (IME), or motor entry point (MEP) on the reference line, and the Y-coordinate was the distance from the nearest point from MEP on the medial border of the tibia to the MEP. IME and MEP distances from the proximal reference point were evaluated using the raw value and the X-coordinate to reference length ratio was determined as a percentage. RESULTS The majority of IMEs were located within 30%-60% of the reference length from the proximal reference point. The majority of the MEPs were located within 40%-60% of the reference length from the proximal reference point. CONCLUSION We recommend the anatomical site for a botulinum toxin injection in the FDL to be within a region 30%-60% of the reference length from the proximal reference point.
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Affiliation(s)
- Hong Geum Kim
- Department of Rehabilitation Medicine, St. Paul's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Myung Eun Chung
- Department of Rehabilitation Medicine, St. Paul's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Dae Heon Song
- Department of Rehabilitation Medicine, St. Paul's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Ju Yong Kim
- Department of Rehabilitation Medicine, St. Paul's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Bo Mi Sul
- Department of Rehabilitation Medicine, St. Paul's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Chang Hoon Oh
- Department of Rehabilitation Medicine, St. Paul's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Nam Su Park
- Department of Rehabilitation Medicine, St. Paul's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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Comparison of ultrasound-guided anterior and posterior approaches for needle insertion into the tibialis posterior in hemiplegic children with spastic cerebral palsy. Am J Phys Med Rehabil 2014; 93:841-8. [PMID: 25180837 DOI: 10.1097/phm.0000000000000170] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Although the tibialis posterior is a potentially difficult muscle to locate for botulinum toxin injection because of its deep location, needle insertion is usually performed using anatomic landmarks for guidance. Accordingly, the ultrasonographic anatomy of the lower leg was investigated in hemiplegic children with spastic cerebral palsy to improve the safety and the accuracy of needle placement into the tibialis posterior. DESIGN Twenty-five subjects (2 yrs 2 mos to 5 yrs 11 mos; 12 boys, 13 girls; Gross Motor Function Classification System levels I-II) were recruited. B-mode, real-time ultrasonography was performed using a 5- to 12-MHz linear array transducer. During anterior and posterior approaches, safety window width (tibia to the neurovascular bundle) and depth (skin to the midpoint of the tibialis posterior) were measured at the upper third and at the midpoint of the tibia. RESULTS For the anterior approach, the safety window width at the upper third of the tibia (mean [SD], 0.63 [0.12] cm, range, 0.44-0.93 cm) was significantly larger than that at the midpoint (0.38 [0.09] cm, range from 0.22 to 0.59 cm, P < 0.05) of the affected leg. However, for the posterior approach, the safety window width at the midpoint (0.74 [0.23] cm, range from 0.21 to 1.18 cm) was significantly larger than that at the upper third of the tibia (0.48 [0.23] cm, range from 0.10 to 0.97 cm, P < 0.05) on the affected leg. CONCLUSIONS Ultrasonographic guidance is a useful, safe, and accurate tool for needle insertion into the tibialis posterior. Considering the safety window width, this study suggests needle placement at the upper third point of the tibia for the anterior approach and at the midpoint for the posterior approach.
