Received Botulinum Toxin A Injections Research Articles

The Impact of Botulinum Toxin Combined with Robot-Assisted Gait Training on Spasticity and Gross Motor Function on Children with Spastic Cerebral Palsy

ABSTRACT Objective To evaluate the impact of combining botulinum toxin-A (BoNT-A) injection with robot-assisted gait training (RAGT) on lower limb spasticity and motor function in children with cerebral palsy. Methods A prospective study was conducted from January 2020 to January 2023, including 68 patients. Twenty patients received the combination of BoNT-A injection and RAGT, while 48 received BoNT-A injection alone. Assessments were performed before the intervention and at 1, 3, and 6 months post-injection using the Modified Tardieu Scale (MTS), sections D and E of the Gross Motor Function Measure-88 (GMFM-88), 6-minute walk test (6MWT), and 10-meter walk test (10MWT). Results Compared to the control group receiving BoNT-A alone, the combination of BoNT-A and RAGT did not significantly improve spasticity-related outcomes, including MTS scores, R1, and R2 angles (p > .05). However, the combination group demonstrated significantly improved gross motor function, particularly in walking, running (GMFM-E), short-term walking endurance (6MWT), and walking speed (10MWT) in children with cerebral palsy after the intervention (p < .05). Conclusion While the addition of RAGT did not enhance the anti-spasticity effects of BoNT-A, it significantly improved gross motor function and walking abilities in children with cerebral palsy.

Effect of Botulinum Toxin Type-A on Improvement of Muscle Function of Lower Limb in Children with Spastic Cerebral Palsy

Background: Spasticity significantly contributes to the functional and postural impairments in children with cerebral palsy (CP), leading to limitations in daily independence, participation, and quality of life. Botulinum Toxin-A (BTX-A) is recognized as an effective treatment for improving outcomes related to spasticity in individuals with CP. Objectives: This study aimed to evaluate the impact of BTX-A treatment on lower limb muscle function in children with spastic CP who were unable to complete physiotherapy sessions due to muscle spasms. Methods: This cross-sectional study reviewed the medical records of 24 children with CP (14 boys, 10 girls; average age: 4.50 ± 2.70 years) who had received BTX-A injections. We recorded demographic characteristics, types of muscle dysfunction, and the number of muscles involved. BTX-A injections were administered at a dosage of 5 units/kg across multiple sites. The severity of spasticity (measured using the Ashworth scale) and motor performance (assessed by the ability to walk and stand) were evaluated 30 days after the BTX-A injection. Satisfaction levels of surgeons, physiotherapists, and parents, along with final functional outcomes, were also gathered. Data analysis was performed using SPSS. Results: The most common movement disorders observed were equinus, knee flexion, and adduction. The median score on the Ashworth scale significantly decreased (P &lt; 0.001) following BTX-A injection. There was a notable improvement in walking and standing performance (P &lt; 0.05), particularly among boys aged 3 years or younger (P &lt; 0.05). Most cases showed satisfactory outcomes 30 days after BTX-A injection. Significant enhancements in the functional outcomes of children with CP were noted after a 30-day follow-up, with no significant differences related to gender, age, or the muscles involved (P &gt; 0.05). Conclusions: The findings suggest a substantial reduction in spasticity and enhancement of functional outcomes in children with cerebral palsy after BTX-A injections. This improvement was especially evident in boys and younger children with fewer muscles involved, accompanied by notably satisfactory outcomes.

Botulinum Toxin Injection into the Digastric Muscle: Current Clinical Use and a Report of Five Cases.

