Survey of Canadian Physician Use of Botulinum Toxin A (BoNT-A) for Paratonia: Real World Insights.

Paratonia is a form of hypertonia characterized by an inability to relax muscles in the setting of cognitive impairment. Paratonia results in pain, refusal of care, and caregiver burden. We sent surveys to 67 Canadian physiatrists and neurologists regarding their experience treating paratonia with botulinum toxin A (BoNT-A). Twenty-seven survey respondents were included in the analysis. Thirteen percent of survey respondents treating paratonia with BoNT-A reported a significant clinically relevant improvement; 74% endorsed a moderately clinically relevant improvement; 13% endorsed a slight clinically relevant improvement. Ninety percent of survey respondents endorsed significant barriers in treating paratonia with BoNT-A.

Spasticity Management Teams, Evaluations, and Tools: A Canadian Cross-Sectional Survey.

OBJECTIVE: The objective of this study is to determine the physical evaluations and assessment tools used by a group of Canadian healthcare professionals treating adults with spasticity. METHODS: A cross-sectional web-based 19-question survey was developed to determine the types of physical evaluations, tone-related impairment measurements, and assessment tools used in the management of adults with spasticity. The survey was distributed to healthcare professionals from the Canadian Advances in Neuro-Orthopedics for Spasticity Congress database. RESULTS: Eighty study participants (61 physiatrists and 19 other healthcare professionals) completed the survey and were included. Nearly half (46.3%, 37/80) of the participants reported having an inter- or trans-disciplinary team managing individuals with spasticity. Visual observation of movement, available range of motion determination, tone during velocity-dependent passive range of motion looking for a spastic catch, spasticity, and clonus, and evaluation of gait were the most frequently used physical evaluations. The most frequently used spasticity tools were the Modified Ashworth Scale, goniometer, and Goal Attainment Scale. Results were similar in brain- and spinal cord-predominant etiologies. To evaluate goals, qualitative description was used most (37.5%). CONCLUSION: Our findings provide a better understanding of the spasticity management landscape in Canada with respect to staffing, physical evaluations, and outcome measurements used in clinical practice. For all etiologies of spasticity, visual observation of patient movement, Modified Ashworth Scale, and qualitative goal outcomes descriptions were most commonly used to guide treatment and optimize outcomes. Understanding the current practice of spasticity assessment will help provide guidance for clinical evaluation and management of spasticity.

Acute neurophysiologic effects of botulinum toxin type A intramuscular injection on extensor digitorum brevis muscle in healthy adults.

INTRODUCTION: Anecdotal clinical experience shows that patients often indicate that their spasticity improves on the day of treatment with intramuscular botulinum injection. Previous research shows that compound motor action potentials (CMAPs) decrease 48 h post-injection. However, no studies to date have assessed the neurophysiological changes less than 48 h post-injection. METHODS: Fifteen healthy control subjects (10 F; mean age 41 ± 11 years) participated in this randomized double-blind study. We injected 10 units of either onabotulinumtoxinA or incobotulinumtoxinA in the extensor digitorum brevis (EDB) muscle, one in each foot. We performed serial CMAP assessments using nerve conduction study of the peroneal nerve at following time intervals after botulinum injection - 2, 4, 6, 24, 26, 28, 30, 48, 72 h and 6 days post-injection. We used an ANOVA with repeated measures separately for each type of toxin. RESULTS: Post-hoc tests using the Bonferroni correction revealed that there was a statistically significant decrease in the mean EDB CMAP amplitude from baseline starting at 24 h post-injection in the incobotulinumtoxinA group (p < 0.05) and 4 h post-injection in the onabotulinumtoxinA group (p < 0.05). CONCLUSION: We conclude that both toxin formulations tested in this study exert a significant decrease in EDB CMAP amplitude in the period of <48 h post-injection.

