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Reduced Neck Muscle S eng h and Al e ed Muscle Mechanical P ope ies in Ce ical
Dys onia Following Bo ulinum Neu o oxin Injec ions : A P ospec i e S udy
Mus alampi, Si pa; Ylinen, Ja i; Ko nilo , Ka a iina; Wei , Adam; Häkkinen, A ja
Mus alampi, S., Ylinen, J., Ko nilo , K., Wei , A., & Häkkinen, A. (2016). Reduced Neck
Muscle S eng h and Al e ed Muscle Mechanical P ope ies in Ce ical Dys onia
Following Bo ulinum Neu o oxin Injec ions : A P ospec i e S udy. Jou nal o
Mo emen Diso de s, 9(1), 44-49. h ps://doi.o g/10.14802/jmd.15035
2016
44 Copy igh © 2016 The Ko ean Mo emen Diso de Socie y
Reduced Neck Muscle S eng h and Al e ed
Muscle Mechanical P ope ies in Ce ical
Dys onia Following Bo ulinum Neu o oxin
Injec ions: A P ospec i e S udy
Si pa Mus alampi,1 Ja i Ylinen,1 Ka a iina Ko nilo ,2 Adam Wei ,3 A ja Häkkinen1,2
1Depa men o Physical Medicine and Rehabili a ion, Cen al Finland Cen al Hospi al, Jy äskylä, Finland
2Depa men o Heal h Sciences, Uni e si y o Jy äskylä, Jy äskylä, Finland
3Depa men o Spo s Medicine, Aspe a O hopaedic and Spo s Medicine Hospi al, Doha, Qa a
ABSTRACT
Objec i eaaTo e alua e changes in he s eng h and mechanical p ope ies o neck muscles and disabili y in pa ien s wi h ce i-
cal dys onia (CD) du ing a 12-week pe iod ollowing bo ulinum neu o oxin (BoNT) injec ions.
Me hodsaaEigh pa ien s wi h CD olun ee ed o his p ospec i e clinical coho s udy. Pa ien s had ecei ed BoNT injec ions
egula ly in neck muscles a h ee-mon h in e als o se e al yea s. Maximal isome ic neck s eng h was measu ed by a dyna-
mome e , and he mechanical p ope ies o he splenius capi is we e e alua ed using wo myo onome e s. Clinical assessmen
was pe o med using he To on o Wes e n Spasmodic To icollis Ra ing Scale (TWSTRS) be o e and a 2, 4, 8, and 12 weeks a -
e he BoNT injec ions.
Resul saaMean maximal isome ic neck s eng h a wo weeks a e he BoNT injec ions dec eased by 28% in ex ension, 25%
in o a ion o he a ec ed side and 17% in lexion. A ou weeks, muscle s i ness o he a ec ed side dec eased by 17% and en-
sion dec eased by 6%. A eigh weeks, he muscle elas ici y on he a ec ed side inc eased by 12%. A wo weeks a e he BoNT
injec ions, he TWSTRS-se e i y and TWSTRS- o al sco es dec eased by 4.3 and 6.4, espec i ely. The s eng h, muscle me-
chanical p ope ies and TWSTRS sco es e u ned o baseline alues a 12 weeks.
ConclusionsaaAl hough maximal neck s eng h and muscle one dec eased a e BoNT injec ions, he disabili y imp o ed. The
changes obse ed a e BoNT injec ions we e empo a y and e u ned o p e-injec ion le els wi hin wel e weeks. Despi e ha ing
a possible nega i e e ec on unc ion and dec easing neck s eng h, he BoNT injec ions imp o ed he pa ien s epo ed disabili y.
Key Wo dsaaMuscle s eng h; Muscle cha ac e is ics; Disabili y; Neck.