The present research aimed to review the clinical applications of botulinum toxin-A (BTX-A) injection into the anterior belly of the digastric muscle (ABDM) and to highlight the potential role of the BTX-A injection into ABDM in preventing postsurgical relapse. Five Class II malocclusion patients who underwent orthognathic surgery received BTX-A injections into both ABDM for the prevention of postoperative relapse. The relapse was evaluated using lateral cephalometric radiographs by comparing the postoperative cephalometric analyses at two different time points, postoperatively at 2 weeks (T1), and long-term, at 9 months after the surgical intervention (T2). The results demonstrated no significant differences between T2 and T1 for the Selle-Nasion-point A (SNA) angle, Selle-Nasion-point B (SNB) angle, point A-Nasion-point B (ANB) angle, mandibular length, and sagittal mandibular position. The patients exhibited stable occlusion without any signs of relapse after the surgery. A single BTX-A injection into the ABDM can effectively prevent postoperative relapse in Class II malocclusion patients, following orthognathic surgery. From a clinical perspective, in case of optimal dosage and procedure, BTX-A injection could be considered as the primary option for the prevention of postsurgical relapse for Class II malocclusion patients.

Successful Multimodal Approach to Megacolon, Enterocutaneous Fistula, and Chronic Incisional Hernia with Loss of Domain: A Case Report

Our case highlights a 41-year-old male with a past medical history of severe diverticular disease since age 30, diabetes mellitus type 2, hypertension, protein calorie malnourishment, and body mass index of 50 kg/m2 who presented for a large bowel obstruction. Active surgical issues included: chronic incisional hernia, enterocutaneous fistulae, and a megacolon secondary to a recto-sigmoid anastomotic stricture. In collaboration with a colorectal surgeon and by using a multimodal approach, we successfully addressed the patient’s gastrointestinal issues and incisional hernia. The multimodal approach included botulinum toxin A (BTA) injections to the abdominal wall flat muscles (external oblique, internal oblique, and transverse abdominus), installation of an abdominal reapproximation anchor (ABRA) dynamic tissue system (DTS), and porcine urinary bladder matrix (PUBM) xenografts. The patient received BTA injections prior to the index operation, which lasted over 12 hours. The ABRA DTS assisted in achieving primary fascial closures. Definitive closure of this class 4 wound was facilitated by the antimicrobial and accelerated wound healing properties of PUBM as well as a unique multimodal approach to achieve exemplary results in a patient with multiple complex surgical issues.

Improvement in health-related quality of life with Botulinum toxin A injection in acquired superior oblique palsy.

This study aimed to investigate the outcomes of Botulinum toxin A (BTA) injection into the inferior oblique (IO) muscle for the management of unilateral acute acquired superior oblique palsy (SOP) and to evaluate changes in health-related quality of life post-injection using the Adult Strabismus-20 (AS-20) questionnaire. A prospective cohort study was performed in patients with unilateral acute acquired SOP who received BTA injections. Four units of BTA were injected into the ipsilateral IO muscle. Ocular examinations were performed pre-and post-injection, including alignment, ocular movement, and cyclotorsion deviation. The patients' AS-20 questionnaire scores were analyzed. A total of 21 patients with acute acquired SOP were included. The initial median vertical deviation was 5 PD (range 1-16), which was improved to 0 PD (range 0-10) at both 1 and 6 months post-injection (p < 0.001 and p < 0.001, respectively). The median torsional deviation was 7° (range 2-18) at baseline and resolved to 0 degrees (range -3-5) at the 1-month and 0° (range -2-7) at the 6-month follow-up (p < 0.001 and p < 0.001, respectively). There were significant increases in the overall score (OAS), psychosocial subscale score (PSS), and functional subscale score (FSS) from baseline values at both the 1-month (p < 0.001, p < 0.001, and p = 0.001, respectively) and 6-month follow-up (all p < 0.001). Injecting BTA into the ipsilateral IO muscle successfully resolved vertical and torsional deviations and significantly improved quality-of-life scores. Our findings show that BTA treatment, as an early treatment for acute acquired SOP, can help patients by significantly improving their quality of life.

Intragastric injection botulinum toxin A for obesity management with or without liraglutide.

