Impact of injection-guiding techniques on the effectiveness of botulinum toxin for the treatment of focal spasticity and dystonia: A systematic review

Abstract

To conduct a systematic review of the impact of different injection-guiding techniques on the effectiveness of BoNT-A for the treatment of focal spasticity and dystonia. Articles were identified through a comprehensive search of the following computerized databases: MEDLINE via Pubmed, Academic Search Premier, Pascal, the Cochrane Library, Scopus, SpringerLink, Web of Science, EM Premium and PsychINFO. Two reviewers (AG and MD) independently selected potential studies based on pre-determined inclusion criteria. The main data were extracted. Methodological quality was graded independently by 2 reviewers using the Physiotherapy Evidence Database (PEDro) assessment scale for randomized controlled trials (RCTs) and the Downs and Black (D&B) evaluation tool for non-RCTs. Level of evidence was determined using the modified Sackett scale. Ten studies were included. Seven were randomized. There was strong evidence (Level 1) that instrumented guiding (Ultrasound [US], Electrical-stimulation [ES], Electromyography [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. A few 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 evidence available for EMG or other instrumented techniques. These results strongly recommend the use of instrumented guiding techniques for 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 techniques.