ORIGINAL ARTICLE
h p://dx.doi.o g/10.14802/jmd.15035 / J Mo Diso d 2016;9(1):44-49
pISSN 2005-940X / eISSN 2093-4939
Recei ed: Augus 19, 2015 Re ised: Oc obe 23, 2015 Accep ed: No embe 10, 2015
Co esponding au ho : Si pa Mus alampi, MSc, Depa men o Physical Medicine and Rehabili a ion, Cen al Finland Cen al Hospi al, Keskussai aalan-
ie 19, Jy äskylä 40620, Finland / Tel: +358 45 1205 700 / Fax: +358 14 2692 931 / E-mail: [email p o ec ed]
cc This is an Open Access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion Non-Comme cial License (h p://c ea i ecommons.o g/
licenses/by-nc/3.0) which pe mi s un es ic ed non-comme cial use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed.
JMD
Ce ical dys onia (CD) is a ocal dys onia causing in olun-
a y ac i a ion o neck and shoulde muscles esul ing in ab-
no mal, sus ained and pain ul pos u ing ha may lead o physi-
cal disabili y and social wi hd awal.1 In ecen yea s, bo ulinum
neu o oxin (BoNT) has become he i s line he apy o CD.2 A
subjec i e eeling o neck weakness has been epo ed as one o
he mos common localized ad e se e en s o BoNT.2-7 In clini-
cal p ac ice, his may some imes be epo ed as ha ing di icul y
keeping he head up igh . Al hough he e ec s o BoNT ha e
been widely s udied,2,5 he e ha e been no p ospec i e s udies
quan i ying changes in maximal isome ic neck muscle s eng h.
Objec i e s eng h measu emen s may help iden i y pa ien s
S eng h & Muscle P ope ies in CD Following BoNT
Mus alampi S, e al.
www.e-jmd.o g 45
wi h neck weakness a e BoNT injec ions ha causes
di icul ies in daily li ing and he e o e need addi-
ional s eng h aining. Addi ionally, e en hough
CD pa ien s ha e equen complain s o neck en-
sion, only one s udy8 has p o ided quan i a i e da a
abou he e ec s o ini ial BoNT injec ions on he
passi e mechanical p ope ies o skele al muscle in
a clinical se ing, despi e ha measu emen de ices
ha e been de eloped o his pu pose. Myo onom-
e e s may p o ide an objec i e, non-in asi e ool o
quan i y changes in muscle p ope ies a e BoNT
injec ions ha we e p e iously ob ained using sub-
jec i e me hods. The aim o his s udy was o e alu-
a e he changes in neck s eng h, he mechanical
p ope ies o neck muscles, and disabili y o e a
wel e-week pe iod ollowing BoNT injec ions in
pa ien s wi h CD who had a wo-yea his o y o BoNT
ea men . We hypo hesized ha he mechanical
p ope ies o muscle luc ua e a e BoNT injec ion,
and his luc ua ion is e lec ed in dec eased muscle
powe and ension, as well as disabili y.
MATERIALS & METHODS
Pa ien s
Twen y- wo pa ien s who we e ecei ing BoNT
injec ions in hei neck muscles in an ou pa ien e-
habili a ion clinic we e in i ed by mail o olun ee
o his p ospec i e clinical coho s udy. Eigh pa-
ien s (3 women, 5 men) olun ee ed. Ten pa ien s
denied because o he long-dis ance a el equi ed
o egula isi s, and ou pa ien s denied o pe -
sonal easons. The mean age (s anda d de ia ion,
SD) o he pa icipan s was 57 (10) yea s; he mean
body mass index (SD) was 24.7 (5.4) kg/m2. The
mean du a ion (SD) om he onse o CD was 14
(12) yea s, and he mean du a ion om he s a o
egula BoNT injec ions was 2.3 (1.6) yea s. The p e-
dominan componen o he CD was o a ion o la -
e ocollis o he neck, which was owa d he le side
in ou pa ien s and owa d he igh side in he e-
maining ou pa ien s. The local e hics commi ee
app o ed he s udy. All subjec s ga e hei w i en
consen be o e pa icipa ing in he s udy.
