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Open Access Study protocol

Study protocol: precision of a protocol for manual intramuscular needle placement checked by passive stretching and relaxing of the target muscle in the lower extremity during BTX-A treatment in children with spastic cerebral palsy, as verified by means of electrical stimulation

Jessica Warnink-Kavelaars12*, Roland Jeroen Vermeulen3 and Jules Guilhelmus Becher1

Author Affiliations

1 Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU University Medical Centre, Boelelaan 1018, Amsterdam, the Netherlands

2 Division of Child and Adolescent Rehabilitation, Reade Centre for Rehabilitation and Rheumatology, Overtoom 283, Amsterdam, the Netherlands

3 Department of Child Neurology, Neuroscience Campus Amsterdam, VU University Medical Centre, Boelelaan 1018, Amsterdam, the Netherlands

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BMC Pediatrics 2013, 13:129  doi:10.1186/1471-2431-13-129

Published: 22 August 2013

Abstract

Background

Intramuscular injection of botulinum toxin type-A given by manual intramuscular needle placement in the lower extremity under general anaesthesia is an established treatment and standard of care in managing spasticity in children with spastic cerebral palsy. Optimal needle placement is essential. However, reports of injection and verification techniques used in previous studies have been partly incomplete and there are methodological shortcomings. This paper describes a detailed protocol for manual intramuscular needle placement checked by passive stretching and relaxing of the target muscle for each individual muscle injection location in the lower extremity during botulinum toxin type-A treatment under general anaesthesia in children with spastic cerebral palsy. It explains the design of a study to verify this protocol, which consists of an injection technique combined with a needle localizing technique, as by means of electrical stimulation to determine its precision.

Methods

Setting: University Medical Centre, Department of Paediatric Rehabilitation Medicine, the Netherlands.

Design: prospective observational study.

Participants: children with spastic cerebral palsy, aged 4 to 18 years, receiving regular botulinum toxin type-A treatment under general anaesthesia to improve their mobility, are recruited from the Department of Paediatric Rehabilitation Medicine at VU University Medical Centre, Amsterdam, the Netherlands.

Method: a detailed protocol for manual intramuscular needle placement checked by passive stretching and relaxing of the target muscle has been developed for each individual muscle injection location of the adductor brevis muscle, adductor longus muscle, gracilis muscle, semimembranosus muscle, semitendinosus muscle, biceps femoris muscle, rectus femoris muscle, gastrocnemius lateralis muscle, gastrocnemius medialis muscle and soleus muscle. This protocol will be verified as by means of electrical stimulation.

Technical details: 25 mm or 50 mm Stimuplex-needle and a Stimuplex-HNS-12 electrical stimulator will be used.

Discussion

Botulinum toxin type-A injected in the intended muscle is expected to yield the greatest effect in terms of activities. Protocols for manual intramuscular needle placement should be described in detail and verified to determine its precision. Detailed and verified protocols are essential to be able to interpret the results of botulinum toxin type-A treatment studies.

Keywords:
Needle placement; Botulinum toxin type-A; Electrical stimulation; Children; Cerebral palsy; Spasticity; Injections