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Objective: To compare the prevalence of mental health disorders in individuals with facial synkinesis, facial paralysis alone, and the general population. Study Design: Retrospective cohort. Setting: Eighty‐two health care organizations across the United States. Methods: The TriNetX Research Network was queried from 2011 to 2021 for patients with facial paralysis without synkinesis, facial paralysis and documented synkinesis, and controls, matched for age, sex, race, and ethnicity. Cases included infectious, iatrogenic, or idiopathic facial paralysis. Patients with pre‐existing depression or anxiety were excluded. Two‐year rates of newly diagnosed depression, anxiety, and mental health prescriptions were compared. Results: Among 127,573 patients with facial paralysis, 92.5% (n = 117,976) had facial paralysis alone, and 7.5% (n = 9597) also had documented synkinesis. Compared to controls, patients with facial paralysis alone had increased risks of new depression (8.9% vs 7.3%, P <.001) and anxiety (10.1% vs 9.6%, P <.001), with higher mental health medication rates (16.6% vs 13.1%, P <.001). Patients with documented synkinesis, in comparison to controls, had the highest risks of depression (19.8% vs 8.6%, P <.001), anxiety (20.5% vs 10.5%, P <.001), and prescriptions (28.1% vs 15.8%, P <.001). The 27.8% (n = 2669) of synkinetic patients treated with chemodenervation had lower rates of depression (8.5% vs 23.5%, P <.001), anxiety (9.0% vs 23.8%, P <.001), and prescriptions (21.6% vs 30.0%, P <.001) compared to synkinetic patients who were not. Conclusion: Facial paralysis, particularly synkinesis, is linked to increased mental health disorders. Integrating mental health screening and treatment into a comprehensive approach is crucial. Chemodenervation is associated with decreased mental health disorders in synkinesis, highlighting its therapeutic potential. [ABSTRACT FROM AUTHOR]

With the development of strabismology, the issues of using Botox in various eye movement pathologies are gaining relevance. The literature analysis shows that the data concerning the effectiveness of Botox are ambivalent and as a rule, are based on short-term results. The review presents the data on the efficiency of the botulinum toxin in the treatment of various oculomotor system diseases in comparison with traditional surgical interventions. Indications for such therapy, application techniques, doses and complications are discussed. The generalized modern data on the functional features of the onset of various pathologies in strabismology help assess the potentials of optimizing strabismus treatment with type A botulinum toxin. To search for the data published between 1973 and 2022, select and summarize them we used Google Scholar, PubMed and eLibrary databases.

Casting is an effective adjunctive treatment, which increases the effects of botulinum toxin on patients with spasticity. The evidence for casting as an adjunctive therapy post-botulinum toxin has been well documented in the literature. However, standardized casting protocols are lacking, with no published descriptions of upper limb casting application post-botulinum toxin injection for spasticity. In this article, we will describe our experience regarding the application of upper limb casting as an adjunctive therapy for elbow spasticity, detailing indications, contraindications, and description of our protocol (materials required and technique). [ABSTRACT FROM AUTHOR]

Ultrasound guidance can enhance existing landmark-based injection methods, even through a brief and single exposure during a cadaveric training course. A total of twelve participants were enrolled in this training program, comprising nine physical medicine and rehabilitation specialists, one pediatrician, and two physician assistants. For each participant, one upper-limb muscle and one lower-limb muscle were randomly chosen from the preselected muscle group. Subsequently, participants were tasked with injecting both of their chosen cadaveric muscles with 1 mL of acrylic paint using a manual needle palpation technique, relying solely on their knowledge of anatomic landmarks. Participants then underwent a personalized, one-to-one ultrasound teaching session, lasting approximately five minutes, conducted by two highly experienced instructors. Following this instructive phase, participants were tasked with a second round of injections, targeting the same two muscles in the lower and upper limbs. However, this time, the injections were performed using anatomical landmarks and ultrasound guidance. To facilitate differentiation from the initial injections, a distinct color of acrylic paint was employed. When employing the anatomical landmark-based approach, the overall success rate for injections was 67%, with 16 out of 24 targeted muscles accurately injected. With the incorporation of ultrasound guidance, the success rate was 92%, precisely targeting 22 out of the 24 muscles under examination. There was an improvement in injection accuracy achievable through the integration of ultrasound guidance, even with minimal training exposure. Our single cadaveric ultra-sound training program contributes valuable insights to the utilization of ultrasound for anatomy training to help optimize the targeting of BoNT-A. [ABSTRACT FROM AUTHOR]

