Should Ultrasound Be Used Routinely to Guide Botulinum Toxin Injections for Spasticity?

Abstract

Background Shoulder dysfunction is common in persons with spinal cord injury (SCI) with an incidence of up to 63%. Dysfunction is a result of muscle imbalances, specifically denervated rotator cuff muscles that are repetitively used during manual wheelchair propulsion. Objective To determine which arm stroke technique, pump (P) or semicircular (SC), is most energy efficient for long periods of propulsion. Design A randomized study with repeated measures observations. Setting The study was performed at an institutional gait analysis laboratory. Participants 18 able‐bodied (AB) male participants were studied and randomized into one of 2 conditions, SC or P. Methods Shoulder muscle fatigue was measured by changes in Borg CR10 Rate of Perceived Exertion (Borg RPE) and upper extremity strength via a handheld dynamometer. Participants were studied and assigned into one of 2 conditions of wheelchair arm propulsion patterns, SC or P group, and propelled on a wheelchair treadmill for 10 minutes. Main Outcome Measures The primary outcomes included recordings of Borg RPE scale during continuous wheelchair propulsion and pre‐ and post‐test dynamometer testing means for bilateral elbow and shoulder extension. Analysis of covariance, t‐tests, and Kruskal‐Wallis tests were used in analyzing data. Results Although not significant (P = .23), the Borg RPE scores for the SC condition were consistently higher than the scores for the P condition. In addition, the dynamometer pre‐ and post‐test readings demonstrated a larger decrease for the SC condition participants than for the P condition participants, but were not statistically significant. Conclusions These data demonstrate that the SC wheelchair propulsion pattern appears to be more fatiguing to shoulder muscles than the P propulsion pattern. However, more data would need to be collected to find a significant difference. Level of Evidence II

A Bayesian Network Meta-Analysis and Systematic Review of Guidance Techniques in Botulinum Toxin Injections and Their Hierarchy in the Treatment of Limb Spasticity

“…For instance, if spread of the toxin is noticed during the injection, the injector can alter the position of the needle to avoid further diffusion and inadvertent weakness of non-spastic muscles. At the same time, anatomical variations or spasticity-induced alterations in muscle trophicity can be discerned and needle placement can be adjusted accordingly [26]. US is particularly useful when a pinpoint accuracy is warranted, such as in fascicle localization within the muscle or in small overlapping muscles.…”

“…Albeit logical, this has only been arbitrarily presumed by practitioners but has not been proven so far. In fact, there are reports suggesting an equivalence of the guided and non-guided approach, while expert opinions vary based on personal experiences in clinical practice [26][27][28][29]. Precedent reviews attempted to compare the effect of guided and non-guided injections on clinical outcome [30][31][32][33].…”