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Dabrowski E, Chambers HG, Gaebler-Spira D, Banach M, Kaňovský P, Dersch H, Althaus M, Geister TL, Heinen F. IncobotulinumtoxinA Efficacy/Safety in Upper-Limb Spasticity in Pediatric Cerebral Palsy: Randomized Controlled Trial. Pediatr Neurol 2021; 123:10-20. [PMID: 34339951 DOI: 10.1016/j.pediatrneurol.2021.05.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/07/2021] [Accepted: 05/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND This randomized phase 3 study with double-blind main period (MP) and open-label extension (OLEX; NCT02002884) assessed incobotulinumtoxinA safety and efficacy for pediatric upper-limb spasticity treatment in ambulant/nonambulant (Gross Motor Function Classification System [GMFCS] I-V) patients, with the option of combined upper- and lower-limb treatment. METHODS Patients were aged two to 17 years with unilateral or bilateral spastic cerebral palsy (CP) and Ashworth Scale (AS) score ≥2 in treatment-selected clinical patterns. In the MP, patients were randomized (2:1:1) to incobotulinumtoxinA 8, 6, or 2 U/kg body weight (maximum 200, 150, 50 U/upper limb), with optional lower-limb injections in one of five topographical distributions (total body dose ≤16 to 20 U/kg, maximum 400 to 500 U, depending on body weight and GMFCS level). In the OLEX, patients received three further treatment cycles, at the highest MP doses (8 U/kg/upper limb group). Outcomes included AS, Global Impression of Change Scale (GICS), and adverse events (AEs). RESULTS AS scores improved from baseline to week 4 in all MP dose groups (n = 350); patients in the incobotulinumtoxinA 8 U/kg group had significantly greater spasticity improvements versus the 2 U/kg group (least-squares mean [standard error] for upper-limb main clinical target pattern -1.15 [0.06] versus -0.93 [0.08]; P = 0.017). Investigator's, child/adolescent's, and parent/caregiver's GICS scores showed improvements in all groups. Treatment benefits were sustained over further treatment cycles. AE incidence did not increase with dose or repeated treatment across GMFCS levels. CONCLUSIONS Data provide evidence for sustained efficacy and safety of multipattern incobotulinumtoxinA treatment in children and adolescents with upper-limb spasticity.
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Affiliation(s)
- Edward Dabrowski
- Beaumont Pediatric Physical Medicine & Rehabilitation - Royal Oak, Royal Oak, Michigan.
| | | | | | - Marta Banach
- Department of Neurology, Collegium Medicum, Jagiellonian University, Krakow, Poland
| | - Petr Kaňovský
- Faculty of Medicine and Dentistry and University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - Hanna Dersch
- Merz Pharmaceuticals GmbH, Frankfurt am Main, Germany
| | | | | | - Florian Heinen
- LMU Klinikum Munich, Division of Pediatric Neurology & LMU Center for Children with Medical Complexity, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
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Lagnau P, Lo A, Sandarage R, Alter K, Picelli A, Wissel J, Verduzco-Gutierrez M, Suputtitada A, Munin MC, Carda S, Khan O, Koçer S, Reebye R. Ergonomic Recommendations in Ultrasound-Guided Botulinum Neurotoxin Chemodenervation for Spasticity: An International Expert Group Opinion. Toxins (Basel) 2021; 13:249. [PMID: 33807196 PMCID: PMC8067138 DOI: 10.3390/toxins13040249] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 02/06/2023] Open
Abstract
Ultrasound (US)-guided botulinum neurotoxin (BoNT) injections are becoming a mainstay in the treatment of muscle spasticity in upper motor neuron syndromes. As a result, there has been a commensurate increase in US-guided BoNT injection for spasticity training courses. However, many of these courses do not emphasize the importance of ergonomics. This paper aims to highlight the importance of ultrasound ergonomics and presents ergonomic recommendations to optimize US-guided BoNT injection techniques in spasticity management. Expert consensus opinion of 11 physicians (4 different continents; representing 8 countries, with an average of 12.6 years of practice using US guidance for BoNT chemodenervation (range 3 to 22 years)). A search using PubMed, College of Physicians and Surgeons of British Columbia database, EMbase was conducted and found no publications relating the importance of ergonomics in US-guided chemodenervation. Therefore, recommendations and consensus discussions were generated from the distribution of a 20-question survey to a panel of 11 ultrasound experts. All 11 surveyed physicians considered ergonomics to be important in reducing physician injury. There was complete agreement that physician positioning was important; 91% agreement that patient positioning was important; and 82% that ultrasound machine positioning was important. Factors that did not reach our 80% threshold for consensus were further discussed. Four categories were identified as being important when implementing ultrasound ergonomics for BoNT chemodenervation for spasticity; workstation, physician, patient and visual ergonomics. Optimizing ergonomics is paramount when performing US-guided BoNT chemodenervation for spasticity management. This includes proper preparation of the workspace and allowing for sufficient pre-injection time to optimally position both the patient and the physician. Lack of awareness of ergonomics for US-guided BoNT chemodenervation for spasticity may lead to suboptimal patient outcomes, increase work-related injuries, and patient discomfort. We propose key elements for optimal positioning of physicians and patients, as well as the optimal setup of the workspace and provide clinical pearls in visual identification of spastic muscles for chemodenervation.
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Affiliation(s)
- Philippe Lagnau
- GF Strong Rehabilitation Centre, Vancouver, BC V5Z 2G9, Canada;
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada; (A.L.); (R.S.); (A.S.); (S.C.); (O.K.)
| | - Alto Lo
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada; (A.L.); (R.S.); (A.S.); (S.C.); (O.K.)
