How satisfied are cervical dystonia patients after 3 years of botulinum toxin type A treatment? Results from a prospective, long-term observational study

Doses of Botulinum Toxin in Cervical Dystonia: Does Ultrasound Guidance Change Injection Practices?

BACKGROUND

Cervical dystonia is widely understood to benefit from botulinum toxin injections. The injection practices may be influenced by specific factors, including the method of injection. Three main guidance methods can be used: palpation of anatomical landmarks, ultrasound, and electromyography. We investigated how target muscles and doses of botulinum toxin were modified after the transition from surface anatomy (non-guided) to ultrasound (US-guided), in patients with cervical dystonia. We also determined the long-term dose trend.

METHODS

We studied a group of 82 patients, who received non-guided injections (median: 16.5 cycles/5.1 years) followed by US-guided injections (median: 12.0 cycles/3.8 years).

RESULTS

More muscles, and especially deep muscles, were injected during the US-guided period. The total dose and number of injected muscles were higher when US guidance was used, but the mean dose per muscle was lower. Over the long term, the total dose stabilized, and the mean dose per muscle decreased during the US-guided period.

CONCLUSIONS

According to our results, the guidance method has a strong impact on the botulinum toxin injection strategy in cervical dystonia (target muscles and dose). Also, the treatment appeared more stable when using US guidance; this could be explained by the good precision of such injections.

Improving the Efficacy of Botulinum Toxin for Cervical Dystonia: A Scoping Review

Cervical dstonia (CD) is a chronic disorder with a significant detrimental impact on quality of life, requiring long-term treatment. Intramuscular injections of botulinum neurotoxin (BoNT) every 12 to 16 weeks have become the first-line option for CD. Despite the remarkable efficacy of BoNT as a treatment for CD, a significantly high proportion of patients report poor outcomes and discontinue the treatment. The reasons that drive sub-optimal response or treatment failure in a proportion of patients include but are not limited to inappropriate muscle targets and/or BoNT dosing, improper method of injections, subjective feeling of inefficacy, and the formation of neutralizing antibodies against the neurotoxin. The current review aims to complement published research focusing on the identification of the factors that might explain the failure of BoNT treatment in CD, highlighting possible solutions to improve its outcomes. Thus, the use of the new phenomenological classification of cervical dystonia known as COL-CAP might improve the identification of the muscle targets, but more sensitive information might come from the use of kinematic or scintigraphic techniques and the use of electromyographic or ultrasound guidance might ensure the accuracy of the injections. Suggestions are made for the development of a patient-centered model for the management of cervical dystonia and to emphasize that unmet needs in the field are to increase awareness about the non-motor spectrum of CD, which might influence the perception of the efficacy from BoNT injections, and the development of dedicated rehabilitation programs for CD that might enhance its effectiveness.

Botulinum toxin for motor disorders

Botulinum neurotoxins are a group of biological toxins produced by the gram-negative bacteria Clostridium botulinum. After intramuscular injection, they produce dose-related muscle relaxation, which has proven useful in the treatment of a large number of motor and movement disorders. In this chapter, we discuss the utility of botulinum toxin treatment in three major and common medical conditions related to the dysfunction of the motor system, namely dystonia, tremor, and spasticity. A summary of the existing literature is provided along with different techniques of injection including those recommended by the authors.

Long-term adherence, safety, and efficacy of repeated onabotulinumtoxinA over five years in chronic migraine prophylaxis

BACKGROUND

OnabotulinumtoxinA (BoNTA) demonstrated a positive benefit-risk in chronic migraine (CM) patients in PREEMPT I and II phase III trials and many subsequent real-world studies. We herein aimed at evaluating the adherence to repeated BoNTA over a period of five years, while secondary objectives included the assessment of its long-term safety/efficacy and patients' satisfaction to treatment.

METHODS

We studied 56 CM patients who had successfully received consequent cycles of BoNTA over five years. Adherence was calculated as the percentage of patients actively choosing to follow with repeated BoNTA treatment, as instructed. Safety and efficacy data were collected throughout the study period. The overall patients' belief in and satisfaction by the efficacy of treatment was assessed at last follow-up, using the self-report 7-point measure patient global impression of change (PGIC).

RESULTS

A total of 36 (64.3%) out of 56 patients remained adherent to BoNTA over five years. Long-term BoNTA exposure was safe and well-tolerated, without severe side-effects justifying treatment discontinuation. The mean monthly headache days and associated clinical efficacy outcomes remained consistent and quite low at last follow-up with evidence of continuous improvements in headache monthly frequency between year three and over five years of therapy. All patients who were able to maintain treatment over five years (n = 36), remained very satisfied and scored at least 5 in PGIC.

