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Aradi S, Hauser RA. Current use of neurotoxins for alleviating symptoms of cervical dystonia. Expert Rev Neurother 2024; 24:787-797. [PMID: 39049547 DOI: 10.1080/14737175.2024.2368638] [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] [Received: 02/27/2024] [Accepted: 06/12/2024] [Indexed: 07/27/2024]
Abstract
INTRODUCTION Cervical dystonia (CD) causes involuntary movements and postures of the head, neck, and shoulders, as well as nonmotor symptoms including pain, mood, and sleep dysfunction, and impacts quality of life. The first-line treatment for CD is botulinum neurotoxin (BoNT) injections. AREAS COVERED The clinical presentation and diagnosis of CD, as well as where BoNT resides in the treatment landscape, is reviewed first. Next, the mechanism of action and the pharmacological differences in the available preparations of BoNT products are explained. The evidence base for motor and nonmotor efficacy and safety of the available BoNT formulations is reviewed, with attention to duration of benefit as a driver of patient satisfaction. Practical determinants of BoNT efficacy are reviewed including muscle selection, accurate muscle injection, factors related to poor or deteriorating response, and immunogenicity. EXPERT OPINION BoNT represents a significant advancement in the treatment of CD. More accurate diagnosis, muscle selection and targeting, and dosing can improve outcomes with existing BoNT formulations. Further refinement of BoNT potency, duration of action, safety, and immunogenicity will help reduce unmet needs in the magnitude and duration of benefit. Additional validation of DBS and MRI-guided focused ultrasound may expand options for patients with toxin nonresponse.
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Affiliation(s)
- Stephen Aradi
- Department of Neurology, Parkinson's Foundation Center of Excellence, University of South Florida, TampaFLUSA
| | - Robert A Hauser
- Department of Neurology, Parkinson's Foundation Center of Excellence, University of South Florida, TampaFLUSA
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LeWitt PA, Hong L, Moehle MS. Anticholinergic drugs for parkinsonism and other movement disorders. J Neural Transm (Vienna) 2024:10.1007/s00702-024-02799-7. [PMID: 38904792 DOI: 10.1007/s00702-024-02799-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 06/02/2024] [Indexed: 06/22/2024]
Abstract
Anticholinergic (AC) drugs, a medication class that acts by blocking nicotinic and muscarinic acetylcholine receptors, were first utilized for therapeutic purposes in the mid-19th century. Initial applications were as symptomatic therapy for Parkinson disease (PD), a practice continuing to the present. Initially, the AC drugs used were naturally-occurring plant compounds. Synthetic AC drugs were developed in the late 1940s and predominated in neurological therapeutics. Until the advent of pharmaceuticals acting upon striatal dopaminergic motor pathways, AC drugs provided the only effective means for lessening tremors and other clinical problems of the PD patient. However, because dopaminergic compounds are so effective at meeting the needs of the typical PD patient, AC medications are far less utilized by clinicians today. In recent years, there has been only a few investigations of AC drugs as neurological treatments. This review will revisit the clinical landscape of AC pharmacology and application for movement disorders along with recent research in search of improving therapeutics with AC drugs.
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Affiliation(s)
- Peter A LeWitt
- Departments of Neurology, Wayne State University School of Medicine and Henry Ford Hospital, 8-D 4201 St. Antoine Street, Detroit, MI, 48201, USA.
| | - Luke Hong
- The Department of Neurology, University of South Florida, Tampa, FL, USA
| | - Mark S Moehle
- Department of Pharmacology and Therapeutics, Center for Translational Research in Neurodegenerative Disease, University of Florida, Gainesville, FL, USA
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Safarpour D, Jabbari B. Botulinum toxin for motor disorders. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:539-555. [PMID: 37620089 DOI: 10.1016/b978-0-323-98817-9.00003-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
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.
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Affiliation(s)
- Delaram Safarpour
- Department of Neurology, Oregon Health & Science University, Portland, OR, United States
| | - Bahman Jabbari
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States.
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Cui Z, Chen T, Wang J, Jiang C, Gao Q, Mao Z, Pan L, Ling Z, Zhang J, Li X. The Long-Term Efficacy, Prognostic Factors, Safety, and Hospitalization Costs Following Denervation and Myotomy of the Affected Muscles and Deep Brain Stimulation in 94 Patients with Spasmodic Torticollis. Brain Sci 2022; 12:brainsci12070881. [PMID: 35884688 PMCID: PMC9313216 DOI: 10.3390/brainsci12070881] [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: 05/23/2022] [Revised: 06/26/2022] [Accepted: 06/27/2022] [Indexed: 02/01/2023] Open
Abstract
The surgical methods for treating spasmodic torticollis include the denervation and myotomy (DAM) of the affected muscles and deep brain stimulation (DBS). This study reports on the long-term efficacy, prognostic factors, safety, and hospitalization costs following these two procedures. We collected data from 94 patients with spasmodic torticollis, of whom 41 and 53 were treated with DAM and DBS, respectively, from June 2008 to December 2020 at the Chinese People’s Liberation Army General Hospital. We used the Tsui scale and the global outcome score of the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) to evaluate the preoperative and postoperative clinical conditions in all patients. We also determined the costs of hospitalization, prognostic factors, and serious adverse events following the two surgical procedures. The mean follow-up time was 68.83 months (range = 13–116). Both resection surgery and DBS showed good results in terms of Tsui (Z = −5.103, p = 0.000; Z = −6.210, p = 0.000) and TWSTRS scores (t = 8.762, p = 0.000; Z = −6.308, p = 0.000). Compared with the DAM group, the preoperative (47.71, range 24–67.25) and postoperative (18.57, range 0–53) TWSTRS scores in the DBS group were significantly higher (Z = −3.161, p = 0.002). We found no correlation between prognostic factors and patient age, gender, or disease duration for either surgical procedure. However, prognostic factors were related to the length of the postoperative follow-up period in the DBS surgery group (Z = −2.068, p = 0.039; Z = −3.287, p = 0.001). The mean hospitalization cost in the DBS group was 6.85 times that found in the resection group (Z = −8.284, p = 0.000). The total complication rate was 4.26%. We found both resection surgery and DBS showed good results in the patients with spasmodic torticollis. Compared with DAM, DBS had a greater improvement in TWSTRS score; however, it was more expensive. Prognostic factors were related to the length of the postoperative follow-up period in patients who underwent DBS surgery.
