title: Impact of Injection-Guiding Techniques on the Effectiveness of Botulinum Toxin for the Treatment of Focal Spasticity and Dystonia: A Systematic Review.
abstract: OBJECTIVE
  To conduct a systematic review of the impact of different injection-guiding techniques on the effectiveness of botulinum toxin type A (BoNT-A) for the treatment of focal spasticity and dystonia.
  
  
  METHODS
  MEDLINE via PubMed, Academic Search Premier, PASCAL, The Cochrane Library, Scopus, SpringerLink, Web of Science, EM Premium, and PsycINFO.
  
  
  METHODS
  Two reviewers independently selected studies based on predetermined inclusion criteria.
  
  
  METHODS
  Data relating to the aim were extracted. Methodological quality was graded independently by 2 reviewers using the Physiotherapy Evidence Database assessment scale for randomized controlled trials (RCTs) and the Downs and Black evaluation tool for non-RCTs. Level of evidence was determined using the modified Sackett scale.
  
  
  RESULTS
  Ten studies were included. Seven were randomized. There was strong evidence (level 1) that instrumented guiding (ultrasonography [US], electrical stimulation [ES], electromyogram [EMG]) was more effective than manual needle placement for the treatment of spasmodic torticollis, upper limb spasticity, and spastic equinus in patients with stroke, and spastic equinus in children with cerebral palsy. Three studies provided strong evidence (level 1) of similar effectiveness of US and ES for upper and lower limb spasticity in patients with stroke, and spastic equinus in children with cerebral palsy, but there was poor evidence or no available evidence for EMG or other instrumented techniques.
  
  
  CONCLUSIONS
  These results strongly recommend instrumented guidance of BoNT-A injection for the treatment of spasticity in adults and children (ES or US), and of focal dystonia such as spasmodic torticollis (EMG). No specific recommendations can be made regarding the choice of instrumented guiding technique, except that US appears to be more effective than ES for spastic equinus in adults with stroke.
authors.affiliation: University Hospital of Brest, Rehabilitation Department, Brest, France. Electronic address: an_ir_ra@yahoo.fr.
authors.forename: Anca-Irina
authors.initials: AI
authors.lastname: Grigoriu
authors.affiliation: LUNAM, University of Angers, University Hospital of Angers, Rehabilitation Department, Angers, France; LUNAM, University of Angers, Angers Laboratory for Research in Engineering Systems (LARIS)-UPRES EA, Angers, France.
authors.forename: Mickael
authors.initials: M
authors.lastname: Dinomais
authors.affiliation: University Hospital of Brest, Rehabilitation Department, Brest, France; Western Brittany University, Brest, France; National Institute of Health and Medical Research (INSERM) UMR 1101, Medical Data Treatment (LaTIM), Brest, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Rémy-Néris
authors.affiliation: University Hospital of Brest, Rehabilitation Department, Brest, France; Western Brittany University, Brest, France; National Institute of Health and Medical Research (INSERM) UMR 1101, Medical Data Treatment (LaTIM), Brest, France.
authors.forename: Sylvain
authors.initials: S
authors.lastname: Brochard
mesh_terms: D019274:Botulinum Toxins, Type A / Q000008:administration & dosage* / Q000627:therapeutic use; D002547:Cerebral Palsy / Q000150:complications; D002986:Clinical Trials as Topic; D004421:Dystonia / Q000188:drug therapy*; D004558:Electric Stimulation; D004576:Electromyography; D006801:Humans; D007273:Injections, Intramuscular; D009128:Muscle Spasticity / Q000188:drug therapy* / Q000209:etiology; D009465:Neuromuscular Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D020521:Stroke / Q000150:complications
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A
keywords: Botulinum toxins; Electric stimulation; Electromyography; Injections, intramuscular; Palpation; Rehabilitation; Ultrasonography