Practice Patterns of Physicians Using Adjunct Therapies with Botulinum Toxin Injection for Spasticity: A Canadian Multicenter Cross-Sectional Survey.

BACKGROUND: Adjunct therapies are nonpharmacological treatments used with botulinum toxin (BoNT) injection that may improve spasticity outcomes. It has been suggested that physicians consider adjunct therapies as a part of comprehensive spasticity management. It is unclear which adjunct therapies are used by physicians in clinical practice. OBJECTIVE: To determine physician practice patterns and perceptions of use of adjunct therapies following BoNT injection for limb spasticity. DESIGN: Cross-sectional national survey of current clinical practice using a 22-item questionnaire developed by the authors. SETTING: Not applicable. PARTICIPANTS: Survey respondents were physicians actively administering BoNT injections for limb spasticity management across Canada (N = 48). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Types of adjunct therapies used by physicians; physician opinions on barriers to adjunct therapy use, patient preferences, and future research priorities. RESULTS: Most physicians prescribe home stretching programs, home active exercise programs, and splinting; however, many physicians perceive that these same adjunct therapies are unwanted by patients. A minority of physicians prescribe electrical stimulation (ES), transcutaneous electrical nerve stimulation (TENS), casting, and extracorporeal shockwave therapy; financial limitations and perceived lack of evidence were identified as barriers to their use. Significantly more physicians practicing in academic settings compared with nonacademic, community, and private practice settings used functional ES (59% vs 11%) and TENS (41% vs 0%) as adjunct therapies (P < .05). Research priorities included determining the effectiveness of immediate postinjection application of adjunct therapies (eg, injected muscle activation with ES or stretching) and nutraceuticals. CONCLUSIONS: Canadian physicians frequently use adjunct therapies in combination with BoNT injection to treat spasticity. Financial and time constraints are identified as barriers to implementation of adjunct therapies that are currently supported by research, and patient preferences may also affect compliance. Future research should focus on adjunct therapies that overcome these barriers.

Challenges in the management of anticoagulated patients with focal spasticity.

INTRODUCTION: In patients taking warfarin, the level of anticoagulation status using the International Normalized Ratio (INR) is one consideration before botulinum toxin type-A (BoNTA) injections; however, there is wide diversity in physician approaches and preferences in using INR status and the INR cut-off values to determine suitability of anticoagulated patients for BoNTA injections. There is no standard approach for treating spasticity with BoNTA injections in patients who are on warfarin or direct anticoagulants (DOACs). OBJECTIVE: Our objective was to review the challenges in the use of BoNTA in patients who are receiving anticoagulants and to present highlights of the Canadian Delphi Study on the management of anticoagulated patients with limb spasticity. METHODS: We present a hypothetical case of a patient with focal spasticity who is also receiving anticoagulants. RESULTS: The results when injecting BoNTA in anticoagulated patients were as follows: 1) BoNTA injections should not be withheld purely because a patient is anticoagulated and other factors need to be considered. 2) A 25G (or higher) needle should be used when injecting into the deepleg compartment muscles. 3) The INR level ≤3.5 should be used when injecting the deep posterior leg compartment muscles. 4) The concern regarding bleeding when using DOACs remain the same as with warfarin when INR is in the therapeutic range. 6) The dose and scheduling of DOACs need not be altered prior to BoNTA injections. CONCLUSIONS: The Canadian consensus statements assist clinicians by providing a framework for consideration to navigate the challenges when injecting BoNTA in anticoagulated patients with spasticity.

Tolerability and Efficacy of Customized IncobotulinumtoxinA Injections for Essential Tremor: A Randomized, Double-Blind, Placebo-Controlled Study.

