• Anatomy
• Botulinum toxin
• Dystonia
• Electrical stimulation (e-stim)
• Electromyography (EMG)
• Guidance
• Hypersalivation
• Spasticity
• Ultrasound

• Botulinum toxin
• Hemiplegia
• Injection technique
• Rehabilitation
• Spasticity

• Humans
• Double-Blind Method
• Muscle Spasticity/drug therapy
• Muscle Spasticity/etiology
• Muscle Spasticity/physiopathology
• Male
• Female
• Middle Aged
• Injections, Intramuscular/methods
• Hemiplegia/etiology
• Hemiplegia/rehabilitation
• Hemiplegia/physiopathology
• Muscle, Skeletal/drug effects
• Muscle, Skeletal/physiopathology
• Botulinum Toxins, Type A/administration & dosage
• Neuromuscular Agents/administration & dosage
• Range of Motion, Articular
• Aged
• Treatment Outcome
• Stroke/complications
• Stroke Rehabilitation
• Adult

• AbobotulinumtoxinA
• Botulinum toxin A
• Goal attainment scaling
• Lower limb spasticity
• rehabilitation

• Botulinum toxin
• Dose response
• Meta-analysis
• Model-based
• Muscle spasticity
• Muscle tone
• Stroke
• Time course

• brachioradialis
• crosstalk
• electrode placement
• surface electromyography
• upper limb

• Elbow
• Electrodes
• Electromyography
• Forearm
• Humans
• Muscle, Skeletal/physiology
• Reproducibility of Results

• Botulinum toxin
• Cervical dystonia
• Muscle thickness
• Posterior neck muscles

• Botulinum toxin
• Brain injury
• Human
• Motor recovery
• Rehabilitation
• Spasticity
• Spinal cord injury
• Stroke

• Botulinum Toxins/therapeutic use
• Cerebral Palsy
• Humans
• Muscle Spasticity/drug therapy
• Neuromuscular Agents/therapeutic use
• Stroke
• Treatment Outcome

• Botulinum Toxins
• Electromyography
• Humans
• Muscle Spasticity/drug therapy
• Muscle, Skeletal
• Reflex
• Reflex, Stretch
• Stroke/complications
• Stroke/drug therapy
• Survivors

Botulinum toxin type A (BTXA) has been used for over 25 years in the management of pediatric lower and upper limb hypertonia, with the first reports in 1993. The most common indication is the injection of the triceps surae muscle for the correction of spastic equinus gait in children with cerebral palsy. The upper limb injection goals include improvements in function, better positioning of the arm, and facilitating the ease of care. Neurotoxin type A is the most widely used serotype in the pediatric population. After being injected into muscle, the release of acetylcholine at cholinergic nerve endings is blocked, and a temporary denervation and atrophy ensues. Targeting the correct muscle close to the neuromuscular junctions is considered essential and localization techniques have developed over time. However, each technique has its own limitations. The role of BTXA is flexible, but limited by the temporary mode of action as a focal spasticity treatment and the restrictions on the total dose deliverable per visit. As a mode of treatment, repeated BTXA injections are needed. This literature reviewed BTXA injection techniques, doses and dilutions, the recovery of muscles and the impact of repeated injections, with a focus on the pediatric population. Suggestions for future studies are also discussed.

• Botulinum toxin type A
• Injection techniques
• cerebral palsy
• dilution
• dosage
• motor endplate targeted injections
• muscle atrophy
• repeated injections

• Adolescent
• Age Factors
• Animals
• Botulinum Toxins, Type A/administration & dosage
• Botulinum Toxins, Type A/adverse effects
• Cerebral Palsy/drug therapy
• Cerebral Palsy/physiopathology
• Child
• Child, Preschool
• Dose-Response Relationship, Drug
• Humans
• Injections, Intramuscular
• Muscle Hypertonia/drug therapy
• Muscle Hypertonia/physiopathology
• Muscle, Skeletal/innervation
• Neuromuscular Agents/administration & dosage
• Neuromuscular Agents/adverse effects
• Recovery of Function
• Treatment Outcome

To determine the location of the motor endplate zones (MoEPs) for the three heads of the triceps brachii muscles during cadaveric dissection and estimate the safe injection zone using ultrasonography.

We studied 12 upper limbs of 6 fresh cadavers obtained from body donations to the medical school anatomy institution in Seoul, Korea. The locations of MoEPs were expressed as the percentage ratio of the vertical distance from the posterior acromion angle to the midpoint of the olecranon process. By using the same reference line as that used for cadaveric dissection, the safe injection zone away from the neurovascular bundle was identified in 6 healthy volunteers via ultrasonography. We identified the neurovascular bundle and its location with respect to the distal end of the humerus and measured its depth from the skin surface.

