Botulinum toxin type A relieves sternocleidomastoid muscle fibrosis in congenital muscular torticollis

Comparison of dual-plane micro-drop injection of botulinum toxin type A with two traditional methods for treating hypertrophic scars in the tension zone: A long-term clinical application study

BACKGROUND

Patients with hypertrophic scarring tend to experience recurrence after treatment, which often occurs in areas of the body with high skin tension.

AIMS

To evaluate better treatments aimed at reducing the risk of scar recurrence in areas of high skin tension.

METHODS

Patients were randomly divided into the following three treatment groups: botulinum toxin type A (BTA) via dual-plane micro-drop injections, triamcinolone acetonide (TAC) suspension, and CO2 via fractional CO2 laser. Interventions were implemented in all three groups once a month for three consecutive sessions. After the final treatment, scarring was evaluated at 1, 3, 6, 12, and 24 months using the Patient and Observer Scar Assessment Scale (POSAS).

RESULTS

The 3-month POSAS score for each scar indicator in the treatment groups was significantly lower than that in the preoperative groups (p < 0.001). The scar score in the TAC group decreased at 3 months and increased thereafter. For other groups, the scar score continually decreased at all time points according to the Patient Scar Assessment Scale. Based on the Observer Scar Assessment Scale, the scar score continuously decreased at all time points in the BTA group; in the TAC group, it decreased at 1 month and increased thereafter; and in the CO2 group, the scar score decreased at 3 months and subsequently stabilized.

CONCLUSIONS

All three treatment methods were effective. However, the BTA group experienced a reduced risk of scar recurrence and maintained long-term treatment effects.

Congenital Muscular Torticollis-Current Understanding and Perinatal Risk Factors: A Retrospective Analysis

INTRODUCTION

Congenital muscular torticollis (CMT) is an asymmetrical head position resulting from structural changes in the sternocleidomastoid (SCM) muscle that occurs early during a child's development or due to perinatal trauma. Children with CMT exhibit a marked imbalance in tension between the SCMs. In a typical clinical picture, an ultrasound scan is performed to reveal characteristic lesions, such as tissue fibrosis or post-traumatic changes. An early diagnosis of CMT in newborns and the implementation of treatment offer the chance of a complete resolution. Torticollis treatment aims to restore the SCM's normal function. Surgical treatment is performed when conservative methods fail to improve the patient's condition. The indications that surgery is needed include a marked shortening of the SCM, persistent fibrosis in the muscle, constant head and facial asymmetry, and rotation or lateral flexion in the cervical spine restricted by >15°. Of all the newborn and infant anomalies, congenital torticollis is the third most common after hip dysplasia and equinovarus deformities. Some authors demonstrate that torticollis coexists with hip dysplasia.

AIM

The aim of this study was to collect data on infants referred to paediatric rehabilitation and to identify the risk factors associated with CMT in this group of patients, as well as to assess demographic and clinical characteristics concerning risk factors.

MATERIALS AND METHODS

The target population for this retrospective study consisted of 111 infants aged 0 to 5 months born in Poland and diagnosed with and undergoing treatment due to CMT. The following were determined: the relationship between the side of the CMT location and the type of delivery (caesarean section vs. vaginal), the relationship between the body weight at birth and the side of the CMT location, the relationship between the extent of SCM thickening and the type of delivery, and the incidence of CMT depending on the order of delivery.

RESULTS AND CONCLUSIONS

The data revealed that CMT is less common in female infants (n = 51, 46%) compared to male (n = 61, 54%) infants, in whom a greater birth weight was reported (p < 005). Seventy-six percent (76%) of the paediatric patients with CMT were the offspring of primipara mothers. More often, children born via vaginal delivery had left-sided torticollis with a more significant broadening of the SCM, as shown on ultrasound scans, than right-sided torticollis. Theories of torticollis development pathophysiology should be deepened and systematised, and further research is needed.