Obesity is a global public health problem with rapidly increasing prevalence in many countries, including Turkey, and different treatment modalities have been used. This study aimed to compare the effect of intragastric botulinum toxin A (BTA) injection and BTA injection combined with low-dose liraglutide in patients with obesity. Records of 701 patients (female/male, 660:41; mean age, 45.6 ± 6.2 years) who received an intragastric injection of BTA for weight loss between November 2019 and May 2020 were reviewed retrospectively. The patients were divided into the BTA group, which included patients who received BTA injection alone, and BTA + liraglutide, which included those who used liraglutide after BTA injection. The demographic characteristics and comorbid diseases of the patients and follow-up results 6 months after the procedure were evaluated. In the comparison of the 3-month and 6-month weights of the patients, weight measurements were significantly lower in the BTA + liraglutide group than in the BTA group (p < 0.001 and p < 0.001, respectively). Adverse effects were observed in 212 (30.2%) of the study participants, of which 25% were observed in the BTA group and 31.8% in the BTA + liraglutide group, with no significant difference. The intragastric injection of BTA combined with liraglutide is a safe method that provides more effective weight loss than BTA alone, which is minimally invasive without any serious adverse effects.

Intravesical Botulinum toxin-A injection in pediatric overactive neurogenic bladder with Detrusor overactivity: Radiologic and clinical outcomes.

The neurogenic bladder is one of the most serious and painful disorders seen in pediatric urology clinics. The upper urinary tract can be impaired by increased bladder pressure. Botulinum toxin-A (BTX-A) is one of the new therapeutic interventions for this disease. Thus, this research was designed to determine the clinical as well as radiological outcomes intravesical BTX-A injections in patients with overactive neurogenic bladder with Detrusor over activity. From March 2012 to March 2019, this cohort study was conducted at Shahid Labbafinejad hospital in Tehran, Iran. Thirty-five pediatric patients with a neurogenic bladder and Detrusor overactivity who fulfilled the eligibility criteria received BTX-A injections. Demographic data, including spinal cord lesions or congenital malformations, upper and lower urinary tract nuclear scans, evidence of vesicoureteral reflux (VUR) and its severity, and hydronephrosis and 72 h voiding diary before and after intervention were all recorded. The mean ± standard deviation age of participants was 9.47 ± 4.61 years. After injection, nocturia and urination frequency as general symptoms of the overactive neurogenic bladder improved (p < 0.05). Also, the severity of hydronephrosis was decreased in 33% of patients following injection. In our study, 32 out of 35 patients had vesicoureteral reflux. Of those, there was complete resolution and downgrading of VUR in 17 (53.12%) and 13 (40.62%) respectively. In the evaluation of voiding cystourethrography (VCUG) before and after the injection, downgrading of VUR was seen in 53% of the cases. In the 99mTc-DMSA nuclear scan before and after the injection, the appearance of a new parenchymal scar and uptake reduction was not observed, which indicates the cessation of scar formation in all patients. Although Enuresis, Urgency, Frequency, Nocturia, and UUI significantly improved after injection.

A Pilot Randomized Controlled Trial of Botulinum Toxin Treatment Combined with Robot-Assisted Therapy, Mirror Therapy, or Active Control Treatment in Patients with Spasticity Following Stroke.

Effects of the combined task-oriented trainings with botulinum toxin A (BoNT-A) injection on improving motor functions and reducing spasticity remains unclear. This study aims to investigate effects of 3 task-oriented trainings (robot-assisted therapy (RT), mirror therapy (MT), and active control treatment (AC)) in patients with stroke after BoNT-A injection. Thirty-seven patients with chronic spastic hemiplegic stroke were randomly assigned to receive RT, MT, or AC following BoNT-A injection over spastic upper extremity muscles. Each session of RT, MT, and AC was 75 min, 3 times weekly, for 8 weeks. Outcome measures were assessed at pretreatment, post-treatment, and 3-month follow-up, involving the Fugl-Meyer Assessment (FMA), Modified Ashworth Scale (MAS), Motor Activity Log (MAL), including amount of use (AOU) and quality of movement (QOM), and arm activity level. All 3 combined treatments improved FMA, MAS, and MAL. The AC induced a greater effect on QOM in MAL at the 3-month follow-up than RT or MT. All 3 combined trainings induced minimal effect on arm activity level. Our findings suggest that for patients with stroke who received BoNT-A injection over spastic UE muscles, the RT, MT, or AC UE training that followed was effective in improving motor functions, reducing spasticity, and enhancing daily function.

