Original papers Medical Ultrasonography

2010, Vol. 12, no. 4, 306-310

Sonoelastography contribution in cerebral palsy spasticity treatment

assessment, preliminary report: A systematic review of the literature
apropos of seven patients
Dan Vasilescu1, Dana Vasilescu2, Sorin Dudea1, Carolina Botar-Jid1, Silviu Sfrângeu1,
Dan Cosma2

1
Radiology Department, University of Medicine and Pharmacy “Iuliu Haţieganu”, Cluj-Napoca, Romania
2
Cluj Rehabilitation Hospital, Department of Pediatric Surgery, University of Medicine and Pharmacy “Iuliu
Haţieganu”, Cluj-Napoca, Romania

Abstract
This paper aims to present our experience of 7 cases of spastic children, using sonoelastography in assessing the muscle
spasticity: the relaxed muscle structures appear mostly soft (green-yellow-red), while contracted or degenerated muscle fibers
appear hard (blue). Using sonoelastographic findings we established the proper place for injecting the botulinum toxin (20 U/
kg Dysport) into the affected muscle. The result was a precise, guided injection, with positive, therapeutic results. It is impor-
tant consider several factors that can influence the evolution of the case: gray scale ultrasound appearance of the muscle, the
patient age, the dosage and the fractionation of toxin.
Keywords: Spasticity, botulinum toxin, sonoelastography

Rezumat
Lucrarea doreşte să prezinte experienţa colectivului nostru în aplicarea sonoelastografiei pentru evaluarea spasticităţii
musculare. Au fost examinati 7 copii cu spasticitate musculară cu diverse localizări: muşchiul relaxat are un aspect moale
(verde-galben-roşu) pe când cel contractat sau degenerat apare dur (albastru). Ţinând cont de constatările sonoelastografice
s-a stabilit locul de injectare a toxinei botulinice (Dysport 20 U/kg). Rezultatul obţinut a fost o injectare precisă şi implicit
un rezultat terapeutic favorabil. Trebuie ţinut cont de mai mulţi factori ce pot influenţa evoluţia cazului: aspectul muşchiului,
vârsta pacientului, dozarea şi fracţionarea toxinei.
Cuvinte cheie: Spasticitate, toxină botulinică, sonoelastografie

Introduction terium. Clinical applications are based on its effect on

Botulinum toxin is a neurotoxin produced by
Clostridium botulinum, a gram-positive anaerobic bac-
Received 04.09.2010 Accepted 02.10.2010
Med Ultrason
2010, Vol. 12, No 4, 306-310
Address for correspondence: Dan Vasilescu
University of Medicine and
Pharmacy “I. Haţieganu” Cluj-Napoca,
8 V. Babeş str., Cluj-Napoca, Romania
Email: vasilescu.dan@umfcluj.ro
the neuro-muscular junction, producing neuromuscular
paralysis. The use of botulinum toxin for medical pur-
poses is mentioned in the late ‘80s. Initial experiments
were conducted on animals and in the late ‘90s the first
applications in humans were made. Currently known ap-
plications are spastic muscle pathology, in dermatology,
in dystonic torticollis, injections in the submandibular
and parotid glands, and even applications in neurogenic
bladder pathology.
Known products approved for clinical use are:
­Onabotulinumtoxin A (Botox), Abobotulinumtoxin A

