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Mohamed AA, Faragalla S, Khan A, Flynn G, Rainone G, Johansen PM, Lucke-Wold B. Neurosurgical and pharmacological management of dystonia. World J Psychiatry 2024; 14:624-634. [PMID: 38808085 PMCID: PMC11129150 DOI: 10.5498/wjp.v14.i5.624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 04/20/2024] [Accepted: 04/26/2024] [Indexed: 05/16/2024] Open
Abstract
Dystonia characterizes a group of neurological movement disorders characterized by abnormal muscle movements, often with repetitive or sustained contraction resulting in abnormal posturing. Different types of dystonia present based on the affected body regions and play a prominent role in determining the potential efficacy of a given intervention. For most patients afflicted with these disorders, an exact cause is rarely identified, so treatment mainly focuses on symptomatic alleviation. Pharmacological agents, such as oral anticholinergic administration and botulinum toxin injection, play a major role in the initial treatment of patients. In more severe and/or refractory cases, focal areas for neurosurgical intervention are identified and targeted to improve quality of life. Deep brain stimulation (DBS) targets these anatomical locations to minimize dystonia symptoms. Surgical ablation procedures and peripheral denervation surgeries also offer potential treatment to patients who do not respond to DBS. These management options grant providers and patients the ability to weigh the benefits and risks for each individual patient profile. This review article explores these pharmacological and neurosurgical management modalities for dystonia, providing a comprehensive assessment of each of their benefits and shortcomings.
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Affiliation(s)
- Ali Ahmed Mohamed
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Steven Faragalla
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Asad Khan
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Garrett Flynn
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Gersham Rainone
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL 33606, United States
| | - Phillip Mitchell Johansen
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL 33606, United States
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32611, United States
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Sedov A, Joshi P, Semenova U, Usova S, Asriyants S, Gamaleya A, Tomskiy A, Jinnah HA, Shaikh AG. Proprioceptive Modulation of Pallidal Physiology in Cervical Dystonia. Mov Disord 2023; 38:2094-2102. [PMID: 37702261 DOI: 10.1002/mds.29603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/08/2023] [Accepted: 08/24/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND There is a growing body of evidence suggesting that botulinum toxin can alter proprioceptive feedback and modulate the muscle-spindle output for the treatment of dystonia. However, the mechanism for this modulation remains unclear. METHODS We conducted a study involving 17 patients with cervical dystonia (CD), seven of whom had prominent CD and 10 with generalized dystonia (GD) along with CD. We investigated the effects of neck vibration, a form of proprioceptive modulation, on spontaneous single-neuron responses and local field potentials (LFPs) recorded from the globus pallidum externus (GPe) and internus (GPi). RESULTS Our findings demonstrated that neck vibration notably increased the regularity of neck-sensitive GPi neurons in focal CD patients. Additionally, in patients with GD and CD, the vibration enhanced the firing regularity of non-neck-sensitive neurons. These effects on single-unit activity were also mirrored in ensemble responses measured through LFPs. Notably, the LFP modulation was particularly pronounced in areas populated with burst neurons compared to pause or tonic cells. CONCLUSION The results from our study emphasize the significance of burst neurons in the pathogenesis of dystonia and in the efficacy of proprioceptive modulation for its treatment. Moreover, we observed that the effects of vibration on focal CD were prominent in the α band LFP, indicating modulation of pallido-cerebellar connectivity. Moreover, the pallidal effects of vibration in GD with CD involved modulation of cerebro-pallidal θ band connectivity. Our analysis provides insight into how vibration-induced changes in pallidal activity are integrated into the downstream motor circuit. © 2023 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Alexey Sedov
- N.N. Semenov Federal Research Center for Chemical Physics, Russian Academy of Sciences, Moscow, Russia
- Moscow Institute of Physics and Technology, Dolgoprudny, Moscow Region, Russia
| | - Prajakta Joshi
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ulia Semenova
- N.N. Semenov Federal Research Center for Chemical Physics, Russian Academy of Sciences, Moscow, Russia
| | - Svetlana Usova
- N.N. Semenov Federal Research Center for Chemical Physics, Russian Academy of Sciences, Moscow, Russia
| | - Svetlana Asriyants
- N.N. Semenov Federal Research Center for Chemical Physics, Russian Academy of Sciences, Moscow, Russia
- Burdenko National Scientific and Practical Center for Neurosurgery, Moscow, Russia
| | - Anna Gamaleya
- Burdenko National Scientific and Practical Center for Neurosurgery, Moscow, Russia
| | - Alexey Tomskiy
- Burdenko National Scientific and Practical Center for Neurosurgery, Moscow, Russia
| | - Hyder A Jinnah
- Department of Neurology, Pediatrics, and Genetics, Emory University, Atlanta, Georgia, USA
| | - Aasef G Shaikh
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Neurology, Case Western Reserve University, Cleveland, Ohio, USA
- Neurological Institute, University Hospitals, Cleveland, Ohio, USA
- Neurology Service, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
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Campanini I, Merlo A, Disselhorst-Klug C, Mesin L, Muceli S, Merletti R. Fundamental Concepts of Bipolar and High-Density Surface EMG Understanding and Teaching for Clinical, Occupational, and Sport Applications: Origin, Detection, and Main Errors. SENSORS (BASEL, SWITZERLAND) 2022; 22:4150. [PMID: 35684769 PMCID: PMC9185290 DOI: 10.3390/s22114150] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/20/2022] [Accepted: 05/26/2022] [Indexed: 06/15/2023]
Abstract
Surface electromyography (sEMG) has been the subject of thousands of scientific articles, but many barriers limit its clinical applications. Previous work has indicated that the lack of time, competence, training, and teaching is the main barrier to the clinical application of sEMG. This work follows up and presents a number of analogies, metaphors, and simulations using physical and mathematical models that provide tools for teaching sEMG detection by means of electrode pairs (1D signals) and electrode grids (2D and 3D signals). The basic mechanisms of sEMG generation are summarized and the features of the sensing system (electrode location, size, interelectrode distance, crosstalk, etc.) are illustrated (mostly by animations) with examples that teachers can use. The most common, as well as some potential, applications are illustrated in the areas of signal presentation, gait analysis, the optimal injection of botulinum toxin, neurorehabilitation, ergonomics, obstetrics, occupational medicine, and sport sciences. The work is primarily focused on correct sEMG detection and on crosstalk. Issues related to the clinical transfer of innovations are also discussed, as well as the need for training new clinical and/or technical operators in the field of sEMG.
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Affiliation(s)
- Isabella Campanini
- LAM-Motion Analysis Laboratory, Neuromotor and Rehabilitation Department, S. Sebastiano Hospital, Azienda USL-IRCCS di Reggio Emilia, Via Circondaria 29, 42015 Correggio, Italy; (I.C.); or (A.M.)
| | - Andrea Merlo
- LAM-Motion Analysis Laboratory, Neuromotor and Rehabilitation Department, S. Sebastiano Hospital, Azienda USL-IRCCS di Reggio Emilia, Via Circondaria 29, 42015 Correggio, Italy; (I.C.); or (A.M.)