Pharmacological Therapies for Connective Tissue Fibrosis in Orthopaedics

Fibrosis is a common and debilitating pathological process that affects many organ systems and contributes to connective tissue disorders in orthopaedics. Tendons heal after acute and chronic injury through a process of fibrovascular scar tissue formation, and soft tissue joint capsules can be affected after traumatic joint injury, leading to arthrofibrosis. Although the precise underlying mechanisms are still being elucidated, fibrosis is thought to be a consequence of dysregulated immune and cytokine signaling that leads to myofibroblast activation and proliferation and subsequent excessive collagen deposition. Current treatments for connective tissue fibrosis include physical therapy and surgery, but there are no therapies that directly target the underlying cellular and molecular mechanisms of fibrosis. Many pharmacological agents have been used to successfully target fibrosis in other tissues and organ systems and thus are a promising treatment option to fill this gap. However, limited evidence is available to guide the use of these agents in musculoskeletal connective tissues. This article provides an overview of pharmacological therapies that have potential to treat connective tissue fibrosis in patients with musculoskeletal conditions, along with the current supporting evidence and future uses of each therapy.

Identifying safety zone of invasive procedures in the sternocleidomastoid muscle using ultrasonography

Dysfunctions of the sternocleidomastoid (SCM) muscle, such as myofascial syndrome, torticollis, and cervical dystonia, have been treated using several invasive procedures. In such situations, it is possible to injure the adjacent nerves. This study aimed to demonstrate the course of these nerves in healthy volunteers using ultrasound. The great auricular nerve (GAN), spinal accessory nerve (SAN), transverse cervical nerve (TCN), and supraclavicular nerve (SCN) were scanned by ultrasonography in 26 healthy volunteers. The neck was scanned in the supine position with the head turned 45° to the contralateral side. The cervical plexus was detected in half of the SCM muscle. Each nerve was then traced to the level of contact with the anterior border of the SCM muscle. The following features of the nerves were recorded bilaterally: vertical and horizontal positions of each nerve at the posterior border of the SCM and the cross-sectional area and depth of each nerve at the reference line and anterior border of the SCM. The mean proportions of GAN, SAN, TCN, and SCN were 26%, 26%, 48%, and 80%, respectively near the posterior border, whereas they were 18%, 23%, and 51% for GAN, SAN, and TCN, respectively, at the level of the reference line. Notably, SCN was not visible at the level of the reference line. The mean TCN proportion was 47% at the anterior border of the SCM. The precise location of the nerves and their relationship with the SCM muscle should be considered during invasive procedures. It is recommended that the procedure be performed in the lower half of the SCM muscle, which refers to 50 to 80% of the proportions in our study.

External treatment of herbal medicine with tuina in congenital muscular torticollis: A protocol for systematic review and meta-analysis

BACKGROUND

This study is the protocol to evaluate the clinical evidence for external treatments using herbal medicine (ETHM) with tuina as a congenital muscular treatment (CMT) in pediatrics.

METHODS

Eleven databases will be searched until June 2022, without any language restrictions: four English databases (MEDLINE, Pubmed, EMBASE, and The Cochrane Central Register of Database of Controlled Trials), three Chinese databases (China National Knowledge Infrastructure, Chinese Scientific Journal Database, and Wan Fang Database), and four Korean electronic databases (Oriental Medicine Advanced Searching Integrated System, Korean Studies Information Service System, National Digital Science Links, and Research Information Sharing Service). This review will include randomized clinical trials (RCTs) of ETHM with tuina as an intervention versus the same tuina. All published RCTs for any ETHM for CMT will be included. Non-RCTs, RCT protocol, animal studies, case reports, reviews, and surveys will be excluded. The methodological quality assessment will be performed using the Cochrane risk of bias (ROBs). Review Manager version 5.4. will be used for the data synthesis and quantitative analysis.

RESULTS AND DISCUSSIONS

The systematic review and meta-analysis will provide evidence for ETHM as a treatment of CMT. The evidence can help clinicians and patients recognize more effective therapeutic and safe inventions.

