Ultrasound-guided injection of botulinum toxin in upper limb: Experience of PMR departement

Abstract

Spasticity of the upper limb is a disabling symptom in patients with vascular hemiplegia, both functionally and orthopedic evolution of these patients. Many treatments exist for spasticity, and botulinum toxin may be an attractive therapeutic alternative, to fight against the often deleterious spasticity. We report a retrospective work of 10 spastic patients treated with ultrasound-guided injection of botulinum toxin into the MPR Casablanca service. Evaluation: before, one month and three months after injection. Evaluation methods: spasticity quantified by the modified Aschwort scale. Analytical assessment (voluntary control, joint assessment, pain related to spasticity) and functional (MIF Barthel, Enjalbert…) of the upper limb interested. The initial score of spasticity was 3 in most observations, voluntary control was rated at 3 in 50% of cases. The ultrasound-guided injection was less painful for our patients that the injection by electrostimulation. After a month of the injection, there was a net decrease of spasticity with parallel improvement of functional parameters. At three months, spasticity has increased by one point in nearly half. Due to its considerable cost, only one patient has benefited from a toxin reinjection 3 months later. Several studies have shown the benefit of treatment with botulinum toxin in the treatment of spasticity in the upper limb and its functional implications. Our results confirm those of the literature, however, the sample size is very small because of the product cost, which is not yet covered by social security funds in Morocco. Botulinum toxin has an interest in spastic upper limb in the patient with vascular hemiplegia and its use should be part of a multidisciplinary approach. Four directions can be used: functional (recover gestures and encourage remaining possibilities to grip), analgesic (limit spontaneous pain during care nursing and during physical therapy), aesthetics (open hand) and hygienic (easy nursing care, and facilitate the establishment of an orthosis). The indication of botulinum toxin must meet specific, customized and realistic targets after analytical and functional assessment of patients. The use of botulinum toxin must be part of a multidisciplinary management and cannot be conceived in isolation.