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Affiliation(s)
- Zhiqiang Cui
- Department of Neurosurgery, The First Medical Clinical Center, PLA General Hospital, Beijing 100853, China; (Z.C.); (J.W.); (Z.M.); (L.P.); (Z.L.); (J.Z.)
| | - Tong Chen
- Department of Neurology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China;
| | - Jian Wang
- Department of Neurosurgery, The First Medical Clinical Center, PLA General Hospital, Beijing 100853, China; (Z.C.); (J.W.); (Z.M.); (L.P.); (Z.L.); (J.Z.)
| | - Chao Jiang
- School of Basic Medical Sciences, North China University of Science and Technology, No. 21 Bohai Road, Caofeidian Eco-City, Tangshan 063210, China; (C.J.); (Q.G.)
| | - Qingyao Gao
- School of Basic Medical Sciences, North China University of Science and Technology, No. 21 Bohai Road, Caofeidian Eco-City, Tangshan 063210, China; (C.J.); (Q.G.)
| | - Zhiqi Mao
- Department of Neurosurgery, The First Medical Clinical Center, PLA General Hospital, Beijing 100853, China; (Z.C.); (J.W.); (Z.M.); (L.P.); (Z.L.); (J.Z.)
| | - Longsheng Pan
- Department of Neurosurgery, The First Medical Clinical Center, PLA General Hospital, Beijing 100853, China; (Z.C.); (J.W.); (Z.M.); (L.P.); (Z.L.); (J.Z.)
| | - Zhipei Ling
- Department of Neurosurgery, The First Medical Clinical Center, PLA General Hospital, Beijing 100853, China; (Z.C.); (J.W.); (Z.M.); (L.P.); (Z.L.); (J.Z.)
| | - Jianning Zhang
- Department of Neurosurgery, The First Medical Clinical Center, PLA General Hospital, Beijing 100853, China; (Z.C.); (J.W.); (Z.M.); (L.P.); (Z.L.); (J.Z.)
| | - Xuemei Li
- Cadre Medical Department, The First Medical Clinical Center, PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing 100853, China
- Correspondence: ; Fax: +10-66938442
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Rosales RL, Cuffe L, Regnault B, Trosch RM. Pain in cervical dystonia: mechanisms, assessment and treatment. Expert Rev Neurother 2021; 21:1125-1134. [PMID: 34569398 DOI: 10.1080/14737175.2021.1984230] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION In patients with cervical dystonia (CD), pain is a major contributor to disability and social isolation and is often the main reason patients seek treatment. Surveys evaluating patient perceptions of their CD symptoms consistently highlight pain as a troublesome and disabling feature of their condition with significant impact on daily life and work. AREAS COVERED In this article, the authors review the epidemiology, assessment, possible mechanisms and treatment of pain in CD, including a meta-analysis of randomized controlled trial data with abobotulinumtoxinA. EXPERT OPINION Mechanisms of pain in CD may be muscle-based and non-muscle based. Accumulating evidence suggests that non-muscle-based mechanisms (such as abnormal transmission and processing of nociceptive stimuli, dysfunction of descending pain inhibitory pathways as well as structural and network changes in the basal ganglia, cortex and other areas) may also contribute to pain in CD alongside prolonged muscle contraction. Chemodenervation with botulinum toxin is considered the first-line treatment for CD. Treatment with botulinum toxin is usually effective, but optimization of the injection parameters should include consideration of pain as a core symptom in addition to the motor problems.
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Affiliation(s)
- Raymond L Rosales
- Dept. of Neurology and Psychiatry, the Neuroscience Institute, University of Santo Tomas Hospital, Manila, Philippines.,The Institute for Neurosciences, St. Luke's Medical Center, Quezon City, Philippines
| | | | | | - Richard M Trosch
- The Parkinson's and Movement Disorders Center, Farmington Hills, MI, USA
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Costanzo M, Belvisi D, Berardelli I, Maraone A, Baione V, Ferrazzano G, Cutrona C, Leodori G, Pasquini M, Conte A, Fabbrini G, Defazio G, Berardelli A. Effect of Botulinum Toxin on Non-Motor Symptoms in Cervical Dystonia. Toxins (Basel) 2021; 13:toxins13090647. [PMID: 34564651 PMCID: PMC8472845 DOI: 10.3390/toxins13090647] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/07/2021] [Accepted: 09/09/2021] [Indexed: 11/16/2022] Open
Abstract
Patients with cervical dystonia (CD) may display non-motor symptoms, including psychiatric disturbances, pain, and sleep disorders. Intramuscular injection of botulinum toxin type A (BoNT-A) is the most efficacious treatment for motor symptoms in CD, but little is known about its effects on non-motor manifestations. The aim of the present study was to longitudinally assess BoNT-A’s effects on CD non-motor symptoms and to investigate the relationship between BoNT-A-induced motor and non-motor changes. Forty-five patients with CD participated in the study. Patients underwent a clinical assessment that included the administration of standardized clinical scales assessing dystonic symptoms, psychiatric disturbances, pain, sleep disturbances, and disability. Clinical assessment was performed before and one and three months after BoNT-A injection. BoNT-A induced a significant improvement in dystonic symptoms, as well as in psychiatric disturbances, pain, and disability. Conversely, sleep disorders were unaffected by BoNT-A treatment. Motor and non-motor BoNT-A-induced changes showed a similar time course, but motor improvement did not correlate with non-motor changes after BoNT-A. Non-motor symptom changes after BoNT-A treatment are a complex phenomenon and are at least partially independent from motor symptom improvement.
