Treatment of "plantar fasciitis"/Plantar Heel Pain Syndrome with botulinum toxin - A novel injection paradigm pilot study.

Randomized controlled trials over the last two decades, although promising with favorable results, have shown varied efficacy in treatment of "plantar fasciitis" with botulinum toxin injection1. One reason may be due to conflating the variabilities of plantar heel conditions solely as plantar fasciitis. Plantar Heel Pain Syndrome can be of one or more etiologies and symptoms which refutes the mistaken tendency to categorize all plantar heel pain singularly as either plantar fasciitis or fasciosis. Recognizing that there is likely an interplay of inflammatory, degenerative, and neuropathic etiologic conditions of this often-difficult malady to treat, a novel injection paradigm of botulinum toxin is explored in the treatment of 4 distinct presentations of Plantar Heel Pain Syndrome with encouraging results. Botulinum toxin injection into two intrinsic foot muscles; Abductor Hallucis and Quadratus Plantae at their origins with electrical stimulation is presented as novel method to treat four distinct etiologies of Plantar Heel Pain Syndrome. This method of botulinum toxin injection resulted in significant prolonged improvement of patient function and pain reduction in four variations of Plantar Heel Pain Syndrome. A precise injection paradigm facilitated with direct intrinsic muscle stimulation of the Abductor Hallucis and Quadratus Plantae at their origins may prove to be effective in reducing the disabilities of Plantar Heel Pain Syndrome and its associated pain.

Ethyl Alcohol Versus Botulinum Toxin A: A Comparative Study of the Visual and Histopathological Outcomes in the Rabbit Anterior Auricular Muscle Model.

BACKGROUND: Botulinum toxin has long been known for its paralytic effects at the neuromuscular junction. Although it has been widely used for vascular and nervous tissues, there has been no study of the aesthetic effects of the application of ethanol to muscle tissues to date. OBJECTIVE: The authors aimed to demonstrate the effects of the application of ethanol to muscle tissues after an intramuscular injection and to compare the effects of botulinum toxin A (BTA) and ethanol. METHODS AND MATERIALS: A total of 28 rabbits were divided into 4 groups (n = 7 each). Botulinum toxin A (5 units) and different concentrations of ethanol (5 cc) were injected into the left and right anterior auricular muscles of all rabbits, respectively. Ear ptosis was assessed, and histopathological examination was performed after all rabbits were euthanized in the eighth week. RESULTS: Muscle function was affected earlier in ethanol-treated ears than in botulinum-treated ears; however, the ptotic effect lasted for a significantly shorter duration in ethanol-injected ears than in BTA-applied ears. CONCLUSION: Ethanol can block muscle function reversibly and can serve as an alternative to BTA, particularly when rapid results are desirable.

Nonsurgical Treatment for Hallux Abducto Valgus with Botulinum Toxin Type A.

BACKGROUND: Hallux abducto valgus (HAV) is a frequently seen abnormality of the first metatarsophalangeal joint. Limited conservative treatment options exist, making surgery the only definitive treatment option for a mild to moderate deformity. Since initially published in 2008, treatment of HAV with botulinum toxin injection has evolved as a potentially effective modality as shown in several subsequent independent studies. METHODS: Botulinum injection of two intrinsic foot muscles (extensor halluces brevis and flexor hallucis brevis) in addition to adductor hallucis under electrical stimulation is presented as an improvement to the original method. RESULTS: The additional muscle injections of botulinum resulted in an further reduction of the HAV deformity and associated pain. CONCLUSIONS: A significant improvement to the injection paradigm developed the author may prove to be more effective in reducing the HAV deformity and its associated pain.

Effects of caffeine on neuromuscular function in a non-fatigued state and during fatiguing exercise.