Botulinum toxin (BTX) injections into the musculature surrounding the brachial plexus have been examined as a potential treatment for neurogenic thoracic outlet syndrome (nTOS). This systematic review identified 15 publications, of which one was a randomized controlled trial. BTX injections performed with ultrasound or electromyographic guidance, and with the inclusion of the pectoralis minor muscle, in addition to the anterior and/or middle scalenes, tended to provide greater symptom improvement and may predict response to first rib resection. Importantly, most studies were of low quality; thus, the results should be interpreted with caution. Further high‐quality studies are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Congenital unilateral lower lip palsy (CULLP), or congenital hypoplasia of the depressor anguli oris muscle, also known as asymmetric crying facies, is a rare condition that results in asymmetry of the lower lip during smiling, laughing, and crying. Although the etiology is unknown, weakness of the depressor labii inferioris (DLI) muscle is implicated as a contributing factor. Currently, no well-established treatment options are available. This case report describes an 18-year-old male patient diagnosed with CULLP. Physical examination revealed a symmetric face at rest, but asymmetry when smiling and opening the mouth. Following the administration of lidocaine into the affected DLI muscle, the patient's smile and lower lip symmetry were immediately restored without any adverse effects. Subsequently, administration of botulinum toxin for neuromodulation of the DLI muscle led to a significant improvement in symmetry and oral function within 2 weeks, which was sustained at 1 month and 3 months post-treatment. No adverse effects were reported, and both patients and families expressed high satisfaction with the outcomes. This case highlights the potential use of neuromodulation as a minimally invasive and effective treatment for CULLP. [ABSTRACT FROM AUTHOR]

Ultrasound guidance can enhance existing landmark-based injection methods, even through a brief and single exposure during a cadaveric training course. A total of twelve participants were enrolled in this training program, comprising nine physical medicine and rehabilitation specialists, one pediatrician, and two physician assistants. For each participant, one upper-limb muscle and one lower-limb muscle were randomly chosen from the preselected muscle group. Subsequently, participants were tasked with injecting both of their chosen cadaveric muscles with 1 mL of acrylic paint using a manual needle palpation technique, relying solely on their knowledge of anatomic landmarks. Participants then underwent a personalized, one-to-one ultrasound teaching session, lasting approximately five minutes, conducted by two highly experienced instructors. Following this instructive phase, participants were tasked with a second round of injections, targeting the same two muscles in the lower and upper limbs. However, this time, the injections were performed using anatomical landmarks and ultrasound guidance. To facilitate differentiation from the initial injections, a distinct color of acrylic paint was employed. When employing the anatomical landmark-based approach, the overall success rate for injections was 67%, with 16 out of 24 targeted muscles accurately injected. With the incorporation of ultrasound guidance, the success rate was 92%, precisely targeting 22 out of the 24 muscles under examination. There was an improvement in injection accuracy achievable through the integration of ultrasound guidance, even with minimal training exposure. Our single cadaveric ultra-sound training program contributes valuable insights to the utilization of ultrasound for anatomy training to help optimize the targeting of BoNT-A.