- Merlo Bioengineering, 43121 Parma, Italy
| | - Catherine Disselhorst-Klug
- Department of Rehabilitation & Prevention Engineering, Institute of Applied Medical Engineering, RWTH Aachen University, Pauwelsstr. 20, 52074 Aachen, Germany;
| | - Luca Mesin
- Mathematical Biology and Physiology Group, Department of Electronics and Telecommunications, Politecnico di Torino, Corso Duca degli Abruzzi 24, 10129 Turin, Italy;
| | - Silvia Muceli
- Division of Signal Processing and Biomedical Engineering, Department of Electrical Engineering, Chalmers University of Technology, Hörsalsvägen 11, 41296 Gothenburg, Sweden;
| | - Roberto Merletti
- Laboratory for Engineering of the Neuromuscular System (LISiN), Department of Electronics and Telecommunications, Politecnico di Torino, Corso Duca degli Abruzzi 24, 10129 Turin, Italy
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Rodrigues FB, Duarte GS, Castelão M, Marques RE, Ferreira J, Sampaio C, Moore AP, Costa J. Botulinum toxin type A versus anticholinergics for cervical dystonia. Cochrane Database Syst Rev 2021; 4:CD004312. [PMID: 33852744 PMCID: PMC8092669 DOI: 10.1002/14651858.cd004312.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND This is an update of a Cochrane Review first published in 2005. Cervical dystonia is the most common form of focal dystonia and is a highly disabling movement disorder, characterised by involuntary, usually painful, head posturing. Currently, botulinum toxin type A (BtA) is considered the first line therapy for this condition. Before BtA, anticholinergics were the most widely accepted treatment. OBJECTIVES To compare the efficacy, safety, and tolerability of BtA versus anticholinergic drugs in adults with cervical dystonia. SEARCH METHODS We searched the Cochrane Movement Disorders' Trials Register to June 2003, screened reference lists of articles and conference proceedings to September 2018, and searched CENTRAL, MEDLINE, and Embase, with no language restrictions, to July 2020. SELECTION CRITERIA Double-blind, parallel, randomised trials (RCTs) of BtA versus anticholinergic drugs in adults with cervical dystonia. DATA COLLECTION AND ANALYSIS Two review authors independently assessed records, selected included studies, extracted data using a paper pro forma, and evaluated the risk of bias and quality of the evidence. We resolved disagreements by consensus or by consulting a third review author. If enough data had been available, we were to perform meta-analyses using a random-effects model for the comparison of BtA versus anticholinergic drugs to estimate pooled effects and corresponding 95% confidence intervals (95% CI). The primary efficacy outcome was improvement in cervical dystonia-specific impairment. The primary safety outcome was the proportion of participants with any adverse event. MAIN RESULTS We included one RCT of moderate overall risk of bias (as multiple domains were at unclear risk of bias), which included 66 BtA-naive participants with cervical dystonia. Two doses of BtA (Dysport; week 0 and 8; mean dose 262 to 292 U) were compared with daily trihexyphenidyl (up to 24 mg daily). The trial was sponsored by the BtA producer. BtA reduced cervical dystonia severity by an average of 2.5 points (95% CI 0.68 to 4.32) on the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) severity subscale 12 weeks after injection, compared to trihexyphenidyl. More participants reported adverse events in the trihexyphenidyl treatment group (76 events), compared with the BtA group (31 events); however, the difference in dropouts due to adverse events was inconclusive between groups. There was a decreased risk of dry mouth, and memory problems with BtA, but the differences were inconclusive between groups for the other reported side effects (blurred vision, dizziness, depression, fatigue, pain at injection site, dysphagia, and neck weakness). AUTHORS' CONCLUSIONS We found very low-certainty evidence that BtA is more effective, better tolerated, and safer than trihexyphenidyl. We found no information on a dose-response relationship with BtA, differences between BtA formulations or different anticholinergics, the utility of electromyography-guided injections, or the duration of treatment effect.
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Affiliation(s)
- Filipe B Rodrigues
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Gonçalo S Duarte
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Mafalda Castelão
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Raquel E Marques
- Department of Ophthalmology, Hospital de Santa Maria, Lisboa, Portugal
| | - Joaquim Ferreira
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | | | | | - João Costa
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
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Duarte GS, Rodrigues FB, Marques RE, Castelão M, Ferreira J, Sampaio C, Moore AP, Costa J. Botulinum toxin type A therapy for blepharospasm. Cochrane Database Syst Rev 2020; 11:CD004900. [PMID: 33211907 PMCID: PMC8094161 DOI: 10.1002/14651858.cd004900.pub3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND This is an update of a Cochrane Review first published in 2005. Blepharospasm is the second most common form of focal dystonia. It is a disabling disorder, characterised by chronic, intermittent or persistent, involuntary eyelid closure, due to spasmodic contractions of the orbicularis oculi muscles. Currently, botulinum toxin type A (BtA) is considered the first line of therapy for this condition. OBJECTIVES To compare the efficacy, safety, and tolerability of BtA versus placebo in people with blepharospasm. SEARCH METHODS We searched Cochrane Movement Disorders' Trials Register, CENTRAL, MEDLINE, Embase, reference lists of included articles, and conference proceedings. We ran all elements of the search, with no language restrictions, in July 2020. SELECTION CRITERIA Double-blind, parallel, randomised, placebo-controlled trials (RCTs) of BtA versus placebo in adults with blepharospasm. DATA COLLECTION AND ANALYSIS Two review authors independently assessed records, selected included studies, extracted data using a paper pro forma, and evaluated the risk of bias. We resolved disagreements by consensus, or by consulting a third review author. We performed meta-analyses using a random-effects model, for the comparison of BtA versus placebo, to estimate pooled effects and corresponding 95% confidence intervals (95% CI). We did not carry out any prespecified subgroup analyses. The primary efficacy outcome was improvement on any validated symptomatic rating scale. The primary safety outcome was the proportion of participants with any adverse event. MAIN RESULTS We included three RCTs, assessed at low to moderate overall risk of bias, which randomised 313 participants with blepharospasm. Two studies excluded participants with poorer prior responses to BtA treatment, therefore, they included an enriched population with a higher probability of benefiting from this therapy. All trials were industry-funded. All RCTs evaluated the effect of a single BtA treatment session. BtA resulted in a moderate to large improvement in blepharospasm-specific severity, with a reduction of 0.93 points on the Jankovic Rating Scale (JRS) severity subscale at four to six weeks after injection (95% confidence interval (CI) 0.61 to 1.25; I² = 9%) compared to placebo. BtA was also resulted in a moderate to large improvement in blepharospasm-specific disability and blepharospasm-specific involuntary movements at four to six weeks after injection (disability: 0.69 JRS disability subscale points, 95% CI 0.18 to 1.19; I² = 74%; blepharospasm-specific involuntary movements: standardised mean difference (SMD) 0.79, 0.31 to 1.27; I² = 58%) compared to placebo. BtA did not show a risk of adverse events (risk ratio (RR) 1.18, 95% CI 0.87 to 1.60; I² = 0%). However, BtA increased the risk of vision complaints and eyelid ptosis (vision complaints: RR 5.73, 95% CI 1.79 to 18.36; I² = 51%; eyelid ptosis: RR 4.02, 95% CI 1.61 to 10.00; I² = 39%). There was no distinction between BtA and placebo in the number of participants who dropped out of the trial. A single trial estimated the duration of effects to be 10.6 weeks (range 6.1 to 19.1). We found no evidence supporting the existence of a clear dose-response relationship with BtA. We found no data reporting the impact of BtA on health-related quality of life, or the development of secondary non-responsiveness. AUTHORS' CONCLUSIONS We are moderately certain that a single BtA treatment resulted in a clinically relevant reduction of blepharospasm-specific severity and disability, and have low certainty that it is well tolerated, when compared with placebo. There is low-certainty evidence that people treated with BtA are not at an increased risk of developing adverse events, though BtA treatment likely increases the risk of visual complaints and eyelid ptosis. There are no data from RCTs evaluating the effectiveness and safety of repeated BtA injection cycles. There is no evidence from RCTs to allow us to draw definitive conclusions on the optimal treatment intervals and doses, or the impact on quality of life.