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Brown R, Dissanayake KN, Skehel PA, Ribchester RR. Endomicroscopy and electromyography of neuromuscular junctions in situ. Ann Clin Transl Neurol 2014; 1:867-83. [PMID: 25540801 PMCID: PMC4265058 DOI: 10.1002/acn3.124] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 09/03/2014] [Indexed: 12/12/2022] Open
Abstract
Objective Electromyography (EMG) is used routinely to diagnose neuromuscular dysfunction in a wide range of peripheral neuropathies, myopathies, and neuromuscular degenerative diseases including motor neuron diseases such as amyotrophic lateral sclerosis (ALS). Definitive neurological diagnosis may also be indicated by the analysis of pathological neuromuscular innervation in motor-point biopsies. Our objective in this study was to preempt motor-point biopsy by combining live imaging with electrophysiological analysis of slow degeneration of neuromuscular junctions (NMJs) in vivo. Methods We combined conventional needle electromyography with fiber-optic confocal endomicroscopy (CEM), using an integrated hand-held, 1.5-mm-diameter probe. We utilized as a test bed, various axotomized muscles in the hind limbs of anaesthetized, double-homozygous thy1.2YFP16: WldS mice, which coexpress the Wallerian-degeneration Slow (WldS) protein and yellow fluorescent protein (YFP) in motor neurons. We also tested exogenous vital stains, including Alexa488-α-bungarotoxin; the styryl pyridinium dye 4-Di-2-Asp; and a GFP conjugate of botulinum toxin Type A heavy chain (GFP-HcBoNT/A). Results We show that an integrated EMG/CEM probe is effective in longitudinal evaluation of functional and morphological changes that take place over a 7-day period during axotomy-induced, slow neuromuscular synaptic degeneration. EMG amplitude declined in parallel with overt degeneration of motor nerve terminals. EMG/CEM was safe and effective when nerve terminals and motor endplates were selectively stained with vital dyes. Interpretation Our findings constitute proof-of-concept, based on live imaging in an animal model, that combining EMG/CEM may be useful as a minimally invasive precursor or alternative to motor-point biopsy in neurological diagnosis and for monitoring local administration of potential therapeutics.
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Affiliation(s)
- Rosalind Brown
- Euan MacDonald Centre for Motor Neurone Disease Research, University of Edinburgh Hugh Robson Building, George Square, Edinburgh, EH8 9XD, United Kingdom
| | - Kosala N Dissanayake
- Euan MacDonald Centre for Motor Neurone Disease Research, University of Edinburgh Hugh Robson Building, George Square, Edinburgh, EH8 9XD, United Kingdom
| | - Paul A Skehel
- Euan MacDonald Centre for Motor Neurone Disease Research, University of Edinburgh Hugh Robson Building, George Square, Edinburgh, EH8 9XD, United Kingdom
| | - Richard R Ribchester
- Euan MacDonald Centre for Motor Neurone Disease Research, University of Edinburgh Hugh Robson Building, George Square, Edinburgh, EH8 9XD, United Kingdom
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Pimentel LHC, Alencar FJ, Rodrigues LRS, Sousa FCFD, Teles JBM. Effects of botulinum toxin type A for spastic foot in post-stroke patients enrolled in a rehabilitation program. ARQUIVOS DE NEURO-PSIQUIATRIA 2014; 72:28-32. [PMID: 24637979 DOI: 10.1590/0004-282x20130189] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 09/19/2013] [Indexed: 11/22/2022]
Abstract
UNLABELLED The objective of this study was to evaluate the effects of botulinum toxin type A (BTX-A) on spastic foot in stroke patients in a rehabilitation program. METHOD Hemiparetic stroke patients (n=21) enrolled in a rehabilitation program were divided into two groups. The first group (n=11) received a total of 300 UI BTX-A, and the second group (n=10) received 100 UI BTX-A. All patients were assessed at baseline and 2, 4, 8 and 12 weeks after injection for Modified Ashworth Score, time walking 10 meters, and the Functional Independence Measure (mFIM) motor score. RESULTS The higher-dose group exhibited a significant improvement in spasticity, and both groups showed an improvement in time walking 10 meters and mFIM, with no significant differences between them. CONCLUSIONS Our findings suggest that gains in gait velocity and functional independence were not correlated to BTX-A dose.