In e en ion
Two o ms o BoNT ype A, onabo ulinum oxinA
(ona-BoNTA, Bo ox®, Alle gan, I ine, CA, USA) (n =
4) and abobo ulinum oxinA (abo-BoNTA, Dyspo ®,
Ipsen, Pa is, F ance) (n = 4), we e used acco ding o
he mos ecen ecommenda ions.2 The o al dose
injec ed in o ce ical muscles was 100 U o ona-
BoNTA and 500 U o abo-BoNTA. All pa ien s e-
cei ed injec ions in he splenius capi is on he a -
ec ed side, and he o he muscles injec ed a ied
acco ding o he dis ibu ion and deg ee o dys onic
muscles. The mean numbe (SD) o injec ed mus-
cles was 5.4 (1.3). Injec ions we e pe o med by wo
physia is s wi h se e al yea s o expe ience o BoNT
ea men in hese pa ien s.
Ou come measu es
Neck s eng h o isome ic lexion, ex ension and
o a ion was measu ed while he pa icipan was in
he si ing posi ion and using a special neck dyna-
mome e acco ding o he echnique epo ed in
p e ious s udies.4,9 The bes esul o h ee maximal
e o s was used in he inal analysis.
The mechanical p ope ies o splenius capi is we e
measu ed on he a ec ed and non-a ec ed sides
wi h wo myo onome e s and wi h he pa icipan
in he s anda d supine posi ion: he head was in a s -
aigh neu al posi ion ( ace down owa d he hole
o he examina ion able) and he hands we e beside
he body. The Myo on-3 (Myo on AS, Tallinn, Es o-
nia) enables measu emen o muscle cha ac e is ics
by eco ding damped oscilla ions o he issue when
a mechanical pe u ba ion is applied o he mus-
cle.10,11 The Myo on-3, which is placed pe pendicu-
la o he muscle, p oduces a sho impulse on he
muscle. An accele a ion ansduce eco ds he da-
mped oscilla ions o he muscle, and he oscilla ion
equency (Hz) cha ac e izes he ension in he
muscle. A loga i hmic dec emen o he oscilla ion
cha ac e izes he muscle elas ici y, whe eas he os-
cilla ion s i ness pa ame e (N/m) cha ac e izes he
muscle’s abili y o esis he o ce ha is shaping i .
Measu emen o he mechanical p ope ies o sple-
nius capi is using he Myo on is shown in Figu e 1.
Muscle compliance was measu ed wi h a compu -
e ized muscle onome e (CMT) (Medi ehabook
L d., Muu ame, Finland).12 The CMT quan i ies he
amoun o issue displacemen as he p obe is pu-
shed down and pe pendicula o he muscle.12 The
esul o a CMT is exp essed as he wo k pe o med
while he p obe comp esses he issue and is calcu-
la ed as he a ea unde he cu e in he o ce-de o -
ma ion-g aph (mJ). A highe alue indica es a highe
46
J Mo Diso d 2016;9(1):44-49
JMD
compliance o he issue. Uppe apezius ac i i y
was measu ed simul aneously wi h myo onome ic
measu emen s by su ace elec omyog aphy (sEMG)
using an ME1000 Analyze (Mega Elec onics L d.,
Kuopio, Finland) o assu e ha only minimal mus-
cula ac i i y was p esen a es .
Clinical assessmen was pe o med using he o al
To on o Wes e n Spasmodic To icollis Ra ing Scale
(TWSTRS) (0 o 85 poin s) and i s h ee subscales.1
The se e i y scale has 10 i ems (0 o 35 poin s), he
disabili y scale has 7 i ems o ac i i ies o daily li ing
(0 o 30 poin s), and he pain scale has 3 i ems (0 o
20 poin s). Highe sco es indica e g ea e impai -
men . Assessmen s we e pe o med p io o BoNT
injec ions ollowed by measu emen s a 2, 4, 8, and
12 weeks a e he injec ions. All measu emen s we e
pe o med in a s anda dized manne by he same
expe ienced physio he apis .
S a is ical analysis
The da a a e epo ed as he means wi h SDs. The
mean changes wi h 95% con idence in e als (CI)
om baseline o he measu emen s a ollow-ups
we e calcula ed. S a is ical compa isons o he ou -
come measu emen s we e pe o med using pai ed
- es s. No adjus men was made o mul iple es -
ing, bu his in o ma ion can be ob ained by mul i-
plying he ac ual p alue by he numbe o compa -
ison made. The le el o p < 0.05 was selec ed o in-
dica e s a is ical signi icance. S a is ical analyses we e
pe o med wi h SPSS ( e sion 22.0; SPSS Inc., Chi-
cago, IL, USA).
