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.
OBJECTIVE
To compare the outcome of manual needle placement, electrical stimulation and ultrasonography-guided techniques for botulinum toxin injection into the forearm muscles of adults with arm spasticity.


METHODS
Randomized controlled trial.


METHODS
University hospital.


METHODS
Sixty chronic stroke patients with wrist and fingers spasticity.


METHODS
After randomization into three groups, each patient received botulinum toxin type A in at least two of these muscles: flexor carpi radialis and ulnaris, flexor digitorum superficialis and profundus (no fascicles selection). The manual needle placement group underwent injections using palpation; the electrical stimulation group received injections with electrical stimulation guidance; the ultrasonography group was injected under sonographic guidance. A sole injector was used.


METHODS
All patients were evaluated at baseline and four weeks after injection.


RESULTS
Modified Ashworth Scale; Tardieu Scale; wrist and fingers passive range of motion.


RESULTS
One month after injection, Modified Ashworth Scale scores improved more in the electrical stimulation group than the manual needle placement group (wrist: P = 0.014; fingers: P = 0.011), as well as the Tardieu angle (wrist: P = 0.008; fingers: P = 0.015) and passive range of motion (wrist: P = 0.004). Furthermore, Modified Ashworth Scale scores improved more in the ultrasonography group than in the manual needle placement group (wrist: P = 0.001; fingers: P = 0.003), as well as the Tardieu angle (wrist: P = 0.010; fingers: P = 0.001) and passive range of motion (wrist: P < 0.001; proximal interphalangeal joints: P = 0.009). No difference was found between the ultrasonography and electrical stimulation groups.


CONCLUSIONS
Instrumental guidance may improve the outcome of botulinum toxin injections into the spastic forearm muscles of stroke patients.
1Neuromotor and Cognitive Rehabilitation Research Centre, Department of Neurological and Movement Sciences, University of Verona, Verona, Italy.
Alessandro
A
Picelli
Davide
D
Lobba
Alessandro
A
Midiri
Paolo
P
Prandi
Camilla
C
Melotti
Silvia
S
Baldessarelli
Nicola
N
Smania
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage* / Q000627:therapeutic use; D004558:Electric Stimulation / Q000379:methods; D005260:Female; D005385:Fingers / Q000503:physiopathology; D005542:Forearm; D006801:Humans; D007273:Injections, Intramuscular / Q000295:instrumentation / Q000379:methods*; D007558:Italy; D008297:Male; D008875:Middle Aged; D009128:Muscle Spasticity / Q000188:drug therapy* / Q000209:etiology / Q000503:physiopathology; D018482:Muscle, Skeletal / Q000187:drug effects*; D009465:Neuromuscular Agents / Q000008:administration & dosage / Q000627:therapeutic use; D010043:Outcome and Process Assessment, Health Care; D016059:Range of Motion, Articular / Q000187:drug effects; D020521:Stroke / Q000150:complications / Q000188:drug therapy*; D000071939:Stroke Rehabilitation; D014463:Ultrasonography / Q000379:methods; D014953:Wrist / Q000503:physiopathology; D055815:Young Adult
D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A
Rehabilitation; forearm; hand; muscle hypertonia