• Alessandro Picelli, Davide Lobba, Alessandro Midiri, Paolo Prandi, Camilla Melotti, Silvia Baldessarelli, and Nicola Smania.
• 1Neuromotor and Cognitive Rehabilitation Research Centre, Department of Neurological and Movement Sciences, University of Verona, Verona, Italy.
• Clin Rehabil. 2014 Mar 1;28(3):232-42.

ObjectiveTo compare the outcome of manual needle placement, electrical stimulation and ultrasonography-guided techniques for botulinum toxin injection into the forearm muscles of adults with arm spasticity.DesignRandomized controlled trial.SettingUniversity hospital.SubjectsSixty chronic stroke patients with wrist and fingers spasticity.InterventionAfter randomization into three groups, each patient received botulinum toxin type A in at least two of these muscles: flexor carpi radialis and ulnaris, flexor digitorum superficialis and profundus (no fascicles selection). The manual needle placement group underwent injections using palpation; the electrical stimulation group received injections with electrical stimulation guidance; the ultrasonography group was injected under sonographic guidance. A sole injector was used.Main MeasuresAll patients were evaluated at baseline and four weeks after injection.OutcomesModified Ashworth Scale; Tardieu Scale; wrist and fingers passive range of motion.ResultsOne month after injection, Modified Ashworth Scale scores improved more in the electrical stimulation group than the manual needle placement group (wrist: P = 0.014; fingers: P = 0.011), as well as the Tardieu angle (wrist: P = 0.008; fingers: P = 0.015) and passive range of motion (wrist: P = 0.004). Furthermore, Modified Ashworth Scale scores improved more in the ultrasonography group than in the manual needle placement group (wrist: P = 0.001; fingers: P = 0.003), as well as the Tardieu angle (wrist: P = 0.010; fingers: P = 0.001) and passive range of motion (wrist: P < 0.001; proximal interphalangeal joints: P = 0.009). No difference was found between the ultrasonography and electrical stimulation groups.ConclusionsInstrumental guidance may improve the outcome of botulinum toxin injections into the spastic forearm muscles of stroke patients.

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