Effectiveness of Ultrasound-guided VS Electrical-stimulation-guided Botulinum Toxin Injections in Triceps Surae Spasticity after Stroke: A Randomized Controlled Study
Keywords:botulinum toxin, triceps surae, ultrasonography, Tardieu scale
Objective: To compare the efficacy of botulinum toxin injections using ultrasound-guidance vs electrical-stimulation-guidance in triceps surae (soleus and gastrocnemius) spasticity after stroke.
Design: A clinical, single-centre, prospective, interventional, single-blind, cross-over, randomized trial, with outpatients in the tertiary care hospital. After randomization, subjects received electrical-stimulation-guided, followed by ultrasound-guided abobotulinumtoxinA injection (n = 15), or the same 2 procedures in the reverse order (n = 15) with the same operator, 4 months apart. The primary endpoint was the Tardieu scale with the knee straight at 1 month after injection.
Results: The 2 groups did not differ in Tardieu scale score (effect size = 0.15, 95% confidence interval (95% CI) –0.22 to 0.51, p = 0.43). In addition, the muscle localization technique used had no influence on walking speed, pain on injection or spasticity, assessed at 1 month after the injection, using the modified Ashworth scale. Ultrasound-guided injections were faster to administer than electrical-stimulation-guided injections.
Conclusion: In agreement with previous research, no differences were found in the efficacy of ultrasound-guided or electrical-stimulation-guided abobotulinumtoxinA injections in triceps surae spasticity after stroke. Both techniques are of equal use in guiding muscle localization for botulinum toxin injections in spastic triceps surae.
This study compared the efficacy of 2 techniques used to localize botulinum toxin (BoNT-A) injections in triceps surae (soleus and gastrocnemius) spasticity after stroke: ultrasound-guidance vs electrical-stimulation-guidance. The results show that electrostimulation guidance and ultrasound guidance have the same efficacy for BoNT-A injections in triceps surae spasticity. The technique used had no influence on spasticity, walking speed, or pain on injection. Administration of ultrasound-guided injections was faster than electrical-stimulation-guided injections.
Marque P, Denis A, Gasq D, Chaleat-Valayer E, Yelnik A, Colin C; et al. Botuloscope: 1-year follow-up of upper limb post-stroke spasticity treated with botulinum toxin. Ann Phys Rehabil Med 2019; 62: 207–213. DOI: 10.1016/j.rehab.2019.06.003 DOI: https://doi.org/10.1016/j.rehab.2019.06.003
Schroeder AS, Berweck S, Lee SH, Heinen F. Botulinum toxin treatment of children with cerebral palsy – a short review of different injection techniques. Neurotox Res 2006; 9: 189–196. DOI: 10.1007/BF03033938 DOI: https://doi.org/10.1007/BF03033938
Berweck S, Schroeder AS, Fietzek UM, Heinen F. Sonography-guided injection of botulinum toxin in children with cerebral palsy. Lancet 2004; 363: 249–250. DOI: 10.1016/S0140-6736(03)15351-2 DOI: https://doi.org/10.1016/S0140-6736(03)15351-2
Berweck S, Heinen F. Use of botulinum toxin in pediatric spasticity (cerebral palsy). Mov Disord 2004; 19: S162–167. DOI: 10.1002/mds.20088 DOI: https://doi.org/10.1002/mds.20088
Picelli A, Tamburin S, Bonetti P, Fontana C, Barausse M, Dambruoso F, et al. Botulinum toxin type A injection into the gastrocnemius muscle for spastic equinus in adults with stroke: a randomized controlled trial comparing manual needle placement, electrical stimulation and ultrasonography-guided injection techniques. Am J Phys Med Rehabil. 2012; 91: 957–964. DOI: 10.1097/PHM.0b013e318269d7f3 DOI: https://doi.org/10.1097/PHM.0b013e318269d7f3