Hyaluronic Acid Compound Filling Plus Mesotherapy vs Botulinum Toxin A for the Treatment of Horizontal Neck Lines: A Multicenter, Randomized, Evaluator-Blinded, Prospective Study in Chinese Subjects.

BackgroundAlthough energy devices and botulinum toxin A (BTX-A) can alleviate age-related laxity, ptosis, and platysmal bands, they have limited efficacy on horizontal neck lines.ObjectivesThe purpose of this study was to investigate the efficacy, safety, and subject satisfaction of a combined treatment of non–cross-linked hyaluronic acid (HA) compound filling plus mesotherapy for the correction of horizontal neck lines, in comparison with BTX-A.MethodsThis multicenter, randomized, evaluator-blinded, prospective study enrolled female patients with moderate-to-severe horizontal neck lines corrected with either 2 or 3 sessions of of non–cross-linked HA compound filling plus mesotherapy or 1 session of BTX-A injection. Improvement of the neck lines grades, Global Aesthetic Improvement Scale (GAIS), patient satisfaction, and adverse events (AEs) were evaluated and compared at 1, 3, 6, and 10 months after the final treatment.ResultsTwenty-five patients received HA filling plus mesotherapy and 23 received BTX-A injection. Compared with BTX-A, the HA compound filling plus mesotherapy significantly improved the horizontal neck lines grades on all follow-up visits (P = 0.000). Cases of different baseline grades (2, 2.5, and 3) demonstrated similar outcomes. The GAIS and patients’ satisfaction ratings were significantly higher for the HA filling plus mesotherapy treatment group (P = 0.000). Significantly higher pain ratings, higher incidence, and longer recovery of AEs (erythema, edema, and ecchymosis) were noticed in the combined treatment group (P < 0.001). No serious AEs occurred.ConclusionsCompared with BTX-A, combined treatment with HA compound filling plus mesotherapy significantly improved moderate-to-severe horizontal neck lines and achieved a high level of patient satisfaction.Level of Evidence: 4

The Effects of Botulinum Toxin A on Pain in Ischemic Vasospasm

The purpose was to describe the impact of botulinum toxin A (BTX-A) administration in patients with ischemic vasospasm on the magnitude and timing of pain relief and subsequent effect on opioid use. The secondary purposes were to determine the role of photoplethysomgraph (PPG) testing on treatment decisions, effect on patient-reported outcomes, and additional procedures. A retrospective analysis of patients who received BTX-A injections was performed. Botulinum toxin type A was injected subcutaneously in symptom-specific 2-level patterns. Pain, shortened version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH), and opioid use (quantified by median morphine equivalents) were recorded and the need for repeat injections or unplanned surgeries was assessed. All patients (n= 20 patients; 31 hands) had ischemic pain from vasospasm and failed multiple pharmacological options. Average follow-up was 10.5 months. All patients had abnormal PPG amplitude (mean, 6.43 mm) at room temperature and increased amplitude (mean, 19.55 mm) after immersion in warm water. All patients (n= 12) with a PPG amplitude increase of 4 mm or greater had clinical success. Eleven of 13 patients had a clinically relevant decrease in pain at 20 minutes after injection. Clinically significant pain relief was sustained for 3 months (visual analog scale decreased by a mean of 4). Median morphine equivalent usage view decreased from 82.5 to 0 after injection. Patient-reported disability (QuickDASH) improved from 49 before treatment to 29 and 26 at 6 weeks and 6 months after BTX-A injection, respectively. Three patients were retreated for recurrent symptoms. Four patients required unplanned secondary procedures. Botulinum toxin type A administration can result in rapid (within 20 minutes) and sustained pain relief for several months with a reduction in opioid prescriptions. Botulinum toxin type A administration also improved patient-reported disability for 6 months. Use of PPG testing to determine baseline perfusion deficit and capacity to improve after warm water immersion was helpful in consideration of BTX-A use. Therapeutic IV.