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Affiliation(s)
- Matteo Costanzo
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell’Università 30, 00185 Rome, Italy; (M.C.); (D.B.); (A.M.); (V.B.); (G.F.); (C.C.); (G.L.); (M.P.); (A.C.); (G.F.)
| | - Daniele Belvisi
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell’Università 30, 00185 Rome, Italy; (M.C.); (D.B.); (A.M.); (V.B.); (G.F.); (C.C.); (G.L.); (M.P.); (A.C.); (G.F.)
- IRCSS Neuromed, Via Atinense 18, 86077 Pozzilli, Italy
| | - Isabella Berardelli
- Department of Neurosciences, Mental Health and Sensory Organs, Faculty of Medicine and Psychology, Suicide Prevention Centre, Sant’Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1035-1039, 00185 Rome, Italy;
| | - Annalisa Maraone
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell’Università 30, 00185 Rome, Italy; (M.C.); (D.B.); (A.M.); (V.B.); (G.F.); (C.C.); (G.L.); (M.P.); (A.C.); (G.F.)
| | - Viola Baione
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell’Università 30, 00185 Rome, Italy; (M.C.); (D.B.); (A.M.); (V.B.); (G.F.); (C.C.); (G.L.); (M.P.); (A.C.); (G.F.)
| | - Gina Ferrazzano
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell’Università 30, 00185 Rome, Italy; (M.C.); (D.B.); (A.M.); (V.B.); (G.F.); (C.C.); (G.L.); (M.P.); (A.C.); (G.F.)
| | - Carolina Cutrona
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell’Università 30, 00185 Rome, Italy; (M.C.); (D.B.); (A.M.); (V.B.); (G.F.); (C.C.); (G.L.); (M.P.); (A.C.); (G.F.)
| | - Giorgio Leodori
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell’Università 30, 00185 Rome, Italy; (M.C.); (D.B.); (A.M.); (V.B.); (G.F.); (C.C.); (G.L.); (M.P.); (A.C.); (G.F.)
- IRCSS Neuromed, Via Atinense 18, 86077 Pozzilli, Italy
| | - Massimo Pasquini
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell’Università 30, 00185 Rome, Italy; (M.C.); (D.B.); (A.M.); (V.B.); (G.F.); (C.C.); (G.L.); (M.P.); (A.C.); (G.F.)
| | - Antonella Conte
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell’Università 30, 00185 Rome, Italy; (M.C.); (D.B.); (A.M.); (V.B.); (G.F.); (C.C.); (G.L.); (M.P.); (A.C.); (G.F.)
- IRCSS Neuromed, Via Atinense 18, 86077 Pozzilli, Italy
| | - Giovanni Fabbrini
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell’Università 30, 00185 Rome, Italy; (M.C.); (D.B.); (A.M.); (V.B.); (G.F.); (C.C.); (G.L.); (M.P.); (A.C.); (G.F.)
- IRCSS Neuromed, Via Atinense 18, 86077 Pozzilli, Italy
| | - Giovanni Defazio
- Department of Medical Sciences and Public Health, University of Cagliari, SS 554 Bivio Sestu, 09042 Monserrato, Italy;
| | - Alfredo Berardelli
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell’Università 30, 00185 Rome, Italy; (M.C.); (D.B.); (A.M.); (V.B.); (G.F.); (C.C.); (G.L.); (M.P.); (A.C.); (G.F.)
- IRCSS Neuromed, Via Atinense 18, 86077 Pozzilli, Italy
- Correspondence:
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Marsili L, Bologna M, Jankovic J, Colosimo C. Long-term efficacy and safety of botulinum toxin treatment for cervical dystonia: a critical reappraisal. Expert Opin Drug Saf 2021; 20:695-705. [PMID: 33831328 DOI: 10.1080/14740338.2021.1915282] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Luca Marsili
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | - Matteo Bologna
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy.,IRCCS Neuromed, Pozzilli (IS), Italy
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Carlo Colosimo
- Department of Neurology, Santa Maria University Hospital, Terni, 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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Anandan C, Jankovic J. Botulinum Toxin in Movement Disorders: An Update. Toxins (Basel) 2021; 13:toxins13010042. [PMID: 33430071 PMCID: PMC7827923 DOI: 10.3390/toxins13010042] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/30/2020] [Accepted: 01/05/2021] [Indexed: 12/17/2022] Open
Abstract
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.
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Wojtasiewicz T, Butala A, Anderson WS. Dystonia. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Tyślerowicz M, Jost WH. Injection into the Longus Colli Muscle via the Thyroid Gland. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2019; 9:tre-09-718. [PMID: 31867133 PMCID: PMC6898894 DOI: 10.7916/tohm.v0.718] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/24/2019] [Indexed: 12/01/2022]
Abstract
Background Anterior forms of cervical dystonia are considered to be the most difficult to treat because of the deep cervical muscles that can be involved. Case Report We report the case of a woman with cervical dystonia who presented with anterior sagittal shift, which required injections through the longus colli muscle to obtain a satisfactory outcome. The approach via the thyroid gland was chosen. Discussion The longus colli muscle can be injected under electromyography (EMG), computed tomography (CT), ultrasonography (US), or endoscopy guidance. We recommend using both ultrasonography and electromyography guidance as excellent complementary techniques for injection at the C5-C6 level.