Spasticity is a complex and often disabling symptom for patients with upper motor neuron syndromes. Although spasticity arises from neurological disease, it often cascades into muscle and soft tissue changes, which may exacerbate symptoms and further hamper function. Effective management therefore hinges on early recognition and treatment. To this end, the definition of spasticity has expanded over time to more accurately reflect the spectrum of symptoms experienced by persons with this disorder. Once identified, clinical and research quantitative assessments of spasticity are hindered by the uniqueness of presentations both for individuals and for specific neurological diagnoses. Objective measures in isolation often fail to reflect the complex functional impact of spasticity. Multiple tools exist to quantitatively or qualitatively assess the severity of spasticity, including clinician and patient‐reported measures as well as electrodiagnostic, mechanical, and ultrasound measures. A combination of objective and patient‐reported outcomes is likely required to better reflect the burden of spasticity symptoms in an individual. Therapeutic options exist for the treatment of spasticity along a broad spectrum from nonpharmacologic to interventional procedures. Treatment strategies may include exercise, physical agent modalities, oral medications, injections, pumps, and surgery. Optimal spasticity management most often requires a multimodal approach, combining pharmacological management with interventions that match the functional needs, goals, and preferences of the patient. Physicians and other healthcare providers who manage spasticity must be familiarized with the full array of spasticity interventions and must frequently reassess results of treatment to ensure the patient's goals of treatment are met. [ABSTRACT FROM AUTHOR]

We describe a case of limb myorhythmia successfully palliated with botulinum toxin injections. The patient is a 30-year-old male evaluated for abnormal movements of the left lower foot that began after an ankle injury for which the patient underwent Achilles tendon scar tissue debridement without improvement. On examination, he had near-constant involuntary, slow, rhythmic flexion/extension tremor of toes 2–4 that was diminished during active movement. Needle electromyography (EMG) revealed a rhythmic, 2–3 Hz tremor isolated to the flexor digitorum brevis. After failure of medical management with muscle relaxants, gabapentin, and levodopa trials, the patient underwent two EMG-guided chemodenervation procedures with incobotulinum toxin A injections of the left flexor digitorum brevis. At 3-month follow-up, he had achieved a sustained 50% reduction in the intensity of the movements and improved quality of life. Myorhythmia is a rare condition characterized by a repetitive, rhythmic, slow frequency (1–4 Hz) movement affecting the cranial and limb muscles. The most common causes include stroke, demyelinating disorders, drug or toxin intake, trauma, and infections. The management of this condition is very limited with pharmacologic agents such as anticholinergics, antispasmodics, anticonvulsants, or dopaminergic agents showing limited efficacy. The use of botulinum toxin chemodenervation aided by EMG muscle targeting can be a useful therapeutic intervention in cases of medication-refractory regionally distributed myorhythmia involving accessible muscles. [ABSTRACT FROM AUTHOR]

Cervical dystonia (CD) is a focal dystonia characterized by involuntary contractions of neck muscles that result in patterned movements and abnormal postures of the head and neck that have a directional quality. CD is the most common form of dystonia presenting to the movement disorders clinic. Botulinum toxin is an effective treatment for cervical dystonia. It has become the first-line treatment for cervical dystonia with a satisfactory relief of symptoms reported in more than 80% of the cases. Multiple small and large scale studies proven that fact and provided Class-A evidence for the benefit. However, 20% of the patients discontinue treatment due to adverse effects, treatment failure and other reasons. With the proper knowledge of toxins and the anatomy of the neck, much better results can be achieved with fewer and self-limiting adverse effects as compared to other modalities. However, the expert consensus recommendations are lacking to guide clinicians for optimal use of botulinum toxin for cervical dystonias. This paper discusses the different available treatments, botulinum injection techniques and the adverse effects involved with the procedure.