(Dysport), Rimabotulinumtoxin B (Myobloc) [1].
The applications, including the therapy for spas-
tic muscles, implied injecting the toxin in the targeted
muscle groups. Until a few years ago, the injections
were made only by clinical palpation or by using muscle
stimulation or by using electromyography (EMG). In re-
cent years, ultrasound techniques were introduced to help
guide the injection.
In 2005, Chin et al [2] published a study which
showed the accuracy of tracing the target muscle with
no guidance. They performed 1,372 separate injections
for upper and lower limb spasticity in 226 cases of
children with cerebral palsy. The accuracy of manual
needle placement when compared to electrical stimula-
tion was satisfactory only for gastro-soleus (>75%); it
was not satisfactory for hip adductors (67%), medial
hamstrings (46%), tibialis posterior (11%), biceps bra-
chii (62%), and for forearm and hand muscles (13% to
35%).
Due to the need for a higher accuracy in needle place-
ment in all muscles, ultrasonography (US) became the
method most frequently used in guiding the injections.
The average time needed to identify and inject the tar-
geted muscle ranged from 5 s in superficial muscles, such
as the gastrocnemius muscle, to 30 s in deep-seated mus-
cles [3].
The use of muscle stimulation and of EMG may
produce local pain and increase the stress level.
In pediatric patients the use of minimally invasive
techniques is required and sedation and analgesia is
often needed. In these cases EMG potentials recorded
from the targeted muscles are low. Also, due to the
contraction of the neighboring muscle, EMG might not
always identify the right pathological muscle group.
All these reasons recommend the use of ultrasound
techniques [4].
Sonoelastography is an ultrasound technique that al-
lows the assessment of tissue elasticity. Its application in
the musculoskeletal field includes the evaluation of the
muscle contraction status. On sonoelastographic images
a relaxed muscle structure will appear mostly soft (green-
yellow-red), while contracted or degenerated muscle fib-
er will appear hard (blue) [5,6].
The purpose of this paper is to present our prelimi-
nary experience in using ultrasound techniques to guide
the injection of botulinum toxin in the muscles of spastic
children.
Method
In our practice we used 20 U/kg botulinum toxin
(Dysport). Seven patients were included in the study
Medical Ultrasonography 2010; 12(4): 306-310 307
until now, who were clinically and US pre-injection
evaluated and thereafter on various time intervals.
­Patients were selected from Cluj Rehabilitation
­Hospital, Department of Pediatric Surgery after or-
thopedic and neurological examination, having indi-
cation for the use of botulinum toxin in relaxing the
spastic muscles. Injections were administered in the
upper and lower limb. The study was approved by the
local Ethics Committee and all the patients or the pa-
tients’ parents gave the consent to participate to the
study.
The ultrasound examination was performed in Cluj
County Emergency Hospital, in Radiology Depart-
ment, using a Hitachi Ultrasound EUB 8500 with 6.5-
13 MHz linear transducer. The examination consisted
of two-dimensional comparative study of the muscle
groups indicated by the orthopedist and elastography
was used for an accurate assessment and identifica-
tion of the contracted muscle groups. The ultrasono-
graphic description of the pathological muscle groups
included muscular fibers ecogenicity, ecogenicity of
the fibroadipose septe and the muscle diameter (the
criteria for atrophy included increased ecogenicity of
the muscles and reduced diameter of the fibers when
compared to the opposite site). Sonolastography had
been applied on muscle groups previously identified by
two-dimensional ultrasound examination. As described
before, relaxed muscle structure would appear mostly
soft (green-yellow-red), while contracted or degener-
ated muscle fiber would appear hard (blue) on sonoe-
lastographic images [6]. Sonoelastographic images ob-
tained were analysed using a dedicated software with
the purpose of obtaining objective and quantifiable
data, useful in establishing an exact imaging diagnosis
and in monitoring this disease. The decision where to
administer the Dysport was made according to the US
findings.
The distance to the pathologic muscle, perpendic-
ular to the skin was measured using points marked
on the surface of the skin at the end of US examina-
tion.
Case 1
Five year old boy with cerebral palsy with spastic-
ity predominantly affecting the lower limb muscles.
Clinical and US assessment was performed in calf
and thigh bilaterally previous injection (fig 1, fig 2).
Evident improvement seen on ultrasound images was
confirmed by the parents and by the clinical examina-
tion
308 Dan Vasilescu et al Sonoelastography contribution in cerebral palsy spasticity treatment assessment

Fig 1. a) Left thigh and b) right thigh before injection (gray scale US and sonoelastography). Hard aspect (contracted) of the
medial gastrocnemius muscle.

Fig 2. a) Left thigh and b) right thigh 6 months after from injection (gray scale US and sonoelastography). Gastrocnemius
muscle looks softer (less contracted).

Fig 3. a) Right pronator teres muscle before injection (gray scale US and sonoelastography) predominantly contracted; b) right
pronator teres muscle 4 weeks after injection. The aspect is softer, less contracted

Fig 4. Right abductor policis muscle a) before injection – contracted aspect of the muscle; b) 4 weeks after injection. The aspect
is softer, less contracted