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Mohan R, Tosolini AP, Morris R. Targeting the motor end plates in the mouse hindlimb gives access to a greater number of spinal cord motor neurons: an approach to maximize retrograde transport. Neuroscience 2014; 274:318-30. [PMID: 24892760 DOI: 10.1016/j.neuroscience.2014.05.045] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 05/05/2014] [Accepted: 05/21/2014] [Indexed: 11/15/2022]
Abstract
Lower motor neuron dysfunction is one of the most debilitating neurological conditions and, as such, significantly impacts on the quality of life of affected individuals. Within the last decade, the engineering of mouse models of lower motor neuron diseases has facilitated the development of new therapeutic scenarios aimed at delaying or reversing the progression of these conditions. In this context, motor end plates (MEPs) are highly specialized regions on the skeletal musculature that offer minimally invasive access to the pre-synaptic nerve terminals, henceforth to the spinal cord motor neurons. Transgenic technologies can take advantage of the relationship between the MEP regions on the skeletal muscles and the corresponding motor neurons to shuttle therapeutic genes into specific compartments within the ventral horn of the spinal cord. The first aim of this neuroanatomical investigation was to map the details of the organization of the MEP zones for the main muscles of the mouse hindlimb. The hindlimb was selected for the present work, as it is currently a common target to challenge the efficacy of therapies aimed at alleviating neuromuscular dysfunction. This MEP map was then used to guide series of intramuscular injections of Fluoro-Gold (FG) along the muscles' MEP zones, therefore revealing the distribution of the motor neurons that supply them. Targeting the entire MEP regions with FG increased the somatic availability of the retrograde tracer and, consequently, gave rise to FG-positive motor neurons that are organized into rostro-caudal columns spanning more spinal cord segments than previously reported. The results of this investigation will have positive implications for future studies involving the somatic delivery and retrograde transport of therapeutic transgenes into affected motor neurons. These data will also provide a framework for transgenic technologies aiming at maintaining the integrity of the neuromuscular junction for the treatment of lower motor neuron dysfunctions.
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Affiliation(s)
- R Mohan
- Translational Neuroscience Facility, School of Medical Sciences, The University of New South Wales, Sydney, NSW, 2052, Australia
| | - A P Tosolini
- Translational Neuroscience Facility, School of Medical Sciences, The University of New South Wales, Sydney, NSW, 2052, Australia
| | - R Morris
- Translational Neuroscience Facility, School of Medical Sciences, The University of New South Wales, Sydney, NSW, 2052, Australia.
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Jiroumaru T, Kurihara T, Isaka T. Establishment of a recording method for surface electromyography in the iliopsoas muscle. J Electromyogr Kinesiol 2014; 24:445-51. [PMID: 24768277 DOI: 10.1016/j.jelekin.2014.02.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 11/21/2013] [Accepted: 02/27/2014] [Indexed: 10/25/2022] Open
Abstract
We examined the availability and reliability of surface electromyography (EMG) signals from the iliopsoas muscle (IL). Using serial magnetic resonance images from fifty healthy young males, we evaluated whether the superficial region of IL was adequate for attaching surface EMG electrodes. Subsequently, we assessed EMG cross-talk from the sartorius muscle (SA)-the nearest to IL-using a selective cooling method in fourteen subjects. The skin above SA was cooled, and the median frequencies of EMG signals from IL and SA were determined. The maximum voluntary contraction during isometric hip flexion was measured before and after selective cooling, and surface EMG signals from SA and IL were measured. The superficial area of IL was adequately large (13.2±2.7cm(2)) for recording surface EMG in all fifty subjects. The maximum perimeter for the medial-lateral skin facing IL was noted at a level 3-5cm distal to the anterior superior iliac spine. Following cooling, the median frequency for SA decreased significantly (from 70.1 to 51.9Hz, p<0.001); however, that for IL did not alter significantly. These results demonstrated that EMG cross-talk from SA was negligible for surface EMG signals from IL during hip flexion.
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Affiliation(s)
- Takumi Jiroumaru
- Graduate School of Sport and Health Science, Ritsumeikan University, Kusatsu, Shiga 525-8577, Japan.