ABSTRACT: Background: The anti-spasticity efficacy of botulinum toxin (BoNT) injection has been well established for patients with chronic stroke; however, extracorporeal shock wave therapy (ESWT), i.e. focused shockwave (FSW) and radial shockwave (RSW), has recently been applied. We aimed to investigate the comparative effectiveness of BoNT vs. ESWT in the reduction of spasticity among stroke survivors. Methods: PubMed, EMBASE, MEDLINE and Cochrane CENTRAL were searched from the earliest record to September 2021 for randomized controlled trials. Weighted mean differences (WMDs) on the reduction of the Modified Ashworth Scale before or at the 6th post-treatment week (short-term) and between the 7th and 12th weeks (mid-term) after the intervention were calculated. Ranking probabilities of the WMD were simulated to determine which treatment had the potential to possess the best effectiveness. inplasy.com registration: INPLASY202170018. Findings: A total of 33 studies comprising 1,930 patients were enrolled. The network meta-analysis revealed that BoNT injections, FSW and RSW were better in spasticity reduction than the control treatment(s) at the short term, with WMDs of -0.69 (95% CI, -0.87 to -0.50), -0.36 (95% CI, -0.69 to -0.03) and -0.62 (95% CI, -0.84 to -0.40), respectively. Likewise, mid-term effects of BoNT injections, FSW and RSW also revealed superiority, with WMDs of -0.44 (95% CI, -0.62 to -0.26), -0.74 (95% CI, -1.26 to -0.23) and -0.79 (95% CI, -1.07 to -0.51), respectively. Ranking probability analysis revealed that RSW had the highest probability of being the best treatment for spasticity reduction at the short-term (62.2%) and mid-term (72.3%) periods during the follow up. Interpretation: BoNT injections and ESWT are effective in alleviating post-stroke spasticity at the mid-term. The effectiveness of ESWT was comparable to BoNT injections, and RSW had the potential to be the best treatment for spasticity reduction among the three treatment options. More prospective trials incorporating head-to-head comparisons of BoNT injections vs. ESWT are needed to validate the role of ESWT in reducing post-stroke spasticity. Funding: The current research project was supported by (1) National Taiwan University Hospital, Bei-Hu Branch; (2) Ministry of Science and Technology (MOST 106–2314-B-002–180-MY3 and 109–2314-B-002–114-MY3); 3) Taiwan Society of Ultrasound in Medicine.

Les syncinésies représentent une séquelle invalidante de la paralysie faciale, qui aggrave l'asymétrie des visages, et diminue la qualité de vie des patients. Leur physiopathologie est partiellement connue, mais ne permet pas d'expliquer l'ensemble des syncinésies. Nous rapportons une revue de littérature de l'état de l'art des connaissances sur la physiopathologie des syncinésies, ainsi que sur leur prise en charge. Il est admis que le mécanisme physiopathologique des syncinésies est mixte. Les phénomènes de plasticité cérébrale, repousse nerveuse aberrante, hyperexcitabilité du noyau de nerf facial et transmission nerveuse éphaptique ont été observés. Nous proposons une nouvelle hypothèse physiopathologique : les syncinésies pourraient être la conséquence du démasquage de circuits latents, existants chez le sujet sain. Nous évoquons trois potentiels circuits latents : les contractions synergiques physiologiques, le recrutement d'unités motrices adjacentes, et la réactivation de circuits latents à distance, de compensation de fonction. Les options de traitement sont multiples, dominées par la chémodénervation dont l'efficacité est indéniable. La rééducation a également prouvé son efficacité, notamment avec les techniques de feedback. Enfin, la chirurgie vient en aide à ces options. Cependant, les indications des différents traitements restent à codifier. La validation de notre hypothèse physiopathologique permettrait une meilleure compréhension et un meilleur dépistage des syncinésies, afin de pouvoir proposer une prise en charge plus adaptée. Synkinesis is a disabling sequelae of facial palsy, which worsens facial asymmetry and diminishes the patients' quality of life. Their physiopathology is partially known, but cannot explain all the synkinesis. We report a literature review of the state of the art concerning the knowledge on synkinesis physiopathology, as well as their management. It is accepted that the physiopathological mechanism of synkinesis is mixed. The phenomena of cerebral plasticity, aberrant nerve regrowth, hyperexcitability of the facial nerve nucleus and ephaptic nerve transmission, have been observed. We propose a new physiopathological hypothesis: synkinesis could be the consequence of latent circuits activation, preexisting in the healthy subject. We could propose three potential latent circuits: physiological synergistic contractions, adjacent motor units recruitment, and reactivation of remote latent circuits for function compensation. The treatment options are multiple, dominated by chemodenervation, whose effectiveness is undeniable. Rehabilitation has also proven its effectiveness, particularly with feedback techniques. Finally, surgery helps with these options. However, the indications of the different treatments remain to be codified. The validation of our physiopathological hypothesis would allow a better understanding and a better screening of synkinesis, in order to propose a more adapted treatment. [ABSTRACT FROM AUTHOR]