NEW FINDINGS: What is the central question of the study? What are the effects of caffeine on neuromuscular function in a non-fatigued state and during fatiguing exercise? What is the main finding and its importance? In a non-fatigued state, caffeine decreased the duration of the silent period evoked by transcranial magnetic stimulation. Caffeine-induced reduction of inhibitory mechanisms in the central nervous system before exercise was associated with an increased performance. Individuals who benefit from caffeine ingestion may experience lower perception of effort during exercise and an accelerated recovery of M-wave amplitude postfatigue. This study elucidates the mechanisms of action of caffeine and demonstrates that inter-individual variability of its effects on neuromuscular function is a fruitful area for further work. ABSTRACT: Caffeine enhances exercise performance, but its mechanisms of action remain unclear. In this study, we investigated its effects on neuromuscular function in a non-fatigued state and during fatiguing exercise. Eighteen men participated in this randomized, double-blind, placebo-controlled crossover trial. Baseline measures included plantarflexion force, drop jump, squat jump, voluntary activation of triceps surae muscle, soleus muscle contractile properties, M-wave, α-motoneuron excitability (H-reflex), corticospinal excitability, short-interval intracortical inhibition, intracortical facilitation, silent period evoked by transcranial magnetic stimulation (SP) and plasma potassium and caffeine concentrations. Immediately after baseline testing, participants ingested caffeine (6 mg·kg-1 ) or placebo. After a 1-h rest, baseline measures were repeated, followed by a fatiguing stretch-shortening cycle exercise (sets of 40 bilateral rebound jumps on a sledge apparatus) until task failure. Neuromuscular testing was carried out throughout the fatigue protocol and afterwards. Caffeine enhanced drop jump height (by 4.2%) and decreased the SP (by 12.6%) in a non-fatigued state. A caffeine-related decrease in SP and short-interval intracortical inhibition before the fatiguing activity was associated with an increased time to task failure. The participants who benefitted from an improved performance on the caffeine day reported a significantly lower sense of effort during exercise and had an accelerated postexercise recovery of M-wave amplitude. Caffeine modulates inhibitory mechanisms of the CNS, recovery of M-wave amplitude and perception of effort. This study lays the groundwork for future examinations of differences in caffeine-induced neuromuscular changes between those who are deemed to benefit from caffeine ingestion and those who are not.

Comparing the Efficacy of OnabotulinumtoxinA, Sacral Neuromodulation, and Peripheral Tibial Nerve Stimulation as Third Line Treatment for the Management of Overactive Bladder Symptoms in Adults: Systematic Review and Network Meta-Analysis.

The American Urological Association guidelines for the management of non-neurogenic overactive bladder (OAB) recommend the use of OnabotulinumtoxinA, sacral neuromodulation (SNM), and peripheral tibial nerve stimulation (PTNS) as third line treatment options with no treatment hierarchy. The current study used network meta-analysis to compare the efficacy of these three modalities for managing adult OAB syndrome. We performed systematic literature searches of several databases from January 1995 to September 2019 with language restricted to English. All randomized control trials that compared any dose of OnabotulinumtoxinA, SNM, and PTNS with each other or a placebo for the management of adult OAB were included in the study. Overall, 17 randomized control trials, with a follow up of 3-6 months in the predominance of trials (range 1.5-24 months), were included for analysis. For each trial outcome, the results were reported as an average number of episodes of the outcome at baseline. Compared with the placebo, all three treatments were more efficacious for the selected outcome parameters. OnabotulinumtoxinA resulted in a higher number of complications, including urinary tract infection and urine retention. Compared with OnabotulinumtoxinA and PTNS, SNM resulted in the greatest reduction in urinary incontinence episodes and voiding frequency. However, comparison of their long-term efficacy was lacking. Further studies on the long-term effectiveness of the three treatment options, with standardized questionnaires and parameters are warranted.

Treatment Effects of Botulinum Toxin Injection and Acupuncture on Blepharospasm Assessed by the Change in Lower Eyelid Tension.