RESULTS
The mean alues o neck s eng h, he mechani-
cal p ope ies o splenius capi is on he a ec ed side,
and he TWSTRS sco es a e shown in Table 1. The e
we e no signi ican di e ences a baseline in o a ion
s eng h o he mechanical p ope ies o splenius ca-
pi is be ween he a ec ed and non-a ec ed sides.
The mean dec ease in neck s eng h a wo weeks
a e he BoNT injec ions was -28% (95% CI: -40 o
Figu e 1. Measu emen o he mechanical p ope ies
o splenius capi is using he Myo on.
Table 1. Mean alues o maximal isome ic neck s eng h, mechanical p ope ies o splenius capi is on he a ec ed side, and TWSTRS sco es a base-
line and egula in e als ollowing bo ulinum oxin injec ions in pa ien s wi h ce ical dys onia
Baseline,
mean (SD)
A 2 wk,
mean (SD)
A 4 wk,
mean (SD)
A 8 wk,
mean (SD)
A 12 wk,
mean (SD)
Neck muscle s eng h
Flexion (N) 92.8 (45.2) 76.7 (37.0)*83.2 (37.4) 90.3 (48.0) 90.1 (41.0)
Ex ension (N) 179.4 (73.5) 128.7 (74.8)*127.7 (68.9)*148.8 (79.3)*172.2 (79.0)
Ro a ion (Nm) 10.6 (6.6) 8.0 (5.4)*8.6 (5.5)*10.2 (7.3) 10.1 (5.8)
Mechanical p ope ies
Tension (Hz) 15.6 (3.1) 14.5 (2.1) 14.6 (2.5)* 15.2 (1.2) 15.4 (2.1)
Elas ici y 1.26 (0.18) 1.34 (0.26) 1.35 (0.19) 1.41 (0.13)*1.39 (0.12)
S i ness (N/m) 319 (109) 274 (93) 265 (82)*278 (53) 244 (32)
Compliance (mJ) 22.1 (4.7) 23.8 (4.8) 24.3 (6.6) 22.4 (3.1) 21.7 (5.9)
TWSTRS
Se e i y (0 o 35) 12.4 (3.8) 8.1 (4.3)*9.1 (4.0)*10.8 (3.0)*13.6 (3.0)
Disabili y (0 o 30) 7.1 (3.9) 6.0 (2.9) 6.4 (2.4) 7.1 (3.9) 8.1 (2.9)
Pain (0 o 20) 6.3 (4.1) 5.3 (4.9) 4.2 (3.4) 5.3 (4.9) 5.3 (4.8)
To al (0 o 85) 25.8 (10.3) 19.4 (9.1)*21.0 (5.7) 23.1 (10.0) 27.0 (8.4)
*signi ican ly di e en om baseline (p < 0.05). Hz: he z, N: new on, m: me e , mJ: millijoule, TWSTRS: To on o Wes e n Spasmodic To icollis Ra ing Scale,
SD: s anda d de ia ion.
S eng h & Muscle P ope ies in CD Following BoNT
Mus alampi S, e al.
www.e-jmd.o g 47
-17) in ex ension (p = 0.001), and -17% (95% CI: -33
o -2) in lexion (p = 0.032). No signi ican change
was obse ed on he non-a ec ed side o o a ion
s eng h among consecu i e measu emen s. The o-
a ion s eng h o he a ec ed side dec eased by -25%
(95% CI: -41 o -9) a wo weeks (p = 0.008). A e
wo weeks, howe e , o a ion s eng h g adually im-
p o ed. A signi ican dec ease in ex ension s eng h
was s ill e iden a eigh weeks, and a dec ease in o-
a ion s eng h was p esen on he a ec ed side a
ou weeks a e he BoNT injec ions. All s eng h
measu es e u ned o he baseline alues wi hin 12
weeks.
Muscle s i ness and ension on he a ec ed side
we e dec eased by 17% (95% CI: -32 o -2) (p =
0.031) and 6% (95% CI: -12 o -1) (p = 0.030), e-
spec i ely, a ou weeks a e he BoNT injec ions.
