*4.1.3 Types and methods of needle insertion under ultrasound control*

1.Way to № 1. Transversely to the ultrasound beam.

The needle is inserted at an angle to the plane of the sensor and, accordingly, transversely to the plane of the ultrasonic beam. The thickness of the ultrasound beam is 2–3 mm. Therefore, when moving the needle, the researcher sees only the displacement of tissues from it and only that part of it, or the slice that passed through the beam (**Figure 29**). This method, despite the limitations of needle visibility, is convenient, easy to learn and most often used in practice.

2.Way to № 2. In the plane of the ultrasonic beam (longitudinally). Introduction of the needle from the end of the working surface of the sensor at an angle. In this case, the entire needle is in the plane of the beam and is fully visible (**Figure 30**).

This method has some limitations: even a slight change in the angle of the sensor relatively to the skin or its displacement leads to the loss of the needle

The task of the doctor is not just to locate and verify the muscle, but also to make an injection. It should be borne in mind that the positioning of the limbs may be difficult due to spasticity and disturbance of the patient's consciousness. Picturing the muscles can be distorted by muscle contraction, etc. Therefore, it is preferable to use portable ultrasound scanner that allows you to easily move the machine around the patient. The most convenient location of the patient is between the doctor and the screen, the doctor does not have to turn around in order to study the ultrasound picture, and he

**Pairing and orientation of ultrasound image and sensor.** Coordination of needle and sensor movements, verification of the resulting image and orientation in the tissues of the body are developed over time. With the necessary experience, no problems in the orientation of the image will arise. For beginners, determining the coincidence of the sides of the sensor and the image on the monitor is an elementary but mandatory rule to get started. To do this, different simple methods are used: palpation of tissues, tapping on the edge of the working surface of the sensor, and

**Work with instrument settings.** The skill of working with the parameters of the device also plays an important role. If for examining of some muscles (quadriceps femoris), special settings are not required, and then when scanning some other – the quality of the settings can affect the effectiveness of the injection. Additional image adjustment may require the location of the long extensors of the thumb and toes, the posterior tibial muscle, as well as the study of the muscles of the foot. There are several basic settings for ultrasound imaging. Depending on the instrument, adjustments can be made manually or partially automatically.

• B-mode – the main imaging mode in which anatomical tissues and organs

can place all the necessary tools directly in front of him/her (**Figure 28**).

*4.1.2 Operating procedure on the ultrasound machine*

*Example of workplace organization for injection under ultrasound control.*

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

positioning the label on the basis of the sensor.

The main adjustment parameters include:

are displayed in real time.

1. Imaging modes:

**72**

**Figure 28.**

from the plane of the beam and, accordingly, its image on the screen. In addition, it creates the need for the passage of the needle through the adjacent muscles and other formations.

3.Way to № 3. Needle insertion after ultrasound control.

measured depth (**Figure 31C**).

sensor is performed using a patch (**Figure 32**).

limb, you must have a few packages.

solution of 0.015% chlorhexidine.

and chlorhexidine can be used.

**Figure 32.** *Sensor in sterile case.*

**75**

screen the end of the needle is.

*Spasticity: Diagnosis and Treatment*

*DOI: http://dx.doi.org/10.5772/intechopen.91046*

In a situation where it is impossible to simultaneously hold the sensor and

Determine the sensor object and depth of injection. Without removing the sensor, put a mark on the edge of the sensor. It is very convenient to use a sterile tip of the cap from the injection needle as a marker (**Figure 31A**). When you press the cap, a clear imprint in the form of a circle remains on the skin (**Figure 31B**). The needle is inserted into the circle on the skin to a

insert the needle into the tissue, you can use the following method:

**Tissue traction.** Sometimes, for various reasons, it is impossible to get a full image of the needle on the screen of the ultrasound machine. In this case, you should focus on the tissue traction that occurs when the needle passes. This effect can be enhanced by light oscillating movements of the needle. This technique allows with a certain degree of error to understand at what depth and in what place on the

**Aseptica.** Introduction of drugs under ultrasound control requires compliance with the rules of asepsis. To do this, there are several different methods of treatment and protection: sterile gloves for the performer, sterile covers for the sensor, sterilizer for the sensor, sterile gel, aseptic solutions for the sensor, and the patient's skin.