Objective: To investigate the treatment effects of botulinum toxin-A (BTA) injection and acupuncture on blepharospasm (BP) evaluated by the change in lower eyelid tension (LET). Methods: A series of 30 patients (male: 8, female: 22) aged between 37 and 83 years (63.80 ± 10.96 yrs) who met the eligibility criteria of BP were recruited in this study, who were randomly assigned to BTA injection group (BTA group, n = 15) and acupuncture treatment group (Acupuncture group, n = 15). BTA injections were administered to the patients in BTA group while patients in acupuncture group received the acupuncture treatment. The LET was measured by a tensiometer in both groups at baseline and at post-treatment. Results: A significant decrease in LETs over 8 weeks was found in acupuncture group (812.76 ± 193.95 Pa at baseline, 549.69 ± 150.04 Pa at 4 weeks, and 510.96 ± 150.66 Pa at 8weeks, respectively; F = 31.127, p << 0.001). There was a significant decrease in LET from 858.61 ± 190.54 Pa at baseline to 414.45 ± 63.38 Pa at 2 weeks after treatment (Z = -4.542, p << 0.01) in BTA group. At the endpoint of the study, a significant difference in LET was found between the acupuncture group (301.80 ± 181.77 Pa) and the BTA group (444.16 ± 193.44 Pa) (t = -2.077, p = 0.047). Conclusions: BP patients have an increased LET. Both BTA and acupuncture are effective in decreasing the LET. Close monitoring of LET holds promise in planning the treatment strategy for Blepharospasm.

Comparison of OnabotulinumtoxinA versus sacral neuromodulation for refractory urinary urge incontinence: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND & AIM: Both intradetrusor OnabotulinumtoxinA (BTX) and Sacral neuromodulation (SNM) as third-line therapies for urgency urinary incontinence (UUI) are increasingly being utilized. However, there are differences in preference between patients and medical personnel in clinical practice. This meta-analysis was designed to compare BTX versus SNM in treatment of UUI. METHODS: We searched the Cochrane Library, PubMed, EMBASE and Web of Science from January 1, 1992 to April 22, 2018. Mean differences (MDs) and risk ratio (RR) with its 95% confidence intervals (CIs) were estimated to compare the outcomes of the groups. All the MDs were after subtracting OnabotulinumtoxinA data from Sacral neuromodulation data. RRs were acquired from comparing OnabotulinumtoxinA data to Sacral neuromodulation data. Two reviewers assessed trial quality and extracted data independently. All statistical analyses were performed using standard statistical procedures provided in Review Manager 5.2. This work has been reported in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines. RESULTS: Seven randomized controlled trials and two retrospective studies (N = 1649 participants) were identified for the present analysis. In change from baseline in UUI episodes (UUIE) per day, comparing BTX groups with SNM groups, the effects were observed through 1, 2, 4, 5 and 6 month, with pooled MDs of -0.62, -0.55, -0.38, -1.02 and -0.50 respectively. In UUIE reduction post treatment, the pooled RRs of complete UUIE reductions through 4 and 6 months respectively were 5.13 and 6.63. Significant results were observed through overall times in more than 75% UUIE reduction. No significance was found in more than 50% UUIE reduction. Significant results were observed in urinary tract infection. More treatment satisfaction were found in BTX groups than that in SNM groups (RR 1.14, 95% CI 1.01-1.29; P = 0.004). CONCLUSIONS: Generally, BTX seems superior to SNM in treatment of UUI but inferior regarding safety. Patients receiving BTX experienced a higher treatment satisfaction.

Two-Year Outcomes of Sacral Neuromodulation Versus OnabotulinumtoxinA for Refractory Urgency Urinary Incontinence: A Randomized Trial.

