Intramuscular Injection Of Botulinum Toxin Research Articles

Bilateral hand dystonia following high-velocity thrust manipulation: a case report.

Thrust manipulation is one of the most commonly used techniques for managing musculoskeletal pain in clinical practice. This involves the application of a high-velocity, low-amplitude force directed to the joints with the intent of achieving joint cavitation. This current case report describes a female in her mid-20s who presented with excessive bilateral and involuntary hand muscle contractions after bilateral thrust manipulation. Dystonia appeared both at rest and during voluntary movements but was aggravated by actions such as finger flexion or spreading and disappeared during sleep. A diagnosis of complex regional pain syndrome (CRPS) type I combined with dystonia was made. Prednisolone administered between 2 and 5 weeks after symptom onset significantly reduced CRPS symptoms, but intramuscular botulinum toxin injection 5 weeks after symptom onset was ineffective at controlling her symptoms. Seven weeks after symptom onset, the patient was administered 2 mg trihexyphenidyl oral twice a day, 2.5 mg diazepam oral twice a day and 5 mg baclofen oral three times a day for 1 month and this significantly reduced dystonia, but complete resolution was not achieved. Clinicians should be aware that dystonia is a rare complication of thrust manipulation.

172 - Selective Bladder Denervation with Radiofrequency Ablation vs Intramuscular Botulinum Toxin Injection in Patients with Refractory Overactive Bladder: A Preliminary Report of Prospective Randomized Comparative Study

172 - Selective Bladder Denervation with Radiofrequency Ablation vs Intramuscular Botulinum Toxin Injection in Patients with Refractory Overactive Bladder: A Preliminary Report of Prospective Randomized Comparative Study

Thoracic Outlet Syndrome.

Thoracic outlet syndrome is a complex syndrome that manifests with symptoms based on the presumed injury or impairment of the neurovascular structures in the thoracic outlet space with its intricate anatomy and pathophysiology. The thoracic outlet is a specific anatomical region with three distinct anatomical spaces - interscalene triangle, the costoclavicular space, and the retro-pectoralis minor space. Thoracic outlet syndrome is classified into neurogenic, venous, and arterial thoracic outlet syndrome and often poses diagnostic challenge to implicate a specific condition or cause. Many cases of thoracic outlet syndrome can be effectively managed through conservative measures, but patients with refractory symptoms may warrant surgical intervention. Modalities such as intramuscular anesthetic and botulinum toxin injections hold promise as diagnostic, therapeutic, and prognostic procedures. Further research and collaboration are needed to develop algorithms for diagnosis and treatment of thoracic outlet syndrome symptoms. This review aims to explore our understanding of thoracic outlet syndrome, with a focus on current evidence and emerging trends.

Intramuscular Botulinum Toxin as an Adjunct to Arthrocentesis with Viscosupplementation in Temporomandibular Disorders: A Proof-of-Concept Case-Control Investigation.

The reduction in joint load is a potential beneficial factor in managing osteoarthritis of the temporomandibular joint (TMJ). This paper aims to compare the effectiveness of the intramuscular injection of botulinum toxin (BTX-A) as an adjunct to TMJ arthrocentesis plus viscosupplementation with arthrocentesis plus viscosupplementation alone in the management of TMJ osteoarthritis. A pilot clinical retrospective study examined TMJ osteoarthritis treatments. Patients were divided into two groups: Group A received BTX-A injections and arthrocentesis with viscosupplementation, while Group B received only arthrocentesis with viscosupplementation. The study assessed outcomes based on mouth opening (MO), pain at rest (PR), pain at mastication (PF), and masticatory efficiency (ME) at various time points (baseline (T0), 1 week (T1), 2 weeks (T2), 3 weeks (T3), and 4 weeks (T4)) up to 2 months after treatment. The study included two groups, each with five patients. Group A received five weekly sessions of arthrocentesis plus viscosupplementation and a single BTX-A injection during the first arthrocentesis appointment. Group B underwent the five-session protocol of arthrocentesis plus viscosupplementation alone. MO, PF, PR, and ME improved quickly in T2 in both groups, but the improvement was of greater importance over the following weeks and lasted longer in Group A. Arthrocentesis with viscosupplementation associated with BTX-A was found to be more effective than arthrocentesis alone in improving clinical outcomes. This suggests that patients with TMJ osteoarthritis and myofascial pain may benefit from reduced muscle tone and joint load.