Background. Primary inferior oblique muscle overaction (PIOOA) may occur for various reasons and happens to 72 % patients with infantile esotropia. The criterion for the first surgical step is prevalence of vertical or horizontal deviation. The choice of tactics weakening inferior oblique muscle is ambiguous.Aims: to carry out retrospective analysis of PIOOA frequency in patients with infantile esotropia; to assess influence of esodeviation reduction by a surgical, chemodenervational or prismatic method on the existing PIOOA dynamics; to assess clinical and functional results of PIOOA treatment.Methods and methods. The retrospective analysis of 572 patients’ cases lay in assessment of PIOOA frequency and rate in patients with infantile esotropia that manifested under 9 months, with different treatment tactics. The prospective part of the research included two groups of patients. Group 1 (106 patients, 222 eyes) – studying the influence of surgical treatment of PIOOA. Group 2 (127 patients, 207 eyes) – studying the effectiveness of surgical PIOOA treatment. Conclusion. PIOOA frequency in case of different treatment tactics for patients with infantile esotropia is from 17 to 69 %, and the degree of its clinical manifestation is from 1.2 ± 0.4 to 2.6 ± 0.8. Bilateral weakening of medial rectus muscle reduces its probability up to 17–19 %, and the degree of its manifestation up to 1.2 ± 0.4. In cases of combination of PIOOA with infantile esotropia from 20 to 25° with paretic component, it is reasonable to carry out esodeviation reduction by means of bilateral recession, chemorecession or prismatic correction as the first treatment stage, whereas the rate of existing PIOOA is credibly reduced. In cases of choice of tactics, which is necessary for clinically significant reduction or elimination of PIOOA, it is reasonable to carry out chemorecession, marginal partial myotomy or myectomy depending on the PIOOA manifestation.

The review presents information concerning the botulinum toxin use in the treatment of children`s strabismus; highlights aspects of the safety and the complications frequency. It contains information about the methods and doses of botulinum toxin injection, and also considers the cases of necessity of further surgery. There are several ways of introducing BTA: the traditional transconjunctival method of administration under the control of electromyography, used by most ophthalmologists, is not acceptable for treating pediatric patients, transconjunctivally into the subtenon space 10 mm from the limbus into the projection zone of the medial rectus muscle using a 1.0 ml tuberculin syringe with 27G needle, introduction to the muscle with the opening of the conjunctiva, which is safer, is carried out under complete visual control and with the release of extraocular muscle. According to the domestic and foreign literature data we can conclude that the injection of botulinum toxin may be an alternative or complement to surgical techniques, injection of botulinum toxin in the treatment of strabismus in children may be an alternative or complement to surgical and pleopto-orthopto-diploptic correction methods, although not in all clinical cases. The treatment approach of such patients should be comprehensive. There are reports that BoNT-A reduces eye deflection in more than 50 % of patients and provides satisfactory long-term results in infants and children. The average safe dose for Botox is 1-3 units for the muscle. The frequency of complications increases with higher doses (especially> 10 units) and with the transconjunctival route of administration without electromyographic control. This clinical example illustrates the effectiveness of botulinum toxin for the non-concomitant strabismus treatment.

Introduction. To summarize our fifteen-years clinical experience of using Botox in strabismology and determine the indications for the most effective use of chemodenervation in the complex treatment of oculomotor system pathology.Patients and methods. To carry out chemodenervation of extraocular muscles, Botox was used. The optimal dose of Botox for intramuscular injection ranged from 1.25 to 5.0 units. The choice of dosage depends on the patient’s age, the type oculomotor system pathology, the level of muscular dysfunction and the purpose of the treatment. The treatment was performed in 376 patients with various disorders of oculomotor system. At the time of treatment, the patients’ ages ranged from 12 to 78 years. Injection of Botox into the extraocular muscles in all cases was the primary method of treatment.Results. In general, the state of relative functional recovery was achieved in 71.81% of cases (in 270 patients). The best results were obtained in treatment of decompensated heterophories, acute heterotrophies, atypical heterotrophies and primary hyperfunction of the inferior oblique muscles (in 100% of cases). In these conditions, the binocular vision was preserved in patients, and the imbalance of the oculomotor system did not show any sign of incomitance. However, patients with paralysis and paresis of the cranial nerves chemodenervation allowed creating conditions for a more complete restoration of muscular functions, to avoid the occurrence of a secondary imbalance in the oculomotor system. In 70.3% cases (185 patients), subsequent surgical treatment was not required. Reliable functional results of treatment allowed creating the optimal algorithm for chemodenervation.Discussion. Chemodenervation of extraocular muscles is an effective independent and additional method of complex treatment of oculomotor system pathology and expands opportunities in patients’ rehabilitation. To achieve maximum functional results, it is necessary to select patients correctly for this procedure, taking into account its appropriateness and advantages over alternative methods of treatment, selection of optimal dosages of Botox.

