title: Study protocol: precision of a protocol for manual intramuscular needle placement checked by passive stretching and relaxing of the target muscle in the lower extremity during BTX-A treatment in children with spastic cerebral palsy, as verified by means of electrical stimulation.
abstract: BACKGROUND
  Intramuscular injection of botulinum toxin type-A given by manual intramuscular needle placement in the lower extremity under general anaesthesia is an established treatment and standard of care in managing spasticity in children with spastic cerebral palsy. Optimal needle placement is essential. However, reports of injection and verification techniques used in previous studies have been partly incomplete and there are methodological shortcomings. This paper describes a detailed protocol for manual intramuscular needle placement checked by passive stretching and relaxing of the target muscle for each individual muscle injection location in the lower extremity during botulinum toxin type-A treatment under general anaesthesia in children with spastic cerebral palsy. It explains the design of a study to verify this protocol, which consists of an injection technique combined with a needle localizing technique, as by means of electrical stimulation to determine its precision.
  
  
  METHODS
  
  
  
  METHODS
  University Medical Centre, Department of Paediatric Rehabilitation Medicine, the Netherlands.
  
  
  METHODS
  prospective observational study.
  
  
  METHODS
  children with spastic cerebral palsy, aged 4 to 18 years, receiving regular botulinum toxin type-A treatment under general anaesthesia to improve their mobility, are recruited from the Department of Paediatric Rehabilitation Medicine at VU University Medical Centre, Amsterdam, the Netherlands.
  
  
  METHODS
  a detailed protocol for manual intramuscular needle placement checked by passive stretching and relaxing of the target muscle has been developed for each individual muscle injection location of the adductor brevis muscle, adductor longus muscle, gracilis muscle, semimembranosus muscle, semitendinosus muscle, biceps femoris muscle, rectus femoris muscle, gastrocnemius lateralis muscle, gastrocnemius medialis muscle and soleus muscle. This protocol will be verified as by means of electrical stimulation.Technical details: 25 mm or 50 mm Stimuplex-needle and a Stimuplex-HNS-12 electrical stimulator will be used.
  
  
  CONCLUSIONS
  Botulinum toxin type-A injected in the intended muscle is expected to yield the greatest effect in terms of activities. Protocols for manual intramuscular needle placement should be described in detail and verified to determine its precision. Detailed and verified protocols are essential to be able to interpret the results of botulinum toxin type-A treatment studies.
authors: Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU University Medical Centre, Boelelaan 1018, Amsterdam, the Netherlands. j.warnink@reade.nl.
authors: Jessica
authors: J
authors: Warnink-Kavelaars
authors: Roland Jeroen
authors: RJ
authors: Vermeulen
authors: Jules Guilhelmus
authors: JG
authors: Becher
mesh_terms: D000293:Adolescent; D000704:Analysis of Variance; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D002547:Cerebral Palsy / Q000188:drug therapy*; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols; D004558:Electric Stimulation; D005260:Female; D006801:Humans; D007273:Injections, Intramuscular / Q000379:methods*; D035002:Lower Extremity / Q000502:physiology*; D008297:Male; D009128:Muscle Spasticity / Q000188:drug therapy; D052580:Muscle Stretching Exercises; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012680:Sensitivity and Specificity
chemical_list: D019274:Botulinum Toxins, Type A
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