Does botulinum toxin affect psycho-social aspects in dystonia?

Dystonia is a movement disorder in which sustained muscle contractions give rise to abnormal postures or involuntary movements. It is a disabling and disfiguring disorder that affects activities of daily living and gives people a bizarre appearance often associated with psychological morbidity, embarrassment and social avoidance. Intramuscular injection of botulinum toxin (BoNT) is the most effective treatment for motor symptoms in focal dystonia, but little is known about its impact on the psycho-social dimension. The main aim of this study was to evaluate psycho-social changes in patients with focal dystonia after starting BoNT treatment using self-reported scales. The Beck Depression Inventory (BDI-II), the 36-Item Short Form Health Survey (SF-36), the Body Uneasiness Test (BUT), the State-Trait Anxiety Inventory (STAI) and the Visual Analogue Scale (VAS) assessing body self-image, satisfaction with physical aspects, social avoidance, self-reported depression, and self-distress were completed by 11 patients with dystonia and 9 patients with hyperhidrosis as a control group before BoNT (T0). VAS was then performed after four weeks (T1) to assess whether BoNT induced changes in the psychosocial dimension. Our results showed that only depressive symptoms and rumination about body defects improved in patients with dystonia after BoNT treatment, while improvement in self-distress and satisfaction with physical aspects was also found in hyperhidrosis. Individuals with hyperhidrosis experience poorer psychological well-being and suffer from higher levels of distress compared to dystonic patients. This suggests that individuals with this disabling condition are more vulnerable to social impact than dystonic patients.

Intramuscular injections of botulinum toxin for the treatment of upper back myofascial pain syndrome: A systematic review of randomized controlled trials

Intramuscular injections of botulinum toxin for the treatment of upper back myofascial pain syndrome: A systematic review of randomized controlled trials

Parietal abdominal pain with lower leg discrepancy: a case report

BackgroundThis report involves the first publication describing a case of parietal abdominal pain due to lower limb length discrepancy.Case presentationA Caucasian male patient in his 50s was referred to our rehabilitation department with chronic abdominal pain that began in childhood. This chronic pain was associated with episodes of acute pain that were partially relieved by grade 3 analgesics. The patient was unable to sit for long periods, had recently lost his job, and was unable to participate in recreational activities with his children. Investigations revealed contracture and hypertrophy of the external oblique muscle and an limb length discrepancy of 3.8 cm (1.5 inches) in the left lower limb. The patient was effectively treated with a heel raise, physiotherapy, intramuscular injection of botulinum toxin, and lidocaine. The patient achieved the therapeutic goals of returning to work, and reducing analgesic use.ConclusionsStructural misbalances, as may be caused by lower leg discrepancy, may trigger muscular compensations and pain. Complete anamnesis and clinical examination must not be trivialized and may reveal previously ignored information leading to a proper diagnosis.

Comparison of Wrinkle Patterns Generated by Intradermal and Intramuscular Botulinum Toxin Injections by Clinical Evaluation.

Botulinum toxin has played a remarkable role in management of forehead wrinkles. Most used is intramuscular technique due to its deposition into the muscles, however, with adverse effects like brow ptosis. This study has been designed for the evaluation of efficacy for intradermal v/s intramuscular route of botulinum toxin injections for forehead wrinkles using clinical correlation. This study included a clinical trial of 32 facial halves divided equally into intradermal and intramuscular injection technique groups, receiving total dose of 8 U. Results were assessed by clinical examination upto 2weeks and 4weeks with parameters; objective wrinkle rate, eyebrow height, eyebrow movement, pain, and satisfaction after treatment. Results showed least mean for objective wrinkle rate in intramuscular group, showing statistically significant improvement. Overall improvement in eyebrow height and eyebrow movement were slightly more for intramuscular group. Pain was lesser for intradermal group, whereas satisfaction of patient of patient post treatment is similar for both the groups. Among intradermal and intramuscular botulinum toxin injection technique, the effect and potency were better for intramuscular technique, whereas the patient comfort and compliance were better for intradermal technique.