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Affiliation(s)
- Gonçalo S Duarte
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Filipe B Rodrigues
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Raquel E Marques
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Ophthalmology University Clinic, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Mafalda Castelão
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Joaquim Ferreira
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | | | | | - João Costa
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
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Rodrigues FB, Duarte GS, Marques RE, Castelão M, Ferreira J, Sampaio C, Moore AP, Costa J. Botulinum toxin type A therapy for cervical dystonia. Cochrane Database Syst Rev 2020; 11:CD003633. [PMID: 33180963 PMCID: PMC8106615 DOI: 10.1002/14651858.cd003633.pub4] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND This is an update of a Cochrane Review first published in 2005. Cervical dystonia is the most common form of focal dystonia, and is a highly disabling movement disorder, characterised by involuntary, usually painful, head posturing. Currently, botulinum toxin type A (BtA) is considered the first line therapy for this condition. OBJECTIVES To compare the efficacy, safety, and tolerability of BtA versus placebo, in people with cervical dystonia. SEARCH METHODS We searched Cochrane Movement Disorders' Trials Register, CENTRAL, MEDLINE, Embase, reference lists of articles, and conference proceedings in July 2020. All elements of the search, with no language restrictions, were last run in July 2020. SELECTION CRITERIA Double-blind, parallel, randomised, placebo-controlled trials (RCTs) of BtA versus placebo in adults with cervical dystonia. DATA COLLECTION AND ANALYSIS Two review authors independently assessed records, selected included studies, extracted data using a paper pro forma, and evaluated the risk of bias. We resolved disagreements by consensus or by consulting a third review author. We performed meta-analyses using a random-effects model, for the comparison of BtA versus placebo, to estimate pooled effects and corresponding 95% confidence intervals (95% CI). We performed preplanned subgroup analyses according to BtA dose used, the BtA formulation used, and the use (or not) of guidance for BtA injections. The primary efficacy outcome was improvement in cervical dystonia-specific impairment. The primary safety outcome was the proportion of participants with any adverse event. MAIN RESULTS We included nine RCTs, with moderate, overall risk of bias, that included 1144 participants with cervical dystonia. Seven studies excluded participants with poorer responses to BtA treatment, therefore, including an enriched population with a higher probability of benefiting from this therapy. Only one trial was independently funded. All RCTs evaluated the effect of a single BtA treatment session, using doses from 150 U to 500 U of onabotulinumtoxinA (Botox), 120 U to 240 U of incobotulinumtoxinA (Xeomin), and 250 U to 1000 U of abobotulinumtoxinA (Dysport). BtA resulted in a moderate to large improvement from the participant's baseline clinical status, assessed by the investigators, with a mean reduction of 8.09 points in the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS total score) at week four after injection (95% CI 6.22 to 9.96; I² = 0%) compared to placebo. This corresponded, on average, to a 18.4% improvement from baseline. The mean difference (MD) in TWSTRS pain subscore at week four was 2.11 (95% CI 1.38 to 2.83; I² = 0%) compared to placebo. Overall, both participants and clinicians reported an improvement of subjective clinical status. It was unclear if dropouts due to adverse events differed (risk ratio (RR) 2.51; 95% CI 0.42 to 14.94; I² = 0%) However, BtA treatment increased the risk of experiencing an adverse event (R) 1.23; 95% CI 1.05 to 1.43; I² = 28%). Neck weakness (14%; RR 3.40; 95% CI 1.19 to 9.71; I² = 15%), dysphagia (11%; RR 3.19; 95% CI 1.79 to 5.70; I² = 0%), and diffuse weakness or tiredness (8%; RR 1.80; 95% CI 1.10 to 2.95; I² = 0%) were the most common treatment-related adverse events. Treatment with BtA resulted in a decreased risk of dropouts. We have moderate certainty in the evidence across all of the aforementioned outcomes, with the exception of subjective assessment and tolerability, in which we have high confidence in the evidence. We found no evidence supporting the existence of a clear dose-response relationship between BtA and improvement in cervical dystonia-specific impairment, a destinction between BtA formulations, or a variation with use of EMG-guided injection for efficacy outcomes. Due to clinical heterogeneity, we did not pool health-related quality of life data, duration of clinical effect, or the development of secondary non-responsiveness. AUTHORS' CONCLUSIONS We are moderately certain in the evidence that a single BtA treatment session resulted in a clinically relevant reduction of cervical dystonia-specific impairment, and pain, and highly certain that it is well tolerated, compared with placebo. There is moderate-certainty evidence that people treated with BtA are at an increased risk of developing adverse events, most notably, dysphagia, neckweakness and diffuse weakness or tiredness. There are no data from RCTs evaluating the effectiveness and safety of repeated BtA injection cycles. There is no evidence from RCTs to allow us to draw definitive conclusions on the optimal treatment intervals and doses, the usefulness of guidance techniques for injection, the impact on quality of life, or the duration of treatment effect.
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Affiliation(s)
- Filipe B Rodrigues
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Gonçalo S Duarte
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Raquel E Marques
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Ophthalmology University Clinic, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Mafalda Castelão
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Joaquim Ferreira
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | | | | | - João Costa
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
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Bladen JC, Favor M, Litwin A, Malhotra R. Switchover study of onabotulinumtoxinA to incobotulinumtoxinA for facial dystonia. Clin Exp Ophthalmol 2020; 48:1146-1151. [PMID: 32710447 DOI: 10.1111/ceo.13829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/22/2020] [Accepted: 07/10/2020] [Indexed: 11/28/2022]
Abstract
IMPORTANCE When making a cost-saving it is important to ensure there is no loss of efficacy. BACKGROUND Clinical effectiveness and efficiency of incobotulinumtoxinA compared to onabotulinumtoxinA in facial dystonia is unclear. Our aim is to evaluate switching from onabotulinumtoxinA to incobotulinumtoxinA in the treatment of essential blepharospasm (EB), hemifacial spasm (HFS) and aberrant facial nerve regeneration (AFR). DESIGN A retrospective study of a prospective, single-masked switchover audit from onabotulinumtoxinA to incobotulinumtoxinA. PARTICIPANTS Twenty essential EB, 12 HFS and six AFR patients. METHODS A switchover from stable onabotulinumtoxinA to incobotulinumtoxinA using a 1:1 unit ratio and contemporaneous efficacy measures. Two nurse injectors performed the injections over a period of 6 years. Each masked patient received three onabotulinumtoxinA and three incobotulinumtoxinA over a minimum of 2 years. MAIN OUTCOME METHODS At each visit, a blepharospasm disability score (BDS), Jankovic score (JS), subjective improvement (SI), duration of maximum effect (DME) and complications were recorded. A cost comparison per unit dose was made. RESULTS Twenty EB, 12 HFS and six AFR received 114 onabotulinumtoxinA and 114 incobotulinumtoxinA treatments. Both brands had similar efficacy, but SI (P < .01) and DME (P < .05) were higher in the HFS group with incobotulinumtoxinA. Complications included bruising (two onabotulinumtoxinA, one incobotulinumtoxinA) and ptosis (three onabotulinumtoxinA, zero incobotulinumtoxinA). OnabotulinumtoxinA was 33% pricier. CONCLUSION AND RELEVANCE Switching from onabotulinumtoxinA to incobotulinumtoxinA did not result in an inferior outcome for the treatment of facial dystonia and led to a cost-saving for the department.
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Affiliation(s)
- John C Bladen
- Corneoplastic Department, Queen Victoria Hospital, East Grinstead, UK
| | - Maribel Favor
- Corneoplastic Department, Queen Victoria Hospital, East Grinstead, UK
| | - Andre Litwin
- Corneoplastic Department, Queen Victoria Hospital, East Grinstead, UK
| | - Raman Malhotra
- Corneoplastic Department, Queen Victoria Hospital, East Grinstead, UK
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Kirshblum S, Solinsky R, Jasey N, Hampton S, Didesch M, Seidel B, Botticello A. Adverse Event Profiles of High Dose Botulinum Toxin Injections for Spasticity. PM R 2020; 12:349-355. [PMID: 31408270 DOI: 10.1002/pmrj.12240] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 08/06/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Steven Kirshblum
- Kessler Institution for Rehabilitation West Orange NJ
- Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School Newark NJ
- Kessler Foundation East Hanover NJ
| | - Ryan Solinsky
- Spaulding Rehabilitation Hospital Boston MA
- Department of Physical Medicine and RehabilitationHarvard Medical School Boston MA
| | - Neil Jasey
- Kessler Institution for Rehabilitation West Orange NJ
- Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School Newark NJ
| | - Stephen Hampton
- Department of Physical Medicine & RehabilitationUniversity of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Michelle Didesch
- Physical Medicine and Rehabilitation, Confluence Health Wenatchee WA
| | - Benjamin Seidel
- Physical Medicine and Rehabilitation, Burke Rehabilitation Hospital White Plains NY
| | - Amanda Botticello
- Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School Newark NJ
- Kessler Foundation East Hanover NJ
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The role of pallidum in the neural integrator model of cervical dystonia. Neurobiol Dis 2019; 125:45-54. [PMID: 30677494 DOI: 10.1016/j.nbd.2019.01.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/15/2019] [Accepted: 01/20/2019] [Indexed: 01/17/2023] Open
Abstract
Dystonia is the third most common movement disorder affecting three million people worldwide. Cervical dystonia is the most common form of dystonia. Despite common prevalence the pathophysiology of cervical dystonia is unclear. Traditional view is that basal ganglia is involved in pathophysiology of cervical dystonia, while contemporary theories suggested the role of cerebellum and proprioception in the pathophysiology of cervical dystonia. It was recently proposed that the cervical dystonia is due to malfunctioning of the head neural integrator - the neuron network that normally converts head velocity to position. Most importantly the neural integrator model was inclusive of traditional proposal emphasizing the role of basal ganglia while also accommodating the contemporary view suggesting the involvement of cerebellum and proprioception. It was hypothesized that the head neural integrator malfunction is the result of impairment in cerebellar, basal ganglia, or proprioceptive feedback that converge onto the integrator. The concept of converging input from the basal ganglia, cerebellum, and proprioception to the network participating in head neural integrator explains that abnormality originating anywhere in the network can lead to the identical motor deficits - drifts followed by rapid corrective movements - a signature of neural integrator dysfunction. We tested this hypothesis in an experiment examining simultaneously recorded globus pallidal single-unit activity, synchronized neural activity (local field potential), and electromyography (EMG) measured from the neck muscles during the standard-of-care deep brain stimulation surgery in 12 cervical dystonia patients (24 hemispheres). Physiological data were collected spontaneously or during voluntary shoulder shrug activating the contralateral trapezius muscle. The activity of pallidal neurons during shoulder shrug exponentially decayed with time constants that were comparable to one measured from the pretectal neural integrator and the trapezius electromyography. These results show that evidence of abnormal neural integration is also seen in globus pallidum, and that latter is connected with the neural integrator. Pretectal single neuron responses consistently preceded the muscle activity; while the globus pallidum internus response always lagged behind the muscle activity. Globus pallidum externa had equal proportion of lag and lead neurons. These results suggest globus pallidum receive feedback from the muscles or the efference copy from the integrator or the other source of the feedback. There was bi-hemispheric asymmetry in the pallidal single-unit activity and local field potentials. The asymmetry correlated with degree of lateral head turning in cervical dystonia patients. These results suggest that bihemispheric asymmetry in the feedback leads to asymmetric dysfunction in the neural integrator causing head turning.