Muscle elas ici y on he a ec ed side was inc eased
by 12% (95% CI: 6 o 18) (p = 0.003) a eigh weeks,
showing a educed elas ic capaci y. No o he signi -
ican changes in he muscle mechanical p ope ies
we e obse ed a e BoNT injec ions. The sEMG
alues eco ded du ing hese measu emen s we e
low a all ime-poin s ( ange om 0 o 14 mV).
The TWSTRS-se e i y and TWSTRS- o al sco es
we e dec eased by 4.3% (95% CI: -6.3 o -2.2) (p =
0.002) and 6.4% (95% CI: -9.1 o -3.6) (p = 0.001),
espec i ely, a wo weeks a e he BoNT injec-
ions. The TWSTRS-se e i y sco e emained signi -
ican ly imp o ed compa ed o baseline un il eigh
weeks a e he ea men . The e we e no signi ican
changes in he TWSTRS-disabili y o pain sco es a
any ime du ing ollow-up. No ad e se e en s we e e-
po ed wi h BoNT injec ions, excep neck weakness.
DISCUSSION
This is he i s ollow-up s udy o quan i y he e -
ec o BoNT injec ions on neck s eng h in pa ien s
wi h CD. A he doses used in he p esen s udy,
BoNT injec ions caused pa ial pa alysis o he mus-
cles injec ed,2,5 and hus he educ ion in s eng h was
expec ed. We ound no p e ious epo s ha quan-
i y changes in neck muscles ha could be compa ed
wi h ou esul s. The p esen s udy showed ha he
luc ua ion in neck s eng h be ween consecu i e
BoNT injec ions is subs an ial. A wo weeks a e
ea men , he dec ease in neck s eng h was he
la ges in ex ension, almos as la ge as ha in o a-
ion, and was less p onounced in lexion. The ime
equi ed o neck s eng h o eco e in he di e -
en mo emen s a ied, and his was p obably due o
he muscles ha we e injec ed. S eng h in all mo-
emen s was no malized o p e-injec ion le els a
wel e weeks. Häkkinen e al.4 showed ha CD pa-
ien s wi h BoNT- ea ed neck muscles show sig-
ni ican ly lowe peak neck s eng h compa ed o
heal hy ma ched con ols. In hei s udy, he s eng h
measu emen s we e pe o med jus p io o he nex
injec ion. Howe e , acco ding o he indings o he
p esen s udy, his was when neck s eng h was high-
es in he CD pa ien s. Thus, he esul s sugges ed
ha BoNT injec ion may ha e long- e m e ec s on
maximal neck s eng h. The p esen s udy shows
ha maximal neck s eng h is conside ably lowe
wo weeks a e injec ion. The cu en neck s eng h
alues a wo weeks a e BoNT injec ions we e ap-
p oxima ely 50 o 60% o he maximal isome ic s -
eng h ha was p e iously epo ed in heal hy sub-
jec s wi h compa able age g oups.13,14 S eng h mea-
su emen s in he p esen s udy we e pe o med wi h
he same equipmen and es p o ocol ha we e used
o he heal hy subjec s in p e ious s udies, and hus
he esul s a e compa able. Fo una e al.15 ha e sh-
own ha BoNT injec ions cause se e e muscle a -
ophy and loss o con ac ile issue in no only he
injec ed muscles bu also he non-injec ed muscles.
Muscle weakness may be pa ly due o ch onic neck
pain, which as was p e iously shown in pa ien s
wi h ch onic mechanical neck pain.9 I is impo an
o no e ha he pa ien s in he p esen s udy had e-
cei ed BoNT injec ions a h ee mon hs in e als
o app oxima ely wo yea s.