In this first, double-blind, randomized, placebo-controlled exploratory trial, we evaluate the efficacy and safety of incobotulinumtoxinA and feasibility of using kinematic tremor assessment to aid in the planning of muscle selection in a multicenter setting. Reproducibility of the planning technology to other clinical sites was explored. In this trial (NCT02207946), patients with upper-limb essential tremor (ET) were randomized 2:1 to a single treatment cycle of incobotulinumtoxinA or placebo. A tremor kinematic analytics investigational device was used to define a customized muscle set for injection, related to the pattern of the wrist, forearm, elbow, and shoulder tremor for each patient, and the incobotulinumtoxinA dose per muscle (total ≤ 200 U). Fahn-Tolosa-Marin (FTM) Part B motor performance score, Global Impression of Change Scale (GICS), and kinematic analysis-based efficacy evaluations were assessed. Thirty patients were randomized (incobotulinumtoxinA, n = 19; placebo, n = 11). FTM motor performance scores showed greater improvement with incobotulinumtoxinA versus placebo at Week 4 (p= 0.003) and Week 8 (p= 0.031). The physician-rated GICS score indicated improvement with incobotulinumtoxinA versus placebo at Week 4 (p < 0.05). IncobotulinumtoxinA also decreased accelerometric hand-tremor amplitude versus placebo from baseline to Week 4 (p= 0.004) and Week 8 (p < 0.001), with persistent tremor reduction up to 24 weeks post-injection. IncobotulinumtoxinA produced a slight and transient reduction of maximal grip strength versus placebo; two patients reported localized finger muscle weakness. Customized incobotulinumtoxinA injections decreased tremor severity and improved hand motor function in patients with upper-limb ET after a single injection cycle, with a favorable tolerability profile. The study showed that tremor kinematic analytics technology could be successfully scaled for use in other clinical sites.

Interrater Reliability of the Modified Ashworth Scale with Standardized Movement Speeds: A Pilot Study.

Purpose: The purpose of this study was to estimate the interrater reliability of the Modified Ashworth Scale (MAS) using consistent movement speeds guided by a metronome when measuring wrist flexor and ankle plantar flexor spasticity in patients with an upper motor neuron (UMN) lesion. The MAS has been found to have inconsistent interrater reliability for scoring the degree of spasticity. Method: This quantitative cross-sectional pilot study occurred in the outpatient spasticity clinic of a community rehabilitation hospital. Participants were a convenience sample of 20 patients with UMN lesions receiving botulinum toxin type A injections for focal spasticity. For each of the muscle groups tested, different pairs of evaluators scored spasticity on the MAS at a velocity of 130° per second. Evaluators were physical therapy students trained by an experienced physical therapist in MAS assessment. Weighted κ values were calculated to measure interrater reliability for each muscle group. Results: The weighted κ values for the wrist flexors and ankle plantar flexors were, respectively, moderate (κw = 0.54; 95% CI: 0.21, 0.87) and slight (κw = 0.08; 95% CI: -0.34, 0.50). Conclusion: Using consistent movement velocity, novice evaluators were able to score spasticity with reasonable interrater reliability when assessing the wrist flexors but not the ankle plantar flexors.

Objectif : évaluer la fiabilité interévaluateur de l'échelle modifiée d'Ashworth (ÉMA) à l'aide de vitesses de mouvement uniformes orientées par un métronome pour mesurer la spasticité des fléchisseurs du poignet et des fléchisseurs plantaires de la cheville chez les patients victimes d'une lésion des motoneurones supérieurs (MNS). Il a été établi que la fiabilité interévaluateur des MNS était inégale lors du classement du degré de spasticité. Méthodologie : la présente étude pilote transversale quantitative a eu lieu à la clinique de spasticité ambulatoire d'un hôpital de réadaptation communautaire. Les participants potentiels provenaient d'un échantillon de commodité formé de 20 patients victimes de lésions des MNS qui se faisaient injecter de la toxine botulique de type A pour soulager leur spasticité focale. Des dyades d'évaluateurs différentes ont classé la spasticité sur l'ÉMA pour chacun des groupes musculaires évalués, à une vélocité de 130 degrés à la seconde. Les évaluateurs étaient des étudiants en physiothérapie formés par un physiothérapeute chevronné dans l'évaluation de l'ÉMA. Ils ont calculé les valeurs kappa pondérées pour mesurer la fiabilité interévaluateur de chaque groupe musculaire. Résultats : les valeurs kappa pondérées des fléchisseurs du poignet et des fléchisseurs plantaires de la cheville étaient modérées (κp = 0,54; IC à 95 % : 0,21; 0,87) et modestes (κp = 0,08; IC à 95 % : −0,34; 0,50), respectivement. Conclusion : au moyen d'une vélocité de mouvement uniforme, les évaluateurs novices ont pu respecter une fiabilité interévaluateur raisonnable pour classer la spasticité des fléchisseurs du poignet, mais pas des fléchisseurs plantaires de la cheville.