INPLASY REGISTRATION NUMBER

INPLASY202210017.

The Action of Botulinum Toxin A on the Sternocleidomastoid Muscle: An Experimental Study on Rats

In this study, we aim to investigate the effective dose of botulinum neurotoxin A that results in paralysis of the sternocleidomastoid muscle for a minimum duration of 28 days in Wistar rats. This research is the first in a series of studies to investigate the value of botulinum toxin A in the healing of clavicle fractures through the temporary paralysis of the sternocleidomastoid. A surgical incision was made under general anaesthesia, and botulinum neurotoxin A in respective doses of 4 and 6 international units (IU) or normal saline in equivalent volumes were injected directly into the exposed muscle. Electromyography was conducted on days 0, 7, and 28 following substance administration to determine the extent of muscle paralysis. Electromyography on day 0 showed no paralysis in either group. Animals injected with neurotoxin all exhibited paralysis on days 7 and 28 that was weaker in the group injected with the smaller dose of 4 IU. One death occurred in the group injected with the higher dose (6 IU), whereas in the control group, no paralysis was seen. Botulinum neurotoxin A in a dose of 6 IU resulted in complete paralysis of the sternocleidomastoid in rats for a minimum of 28 days. A dose of 4 IU resulted in less potent paralysis but was safer in our research. Botulinum neurotoxin is a substance utilised in cosmetics and therapeutics for many years, yet research shows that its use can be expanded to target a wider range of pathologies. In this series of studies, we aim to explore the neurotoxin's applications on the treatment of clavicle fractures. To investigate this, we need to first establish the duration of its action on the sternocleidomastoid muscle.

Bioreactors for Vocal Fold Tissue Engineering

It is estimated that almost one-third of the United States population will be affected by a vocal fold (VF) disorder during their lifespan. Promising therapies to treat VF injury and scarring are mostly centered on VF tissue engineering strategies such as the injection of engineered biomaterials and cell therapy. VF tissue engineering, however, is a challenging field as the biomechanical properties, structure, and composition of the VF tissue change upon exposure to mechanical stimulation. As a result, the development of long-term VF treatment strategies relies on the characterization of engineered tissues under a controlled mechanical environment. In this review, we highlight the importance of bioreactors as a powerful tool for VF tissue engineering with a focus on the current state of the art of bioreactors designed to mimic phonation in vitro. We discuss the influence of the phonatory environment on the development, function, injury, and healing of the VF tissue and its importance for the development of efficient therapeutic strategies. A concise and comprehensive overview of bioreactor designs, principles, operating parameters, and scalability are presented. An in-depth analysis of VF bioreactor data to date reveals that mechanical stimulation significantly influences cell viability and the expression of proinflammatory and profibrotic genes in vitro. Although the precision and accuracy of bioreactors contribute to generating reliable results, diverse gene expression profiles across the literature suggest that future efforts should focus on the standardization of bioreactor parameters to enable direct comparisons between studies. Impact statement We present a comprehensive review of bioreactors for vocal fold (VF) tissue engineering with a focus on the influence of the phonatory environment on the development, function, injury, and healing of the VFs and the importance of mimicking phonation on engineered VF tissues in vitro. Furthermore, we put forward a strong argument for the continued development of bioreactors in this area with an emphasis on the standardization of bioreactor designs, principles, operating parameters, and oscillatory regimes to enable comparisons between studies.

A consensus statement on the use of botulinum toxin in pediatric patients

Botulinum toxin has been used in medicine for the past 30 years. However, there continues to be controversy about the appropriate uses and dosing, especially in the pediatric population. A panel of nine pediatric physiatrists from different regions and previous training programs in the United States were nominated based on institutional reputation and botulinum toxin (BoNT) experience. Based on a review of the current literature, the goal was to provide the rationale for recommendations on the administration of BoNT in the pediatric population. The goal was not only to review safety, dosing, and injection techniques but also to develop a consensus on the appropriate uses in the pediatric population. In addition to upper and lower limb spasticity, the consensus also provides recommendations for congenital muscular torticollis, cervical dystonia, sialorrhea, and brachial plexus palsies.