For practical execution of the procedure, the scanner sensor can be protected by

**Gel.** Sterile ultrasonic gel is used for invasive manipulations under ultrasound control. Release form is sachets of 15 g, so when conducting the therapy even on one

**Treatment of the injection field.** The patient's skin should be treated with a

**Sensor processing**. Treatment of the sensor with alcohol is undesirable. This causes damage to the rubber coating of the work surface and premature failure of the sensor. To sterilize the sensor, special solutions of the Sani-Cloth series are used

a sterile disposable cover, which has an adhesive base inside for fixing to the working part of the sensor. The adhesive base itself in this case also replaces the gel for ultrasound. Sterile cover can be replaced with a sterile glove, and instead of the adhesive base, you can use usual gel, which is applied to the working part of the sensor and the inner surface of the glove. Fixation of the glove on the handle of the

### **Figure 29.**

*Relative positions of the needle and the sensor introduction in a transverse slice of the needle as a point in the round pronator.*

### **Figure 30.**

*The relative position of the needle and sensor in the longitudinal introduction and the needle along the ultrasound beam in a circular pronator.*

### **Figure 31.**

*(А) Tissue marking, (B) needle cap pressure mark on skin, and (С) inserting the needle into the center of the marking.*

from the plane of the beam and, accordingly, its image on the screen. In addition, it creates the need for the passage of the needle through the adjacent

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

*The relative position of the needle and sensor in the longitudinal introduction and the needle along the*

*(А) Tissue marking, (B) needle cap pressure mark on skin, and (С) inserting the needle into the center of the*

*Relative positions of the needle and the sensor introduction in a transverse slice of the needle as a point in the*

muscles and other formations.

**Figure 30.**

**Figure 31.**

*marking.*

**74**

**Figure 29.**

*round pronator.*

*ultrasound beam in a circular pronator.*

3.Way to № 3. Needle insertion after ultrasound control.

In a situation where it is impossible to simultaneously hold the sensor and insert the needle into the tissue, you can use the following method:

Determine the sensor object and depth of injection. Without removing the sensor, put a mark on the edge of the sensor. It is very convenient to use a sterile tip of the cap from the injection needle as a marker (**Figure 31A**). When you press the cap, a clear imprint in the form of a circle remains on the skin (**Figure 31B**). The needle is inserted into the circle on the skin to a measured depth (**Figure 31C**).

**Tissue traction.** Sometimes, for various reasons, it is impossible to get a full image of the needle on the screen of the ultrasound machine. In this case, you should focus on the tissue traction that occurs when the needle passes. This effect can be enhanced by light oscillating movements of the needle. This technique allows with a certain degree of error to understand at what depth and in what place on the screen the end of the needle is.

**Aseptica.** Introduction of drugs under ultrasound control requires compliance with the rules of asepsis. To do this, there are several different methods of treatment and protection: sterile gloves for the performer, sterile covers for the sensor, sterilizer for the sensor, sterile gel, aseptic solutions for the sensor, and the patient's skin.

For practical execution of the procedure, the scanner sensor can be protected by a sterile disposable cover, which has an adhesive base inside for fixing to the working part of the sensor. The adhesive base itself in this case also replaces the gel for ultrasound. Sterile cover can be replaced with a sterile glove, and instead of the adhesive base, you can use usual gel, which is applied to the working part of the sensor and the inner surface of the glove. Fixation of the glove on the handle of the sensor is performed using a patch (**Figure 32**).

**Gel.** Sterile ultrasonic gel is used for invasive manipulations under ultrasound control. Release form is sachets of 15 g, so when conducting the therapy even on one limb, you must have a few packages.

**Treatment of the injection field.** The patient's skin should be treated with a solution of 0.015% chlorhexidine.

**Sensor processing**. Treatment of the sensor with alcohol is undesirable. This causes damage to the rubber coating of the work surface and premature failure of the sensor. To sterilize the sensor, special solutions of the Sani-Cloth series are used and chlorhexidine can be used.