Use of Shear Wave Elastography for Quantitative Assessment of Muscle Stiffness After Botulinum Toxin Injection in Children With Cerebral Palsy.

This study aimed to investigate the stiffness of the gastrocnemius (GC) muscle with acoustic radiation force impulse (ARFI) elastography after botulinum toxin-A (BTX-A) injection in children with spastic cerebral palsy (CP) and to examine the relationship between elastographic and clinical parameters. This prospective randomized single-blind controlled clinical study included 49 lower extremities of 33 children with spastic CP. They were randomized into 2 groups: group 1 (n = 25 extremities in 17 children) received BTX-A injection and a home-based exercise program; group 2 (n = 24 extremities in 16 children) received only a home-based exercise program. Patients were evaluated in pretreatment and posttreatment periods in the first and third months with ARFI elastography, the Modified Ashworth Scale, Modified Tardieu Scale, Pediatric Functional Independence Measure, Gross Motor Function Classification System, and goniometric range of motion measurement of the ankle. A statistically significant difference was found in elastography of the GC muscle in group 1 only at the first month after treatment (P < .05). No statistical difference was found in elastography of the GC after treatment in group 2. According to the Modified Ashworth Scale, Modified Tardieu Scale, and ankle passive range of motion, group 1 showed significant improvements after treatment (P < .05). Also, there was a significant correlation between these clinical parameters and elastographic measurements (P < .05). According to the results of this study, the measurements from ARFI elastography combined with clinical parameters might be useful for evaluation of spasticity after BTX-A treatment in children with CP. Also, they might be useful in distinguishing patients who will benefit clinically, especially in the early stages of treatment.

Comparison of the efficacy of intramuscular botulinum toxin type-A injection into the pectoralis major and the teres major muscles and suprascapular nerve block for hemiplegic shoulder pain: a prospective, double-blind, randomized, controlled trial.

This study aims to investigate the effect of botulinum toxin-A (BoNT-A) injection into pectoralis major and teres major muscles and suprascapular nerve block (SSNB) on pain, range of motion (ROM), and upper extremity function for (hemiplegic shoulder pain) HSP, and to compare the effectiveness of these two methods. Sixty patients with HSP were randomly assigned into 2 groups. The Group 1 (n= 30) received BoNT-A injection into the pectoralis major and teres major, and the Group 2 (n= 30) received SSSB. Patients were evaluated just before the start of the study, and 2 and 6weeks after the start of the study with visual analog scale (VAS), Modified Ashworth Scale (MASH), the passive ROM, and the Fugl-Meyer Scale (FMS) arm section. In Group 1, statistically significant improvement was found in all evaluation parameters on 2th and 6th week. Group 2 showed significant improvement in all parameters on week 2 (p< 0.05), and significant improvement was observed in MASH and pain in abduction in the 6th week (p< 0.05). When the groups were compared with each other, a statistically significant difference was observed in MASH, ROM, and FMS parameters on week 2 in favor of Group 1; in all evaluation parameters, there was a statistically significant difference in favor of Group 1 on week 6 (p< 0.05). We concluded that BoNT-A injection into the pectoralis major and teres major muscles for HSP was equal in the short term and more effective in the middle term compared with SSNB treatment in improving pain, ROM, and function.

Predictors of Poor Response and Adverse Events Following Botulinum Toxin-A for Refractory Idiopathic Overactive Bladder