CONCLUSION

Considerably high adherence, considerable satisfaction and sustained safety/efficacy were observed in patients followed up for five years, supporting a favorable benefit/risk profile for consistently delivering long-term BoNTA in CM.

Development of a patient journey map for people living with cervical dystonia

Background

Patient journey maps are increasingly used as a tool that enables healthcare providers to refine their service provision to best meet patient needs. We developed a cervical dystonia patient journey map (CDPJM) that describes the holistic patient experience from pre-diagnosis through to long-term treatment.

Methods

The CDPJM was developed in 2 stages; a patient survey (open questions and multichoice) of 15 patients with CD was conducted to inform the design of the CDPJM, which was then refined and validated by an expert-patient focus group.

Results

Qualitative analysis of the patient survey supported five key stages of the patient journey: symptom onset, diagnosis and therapeutic relationship with healthcare professionals, initiation of care for CD, start of CD treatment, and living with treated CD. Following symptom onset, survey respondents described having multiple visits to their family doctor who prescribed strong pain killers and muscle relaxants and referred their patient to up to 10 different specialists for diagnosis. Over half (53.3%) of respondents had received ≥ 1 misdiagnosis. Respondents reported relief at having a diagnosis but a lack of understanding of the prognosis and treatment options; 46.7% said their neurologist did not spend enough time addressing their concerns. Survey respondents reported using a variety of alternative sources of information, including the internet (86.7%), self-help groups (66.7%) and information leaflets provided by health care professionals (60.0%). While botulinum toxin (BoNT) was consistently discussed as the main treatment option, some neurologists also mentioned physiotherapy, counselling, and other complementary approaches. However, patients were often left to seek complementary services themselves. Patients reported a ‘rollercoaster’ of relief with BoNT treatment with symptoms (and subsequent impact on daily life) returning towards the end of an injection cycle. “When BoNT works well I can return to an almost normal life … when the injections stop working so well, I have to rest more and avoid going to work and experience life restrictions.”

Conclusions

We present the first patient journey map for CD that can be used to guide local service mapping and to compare current provision with what patients say they want and need.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-022-02270-4.

Botulinum Toxin Type A Injection Improves the Intraperitoneal High Pressure in Rats Treated with Abdominal Wall Plasty

The aim of the study is mainly to study the subject of BoNT-A injection to improve IAH in rats undergoing abdominal angioplasty. The study problem in surgery, especially in ICU, burn, and trauma centers, intra-abdominal hypertension (IAH), and abdominal compartment syndrome (ACS) are common complications. At present, there are various treatments for IAH. The intramuscular injection of Botulinum toxin type A (BoNT-A) into the abdominal wall has received a lot of attention. Based on this, this study proposes a method for measuring abdominal pressure, applies BoNT-A to reduce abdominal pressure in the IAH state of abdominal wall angioplasty, and explores a way to increase the compliance of the abdominal wall under the premise of maintaining the sealing of the abdominal cavity, so as to realize the expansion of the abdominal cavity. A method is achieved to reduce intra-abdominal pressure and eliminate or alleviate ACS. The results of the experiment showed that when the rats in the control group were injected with the same amount of normal saline as the rats in the experimental group, the IAP was significantly higher than that in the experimental group (P < 0.05). This shows that BoNT-A increases the compliance of the abdominal wall while maintaining the closure of the abdominal cavity, thereby increasing the volume of the abdominal cavity and alleviating the state of IAH in rats.

Long-term efficacy and safety of botulinum toxin treatment for cervical dystonia: a critical reappraisal

Introduction: Botulinum toxin (BoNT) injections represent the gold standard treatment for cervical dystonia (CD). Different types of BoNT have been used for the treatment of CD, but only two serotypes, BoNT type A (BoNT-A) and type B (BoNT-B), have been approved by regulatory agencies. Efficacy and safety of BoNT have been well documented by many short-term studies, but the longterm effects have been investigated only relatively recently.Areas covered: In the present review, we aimed to critically reappraise the existing evidence on the long-term efficacy and safety of BoNT treatment in CD. The examined studies mainly explored BoNT-A serotypes. Only a few studies examined the long-term effects of BoNT-B serotypes, and only one head-to-head comparison between BoNT-A and BoNT-B was found. BoNT was consistently reported to be an effective and safe treatment for CD patients, with good outcomes and a few adverse events in the long-term. However about a third of patients still drop out from the treatment during a long-term follow-up.Expert opinion: We conclude that BoNT is safe and effective in the long-term treatment of patients with CD. Additional studies are needed to further explore patients real-life experiences and perspectives to better understand the long-term outcomes and reasons for discontinuation of treatment.