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Hirjak D, Kubera KM, Bienentreu S, Thomann PA, Wolf RC. [Antipsychotic-induced motor symptoms in schizophrenic psychoses-Part 1 : Dystonia, akathisia und parkinsonism]. DER NERVENARZT 2019; 90:1-11. [PMID: 30128734 DOI: 10.1007/s00115-018-0582-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Acute antipsychotic-induced movement disorders (AIMD) are clinically relevant since they are frequently associated with high subjective distress, and since over the long-term they can negatively impact treatment adherence of patients with schizophrenic psychoses. This review article summarizes the relevant studies on the prevalence, risk factors, prevention and treatment options and instruments for early prediction of acute AIMD in schizophrenic psychoses. The current evidence and treatment recommendations are divided into three main areas: acute dystonia, akathisia, and parkinsonism. For the treatment of acute dystonia trihexyphenidyl and biperiden have shown their efficacy. Considering pharmacological treatment of akathisia, there is some preliminary evidence for medication with lipophilic beta-receptor blockers (propranolol and pindolol), clonidine, benzodiazepines, mianserin, mirtazapine und trazodone. The treatment options for drug-induced parkinsonism include reduction or switching from one antipsychotic to another with a lower affinity for dopamine D2 receptors, amantadine or in the regular administration of anticholinergic drugs. In conclusion, acute AIMD is easily to recognize but is not always effectively and durably treated. Early recognition and treatment of acute AIMD could be associated with improved treatment outcomes.
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Affiliation(s)
- D Hirjak
- Zentralinstitut für Seelische Gesundheit, Klinik für Psychiatrie und Psychotherapie, Medizinische Fakultät Mannheim, Universität Heidelberg, J5, 68159, Mannheim, Deutschland.
| | - K M Kubera
- Zentrum für Psychosoziale Medizin, Klinik für Allgemeine Psychiatrie, Universität Heidelberg, Heidelberg, Deutschland
| | - S Bienentreu
- Fachklinik für Psychiatrie und Psychotherapie, MARIENBORN GmbH, Zülpich, Deutschland
| | - P A Thomann
- Zentrum für Psychosoziale Medizin, Klinik für Allgemeine Psychiatrie, Universität Heidelberg, Heidelberg, Deutschland
- Zentrum für Seelische Gesundheit, Gesundheitszentrum Odenwaldkreis, Erbach, Deutschland
| | - R C Wolf
- Zentrum für Psychosoziale Medizin, Klinik für Allgemeine Psychiatrie, Universität Heidelberg, Heidelberg, Deutschland
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Camargo CHF, Teive HAG. Use of botulinum toxin for movement disorders. Drugs Context 2019; 8:212586. [PMID: 31258617 PMCID: PMC6586173 DOI: 10.7573/dic.212586] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/23/2019] [Accepted: 05/23/2019] [Indexed: 01/04/2023] Open
Abstract
The term movement disorders encompasses all disorders hypokinetic and hyperkinetic, which were previously known as extrapyramidal syndromes. With the definition of movement disorders and their diagnostic criteria and classifications, new studies for therapeutics could be performed. New drugs were launched, functional neurosurgery was developed, and the introduction of botulinum toxin (BoNT) for hyperkinesias was introduced. BoNT is an important therapy for dystonia, tics, myoclonus, and tremors. The aim of this review is to present the new and well-established uses of BoNT for movement disorders.
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Affiliation(s)
- Carlos Henrique Ferreira Camargo
- Neurological Diseases Group, Graduate Program of Internal Medicine, Internal Medicine Department, Hospital de Clínicas, Federal University of Paraná, Curitiba, PR, Brazil
| | - Hélio Afonso Ghizoni Teive
- Neurological Diseases Group, Graduate Program of Internal Medicine, Internal Medicine Department, Hospital de Clínicas, Federal University of Paraná, Curitiba, PR, Brazil.,Movement Disorders Unit, Neurology Service, Internal Medicine Department, Hospital de Clínicas, Federal University of Paraná, Curitiba, PR, Brazil
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14
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Mittal SO, Lenka A, Jankovic J. Cervical dystonia: an update on therapeutics. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1613978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Shivam Om Mittal
- , Parkinson's Disease and Movement Disorders Clinic, Cleveland Clinic, Abu Dhabi, UAE
| | - Abhishek Lenka
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Joseph Jankovic
- Department of Neurology, Baylor College of Medicine, Parkinson’s Disease Center and Movement Disorders Clinic, Houston, TX, USA
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Odorfer TM, Malzahn U, Matthies C, Heuschmann PU, Volkmann J. Pallidal neurostimulation versus botulinum toxin injections in the treatment of cervical dystonia: protocol of a randomized, sham-controlled trial (StimTox-CD). Neurol Res Pract 2019; 1:2. [PMID: 33324868 PMCID: PMC7650073 DOI: 10.1186/s42466-019-0007-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 01/20/2019] [Indexed: 11/10/2022] Open
Abstract
Background Selective peripheral denervation via botulinum neurotoxin injections into dystonic muscles is the first-line treatment for cervical dystonia. Pallidal neurostimulation is a potent alternative, but currently restricted to patients failing on neurotoxin therapy. As botulinum neurotoxin is partially effective but often unsatisfactory in a relevant proportion of patients, earlier neurostimulation might be advantageous in providing stable symptom control and preventing disability. This trial intends to demonstrate, that pallidal neurostimulation is superior to neurotoxin injections in best clinical practice for controlling the symptoms of cervical dystonia and that it is safe in patients with a partial therapy response to peripheral denervation. We hypothesize a better outcome in everyday functioning and health-related quality of life of neurostimulated patients. Methods We aim to recruit 66 cervical dystonia patients into a double-blind comparison of pallidal neurostimulation versus botulinum neurotoxin type A. Eligible patients need ≥25% motor symptom reduction 4 weeks after a neurotoxin test injection, but are willing to undergo DBS surgery due to unsatisfactory symptom control. All participants will be implanted with a DBS system, and randomized into 2 groups: First group will receive effective neurostimulation and saline injections into dystonic muscles. Second group is treated with regular neurotoxin injections and undergoes a sham-stimulation. Primary outcome is the change in TWSTRS total score between baseline and 6 months of therapy. Secondary outcome parameters are corresponding changes in TWSTRS motor score, Tsui score, CDQ-24 and SF-36. Safety will be assessed by frequency and severity of reported adverse events. Statistical analysis includes intention-to-treat and per protocol populations, analysis based on imputation of missing values and analysis adjusting for differences in baseline TWSTRS. After 6 months of blinded treatment all patients will receive open-label neurostimulation and neurotoxin treatment as needed, and are followed up 48 weeks after randomization. Perspective We will assess if pallidal neurostimulation is a safe and effective alternative to selective peripheral denervation by botulinum toxin injections in cervical dystonia, which may be offered earlier in the course of disease based on patient preference. A positive study outcome would influence future treatment guidelines of cervical dystonia. Trial registration EudraCT registration number: 2016-001378-13.