**Figure 32.** *Sensor in sterile case.*

### *4.1.4 Methods of administration of BoNT in the intramuscular motor endpoint*

Neuromuscular transmission is carried out by axon terminals in limited areas of intramuscular motor endpoint (IME). Accurate introduction to IME makes botulinum therapy more effective. The distribution of IME in the left and right limbs is identical; it does not depend on gender and age. The number of muscle motor points depends on the complexity of its functions and does not depend on its mass [47].

After finding a muscle using ultrasound navigation to orient the IME projection of the corresponding muscles on the human body, use the location map or find them using electroneuromyography (EMG). A cutaneous bipolar stimulating electrode is used to search for muscle IME. The study is carried out at a current strength of 5–10 mA and a frequency of 2 Hz [47–49]. The use of location maps in combination with ultrasound navigation significantly increases the effectiveness of treatment (**Figures 33–40**) [47].

### *4.1.4.1 Complex treatment of spasticity*

Given the timing of the development of spasticity and the risk of complications, which in the future significantly reduces the effectiveness of rehabilitation and increases the cost of treatment, treatment of spasticity should be started when just its first signs appear. The period requiring special attention for early diagnosis and treatment is between 3 and 12 weeks after brain damage. In severe paresis, the period of occurrence of spasticity may coincide with the first signs of muscle strength and purposeful movement [50, 51].

Basically, all the drugs BoNT produced in the world are standardized to the 100 unit equivalent of Botox. The only drug that stands out from this series is Dysport. All drugs, except for Dysport, are similar in dosage of introduction to the relevant muscles and multiples of 100 Units. The drug Dysport is 500-unit drug and is

significantly different from the 100 individual drugs, dosage of the injection in the

*Image of anatomy of m. Flexor pollicis longus (FPL), m. Flexor digitorum superficialis (FDS), m. Flexor carpi*

*Image of anatomy m. Biceps brachii (BB) and m. Brachialis (Br) and projections of their IME on the surface of*

*Image of anatomy of m. Brachioradialis (BR), Extensor carpi radialis longus (ECRL), Extensor carpi radialis brevis (ECRB), Flexor carpi radialis (FCR), m. Pronator teres (PT), and projections of their IME on the*

To optimize the calculation of drug consumption and prognosis of needs, it is advisable to use models of patients based on the frequency of participation in the

muscle (**Tables 2** and **3**) [7, 50–54].

*ulnaris (FCU), and projections of their IME on the surface of the body.*

**Figure 34.**

*Spasticity: Diagnosis and Treatment*

*DOI: http://dx.doi.org/10.5772/intechopen.91046*

**Figure 35.**

**Figure 36.**

**77**

*surface of the body.*

*the body.*

**Figure 33.** *Location map of muscle motor points for botulinum toxin injections in the treatment of spasticity.*

### *Spasticity: Diagnosis and Treatment DOI: http://dx.doi.org/10.5772/intechopen.91046*

### **Figure 34.**

*4.1.4 Methods of administration of BoNT in the intramuscular motor endpoint*

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

ment (**Figures 33–40**) [47].

**Figure 33.**

**76**

*4.1.4.1 Complex treatment of spasticity*

strength and purposeful movement [50, 51].

Neuromuscular transmission is carried out by axon terminals in limited areas of intramuscular motor endpoint (IME). Accurate introduction to IME makes botulinum therapy more effective. The distribution of IME in the left and right limbs is identical; it does not depend on gender and age. The number of muscle motor points depends on the complexity of its functions and does not depend on its mass [47]. After finding a muscle using ultrasound navigation to orient the IME projection of the corresponding muscles on the human body, use the location map or find them using electroneuromyography (EMG). A cutaneous bipolar stimulating electrode is used to search for muscle IME. The study is carried out at a current strength of 5–10 mA and a frequency of 2 Hz [47–49]. The use of location maps in combination with ultrasound navigation significantly increases the effectiveness of treat-

Given the timing of the development of spasticity and the risk of complications,

Basically, all the drugs BoNT produced in the world are standardized to the 100 unit equivalent of Botox. The only drug that stands out from this series is Dysport. All drugs, except for Dysport, are similar in dosage of introduction to the relevant muscles and multiples of 100 Units. The drug Dysport is 500-unit drug and is

which in the future significantly reduces the effectiveness of rehabilitation and increases the cost of treatment, treatment of spasticity should be started when just its first signs appear. The period requiring special attention for early diagnosis and treatment is between 3 and 12 weeks after brain damage. In severe paresis, the period of occurrence of spasticity may coincide with the first signs of muscle