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Sienaert P, van Harten P, Rhebergen D. The psychopharmacology of catatonia, neuroleptic malignant syndrome, akathisia, tardive dyskinesia, and dystonia. HANDBOOK OF CLINICAL NEUROLOGY 2019; 165:415-428. [PMID: 31727227 DOI: 10.1016/b978-0-444-64012-3.00025-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Although highly prevalent, motor syndromes in psychiatry and motor side effects of psychopharmacologic agents remain understudied. Catatonia is a syndrome with specific motor abnormalities that can be seen in the context of a variety of psychiatric and somatic conditions. The neuroleptic malignant syndrome is a lethal variant, induced by antipsychotic drugs. Therefore, antipsychotics should be used with caution in the presence of catatonic signs. Antipsychotics and other dopamine-antagonist drugs can also cause motor side effects such as akathisia, (tardive) dyskinesia, and dystonia. These syndromes share a debilitating impact on the functioning and well-being of patients. To reduce the risk of inducing these side effects, a balanced and well-advised prescription of antipsychotics is of utmost importance. Clinicians should be able to recognize motor side effects and be knowledgeable of the different treatment modalities.
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Affiliation(s)
- Pascal Sienaert
- Academic Center for ECT and Neuromodulation (AcCENT), University Psychiatric Center KU Leuven, Kortenberg, Belgium.
| | - Peter van Harten
- Research Department, GGz Centraal Innova, Amersfoort, and Department of Mental Health and Neuroscience, Faculty of Health Medicine and Life Sciences, University of Maastricht, Maastricht, The Netherlands
| | - Didi Rhebergen
- Department of Psychiatry and Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
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Lee SY, Lee HD, Cho YS, Han SH. Treatment of focal dystonia involving multiple muscles with a single injection of botulinum toxin A to 1 muscle: A case report. Medicine (Baltimore) 2018; 97:e12785. [PMID: 30334967 PMCID: PMC6211890 DOI: 10.1097/md.0000000000012785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
RATIONALE Botulinum toxin A (BTX-A) injection is effective in treating focal dystonia. However, there are no prior reports regarding the treatment of progressive focal dystonia by a single BTX-A injection that affect a distant muscle. PATIENT CONCERNS A 19-year-old male was referred to the rehabilitation clinic with a complaint of involuntary movement in his left big toe. The involuntary movement pattern was initially observed in the abduction direction only; however, it progressed to irregular mixed patterns in the flexion and abduction directions. DIAGNOSES In needle electromyography, abnormal dystonic patterns were observed in the left abductor hallucis (AH), flexor hallucis longus, and flexor hallucis brevis muscles. INTERVENTIONS AND OUTCOMES These symptoms resolved with a single BTX-A injection to the AH muscle. LESSONS In this case, a single BTX-A injection to 1 muscle for treating progressive focal dystonia was effective on a distant noninjected muscle.
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Abstract
Dystonia is a neurological condition characterized by abnormal involuntary movements or postures owing to sustained or intermittent muscle contractions. Dystonia can be the manifesting neurological sign of many disorders, either in isolation (isolated dystonia) or with additional signs (combined dystonia). The main focus of this Primer is forms of isolated dystonia of idiopathic or genetic aetiology. These disorders differ in manifestations and severity but can affect all age groups and lead to substantial disability and impaired quality of life. The discovery of genes underlying the mendelian forms of isolated or combined dystonia has led to a better understanding of its pathophysiology. In some of the most common genetic dystonias, such as those caused by TOR1A, THAP1, GCH1 and KMT2B mutations, and idiopathic dystonia, these mechanisms include abnormalities in transcriptional regulation, striatal dopaminergic signalling and synaptic plasticity and a loss of inhibition at neuronal circuits. The diagnosis of dystonia is largely based on clinical signs, and the diagnosis and aetiological definition of this disorder remain a challenge. Effective symptomatic treatments with pharmacological therapy (anticholinergics), intramuscular botulinum toxin injection and deep brain stimulation are available; however, future research will hopefully lead to reliable biomarkers, better treatments and cure of this disorder.
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Safety Profile of High-Dose Botulinum Toxin Type A in Post-Stroke Spasticity Treatment. Clin Drug Investig 2018; 38:991-1000. [DOI: 10.1007/s40261-018-0701-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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The effect of a single botulinum toxin treatment on somatosensory processing in idiopathic isolated cervical dystonia: an observational study. J Neurol 2018; 265:2672-2683. [DOI: 10.1007/s00415-018-9045-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/29/2018] [Accepted: 08/30/2018] [Indexed: 02/01/2023]
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Pain in focal dystonias – A focused review to address an important component of the disease. Parkinsonism Relat Disord 2018; 54:17-24. [DOI: 10.1016/j.parkreldis.2018.04.030] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 04/05/2018] [Accepted: 04/26/2018] [Indexed: 12/16/2022]
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Bladen JC, Gill JS, Miszkiel K, Ezra DG. Stroke-induced resolution of primary blepharospasm: evidence for the lenticular nucleus as a control candidate. BMJ Case Rep 2018; 2018:bcr-2018-224339. [DOI: 10.1136/bcr-2018-224339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Yi YG, Kim K, Yi Y, Choi YA, Leigh JH, Bang MS. Botulinum Toxin Type A Injection for Cervical Dystonia in Adults with Dyskinetic Cerebral Palsy. Toxins (Basel) 2018; 10:E203. [PMID: 29772695 PMCID: PMC5983259 DOI: 10.3390/toxins10050203] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 05/04/2018] [Accepted: 05/15/2018] [Indexed: 11/23/2022] Open
Abstract
We aimed to evaluate the efficacy and safety of injecting botulinum toxin A (BoNT-A) into the neck muscles to treat cervical dystonia (CD) in patients with dyskinetic cerebral palsy (CP). This was a randomized, double-blinded, placebo-controlled trial with cross-over design. We prospectively enrolled adults with dyskinetic CP who were over 20 years old and had been clinically diagnosed with CD for more than one year. The primary outcome measure was the change in Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) at four weeks from the baseline TWSTRS. Seventeen patients were initially enrolled, but one patient was excluded after the final evaluation because of a violation of the study protocol. At four weeks, the BoNT-A injections showed significant improvement in TWSTRS total scores compared to the saline injections (p = 0.0286 for ANCOVA). At 12 weeks, the BoNT-A injections resulted in greater improvements in TWSTRS total scores than the saline injections without statistical significance (p = 0.0783 for ANCOVA). Dysphagia occurred in three out of 16 patients: two after BoNT-A and one after saline. The dysphagia was transient and improved naturally within two weeks without any special treatment. BoNT-A injection for CD in adults with dyskinetic CP is relatively safe and improves pain and disability.
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Affiliation(s)
- You Gyoung Yi
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Keewon Kim
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Youbin Yi
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Young-Ah Choi
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Ja-Ho Leigh
- Department of Rehabilitation Medicine, Incheon St. Mary's Hospital, Incheon 22711, Korea.