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Affiliation(s)
- Thorsten M Odorfer
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Uwe Malzahn
- Clinical Trial Center, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Cordula Matthies
- Department of Neurosurgery, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Peter U Heuschmann
- Clinical Trial Center, University Hospital Würzburg, 97080 Würzburg, Germany.,Institute of Clinical Epidemiology and Biometry, University of Würzburg, Comprehensive Heart Failure Center, University of Würzburg, 97080 Würzburg, Germany
| | - Jens Volkmann
- Department of Neurology, University Hospital Würzburg, 97080 Würzburg, Germany
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16
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Tailor the pharmacological management of childhood dystonia to meet the needs of each child. DRUGS & THERAPY PERSPECTIVES 2018. [DOI: 10.1007/s40267-018-0495-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Abstract
Dystonia is one of the most frequent movement disorders in childhood. It can impede normal motor development and cause significant motor disability. The diagnostic evaluation of childhood dystonia is challenging due to the phenotypic variability and heterogeneous etiologies. Evidence to guide the diagnostic evaluation and treatment is limited. Assessment is primarily directed by clinical history and distinctive examination findings. Neuroimaging is typically necessary to evaluate for acquired or complex inherited dystonias. A trial of levodopa can be both diagnostic and therapeutic in children with dopa-responsive dystonia. However, for the majority of children with early-onset dystonia, treatment is symptomatic with varying efficacy. There is a paucity of therapeutic trials for childhood dystonia and most treatment recommendations are consensus or expert opinion driven. This review summarizes the available evidence and guidelines on the diagnostic evaluation and pharmacological treatment of childhood-onset dystonia and provides practical frameworks to approach both issues based on best evidence.
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Relja M, Miletić V. When movement disorders hurt: Addressing pain in hyperkinetic disorders. Parkinsonism Relat Disord 2017; 44:110-113. [PMID: 29111426 DOI: 10.1016/j.parkreldis.2017.08.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 08/08/2017] [Indexed: 11/29/2022]
Abstract
Pain is an important nonmotor symptom in movement disorders. Dystonia is a hyperkinetic movement disorder characterized by involuntary, sustained or intermittent muscle contractions causing abnormal movements, postures or both. Contrary to common views the nonmotor symptoms are present in dystonia patients. Pain is a prevailing feature of cervical dystonia (CD), the most common form of focal dystonia. The mechanism of pain in CD remains mostly unknown, but there are growing evidence that it could not be only the consequence of muscle hyperactivity. We have shown that botulinum toxin (BoNT) produced pain relief before muscle relaxation and that effect on pain relief lasted longer than the effect on motor improvement. More and more data suggest that pain relief could be attributed to the direct effect of BoNT type A on central nervous system. Pain, depression, and anxiety have been shown to be significant determinants of QoL in focal dystonia patients. Routine clinical examination in patients with dystonia should include evaluation of motor as well as non-motor symptoms. Selective rating assessment should be used in clinical practice to quantify pain. Specific assessment of pain is important to determine the effect of BoNT as the most effective treatment in focal dystonia.
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Affiliation(s)
- Maja Relja
- Referral Center for Movement Disorders, Department of Neurology, University Hospital Center Zagreb, Medical School University of Zagreb, 10000 Zagreb, Croatia.