BACKGROUND: Urgency urinary incontinence (UUI) is a chronic condition for which sacral neuromodulation (SNM) (InterStim/Medtronic) and onabotulinumtoxinA (BTX) (BotoxA/Allergan) are utilized. These therapies have not been compared over extended time. OBJECTIVE: To compare UUI episodes (UUIE) over 24 mo following SNM or BTX. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, open-label, randomized, extension trial (February 2012-July 2016) at nine US medical centers involving 386 women with ≥6 UUIE over 3 d inadequately managed by medications. Participants were clinical responders to treatment: ≥50% reduction in UUIEs after SNM placement or 1 mo post BTX. INTERVENTION: SNM (n=194) versus 200 U BTX (n=192). SNM reprogrammings occurred throughout the 24 mo. After 6 mo, two additional BTX injections were allowed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary outcome: change in mean daily UUIE over 24 mo. SECONDARY OUTCOMES: no UUIE, ≥75% and ≥50% UUIE reduction; Overactive Bladder Questionnaire Short Form; Urinary Distress Inventory short form; Incontinence Impact Questionnaire; Patient Global Impression of Improvement; Overactive Bladder Satisfaction of Treatment Questionnaire; and adverse events (AEs). Primary analysis used a linear mixed model. RESULTS AND LIMITATIONS: Outcome data were available for 260/298 (87%) clinical responders. No difference in decreased mean UUIE was found over 24 mo (-3.88 vs -3.50 episodes/d,95% confidence interval [CI]=-0.14-0.89; p=0.15), with no differences in UUI resolution, ≥75% or ≥50% UUIE reduction. BTX group maintained higher satisfaction (mean difference=-9.14, 95% CI=-14.38--3.90; p<0.001), treatment endorsement (mean difference=-12.16, 95% CI=-17.7--6.63; p<0.001) through 24 mo. Other secondary measures did not differ. Recurrent urinary tract infections (UTIs) were higher after BTX (24% vs 10%; p<0.01), 6% required intermittent catheterization post second injection. SNM revision and removals occurred in 3% and 9% patients, respectively. CONCLUSIONS: Both treatments offered sustainable UUI improvement, and higher BTX dosing had low clean intermittent catheterization rates, but with UTI risk. SNM revision/removal rates were low due to standardized lead placement with strict treatment response definitions. PATIENT SUMMARY: We compared a large group of US women with severe urgency urinary incontinence (UUI) who received sacral neuromodulation (InterStim) or onabotulinumtoxinA (Botox A) therapy during a 2-yr period. We found that both therapies had similar success in reducing UUI symptoms, and adverse events were low. However, women in the BotoxA group had higher satisfaction and endorsement with their treatment, but with a higher chance of a urinary tract infection. We conclude that both therapies offer sustained reduction in daily incontinence over 2 yr.

Efficacy of botulinum toxin in treating myofascial pain and occlusal force characteristics of masticatory muscles in bruxism.

AIM AND OBJECTIVE: The present study was conducted in patients with bruxism to evaluate the effect of botulinum toxin type A (BTX-A) (Botox, Allergan, Inc., Irvine, CA, USA) in the treatment of myofascial pain and the occlusal force characteristics of masticatory muscles. MATERIALS AND METHODS: Twenty-four diagnosed with bruxism were randomly divided into three groups (n = 8) and treated by bilateral intramuscular injection of BTX-A and placebo-treated with saline placebo injections and control group where no injections were given. The clinical parameters such as pain at rest and during chewing were assessed and occlusal force analysis system to measure the distribution of occlusal force in bruxism patients. All the three groups were assessed at baseline time and at 1 week, 3 months, and 6 months follow-up appointments. Descriptive analysis showed that improvements in parameters such as pain at rest; pain during chewing clinical outcome variables were higher in the botox treated group than in the placebo-treated subjects. RESULTS: The pain at rest and at chewing decreased in the BTX-A group while remaining constant in the placebo group and control group. There was a significant change in maximum occlusal force in the BTX-A group compared with the other two groups (P < 0.05, post hoc Bonferroni test, no exact P value), and there was no significant difference between the placebo and control groups (post hoc Bonferroni test, no exact P value). CONCLUSION: Results from the present study supported the efficacy of BTX-A to reduce myofascial pain symptoms in bruxers, and effective in reducing the occlusal force.

[Botulinus toxin in complex treatment of myofacial pain syndrome]. / Botulotoksin v kompleksnom lechenii patsientov s miofastsial'nym bolevym sindromom disfunktsii visochno-nizhnecheliustnogo sustava.