| | - Toshiyuki Kurihara
- Graduate School of Sport and Health Science, Ritsumeikan University, Kusatsu, Shiga 525-8577, Japan
| | - Tadao Isaka
- Graduate School of Sport and Health Science, Ritsumeikan University, Kusatsu, Shiga 525-8577, Japan
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Beretta Piccoli M, Rainoldi A, Heitz C, Wüthrich M, Boccia G, Tomasoni E, Spirolazzi C, Egloff M, Barbero M. Innervation zone locations in 43 superficial muscles: Toward a standardization of electrode positioning. Muscle Nerve 2013; 49:413-21. [DOI: 10.1002/mus.23934] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Matteo Beretta Piccoli
- Department of Health Sciences; University of Applied Sciences and Arts of Southern Switzerland, SUPSI; Manno Switzerland
| | - Alberto Rainoldi
- Motor Science Research Center, School of Exercise and Sport Science, S.U.I.S.M., Department of Medical Sciences; University of Turin; Turin Italy
| | - Carolin Heitz
- Department of Health Sciences; University of Applied Sciences and Arts of Southern Switzerland, SUPSI; Landquart Switzerland
| | - Marianne Wüthrich
- Department of Health Sciences; University of Applied Sciences and Arts of Southern Switzerland, SUPSI; Landquart Switzerland
| | - Gennaro Boccia
- Motor Science Research Center, School of Exercise and Sport Science, S.U.I.S.M., Department of Medical Sciences; University of Turin; Turin Italy
| | - Enrico Tomasoni
- Motor Science Research Center, School of Exercise and Sport Science, S.U.I.S.M., Department of Medical Sciences; University of Turin; Turin Italy
| | - Carlo Spirolazzi
- School of Physiotherapy; Vita-Salute San Raffaele University; Milan Italy
| | - Michele Egloff
- Department of Health Sciences; University of Applied Sciences and Arts of Southern Switzerland, SUPSI; Manno Switzerland
| | - Marco Barbero
- Department of Health Sciences; University of Applied Sciences and Arts of Southern Switzerland, SUPSI; Manno Switzerland
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The effect of Clostridium botulinum toxin type A injections on motor unit activity of the deep digital flexor muscle in healthy sound Royal Dutch sport horses. Vet J 2013; 198 Suppl 1:e147-51. [DOI: 10.1016/j.tvjl.2013.09.050] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Cattaneo L, Pavesi G. The facial motor system. Neurosci Biobehav Rev 2013; 38:135-59. [PMID: 24239732 DOI: 10.1016/j.neubiorev.2013.11.002] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 10/18/2013] [Accepted: 11/02/2013] [Indexed: 12/23/2022]
Abstract
Facial movements support a variety of functions in human behavior. They participate in automatic somatic and visceral motor programs, they are essential in producing communicative displays of affective states and they are also subject to voluntary control. The multiplicity of functions of facial muscles, compared to limb muscles, is reflected in the heterogeneity of their anatomical and histological characteristics that goes well beyond the conventional classification in single facial muscles. Such parcellation in different functional muscular units is maintained throughout the central representation of facial movements from the brainstem up to the neocortex. Facial movements peculiarly lack a conventional proprioceptive feedback system, which is only in part vicariated by cutaneous or auditory afferents. Facial motor activity is the main marker of endogenous affective states and of the affective valence of external stimuli. At the cortical level, a complex network of specialized motor areas supports voluntary facial movements and, differently from upper limb movements, in such network there does not seem to be a prime actor in the primary motor cortex.
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Affiliation(s)
- Luigi Cattaneo
- Center for Mind/Brain Sciences, University of Trento, Via delle Regole 101, Mattarello, Trento 38123, Italy.
