The 40 injection sessions involving the upper limbs were eliminated from consideration, as were 5 sessions with patients more than 18 years of age, 2 in which the data were insufficient, and 1 because localization had been exclusively anatomical. The remaining sessions were analyzed. Average age of the children was An average of 5. Forty-three percent of the subjects were girls. The groups in which localization was obtained by either ultrasound or electrostimulation did not significantly differ in terms of age, number of injection sites, average duration of injection, volume injected or pre-analgesic techniques applied.
As regards hydroxyzine and paracetamol, frequency of use was too low to carry out statistical analysis. As shown in Fig. The VAS average was significantly higher in the electrostimulation group than in the ultrasound group: 4.
The average FLACC score was significantly higher in the electrostimulation group than in the ultrasound group: 3. Our findings show that whether pain is measured by self-evaluation or by hetero-evaluation, it is significantly lower when toxin injections are carried out using ultrasound localization.
To our knowledge, this is the first study to assess the role of the localization technique chosen with regard to perception of the pain induced by botulinum toxin injections in children.
During muscle localization procedures, the pain provoked by electrostimulation is well known and has been observed by all the physicians having applied the technique. However, it was hardly obvious that lessened pain during the localization phase would lead to a significant decrease in perception of pain with regard to the injection taken as a whole.
In fact, the overall procedure of intramuscular botulinum toxin injection involves numerous additional algesic elements, such as the puncture, product injection itself, and the anxiety engendered by the hospital environment.
In this respect, recent studies by Brochard et al. And yet, our study demonstrates that a less painful localization technique, in this case ultrasound, indeed affects the child's perception of pain with regard to the procedure taken as a whole.
As regards quantitative pain assessment during the sessions organized for our sample, the VAS average came to 3. Click here to see the Library ], and they are close to those already reported, particularly by Brochard et al.
The study by Brochard et al. These results show that pain treatment with present-day protocols is still insufficient, and they underline the interest of ongoing attempts to develop a less painful technique.
During each session, an average of 5. On the other hand, in our study, the number of injection sites is lower 5. At times, ultrasound localization allows for injection of several muscles at a single injection site. For example, the soleus muscle and the underlying gastrocnemius muscle can receive one injection at a single site by inserting a needle more deeply and through visualization of the perimysium separating the two muscles. Our results do not include comparative evaluation of procedure effectiveness according to the localization technique applied; that was not the objective of our study.
Use of ultrasound obviously necessitates an available ultrasound apparatus, which is expensive and requires a sizable investment when centers do not possess the device. The main limit of this study is the lack of randomization, which would have enabled us to distribute the patients between the two groups according to the localization technique applied. In point of fact, a localization technique was chosen by the injecting physician according to the availability of an ultrasound apparatus.
Another methodological limit consisted of the impossibility of blinded evaluation. Indeed, our localization technique can hardly be hidden from the patient or the caretaker assessing the pain felt by the child during the procedure. Moreover, our study was not designed to evaluate comparative effectiveness from the standpoint of the efficacy of a procedure according to the localization technique applied.
Complementary studies are necessary. In our study, localization using electrostimulation intensified the pain provoked by injections of botulinum toxin in our group of children. Ultrasound is an interesting technique that could help to diminish the pain experienced during the localization phase and might lead to decreased perception of pain throughout the session.
Complementary studies in adult populations would be useful, and they could help to compare the effectiveness of therapeutic procedures according to the localization technique applied. Were ultrasound apparatuses to become less expensive to acquire, and were more PRM physicians to be trained, use of the technique could grow more widespread. The authors declare that they have no conflicts of interest concerning this article. Malheureusement la réalisation de ces injections intramusculaires est parfois douloureuse rendant ce geste difficile chez les enfants.
Il existe plusieurs techniques de repérage à notre disposition. Depuis quelques années, le repérage par échographie se développe. Des études récentes montrent son intérêt dans les injections intramusculaires pour le traitement de la spasticité chez les enfants. Sur le verso de la réglette, la cotation se fait de 0 à Les variables ont été exprimées en moyennes avec écarts-types pour les valeurs quantitatives et en pourcentages pour les valeurs qualitatives.