Impact of Passive Leg Cycling in Persons With Spinal Cord Injury: A Systematic Review.

Background: Passive leg cycling is an important clinical tool available for rehabilitation after spinal cord injury (SCI). Passive cycling can be used to derive exercise-related benefits in patients with poor motor control. There have been a number of studies examining the effects of passive cycling on a variety of outcomes. There is need for a systematic assessment of the cycling parameters and the associated clinical changes in cardiovascular, neuromuscular, and musculoskeletal outcomes after passive cycling. Objectives: To assess the effectiveness of passive leg cycling interventions on cardiovascular, neuromuscular, and musculoskeletal outcomes post SCI, and to describe intensity, duration, and type of passive leg cycling post SCI. Methods: PRISMA guided systematic review of literature based on searches in the following databases: PubMed/MEDLINE, PEDro, EMBASE, Cochrane Library, and Google Scholar. Peer-reviewed publications that were written in English were included if they described the effects of a single session or multiple sessions of passive leg cycling in persons post SCI. Results: Eleven papers were included: two were randomized controlled trials (RCTs), one was a crossover trial, and the rest were pre-post single-group designs. Three studies (including two RCTs) reported statistically significant benefits of multiple sessions of passive cycling on leg blood flow velocity, spasticity, reflex excitability and joint range of motion, and markers of muscle hypertrophy. About half of the single session studies showed statistically significant improvement in acute responses. Conclusion: Multiple sessions of passive leg cycling showed benefits in three categories - cardiovascular, musculoskeletal, and neurological - with medium to large effect sizes.

A Delphi-Based Consensus Statement on the Management of Anticoagulated Patients With Botulinum Toxin for Limb Spasticity.

OBJECTIVE: To create a consensus statement on the considerations for treatment of anticoagulated patients with botulinum toxin A (BoNTA) intramuscular injections for limb spasticity. DESIGN: We used the Delphi method. SETTING: A multiquestion electronic survey. PARTICIPANTS: Canadian physicians (N=39) who use BoNTA injections for spasticity management in their practice. INTERVENTIONS: After the survey was sent, there were e-mail discussions to facilitate an understanding of the issues underlying the responses. Consensus for each question was reached when agreement level was ≥75%. MAIN OUTCOME MEASURES: Not applicable. RESULTS: When injecting BoNTA in anticoagulated patients: (1) BoNTA injections should not be withheld regardless of muscles injected; (2) a 25G or smaller size needle should be used when injecting into the deep leg compartment muscles; (3) international normalized ratio (INR) level should be ≤3.5 when injecting the deep leg compartment muscles; (4) if there are clinical concerns such as history of a fluctuating INR, recent bleeding, excessive or new bruising, then an INR value on the day of injection with point-of-care testing or within the preceding 2-3 days should be taken into consideration when injecting deep compartment muscles; (5) the concern regarding bleeding when using direct oral anticoagulants (DOACs) should be the same as with warfarin (when INR is in the therapeutic range); (6) the dose and scheduling of DOACs should not be altered for the purpose of minimizing the risk of bleeding prior to BoNTA injections. CONCLUSIONS: These consensus statements provide a framework for physicians to consider when injecting BoNTA for spasticity in anticoagulated patients. These consensus statements are not strict guidelines or decision-making steps, but rather an effort to generate common understanding in the absence of evidence in the literature.

