Injection Techniques
Improve your Effectiveness
Peter Harding – City Hospital Birmingham
Dawn Hicklin – City Hospital Birmingham
June 2009
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Beyond the Call of Duty !!
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Aims
• Brief understanding of Electromyography
(EMG)
• Brief Understanding of Neurostimulator
• Relationships of superficial, intermediate
and deep muscles
• Practical demonstration of localizing and
stimulating deep muscles of the forearm
and lower leg.
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Site/Action of BTX-A
• Site/action of BTX-A is at the
neuromuscular junction or motor end
plate.
• The max paralysing effect is when the
BTX-A is injected into the end plate.
• The effect progressively diminishes as the
distance between the injection site and the
end plate increases.
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Site/Action of BTX-A
• Accurate placement of the toxin in the
motor end plate is not usually necessary.
• BTX-A has a very strong affinity for the
motor end plates.
• When injected near to the end plate BTXA will diffuse readily and bind with the presynaptic terminal.
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Sites of Motor End Plates
• This is possible in most cases by
anatomical land marks.
• Almost all muscles of the legs and arms
have a single innervation band, situated in
the middle of the muscle.
• Rarely innervation band are scattered
along the entire length of the muscle.
Examples being Gracilis and Sartorius.
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Multiple Innervation Bands
• Occur in muscles that arise from several
body segments e.g. muscles of the
abdominal wall.
• Each segment has its own motor point.
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Localization of Motor End-Plates
using EMG:
•
1.
2.
3.
4.
Needle EMG may be useful in the management of
patients with spasticity for several reasons:
Accurate localisation of motor end plate zones in small
or deep, inaccessible muscles.
Helps to distinguish between spasticity and
contracture.
Contribution of individual muscles in the patient’s
presenting symptoms. (e.g.elbow flexor spasticity).
Confirm the presence of selective (voluntary) motor
activity for a given muscle or group of muscles.
(Professor Magid Bakheit)
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Explanation of EMG
• In resting muscles small amounts (quanta) of
acetylcholine are released continuously and in a
random fashion from the Motor end-plates.
• These result in electrical discharges known as
miniature end-plate potentials (MEPPs).
• These are detected on EMG as “end-plate
ripples” or monophasic spike discharges
(MSDs).
(Professor Magid Bakheit 2001)
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
End Plate Noise (video)
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Characteristics of EMG - MEPPs & MSDs
1.
2.
3.
4.
5.
The end-plate ripple is a spontaneous low voltage (1040 microvolts) increase in the EMG baseline.
The monophasic spike discharge is seen as a negative
EMG deflection with a 50-130 microvolt amplitude and
a 0.5-2.0 msec duration.
They occur at a frequency of between 8-30Hz
NB +ve deflection on EMG is directed downwards.
Detection of the end-plate ripple or the MSDs means
that the needle is in the end-plate zone.
(Professor Magid Bakheit)
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
EMG traces
• EMG is different at rest, and in response to
stretch at different velocities…a velocitydependent kinetic stretch response.
• Static stretch response, stretch is maintained to
see the response to sustained stretch. …such
fatigue would encourage the use of splinting
• Stretch response may also fatigue in response
to repeated stretch.
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Typical EMG responses. (UMN)
• Response to rapid stretch
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
EMG Noise
Stretching a spastic muscle (video)
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Typical EMG responses. (UMN)
• Spasticity
• Bursts of EMG activity.
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Typical EMG responses. (UMN)
• Static stretch response in a spastic muscle
• After initial burst, the EMG is maintained as long
as the stretch is sustained.
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Neuro-stimulator
After inserting the needle, a muscle contraction
can be triggered by stimulation of repetitive
weak pulses of current:
Current <5mA
Pulse Duration 0.01-0.1ms
Frequency 1-2 HZ
NB if an isolated muscle contraction can be
triggered in the target muscle at current levels
of<1mA, the needle tip is in the vicinity of the
motor end-plate.
(Professor Tony Ward 2005)
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Neuro-stimulation of FPL (video)
This is what should be observed
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Neuro-stimulator
Lack of muscle contraction in spite of
accurate location of the needle insertion
and adequate stimulation-particularly in
chronic spasticity-indicate advanced
connective tissue changes within the
muscle.