Cutaneous Allergic Reaction to Intramuscular Botulinum Toxin Injection for Spasticity – A Case Report

Cutaneous Allergic Reaction to Intramuscular Botulinum Toxin Injection for Spasticity – A Case Report

Localisation of the centre of the highest region of muscle spindle abundance of anterior forearm muscles.

The centre of the highest region of muscle spindle abundance (CHRMSA) in the intramuscular nerve-dense region has been suggested as the optimal target location for injecting botulinum toxin A to block muscle spasms. The anterior forearm muscles have a high incidence of spasticity. However, the CHRMSA in the intramuscular nerve-dense region of the forearm anterior muscle group has not been defined. This study aimed to accurately define the body surface position and the depth of CHRMSA in an intramuscular nerve-dense region of the anterior forearm muscles. Twenty-four adult cadavers (57.7 ± 11.5 years) were included in this study. The curved line close to the skin connecting the medial and lateral epicondyles of the humerus was designated as the horizontal reference line (H line), and the line connecting the medial epicondyle of the humerus and the ulnar styloid was defined as the longitudinal reference line (L line). Modified Sihler's staining, haematoxylin-eosin staining and computed tomography scanning were employed to determine the projection points (P and P') of the CHRMSAs on the anterior and posterior surfaces of the forearm. The positions (PH and PL) of point P projected onto the H and L lines, and the depth of each CHRMSA, were determined using the Syngo system. The PH of the CHRMSA of the ulnar head of pronator teres, humeral head of pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, ulnar part of flexor digitorum superficialis, radial part of flexor digitorum superficialis, flexor pollicis longus, ulnar part of flexor digitorum profundus, radial portion of flexor digitorum profundus and pronator quadratus muscles were located at 42.48%, 45.52%, 41.20%, 19.70%, 7.77%, 25.65%, 47.42%, 53.47%, 12.28%, 38.41% and 51.68% of the H line, respectively; the PL were located at 18.38%, 12.54%, 28.83%, 13.43%, 17.65%, 32.76%, 57.32%, 64.12%, 20.05%, 45.94% and 88.71% of the L line, respectively; the puncture depths were located at 21.92%, 27.25%, 23.76%, 18.04%, 15.49%, 31.36%, 26.59%, 41.28%, 38.72%, 45.14% and 53.58% of the PP' line, respectively. The percentage values are the means of individual values. We recommend that the body surface puncture position and depth of the CHRMSA are the preferred locations for the intramuscular injection of botulinum toxin A to block anterior forearm muscle spasms.

Virtual Reality for Decreasing Procedural Pain during Botulinum Toxin Injection Related to Spasticity Treatment in Adults: A Pilot Study.

Botulinum toxin injections are commonly used for the treatment of spasticity. However, injection procedures are associated with pain and procedural anxiety. While pharmacological approaches are commonly used to reduce these, innovative technology might be considered as a potential non-pharmacological alternative. Given this context, immersive virtual reality (VR) has shown effectiveness in the management of procedural pain. Our retrospective pilot study aimed to assess the potential added value of virtual reality in the management of pain and anxiety during intramuscular injections of botulinum toxin. Seventeen adult patients receiving botulinum toxin injections were included. A numerical rating scale was used to assess pain and anxiety during the injection procedure. The patients reported the pain experienced during previous injections without VR before injection and the pain experienced in the current procedure with VR after the end of the procedure. The level of satisfaction of VR experience, whether or not they agreed to reuse VR for the subsequent toxin botulinum injection, and whether or not they would recommend VR to other patients were assessed. The use of virtual reality led to a decrease of 1.8 pain-related points compared to the procedure without technology. No significant improvement in the level of anxiety was reported. Patients were very satisfied with their VR experiences (7.9 out of 10), and many would agree to reuse VR in their next injection procedure (88%) and to recommend the use of VR in other patients (100%). VR was useful for managing procedural pain related to botulinum toxin injection in adults, with a high level of satisfaction reported by the patients. VR should be considered as a valuable alternative to pharmacological approaches to manage procedural pain during botulinum toxin injection in adults.

An analysis of the efficacy of botulinum neurotoxin type a in treating cervical dystonia.