La valeur de p est considérée comme significative si inférieure à 0, Le logiciel SAS version 9. Les 40 séances où les injections avaient été effectuées au niveau des membres supérieurs ont été exclues, 5 séances ont été exclues car concernant des patients âgés de plus de 18 ans, 2 pour données insuffisantes, et 1 car le repérage avait été effectué anatomiquement uniquement.
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DresslerClinical presentation and management of antibody-induced failure of botulinum toxin therapyMovement Disordersvol. For this reason, we are beginning to inject deep muscles, like the tibialis posterior or upper limb muscles, with ultrasound guidance. In our study, the injecting practitioner already had a lot of experience.
It is plausible that the same study, but with a practitioner with less injection experience, would have revealed a more significant difference between the group for which ultrasound guidance was used and the one for which manual guidance was used; the ultrasound would have played a educational role for the doctor performing the injections. Finally, this technique probably provides a better level of injection safety, by permitting the practitioner to see, and thus to avoid, the vascular-nerve bundles.
This effectiveness level can be explained by the fact that the fibrotic and retractile phenomena are less significant in young children, thus permitting the anti-spastic effect of the toxin to be revealed more easily. It also seems that motor development is greater during this period, so eliminating the problematic spasticity has a rapid influence on overall motricity.
That this effectiveness is also better in children over 12 than in children from 6 to 12 years old was more surprising. This can probably be explained by the fact that many of the children over 12 had already had musculo-tendinous surgical treatments in their lower limbs, which helped the practitioner target more precisely the muscles to be injected, with higher doses per muscles than those that could be injected with multi-site injections for which the total dose set by the AMM must be distributed among several muscles.
Koman et al. The clinical effectiveness is dose-dependant, with significantly higher analytical improvement with doses greater than 0. The functional improvement measured by GMFM could at first glance seem limited, since it only involved a quarter of our patients. In contrast, Ubhi et al. In fact, the other categories were often already saturated at the time of the pre-injection examination in walking children with cerebral palsy, and thus there was no possibility for improvement in these categories.
One other factor limiting the pertinence of these functional results is that our post-toxin evaluation was done rapidly, 3 or 4 weeks after the injections, before the successive cast fittings for those who could benefit from this procedure. The primary limit of our study is that it was not a double-blind study, which makes interpreting the results less reliable.
However, this research highlights the usefulness of ultrasound guidance for botulinum toxin injections in the lower limbs of children with cerebral palsy, both on the clinical and functional levels. Because both a radiologist and a re-education specialist need to be available at the same time, the muscle groups that would benefit the most from this technique e.
This research should be continued with more sensitive methods for evaluating effectiveness and higher doses of botulinum toxin. Une évaluation régulière de cette pratique est nécessaire. Les enfants étaient revus cliniquement et fonctionnellement trois à four semaines après les injections.
Comme Ubhi et al. Selon la corpulence du patient, la fréquence de la sonde linéaire variait de six à Le test t était utilisé pour la comparaison entre deux groupes. La meilleure efficacité clinique est retrouvée chez les enfants de moins de six ans 53 p.
Efficacité clinique de la toxine botulique selon les groupes musculaires, en pourcentage du nombre de groupes musculaires injectés. On retrouve une amélioration fonctionnelle globale chez 24 p. Dans cette étude, nous retrouvons une efficacité clinique analytique chez environ la moitié des enfants. On retrouve chez ces patients une grande variabilité interindividuelle. Dans celle de Wissel et al.
Il est à noter que notre évaluation post-toxine a été réalisée à trois ou quatre semaines, avant la réalisation de plâtres successifs qui était parfois décidée à cette même consultation post-toxine. Une nouvelle évaluation après la réalisation de plâtres aurait alors sans aucun doute montré une amélioration analytique plus nette. Nous commençons de ce fait à injecter sous échographie des muscles profonds comme le tibial postérieur ou des muscles du membre supérieur.
Le fait que cette efficacité soit également meilleure chez les enfants de plus de 12 ans par rapport aux enfants de 6—12 ans est plus surprenant. Ubhi et al. Muscles fins? Français Español Italiano.
Journal page Archives Sommaire. Rousseaux, W. Daveluy, O.