Impact of Spasticity on Balance Control during Quiet Standing in Persons after Stroke.

BACKGROUND: Balance impairments, falls, and spasticity are common after stroke, but the effect of spasticity on balance control after stroke is not well understood. METHODS: In this cross-sectional study, twenty-seven participants with stroke were divided into two groups, based on ankle plantar flexor spasticity level. Fifteen individuals with high spasticity (Modified Ashworth Scale (MAS) score of ≥2) and 12 individuals with low spasticity (MAS score <2) completed quiet standing trials with eyes open and closed conditions. Balance control measures included centre of pressure (COP) root mean square (RMS), COP velocity, and COP mean power frequency (MPF) in anterior-posterior and mediolateral (ML) directions. Trunk sway was estimated using a wearable inertial measurement unit to measure trunk angle, trunk velocity, and trunk velocity frequency amplitude in pitch and roll directions. RESULTS: The high spasticity group demonstrated greater ML COP velocity, trunk roll velocity, trunk roll velocity frequency amplitude at 3.7 Hz, and trunk roll velocity frequency amplitude at 4.9 Hz, particularly in the eyes closed condition (spasticity by vision interaction). ML COP MPF was greater in the high spasticity group. CONCLUSION: Individuals with high spasticity after stroke demonstrated greater impairment of balance control in the frontal plane, which was exacerbated when vision was removed.

Patterns of botulinum toxin treatment for spasticity and bleeding complications in patients with thrombotic risk.

The purpose of this study was to assess the prevalence of compartment syndrome or major bleeding episodes and compare compartment syndrome, patient and intervention characteristics in 110 patients with stroke (treated with Warfarin, new oral anticoagulants, antiplatelet, or no anticoagulants) treated for spasticity in deep leg compartment muscles with botulinum toxin injections [onabotulinumtoxinA (n = 77); incobotulinumtoxinA (n = 33)]. We reviewed 674 injection cycles (range 1-25 cycles per patient) and found no cases of compartment syndrome in any patient groups.

Goals Set by Patients Using the ICF Model before Receiving Botulinum Injections and Their Relation to Spasticity Distribution.

Purpose: Goal Attainment Scaling (GAS) is used to assess functional gains in response to treatment. Specific characteristics of the functional goals set by individuals receiving botulinum toxin type A (BoNTA) injections for spasticity management are unknown. The primary objectives of this study were to describe the characteristics of the goals set by patients before receiving BoNTA injections using the International Classification of Functioning, Disability and Health (ICF) and to determine whether the pattern of spasticity distribution affected the goals set. Methods: A cross-sectional retrospective chart review was carried out in an outpatient spasticity-management clinic in Toronto. A total of 176 patients with a variety of neurological lesions attended the clinic to receive BoNTA injections and completed GAS from December 2012 to December 2013. The main outcome measures were the characteristics of the goals set by the participants on the basis of ICF categories (body functions and structures, activity and participation) and the spasticity distribution using Modified Ashworth Scale scores. Results: Of the patients, 73% set activity and participation goals, and 27% set body functions and structures goals (p<0.05). In the activity and participation category, 30% of patients set moving and walking goals, 28% set self-care and dressing goals, and 12% set changing and maintaining body position goals. In the body functions and structures category, 18% set neuromuscular and movement-related goals, and 8% set pain goals. The ICF goal categories were not related to the patterns of spasticity (upper limb vs. lower limb or unilateral vs. bilateral spasticity) or type of upper motor neuron (UMN) lesion (p>0.05). Conclusion: Our results show that patients receiving BoNTA treatment set a higher percentage of activity and participation goals than body functions and structures goals. Goal classification was not affected by type of spasticity distribution or type of UMN disorder.