Establishment of a long-term hypertrophic scar model by injection of anhydrous alcohol: A rabbit model

The processes of hypertrophic scar formation are extremely complex, and current animal models have limitations in terms of the complete characterization of lesions. An ideal animal model is indispensable for exploring the complex progression of scar formation to elucidate its pathophysiology and to perform therapeutic testing. This study aimed to establish a long-term, consistent and easily testable animal model by injecting anhydrous alcohol into the dorsal trunk dermis of rabbits. The rabbits were injected with different amounts of anhydrous alcohol. Anhydrous alcohol was infiltrated into the subcutaneous and superficial fascia. The optimal amount of anhydrous alcohol was determined by measuring the area and thickness of the scar. The typical model was established by determining the optimum dosage, and then we analysed the histological characteristics and fibrosis-associated protein expression. The dermal scar was generated by treating with 2 ml/kg anhydrous alcohol and displayed histopathologic features that characterize human hypertrophic scarring, including a parallel collagen fibre orientation, dermal and epidermal thickening, broad collagen deposition and the loss of dermal adnexal structures. The expression of fibrotic pan-markers was also enhanced. Moreover, the scar features and duration were compared between the anhydrous alcohol model and the rabbit ear model. Our results show that injecting anhydrous alcohol in the rabbit model thickened the dermal tissue, stimulated dermal fibroproliferation and resulted in hypertrophic scars with protein and histologic features similar to those seen in humans. Taken together, the findings from this study show that our model could be a feasible and useful tool for further research on the pathogenesis of hypertrophic scars.

Histone Deacetylase 3-Mediated Inhibition of microRNA-19a-3p Facilitates the Development of Rheumatoid Arthritis-Associated Interstitial Lung Disease

Histone deacetylase (HDAC) has been implicated in rheumatoid arthritis (RA) progression. We investigated the roles of histone deacetylase 3 (HDAC3) involved in RA-associated interstitial lung disease (ILD) fibrosis. Firstly, we measured the expression of HDAC3 and interleukin 17 receptor A (IL17RA) in lung tissue samples from normal controls, idiopathic pulmonary fibrosis (IPF) patients, and RA-ILD patients. Next, chromatin immunoprecipitation (ChIP) and dual luciferase reporter assay were employed to detect the interaction between HDAC3 and microRNA-19a-3p (miR-19a-3p) and between miR-19a-3p and IL17RA. Further, immunohistochemistry was used to localize HDAC3 and IL17RA expression in lung tissues. Additionally, functional assays were conducted followed by expression determination of HDAC3, miR-19a-3p, and IL17RA with reverse transcription quantitative PCR (RT-qPCR) and Western blot analysis. The effect of HDAC3 on RA-ILD in the constructed RA-ILD mouse model was also studied based on arthritis assessment. We found overexpressed HDAC3 and IL17RA as well as silenced miR-19a-3p in RA-ILD mouse model and RA-ILD patients. In the mouse model, HDAC3 downregulated miR-19a-3p in lung fibroblasts to promote the progression of RA-ILD fibrosis. In lung fibroblasts of RA-ILD mice, IL17RA was a target gene of miR-19a-3p. miR-19a-3p negatively regulated IL17RA, thereby increasing the expression of fibrosis markers, COL1A1, COL3A1, and FN, in lung fibroblasts of mice. Taken together, HDAC3 upregulated IL17RA expression by targeting miR-19a-3p to facilitate the RA-ILD fibrosis development, which sheds light on a new HDAC3/miR-19a-3p/IL17RA axis functioning in RA-ILD fibrosis.