| | - Vladimir Miletić
- Referral Center for Movement Disorders, Department of Neurology, University Hospital Center Zagreb, Medical School University of Zagreb, 10000 Zagreb, Croatia
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Contarino MF, Van Den Dool J, Balash Y, Bhatia K, Giladi N, Koelman JH, Lokkegaard A, Marti MJ, Postma M, Relja M, Skorvanek M, Speelman JD, Zoons E, Ferreira JJ, Vidailhet M, Albanese A, Tijssen MAJ. Clinical Practice: Evidence-Based Recommendations for the Treatment of Cervical Dystonia with Botulinum Toxin. Front Neurol 2017; 8:35. [PMID: 28286494 PMCID: PMC5323428 DOI: 10.3389/fneur.2017.00035] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 01/25/2017] [Indexed: 12/14/2022] Open
Abstract
Cervical dystonia (CD) is the most frequent form of focal dystonia. Symptoms often result in pain and functional disability. Local injections of botulinum neurotoxin are currently the treatment of choice for CD. Although this treatment has proven effective and is widely applied worldwide, many issues still remain open in the clinical practice. We performed a systematic review of the literature on botulinum toxin treatment for CD based on a question-oriented approach, with the aim to provide practical recommendations for the treating clinicians. Key questions from the clinical practice were explored. Results suggest that while the beneficial effect of botulinum toxin treatment on different aspects of CD is well established, robust evidence is still missing concerning some practical aspects, such as dose equivalence between different formulations, optimal treatment intervals, treatment approaches, and the use of supportive techniques including electromyography or ultrasounds. Established strategies to prevent or manage common side effects (including excessive muscle weakness, pain at injection site, dysphagia) and potential contraindications to this treatment (pregnancy and lactation, use of anticoagulants, neurological comorbidities) should also be further explored.
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Affiliation(s)
- Maria Fiorella Contarino
- Department of Neurology, Haga Teaching Hospital, The Hague, Netherlands; Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands
| | - Joost Van Den Dool
- Department of Neurology AB 51, University Medical Centre Groningen, Groningen, Netherlands; ACHIEVE Centre of Expertise, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
| | - Yacov Balash
- Movement Disorders Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kailash Bhatia
- Sobell Department, Institute of Neurology, National Hospital for Neurology, University College London , London , UK
| | - Nir Giladi
- Movement Disorders Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Johannes H Koelman
- Department of Neurology/Clinical Neurophysiology, Academic Medical Center , Amsterdam , Netherlands
| | - Annemette Lokkegaard
- Department of Neurology, Copenhagen University Hospital Bispebjerg , Copenhagen , Denmark
| | - Maria J Marti
- Department of Neurology, Hospital Clinic i Universitari, Institut D'Investigacio Biomedica August Pi i Sunyer (IDIBAPS), CIBERNED , Barcelona , Spain
| | - Miranda Postma
- Department of Neurology/Clinical Neurophysiology, Academic Medical Center , Amsterdam , Netherlands
| | - Maja Relja
- Movement Disorders Center, Department of Neurology, Clinical Medical Center School of Medicine, Zagreb University , Zagreb , Croatia
| | - Matej Skorvanek
- Department of Neurology, P. J. Safarik University, Kosice, Slovakia; Department of Neurology, University Hospital of L. Pasteur, Kosice, Slovakia
| | - Johannes D Speelman
- Department of Neurology/Clinical Neurophysiology, Academic Medical Center , Amsterdam , Netherlands
| | - Evelien Zoons
- Department of Neurology/Clinical Neurophysiology, Academic Medical Center , Amsterdam , Netherlands
| | - Joaquim J Ferreira
- Clinical Pharmacology Unit, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon , Lisbon , Portugal
| | - Marie Vidailhet
- Sorbonne University, UPMC Paris-6, Paris, France; Brain and Spine Institute - ICM, Centre for Neuroimaging Research - CENIR, UPMC UMR 1127, Paris, France; INSERM U 1127, Paris, France; CNRS UMR 7225, Team Control of Normal and Abnormal Movement, Paris, France; Department of Neurology, Salpêtriere Hospital, AP-HP, Paris, France
| | - Alberto Albanese
- Department of Neurology, Humanitas Research Hospital, Milano, Italy; Department of Neurology, Università Cattolica del Sacro Cuore, Milano, Italy
| | - Marina A J Tijssen
- Department of Neurology AB 51, University Medical Centre Groningen , Groningen , Netherlands
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Pirio Richardson S, Wegele AR, Skipper B, Deligtisch A, Jinnah HA. Dystonia treatment: Patterns of medication use in an international cohort. Neurology 2017; 88:543-550. [PMID: 28077492 DOI: 10.1212/wnl.0000000000003596] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 11/08/2016] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To determine the frequency of medication use in patients with dystonia enrolled in an international biorepository study. METHODS In a cross-sectional analysis, we included 2,026 participants enrolled at 37 sites in the United States, Canada, Europe, and Australia through Project 1 of the Dystonia Coalition, an international biorepository study. The primary aim was to assess the frequency of medication classes recommended for treating patients with dystonia, and the secondary aim was to compare characteristics (disease type, age, sex, duration of disease, comorbid conditions, severity). RESULTS Querying the database for the presence of any medication for dystonia used (includes both injectable and oral therapy), we found 73% using medications (n = 1,488) and 27% using no dystonia medications (n = 538). Furthermore, 61% of the total sample used botulinum toxin (BoNT) therapy alone or in combination. Differences were found in medication use patterns by dystonia type, with the lowest oral medication use in focal dystonia and highest use in generalized dystonia; by region, with highest BoNT therapy rate reported in Italy and the lowest in the Northeast region of the United States; and by focal dystonia subtype, with highest BoNT therapy alone in blepharospasm and spasmodic dysphonia (49%) and lowest in other cranial dystonia (32%). CONCLUSIONS The majority of patients with dystonia enrolled in the Dystonia Coalition Project 1 were using medications to treat their dystonia. Overall, a complex picture of medication use patterns emerged, with factors such as region, disease duration, type of dystonia, disease severity, and psychiatric comorbidities all playing a significant role.
