title: Botulinum neurotoxin treatment in children with cerebral palsy: validation of a needle placement protocol using passive muscle stretching and relaxing.
abstract: OBJECTIVE
  To validate a detailed intramuscular needle placement protocol using passive muscle stretching and relaxing for botulinum neurotoxin type A (BoNT-A) treatment in the lower extremity of children with spastic cerebral palsy (CP), with verification by electrical stimulation.
  
  
  METHODS
  A prospective observational study was performed in 75 children with spastic CP who received regular BoNT-A treatment under general anaesthesia (52 males, 23 females; mean age 8y 9mo, SD 3y 7mo, range 4-18y; mean body mass index 16.2, SD 3.7, range 7.7-26.7). A total of 1084 intramuscular needle placements using passive muscle stretching and relaxing were verified by electrical stimulation. Primary outcome was the positive predictive value.
  
  
  RESULTS
  Intramuscular needle placement in the muscles adductor brevis, adductor longus, gracilis, semimembranosus, semitendinosus, biceps femoris, rectus femoris, and lateral and medial heads of the gastrocnemius and soleus had a positive predictive value ranging from 85.7% to 100% (95% confidence interval ranging from 71.5-89.9% to 91.4-100%).
  
  
  CONCLUSIONS
  This validated detailed protocol for intramuscular needle placement using passive muscle stretching and relaxing for BoNT-A treatment in the lower extremity of children with spastic CP is reliable and has a high positive predictive value.
authors.affiliation: Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU University Medical Center, Amsterdam, The Netherlands.|Department of Rehabilitation Medicine, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Jessica
authors.initials: J
authors.lastname: Warnink-Kavelaars
authors.affiliation: Child Neurology, Department of Neurology, Maastricht University Medical Center+, Maastricht, the Netherlands.
authors.forename: R Jeroen
authors.initials: RJ
authors.lastname: Vermeulen
authors.affiliation: Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Annemieke I
authors.initials: AI
authors.lastname: Buizer
authors.affiliation: Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Jules G
authors.initials: JG
authors.lastname: Becher
mesh_terms: D000293:Adolescent; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage*; D002547:Cerebral Palsy / Q000188:drug therapy*; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols / Q000592:standards*; D004558:Electric Stimulation; D005260:Female; D006801:Humans; D007267:Injections / Q000379:methods* / Q000592:standards; D007273:Injections, Intramuscular / Q000379:methods; D008297:Male; D018482:Muscle, Skeletal; D009465:Neuromuscular Agents / Q000008:administration & dosage*
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A