| | - Moon Suk Bang
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
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Castelão M, Marques RE, Duarte GS, Rodrigues FB, Ferreira J, Sampaio C, Moore AP, Costa J. Botulinum toxin type A therapy for cervical dystonia. Cochrane Database Syst Rev 2017; 12:CD003633. [PMID: 29230798 PMCID: PMC6486222 DOI: 10.1002/14651858.cd003633.pub3] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND This is an update of a Cochrane Review first published in 2005. Cervical dystonia is the most common form of focal dystonia and is a highly disabling movement disorder characterised by involuntary, usually painful, head posturing. Currently, botulinum toxin type A (BtA) is considered the first line therapy for this condition. OBJECTIVES To compare the efficacy, safety, and tolerability of botulinum toxin type A (BtA) versus placebo in people with cervical dystonia. SEARCH METHODS To identify studies for this review we searched Cochrane Movement Disorders' Trials Register, CENTRAL, MEDLINE, Embase, reference lists of articles and conference proceedings. All elements of the search, with no language restrictions, were run in October 2016. SELECTION CRITERIA Double-blind, parallel, randomised, placebo-controlled trials (RCTs) of BtA versus placebo in adults with cervical dystonia. DATA COLLECTION AND ANALYSIS Two review authors independently assessed records, selected included studies, extracted data using a paper pro forma, and evaluated the risk of bias. We resolved disagreements by consensus or by consulting a third review author. We performed meta-analyses using a random-effects model for the comparison of BtA versus placebo to estimate pooled effects and corresponding 95% confidence intervals (95% CI). In addition, we performed preplanned subgroup analyses according to BtA dose used, the BtA formulation used, and the use or not of guidance for BtA injection. The primary efficacy outcome was improvement in cervical dystonia-specific impairment. The primary safety outcome was the proportion of participants with any adverse event. MAIN RESULTS We included eight RCTs of moderate overall risk of bias, including 1010 participants with cervical dystonia. Six studies excluded participants with poorer responses to BtA treatment, therefore including an enriched population with a higher probability of benefiting from this therapy. Only one trial was independently funded. All RCTs evaluated the effect of a single BtA treatment session, using doses from 150 U to 236 U of onabotulinumtoxinA (Botox), 120 U to 240 U of incobotulinumtoxinA (Xeomin), and 250 U to 1000 U of abobotulinumtoxinA (Dysport).BtA was associated with a moderate-to-large improvement in the participant's baseline clinical status as assessed by investigators, with reduction of 8.06 points in the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS total score) at week 4 after injection (95% CI 6.08 to 10.05; I2 = 0%) compared to placebo, corresponding on average to a 18.7% improvement from baseline. The mean difference (MD) in TWSTRS pain subscore at week 4 was 2.11 (95% CI 1.38 to 2.83; I2 = 0%). Overall, both participants and clinicians reported an improvement of subjective clinical status. There were no differences between groups regarding withdrawals due to adverse events. However, BtA treatment was associated with an increased risk of experiencing an adverse event (risk ratio (RR) 1.19; 95% CI 1.03 to 1.36; I2 = 16%). Dysphagia (9%) and diffuse weakness/tiredness (10%) were the most common treatment-related adverse events (dysphagia: RR 3.04; 95% CI 1.68 to 5.50; I2 = 0%; diffuse weakness/tiredness: RR 1.78; 95% CI 1.08 to 2.94; I2 = 0%). Treatment with BtA was associated with a decreased risk of participants withdrawing from trials. We have moderate certainty in the evidence across all of the aforementioned outcomes.We found no evidence supporting the existence of a clear dose-response relationship with BtA, nor a difference between BtA formulations, nor a difference with use of EMG-guided injection.Due to clinical heterogeneity, we did not pool data regarding health-related quality of life, duration of clinical effect, or the development of secondary non-responsiveness. AUTHORS' CONCLUSIONS We have moderate certainty in the evidence that a single BtA treatment session is associated with a significant and clinically relevant reduction of cervical dystonia-specific impairment, including severity, disability, and pain, and that it is well tolerated, when compared with placebo. There is also moderate certainty in the evidence that people treated with BtA are at an increased risk of developing adverse events, most notably dysphagia and diffuse weakness. There are no data from RCTs evaluating the effectiveness and safety of repeated BtA injection cycles. There is no evidence from RCTs to allow us to draw definitive conclusions on the optimal treatment intervals and doses, usefulness of guidance techniques for injection, the impact on quality of life, or the duration of treatment effect.
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Affiliation(s)
- Mafalda Castelão
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Raquel E Marques
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Gonçalo S Duarte
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Filipe B Rodrigues
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Joaquim Ferreira
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Cristina Sampaio
- CHDI Foundation155 Village BoulevardSuite 200PrincetonNJUSA08540
| | - Austen P Moore
- The Walton Centre NHS Foundation TrustLower LaneLiverpoolUKL9 7LJ
| | - João Costa
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAv. Prof. Egas MonizLisboaPortugal1649‐028
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Nakamura Y. [Botulinum toxin for treatment of the focal dystonia]. Rinsho Shinkeigaku 2017; 57:367-372. [PMID: 28652522 DOI: 10.5692/clinicalneurol.cn-001018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Dystonia is defined as a movement disorder characterized by sustained or intermittent muscles contraction causing abnormal, often repetitive, movements, postures, or both. Dystonic movements are typically patterned and twisting, and may be tremulous. The precis diagnosis of dystonia is difficult for physicians because neurological brain imaging does not provide enough practical information. The diagnosis is depend on clinical experience of physicians. Botulinum toxin treatment is the accepted standard of care for patients with focal dystonia. Botulinum toxin treatment results in significant improvement of decreasing the symptom of dystonia. The success of treatment is dependent on muscle selection for treating involved muscles. Usually performance of botulinum toxin treatment is injected according to clinical experience of surface anatomy or clinical location method. However, the benefit of guidance of botulinum toxin treatment is improve outcome in dystonia. Injection techniques with ultra sound echogram or EMG guidance to identify dystonic muscles can be more benefit for patients.
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Muthukumar M, Desai K, Abogunrin S, Harrower T, Gabriel S, Dinet J. Cost-effectiveness analysis of abobotulinumtoxinA for the treatment of cervical dystonia in the United Kingdom. CLINICOECONOMICS AND OUTCOMES RESEARCH 2017; 9:211-229. [PMID: 28458568 PMCID: PMC5402907 DOI: 10.2147/ceor.s112254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Cervical dystonia (CD) involves painful involuntary contraction of the neck and shoulder muscles and abnormal posture in middle-aged adults. Botulinum neurotoxin type A (BoNT-A) is effective in treating CD but little is known about its associated cost-effectiveness. OBJECTIVE To evaluate the cost-effectiveness of abobotulinumtoxinA for treating CD from the UK payer perspective. METHODS A Markov model was developed to evaluate the cost-effectiveness of abobotulinum-toxinA versus best supportive care (BSC) in CD, with a lifetime horizon and health states for response, nonresponse, secondary nonresponse, and BSC in patients with CD (mean age: 53 years; 37% male). Clinical improvement measured using Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) was mapped to utility using data from a randomized trial of abobotulinumtoxinA. Health care resource use, costs, and other inputs were from the British National Formulary, Personal Social Services Research Unit, published literature, or expert opinion. Costs and outcomes were discounted at 3.5% per annum. RESULTS In the base case, the incremental lifetime quality-adjusted life-years (QALYs) gained from abobotulinumtoxinA arm versus BSC was 0.253 per patient, whereas the incremental cost was £7,160, leading to an incremental cost-effectiveness ratio (ICER) of £30,468 per QALY. One-way sensitivity analyses showed that these results were sensitive to the proportion of responders to abobotulinumtoxinA at first injection, duration between injections, the number of reinjections allowed among primary nonresponders, and any difference in baseline TWSTRS value between the BSC and abobotulinumtoxinA arms. Probabilistic sensitivity analysis showed that abobotulinumtoxinA was cost-effective 46% and 49% of times at thresholds of £20,000 and £30,000 per QALY, respectively. Scenarios are considered including vial-sharing, productivity losses, secondary response/nonresponse at subsequent injections, 5-year time horizon, and alternative reinjection intervals for BoNT-As produced ICERs ranging from cost-saving to £40,777 per QALY, versus BSC. CONCLUSION AbobotulinumtoxinA was found to be cost-effective in treating adults with CD, at acceptable willingness-to-pay thresholds in the UK.