Advanced Simultaneous Isolation, Culture, and Identification of Myoblasts and Fibroblasts From Sternocleidomastoid Muscle of Congenital Muscular Torticollis

BACKGROUND

Congenital muscular torticollis (CMT) is a common pediatric disease caused by contracture of sternocleidomastoid muscle (SCM) that leads to neck stiffness and deformity. Based on the adhesion characteristics of different cells in affected SCM of CMT, myoblasts and fibroblasts can be isolated simultaneously by advanced culture conditions. Our study aimed to explore and optimize the isolation, culture, and identification of myoblasts and fibroblasts in SCM of CMT.

METHODS

Myoblasts and fibroblasts were separated by combined digestion with trypsin and collagenase. With this improved method, the morphology of isolated myoblasts and fibroblasts was observed under the microscope, the cell growth curve was drawn, and the purity of myoblasts and fibroblasts was determined by immunofluorescence.

RESULTS

The method allowed to satisfactorily culture myoblasts and fibroblasts. The cells could stably grow and be passaged, provided they were at least 80% confluent. Immunofluorescence of myoblasts and fibroblasts showed high rate of positive staining, and cell count showed excellent growth state. Moreover, according to the growth curve, fibroblasts grew at a higher rate than myoblasts.

CONCLUSIONS

The isolated myoblasts and fibroblasts have high purity, intact structure, and relatively high vitality. This method can be used to establish a cell model with myoblasts and fibroblasts, which can be applied to investigate etiology of CMT or mechanisms of drug action.

The Effectiveness and Safety of Botulinum Toxin Injections for the Treatment of Congenital Muscular Torticollis

OBJECTIVE

Botulinum toxin have been used to treat congenital muscular torticollis for the last 25 years; however, few studies have been published with only limited cases and short-term follow-up. The aim of the present study is to systematically review the effectiveness and safety of botulinum toxin injections for congenital muscular torticollis by analyzing these relevant literatures.

METHODS

The authors searched PubMed, Web of Science, EMBASE, Cochrane Library, China Biology Medicine, for all articles about botulinum toxin injections for the congenital muscular torticollis. The MINORS evaluation tool was adopted to evaluate the quality of these studies. Meta-analysis calculations are made by R software 3.6.2.

RESULTS

This study search involved strict inclusion criteria and targeted data collection. Ten studies were included, with a total of 411 patients, comprising 1 non-randomized experimental study and 9 cases or case series. The results of our meta-analysis of single rate showed that the overall effective rate of botulinum toxin for congenital muscular torticollis was 84% (95% confidence interval [CI] 67%-96%). After botulinum toxin treatment, the conversion rate to surgery was 9% (95% CI 4%-22%), and the adverse reaction rate was 1% (95% CI 0%-3%). The most common adverse reactions among these included studies involve injection site erythema and transient dysphagia.

CONCLUSION

Current evidence shows that botulinum toxin injections for the treatment of congenital muscular torticollis is safe and effective, with few serious adverse reactions. Further well-designed, larger randomized trials are warranted.

Out of the spasticity box: Off-label uses of botulinum toxin in children

Botulinum toxin is frequently used as a therapeutic for a variety of non-FDA approved indications in children. This narrative literature review explores three off-label uses of botulinum toxin in pediatric conditions including congenital muscular torticollis, spastic trismus, and neonatal brachial plexus palsy. While more research is needed to establish treatment, dosing and localization guidelines for the use of botulinum toxin in these commonly treated conditions, available evidence is discussed.

Use of Combined Botulinum Toxin and Physical Therapy for Treatment Resistant Congenital Muscular Torticollis

BACKGROUND

Physical therapy (PT) alone is not always effective for treatment of congenital muscular torticollis (CMT). The adjunctive use of botulinum toxin (BTX) injection into the sternocleidomastoid, followed by PT, could provide correction and avoid more invasive surgery. Aims of the study were to review clinical and caregiver-reported outcomes of children with resistant CMT treated by BTX injection combined with a guided-PT program.

