botox-treatment

Botulium Toxin Treatment

Equipment Requirements:

Teflon-coated, hollow EMG needle
Referencd lead with surface electrode
EMG machine (standard or portable)
ES (in EMG machine or as portable unit)
Alcohol skin cleanser
Syringe
Preservation-free 0.9% saline
Botulinum Toxin

BTX-A INJECTIONS
- How is BTX-A injected?
  - BTX-A is injected in the same manner as local anesthetics. A 23-gauge to 26-gauge needle is placed into the target muscle. Targeting is confirmed by palpation in larger muscles, or by EMG or ES monitoring in small or deep muscle groups. Ultrasound, fluoroscopy or CT may also be used.
  - Hollow electromyography needles are often used, decreasing the number of needle sticks and increasing the accuracy of needle placement. Local anesthetic cream, general anesthesia, or sedation may be necessary, particularly for some children. Following preparation of the area to be injected, sterile gloves and a "no-touch" skin entry site technique are used.
- How often can BTX-A injections be given?
  - BTX-A injections are usually needed at 3 to 6 month intervals to maintain therapeutic benefit, depending on the location and severity of spasticity. Reinjections should not be given any sooner than 3 months after the last injections to decrease the possibility antibody formation.

Injection Preparation

Kept frozen in vial until use
Normal saline (preservative-free 0.9% saline solution)
- used within 4 hours
- store @ 2 to 4 degrees until use
- toxin diluted to desired concentration just prior to usage
1.0 ml syringes
Needles: 26 - 30 gauge, 1/2 inch (1.5cm)
Alcohol wipes; gauze sponges

EMG machine

teflon-coated monopolar injection needles
EMG guidance is not required for injection into most muscles
EMG guidance can facilitate the injection of deeper muscles

EMG guidance can optimize the treatment of conditions in which the identity of the hyperactive muscle is challenging or unclear on clinical exam (torticollis, retrocollis, combination)

EMG is commonly used to confirm needle location before BTX injection
The objective is to record motor unit potentials that are close in roximity to the needle tip, and confirm placement in the target tissue
Crisp, full sized bi- or triphasic motor unit potentials (MUPs) with fast rise times indicate placement near a contracting fascicle, though not necessarily the target fascicle
MUP activity should be absent during passive range of motion of the target, and voluntary activation of non-target muscles

Injection Technique
- Toxin diluted to desired concentration
- Needle size dependent upon site of injection and physician preference
- Select most actively contracting muscles; Aspirate - then inject

Dilutions for Injection

Each vial contains 100 Units botulinum toxin type A

Final Dilution	Saline Added to Vial
2.5 U/0.1 ml	4 ml
5.0 U/0.1 ml	2 ml
10.0 U/0.1 ml	1 ml

BOTOXŽ and DYSPORT UNITS
- When converting between brands of toxin, conversion ration is approximately 1:4
- 1 BOTOXŽ Unit = 3 - 5 DYSPORT Units
- The reason for this disparity is not clear
TREATMENT
- Patient is awake,with no surgical anesthesia risk
- High patience acceptance compared to systemic medications
- Extremely effective in reducing excessive muscle tone and associated pain and deformity
- Benefits persists for months
- Facilitates rehabilitation goals, i.e. increased ROM, ease of hygiene, positioning, fit for orthotics or braces
- Improves "quality of life" for patient and care-givers
- Effects are local and dose dependent; minimal distal effect
- Selected, graded weakness in injected and adjacent muscles
- If too much weakness develops, strength gradually returns
- Can be used in conjunction with other therapies: i.e.: systemic medications, intrathecal baclofen pump - to allow optimal tailoring of therapy for clinical situation