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Affiliation(s)
| | | | | | | | | | - Jerome Dinet
- Health Economics and Outcomes Research (Global), Ipsen Pharma, Boulogne-Billancourt, France
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Duarte GS, Castelão M, Rodrigues FB, Marques RE, Ferreira J, Sampaio C, Moore AP, Costa J. Botulinum toxin type A versus botulinum toxin type B for cervical dystonia. Cochrane Database Syst Rev 2016; 10:CD004314. [PMID: 27782297 PMCID: PMC6461154 DOI: 10.1002/14651858.cd004314.pub3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND This is an update of a Cochrane review first published in 2003. Cervical dystonia is the most common form of focal dystonia and is a disabling disorder characterised by painful involuntary head posturing. There are two available formulations of botulinum toxin, with botulinum toxin type A (BtA) usually considered the first line therapy for this condition. Botulinum toxin type B (BtB) is an alternative option, with no compelling theoretical reason why it might not be as- or even more effective - than BtA. OBJECTIVES To compare the efficacy, safety and tolerability of botulinum toxin type A (BtA) versus botulinum toxin type B (BtB) in people with cervical dystonia. SEARCH METHODS To identify studies for this review we searched the Cochrane Movement Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, reference lists of articles and conference proceedings. All elements of the search, with no language restrictions, were last run in October 2016. SELECTION CRITERIA Double-blind, parallel, randomised, placebo-controlled trials (RCTs) comparing BtA versus BtB in adults with cervical dystonia. DATA COLLECTION AND ANALYSIS Two independent authors assessed records, selected included studies, extracted data using a paper pro forma, and evaluated the risk of bias. We resolved disagreements by consensus or by consulting a third author. We performed meta-analyses using the random-effects model, for the comparison BtA versus BtB to estimate pooled effects and corresponding 95% confidence intervals (95% CI). No prespecified subgroup analyses were carried out. The primary efficacy outcome was improvement on any validated symptomatic rating scale, and the primary safety outcome was the proportion of participants with adverse events. MAIN RESULTS We included three RCTs, all new to this update, of very low to low methodological quality, with a total of 270 participants.Two studies exclusively enrolled participants with a known positive response to BtA treatment. This raises concerns of population enrichment, with a higher probability of benefit from BtA treatment. None of the trials were free of for-profit bias, nor did they provide information regarding registered study protocols. All trials evaluated the effect of a single Bt treatment session, and not repeated treatment sessions, using doses from 100 U to 250 U of BtA (all onabotulinumtoxinA, or Botox, formulations) and 5000 U to 10,000 U of BtB (rimabotulinumtoxinB, or Myobloc/Neurobloc).We found no difference between the two types of botulinum toxin in terms of overall efficacy, with a mean difference of -1.44 (95% CI -3.58 to 0.70) points lower on the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) for BtB-treated participants, measured at two to four weeks after injection. The proportion of participants with adverse events was also not different between BtA and BtB (BtB versus BtA risk ratio (RR) 1.40; 95% CI 1.00 to 1.96). However, when compared to BtA, treatment with BtB was associated with an increased risk of one adverse events of special interest, namely treatment-related sore throat/dry mouth (BtB versus BtA RR of 4.39; 95% CI 2.43 to 7.91). Treatment-related dysphagia (swallowing difficulties) was not different between BtA and BtB (RR 2.89; 95% CI 0.80 to 10.41). The two types of botulinum toxin were otherwise clinically non-distinguishable in all the remaining outcomes. AUTHORS' CONCLUSIONS The previous version of this review did not include any trials, since these were still ongoing at the time. Therefore, with this update we are able to change the conclusions of this review. There is low quality evidence that a single treatment session of BtA (specifically onabotulinumtoxinA) and a single treatment session of BtB (rimabotulinumtoxinB) are equally effective and safe in the treatment of adults with certain types of cervical dystonia. Treatment with BtB appears to present an increased risk of sore throat/dry mouth, compared to BtA. Overall, there is no clinical evidence from these single-treatment trials to support or contest the preferential use of one form of botulinum toxin over the other.
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Affiliation(s)
- Gonçalo S Duarte
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAvenida Professor Egas MonizLisboaLisboaPortugal1649‐028
- Instituto de Medicina MolecularClinical Pharmacology UnitAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Mafalda Castelão
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAvenida Professor Egas MonizLisboaLisboaPortugal1649‐028
- Instituto de Medicina MolecularClinical Pharmacology UnitAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Filipe B Rodrigues
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAvenida Professor Egas MonizLisboaLisboaPortugal1649‐028
- Instituto de Medicina MolecularClinical Pharmacology UnitAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Raquel E Marques
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAvenida Professor Egas MonizLisboaLisboaPortugal1649‐028
- Instituto de Medicina MolecularClinical Pharmacology UnitAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Joaquim Ferreira
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAvenida Professor Egas MonizLisboaLisboaPortugal1649‐028
- Instituto de Medicina MolecularClinical Pharmacology UnitAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Cristina Sampaio
- CHDI Foundation155 Village BoulevardSuite 200PrincetonNJUSA08540
| | - Austen P Moore
- The Walton Centre NHS Foundation TrustLower LaneLiverpoolUKL9 7LJ
| | - João Costa
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAvenida Professor Egas MonizLisboaLisboaPortugal1649‐028
- Instituto de Medicina MolecularClinical Pharmacology UnitAv. Prof. Egas MonizLisboaPortugal1649‐028
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Abstract
PURPOSE OF REVIEW The dystonias are a family of related disorders with many different clinical manifestations and causes. This review summarizes recent developments regarding these disorders, focusing mainly on advances with direct clinical relevance from the past 2 years. RECENT FINDINGS The dystonias are generally defined by their clinical characteristics, rather than by their underlying genetic or neuropathological defects. The many varied clinical manifestations and causes contribute to the fact that they are one of the most poorly recognized of all movement disorders. A series of recent publications has addressed these issues, offering a revised definition and more logical means for classifying the many subtypes. Our understanding of the genetic and neurobiological mechanisms responsible for different types of dystonias also has grown rapidly, creating new opportunities and challenges for diagnosis, and identifying increasing numbers of rare subtypes for which specific treatments are available. SUMMARY Recent advances in describing the clinical phenotypes and determining associated causes have pointed to the need for new strategies for diagnosis, classification, and treatment of the dystonias.
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Affiliation(s)
- Hyder A Jinnah
- aDepartment of Neurology, Human Genetics & Pediatrics, Emory University, Atlanta, Georgia bDystonia Medical Research Foundation, Chicago, Illinois cNational Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
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Scaglione F. Conversion Ratio between Botox®, Dysport®, and Xeomin® in Clinical Practice. Toxins (Basel) 2016; 8:E65. [PMID: 26959061 PMCID: PMC4810210 DOI: 10.3390/toxins8030065] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 02/23/2016] [Accepted: 02/26/2016] [Indexed: 11/16/2022] Open
Abstract
Botulinum neurotoxin has revolutionized the treatment of spasticity and is now administered worldwide. There are currently three leading botulinum neurotoxin type A products available in the Western Hemisphere: onabotulinum toxin-A (ONA) Botox(®), abobotulinum toxin-A (ABO), Dysport(®), and incobotulinum toxin A (INCO, Xeomin(®)). Although the efficacies are similar, there is an intense debate regarding the comparability of various preparations. Here we will address the clinical issues of potency and conversion ratios, as well as safety issues such as toxin spread and immunogenicity, to provide guidance for BoNT-A use in clinical practice. INCO was shown to be as effective as ONA with a comparable adverse event profile when a clinical conversion ratio of 1:1 was used. The available clinical and preclinical data suggest that a conversion ratio ABO:ONA of 3:1-or even lower-could be appropriate for treating spasticity, cervical dystonia, and blepharospasm or hemifacial spasm. A higher conversion ratio may lead to an overdosing of ABO. While uncommon, distant spread may occur; however, several factors other than the pharmaceutical preparation are thought to affect spread. Finally, whereas the three products have similar efficacy when properly dosed, ABO has a better cost-efficacy profile.
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Affiliation(s)
- Francesco Scaglione
- Department of Oncology and Onco-Hematology, University of Milan, Via Vanvitelli 32, 20129 Milan, Italy.
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Schnitzler A, Ruet A, Baron S, Buzzi JC, Genet F. Botulinum toxin A for treating spasticity in adults: Costly for French hospitals? Ann Phys Rehabil Med 2015; 58:265-8. [DOI: 10.1016/j.rehab.2015.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 06/12/2015] [Accepted: 06/12/2015] [Indexed: 11/28/2022]
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Albanese A, Romito LM, Calandrella D. Therapeutic advances in dystonia. Mov Disord 2015; 30:1547-56. [DOI: 10.1002/mds.26384] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 07/27/2015] [Accepted: 07/30/2015] [Indexed: 12/15/2022] Open
Affiliation(s)
- Alberto Albanese
- Istituto Clinico Humanitas; Rozzano Milano Italy
- Istituto di Neurologia, Università Cattolica del Sacro Cuore; Milano Italy
| | - Luigi M. Romito
- Neurologia I, Istituto Neurologico Carlo Besta; Milano Italy
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Albanese A, Abbruzzese G, Dressler D, Duzynski W, Khatkova S, Marti MJ, Mir P, Montecucco C, Moro E, Pinter M, Relja M, Roze E, Skogseid IM, Timerbaeva S, Tzoulis C. Practical guidance for CD management involving treatment of botulinum toxin: a consensus statement. J Neurol 2015; 262:2201-13. [PMID: 25877834 PMCID: PMC4608989 DOI: 10.1007/s00415-015-7703-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 03/04/2015] [Accepted: 03/05/2015] [Indexed: 01/02/2023]
Abstract
Cervical dystonia is a neurological movement disorder causing abnormal posture of the head. It may be accompanied by involuntary movements which are sometimes tremulous. The condition has marked effects on patients’ self-image, and adversely affects quality of life, social relationships and employment. Botulinum neurotoxin (BoNT) is the treatment of choice for CD and its efficacy and safety have been extensively studied in clinical trials. However, current guidelines do not provide enough practical information for physicians who wish to use this valuable treatment in a real-life setting. In addition, patients and physicians may have different perceptions of what successful treatment outcomes should be. Consequently, an international group of expert neurologists, experienced in BoNT treatment, met to review the literature and pool their extensive clinical experience to give practical guidance about treatment of CD with BoNT. Eight topic headings were considered: the place of BoNT within CD treatment options; patient perspectives and desires for treatment; assessment and goal setting; starting treatment with BoNT-A; follow-up sessions; management of side effects; management of non-response; switching between different BoNT products. One rapporteur took responsibility for summarising the current literature for each topic, while the consensus statements were developed by the entire expert group. These statements are presented here along with a discussion of the background information.