| | - Giovanni Pavesi
- Department of Neuroscience, University of Parma, Via Gramsci 14, Parma 43100, Italy
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Botulinum toxin A treatment of the lower extremities in children with cerebral palsy. J Child Orthop 2013; 7:383-7. [PMID: 24432099 PMCID: PMC3838518 DOI: 10.1007/s11832-013-0511-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 06/17/2013] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES In the last 2 decades, BTX-A is increasingly being used in the management of spasticity in children with Cerebral Palsy (CP) and there is no doubt about its effect on range of motion, spasticity reduction and gait pattern in this patient population. However, in daily practice, there is still an ongoing search for the best way to apply BTX-A. Two studies were set up to evaluate how successful an integrated multilevel treatment approach is in children with CP. The first study identifies crucial factors within the treatment strategy which may predict the outcome. The second study evaluates the efficacy of repeated BTX-A injections. METHODS Patient selection was based on following criteria: diagnosis of CP, lower limb BTX-A treatment, age at time of treatment <24 years, no combined surgery at the time of BTX-A injections, 3D gait analysis and clinical evaluation pre and 2 months post BTX-A injections. The first study included the last treatment of 577 patients. In the second study, the first and last BTX-A treatment of 222 children were included. The Goal Attainment Scale (GAS) was used to evaluate the functional outcome of each treatment session. RESULTS In the first study, the mean GAS score of the total group was 51.7 (±7.5). Considering a converted total score of 50 as cut-off score for successful treatment, 67.1 % of the treatments were successful. Significantly higher GAS scores were found in mildly involved children compared to more involved children (p < 0.0001) and for multilevel injections or injections in the distal muscle groups only compared to injections in the proximal muscles of the lower limb only (p < 0.0001). Other crucial factors for a successful outcome were amount of physical therapy per week (p=0.0026), post injection casting (p=0.005) and frequency of using day and night orthoses after injection (p < 0.0001). In the second study, the mean GAS score of the total group decreased from 54.8 (±6.8) at the first treatment to 50.7 (±6.9) at the last treatment, indicating that on average, repeated BTX-A treatment is successful. CONCLUSION The integrated multilevel BTX-A approach is successful in children with CP. Several factors might help the clinician to select patients that are most likely to benefit from the treatment, to assure the most optimal treatment strategy and to predict the outcome. Each treatment should be carefully planned and goals should be well chosen, because the effectiveness of the BTX-A treatment may decrease with increasing number of treatments in the same patient.
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Abstract
OBJECTIVE The aim of this study was to determine the location of the motor points and the intramuscular branches of the wrist flexors in relation to bony landmarks. DESIGN Sixteen limbs from eight adult cadavers were anatomically dissected. The motor branch points of the flexor carpi radialis and flexor carpi ulnaris muscles and the proximal limit points and the distal limit points in relation to a reference line connecting the medial epicondyle and the pisiform bone or one connecting the medial epicondyle and the base of the second metarcarpal bone were identified. RESULTS For the flexor carpi radialis muscles, the motor branch points were located at a distance of 27% ± 6% of the reference line, whereas the proximal limit points and the distal limit points were located at a distance of 21% ± 5% and 37% ± 8% of the reference line. For the flexor carpi ulnaris muscles, the corresponding data were 32% ± 8%, 23% ± 6%, and 43% ± 9%. CONCLUSIONS The results may assist in enhancing accuracy when localizing points for neuromuscular blockade of the wrist flexors. The optimal area for flexor carpi radialis muscle injection is at a quarter point and that for flexor carpi ulnaris muscle injection is at one-third point along each reference line from the medial epicondyle.
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Peña E. Treatment with botulinum toxin: An update. World J Neurol 2013; 3:29-41. [DOI: 10.5316/wjn.v3.i3.29] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/10/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023] Open
Abstract
Botulinum neurotoxin (BoNT) is a potent toxin produced by the anaerobic bacterium clostridium botulinum. It causes flaccid, long-lasting, local and reversible paralysis. In addition, BoNT inhibits the secretion of the exocrine glands and could have properties in the control of pain. Thus, BoNT is useful in the treatment of many neuromuscular conditions where an increase of muscle tone is associated with the pathogenic mechanism. Furthermore, BoNT is recommended in the treatment of some hypersecretion disorders of the exocrine gland and could play a role in the treatment of migraine and other chronic pain conditions. In the BoNT therapy adverse effects are usually mild and reversible. However, repeated injections of BoNT can lead to the development of neutralizing antibodies that can subsequently inhibit the biological activity of the toxin. In this sense, many factors can influence the immunogenicity of the BoNT, such as product-related factors, the dose of BoNT used, the frequency of injection and the previous exposure to the toxin. In this review, we are going to discuss the current clinical applications of BoNT with a special focus on evidence, doses, injection technique and adverse effects for those applications more frequently used in neurology, namely spasticity, blepharospasm, hemifacial spasm, cervical dystonia and other focal dystonias, as well as chronic migraine, tremor, sialorrhea, facial palsy, neurogenic bladder and many other neurological condition.
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