Botulinum toxin treatment of dystonic anterocollis: What to inject

BACKGROUND

Anterocollis (AC) is a rare form of cervical dystonia, which responds poorly to botulinum toxin treatment.

OBJECTIVES

To recognise the different clinical phenotypes of AC and to detail the selection of muscles from the results of treating a cohort of 15 AC patients with Botulinum Toxin.

METHODS

The study was performed using prospectively collected data. We included 15 patients with cervical dystonia and AC posture, treated between 2016 and 2019 in our joint Neuro-ENT clinic. We excluded patients with posterior cervical muscle weakness and patients with Parkinsonism. We characterised the primary dystonic posture of every AC patient as posterior sagittal shift, head flexion or neck flexion, or a combination of the three.

RESULTS

All AC patients had a more widespread dystonic picture with a majority having Meige syndrome, but AC was the most problematic feature. Treatment with botulinum toxin required the injection not only of the deep cervical flexor (DCF), but also the sterno-cleido-mastoid (SCM) and moreover the supra-hyoid (SH) muscles. The choice between the longus capiti and the longus colli depended on the AC posture. Half of the patients had a dramatic improvement with 90% satisfaction or above.

CONCLUSION

AC posture is a complex but treatable type of CD. A joint Neuro-ENT clinic is an ideal setting in which to target all the dystonic muscles. This allows the injection of the longus capiti (under nasal endoscopic approach) as well as the supra-hyoid and SCM muscles in the same session.

[Treatment satisfaction in patients with cervical dystonia : Subgroup analysis of INTEREST-IN-CD-2]

Hintergrund

Obwohl Botulinumtoxin‑A (BoNT-A) von Leitlinien als First-line-Therapie der fokalen zervikalen Dystonie (ZD) empfohlen wird, existieren kaum Langzeitdaten zu den Behandlungsmodalitäten in der klinischen Routine.

Fragestellung

Die vorliegende Subgruppenanalyse untersuchte Patientenzufriedenheit und Symptomkontrolle unter Berücksichtigung von Behandlungsmodalitäten der BoNT-A-Therapie zwischen ZD-Patienten in Deutschland und Österreich (DE/AT, n = 79) und der internationalen Gesamtkohorte (n = 995).

Material und Methoden

INTEREST-IN-CD2 war eine prospektive, multizentrische, longitudinale Beobachtungsstudie, die über 3 Jahre der Therapie erwachsener Patienten mit idiopathischer ZD unter BoNT-A-Behandlung folgte. Primärer Endpunkt war die Patientenzufriedenheit mit der Therapie gemessen an der maximalen Zufriedenheit zwischen 2 Injektionen und der Zufriedenheit zum Zeitpunkt der Reinjektion.

Ergebnisse

Die Therapiezufriedenheit im Wirkmaximum war in beiden Populationen im Studienverlauf stabil und vergleichbar gut (82,3–92,7 % bzw. 85,0–89,9 %). Mit nachlassender BoNT-A-Wirkung zum Ende des Behandlungsintervalls sank die Zufriedenheit ab: Zu Studienbeginn in beiden Gruppen ähnlich (54,2 % vs. 51,4 %), fiel sie numerisch in der der DE/AT-Gruppe bis auf 32,7 % ab, blieb dagegen in der Gesamtpopulation stabil. Die Toronto Western Spasmodic Torticollis Rating Scale(TWSTRS)- und Tsui-Scores zeigten keine wesentlichen Unterschiede zwischen der DE/AT-Gruppe und der Gesamtpopulation.

Schlussfolgerungen

Die Studie bestätigt insgesamt eine gute klinische Symptomkontrolle durch BoNT‑A. Die im Vergleich von DE/AT zur internationalen Gesamtkohorte gesehenen numerischen Unterschiede in der aktuellen Zufriedenheit sind möglicherweise bedingt durch abweichende Anteile BoNT-A-naiver Patienten beider Gruppen, da diese unterschiedliche Zufriedenheit als vorbehandelte Patienten äußerten.

Zusatzmaterial online

Die Onlineversion dieses Beitrags (10.1007/s00115-021-01120-1) enthält weitere Infomaterialien. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.

Morphological characteristics of the posterior neck muscles and anatomical landmarks for botulinum toxin injections

PURPOSE

Cervical dystonia is a common movement disorder for which botulinum toxin (BoNT) is the first choice treatment. Injecting the specific neck muscles can be challenging because of their thin morphology and deep locations. We, therefore, designed a study to investigate the locations of the posterior neck muscles to help the physician predict the locations of the targeted neck muscles and to protect the vertebral vessels from injury during deep injections.