*Location map of muscle motor points for botulinum toxin injections in the treatment of spasticity.*

*Image of anatomy m. Biceps brachii (BB) and m. Brachialis (Br) and projections of their IME on the surface of the body.*

### **Figure 35.**

*Image of anatomy of m. Brachioradialis (BR), Extensor carpi radialis longus (ECRL), Extensor carpi radialis brevis (ECRB), Flexor carpi radialis (FCR), m. Pronator teres (PT), and projections of their IME on the surface of the body.*

### **Figure 36.**

*Image of anatomy of m. Flexor pollicis longus (FPL), m. Flexor digitorum superficialis (FDS), m. Flexor carpi ulnaris (FCU), and projections of their IME on the surface of the body.*

significantly different from the 100 individual drugs, dosage of the injection in the muscle (**Tables 2** and **3**) [7, 50–54].

To optimize the calculation of drug consumption and prognosis of needs, it is advisable to use models of patients based on the frequency of participation in the

### **Figure 37.**

*Image of anatomy m. Pectoralis major (PM) and projections of their IME on the surface of the body.*

**Figure 40.**

**1A** Flexion of the wrist, fingers and thumb

*Spasticity: Diagnosis and Treatment*

*DOI: http://dx.doi.org/10.5772/intechopen.91046*

**2A** Flexion of the wrist, fingers and thumb

**3A** Flexion of the wrist, fingers and thumb

Pronation of the forearm

Pronation of the forearm

Elbow flexion

Pronation of the forearm

Elbow flexion

Impossibility of shoulder retraction and arm extension

*Models of patients with spasticity in the upper limb.*

**Table 2.**

**79**

**4A** Flexion of the wrist, fingers and thumb

*Image of anatomy mm. Gastrocnemius (G/c), Soleus (S), and projections of their IME on the surface of the body.*

Flexor digitorum superfacialis Flexor digitorum profundus Flexor pollicis longus

Flexor digitorum superfacialis Flexor digitorum profundus Flexor pollicis longus

Flexor digitorum superfacialis Flexor digitorum profundus Flexor pollicis longus

*Very rarely are all muscles involved, so most often the average dosage*

> Flexor digitorum superfacialis Flexor digitorum profundus Flexor pollicis longus

Pectoralis major *Very rarely are all muscles involved, so most often the average dosage*

<sup>80</sup> Flexor carpi radialis

*Sometimes one of two*

*Sometimes one of two*

*More often one-two from three (BB less often than others)*

*Sometimes one of two*

*More often one-two from three (BB less often than others)*

**the BoNT, U**

60 60 20

**Dysport, U**

> 200 200 60

**140 460**

**230 740**

**410 1600**

**530 1600**

**Model Pattern of spasticity Muscles 100 Units of**

Pronator teres

Flexor carpi radialis Pronator teres

Brachialis Brachioradialis Biceps brachii (BB)

Flexor carpi radialis Pronator teres

Brachialis Brachioradialis Biceps brachii (BB)

### **Figure 38.**

*Image of anatomy mm. Vastus lateralis (VL), Vastus medialis (VM), m. Rectus femoris (RF), m. Tibialis anterior (TA), and projections of their IME on the surface of the body.*

### **Figure 39.**

*Image of the anatomy of m. Semimembranosus (S/m), m. Semitendinosus (S/t) m. Gracilis (Gr), and projections of their IME on the surface of the body.*

formation of a pattern of specific muscles (**Tables 2** and **3**). The use of these models allows you to accurately determine the required amount of the drug and the cost of treatment of spasticity.

### *Spasticity: Diagnosis and Treatment DOI: http://dx.doi.org/10.5772/intechopen.91046*

### **Figure 40.**

*Image of anatomy mm. Gastrocnemius (G/c), Soleus (S), and projections of their IME on the surface of the body.*


### **Table 2.**

*Models of patients with spasticity in the upper limb.*

formation of a pattern of specific muscles (**Tables 2** and **3**). The use of these models allows you to accurately determine the required amount of the drug and the cost of

*Image of the anatomy of m. Semimembranosus (S/m), m. Semitendinosus (S/t) m. Gracilis (Gr), and*

*Image of anatomy mm. Vastus lateralis (VL), Vastus medialis (VM), m. Rectus femoris (RF), m. Tibialis*

*Image of anatomy m. Pectoralis major (PM) and projections of their IME on the surface of the body.*

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

*anterior (TA), and projections of their IME on the surface of the body.*

treatment of spasticity.