METHODS

Medical records of consecutive children with resistant CMT treated by our protocol between 2010 and 2015 were reviewed. A minimum 2-year follow-up was required. Demographic parameters, numbers of BTX required and pre-BTX and post-BTX head tilt and range of neck rotation were recorded. A univariate analysis test was conducted to identify variables related to the need of repeated BTX injections. A phone interview with the caregivers was done regarding their satisfaction.

RESULTS

A cohort of 39 patients with treatment resistant CMT were identified that had an average age of 14 (range, 6.5 to 27.6) months at initiation of BTX treatment. Multiple BTX injections were utilized in 21/39 (54%) of patients. No patient required tendon lengthening surgery. At the final evaluation, there was improvement in both head tilt (18.7±6.8 degrees vs. 1.7±2.4 degrees, mean difference (95% CI) 16.9 (14.6-19.3); P<0.001) and range of neck motion (56.0°±11.7 degrees vs. 86.0±3.8 degrees, mean difference (95% CI) 30.0 (26.1-33.9), P<0.001). Pre-BTX parameters were not associated with the requirement of repeated BTX injections (P>0.05). Caregivers were satisfied with the treatment protocol. No untoward effect was observed during the study period.

CONCLUSIONS

The proposed minimally invasive protocol provided correction of resistant CMT and obviated the need for more invasive surgical procedures.

LEVEL OF EVIDENCE

Level IV.

Botulinum toxin type A prevents the phenotypic transformation of fibroblasts induced by TGF‑β1 via the PTEN/PI3K/Akt signaling pathway

Hypertrophic scar (HS) is a common type of dermatosis. Botulinum toxin type A (BTXA) can exert an anti-HS effect; however, the regulatory mechanisms underlying this effect remain unclear. Thus, the aim of this study was to examine the effects of BTXA on phosphatase and tensin homolog deleted on chromosome ten (PTEN) expression and the fibroblast phenotypic transformation induced by transforming growth factor (TGF)-β1, which is an important regulatory factor involved in the process of HS. For this purpose, fibroblasts were treated with various concentrations of BTXA and then treated with 10 ng/ml of TGF-β1 with gradient concentrations of BTXA. The proliferation and apoptosis of fibroblasts were measured by cell counting kit-8 assay (CCK-8) and flow cytometry, respectively. PTEN methylation was analyzed by methylation-specific PCR (MSP) and DNA methyltransferase (DNMT) activity was determined using a corresponding kit. RT-qPCR and western blot analysis were performed to detect the transcription and translation levels. The results revealed that BTXA suppressed the proliferation and increased the apoptosis of fibroblasts treated with TGF-β1 in a dose-dependent manner. BTXA in combination with TGF-β1 suppressed the expression of molecules related to the extracellular matrix (ECM), epithelial-mesenchymal transition (EMT) and apoptosis. BTXA reduced the PTEN methylation level and downregulated the expression levels of methylation-associated genes. BTXA also inhibited the phosphorylation of phosphoinositide 3-kinase (PI3K) and Akt. On the whole, the findings of this study indicate that BTXA may inhibit fibroblast phenotypic transformation by regulating PTEN methylation and the phosphorylation of related pathways. The findings of this study can provide a theoretical basis for HS treatment.

[Torticollis in children]

BACKGROUND

Torticollis is a common neck deformity in both newborn and older children. The various causes of the abnormal posturing of the head differ in severity, long-term consequences and their treatment.

METHODS

This article gives an overview of the differential diagnoses of torticollis in children and current literature, and provides insight into our diagnostic and therapeutic algorithm.

RESULTS

A distinction is drawn between congenital and acquired deformities and whether or not they are painful. Most commonly, children present with a congenital muscular torticollis, which has an estimated incidence of 0.3 to 1.9%. The main differential diagnosis of congenital muscular torticollis is Klippel-Feil syndrome. Acquired torticollis often has more severe causes and always needs a thorough diagnostic clarification.

CONCLUSION

The knowledge of possible causes and their treatment is essential to provide adequate care for affected children and their families and to prevent long-term consequences.