Efficacy of therapeutic ultrasound and transcutaneous electrical nerve stimulation compared with botulinum toxin type A in the treatment of spastic equinus in adults with chronic stroke: a pilot randomized controlled trial.

BACKGROUND: Therapeutic ultrasound and transcutaneous electrical nerve stimulation (TENS) have been described as being effective in the treatment of spasticity. No previous study compared these physical modalities with a first-line treatment for spasticity, such as botulinum toxin type A. OBJECTIVE: To compare the effects of therapeutic ultrasound and TENS with botulinum toxin type A on spasticity after stroke. METHODS: Thirty patients with chronic stroke and spastic equinus were randomly assigned to 3 groups: 1 group received therapeutic ultrasound to the affected leg calf muscles, 1 group underwent TENS to the tibial nerve of the affected leg, and 1 group was injected with onabotulinum toxin A in the spastic gastrocnemius. All patients were evaluated immediately before treatment and 15, 30, and 90 days after the first clinical evaluation. The following outcome measures were considered: ankle passive dorsiflexion range of motion and the modified Ashworth scale. RESULTS: Patients injected with botulinum toxin type A had significantly better ankle passive range of motion than those treated with physical modalities at all posttreatment evaluations. At second and third posttreatment evaluations, the modified Ashworth scale indicated significantly greater improvement in patients injected with botulinum toxin type A than in those treated with physical modalities. No difference was found between groups treated with physical modalities. CONCLUSIONS: Our findings support the hypothesis that botulinum toxin type A is more effective than therapeutic ultrasound and TENS for treating focal spasticity in patients with chronic stroke.

Is spastic muscle echo intensity related to the response to botulinum toxin type A in patients with stroke? A cohort study.

OBJECTIVE: To investigate the relationship between gastrocnemius muscle echo intensity and response to botulinum toxin type A (BoNT-A) in patients with spastic equinus foot resulting from stroke. DESIGN: Cohort study. SETTING: University hospital. PARTICIPANTS: Adult patients (N=56) with spastic equinus foot resulting from stroke scheduled to receive BoNT-A injection into the gastrocnemius muscle. INTERVENTIONS: All patients were injected with BoNT-A (abobotulinumtoxinA) into the gastrocnemius muscle with an ultrasonography-guided, multisite injection technique. The toxin dose was 250U for the gastrocnemius medialis and 250U for the gastrocnemius lateralis (dilution 500U/2mL) in each patient. All patients were evaluated before and 4 weeks after BoNT-A injection. MAIN OUTCOME MEASURES: Spastic gastrocnemius muscle echo intensity visually graded with the Heckmatt scale. Clinical assessment of the spastic gastrocnemius with the Modified Ashworth Scale, Tardieu Scale, and ankle passive range of motion. RESULTS: Postintervention testing at 4 weeks showed overall significant improvements in the clinical assessment of the spastic gastrocnemius muscle. No significant change was observed in the echo muscle intensity of the spastic gastrocnemius after BoNT-A injection. Post hoc comparisons showed that all clinical outcomes were significantly better in those patients with echo muscle intensity of the spastic gastrocnemius graded II on the Heckmatt scale than those with grades III (P<.001) and IV (P<.001) after botulinum toxin injection. CONCLUSIONS: These findings support the hypothesis that patients with higher spastic muscle echo intensity have a reduced response to BoNT-A.

Botulinum toxin type A injection into the gastrocnemius muscle for spastic equinus in adults with stroke: a randomized controlled trial comparing manual needle placement, electrical stimulation and ultrasonography-guided injection techniques.

OBJECTIVE: The aim of this study was to compare the clinical outcomes of manual needle placement, electrical stimulation, and ultrasonography-guided techniques for botulinum toxin injection into the gastrocnemius of adults with spastic equinus after stroke. DESIGN: After randomization into three groups, each patient received the same dose of botulinum toxin type A into the lateral and medial head of the gastrocnemius muscle (OnabotulinumtoxinA, 100U per head) of the affected leg. The manual needle placement group (n = 15) underwent injections using anatomic landmarks and palpation; the electrical stimulation group (n = 15) received injections with electrical stimulation guidance; and the ultrasonography group (n = 17) was injected under sonographic guidance. The modified Ashworth scale, the Tardieu scale, and the ankle passive range of motion were measured at baseline and 1 mo after injection. Nonparametric statistical analysis was used. RESULTS: One month after injection, the modified Ashworth scale improved better in the ultrasonography group than in the manual needle placement group (P = 0.008). The ankle passive range of motion improved better in the ultrasonography group than in the electrical stimulation (P = 0.004) and manual needle placement (P < 0.001) groups. No difference was found between groups for the Tardieu scale. CONCLUSIONS: Ultrasonography-guided injection technique could improve the clinical outcome of botulinum toxin injections into the gastrocnemius of adults with spastic equinus.

Accuracy of botulinum toxin type A injection into the gastrocnemius muscle of adults with spastic equinus: manual needle placement and electrical stimulation guidance compared using ultrasonography.

OBJECTIVE: To investigate the accuracy of manual needle placement and electrical stimulation guidance, compared using ultrasonography, for injection of botulinum toxin type A into the gastrocnemius muscle of adults with spastic equinus. DESIGN: Prospective clinical study. SUBJECTS: A total of 81 adults with stroke who were scheduled to receive botulinum toxin type A injection into the gastrocnemius muscle. METHODS: After randomization into two groups, each patient was injected into two sites at each head of the gastrocnemius muscle. The manual needle placement group (n = 42) underwent injections using anatomical landmarks and palpation. The electrical stimulation guidance group (n = 39) underwent injections under electrical stimulation guidance. The accuracy of needle placement and muscle thickness at each injection site were compared by means of ultrasonography. RESULTS: The overall accuracy of manual needle placement and electrical stimulation guidance, measured using ultrasonography, was significantly higher for the gastrocnemius medialis than for the lateralis (92.0% vs 79.0%). The gastrocnemius medialis was significantly thicker than the lateralis (mean 13.25 mm (standard deviation (SD) 1.86 mm) vs 10.84 mm (SD 1.52 mm). CONCLUSION: Electrical stimulation guidance may be useful for injections into the gastrocnemius lateralis of adults with spastic equinus. However, neither manual needle placement nor electrical stimulation guidance showed complete accuracy, when measured using ultrasonography.