ObjectiveTo ascertain whether a poor response and adverse events (voiding dysfunction and urinary tract infection) were predictable for first time botulinum toxin-A (BTX-A) injections in a patient cohort of refractory idiopathic overactive bladder with detrusor overactivity. MethodsPatients who received BTX-A injections for the first time between the dates of March 2004-August 2017 were analyzed in this single center study. Urogenital Distress Inventory short form (UDI-6) questionnaires were collected both preinjection and postinjection prospectively. A poor response was defined as a decrease of less than 16.7 on the UDI-6 questionnaire. Additional information was gathered from patient records in a retrospective fashion. Predictors of poor response, voiding dysfunction, and UTI were analyzed with multivariate logistic regression analysis. ResultsSeventy-four patients were analyzed. The only predictor of poor response was male gender (OR, 5.45; 95% CI 1.83-16.47; P = .002). Lower maximum urinary flow rates (OR, 0.91; 95% CI, 0.83-0.99; P = .023), male gender (OR, 5.14; 95% CI 1.41-18.72; P = .013), and hysterectomy in females (OR, 4.55; 95% CI, 1.09-18.87; P = .038) were predictors of clean intermittent self catheterisation (CISC). There was an increased risk of UTIs in patients who performed CISC (OR, 5.26; 95% CI 1.38-20.0; P = .015). ConclusionMale gender was associated with a poor response to BTX-A injections and increased risk of CISC. Lower maximum urinary flow rates and women with hysterectomies were at increased risk of requiring CISC postinjection. Performing CISC was associated with increased risk of UTI. These factors could be helpful when counselling or selecting patients.

Botulinum toxin-A injection into the anterior belly of the digastric muscle for the prevention of post-operative open bite in class II malocclusions: a case report and literature review

BackgroundClass II malocclusion patients with hyperdivergent facial types are characterized by short mandibular body lengths and anterior open bite. Accordingly, the treatment for hyperdivergent skeletal class II malocclusion is a lengthening of the mandibular body length and a counterclockwise rotation of the mandible. To prevent post-operative relapse, botulinum toxin-A (BTX-A) injection can be a retention modality.Case presentationA class II open-bite patient received BTX-A injection to the anterior belly of her digastric muscle for the prevention of post-operative relapse. The relapse was evaluated via a clinical examination and a lateral cephalometric radiograph after the completion of post-surgical orthodontic treatment. The patient showed stable occlusion without any signs of relapse at 15 months post-operatively.ConclusionIn this case presentation, a single injection into the anterior belly of the digastric muscle was sufficient for the prevention of post-operative open bite.

614 Investigation of the efficacy and safety of topical vibration anesthesia to reduce pain from cosmetic botulinum toxin A injections in Chinese patients

Vibration anesthesia has been proved to be effective to reduce pain during facial cosmetic injections, but it has not been studied in Chinese patients and anatomic sites other than face. This study was to investigate the efficacy and safety of vibration anesthesia for pain reduction associated with cosmetic botulinum toxin A (BTX-A) injections in Chinese patients and anatomic sites other than face. In this prospective, randomized, split-face, self-controlled study, 53 patients received BTX-A injections for facial rhytids reduction, lower face, shoulder, or posterior leg contour reshaping. A vibration stimulus was co-administered with the BTX-A injections on one side (treatment), whereas the other side received the BTX-A injections only (control). Immediately after treatment, the patients completed a questionnaire composed of a visual analogue scale of pain sensation (VAS), a preference question, and a statement of the feelings and/or questions they might have about the vibration treatment. The patients were also followed up two weeks later. The patients experienced both clinically and statistically significant pain reduction when a vibration was co-administered with injections. The mean patient-reported VAS scores were 3.6 ± 1.3 for the vibration-treated side and 5.6 ± 1.8 for the control side (p = 0.000). No difference was found between the patients receiving two different BTX-A products injection. No difference was found between the treatment-naïve patients and repeated patients. Overall, 75% of patients preferred to receive vibration for their next treatment. Positive feedback, psychological benefits, and needs for optimizing vibration parameters were identified in the paitents’ statement. No adverse events and no delayed or declined toxin effect were reported. Topical vibration anesthesia during cosmetic BTX-A injections had a beneficial effect that was statistically and clinically significant in terms of patients’ assessment of pain. It may have applications in other cosmetic procedures.