Cervical dystonia (CD) is a focal dystonia characterized by involuntary contractions of neck muscles that result in patterned movements and abnormal postures of the head and neck that have a directional quality. CD is the most common form of dystonia presenting to the movement disorders clinic. Botulinum toxin is an effective treatment for cervical dystonia. It has become the first-line treatment for cervical dystonia with a satisfactory relief of symptoms reported in more than 80% of the cases. Multiple small and large scale studies proven that fact and provided Class-A evidence for the benefit. However, 20% of the patients discontinue treatment due to adverse effects, treatment failure and other reasons. With the proper knowledge of toxins and the anatomy of the neck, much better results can be achieved with fewer and self-limiting adverse effects as compared to other modalities. However, the expert consensus recommendations are lacking to guide clinicians for optimal use of botulinum toxin for cervical dystonias. This paper discusses the different available treatments, botulinum injection techniques and the adverse effects involved with the procedure. [ABSTRACT FROM AUTHOR]

In each condition, there is sensory deafferentation and reduction in thalamic and sensory input to the cortex, which produces pain.[5] There are limited studies on the mechanism of pain generation in CBS. We report what may be the first case of CBS pain treated with stellate ganglion blockade. Keywords: corticobasal syndrome; stellate; pain; chemodenervation EN corticobasal syndrome stellate pain chemodenervation 848 849 2 05/18/23 20230501 NES 230501 Corticobasal syndrome (CBS) is a neurodegenerative condition characterized by cortical and extrapyramidal dysfunction. [Extracted from the article]

Introduction and hypothesis: Botulinum toxin (BoNT) is increasingly used for pain, especially with muscle spasm. We describe our methodology for BoNT treatment of chronic pelvic pain (CPP) in women and place it in the context of the literature on techniques for this use. Methods: Databases were searched using terms "botulinum toxin," "pelvic pain," and "vaginismus." Reports on vaginismus/vulvodynia/vestibulodynia (included if pelvic floor muscles were injected) were grouped as "vaginismus/vulvar pain disorders" (V/VPD). We analyzed the type of report, condition, toxin serotype/brand, dose/dilution, muscle selection, guidance technique, and anesthesia. Publications from the same authors without unique information were combined for specific analyses. Results: Thirty-eight reports had analyzable information; many lacked complete information. Most were open-label prospective reports; there were four technical reports, one randomized comparison of doses and one placebo-controlled study of efficacy. Pelvic floor muscles were approached transvaginally, transperineally or transgluteally. BoNT brand/dose/dilution varied widely. Muscle localization techniques included anatomical landmarks only, electromyography, electrical stimulation with/without ultrasound, and fluoroscopy/CT scanning. Papers discussing analgesia utilized general anesthesia, conscious sedation with/without topical/local anesthesia, topical/local agent alone or pudendal block before or after injection. Cumulatively, 58–100% of patients with CPP and 71–100% of those with V/VPD improved. Serious adverse events (transient fecal incontinence/constipation, urinary incontinence/retention) were more frequent with higher doses. Conclusions: BoNT can be safely and tolerably injected into pelvic floor muscles in women as an out-patient procedure. This study identifies methodological factors to be considered in future studies and the critical need for high-quality clinical trials for this emerging treatment. [ABSTRACT FROM AUTHOR]

