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OnabotulinumtoxinA muscle injection patterns in adult spasticity: a systematic literature review

Luba Nalysnyk1*, Spyridon Papapetropoulos2, Philip Rotella3, Jason C Simeone3, Katharine E Alter45 and Alberto Esquenazi6

Author Affiliations

1 Epidemiology & Database Analytics, United BioSource Corporation, Lexington, MA, USA

2 Neurosciences, Medical Affairs, Allergan, Inc., Irvine, CA, USA

3 Health Economics and Epidemiology, Evidera, Lexington, MA, USA

4 Rehabilitation Medicine, Mount Washington Pediatric Hospital, Baltimore, MD, USA

5 Rehabilitation Medicine, NIH, Bethesda, MD, USA

6 Gait & Motion Analysis Laboratory, MossRehab & Albert Einstein Medical Center, Elkins Park, PA, USA

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BMC Neurology 2013, 13:118  doi:10.1186/1471-2377-13-118

Published: 8 September 2013



OnabotulinumtoxinA has demonstrated significant benefit in adult focal spasticity. This study reviews the injection patterns (i.e., muscle distribution, dosing) of onabotulinumtoxinA for treatment of adult spasticity, as reported in published studies.


A systematic review of clinical trials and observational studies published between 1990 and 2011 reporting data on muscles injected with onabotulinumtoxinA in adult patients treated for any cause of spasticity.


28 randomized, 5 nonrandomized, and 37 single-arm studies evaluating 2,163 adult patients were included. The most frequently injected upper-limb muscles were flexor carpi radialis (64.0% of patients), flexor carpi ulnaris (59.1%), flexor digitorum superficialis (57.2%), flexor digitorum profundus (52.5%), and biceps brachii (38.8%). The most frequently injected lower-limb muscles were the gastrocnemius (66.1% of patients), soleus (54.7%), and tibialis posterior (50.5%). The overall dose range reported was 5–200 U for upper-limb muscles and 10–400 U for lower-limb muscles.


The reviewed evidence indicates that the muscles most frequently injected with onabotulinumtoxinA in adults with spasticity were the wrist, elbow, and finger flexors and the ankle plantar flexors. OnabotulinumtoxinA was injected over a broad range of doses per muscle among the studies included in this review, but individual practitioners should be mindful of local regulatory approvals and regulations.

Botulinum toxin; OnabotulinumtoxinA; Spasticity; Muscles; Injection patterns