Objectif : l'échelle de réalisation des objectifs (Goal Attainment Scaling ou GAS) est employée pour évaluer les gains fonctionnels en réponse à un traitement. On ne connaît pas les caractéristiques des objectifs fonctionnels établis par les personnes recevant des injections de toxine botulinique de type A (BoNTA) pour la prise en charge de la spasticité. Cette étude vise à décrire les caractéristiques des objectifs établis par les patients avant de recevoir des injections de BoNTA à l'aide de la Classification internationale du fonctionnement, du handicap et de la santé (CIF) et à déterminer si le modèle de distribution de la spasticité avait un effet sur les objectifs établis. Méthodologie : on a mené une revue rétrospective transversale des dossiers d'une clinique ambulatoire de prise en charge de la spasticité à Toronto. Au total, 176 patients ayant diverses lésions neurologiques sont venus à la clinique pour recevoir des injections de BoNTA et ont rempli la GAS entre décembre 2012 et décembre 2013. On a recensé les caractéristiques des objectifs en fonction des catégories de la CIF (fonctions organiques et structures anatomiques, activités et participation) et de la distribution de la spasticité à l'aide de l'échelle d'Ashworth modifiée. Résultats : de tous les patients, 73 % ont établi des objectifs liés aux activités et à la participation et 27 %, des objectifs liés aux fonctions organiques et aux structures anatomiques (p<0,05). Dans la catégorie des activités et de la participation, 30 % de tous les patients ont établi des objectifs par rapport à « marcher et se déplacer ¼, 28 % ont établi des objectifs par rapport aux « soins personnels ¼ et à « s'habiller ¼, et 12 %, par rapport à « modifier et maintenir sa position corporelle ¼. Dans la catégorie des fonctions organiques et des structures anatomiques, 18 % des participants ont établi des objectifs liés aux « fonctions de l'appareil locomoteur et au mouvement ¼ et 8 % ont établi des objectifs par rapport à la « douleur ¼. Les catégories d'objectifs de la CIF n'étaient pas liées aux modèles de spasticité (spasticité des membres supérieurs par rapport aux membres inférieurs ou spasticité unilatérale par rapport à bilatérale) ou au type de lésion des motoneurones supérieurs (p>0,05). Conclusion : nos résultats montrent que les patients qui reçoivent un traitement de BoNTA établissent un pourcentage plus élevé d'objectifs liés aux activités et à la participation qu'aux fonctions organiques et aux structures anatomiques. Le type de distribution de la spasticité ou le type de lésion des motoneurones n'a pas eu d'effet sur la classification des objectifs.

The effect of water-based exercises on balance in persons post-stroke: a randomized controlled trial.

OBJECTIVE: Water-based exercises have been used in the rehabilitation of people with stroke, but little is known about the impact of this treatment on balance. This study examined the effect of water-based exercises compared to land-based exercises on the balance of people with sub-acute stroke. METHODS: In this single-blind randomized controlled study, 32 patients with first-time stroke discharged from inpatient rehabilitation at West Park Healthcare Centre were recruited. Participants were randomized into W (water-based + land; n = 17) or L (land only; n = 15) exercise groups. Both groups attended therapy two times per week for six weeks. Initial and progression protocols for the water-based exercises (a combination of balance, stretching, and strengthening and endurance training) and land therapy (balance, strength, transfer, gait, and stair training) were devised. Outcomes included the Berg Balance Score, Community Balance and Mobility Score, Timed Up and Go Test, and 2 Minute Walk Test. RESULTS: Baseline characteristics of groups W and L were similar in age, side of stroke, time since stroke, and wait time between inpatient discharge and outpatient therapy on all four outcomes. Pooled change scores from all outcomes showed that significantly greater number of patients in the W-group showed improvement post-training compared to the L-group (p < 0.05). More patients in W-group showed change scores exceeding the published minimal detectable change scores. DISCUSSION: A combination of water- and land-based exercises has potential for improving balance. The results of this study extend the work showing benefit of water-based exercise in chronic and less-impaired stroke groups to patients with sub-acute stroke.