The MoEPs for the long, lateral, and medial heads were located at a median of 43.8%, 54.8%, and 60.4% of the length of the reference line in cadaver dissection. The safe injection zone of the medial head MoEPs corresponded to a depth of approximately 3.5 cm from the skin surface and 1.4 cm away from the humerus, as determined by sonography.

Correct identification of the motor points for each head of the triceps brachii would increase the precision and efficacy of motor point injections to manage elbow extensor spasticity.

• Muscle overactivity
• Pharmacotherapy
• Spasticity
• Toxins
• Treatment
• Upper motor neuron syndrome

• humans
• baclofen
• baclofen/therapeutic use
• botulinum toxins, type a
• botulinum toxins, type a/therapeutic use
• brain injuries, traumatic
• brain injuries, traumatic/complications
• casts, surgical
• electric stimulation therapy
• head‐down tilt
• muscle relaxants, central
• muscle relaxants, central/therapeutic use
• muscle spasticity
• muscle spasticity/etiology
• muscle spasticity/therapy
• neuromuscular agents
• neuromuscular agents/therapeutic use
• randomized controlled trials as topic

• Baclofen/therapeutic use
• Botulinum Toxins, Type A/therapeutic use
• Brain Injuries, Traumatic/complications
• Casts, Surgical
• Electric Stimulation Therapy
• Head-Down Tilt
• Humans
• Muscle Relaxants, Central/therapeutic use
• Muscle Spasticity/etiology
• Muscle Spasticity/therapy
• Neuromuscular Agents/therapeutic use
• Randomized Controlled Trials as Topic

Background: OnabotulinumtoxinA (BoNT-A) can temporarily decrease spasticity following stroke, but whether there is an associated improvement in upper limb function is less clear. This study measured the benefit of adding weekly rehabilitation to a background of BoNT-A treatments for chronic upper limb spasticity following stroke. Methods: This was a multi-center clinical trial. Thirty-one patients with post-stroke upper limb spasticity were treated with BoNT-A. They were then randomly assigned to 24 weeks of weekly upper limb rehabilitation or no rehabilitation. They were injected up to two times, and followed for 24 weeks. The primary outcome was change in the Fugl–Meyer upper extremity score, which measures motor function, sensation, range of motion, coordination, and speed. Results: The ‘rehab’ group significantly improved on the Fugl–Meyer upper extremity score (Visit 1 = 60, Visit 5 = 67) while the ‘no rehab’ group did not improve (Visit 1 = 59, Visit 5 = 59; p = 0.006). This improvement was largely driven by the upper extremity “movement” subscale, which showed that the ‘rehab’ group was improving (Visit 1 = 33, Visit 5 = 37) while the ‘no rehab’ group remained virtually unchanged (Visit 1 = 34, Visit 5 = 33; p = 0.034). Conclusions: Following injection of BoNT-A, adding a program of rehabilitation improved motor recovery compared to an injected group with no rehabilitation.

• muscle spasticity
• occupational therapy
• onabotulinumtoxinA
• physical therapy
• rehabilitation
• stroke

• Botulinum toxin
• electrical stimulation
• randomized controlled trial
• spasticity

• Botulinum Toxins, Type A/administration & dosage
• Electric Stimulation Therapy/methods
• Electromyography/methods
• Evidence-Based Medicine
• Female
• Humans
• Injections, Intramuscular
• Lower Extremity
• Male
• Muscle Spasticity/diagnosis
• Muscle Spasticity/drug therapy
• Muscle Spasticity/rehabilitation
• Neuromuscular Agents/administration & dosage
• Outcome Assessment, Health Care
• Prognosis
• Randomized Controlled Trials as Topic
• Severity of Illness Index

Introduction. This study aimed to improve the accuracy of manual needle placement into the trapezius (TM) for smooth shoulder line. Methods. For macroscopic study 12 TMs and for microscopic study 4 cadavers were detached and then sampled, 1⁎1 cm at the four points from the origin to insertion site (0% at the most lateral point of external occipital protuberance and 100% at the most lateral point of acromion). Results. Most of the nerve endings observed during macroscopic investigations were concentrated in the 60–80% region, and the second most distributed region was the 40–60% region. The microscopic results revealed that the 60–80% region on the reference line had the most dense neuromuscular junction area, while the 40–60% and 80–100% areas were similar in their neuromuscular junction densities. Discussion. These anatomical results will be useful in clinical settings especially for cosmetic surgeons.