Purpose: To perform a systematic review of the application of botulinum toxin A (BTA) in the management of strabismus in the adult and pediatric populations. Materials and methods: A systematic literature search was performed using the Medline database. Results: In 1989, with the FDA approval of botulinum toxin (onabotulinum toxin A, or BTA) for the treatment of strabismus, patients were provided with an alternative to surgical recession. In this review, we discuss the uses of BTA in the treatment of acute onset comitant esotropia or smaller angle esotropia and as an adjunct to surgery for larger angle esotropia or sixth nerve palsy. Its uses are also explored in intermittent exotropia and vertical strabismus, including thyroid-associated orbitopathy, fourth nerve palsies, and other orbital pathology. Discussion: Despite its transient kinetics, BTA can have permanent effects on ocular alignment, promoting binocularity and reduction of diplopia, and can serve as a primary treatment or a muscle sparing option in patients at risk of anterior segment ischemia or need for future surgeries. [ABSTRACT FROM AUTHOR]

Ultrasound (US)-guided botulinum neurotoxin (BoNT) injections are becoming a mainstay in the treatment of muscle spasticity in upper motor neuron syndromes. As a result, there has been a commensurate increase in US-guided BoNT injection for spasticity training courses. However, many of these courses do not emphasize the importance of ergonomics. This paper aims to highlight the importance of ultrasound ergonomics and presents ergonomic recommendations to optimize US-guided BoNT injection techniques in spasticity management. Expert consensus opinion of 11 physicians (4 different continents; representing 8 countries, with an average of 12.6 years of practice using US guidance for BoNT chemodenervation (range 3 to 22 years)). A search using PubMed, College of Physicians and Surgeons of British Columbia database, EMbase was conducted and found no publications relating the importance of ergonomics in US-guided chemodenervation. Therefore, recommendations and consensus discussions were generated from the distribution of a 20-question survey to a panel of 11 ultrasound experts. All 11 surveyed physicians considered ergonomics to be important in reducing physician injury. There was complete agreement that physician positioning was important; 91% agreement that patient positioning was important; and 82% that ultrasound machine positioning was important. Factors that did not reach our 80% threshold for consensus were further discussed. Four categories were identified as being important when implementing ultrasound ergonomics for BoNT chemodenervation for spasticity; workstation, physician, patient and visual ergonomics. Optimizing ergonomics is paramount when performing US-guided BoNT chemodenervation for spasticity management. This includes proper preparation of the workspace and allowing for sufficient pre-injection time to optimally position both the patient and the physician. Lack of awareness of ergonomics for US-guided BoNT chemodenervation for spasticity may lead to suboptimal patient outcomes, increase work-related injuries, and patient discomfort. We propose key elements for optimal positioning of physicians and patients, as well as the optimal setup of the workspace and provide clinical pearls in visual identification of spastic muscles for chemodenervation.

The results of controlled investigations suggest that botulinumtoxin type A (BTA) leads to decrease headache intensity and prevent migraine attacks. The antinociceptive mechanisms of BTA action remain unclear. Modern and previous hypothesis of antinociceptive action BTA in chronic migraine (CM) are discussed in details. Recent experimental and clinical evidence strongly suggest that BTA has aspecific antinociceptive effect realized through inhibition of proinflammatory neurotransmitters release not only from the sensory terminals but from muscle nociceptors. The mechanism of the action of BTA in CM has more than one target and is considered to involve different pathophysiological levels CM: neurogenic inflammation, peripheral and central sensitization. The administration of BTA on the PREEMPT principle (paradigm) ensures optimal neurotoxin distribution in the anatomic areas in accordance with their sensory innervation by cervical segments and sensory fibers in the trigeminal system, the terminal branches which are the major target of BTA in the treatment of CM.