Effect of Botulinum Toxin on Clonus: A Systematic Review.

OBJECTIVE: To conduct a systematic review of the literature that examined the effect of botulinum toxin type A on clonus. DATA SOURCES: A literature search of multiple databases (PubMed, Cochrane, Google Scholar, Embase) was performed to identify articles published in English in the past 30 years (1986-2016). STUDY SELECTION: Two reviewers independently applied the following inclusion criteria: (1) any adult patients older than 18 years with upper motor lesion; (2) any location and duration of clonus; and (3) subjective and objective measurements of clonus tested at least 2 weeks after botulinum toxin injection. DATA EXTRACTION: Two reviewers independently extracted the data and assessed the methodological quality. A consensus method was used to solve disagreements. DATA SYNTHESIS: The systematic review resulted in 164 articles, of which 14 met the inclusion criteria: 3 were randomized controlled trials, 1 was nonrandomized, and 6 were case series and 3 case studies. All studies (181 patients) showed improvement in clonus: 6 of 14 results were statistically significant. Different scales were used for clonus measurement, such as clonus score, patient diaries, clonus spasm score, and electromyogram duration. CONCLUSIONS: Overall, there was preliminary evidence indicating improvement in clonus after botulinum injection. The major drawback with studies reviewed here was a large variation in the type of clonus assessment tools, which also lacked validity, reliability, and sensitivity to small changes in clonus.

Shoulder Retractor Strengthening Exercise to Minimize Rhomboid Muscle Activity and Subacromial Impingement.

PURPOSE: We investigated the best position for shoulder retractor strengthening exercise to maximize middle trapezius activity and minimize rhomboid major activity. Although both trapezius and rhomboids are scapular retractors, rhomboids also act as downward rotators of the scapula, which can worsen subacromial impingement. METHODS: Twelve healthy participants (age 30 [SD 6] y) with no history of shoulder pain were recruited for this study, which used fine-wire electromyography to examine maximal muscle activation of the middle trapezius and rhomboid major muscle fibres in four different positions: with the shoulder in 90° abduction with elbow completely extended and (1) shoulder internal rotation, (2) shoulder neutral rotation, (3) shoulder external rotation, and (4) rowing (shoulder neutral rotation and elbow flexed 90°). The ratio of trapezius to rhomboid muscles was compared with Wilcoxon signed-rank tests. RESULTS: Muscle activation ratio during shoulder retraction exercise was significantly lower by 22% (i.e., rhomboid was more active than middle trapezius) when performed with the shoulder in rowing position (elbow flexed) than with the shoulder in external rotation (elbow extended) position (p=0.031). All four positions produced coactivation of trapezius and rhomboids. DISCUSSION: Rowing position may not be the best position for shoulder retractor strengthening in patients with impingement syndrome. The preferable position for maximizing middle trapezius activity and minimizing rhomboid activity may be shoulder external rotation with elbow extended.

