A practical booklet for ultrasound-guided botulinum toxin injections.

In the last 15 years, the use of ultrasound to guide botulinum neurotoxin type A injections has been advocated by many authors, with growing evidence showing the benefits of using ultrasound guidance to improve the efficacy of injections. Patients with spasticity may show severely altered postures, atrophy and fibrotic modifications of target muscles, leading to significant challenges in recognising and differentiating between the muscles to be injected or not. At present time, there are no available books with images that clarify how to identify and inject muscles in patients showing these problems. Another problem we considered is the accessibility, from an economic standpoint, of medical books for clinicians in low-income countries. We have created a practical booklet to help clinicians acquire the confidence and expertise needed to administer US-guided injections in patients with severe spasticity, combining the experience of more than 10 years in training clinicians in ultrasound-guided injections. We utilised our experience to create a method that offers a consistent way to recognise muscles, even in challenging conditions. The aim of our booklet is to offer a reliable technique for identify and target muscles in patients with altered muscular structure and pathological postures due to spasticity, relying on easily identifiable anatomical structures such as bones, vessels or nerves, or "iconic" patterns that can easily be learned and remembered. We have provided images and anatomical schemes, as well as ergonomic clinical pearls, to help clinicians providing reliable ultrasound-guided injections. To reduce barriers to education, this booklet is be distributed for free without any royalties.