Abstract
BackgroundIntramuscular injection of botulinum toxin type-A given by manual intramuscular needle placement in the lower extremity under general anaesthesia is an established treatment and standard of care in managing spasticity in children with spastic cerebral palsy. Optimal needle placement is essential. However, reports of injection and verification techniques used in previous studies have been partly incomplete and there are methodological shortcomings. This paper describes a detailed protocol for manual intramuscular needle placement checked by passive stretching and relaxing of the target muscle for each individual muscle injection location in the lower extremity during botulinum toxin type-A treatment under general anaesthesia in children with spastic cerebral palsy. It explains the design of a study to verify this protocol, which consists of an injection technique combined with a needle localizing technique, as by means of electrical stimulation to determine its precision.MethodsSetting: University Medical Centre, Department of Paediatric Rehabilitation Medicine, the Netherlands.Design: prospective observational study.Participants: children with spastic cerebral palsy, aged 4 to 18 years, receiving regular botulinum toxin type-A treatment under general anaesthesia to improve their mobility, are recruited from the Department of Paediatric Rehabilitation Medicine at VU University Medical Centre, Amsterdam, the Netherlands.Method: a detailed protocol for manual intramuscular needle placement checked by passive stretching and relaxing of the target muscle has been developed for each individual muscle injection location of the adductor brevis muscle, adductor longus muscle, gracilis muscle, semimembranosus muscle, semitendinosus muscle, biceps femoris muscle, rectus femoris muscle, gastrocnemius lateralis muscle, gastrocnemius medialis muscle and soleus muscle. This protocol will be verified as by means of electrical stimulation.Technical details: 25 mm or 50 mm Stimuplex-needle and a Stimuplex-HNS-12 electrical stimulator will be used.DiscussionBotulinum toxin type-A injected in the intended muscle is expected to yield the greatest effect in terms of activities. Protocols for manual intramuscular needle placement should be described in detail and verified to determine its precision. Detailed and verified protocols are essential to be able to interpret the results of botulinum toxin type-A treatment studies.
Highlights
Intramuscular injection of botulinum toxin type-A given by manual intramuscular needle placement in the lower extremity under general anaesthesia is an established treatment and standard of care in managing spasticity in children with spastic cerebral palsy
The present study describes a detailed protocol for manual intramuscular needle placement in the lower extremity checked by PSRM for each individual muscle injection location during botulinum toxin type-A treatment under general anaesthesia in children with spastic cerebral palsy
A detailed protocol for manual intramuscular needle placement checked by PSRM has been developed for each individual muscle and its injection locations of the adductor brevis muscle (ADB), adductor longus muscle (ADL), gracilis muscle (GR), semimembranosus muscle (SEM), semitendinosus muscle (SET), biceps femoris muscle (BF), rectus femoris muscle (RF), gastrocnemius lateralis muscle (GL), gastrocnemius medialis muscle (GM) and soleus muscle (SO)
Summary
A detailed protocol for manual intramuscular needle placement checked by PSRM has been developed for each individual muscle and its injection locations of the adductor brevis muscle (ADB), adductor longus muscle (ADL), gracilis muscle (GR), semimembranosus muscle (SEM), semitendinosus muscle (SET), biceps femoris muscle (BF), rectus femoris muscle (RF), gastrocnemius lateralis muscle (GL), gastrocnemius medialis muscle (GM) and soleus muscle (SO) (see Additional file 1) This protocol describes the origin, the insertion, the relationship to other structures, the innervation and function of the muscle. Participants Children with spastic cerebral palsy, aged 4 to 18 years, receiving regular BTX-A treatment under general anaesthesia to improve their mobility, will be recruited from the Department of Paediatric Rehabilitation Medicine, VU University Medical Centre, Amsterdam, the Netherlands. Exclusion criteria: 1. Risk > 2 of the American Society of Anesthesiologists (ASA) physical status classification system during anaesthesia
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