To systematically review randomized controlled trials of botulinum neurotoxin for limb spasticity to determine whether different injection techniques affect spasticity outcomes.
MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials electronic databases were searched for English language human randomized controlled trials from 1990 to 13 May 2016. Studies were assessed in duplicate for data extraction and risk of bias using the Physiotherapy Evidence Database scale and graded according to Sackett’s levels of evidence.
Nine of 347 studies screened met selection criteria. Four categories of botulinum neurotoxin injection techniques were identified: (1) injection localization technique; (2) injection site selection; (3) injectate volume; (4) injection volume and site selection. There is level 1 evidence that: ultrasound, electromyography, and electrostimulation are superior to manual needle placement; endplate injections improve outcomes vs. multisite quadrant injections; motor point injections are equivalent to multisite injections; high volume injections are similar to low volume injections; and high volume injections distant from the endplate are more efficacious than low volumes closer to the endplate.
Level 1 evidence exists for differences in treatment outcomes using specific botulinum neurotoxin injection techniques. Findings are based on single studies that require independent replication and further study.
|1.||Francisco GE, Vaughn A. Botulinum toxin in upper limb. Am J Phys Med Rehabil 2002; 81(5): 355–363. Google Scholar CrossRef, Medline|
|2.||Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med 2009; 6(7): e1000097. Google Scholar CrossRef, Medline|
|3.||Snow BJ, Tsui JK, Bhatt MH, Varelas M, Hashimoto SA, Calne DB. Treatment of spasticity with botulinum toxin: A double-blind study. Ann Neurol 1990; 28(4): 512–515. Google Scholar CrossRef, Medline|
|4.||Moher D, Jadad AR, Nichol G, Penman M, Tugwell P, Walsh S. Assessing the quality of randomized controlled trials: An annotated bibliography of scales and checklists. Control Clin Trials 1995; 16(1): 62–73.Google Scholar CrossRef, Medline|
|5.||Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Google Scholar|
|6.||Moseley AM, Herbert RD, Sherrington C, Maher CG. Evidence for physiotherapy practice: A survey of the Physiotherapy Evidence Database (PEDro). Aust J Physiother 2002; 48(1): 43–49. Google Scholar CrossRef, Medline|
|7.||Lui J, Sarai M, Mills PB. Chemodenervation for treatment of limb spasticity following spinal cord injury: A systematic review. Spinal Cord 2015; 53(4): 252–264. Google Scholar CrossRef, Medline|
|8.||Mills PB, Fung CK, Travlos A, Krassioukov A. Nonpharmacologic management of orthostatic hypotension: A systematic review. Arch Phys Med Rehabil 2015; 96(2): 366–375.e6. Google Scholar CrossRef, Medline|
|9.||Centre for Evidence-Based Medicine. Reflections on David Sackett’s time at the Centre for Evidence-Based Medicine. Available at: www.cebm.net/ (accessed 15 March 2015).|
|10.||Eng J, Teasell R, Miller W, . Spinal cord injury rehabilitation evidence: Method of the SCIRE systematic review. Top Spinal Cord Inj Rehabil 2007; 13(1): 1–10. Google Scholar CrossRef, Medline|
|11.||Picelli A, Tamburin S, Bonetti P, . 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(11): 957–964. Google Scholar CrossRef, Medline|
|12.||Picelli A, Lobba D, Midiri A, . 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(3): 232–242. Google Scholar Link|
|13.||Ploumis A, Varvarousis D, Konitsiotis S, Beris A. Effectiveness of botulinum toxin injection with and without needle electromyographic guidance for the treatment of spasticity in hemiplegic patients: A randomized controlled trial. Disabil Rehabil 2014; 36(4): 313–318. Google Scholar CrossRef, Medline|
|14.||Santamato A, Micello MF, Panza F, . Can botulinum toxin type A injection technique influence the clinical outcome of patients with post-stroke upper limb spasticity? A randomized controlled trial comparing manual needle placement and ultrasound-guided injection techniques. J Neurol Sci 2014; 347(1–2): 39–43. Google Scholar CrossRef, Medline|
|15.||Gracies JM, Lugassy M, Weisz DJ, Vecchio M, Flanagan S, Simpson DM. Botulinum toxin dilution and endplate targeting in spasticity: A double-blind controlled study. Arch Phys Med Rehabil 2009; 90(1): 9–16.e2. Google Scholar CrossRef, Medline|
|16.||Childers MK, Pt DL, Henry H. Comparision of two injection techniques using botulinum toxin in spastic hemiplegia. Am J Phys Med Rehabil 1996; 75(6): 462–469. Google Scholar CrossRef, Medline|
|17.||Im S, Park JH, Son SK, Shin J-E, Cho SH, Park G-Y. Does botulinum toxin injection site determine outcome in post-stroke plantarflexion spasticity? Comparison study of two injection sites in the gastrocnemius muscle: A randomized double-blind controlled trial. Clin Rehabil 2014; 28(6): 604–613. Google Scholar Link|
|18.||Mayer NH, Whyte J, Wannstedt G, Ellis C. Comparative impact of 2 botulinum toxin injection techniques for elbow flexor hypertonia. Arch Phys Med Rehabil 2008; 89(5): 982–987. Google Scholar CrossRef, Medline|
|19.||Picelli A, Bonetti P, Fontana C, . Accuracy of botulinum toxin type A injection into the gastrocnemius muscle of adults with spastic equinus: Manual needle placement and electrical stimulation guidance compared using ultrasonography. J Rehabil Med 2012; 44(5): 450–452. Google Scholar CrossRef, Medline|
|20.||Deshpande S, Gormley ME, Carey JR. Muscle fiber orientation in muscles commonly injected with botulinum toxin: An anatomical pilot study. Neurotox Res 2006; 9(2–3): 115–120. Google Scholar CrossRef, Medline|
|21.||Braddom R. Physical Medicine and Rehabilitation. Philadelphia, PA: Elsevier Saunders, 2011, 180pp. Google Scholar|
|22.||Mills PB, Finlayson H, Sudol M, O’Connor R. Systematic review of adjunct therapies to improve outcomes following botulinum toxin injection for treatment of limb spasticity. Clin Rehabil 2016; 30(6): 537–548. Google Scholar Link|
|23.||World Health Organization. International Classification of Functioning, Disability and Health (ICF). World Health Organization, http://www.who.int/classifications/icf/icf_more/en/ (accessed 27 March 2014).|