• Botulinum Toxins/administration & dosage
• Botulinum Toxins, Type A
• Humans
• Injections, Intramuscular
• Muscle Spasticity/drug therapy
• Neuromuscular Agents
• Ultrasonography, Interventional

• Botulinum toxins
• Electric stimulation
• Electromyography
• Injections, intramuscular
• Palpation
• Rehabilitation
• Ultrasonography

• Onabotulinum toxin
• cerebral palsy
• fibrosis
• myopathy
• spasticity

• Botulinum toxin
• electromyography
• injection location
• muscle spasticity
• randomized controlled trial
• range of motion
• stroke

Spasticity after the occurrence of stroke induces limb deformity, functional disability and/or pain in patients, which limits their activities of daily living and deteriorates their quality of life. Botulinum toxin (BTX) has recently been reported as an efficacious therapeutic agent for the treatment of spasticity. Systematic review and meta-analysis studies have demonstrated that BTX therapy after stroke reduces spasticity and increases physical activity capacity and performance levels. Moreover, BTX can be used as an adjuvant in physiotherapy. Several studies have confirmed that the combination of BTX therapy and physiotherapy improves motor recovery. However, to date, only a few such combination studies have been conducted and their findings are considered preliminary and controversial. Therefore, future studies are required to determine the appropriate combination of treatment methods that will aid motor recovery.

• Botulinum toxin
• Rehabilitation
• Stroke
• Spasticity
• Neurorehabilitation

OnabotulinumtoxinA has demonstrated significant benefit in adult focal spasticity. This study reviews the injection patterns (i.e., muscle distribution, dosing) of onabotulinumtoxinA for treatment of adult spasticity, as reported in published studies.

A systematic review of clinical trials and observational studies published between 1990 and 2011 reporting data on muscles injected with onabotulinumtoxinA in adult patients treated for any cause of spasticity.

28 randomized, 5 nonrandomized, and 37 single-arm studies evaluating 2,163 adult patients were included. The most frequently injected upper-limb muscles were flexor carpi radialis (64.0% of patients), flexor carpi ulnaris (59.1%), flexor digitorum superficialis (57.2%), flexor digitorum profundus (52.5%), and biceps brachii (38.8%). The most frequently injected lower-limb muscles were the gastrocnemius (66.1% of patients), soleus (54.7%), and tibialis posterior (50.5%). The overall dose range reported was 5–200 U for upper-limb muscles and 10–400 U for lower-limb muscles.

The reviewed evidence indicates that the muscles most frequently injected with onabotulinumtoxinA in adults with spasticity were the wrist, elbow, and finger flexors and the ankle plantar flexors. OnabotulinumtoxinA was injected over a broad range of doses per muscle among the studies included in this review, but individual practitioners should be mindful of local regulatory approvals and regulations.

To localize the site of motor points within human biceps brachii muscles through surface mapping using electrophysiological method.

We recorded the compound muscle action potentials of each lattice of the biceps brachii in 40 healthy subjects. Standardized reference lines were made as the following: 1) a horizontal reference line (elbow crease) and 2) a vertical reference line connecting coracoid process and mid-point of the horizontal reference line. The Compound muscle action potentials were mapped in reference to the standardized reference lines. The locations of motor points were mapped to the skin surface, in the ratio to the length of the vertical and the half of the horizontal reference lines.

The motor point of the short head of biceps was located at 69.0±4.9% distal and 19.1±9.5% medial to the mid-point of horizontal reference line. The location of the motor point of the long head of the biceps was 67.3±4.3% distal and 21.4±8.7% lateral. The motor point of the short head of the biceps was located more medially and distally in the male subjects compared to that in the female (p<0.05).

This study showed electrophysiological motor points of the biceps brachii muscles through surface mapping. This data might improve the clinical efficacy and the feasibility of motor point targeting, when injecting botulinum neurotoxin in biceps brachii.

• Biceps brachii
• Botulinum toxin
• Motor point
• Motor point block
• Surface mapping

• Bibliometrics
• Humans
• Periodicals as Topic
• Physical and Rehabilitation Medicine
• Randomized Controlled Trials as Topic
• Research Design
• Sample Size

• 7R21DK081773 NIDDK NIH HHS

• Aged
• Aged, 80 and over
• Body Weights and Measures/methods
• Cadaver
• Female
• Humans
• Humerus/anatomy & histology
• Humerus/innervation
• Male
• Middle Aged
• Motor Neurons
• Muscle, Skeletal/anatomy & histology
• Muscle, Skeletal/innervation
• Musculocutaneous Nerve/anatomy & histology