(Professor Tony Ward 2005)
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Standard Set-up
Colour Coordinated wiring
EMG & E-Stim
EMG Needle
ECG
Electrodes
Anterior Approach to injecting Tibialis Posterior
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Muscle Layers of the forearm
Superficial:
1. Pronator Teres
2. Flexor Carpi Radialis
3. Flexor Carpi Ulnaris
4. Palmaris Longus
5. Brachioradialis
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Superficial Muscles
Brachioradialis
Pronator Teres
Flexor Carpi Radialis
Flexor Carpi Ulnaris
Palmaris Longus
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Source of Information:
Illustrated Clinical Anatomy;
Peter Abrahams, John Craven
and John Lumley
Anterior Aspect of Right Arm
Superficial Muscles
Source of Information:
Illustrated Clinical Anatomy;
Peter Abrahams, John Craven
and John Lumley
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Intermediate Muscle
Flexor Digitorum
Superficialis
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Source of Information:
Illustrated Clinical Anatomy;
Peter Abrahams, John Craven
and John Lumley
Anterior Aspect of Right Arm
Intermediate Muscles
Source of Information:
Illustrated Clinical Anatomy;
Peter Abrahams, John Craven
and John Lumley
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Flexor Digitorum Profundus
Intermediate Muscle
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Deep Muscles
1.
2.
3.
4.
Supinator
Flexor Digitorum Superficialis
Flexor Pollicis Longus
Pronator Quadratus
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Deep Muscles
Supinator
Flexor Pollicis
Longus
Flexor Digitorum
Profundus
Pronator
Quadratus
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Source of Information:
Illustrated Clinical Anatomy;
Peter Abrahams, John Craven
and John Lumley
Anterior Aspect of Right Arm
Deep Muscles
Source of Information:
Illustrated Clinical Anatomy;
Peter Abrahams, John Craven
and John Lumley
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Deep muscles of the forearm – Bony origins
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Source of Information: Illustrated Clinical Anatomy; Peter Abrahams, John Craven and John Lumley
Flexor Pollicis Longus
Deep Muscle
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Posterior Crural Muscles
Superficial
1. Gastrocnemius Medial and Lateral Heads
Intermediate
1. Soleus
Deep
1. Popliteus
2. Flexor Digitorum Longus
3. Flexor Hallucis Longus
4. Tibialis Posterior
5. Peroneus Longus & Brevis
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Superficial Posterior Crural Muscles
Medial Heads of
Gastrocnemius
Lateral Heads of
Gastrocnemius
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Source of Information:
Illustrated Clinical Anatomy;
Peter Abrahams, John Craven
and John Lumley
Surface Anatomy
Popliteus
Soleus
Peroneus (Fibularis) Longus
Flexor Digitorum
Longus
Tibialis Posterior
Flexor Hallucis Longus
Peroneus (Fibularis) Brevis
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Source of Information:
Illustrated Clinical Anatomy;
Peter Abrahams, John Craven
and John Lumley
Gastroc and Soleus
Lateral
Head
Medial
Head
1 Needle Point
Deep = Soleus
Soleus
Superficial = Gastroc
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Calf Stimulation
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Deep Aspect Muscles
Soleus &
Gastrocnemius
Removed
Source of Information:
Illustrated Clinical Anatomy;
Peter Abrahams, John Craven
and John Lumley
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Tibialis Posterior
Insert needle
through
Tibialis
Anterior –
“Pop”
Interosseous
Membrane
Lateral Border
of Tibia
Head of Fibula
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Flexor Hallucis Longus
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
Posterior Aspect – Muscle
Attachments
Source of Information:
Illustrated Clinical Anatomy;
Peter Abrahams, John Craven
and John Lumley
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin
References
1. Professor A. Magid Bakheit (2001): Botulinum
Toxin Treatment of Muscle Spasticity. Blackwell
Publishing.
2. Professor Tony Ward (2005):
Treatment of Sapasticity with Botulinum A Toxin Pocket atlas
Volume 2
3. Peter Abrahams, John Craven & John Lumley
(2005)
Illustrated Clinical Anatomy: Hodder Arnold
Publications.
Wessex ACPIN Spasticity Presentation 2009. © Peter Harding / Dawn Hicklin