The muscle mechanical p ope ies measu ed in
his s udy we e al e ed a e BoNT injec ions. Muscle
ension and s i ness alues dec eased a ou weeks
a e BoNT injec ions, and elas ici y alues inc eased
a eigh weeks a e BoNT injec ions. The esul s o
he p esen s udy a e somewha simila o he e-
sul s epo ed by Ma ulli e al.,8 who combined
BoNT injec ions and physio he apy o he ea -
men o CD in 15 pa ien s. They pe o med clinical
e alua ion and myo onome ic measu emen s us-
ing he Myo on-3 be o e and a one, wo, and h ee
mon hs ollowing BoNT injec ions. Thei s udy
ound ha muscle ension, s i ness, and elas ici y
alues measu ed wi h he Myo on we e dec eased
a e BoNT injec ions a one, wo, and h ee mon hs

48
J Mo Diso d 2016;9(1):44-49
JMD
a e injec ions. Howe e , he di e ences in s udy
designs be ween ha s udy and he p esen s udy
may pa ly explain he di e ences in esul s. Pa-
ien s in he p esen s udy had been ecei ing BoNT
injec ions o yea s, whe eas pa ien s in he s udy o
Ma ulli e al.8 ecei ed hei i s BoNT injec ions.
I has been epo ed ha long- e m use o BoNT e-
sul s in a dec ease in con ac ile issue and an inc -
ease in connec i e issue,15 hus making he muscle
mo e igid. Consequen ly, acu e changes in muscle
p ope ies would become less ob ious. No changes
we e obse ed in he muscle compliance alues. This
esul may be me hodological: i was di icul o
posi ion he measu emen de ice on a small, ound
muscle. The CMT echnique is p obably mo e sui -
able o la ge muscles.11
The indings in ou s udy on disabili y a e consis-
en wi h hose o p e ious s udies epo ing sho -
e m unc ional imp o emen in CD a e BoNT
injec ions.2,3,5-7 In he p esen s udy, he TWSTRS-
o al and TWSTRS-se e i y sco es we e signi ican -
ly lowe a wo weeks compa ed wi h he p e-injec-
ion sco es. These indings also showed ha he
sco es e u ns o p e-injec ion s a e o e he cou se
o he h ee-mon h ollow-up, as was epo ed in
ea lie s udies.2,3,5-7 The p esen s udy shows ha he
changes in clinical sco es a e associa ed wi h objec-
i ely measu ed changes in muscle p ope ies. Fu -
he mo e, he esul s show ha , despi e a possible
nega i e e ec on unc ion ha included dec eased
neck s eng h, he BoNT injec ions imp o ed he
pa ien s epo ed disabili y.
The ac ha he g oup o pa ien s who we e ea -
ed in he p esen s udy had been unde going egu-
la he apy wi h BoNT injec ions o se e al yea s
indica es hei baseline disabili y sco es we e p ob-
ably less se e e han hose wi hou ea men . The e-
o e, he changes in he ea men g oup we e small-
e han hose in he un ea ed g oups.3,7 Howe e , in
his s udy, he aim was o e alua e changes in he pa-
ien g oup wi h he long- e m use o BoNT. The
small and he e ogeneous s udy g oup used in he
p esen s udy may no ha e p o ided su icien powe
o de ec small changes in ou come measu es. Fu -
he esea ch wi h a la ge s udy g oup and a longe
ollow-up pe iod is needed o s udy he e ec s o
BoNT injec ions on muscle s eng h and he mech-
anical p ope ies o muscles.
This s udy showed ha al hough maximal s eng h,
ension, s i ness, and elas ic capaci y we e educed
in neck muscles a e BoNT injec ions, he se e i y
o neck complain s dec eased in pa ien s wi h CD.
Neck muscle s eng h, muscle mechanical p ope -
ies and disabili y sco es e u ned o p e-injec ion
le els wi hin wel e weeks.
Con lic s o In e es
One o he co-au ho s, Ja i Ylinen, has de eloped he Com-
pu e ized Muscle Tonome e , and is one o he owne s o he
company Medi ehabook L d. No o he po en ial con lic o in-
e es decla ed.
Acknowledgmen s
This esea ch was suppo ed by he Finnish Funding Agency
o Technology and Inno a ion, and Jy äskylä Cen al Hospi al
in Finland.
REFERENCES
1. C owne BE. Ce ical dys onia: disease p o ile and clinical
managemen . Phys The 2007;87:1511-1526.