The aim of the study was to assess the efficacy of type A Botulinus toxin (BTA) in pain release by TMJ functional pain disorders. The study included 211 patients with TMJ functional pain disorder (20.4% males and 79.6% females; mean age 45.3 years). The patients underwent clinical examination and bioelectric activity assessment of masticatory muscles by electromyography (EMG). EMG specters of 20 healthy volunteers with intact dental arches served as a control. After examination BTA was injected in muscular pain trigger points. All patients had muscular hypertonus, unilateral in 88.6% and bilateral in 11.4%. EMG showed the decrease of masticatory muscle activity on affected side to mean values of 165±20 mkV (30.0%, p<0.05) and on contralateral side to 460±31 mkV (89.6%, p>0.05). BTA injections in tensed muscles released significantly muscle-induced facial pain and improved quality of life. During 6 months follow up myofacial pain disorder relapse was seen in 3 patients. The results allow recommending BTA injection in muscular pain trigger points for treatment of myofacial pain syndrome and prolonged muscle relaxation.

[Mapping of motor-points in the flexor muscles of the arm for the optimization of botulinum toxin injections in treatment of spasticity]. / Kartirovanie motornykh tochek myshts-sgibatelei ruki dlia optimizatsii vvedeniia botulinicheskogo toksina pri lechenii spastichnosti.

AIM: To study the location and verification of motor points (MP) of the upper limbs for targeting botulinum toxin (BT) type A injections in the treatment of spasticity. MATERIAL AND METHODS: Twenty healthy people were examined. Using electromyography a complete study of the muscles of the upper limbs was conducted. RESULTS: Anatomical localization of MP was performed. The location of MP is identical and does not depend on sex, age and the dominant limb. Tables and maps of MP locations are presented. CONCLUSION: MP in the flexor muscles of the arm were identified. A surface map with MP location was created. This data may improve the clinical efficacy and feasibility of MP targeting, when injecting BT in spasticity.

The effect of topical thiocolchicoside in preventing and reducing the increase of muscle tone, stiffness, and soreness: A real-life study on top-level road cyclists during stage competition.

In professional road cyclists, the majority of overuse injuries affect the lower limbs and are mostly represented by contractures or muscle shortening, characterized by an increase of tone and stiffness and a variation of elasticity. Treatment and prevention of these specific conditions may include physical, supplementary, and pharmacologic support. The aim of this real-life study was to determine: first, the alterations of tone, stiffness, elasticity, and soreness of rectus femoris (RF) and biceps femoris (BF) in top class cyclists engaged in 3 multistage races, and second, whether any variable in the management of the athletes may affect the prevention and/or reduction of such alterations.Twenty-three professional cyclists competing in 3 international, cycling stage races were assessed. Athletes could receive, upon the approval of the medical staff, physical, dietary, and/or pharmacological management which could include treatments with topical over-the-counter myorelaxants to prevent and/or reduce muscle contractures. MyotonPro was used to daily measure tone, stiffness, and elasticity in RF and BF in relaxed and contracted state after every stage. In parallel, BF and RF soreness was also assessed with a Likert scale.All athletes received the same general massage management; none of them received dietary supplements; some of the athletes were treated with a topical myorelaxant thiocolchicoside (TCC 0.25%) foam 3 times daily. TCC was identified as the only variable able to affect these muscle parameters in the cyclists. Tone, stiffness (regardless of the state), and soreness significantly increased over time either in BF or RF in all athletes. In the group of athletes that used TCC (n = 11; TCC+) the increase in tone, stiffness, and soreness was significantly lower than in the group not receiving TCC (n = 12; No-TCC). Elasticity varied coherently with tone and stiffness.A very intense and protracted sport activity increases muscular tone, stiffness, and soreness over time. Topical TCC foam significantly attenuates these alterations and might represent an efficient strategy both to prevent and manage contractures and their consequences in professional cyclists as well in athletes from other disciplines involving similar workloads.

Management of refractory idiopathic overactive bladder: intradetrusor injection of botulinum toxin type A versus posterior tibial nerve stimulation.