- Division of Physical Medicine and Rehabilitation, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Ryan Sandarage
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada; (A.L.); (R.S.); (A.S.); (S.C.); (O.K.)
- Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
| | - Katharine Alter
- Functional and Applied Biomechanics Section, Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA;
| | - Alessandro Picelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy;
| | - Jorg Wissel
- Neurological Rehabilitation & Physical Therapy, Department of Neurology with Stroke Unit, Vivantes Hospital Spandau, 13585 Berlin, Germany;
| | - Monica Verduzco-Gutierrez
- Department of Rehabilitation Medicine, Joe-R.-and-Teresa-Lozano Long School of Medicine, UT Health San Antonio, San Antonio, TX 78229, USA;
| | - Areerat Suputtitada
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada; (A.L.); (R.S.); (A.S.); (S.C.); (O.K.)
- Department of Rehabilitation Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | - Michael C. Munin
- Physical Medicine and Rehabilitation School of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA;
| | - Stefano Carda
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada; (A.L.); (R.S.); (A.S.); (S.C.); (O.K.)
- Neuropsychology and Neurorehabilitation Service, Department of Clinical Neuroscience, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Omar Khan
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada; (A.L.); (R.S.); (A.S.); (S.C.); (O.K.)
- Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharines, ON L2T 4C2, Canada
| | - Serdar Koçer
- Centre de Rééducation Hôpital du Jura, 2900 Porrentruy, Switzerland;
| | - Rajiv Reebye
- GF Strong Rehabilitation Centre, Vancouver, BC V5Z 2G9, Canada;
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada; (A.L.); (R.S.); (A.S.); (S.C.); (O.K.)
- Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
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The relationship between obstructive sleep apnea and Parkinson's disease: a systematic review and meta-analysis. Neurol Sci 2020; 41:1153-1162. [PMID: 31897944 DOI: 10.1007/s10072-019-04211-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/18/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a common sleep disorder in Parkinson's disease (PD). However, the relationship between OSA and PD is still inconsistent. Our study was aimed to evaluate the relationship between PD and OSA. METHODS Studies on OSA and PD were searched using PubMed, Embase, Web of Science, Cochrane library, and Chinese National Knowledge Infrastructure databases. Review Manager 5.3 software was used to calculate the pooled estimate effect. The inverse variance model was used to pool the mean difference (MD) or hazard ratios (HRs); the Mantel-Haenszel method was used to pool the odds ratio (OR). Heterogeneity among the studies was assessed using I2 statistic and Q test. RESULTS A total of 12 studies with 93,332 cases were deemed eligible and included in our meta-analysis. Overall, the occurrence of PD was more frequent in patients with OSA (HR 1.59, 95% CI, 1.36-1.85). The subgroup analysis demonstrated the risk similarly by sex. Male and female had HR of incident PD with OSA of 1.56 (95% CI, 1.30-1.87) and 1.60 (95% CI, 1.21-2.11), respectively. The incidence of OSA did not increase in PD patients (OR 0.89, 95% CI, 0.53-1.49). The MD of apnea-hypopnea index (AHI) in PD patients was also not statistically significant (P = 0.5). CONCLUSIONS The results indicate that OSA is one of independent risk factors of PD. However, OSA does not seem to be abnormally frequent in PD.
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Schramm A, Bäumer T, Fietzek U, Heitmann S, Walter U, Jost WH. Relevance of sonography for botulinum toxin treatment of cervical dystonia: an expert statement. J Neural Transm (Vienna) 2015; 122:1457-63. [PMID: 25547861 PMCID: PMC4591194 DOI: 10.1007/s00702-014-1356-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Accepted: 12/20/2014] [Indexed: 11/26/2022]
Abstract
Botulinum neurotoxin A (BoNT A) is the first-line treatment for cervical dystonia. However, although BoNT A has a favorable safety profile and is effective in the majority of patients, in some cases the treatment outcome is disappointing or side effects occur when higher doses are used. It is likely that in such cases either the target muscles were not injected accurately or unintended weakness of non-target muscles occurred. It has been demonstrated in clinical trials for spastic movement disorders that sonography-guided BoNT A injections could improve treatment outcome. As the published evidence for a benefit of sonography-guided BoNT injection in patients with cervical dystonia is scarce, it is the aim of this review to discuss the relevance of sonography in this indication and provide a statement from clinical experts for its use. The clear advantage of sonography-guided injections is non-invasive, real-time visualization of the targeted muscle, thus improving the precision of injections and potentially the treatment outcomes as well as avoiding adverse effects. Other imaging techniques are of limited value due to high costs, radiation exposure or non-availability in clinical routine. In the hands of a trained injector, sonography is a quick and non-invasive imaging technique. Novel treatment concepts of cervical dystonia considering the differential contributions of distinct cranial and cervical muscles can reliably be implemented only by use of imaging-guided injection protocols.
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Affiliation(s)
- Axel Schramm
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Tobias Bäumer
- Department of Movement Disorders and Neuropsychiatry, University of Lübeck, Lübeck, Germany
| | - Urban Fietzek
- Department of Neurology and Clinical Neurophysiology, Schön Klinik München Schwabing, Munich, Germany
| | - Susanne Heitmann
- Department of Neurology, Deutsche Klinik für Diagnostik, Wiesbaden, Germany
| | - Uwe Walter
- Department of Neurology, University of Rostock, Rostock, Germany
| | - Wolfgang H Jost
- Department of Neurology, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
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