2. No ak I, Campbell L, Boyce M, Fung VS; Ce eb al Palsy In-
s i u e. Bo ulinum oxin assessmen , in e en ion and a -
e ca e o ce ical dys onia and o he causes o hype onia
o he neck: in e na ional consensus s a emen . Eu J Neu ol
2010;17 Suppl 2:94-108.
3. Cos a J, Espí i o-San o C, Bo ges A, Fe ei a JJ, Coelho M,
Moo e P, e al. Bo ulinum oxin ype A he apy o ce ical
dys onia. Coch ane Da abase Sys Re 2005;(1):CD003633.
4. Häkkinen A, Ylinen J, Rin a-Ke u i M, Tal i ie U, Kau iain-
en H, Rissanen A. Dec eased neck muscle s eng h is highly
associa ed wi h pain in ce ical dys onia pa ien s ea ed
wi h bo ulinum oxin injec ions. A ch Phys Med Rehabil
2004;85:1684-1688.
5. Halle M, Albanese A, D essle D, Segal KR, Simpson DM,
T uong D, e al. E idence-based e iew and assessmen o
bo ulinum neu o oxin o he ea men o mo emen dis-
o de s. Toxicon 2013;67:94-114.
6. Rami ez-Cas aneda J, Janko ic J. Long- e m e icacy, sa e y,
and side e ec p o ile o bo ulinum oxin in dys onia: a 20-
yea ollow-up. Toxicon 2014;90:344-348.
7. T uong D, B odsky M, Lew M, B ashea A, Janko ic J, Mol-
ho E, e al. Long- e m e icacy and sa e y o bo ulinum oxin
ype A (Dyspo ) in ce ical dys onia. Pa kinsonism Rela
Diso d 2010;16:316-323.
8. Ma ulli R, Ianie i G, Megna G, Lancioni G, Saggini R, Ra-
nie i M, e al. Bo ulinum oxin ype A in ce ical dys onia.
In J Immunopa hol Pha macol 2012;25(1 Suppl):23S-28S.
9. Ylinen J, Salo P, Nykänen M, Kau iainen H, Häkkinen A.
Dec eased isome ic neck s eng h in women wi h ch onic
neck pain and he epea abili y o neck s eng h measu e-
men s. A ch Phys Med Rehabil 2004;85:1303-1308.
10. Chuang LL, Lin KC, Wu CY, Chang CW, Chen HC, Yin HP,
e al. Rela i e and absolu e eliabili ies o he myo onome ic
measu emen s o hemipa e ic a ms in pa ien s wi h s oke.
A ch Phys Med Rehabil 2013;94:459-466.
11. Mus alampi S, Ylinen J, Kau iainen H, Wei A, Häkkinen
A. Acu e e ec s o cold pack on mechanical p ope ies o
he quad iceps muscle in heal hy subjec s. Phys The Spo
2012;13:265-269.
12. Ylinen J, Tei inen I, Kainulainen V, Kau iainen H, Vehmas-
S eng h & Muscle P ope ies in CD Following BoNT
Mus alampi S, e al.
www.e-jmd.o g 49
koski K, Häkkinen A. Repea abili y o a compu e ized mus-
cle onome e and he e ec o issue hickness on he es i-
ma ion o muscle one. Physiol Meas 2006;27:787-796.
13. Salo PK, Ylinen JJ, Mälkiä EA, Kau iainen H, Häkkinen AH.
Isome ic s eng h o he ce ical lexo , ex enso , and o a-
o muscles in 220 heal hy emales aged 20 o 59 yea s. J
O hop Spo s Phys The 2006;36:495-502.
14. Ylinen JJ, Sa olainen S, Ai aksinen O, Kau iainen H, Salo P,
Häkkinen A. Dec eased s eng h and mobili y in pa ien s
a e an e io ce ical diskec omy compa ed wi h heal hy
subjec s. A ch Phys Med Rehabil 2003;84:1043-1047.
15. Fo una R, Vaz MA, Yousse AR, Longino D, He zog W.
Changes in con ac ile p ope ies o muscles ecei ing e-
pea injec ions o bo ulinum oxin (Bo ox). J Biomech 2011;
44:39-44.