Picelli A, Lobba D, Midiri A, Prandi P, Melotti C, Baldessarelli S, et al. Botulinum toxin injection into the forearm muscles for wrist and fingers spastic overactivity in adults with chronic stroke: a randomized controlled trial comparing three injection techniques. Clin Rehabil 2014; 28: 232–242. DOI: 10.1177/0269215513497735 DOI: https://doi.org/10.1177/0269215513497735
Walker HW, Lee MY, Bahroo LB, Hedera P, Charles D. Botulinum toxin injection techniques for the management of adult spasticity. PM R 2015; 7: 4174–4127. DOI: 10.1016/j.pmrj.2014.09.021 DOI: https://doi.org/10.1016/j.pmrj.2014.09.021
Grigoriu AI, Dinomais M, Rémy-Néris O, Brochard S. Impact of injection-guiding techniques on the effectiveness of botulinum toxin for the treatment of focal spasticity and dystonia: a systematic review. Arch Phys Med Rehabil 2015; 96: 2067–2078.e1. DOI: 10.1016/j.apmr.2015.05.002 DOI: https://doi.org/10.1016/j.apmr.2015.05.002
Turna IF, Erhan B, Gunduz NB, Turna O. The effects of different injection techniques of botulinum toxin a in post-stroke patients with plantar flexor spasticity. Acta Neurol Belg 2020; 120: 639–643. DOI: 10.1007/s13760-018-0969-x DOI: https://doi.org/10.1007/s13760-018-0969-x
Morel C, Hauret I, Andant N, Bonnin A, Pereira B, Coudeyre E. Efficacy of two injection-site localisation techniques for botulinum toxin injections: a single-blind, crossover, randomised trial protocol among adults with hemiplegia due to stroke. BMJ Open 2016; 6: e011751. DOI: 10.1136/bmjopen-2016-011751 DOI: https://doi.org/10.1136/bmjopen-2016-011751
Park CS, An SH. Reliability and validity of the modified functional ambulation category scale in patients with hemiparalysis. J Phys Ther Sci 2016; 28: 2264–2267. DOI: 10.1589/jpts.28.2264 DOI: https://doi.org/10.1589/jpts.28.2264
Gracies JM. Evaluation de la spasticité – Apport de l’échelle de Tardieu. Motricité Cérébrale 2001; 22: 1–16.
Cohen, J. Statistical power analysis for the behavioural sciences (2nd edn). Hillsdale, NJ, USA: Erlbaum; 1988.
Mathevon L, Davoine P, Tardy D, Bouchet N, Gornushkina L, Perennou D. Pain during botulinum toxin injections in spastic adults: influence of patients’ clinical characteristics and of the procedure. Ann Phys Rehabil Med 2018; S61: e359. DOI.org/10.1016/j.rehab.2018.05.837 DOI: https://doi.org/10.1016/j.rehab.2018.05.837
Singh P, Joshua AM, Ganeshan S, Suresh S. Intra-rater reliability of the modified Tardieu scale to quantify spasticity in elbow flexors and ankle plantar flexors in adult stroke subjects. Ann Indian Acad Neurol 2011; 14: 23–26. DOI: 10.4103/0972-2327.78045 DOI: https://doi.org/10.4103/0972-2327.78045
Lee JH, Lee SH, Song SH. Clinical effectiveness of botulinum toxin type B in the treatment of subacromial bursitis or shoulder impingement syndrome. Clin J Pain. 2011; 27: 523–528. DOI: 10.1097/AJP.0b013e31820e1310 DOI: https://doi.org/10.1097/AJP.0b013e31820e1310
How to Cite
Copyright (c) 2023 Isabelle Hauret, Lech Dobija, Pascale Givron, Anna Goldstein, Bruno Pereira, Emmanuel Coudeyre
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
All digitalized JRM contents is available freely online. The Foundation for Rehabilitation Medicine owns the copyright for all material published until volume 40 (2008), as from volume 41 (2009) authors retain copyright to their work and as from volume 49 (2017) the journal has been published Open Access, under CC-BY-NC licences (unless otherwise specified). The CC-BY-NC licenses allow third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for non-commercial purposes, provided proper attribution to the original work.