The first-line treatment for cervical dystonia (CD) consists of repeated intramuscular injections of botulinum toxin (BoNT). However, the efficacy in some patients may be unsatisfactory and they may discontinue treatment. To examine the factors associated with the maximum rate of remission in patients with CD after initial botulinum neurotoxin type A (or botulinum toxin type A abbreviated as BTX-A or BoNT-A) treatment. Patients with CD who received BoNT-A injections were evaluated using the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) and the Tsui scale, with follow-up endpoints lasting until the start of the second injection. Patients who did not receive a second injection of BoNT-A were followed up for at least 5 months. The maximum remission rates were determined using the lowest Tsui and TWSTRS total scores during the follow-up period. We obtained basic information about these patients such as age, gender, duration of disease, presence of additional disease, types of torticollis, presence of anxiety, depression, tremors, single-photon emission computed tomography (SPECT) findings, injected dose, and so on from their medical records. A total of 70 patients with CD participated in this study, with males comprising 35.7% (25 individuals) with an average age of 45 ± 14 years old. The duration of disease was an independent risk factor for determining whether a complete remission has been attained using the Tsui scale (odds ratio [OR] = 0.978, 95% confidence interval [CI]: 0.959-0.997, P= 0.026). The optimal cut-off point for predicting patients who were unable to achieve complete remission based on duration of disease was 7.5 months (AUG = 0.711). Patients with CD with additional disease had greater difficulty achieving complete remission than those with CD alone based on TWSTRS assessments (P= 0.049). During the study, approximately 17% of all participants reported experiencing adverse reactions that lasted between 1 to 3 weeks before disappearing. BoNT is an effective and safe method for treating CD. The maximum remission rates of patients after their first injections are influenced by the duration of their disease. Thus, treatment using BoNT injections must be administered as soon as possible.

Post-Stroke Spastic Movement Disorder and Botulinum Toxin A Therapy: Early Detection And Early Injection.

Post-stroke spastic movement disorder (PS-SMD) develops in up to 40% of stroke survivors after a first ever stroke within the first year. Chronic PS-SMD is often associated with severe disabilities and complications, emphasizing the importance of its early recognition and early adequate management. Extensive research has aimed to accurately predict and sensitively detect a PS-SMD. Symptomatic therapies include conventional rehabilitation and local intramuscular injections of botulinum toxin A (BoNT-A). The latter is widely used, but primarily in the chronic phase of stroke. However, recent studies have shown the safety and efficacy of BoNT-A therapy even in the acute phase and early sub-acute phase after stroke, i.e., within three months post-stroke, leading to an improved long-term outcome in stroke rehabilitation. Local BoNT-A injections evolve as the primary approach in focal, multifocal, and segmental chronic or acute/subacute PS-SMD. Patients at high risk for or manifest PS-SMD should be identified by an early spasticity risk assessment. By doing so, PS-SMD can be integral part of the patient-centered goal-setting process of a multiprofessional spasticity-experienced team. The benefit of an early PS-SMD treatment by BoNT-A should predominate putative degenerative muscle changes due to long-term BoNT-A therapy by far. This, as early treatment effectively avoids complications typically associated with a PS-SMD, i.e., contractures, pain, skin lesions. The management of PS-SMD requires a comprehensive and multidisciplinary approach. Early assessment, patient-centered goal setting, early intervention, and early use of BoNT-A therapy prevents from PS-SMD complications and may improve rehabilitation outcome after stroke.

Wide range applications of botulinum toxin in medicine - literature review

Introduction and purpose : Botulinum toxin is one of the most dangerous natural toxins. Botulinum toxin poisoning causes botulism. Botulism is a set of systemic symptoms resulting from flaccid muscle paralysis. The first symptomatology of toxin poisoning was described at the beginning of the 19th century. After more than 200 years, botulinum toxin is associated primarily with aesthetic medicine treatments, where it is used to temporarily improve the appearance, mainly by reducing mimic wrinkles. Aim of the study: The aim of the study is to collect information available in PubMed, Google Scholar, academic textbooks and characteristics of botulinum toxin medicinal products, especially regarding its wide use, mechanism of action, adverse events and contraindications. As a result, the presentation of the versatile use of botulinum toxin as a medicinal product in many fields of medicine. Brief description of the state of knowledge: Botulinum toxin is produced by the anaerobic bacteria Clostridium botulinum. Its mechanism of action consists in flaccid muscle paralysis. Most preparations with botulinum toxin are only registered for strictly defined aesthetic medicine treatments. Other registered indications for the use of medicinal products with botulinum toxin include overactive bladder, various types of spasticity and prevention of headaches. In addition, in medicine, botulinum toxin is commonly used off-label. Summary: Botulinum toxin is widely used not only in aesthetic medicine. Intramuscular injections of botulinum toxin are successfully used in various fields of medicine, such as: urology, neurology, ophthalmology, gastroenterology, dermatology, gynecology, otolaryngology, dentistry and even psychiatry.