METHODS

The posterior neck region was divided into four quadrants by imaginary lines passing vertically and transversely through the spinous process of C2 vertebra (C2_sp). The thicknesses and depth of the posterior neck muscles were measured in ten formaldehyde-fixed adult male cadavers. These muscles were located and a projection of them was drawn on the neck. Using the measurements, colored latex in place of BoNT was injected into them in one cadaver. The cadaver was dissected to investigate whether the muscles were colored.

RESULTS

2 cm above the C2_sp, trapezius, splenius capitis (SPC) and semispinalis capitis (SSC) were colored at depths of 10.70 mm, 11.88 mm and 15.91 mm, respectively. 2 cm below the C2_sp, the trapezius, SPC and SSC were colored at depths of 20.89 mm, 23.25 mm and 27.63 mm, respectively. The posterior neck muscles were had taken up their assigned colors when they were injected according to the results obtained in this study. The vertebral vessels were not colored.

CONCLUSIONS

Although BoNT injection into the posterior neck muscles is challenging, we think that it can be practically and safely applied using the measurements obtained in this study.

Botulinum Toxin in Movement Disorders: An Update

Since its initial approval in 1989 by the US Food and Drug Administration for the treatment of blepharospasm and other facial spasms, botulinum toxin (BoNT) has evolved into a therapeutic modality for a variety of neurological and non-neurological disorders. With respect to neurologic movement disorders, BoNT has been reported to be effective for the treatment of dystonia, bruxism, tremors, tics, myoclonus, restless legs syndrome, tardive dyskinesia, and a variety of symptoms associated with Parkinson's disease. More recently, research with BoNT has expanded beyond its use as a powerful muscle relaxant and a peripherally active drug to its potential central nervous system applications in the treatment of neurodegenerative disorders. Although BoNT is the most potent biologic toxin, when it is administered by knowledgeable and experienced clinicians, it is one of the safest therapeutic agents in clinical use. The primary aim of this article is to provide an update on recent advances in BoNT research with a focus on novel applications in the treatment of movement disorders. This comprehensive review of the literature provides a critical review of evidence-based clinical trials and highlights recent innovative pilot studies.

Patient perspectives on the therapeutic profile of botulinum neurotoxin type A in cervical dystonia

BACKGROUND

Botulinum neurotoxin type A (BoNT-A) is an effective pharmacological treatment for the management of cervical dystonia (CD) that requires repeated administration at variable intervals. We explored patient perceptions of the impact of CD and the waning of BoNT-A therapeutic effects.

METHODS

An internet-based survey was conducted through Carenity, a global online patient community, from May to September 2019. Eligible respondents were adults with CD who had ≥ 2 previous BoNT-A injections.

RESULTS

209 respondents (81% females; mean age of 49.7 years) met the screening criteria. The mean BoNT-A injection frequency was 3.9 injections/year. The mean reported onset of BoNT-A therapeutic effect was 11.7 days and the time to peak effect was 4.5 weeks. Symptom re-emergence between injections was common (88%); the time from injection to symptom re-emergence was 73.6 days (~ 10.5 weeks). Treatment was not reported to completely abolish symptoms, even at peak effect. However, symptom severity was rated (0 = no symptoms; 10 = very strong symptoms) as lowest at the peak of treatment effects (mean scores ~ 3/10), increasing as the effects of treatment start waning (~ 5.5/10) and was strongest one day before the next session (~ 7-8/10). The impact of CD on quality of life followed the same 'rollercoaster' pattern.

CONCLUSIONS

This survey highlights the burden of CD symptoms, even in patients undergoing regular treatment. Symptom re-emergence is common and has significant impact on daily activities and quality of life. Greater awareness of the therapeutic profile of BoNT-A treatment should lead to better informed therapeutic discussions and planning.

Cervical dystonia: factors deteriorating patient satisfaction of long-term treatment with botulinum toxin

OBJECTIVES

Botulinum toxin (BoNT) is an effective first-line treatment for cervical dystonia (CD). Despite generally good therapeutic efficacy, approximately 20-40% of CD patients do not achieve acceptable relief of the dystonic symptoms. The aim of this study was to identify factors of low patient satisfaction of long-term BoNT therapy for CD.

METHODS

In this case-control study CD patients treated with BoNT intramuscular injections for up to 24 years were assessed by two independent assessors in three validated scales: TWSTRS, Tsui and VAS for pain measurement. Data on received BoNT doses and treatment duration were obtained from medical history. All of participants rated their long-term treatment satisfaction compared to the therapy onset on a 0-3 scale.