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Affiliation(s)
- Alberto Albanese
- Neurologia I Istituto Neurologico Carlo Besta, Università Cattolica del Sacro Cuore, Via G. Celoria, 11, 20133, Milan, Italy.
| | - Giovanni Abbruzzese
- Centre for Parkinson's Disease and Movement Disorders DINOGMI, University of Genoa Largo Daneo 3, 16132, Genoa, Italy
| | - Dirk Dressler
- Movement Disorders Section, Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Wojciech Duzynski
- Section of Neurology, Department of Clinical Sciences, Lund University, Jan Waldenströms gata 15, 205 02, Malmö, Sweden
| | - Svetlana Khatkova
- Neurological Department for Post-Stroke Patients, Moscow Federal State Hospital for Treatment and Rehabilitation Ministry of Health Russia, Moscow, Russia
| | - Maria Jose Marti
- Neurology Service, Institut Cliníc de Neurosciències (ICN), CIBERNED, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Pablo Mir
- Unidad de Trastornos del Movimiento, Servicio de Neurología y Neurofisiología Clínica, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Seville, Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Seville, Spain
| | - Cesare Montecucco
- Department of Biomedical Sciences, University of Padova, Via Ugo Bassi n. 58/B, 35121, Padua, Italy
| | - Elena Moro
- Division of Neurology, CHU of Grenoble, Joseph Fourier University, Grenoble, France
| | - Michaela Pinter
- Center for Neurorehabilitation, Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria
| | - Maja Relja
- Referral Center for Movement Disorders, Department of Neurology, School of Medicine, University Hospital Center Zagreb, University of Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia
| | - Emmanuel Roze
- AP-HP, Hôpital de la Pitié Salpêtrière, Département de Neurologie, 75013, Paris, France
- Inserm U 1127, CNRS UMR 7225, Sorbonne Universités, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, 75013, Paris, France
| | - Inger Marie Skogseid
- Movement Disorders Unit, Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Sofiya Timerbaeva
- Department of Neurogenetics, Research Center of Neurology, Russian Academy of Medical Sciences, 80 Volokolamskoye shosse, Moscow, 125367, Russian Federation
| | - Charalampos Tzoulis
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Kazerooni R, Broadhead C. Cost-utility analysis of botulinum toxin type A products for the treatment of cervical dystonia. Am J Health Syst Pharm 2015; 72:301-7. [DOI: 10.2146/ajhp140276] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Mills RR, Pagan FL. Patient considerations in the treatment of cervical dystonia: focus on botulinum toxin type A. Patient Prefer Adherence 2015; 9:725-31. [PMID: 26082621 PMCID: PMC4459632 DOI: 10.2147/ppa.s75459] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Cervical dystonia is the most common form of focal dystonia characterized by involuntary muscle contractions causing abnormal movements and posturing of the head and neck and is associated with significant pain. Botulinum toxin is considered first-line therapy in the treatment of pain and abnormal head posturing associated with cervical dystonia. There are currently three botulinum toxin type A neurotoxins and one botulinum type B neurotoxin commercially available and US Food and Drug Administration (FDA) labeled for the treatment of cervical dystonia. This review will focus on the efficacy, safety, and therapeutic use of botulinum type A neurotoxins in the treatment of cervical dystonia. We conclude with a discussion of factors influencing toxin selection including therapeutic effect, duration of effect, side effect profile, cost, and physician preference.
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Affiliation(s)
- Reversa R Mills
- Department of Neurology, Movement Disorders and Neurorestoration Division, Georgetown University Hospital, Washington, DC, USA
| | - Fernando L Pagan
- Department of Neurology, Movement Disorders and Neurorestoration Division, Georgetown University Hospital, Washington, DC, USA
- Correspondence: Fernando L Pagan, Department of Neurology, Movement Disorders and Neurorestoration Division, Georgetown University Hospital, 3900 Reservoir Rd, NW, 7 PHC, Washington, DC 20007, USA, Tel +1 202 444 8525, Fax +1 202 444 4115, Email
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Evidente VGH, Pappert EJ. Botulinum toxin therapy for cervical dystonia: the science of dosing. Tremor Other Hyperkinet Mov (N Y) 2014; 4:273. [PMID: 25414799 PMCID: PMC4233211 DOI: 10.7916/d84x56bf] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 09/24/2014] [Indexed: 06/04/2023] Open
Abstract
The first-line treatment for cervical dystonia (CD) is botulinum toxin type A (BoNT-A), which has been established as a highly effective and well-tolerated therapy. However, this treatment is also complex and challenging to apply in clinical practice. Approximately 20% of patients discontinue therapy due to treatment failure, adverse effects, and other reasons. In addition, expert consensus recommendations are lacking to guide physicians in the optimal use of BoNT-A for CD. Among the issues still to be clarified is the optimal dosing frequency. The generally accepted standard for intervals between BoNT-A injections is ≥12 weeks; however, this standard is based primarily on the methodology of pivotal trials for the BoNT-A products, rather than on evidence that it is optimal in comparison to other intervals. While some retrospective, observational studies of BoNT-A used in clinical practice appear to support the use of ≥12-week dosing intervals, it is often unclear in these studies how the need for reinjection was determined. In contrast, a prospective dose-ranging trial in which patients were allowed to request reinjection as early as 8 weeks showed that about half of patients receiving abobotulinumtoxinA, at the currently recommended initial dose of 500 U, requested reinjection at 8 weeks. Moreover, results from an open-label, 68-week extension phase of the pivotal trial of incobotulinumtoxinA showed that 47.1% of patients had received reinjection at ≤12 weeks. Ongoing studies, such as the Cervical Dystonia Patient Registry for Observation of BOTOX® Efficacy (CD PROBE), may help clarify this question of optimal dosing intervals for BoNT-A in CD.
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Killoran A, Biglan KM. Current therapeutic options for Huntington's disease: good clinical practice versus evidence-based approaches? Mov Disord 2014; 29:1404-13. [PMID: 25164707 DOI: 10.1002/mds.26014] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 07/18/2014] [Accepted: 08/06/2014] [Indexed: 01/17/2023] Open
Abstract
Therapeutic decision-making in Huntington's disease (HD) is often guided by clinical experience, because of the limited empirical evidence available. The only medication for HD that has met the regulatory hurdle for approval is tetrabenazine, indicated for the treatment of chorea. However, its use has limitations, and in the setting of specific contraindications or comorbidities the treatment of choice for chorea is still the multipurpose antipsychotics. For the management of psychiatric disturbances, selective serotonin reuptake inhibitors (SSRIs) and mood stabilizers are often used, although empirical evidence is lacking. Finally, no known effective treatment is available for cognitive dysfunction in HD. We discuss the limited evidence available and current expert opinion on medical treatment of the dominant motor, psychiatric, and cognitive features of HD. This follows a brief introduction on the general principles of HD management and on evidence-based medicine in relation to clinical practice.
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Affiliation(s)
- Annie Killoran
- West Virginia University, Morgantown, West Virginia, USA
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Pedemonte C, Pérez Gutiérrez H, González E, Vargas I, Lazo D. Use of onabotulinumtoxinA in post-traumatic oromandibular dystonia. J Oral Maxillofac Surg 2014; 73:152-7. [PMID: 25315313 DOI: 10.1016/j.joms.2014.07.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 07/16/2014] [Accepted: 07/21/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE Post-traumatic oromandibular dystonia (PTOD) is a disorder whose symptoms can include bruxism, muscle pain, and involuntary muscle contraction, among others. The use of onabotulinumtoxinA (ObT-A) is helpful in controlling the symptoms of patients with PTOD. The aim of this study was to evaluate the use of ObT-A in the treatment of PTOD. MATERIALS AND METHODS In this prospective case-series study, the population consisted exclusively of patients diagnosed with PTOD, without distinction by age or gender, from January 2007 to December 2010. The patients were diagnosed with PTOD and treated with ObT-A infiltration (primary predictor) at the Department of Maxillofacial Surgery at the Hospital Clínico Mutual de Seguridad (Santiago, Chile). The primary outcome variables were bruxism, muscle pain, and involuntary muscle contraction. The data were obtained through questionnaires registered in tables at each control. Systat 13.1 was used for statistical analysis. The statistical test used to compare patients' evolution over time was the test of signs. RESULTS Thirty male patients 18 to 65 years old diagnosed with PTOD were treated with ObT-A infiltrations. The signs and symptoms associated with oromandibular dystonia (bruxism, muscle pain, and involuntary muscle contraction) were decreased in all patients after ObT-A infiltrations. CONCLUSIONS The positive results and the absence of complications recommend the use of the infiltration protocol presented in this study for the treatment of PTOD.