Double vision due to lateral rectus injury after cosmetic botulinum toxin injections.

Facial intramuscular injections of Botulinum toxin (BoNT) injections are among the most common cosmetic procedures in dermatology. Rarely, serious adverse reactions such as blepharoptosis, diplopia and periorbital hematoma may occur with improper administration technique. Here we report a case of painless diplopia 5 weeks post-BoNT injection for 'crow's feet' likely due to inadvertent BoNT diffusion into the lateral rectus muscle causing a temporary palsy. This case aims to raise awareness of proper cosmetic BoNT injection techniques in the periorbital area to avoid ophthalmic complications.

Comparison of Two Versus Three Bilateral Botulinum Toxin Injections Prior to Abdominal Wall Reconstruction.

Background: Intramuscular injection of botulinum toxin A (BTA) induces a temporary muscle paralysis. In patients with a ventral hernia, preoperative injection of BTA in the muscles of the lateral abdominal wall (LAW) leads to thinning and lengthening of these muscles, making fascial closure more likely. In many hernia centres, treatment with BTA prior to abdominal wall reconstruction has therefore become standard care. However, evidence on the optimal BTA strategy is lacking. Methods: In this single-centre retrospective study, we analysed a consecutive cohort of ventral hernia patients that underwent bilateral BTA injections prior to abdominal wall reconstruction with available CT before and after BTA. We only included patients that were treated with exactly 600 units of Dysport®, diluted into 120mL of saline, via either two- or three injections on each side into all three LAW muscle layers. The primary outcome was the change in LAW muscle length and thickness, comparing CT measures from before BTA and 4-6weeks after the injections. Results: We analysed 67 patients; 30 had received two injections bilaterally and 37 had received three injections bilaterally. Baseline data showed no significant differences in LAW muscle thickness or length between groups. In both groups, the median LAW muscle thickness decreased with 0.5cm (p < 0.001). The LAW muscle length increased with 0.9cm (p = 0.001) and 1.2cm (p < 0.001) in the two- and three bilateral injection group, respectively. The BTA-induced changes in LAW thickness and length were not significantly different between both groups (p = 0.809 and p = 0.654, respectively). Discussion: When using the exact same dosage and distribution volume of BTA in patients with a complex abdominal wall defect, two injections bilaterally in the lateral abdominal wall muscles are as effective as three injections bilaterally.

Optimizing the results of facial animation surgery: Botulinum toxin injection into free functional gracilis flap transfer

Although neuromuscular gracilis transplantation is the best choice for facial reanimation in patients with congenital or inveterate palsy, the results are not completely satisfactory. Ancillary procedures developed to achieve better symmetry of the smile and reduce the hypercontractility of the transplanted muscle have been reported. However, the intramuscular injection of botulinum toxin has not been described for this purpose. Patients undergoing gracilis injections of botulinum toxin after facial reanimation surgery between September 1, 2020, and June 1, 2022, were retrospectively enrolled in this study. We collected photographs taken before and 20-30 days after injection and compared the symmetry of the face using software. Nine patients with a mean age of 23.56 years (range, 7-56 years) were enrolled. Reinnervation of the muscle was provided by the contralateral healthy facial nerve via a sural cross-graft (four patients), by the ipsilateral masseteric nerve (three cases), and by the contralateral masseteric and facial nerve (two). Using Emotrics software, we identified differences in the commissure excursion discrepancy of 3.82mm, the smile angle discrepancy of 0.084°, and the dental show discrepancy of 1.49mm; the average difference in the commissure height deviation was 2.26mm (P=0.02), and those in the upper- and lower-lip height deviation were 1.05mm and 1.49mm, respectively. Gracilis injection of botulinum toxin after gracilis transplantation is a safe and feasible procedure that could be applicable to all patients with asymmetric smiles related to excessive transplant contraction. It yields good esthetic results with little to no related morbidity.

