Ergonomic Recommendations in Ultrasound-Guided Botulinum Neurotoxin Chemodenervation for Spasticity: An International Expert Group Opinion

Abstract

Ultrasound (US)-guided botulinum neurotoxin (BoNT) injections are becoming a mainstay in the treatment of muscle spasticity in upper motor neuron syndromes. As a result, there has been a commensurate increase in US-guided BoNT injection for spasticity training courses. However, many of these courses do not emphasize the importance of ergonomics. This paper aims to highlight the importance of ultrasound ergonomics and presents ergonomic recommendations to optimize US-guided BoNT injection techniques in spasticity management. Expert consensus opinion of 11 physicians (4 different continents; representing 8 countries, with an average of 12.6 years of practice using US guidance for BoNT chemodenervation (range 3 to 22 years)). A search using PubMed, College of Physicians and Surgeons of British Columbia database, EMbase was conducted and found no publications relating the importance of ergonomics in US-guided chemodenervation. Therefore, recommendations and consensus discussions were generated from the distribution of a 20-question survey to a panel of 11 ultrasound experts. All 11 surveyed physicians considered ergonomics to be important in reducing physician injury. There was complete agreement that physician positioning was important; 91% agreement that patient positioning was important; and 82% that ultrasound machine positioning was important. Factors that did not reach our 80% threshold for consensus were further discussed. Four categories were identified as being important when implementing ultrasound ergonomics for BoNT chemodenervation for spasticity; workstation, physician, patient and visual ergonomics. Optimizing ergonomics is paramount when performing US-guided BoNT chemodenervation for spasticity management. This includes proper preparation of the workspace and allowing for sufficient pre-injection time to optimally position both the patient and the physician. Lack of awareness of ergonomics for US-guided BoNT chemodenervation for spasticity may lead to suboptimal patient outcomes, increase work-related injuries, and patient discomfort. We propose key elements for optimal positioning of physicians and patients, as well as the optimal setup of the workspace and provide clinical pearls in visual identification of spastic muscles for chemodenervation.

Best Practice Guidelines for the Management of Patients with Post-Stroke Spasticity: A Modified Scoping Review

“…These include the ability to visualize the needle’s trajectory in real time, thereby preventing harm to vital tissues, particularly with in-plane guidance. Additionally, US guiding allows for the precise localization of the target muscle groups [ 45 , 46 ]. Selection of key muscles to be injected.…”

“…US -guided BoNT-A injections for muscle spasticity are increasingly popular and essential. Lagnau P et al [ 46 ] underscored the significance of US ergonomics in BoNT-A injections and offered expert recommendations. The lack of awareness of ergonomics for US-guided BoNT-A injections may lead to suboptimal patient outcomes, increased work-related injuries, and patient discomfort.…”

Ultrasonographic Evaluation of Three Approaches for Botulinum Toxin Injection into Tibialis Posterior Muscle in Chronic Stroke Patients with Equinovarus Foot: An Observational Study

“…Regarding the injection technique, the clinician should take into account some important points: a comfortable position for both patient and clinician should be obtained [31], the injection site should be fully exposed, the probe should be perpendicular to the plane of the target limb and the needle could be inserted along the longitudinal axis (in-plane) or short axis (out of plane) of the probe. In our practice, we usually performed an out of plane injection into TP that allowed us a more comfortable needle entry angle and less distance to the target.…”

Muscle Ultrasound in Clinical Neurology: Diagnostic Uses and Guidance of Botulinum Toxin Injection

“…Optimal positioning of patients, physician, and MUS device should be secured when MUS-guided injection is intended. 58 Accurate clinical investigation of the patients, skilful planning of BoNT dose and injection targets, and precise anatomic knowledge are prerequisites of treatment success. 6,59-64 MUS is useful not only for targeting and documentation of the injection procedure but may also aid in the identification of hypertonic (spastic, dystonic) muscles, e.g., by comparing muscle thickness and echogenicity between affected and unaffected side, 60,65 or by applying sono-elastography.…”