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Affiliation(s)
- Christian Pedemonte
- Maxillofacial Surgeon, Department of Maxillofacial Surgery, Hospital Clínico Mutual de Seguridad, Santiago, Chile
| | - Hernán Pérez Gutiérrez
- Dental Surgeon, Department of Maxillofacial Surgery, Hospital Clínico Mutual de Seguridad, Santiago, Chile.
| | - Edgardo González
- Maxillofacial Surgeon, Department of Maxillofacial Surgery, Hospital Clínico Mutual de Seguridad, Santiago, Chile
| | - Ilich Vargas
- Maxillofacial Surgeon, Department of Maxillofacial Surgery, Hospital Clínico Mutual de Seguridad, Santiago, Chile
| | - Diego Lazo
- Dental Surgeon, Department of Maxillofacial Surgery, Hospital Clínico Mutual de Seguridad, Santiago, Chile
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Delnooz CCS, Veugen LC, Pasman JW, Lapatki BG, van Dijk JP, van de Warrenburg BPC. The clinical utility of botulinum toxin injections targeted at the motor endplate zone in cervical dystonia. Eur J Neurol 2014; 21:1486-e98. [PMID: 25060697 DOI: 10.1111/ene.12517] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 05/26/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Cervical dystonia (CD) patients usually receive repeated botulinum neurotoxin (BoNT) injections. The aims of this study were to evaluate the feasibility of motor endplate zone (MEZ) detection of relevant cervical muscles in CD patients receiving chronic BoNT treatment and to compare the treatment effect of half-dosed, endplate-targeted injections to standard BoNT injections. METHODS In study 1, high-density surface electromyography (HD-sEMG) was recorded from the sternocleidomastoid (SCM) and splenius capitis (SC) muscles in 18 CD patients with ongoing BoNT treatment, by which the location of the MEZ was determined. In study 2, nine additional patients with rotational-type CD participated in a treatment effect study where they received either half of their regular BoNT dose through endplate-targeted injections or their normal BoNT dose through standard injections (crossover design). Dystonia severity was recorded before and 4 weeks after each treatment session (Toronto Western Spasmodic Torticollis Rating Scale severity subscore). RESULTS In the SCM muscle the MEZ was located at the lower border of the superior third part of the muscle, and in the SC muscle at half muscle length. Endplate-targeted, half-dosed BoNT injection resulted in a similar treatment effect to injecting the full dose in the standard technique. CONCLUSIONS Half-dosed, endplate-targeted BoNT injections lead to a similar treatment effect to the standard BoNT injection protocol. MEZ detection confronts the clinician with some technical challenges, such as the ability of accurate and technically optimal placement of the electrode grid and correct interpretation of the HD-sEMG signal.
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Affiliation(s)
- C C S Delnooz
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
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Marsh WA, Monroe DM, Brin MF, Gallagher CJ. Systematic review and meta-analysis of the duration of clinical effect of onabotulinumtoxinA in cervical dystonia. BMC Neurol 2014; 14:91. [PMID: 24767576 PMCID: PMC4013807 DOI: 10.1186/1471-2377-14-91] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 04/17/2014] [Indexed: 12/31/2022] Open
Abstract
Background Botulinum toxins are considered first-line therapy for treatment of cervical dystonia (CD) and must be injected on a repeat basis. Understanding the duration of clinical benefit of botulinum toxins and its impact on health care utilization are thus important in the contemporary environment. However, there is currently no overall consensus on the duration of effect of onabotulinumtoxinA in the treatment of CD. We performed a systematic review and meta-analysis to identify the duration of effect of onabotulinumtoxinA in CD and investigate factors that may influence it. Methods A systematic literature search identified prospective or retrospective studies reporting duration of effect of onabotulinumtoxinA for the treatment of CD. Inclusion criteria included peer-reviewed, non-review, English-language articles published between January 1980 and January 2013. A formal meta-analysis using Comprehensive Meta-Analysis Version 2 was conducted to identify the duration of effect of onabotulinumtoxinA in the treatment of CD; both fixed and random effects models were performed. Subgroup analyses were performed to identify factors that influenced the duration of effect of onabotulinumtoxinA. Results A total of 18 studies (including >1,900 patients) met the inclusion criteria and were used for the meta-analysis. The mean duration of effect of onabotulinumtoxinA in CD was found to be 93.2 days (95% CI 91.8-94.6 days) for the fixed effects model and 95.2 days (95% CI 88.9-101.4 days) for the random effects model. A meta-regression found that dose of onabotulinumtoxinA and country of origin influenced the duration of effect of onabotulinumtoxinA, whereas quality score of the article and study type did not. In particular, doses ≥180 Units were associated with longer durations of effect than doses <180 Units (107-109 days vs. 86-88 days, respectively; p < 0.01). Limitations included pooling studies that used discrete definitions of duration and had different designs and study quality. Conclusions Based on the published literature, the mean duration of effect of onabotulinumtoxinA in CD was 93-95 days (13.2-13.5 weeks). This suggests that, in general, patients with CD treated with onabotulinumtoxinA should require ~4 treatments per year.
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A Beautician’s Dystonia: Long-Lasting Effect of Botulinum Toxin. Case Rep Neurol Med 2014; 2014:686181. [PMID: 25143844 PMCID: PMC4124709 DOI: 10.1155/2014/686181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 06/03/2014] [Accepted: 07/06/2014] [Indexed: 11/17/2022] Open
Abstract
Treatment options for dystonia are not curative but symptomatic; the treatment of choice for focal dystonias is repeated botulinum toxin injections. Here, we present the case of a 46-year-old beautician with focal dystonia in her left hand that affected her ability to work. Pharmacological treatment with clonazepam and gabapentin failed to resolve her symptoms and was discontinued due to side effects (sleepiness, gastrointestinal disorders). Intramuscular injection of botulinum toxin (incobotulinumtoxinA, Xeomin) into the extensor digitorum communis (35 U), flexor carpi radialis (35 U), and flexor digitorum superficialis (30 U) muscles resulted in complete resolution of symptoms at clinical assessments at 1, 3, 6, and 10 months after the injections, confirmed by the results of surface electromyography 10 months after treatment. The patient was able to work again 1 month after treatment. No reinjection has been necessary at the last evaluation (12 months after treatment). In conclusion, botulinum toxin is an effective treatment for focal dystonia that can have long-lasting effects and can improve patients' ability to work and quality of life.
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Abstract
Selecting the appropriate treatment for dystonia begins with proper classification of disease based on age, distribution, and underlying etiology. The therapies available for dystonia include oral medications, botulinum toxin, and surgical procedures. Oral medications are generally reserved for generalized and segmental dystonia. Botulinum toxin revolutionized the treatment of focal dystonia when it was introduced for therapeutic purposes in the 1980s. Surgical procedures are available for medication-refractory dystonia, markedly affecting an individual's quality of life.
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Affiliation(s)
- Mary Ann Thenganatt
- Parkinson’s Disease Center & Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, 6550 Fannin, Suite 1801, Houston, TX 77030 USA
| | - Joseph Jankovic
- Parkinson’s Disease Center & Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, 6550 Fannin, Suite 1801, Houston, TX 77030 USA
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Abstract
Dystonia is a common movement disorder seen by neurologists in clinic. Genetic forms of the disease are important to recognize clinically and also provide valuable information about possible pathogenic mechanisms within the wider disorder. In the past few years, with the advent of new sequencing technologies, there has been a step change in the pace of discovery in the field of dystonia genetics. In just over a year, four new genes have been shown to cause primary dystonia (CIZ1, ANO3, TUBB4A and GNAL), PRRT2 has been identified as the cause of paroxysmal kinesigenic dystonia and other genes, such as SLC30A10 and ATP1A3, have been linked to more complicated forms of dystonia or new phenotypes. In this review, we provide an overview of the current state of knowledge regarding genetic forms of dystonia—related to both new and well-known genes alike—and incorporating genetic, clinical and molecular information. We discuss the mechanistic insights provided by the study of the genetic causes of dystonia and provide a helpful clinical algorithm to aid clinicians in correctly predicting the genetic basis of various forms of dystonia.
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Affiliation(s)
- Gavin Charlesworth
- Department of Molecular Neuroscience, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK
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