Plant Toxins as Potential Alternatives to Botulinum Toxin for Eye-Movement Disorder Therapy

The most successful alternative to traditional surgery for ocular muscle spasm treatment is the intramuscular injection of botulinum toxin (BTX), which allows the maintenance of the muscle dynamics and the absence of scars. However, the main BTX disadvantage is its nonpermanent effect. A possible way for overcoming this obstacle could be represented by the enzymatic surgery using plant toxins known as ribosome-inactivating proteins (RIPs). In this paper, two highly toxic RIPs, namely, ricin and stenodactylin, were considered in a preliminary study for their possible use in the treatment of strabismus and oculofacial dystonias, as alternatives to BTX. Both RIPs showed a strong cytotoxic effect against rhabdomyosarcoma cell lines and myotube differentiated cells, with stenodactylin being about 10-fold more toxic than ricin. Moreover, stenodactylin showed a much higher cytotoxicity on myoblasts than on rhabdomyosarcoma cells. In our experimental conditions, stenodactylin did not damage conjunctival cells. Despite the limitations due to in vitro experiments, our data show that the high cytotoxicity of stenodactylin allows the use of a very low dose and, consequently, of very low injection volumes. This can represent a great advantage in the case of in vivo locoregional treatment. Furthermore, it is possible to modulate the chemoablation of myocytes while destroying myoblasts, thus reducing regenerative phenomena. The risk of cytotoxicity to surrounding tissues would be strongly reduced by the low injected volume and the relative resistance of conjunctival cells. In conclusion, our data suggest that stenodactylin and ricin could represent potential candidates to substitute BTX in ocular dystonia therapy.

Preliminary Findings of the Efficacy of Botulinum Toxin in Temporomandibular Disorders: Uncontrolled Pilot Study

Temporomandibular disorders are a common pathology affecting up to 70% of the population, with a maximum incidence in young patients. We used a sample of twenty patients recruited in the Maxillofacial Surgery Service of the University Hospital of Salamanca (Spain), who met the inclusion criteria, with unilateral painful symptomatology of more than three months' duration. All patients were randomly treated by intramuscular and intra-articular injections of botulinum toxin (100 U) in eight predetermined points. Pain symptomatology was assessed by the visual analog scale (VAS) at the different locations, together with joint symptomatology, at baseline and six weeks after treatment. Adverse effects were also evaluated. In 85% of the patients, pain upon oral opening improved and 90% showed improvement in pain upon mastication. A total of 75% of the patients reported improvement in joint clicking/noise. Headaches improved or disappeared in 70% of the patients treated. Despite the limitations of the study and the preliminary results, intramuscular and intra-articular infiltrations with botulinum toxin were effective in the treatment of symptoms associated with temporomandibular disorders (TMDs), with minimal adverse effects.

Canadian Physicians' Use of Intramuscular Botulinum Toxin Injections for Shoulder Spasticity: A National Cross-Sectional Survey.

Spasticity of the upper extremity can result in severe pain, along with many complications that can impair a patient's activities of daily living. Failure to treat patients with spasticity of the upper limb can result in a decrease in the range of motion of joints and contracture development, leading to further restriction in daily activities. We aimed to investigate the practice patterns of Canadian physicians who utilize Botulinum toxin type-A (BoNT-A) injections in the management of shoulder spasticity. 50 Canadian Physical Medicine and Rehabilitation (PM&R) physicians completed a survey with an estimated completion rate of (36.23%). The demographics of the survey participants came from a variety of provinces, clinical settings, and patient populations. The most common muscle injected for shoulder adduction and internal rotation spasticity was the pectoralis major, this was followed by latissimus dorsi, pectoralis minor, subscapularis and teres major. Injection of BoNT-A for problematic post-stroke shoulder spasticity was common, with (81.48%) of participants responding that it was always or often used in their management of post-stroke spasticity (PSS). Dosing of BoNT-A demonstrated variability for the muscle injected as well as the type of toxin used. The goals of the patients, caregivers, and practitioners were used to help guide the management of these patients. As a result, the practice patterns of Canadian physicians who treat shoulder spasticity are varied, due to numerous patient factors. Future studies are needed to analyze optimal treatment patterns, and the development of algorithms to standardize care.