Fig 5. a) Initial contracted aspect of left medial gastrocnemius muscle (gray scale US and sonoelastography); b) unchanged
aspect at 2 weeks after injection based on clinical palpation
Fig 6. The same case as in fig 5. a) US reassessment followed by marking the points for injection; b) US control after 3 weeks.
Improved appearance, the muscle looks softer this time
Case 2
Seven year old boy. Cerebral palsy predominantly af-
fecting the upper limb muscles. Clinical and ultrasound
evaluation was performed on the arm and forearm, bi-
laterally (fig 3, fig 4). Ultrasound appearance was con-
firmed also by clinical examination.
Case 3
Seven year old girl. Cerebral palsy with predominant
spasticity of the lower limb muscles. First injection was
administered after clinical palpation of the muscle group
indicated by a previous US exam. The failure in clinical
response imposed a new injection, this time with US con-
trol (marking points on the patient’s skin and indicating
the depth of the pathological muscle) (fig 4, fig 5).
This case is a good example of repeating the toxin
administration if there is no favorable response, before
considering that the case as resistant to the therapy. The
incorrect administration of the toxin could be another
reason for this failure
Case 4-6
These 3 patients (age 3, 4, and 7 years) had limb
palsy. After US guided toxin administration all presented
favorable overall evolution.
Medical Ultrasonography 2010; 12(4): 306-310 309
Case 7
Ten year old boy with cerebral palsy predominant to
the lower limb muscles. No improvement was obtained
after toxin administration.
Results and Discussion
The use of Botulinum toxin in pediatric patients re-
quires a complex evaluation: orthopedic, neurological
and imaging. One of the reasons of therapeutic failures
may be an incomplete evaluation of the case. This sug-
gests the need of teamwork: neurologist-radiologist-or-
thopedist-physical therapist and that standardized tests
are needed to monitor the evolution of cases.
The cases presented in this paper show related fea-
tures regarding the location of muscle groups that were
suitable for the injection of botulinum toxin, including
upper and/or lower limbs. In our opinion an unsatisfac-
tory therapeutic result after Botulinum toxin injection
would be expected if the muscles had structural altera-
tions with the appearance of fibrosis (gray scale US); if
the toxin was administrated in other structures than those
indicated by the ultrasound examination; in cases of pa-
tients older than 7 years; if the treatment was not fol-
lowed by a proper physical therapy;
310 Dan Vasilescu et al Sonoelastography contribution in cerebral palsy spasticity treatment assessment
Improvement of protocols for clinical and ultrasound
examination could lower the rate of treatment failure. It
is also necessary to administer a sufficient dose of toxin
to achieve the expected effect and the injection should be
followed by a proper physiotherapy. Dosage should be in-
dividualized to each patient and suitably fractionated for
targeted muscle groups. It should also be considered as an
option to inject the muscle in several different points. We
appreciated that the use of US had an important contribu-
tion in the easiness of a precise tracking of the muscle
groups, being the easiest technique in pediatric patients.
Schroeder et al [7] concluded that in most aspects ul-
trasound is superior to EMG (table I). Sonoelastography
improves the findings of grayscale US in assessing the
degree of muscle contraction, especially in the cases with
less information then the ones offered by EMG.
Superior therapeutic results seem to be obtained by com-
bining two-dimensional ultrasound with sonoelastography
to mark the exact injection site or making the approach ul-
trasound guided, as it can be seen in the 3-rd presented case.
Larger studies are needed to confirm the substantial
contribution of sonoelastography, but also to discover
new aspects that would improve the therapeutic decision.
For a better evaluation of muscle contraction status we
need more experience with the benefits of sonoelastogra-
phy in the musculoskeletal pathology.

Table I. Differences between EMG, muscle stimulation and US in guiding the toxine injection [7].
EMG Muscle stimulation US
Identification accuracy o + +
Time for identify the muscle group – o +
Availability of technical equipment o o +
Pain and stress caused by the method – – +
Dependency on expert experience – – o
Necessary number of stabs – – +
Depth injection control o o +
Differentiation of adjacent muscle groups (also contracted) o o +
Differentiation of the muscle from surrounding tissues – – +
Dependence on patient cooperation – + +
The possibility to confirm the correct placement after injection – – +
The possibility of injection documentation – – +
Issues related to sedation–analgesia association – + +
Control of neuro–muscular junction proximity + + –
Control of muscular hyperactivity + o –
Control of muscle dimension o o +
Control of muscle fibrosis o o +
Potential for future technology development and research o – +
-: unfavourable; +: advantageous; o: acceptable

References

  1. Kedlaya D. Botulinum Toxin, Overview. Emedicine 2010.  
http://emedicine.medscape.com/article/325451-overview
  2. Chin T, Selber P, Graham HK. Accuracy of intramuscular
injection of botulinum toxin A: a comparison between man-
ual needle placement and placement guided by electrical  
stimulation. Pediatr Orthop 2005;25: 286-291.
  3. Berweck S, Schroeder AS, Fietzek UM, Heinen F. Sonog-
raphy-guided injection of botulinum toxin in children with  
cerebral palsy. Lancet 2004;363: 249 – 250.
  4. Berweck S, Wissel J. Sonographic Imaging for Guiding Botuli-
num Toxin Injections in Limb Muscles. ACNR 2004; 4:28-29.
5. Botar-Jid C, Vasilescu D, Dudea S. Ecografia tridimensională
şi elastografia în patologia aparatului locomotor. In:
­Daniela Fodor (ed). Ecografie clinică musculoscheletală.
Ed. Medicală Bucureşti 2009: 381-396.
6. Botar-Jid C, Damian L, Dudea SM, Vasilescu D, Rednic S, Badea
R. The contribution of ultrasonography and sonoelastography in
assessment of myositis. Med Ultrason 2010; 12: 120-126.
7. Schroeder AS, Berweck S, Lee SH, Heinen F. Botulinum
toxin treatment of children with cerebral palsy – a short
review of different injection techniques. Neurotox Res
2006;9:189-196