Objet: Chercher la meilleure position pour un exercice de renforcement du rétracteur de l'épaule afin de maximiser l'activité du trapèze moyen et de réduire celle du grand rhomboïde au minimum. Même si les deux sont des rétracteurs de l'omoplate, les rhomboïdes font aussi pivoter l'omoplate vers le bas, ce qui peut aggraver la compression subacromiale. Méthodes: On a recruté 12 participants en bonne santé (âgés de 30 [ET 6] ans) sans antécédent de douleur à l'épaule pour cette étude dans le cadre de laquelle on a utilisé l'électromyographie à fil fin pour étudier l'activité maximale des fibres musculaires du trapèze moyen et du grand rhomboïde dans différentes positions: épaule en abduction à 90° avec coude en extension complète et a) rotation de l'épaule vers l'intérieur, b) rotation neutre de l'épaule, c) rotation de l'épaule vers l'extérieur d) mouvement d'aviron (rotation neutre de l'épaule et coude en flexion à 90°). On a comparé le ratio des trapèzes par rapport aux rhomboïdes au moyen du test de Wilcoxon pour observations appariées. Résultats: Le ratio d'activation musculaire au cours de l'exercice de rétraction de l'épaule était beaucoup moins élevé de 22% (c.-à-d. que le rhomboïde était plus actif que le trapèze moyen) l'épaule en position d'aviron (coude en flexion) qu'en position de rotation vers l'extérieur (coude en extension) (p=0,031). Les quatre positions ont produit une coactivation du trapèze et des rhomboïdes. Discussion: La position d'aviron n'est peut-être pas la meilleure position pour renforcer le rétracteur de l'épaule chez les patients qui ont un syndrome de pincement. La position préférée pour maximiser l'activité du trapèze moyen et réduire celle des rhomboïdes au minimum peut être la rotation vers l'extérieur, le coude en extension.

Correction: Survey of Botulinum Toxin Injections in Anticoagulated Patients: Korean Physiatrists' Preference in Controlling Anticoagulation Profile Prior to Intramuscular Injection.

[This corrects the article on p. 279 in vol. 40, PMID: 27152278.].

Survey of Botulinum Toxin Injections in Anticoagulated Patients: Korean Physiatrists' Preference in Controlling Anticoagulation Profile Prior to Intramuscular Injection.

OBJECTIVE: To evaluate Korean physiatrists' practice of performing intramuscular botulinum toxin injection in anticoagulated patients and to assess their preference in controlling the bleeding risk before injection. METHODS: As part of an international collaboration survey study, a questionnaire survey was administered to 100 Korean physiatrists. Physiatrists were asked about their level of experience with botulinum toxin injection, the safe international normalized ratio range in anticoagulated patients undergoing injection, their tendency for injecting into deep muscles, and their experience of bleeding complications. RESULTS: International normalized ratio <2.0 was perceived as an ideal range for performing Botulinum toxin injection by 41% of the respondents. Thirty-six respondents replied that the international normalized ratio should be lowered to sub-therapeutic levels before injection, and 18% of the respondents reported that anticoagulants should be intentionally withheld and discontinued prior to injection. In addition, 20%-30% of the respondents answered that they were uncertain whether they should perform the injection regardless of the international normalized ratio values. About 69% of the respondents replied that they did have any standardized protocols for performing botulinum toxin injection in patients using anticoagulants. Only 1 physiatrist replied that he had encountered a case of compartment syndrome. CONCLUSION: In accordance with the lack of consensus in performing intramuscular botulinum toxin injection in anticoagulated patients, our survey shows a wide range of practices among many Korean physiatrists; they tend to avoid botulinum toxin injection in anticoagulated patients and are uncertain about how to approach these patients. The results of this study emphasize the need for formulating a proper international consensus on botulinum toxin injection management in anticoagulated patients.

Physician Preferences for Botulinum Toxin Injections in Anticoagulated Patients with Spasticity.

To understand physician preferences and bleeding complication rates of intramuscular botulinum neurotoxin type A injections for spasticity management in anticoagulated patients, questionnaires were mailed to 138 physicians across Canada. The international normalized ratio comfort range for injections was <2.0 in 10%, 2.0 to 2.5 in 35%, 2.6 to 3.0 in 25%, and 3.1 to 3.5 in 20% of physicians. Only 23% injected outside their comfort value and 57% did not; 72% did not normalize the international normalized ratio value before injections. Only one injector reported the development of compartment syndrome. As expected, high variability exists in physician preferences in botulinum neurotoxin type A injection in anticoagulated patients.