INTRODUCTION: To compare the safety and efficacy of posterior tibial nerve stimulation (PTNS) versus an intradetrusor injection of botulinum toxin type-A (BTX-A) 100 U in the management of refractory idiopathic overactive bladder (OAB). MATERIALS AND METHODS: We randomized 60 patients with refractory idiopathic OAB to receive an intradetrusor injection of BTX-A 100 U or PTNS. We assessed the patients at baseline, 6 weeks, 3 months, 6 months, and 9 months, and determined their clinical symptoms, overall OAB symptom score, urgency score, quality-of-life score, and urodynamic study parameters. RESULTS: The two patient groups had similar baseline characteristics. After treatment, the patients in the BTX-A group had significant improvements in all parameters compared to their baseline values. Patients in the PTNS group initially had significant improvements in all parameters, but by 9 months, this was no longer true for most parameters. In general, the improvements were more significant in the BTX group, especially at 9 months. In the BTX-A group, two patients (6.6%) needed clean intermittent catheterization; 3 patients (2 women and 1 man; 10% of patients) had mild hematuria, and 2 patients (6.6%) had urinary tract infections (UTIs). In the PTNS group, local adverse effects included minor bleeding spots and temporary pain. CONCLUSIONS: Intradetrusor injection of BTX-A and PTNS are both effective to manage refractory idiopathic OAB. BTX-A is more effective than PTNS and is also durable, minimally invasive, reversible, and safe, but it also has more side effects.

Localized myofascial pain responds better than referring myofascial pain to botulinum toxin injections.

Myofascial pain of the muscles of mastication is a common temporomandibular disorder. Patients unresponsive to conservative treatment modalities pose a therapeutic challenge to the treating clinician. The efficacy of intramuscular botulinum toxin injections for recalcitrant cases is still not well established due to mixed results from clinical trials. The Diagnostic Criteria of Temporomandibular Disorders (DC/TMD) classified chronic muscle pain broadly into a localized pattern (when pain is localized to the site of palpation or the muscle palpated) and a referring pattern (when the pain spreads beyond the boundary of the muscle being palpated). The medical records of 25 consecutive patients treated with botulinum were analysed retrospectively. Significant pain reduction was achieved in 69.2% of the patients with localized myofascial pain and 16.7% of the patients with referring myofascial pain (P=0.015). Seventy-seven per cent of the patients with localized myofascial pain reported using less analgesic throughout the follow-up period, whereas only 25% of the patients with referring myofascial pain (P=0.017). The effects of botulinum toxin in responsive patients subsided after a mean of 3.21 months. Patients with localized myofascial pain benefited from botulinum toxin injections, but patients with referring myofascial pain responded poorly to this treatment.

Clown-care reduces pain in children with cerebral palsy undergoing recurrent botulinum toxin injections- A quasi-randomized controlled crossover study.

OBJECTIVE: We investigated the impact of clown-care on pain in 45 children with cerebral palsy who underwent recurrent Botulinum-toxin injections (age 7.04± 4.68 years). Participants were randomized to receive either clown (n = 20) or standard (n = 25) -care. METHODS: Pain Visual-Analogue-Scale (range 1-5) was reported before and after procedures. Pain assessment was lower for children undergoing Botulinum-toxin injections with clown-care (2.89± 1.36) compared to standard-care (3.85± 1.39; p = 0.036) even though pain anticipated prior to procedures was similar (~3). FINDINGS: Children who underwent the first procedure with clown-care reported lower pain even after they crossed-over to the following procedure which was standard (p = 0.048). Carryover effect was more prominent in injection-naïve children (p = 0.019) and during multiple procedures (p = 0.009). Prior pain experience correlated with pain in subsequent procedures only when first experience was standard-care (p = 0.001). CONCLUSIONS: Clown-care alleviated pain sensation during Botulinum-toxin injections and initial clown-care experience reduced pain during subsequent injections even though clowns were not present. TRIAL REGISTRATION: clinicaltrials.gov ID # NCT01377883.