Introduction: Congenital unilateral lower lip palsy is an infrequently encountered condition that manifests as lower lip asymmetry during smiling, laughing, and crying. Treatment options are not well characterized. Methods: The authors present the case of a 51-year-old woman who was referred for surgical intervention for facial paralysis. Physical examination demonstrated a symmetric face at rest that became asymmetric when smiling. The asymmetry, evident by inappropriate inferior displacement of the lower lip, was secondary to unilateral contraction and presence of the depressor labii inferioris. The depressor anguli oris was symmetric bilaterally. Her presentation was consistent with congenital unilateral lower lip palsy. Results: Lidocaine was injected into the depressor labii inferioris on the side of the face that demonstrated unilateral presence and contraction. This resulted in symmetry of the smile and lower lip without untoward effect. Onabotulinum toxin A was thereafter injected into the depressor labii inferioris. In-office treatment with botulinum toxin injection resulted in a 4-month improvement in smile symmetry. Conclusion: Chemodenervation is a safe and minimally invasive method to improve smile symmetry and lower lip position in cases of congenital unilateral lower lip palsy. [ABSTRACT FROM AUTHOR]

Injections of botulinum neurotoxins (BoNTs) are prescribed by clinicians for a variety of disorders that cause over-activity of muscles; glands; pain and other structures. Accurately targeting the structure for injection is one of the principle goals when performing BoNTs procedures. Traditionally; injections have been guided by anatomic landmarks; palpation; range of motion; electromyography or electrical stimulation. Ultrasound (US) based imaging based guidance overcomes some of the limitations of traditional techniques. US and/or US combined with traditional guidance techniques is utilized and or recommended by many expert clinicians; authors and in practice guidelines by professional academies. This article reviews the advantages and disadvantages of available guidance techniques including US as well as technical aspects of US guidance and a focused literature review related to US guidance for chemodenervation procedures including BoNTs injection. [ABSTRACT FROM AUTHOR]

Selection of muscles for botulinum toxin injection for limb dystonia is particularly challenging. Limb dystonias vary more widely in the pattern of dystonic movement and involved muscles than cervical dystonia or blepharospasm. The large variation in how healthy individuals perform skilled hand movements, the large number of muscles in the hand and forearm, and the presence of compensatory actions in patients with dystonia add to the complexity of choosing muscles for injection. In this article, we discuss approaches to selecting upper and lower extremity muscles for chemodenervation treatment of limb dystonia. [ABSTRACT FROM AUTHOR]

Botulinum neurotoxin (BoNT) has existed for thousands of years; however, it was not medically utilized until investigations into its therapeutic use began in sincerity during the late 1970s and 1980s. This, coupled with the reclassification of spasmodic dysphonia as a focal dystonia, led to the use of chemodenervation for this disorder, which has since become a refined technique. Indeed, due to its safety and efficacy, BoNT has been investigated in multiple neurolaryngology disorders, including spasmodic dysphonia, vocal tremor, and muscle tension dysphonia. BoNT has been shown to be a useful and safe adjunct in the treatment for these disorders and may reduce or eliminate oral pharmacotherapy and/or prevent the need for a surgical intervention. We present the historical background, development, proposed mechanisms of action, uses, and techniques for administering BoNT for laryngeal disorders, with a particular focus on spasmodic dysphonia. [ABSTRACT FROM AUTHOR]

Background: Chemodenervation (CD) involves injecting drugs such as phenol, botulinum toxin, or alcohol to reduce muscle spasticity. However, they interfere with daily activities of children with cerebral palsy (CP). Rehabilitation residency training in Thailand currently requires performing a minimum of five CD procedures. However, the effect of this policy on post-training practice is unknown. Objective: To explore the influence of CD training during residency on post-training clinical practice and their current use of it in treating CP patients. Material and Method: The questionnaires were sent to 431 Thai physiatrists nationwide by both electronic and postal mails. The responses were collected within a three-month period. Results: Of 116 (27%) respondents with usable questionnaires, 85 (73%) were trained during their residency to perform CD and 46 (40%) performed it in their practice. Those trained to perform CD were more likely in their subsequent practice to do so (p = 0.0140), and younger age was associated with performing it (p = 0.0055). The number of CD procedures performed during residency correlated directly with reported confidence in performing the procedure in later practice (p<0.0001). The most common reasons for not performing CD were few CP cases in their care, and unavailable equipment or injection agent. Conclusion: Although only a cross-sectional study, the findings suggest that increasing the number of CD procedures required in rehabilitation residency may increase the use of CD to benefit CP patients in future clinical practice. [ABSTRACT FROM AUTHOR]