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Affiliation(s)
- Sarah Pirio Richardson
- From the Departments of Neurology (S.P.R., A.R.W., A.D.) and Family and Community Medicine (B.S.), University of New Mexico Health Sciences Center, Albuquerque; and Departments of Neurology, Human Genetics, and Pediatrics (H.A.J.), Emory University School of Medicine, Atlanta, GA.
| | - Ashley R Wegele
- From the Departments of Neurology (S.P.R., A.R.W., A.D.) and Family and Community Medicine (B.S.), University of New Mexico Health Sciences Center, Albuquerque; and Departments of Neurology, Human Genetics, and Pediatrics (H.A.J.), Emory University School of Medicine, Atlanta, GA
| | - Betty Skipper
- From the Departments of Neurology (S.P.R., A.R.W., A.D.) and Family and Community Medicine (B.S.), University of New Mexico Health Sciences Center, Albuquerque; and Departments of Neurology, Human Genetics, and Pediatrics (H.A.J.), Emory University School of Medicine, Atlanta, GA
| | - Amanda Deligtisch
- From the Departments of Neurology (S.P.R., A.R.W., A.D.) and Family and Community Medicine (B.S.), University of New Mexico Health Sciences Center, Albuquerque; and Departments of Neurology, Human Genetics, and Pediatrics (H.A.J.), Emory University School of Medicine, Atlanta, GA
| | - H A Jinnah
- From the Departments of Neurology (S.P.R., A.R.W., A.D.) and Family and Community Medicine (B.S.), University of New Mexico Health Sciences Center, Albuquerque; and Departments of Neurology, Human Genetics, and Pediatrics (H.A.J.), Emory University School of Medicine, Atlanta, GA
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Kongsaengdao S, Maneeton B, Maneeton N. Quality of life in cervical dystonia after treatment with botulinum toxin A: a 24-week prospective study. Neuropsychiatr Dis Treat 2017; 13:127-132. [PMID: 28138245 PMCID: PMC5237598 DOI: 10.2147/ndt.s116325] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE This study aimed to identify possible improvements in disease-specific health-related quality of life (HRQoL) after multiple injections of botulinum toxin A over 24 weeks in Thai cervical dystonia (CD) patients. MATERIALS AND METHODS A 24-week prospective study comparing HRQoL of Thai CD patients before and after multiple injections of botulinum toxin A at 3-month intervals was performed. Disease-specific HRQoL was assessed by using the Cervical Dystonia Impact Profile-58 questionnaire (CDIP-58) and the Craniocervical Dystonia Questionnaire-24 (CDQ-24). General HRQoL was assessed by using the Medical Outcomes' 36-Item Short Form Health Survey (SF-36) and the EuroQoL 5-dimension questionnaire (EQ-5D). All the assessments were performed before and after the 24-week treatment period. RESULTS A total of 20 CD patients were enrolled in this study from April to December 2011. CDIP-58 and CDQ-24 scores, which assess disease-specific HRQoL, showed a significant improvement after 24 weeks of treatment by botulinum toxin A (P<0.001). However, EQ-5D and SF-36 scores, which assess general HRQoL, showed no significant improvement after the treatment (P>0.05). CONCLUSION CD patients' disease-specific HRQoL improved after being treated with multiple botulinum toxin A injections. However, general HRQoL was not improved.
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Affiliation(s)
- Subsai Kongsaengdao
- Division of Neurology, Department of Medicine, Rajvithi Hospital, Department of Medical Services, Public Health Ministry, Bangkok, Thailand; Department of Medicine, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Benchalak Maneeton
- Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Thailand
| | - Narong Maneeton
- Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Thailand
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Camargos S, Cardoso F. Understanding dystonia: diagnostic issues and how to overcome them. ARQUIVOS DE NEURO-PSIQUIATRIA 2016; 74:921-936. [DOI: 10.1590/0004-282x20160140] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 07/07/2016] [Indexed: 08/30/2023]
Abstract
ABSTRACT The diagnosis and treatment of dystonia are challenging. This is likely due to gaps in the complete understanding of its pathophysiology, lack of animal models for translational studies, absence of a consistent pathological substrate and highly variable phenotypes and genotypes. The aim of this review article is to provide an overview of the clinical, neurophysiological and genetic features of dystonia that can help in the identification of this movement disorder, as well as in the differential diagnosis of the main forms of genetic dystonia. The variation of penetrance, age of onset, and topographic distribution of the disease in carriers of the same genetic mutation indicates that other factors – either genetic or environmental – might be involved in the development of symptoms. The growing knowledge of cell dysfunction in mutants may give insights into more effective therapeutic targets.
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van den Dool J, Tijssen M, Koelman J, Engelbert R, Visser B. Determinants of disability in cervical dystonia. Parkinsonism Relat Disord 2016; 32:48-53. [DOI: 10.1016/j.parkreldis.2016.08.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 07/26/2016] [Accepted: 08/12/2016] [Indexed: 11/29/2022]
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Wang L, Zhu L, Luan R, Wang L, Fu J, Wang X, Sui L. Analyzing gene expression profiles in dilated cardiomyopathy via bioinformatics methods. ACTA ACUST UNITED AC 2016; 49:e4897. [PMID: 27737314 PMCID: PMC5064772 DOI: 10.1590/1414-431x20164897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 07/28/2016] [Indexed: 11/22/2022]
Abstract
Dilated cardiomyopathy (DCM) is characterized by ventricular dilatation, and it is a
common cause of heart failure and cardiac transplantation. This study aimed to
explore potential DCM-related genes and their underlying regulatory mechanism using
methods of bioinformatics. The gene expression profiles of GSE3586 were downloaded
from Gene Expression Omnibus database, including 15 normal samples and 13 DCM
samples. The differentially expressed genes (DEGs) were identified between normal and
DCM samples using Limma package in R language. Pathway enrichment analysis of DEGs
was then performed. Meanwhile, the potential transcription factors (TFs) and
microRNAs (miRNAs) of these DEGs were predicted based on their binding sequences. In
addition, DEGs were mapped to the cMap database to find the potential small molecule
drugs. A total of 4777 genes were identified as DEGs by comparing gene expression
profiles between DCM and control samples. DEGs were significantly enriched in 26
pathways, such as lymphocyte TarBase pathway and androgen receptor signaling pathway.