Clinical Nursing Recommendations for the Treatment of the BTX-A Injections Due to Neurological Detrusor Overactivity

Background: Neurological detrusor overactivity (NDO) is commonly associated with various neurogenic diseases. Botulinum toxin A (BTX-A) has been proposed as alternatives to traditional treatments. Objective: To summarize the clinical experience of nursing care for the treatment of the Botulinum toxin A (BTX-A) injections due to neurological detrusor overactivity (NDO). Methods: We reviewed the data of 32 inpatients who received BTX-A injections between August 2014 to July 2016. Their mean age was 27.4 years old (range: 19 - 38). They were all on clean intermittent catheterization. All patients presented detrusor overactivity resistant to oral anticholinergic treatment. Results: There were significant difference between outcomes at baseline and week12 for Pdetmax (60.08 cmH2O vs. 28.04 cmH2O, P < 0.001), VFIDC (165.55 ml vs. 276.07, P < 0.001), and urinary incontinence respectively. Prompt psychological counseling and nursing help reduce the patients’ passive psychology, enhance their confidence with good postoperative recovery and symptoms improvement. Conclusions: Patients were satisfied with the treatment and nursing by targeted perioperative nursing.

Botulinum Toxin A Plays an Important Role in the Placement of Implants Deep Within the Pectoralis Major Muscle for Mammaplasty: A Systematic Review and Meta-analysis.

Breast prosthesis implants have been safely and efficiently used in the plastic surgery department. With the increasing demand for aesthetics, these silicon implants were not only used in breast augmentation surgery but also in breast reconstruction after mastectomy. Nevertheless, breast prosthesis implantation brings a lot of complications, such as: postoperative chronic pain, capsule contracture, prosthesis displacement and prosthesis rupture and infection in severe cases. From the year 1998, botulinum toxin A (BTX-A), a neurotoxin, has been reported to be effective for pain control, capsule contracture lessening, expander enlargement and so on. However, those articles included all kinds of study types: randomized, double-blinded controlled trial (RCT), nonrandomized trial, retrospective analysis and case series, besides the outcomes were varied. To clarify how BTX-A acts at the mammaplasty field, we made this systematic review and meta-analysis. To review how BTX-A acts in the field of mammaplasty as well as discuss the relative mechanisms of BTX-A and the related research progress. We searched Pubmed, Embase, Cochrane, Web of science, Clinical trials, Wanfang Database and VIP from inception until March 2018 for papers reporting the use of BTX-A in the breast surgery using implants deep within the pectoralis major muscle. System review, viewpoints and case reports were excluded. Ten articles met the criteria for inclusion including six prospective controlled (2 RCT; 4 other trails), three retrospective cohorts and one case series. These studies were all about patients using BTX-A during or after breast surgery with expanders or prostheses. A total of 682 patients were enrolled, 543 (79.61%) accepted BTX-A injection, 185 underwent mastectomies with immediate reconstruction, 13 with delayed reconstruction, 295 mastectomies with either immediate or delayed reconstruction and 189 with breast augmentation using silicone prostheses. The study time ranging from 4months to 13years, 15 patients (2.76%) received BTX-A injection more than two times, 9.2% received less than 75U BTX-A, 34.3% 75-100U, 0.18% 250U, and in 56.4% the dosage was not stated. No complications associated with BTX-A were mentioned, almost all the studies reported efficacy for pain control. Other assessments included increased speed of expander enlargement and volume were mentioned in four papers, two articles analyzed the visual analogue scores, three suggested relief of capsular contracture, two reported lower narcotic use, three mentioned shorter hospital stays and one proved lowering the rate of unplanned expander. It seems all the studies demonstrate the valid usage of BTX-A, but the quality of this evidence still under the line. We could try to use BTX-A as a new method in the field of mammaplasty. There are so many advantages such as postoperative pain relief, reducing the hospital stay, and increasing operation success rate, but rigorous methodological evidence is still lacking. A lot of studies were retrospective, only two studies used the RCT method. Therefore, to obtain strong evidence to clarify the usage of BTX-A, more randomized double-blinded controlled trials will be required, meanwhile the mechanism study adds to the evidence. This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

P 156 – Sex and age influence on balance normative data using Biodex Balance System SD