*projections of their IME on the surface of the body.*

**Figure 39.**

**78**

**Figure 38.**

**Figure 37.**


The treatment scheme of spasticity with the complex use of peripheral muscle relaxants (BoNT) and central muscle relaxants (baclofen) action may also be effective. Baclofen should be prescribed 25 3 days after the introduction of BoNT. This treatment scheme provides a sufficient clinical effect for 110 10 days after the

*All muscles are never involved, so the average dosage is*

**Muscles 100 Units**

*FDL and FHL are more common than FDB and FHL, and FDL is more common than FHL. A rare combination of long and short flexors of the fingers.*

**of the BoNT, U**

**Dysport, U**

**500 1500**

monotherapy. With an average spasticity treatment time of 2 years, this combina-

injection session, which is 14–25 days longer than the action of BoNT in

tion reduces the number of injection sessions from 7 to 5.

Flexor digitorum longus (FDL) Flexor halucis longus (FHL) Flexor digitorum brevis Flexor halucis brevis

**Model Pattern of**

**Table 3.**

**81**

**spasticity**

*Spasticity: Diagnosis and Treatment*

*DOI: http://dx.doi.org/10.5772/intechopen.91046*

*Models of patients with spasticity in the low limb.*


**Table 3.**

**Model Pattern of**

**spasticity**

1L Dynamic Semitendinosus

2L Static Gastrocnemius

3L Dynamic + Static Semitendinosus

4L Static + Flexion of fingers and big toe

5L Dinamic+ Static + Flexion of fingers and big toe

**80**

Semimembranosus

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

Gracilis Biceps femoris

caput mediale (G/c c.m.)

Tibialis posterior Soleus Tibialis anterior

Semimembranosus

Gracilis Biceps femoris

Gastrocnemius caput mediale (G/c c.m.) Tibialis posterior Soleus Tibialis anterior

Gastrocnemius caput mediale (G/c c.m.) Tibialis posterior Soleus Tibialis anterior

Flexor digitorum longus (FDL) Flexor halucis longus (FHL) Flexor digitorum brevis (FDB) Flexor halucis brevis (FHB)

Semitendinosus Semimembranosus

> Gracilis Biceps femoris

Gastrocnemius caput mediale (G/c c.m.) Tibialis posterior Soleus Tibialis anterior

**Muscles 100 Units**

*Very rarely are all muscles involved, so most often the average dosage*

*Very rarely are all muscles involved, so most often the average dosage*

*All muscles are never involved, so the average dosage is*

*All muscles are never involved, so the average dosage is*

*Often Very rarely*

*Most often one of the muscles in combination with G/c c. m.*

> *Often Very rarely*

*Almost always Most often one of the muscles in combination with G/c c. m.*

*Almost always Most often one of the muscles in combination with G/c c. m.*

*FDL and FHL are more common than FDB and FHL, and FDL is more common than FHL. A rare combination of long and short flexors of the fingers.*

> *Often Very rarely*

*Almost always Most often one of the muscles in combination with G/c c. m.*

*Almost always* 80

*Almost always* 80

*Almost always* 80

*Almost always* 100 400

**of the BoNT, U**

100

80 140

100 80 80

100

80 140

100

80 140

**Dysport, U**

> 300 400

200 500

400 300 300

300 400

200 500

300 400

200 500

**300 1000**

**250 800**

**200 700**

**450 1500**

*Models of patients with spasticity in the low limb.*

The treatment scheme of spasticity with the complex use of peripheral muscle relaxants (BoNT) and central muscle relaxants (baclofen) action may also be effective. Baclofen should be prescribed 25 3 days after the introduction of BoNT. This treatment scheme provides a sufficient clinical effect for 110 10 days after the injection session, which is 14–25 days longer than the action of BoNT in monotherapy. With an average spasticity treatment time of 2 years, this combination reduces the number of injection sessions from 7 to 5.

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