RESULTS

Study was completed by 58 participants who were treated with BoNT for 9.0 ± 6.3 years and received a median of 19 injection cycles. None/low therapy satisfaction was reported by 20.7% of participants. Compared to moderate/good treatment satisfaction, CD patients with none/low BoNT efficacy had increased incidence of cervical pain (p =.018), enhanced mean VAS score for pain (p =.037) and had higher coexistence of oromandibular dystonia (p =.018). In addition, worse treatment satisfaction correlated with shorter time intervals between treatment cycles, enhanced scores of Tsui total, TWSTRS total, as well as TWSTRS subscales: severity, disability and pain.

CONCLUSION

Cervical pain and coexistence of oromandibular dystonia deteriorated long-term treatment satisfaction in CD patients. Higher scores of Tsui and TWSTRS subscales were correlated with worse subjective BoNT treatment response.

Impact of abobotulinumtoxinA on the clinical features of cervical dystonia in routine practice

INTRODUCTION

The efficacy and safety of abobotulinumtoxinA in the management of cervical dystonia has been established in randomized, controlled trials that use a selected trial population. In this meta-analysis of observational data, we evaluated the real-life effectiveness of abobotulinumtoxinA as delivered in routine clinical practice.

METHODS

Meta-analysis of patient-level data for adult patients with cervical dystonia treated with abobotulinumtoxinA from three prospective, multicenter, observational studies (NCT01314365, NCT00833196 and NCT01753349).

RESULTS

We report data for patients treated with abobotulinumtoxinA over one injection cycle at 181 neurology centers in 35 countries. CD clinical features as assessed by Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) Total scores (N = 920) significantly reduced by a mean [95%CI] of -12.9 [-13.9, -11.8] points at Week 4 (N = 449) and -3.2 [-3.8, -2.7] points at the end of the injection cycle (N = 890). All three TWSTRS domains (symptom severity, disability and pain) contributed to the overall improvement. Patients were generally content with symptom control at peak effect of the treatment cycle, with 86% reporting overall satisfaction.

CONCLUSION

Findings from this meta-analysis of observational studies confirm the effectiveness of abobotulinumtoxinA in routine practice. Despite inclusion of a broader population sample, the magnitude of improvements observed is consistent with that seen in the pivotal, randomized controlled trials.

Caregiver burden and health-related quality of life in idiopathic dystonia patients under botulinum toxin treatment: a cross-sectional study

Dystonia is a chronic movement disorder that is associated with a reduction in health-related quality of life (HR-QoL) and restriction of activities of daily living. Botulinum neurotoxin (BT) improves disease-specific HR-QoL by reducing abnormal movements, postures, and pain. We examined the burden of the corresponding primary caregiver as a potential important factor for disease management and HR-QoL of dystonia patients under treatment with BT. 114 patients with focal, segmental, or generalized dystonia were recruited, together with 93 corresponding caregivers, whose burden was investigated using the Caregiver Burden Inventory. In addition, all participants were assessed for cognitive impairment, depression, anxiety, alexithymia, and HR-QoL. Only a small proportion of caregivers suffered from caregiver burden. Despite BT therapy, patients' HR-QoL was decreased compared to the age-matched general German population. Psychological symptoms, notably anxiety, and depression correlated significantly with reduced HR-QoL. Our data imply that caregiver burden emerged to be an issue in subgroups of dystonia patients. Furthermore, HR-QoL of dystonia patients is reduced even under optimized BT treatment in a specialized center.

The Use of Botulinum Toxin for Treatment of the Dystonias

Dystonias are characterized by involuntary muscle contractions, twisting movements, abnormal postures, and often tremor in various body regions. However, in the last decade several studies have demonstrated that dystonias are also characterized by sensory abnormalities. While botulinum toxin is the gold standard therapy for focal dystonia, exactly how it improves this disorder is not entirely understood. Neurophysiological studies in animals and humans have clearly demonstrated that botulinum toxin improves dystonic motor manifestations by inducing chemodenervation, therefore weakening the injected muscles. In addition, neurophysiological and neuroimaging evidence also suggests that botulinum toxin modulates the activity of various neural structures in the CNS distant from the injected site, particularly cortical motor and sensory areas. Concordantly, recent studies have shown that in patients with focal dystonias botulinum toxin ameliorates sensory disturbances, including reduced spatial discrimination acuity and pain. Overall, these observations suggest that in these patients botulinum toxin-induced effects encompass complex mechanisms beyond chemodenervation of the injected muscles.