The effect of botulinum toxin A (BoNTA) injection on flexed-elbow deformity is usually evaluated using the Modified Ashworth Scale (MAS), but only with the muscle tone at rest. Some patients show the flexed-elbow deformity during gait despite low muscle tone at rest.This study aimed to evaluate the effect of BoNTA injection on flexed-elbow deformity during gait using a three-dimensional motion analysis system.Twenty stroke patients with spastic flexed-elbow deformity during gait received BoNTA injections into the upper limb muscles. The MAS score of the elbow flexors, passive elbow range of motion, comfortable overground gait velocity, and elbow flexion angle during treadmill gait were evaluated just before and 2, 6, and 12 weeks after the injection. Twenty-five healthy subjects were also recruited to provide a normal reference of the elbow flexion angle.The MAS scores at 2, 6 and 12 weeks after the injection were significantly lower than that before the injection. Some patients showed no spasticity at rest but an obviously flexed elbow during gait. The elbow flexion angles during gait at 2 and 6 weeks after the injection were significantly lower than that before the injection.BoNTA injections to the upper limb muscles reduced muscle tone at rest and flexed-elbow deformity during gait. However, the elbow flexion angle during gait returned to its pre-injection level sooner than the muscle tone at rest. We strongly recommend evaluating muscle tone during motion and at rest, preferably using three-dimensional motion analysis since it can objectively detect small changes.

Quantitative assessment for flexed-elbow deformity during gait following botulinum toxin A treatment

BackgroundThe effect of botulinum toxin A (BoNTA) injection on flexed-elbow deformity is usually evaluated using the Modified Ashworth Scale (MAS), but only with the muscle tone at rest. Some patients show the flexed-elbow deformity during gait despite low muscle tone at rest. ObjectiveThis study aimed to evaluate the effect of BoNTA injection on flexed-elbow deformity during gait using a three-dimensional motion analysis system. MethodsTwenty stroke patients with spastic flexed-elbow deformity during gait received BoNTA injections into the upper limb muscles. The MAS score of the elbow flexors, passive elbow range of motion, comfortable overground gait velocity, and elbow flexion angle during treadmill gait were evaluated just before and 2, 6, and 12 weeks after the injection. Twenty-five healthy subjects were also recruited to provide a normal reference of the elbow flexion angle. ResultsThe MAS scores at 2, 6 and 12 weeks after the injection were significantly lower than that before the injection. Some patients showed no spasticity at rest but an obviously flexed elbow during gait. The elbow flexion angles during gait at 2 and 6 weeks after the injection were significantly lower than that before the injection. ConclusionsBoNTA injections to the upper limb muscles reduced muscle tone at rest and flexed-elbow deformity during gait. However, the elbow flexion angle during gait returned to its pre-injection level sooner than the muscle tone at rest. We strongly recommend evaluating muscle tone during motion and at rest, preferably using three-dimensional motion analysis since it can objectively detect small changes.

Investigation of the Efficacy and Safety of Topical Vibration Anesthesia to Reduce Pain From Cosmetic Botulinum Toxin A Injections in Chinese Patients: A Multicenter, Randomized, Self-Controlled Study.

Vibration has been proved to be effective to reduce pain during facial cosmetic injections, but it has not been studied in Chinese patients. To investigate the efficacy and safety of vibration for pain reduction associated with cosmetic botulinum toxin A (BTX-A) injections in Chinese patients. In this prospective, randomized, split-face and right-left, self-controlled study, 53 patients received BTX-A injections for rhytid reduction, lower face, shoulder, and leg reshaping. Injections were given in a split-face and right-left design randomly assigned. A vibration stimulus was coadministered with BTX-A injections on one side, whereas the other side received BTX-A injections only. Patients completed a questionnaire immediately after treatment and were followed up 2 weeks later. A visual analog scale of pain sensation was statistically analyzed. The patients experienced both clinically and statistically significant pain reduction when a vibration was coadministered with injections. Patients reported less pain on the treated side compared with the control side. Overall, 75% of patients preferred to receive vibration with their next treatment. No adverse events were reported. Vibration is an effective and safe way to reduce pain during cosmetic BTX-A injections and may have applications in other cosmetic procedures.