Effectiveness of botulinum toxin type A for the treatment of chronic masticatory myofascial pain: A case series.

BACKGROUND: The aim of this study is to evaluate the effectiveness of botulinum toxin type A (BTX-A) for the treatment of chronic masticatory myofascial pain (MMP) over 12 months and to test a standardized protocol. METHODS: This is a prospective case series of consecutive adult patients with chronic MMP treated with injection of BTX-A into the bilateral temporalis and masseter muscles. The authors used the same anatomic landmarks and dosage and followed each patient for 12 months. The primary outcome variables were reduction in pain measured with visual analog scale (VAS) and Physician Global Assessment (PGA). Secondary outcome variables were change in maximum pain-free opening, change in palpatory pain points in the face and oral cavity, and change in results from a questionnaire measuring disability, dysfunction, and psychosocial effects of the disease. RESULTS: The authors included 15 women and 4 men (mean [standard deviation] age, 32.7 [6.9] years) in the study. Pain decreased significantly as measured with the VAS (P < .0001) and PGA (P < .0001). Maximum pain-free opening increased significantly (P = .010), but maximum voluntary opening did not change significantly (P = .837). The number of palpatory pain points (P < .0001) and the symptom questionnaire score decreased over time (P < .0001). CONCLUSIONS: The results of this case series suggest that injecting BTX-A into the bilateral temporalis and masseter muscles may be a safe and effective treatment for chronic MMP. PRACTICAL IMPLICATIONS: Controlled clinical trials are needed to confirm whether administration of BTX-A is effective in treating facial pain.

Does the method of botulinum neurotoxin injection for limb spasticity affect outcomes? A systematic review.

OBJECTIVE: To systematically review randomized controlled trials of botulinum neurotoxin for limb spasticity to determine whether different injection techniques affect spasticity outcomes. METHODS: MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials electronic databases were searched for English language human randomized controlled trials from 1990 to 13 May 2016. Studies were assessed in duplicate for data extraction and risk of bias using the Physiotherapy Evidence Database scale and graded according to Sackett's levels of evidence. RESULTS: Nine of 347 studies screened met selection criteria. Four categories of botulinum neurotoxin injection techniques were identified: (1) injection localization technique; (2) injection site selection; (3) injectate volume; (4) injection volume and site selection. There is level 1 evidence that: ultrasound, electromyography, and electrostimulation are superior to manual needle placement; endplate injections improve outcomes vs. multisite quadrant injections; motor point injections are equivalent to multisite injections; high volume injections are similar to low volume injections; and high volume injections distant from the endplate are more efficacious than low volumes closer to the endplate. CONCLUSION: Level 1 evidence exists for differences in treatment outcomes using specific botulinum neurotoxin injection techniques. Findings are based on single studies that require independent replication and further study.

Analgesic Effect of Botulinum Toxin A in Myofascial Pain Syndrome Patients Previously Treated with Local Infiltration of Anesthetic and Steroids.

The purpose of this study was to evaluate the analgesic effect of botulinum toxin A (BoNTA) injections in patients with myofascial pain syndrome (MPS) who were previously treated with the local infiltration of anesthetic and steroids (LIAS). The study included a retrospective phase and a longitudinal open-label prospective phase, which were conducted on consecutive patients with MPS previously treated with the local infiltration of anesthetic (levobupivacaíne 0.25%) and steroids (triamcinolone 40 mg). Eligible patients were treated with a single intramuscular injection of BoNTA (Botox; Allergan, Inc., Irvine, CA). The treatment efficacy was determined according to the degree of pain relief obtained. Eighty-two patients met the inclusion/exclusion criteria and were included in the study. Successful results were obtained for 32 (39.0%) and 30 (36.6%) patients, during treatment with BoNTA and LIAS, respectively. The mean (standard deviation) length of the analgesic effect was significantly longer with BoNTA (29.6 [SD = 17.7] weeks) than with LIAS (8.5 [SD = 6.4] weeks), P <.0001. As regards the side effects, 19 (23.2%) patients reported transient soreness at the injection site for 2 to 3 days with BoNTA. The MPS patients previously treated with a local infiltration of anesthetic and steroids who then received a single injection of BoNTA experienced significantly reduced pain for a relatively long time.

Efficacy of two injection-site localisation techniques for botulinum toxin injections: a single-blind, crossover, randomised trial protocol among adults with hemiplegia due to stroke.

INTRODUCTION: Botulinum toxin injections are an effective treatment for limb spasticity following stroke. Different tracking techniques are used for this purpose: palpation, electrostimulation, electromyography and ultrasound. Yet very few studies have compared these different techniques, and none has successfully proved the superior efficacy of ultrasound-guided injections compared to another tracking method. The primary objective of our study was therefore to compare the efficacy of botulinum toxin injections depending on the tracking technique used: ultrasound versus electrostimulation. METHODS AND ANALYSIS: This is a clinical, single-centre, prospective, interventional, single-blind, crossover, randomised trial. In total, 30 patients aged between 18 and 80 years presenting with triceps surae spasticity (evaluated >1 on the modified Ashworth scale) associated with hemiplegia sequelae due to stroke will be included. The patients will be selected among those who attend for consultation the Physical Medicine and Rehabilitation Department of the Clermont-Ferrand University Hospital. One group will receive the abobotulinumtoxinA (BoNT-A) injection guided by electrostimulation then ultrasound, and the second group's botulinum toxin injections will be guided by ultrasound then electrostimulation. For each patient, the duration of study participation is 5 months. The primary end point is variation in passive ankle dorsiflexion range of motion at slow and high speeds (Tardieu scale) with the knee straight. ETHICS AND DISSEMINATION: This study received ethics approval form the CPP of Rhônes-Alpes region. Results will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT01935544; pre-results.

Cortical and spinal excitability in patients with multiple sclerosis and spasticity after oromucosal cannabinoid spray.

BACKGROUND: Delta-9-tetrahydrocannabinol and cannabidiol (THC:CBD) oromucosal spray (Sativex®) has been recently approved for the management of treatment-resistant multiple sclerosis (MS) spasticity. Although the symptomatic relief of Sativex® on MS-spasticity has been consistently demonstrated, the pathogenetic implications remain unclear and the few electrophysiological studies performed to address this topic yielded controversial results. We therefore aimed to investigate the mechanisms underpinning the modulation of spastic hypertonia by Sativex®, at both central and spinal levels, through an extensive neurophysiological battery in patients with MS. METHODS: Nineteen MS patients with treatment-resistant spasticity were recruited. Before and after 4weeks of treatment with Sativex® patients were clinically assessed with the Modified Ashworth Scale (MAS) and underwent a large neurophysiological protocol targeting measures of excitability and inhibition at both cortical [e.g., intracortical facilitation (ICF), short (SICI) and long (LICI) intracortical inhibition, cortical silent period (CSP)] and spinal level [e.g., H-reflex, H/M ratio and recovery curve of the H-reflex (HRC)]. A group of 19 healthy subjects served as controls. RESULTS: A significant reduction of the MAS score after 4weeks of Sativex® treatment was detected. Before treatment, an increase in the late facilitatory phase of HRC was recorded in patients compared to the control group, that normalised post treatment. At central level, SICI and LICI were significantly higher in patients compared to healthy subjects. After therapy, a significant strengthening of inhibition (e.g. reduced LICI) and a non-significant facilitation (e.g. marginally increased ICF) occurred, suggesting a modulatory effect of Sativex® on different pathways, predominantly of inhibitory type. Sativex® treatment was well tolerated, with only 3 patients complaining about dizziness and bitter taste in their mouth. DISCUSSION: Our results confirm the clinical benefit of Sativex® on spastic hypertonia and demonstrate that it might modulate both cortical and spinal circuits, arguably in terms of both excitation and inhibition. We suggest that the clinical benefit was likely related to a net increase of inhibition at cortical level that, in turn, might have influenced spinal excitability.