Furthermore, potential TFs (SP1, LEF1, and NFAT) were identified, as well as
potential miRNAs (miR-9, miR-200 family, and miR-30 family). Additionally, small
molecules like isoflupredone and trihexyphenidyl were found to be potential
therapeutic drugs for DCM. The identified DEGs (PRSS12 and FOXG1), potential TFs, as
well as potential miRNAs, might be involved in DCM.
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Affiliation(s)
- Liming Wang
- Emergency Department, The Second Affiliated Hospital of Xi'an, Jiaotong University, Xi'an, China
| | - L Zhu
- Department of Emergency Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - R Luan
- Medical Department, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - L Wang
- Department of Emergency Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - J Fu
- Emergency Department, The Second Affiliated Hospital of Xi'an, Jiaotong University, Xi'an, China
| | - X Wang
- Department of Emergency Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - L Sui
- Department of Emergency Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
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Padberg M, de Bruijn SFTM, de Haan RJ, Tavy DLJ. Treatment of Chronic Tension-Type Headache with Botulinum Toxin: A Double-Blind, Placebo-Controlled Clinical Trial. Cephalalgia 2016; 24:675-80. [PMID: 15265057 DOI: 10.1111/j.1468-2982.2004.00738.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Botulinum toxin is increasingly advocated as effective treatment in chronic tension-type headache. We conducted a randomized, placebo-controlled clinical trial to prove efficacy of botulinum toxin in chronic tension-type headache. Patients were randomly assigned to receive botulinum toxin (maximum 100 units) or placebo (saline) in muscles with increased tenderness. After 12 weeks there was no significant difference between the two treatment groups in decrease of headache intensity on VAS (-3.5 mm, 95% confidence interval (CI) -20 to +13), mean number of headache days (-7%; 95% CI -20 to +4), headache hours per day (-1.4%; 95% CI -3.9 to +1.1), days on which symptomatic treatment was taken (-1.9%; 95% CI -11 to +7) and number of analgesics taken per day (-0.01; 95% CI -0.25-0.22). There was no significant difference in patient's assessment of improvement after week 4, 8 and 12. Botulinum toxin was not proven effective in treatment of chronic tension-type headache. Increased muscle tenderness might not be as important in pathophysiology of chronic tension-type headache as hitherto believed.
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Affiliation(s)
- M Padberg
- Department of Neurology and Clinical Neurophysiology, Leyenburg Hospital, The Hague, The Netherlands
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Marion MH, Humberstone M, Grunewald R, Wimalaratna S. British Neurotoxin Network recommendations for managing cervical dystonia in patients with a poor response to botulinum toxin. Pract Neurol 2016; 16:288-95. [PMID: 26976927 PMCID: PMC4975836 DOI: 10.1136/practneurol-2015-001335] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2016] [Indexed: 11/24/2022]
Abstract
Botulinum toxin (BoNT) injections are an effective treatment for cervical dystonia. Approximately 20% of patients eventually stop BoNT treatment, mostly because of treatment failure. These recommendations review the different therapeutic interventions for optimising the treatment in secondary poor responder patients. Immunoresistance has become less common over the years, but the diagnosis has to be addressed with a frontalis test or an Extensor Digitorum Brevis test. In case of immunoresistance to BoNT-A, we discuss the place the different therapeutic options (BoNT-A holidays, BoNT-B injections, alternative BoNT-A injections, deep brain stimulation). When poor responders are not immunoresistant, they benefit from reviewing (1) injections technique with electromyography or ultrasound guidance, (2) muscles selection and (3) dose of BoNT. In addition, in both scenarios, a holistic approach including drug treatment, retraining and psychological support is valuable in the management of these complex and severe cervical dystonia.
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Affiliation(s)
| | - Miles Humberstone
- Department of Neurology, Nottingham University Hospitals, Nottingham, UK Department of Neurology, United Lincolnshire Hospitals, Lincoln, UK
| | - Richard Grunewald
- Department of Neurology, Sheffield Teaching Hospitals NHS FT, Sheffield, UK
| | - Sunil Wimalaratna
- Department of Neurology, Kettering General Hospital NHS Foundation Trust, Kettering, UK
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Dutta SR, Passi D, Singh M, Singh P, Sharma S, Sharma A. Botulinum toxin the poison that heals: A brief review. Natl J Maxillofac Surg 2016; 7:10-16. [PMID: 28163472 PMCID: PMC5242063 DOI: 10.4103/0975-5950.196133] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Botulinum neurotoxins, causative agents of botulism in humans, are produced by Clostridium botulinum, an anaerobic spore-former Gram-positive bacillus. Botulinum neurotoxin poses a major bioweapon threat because of its extreme potency and lethality; its ease of production, transport, and misuse; and the need for prolonged intensive care among affected persons. This paper aims at discussing botulinum neurotoxin, its structure, mechanism of action, pharmacology, its serotypes and the reasons for wide use of type A, the various indications and contraindications of the use of botulinum neurotoxin and finally the precautions taken when botulinum neurotoxin is used as a treatment approach. We have searched relevant articles on this subject in various medical databases including Google Scholar, PubMed Central, ScienceDirect, Wiley Online Library, Scopus, and Copernicus. The search resulted in more than 2669 articles, out of which a total of 187 were reviewed. However, the review has been further constricted into only 54 articles as has been presented in this manuscript keeping in mind the page limitation and the limitation to the number of references. A single gram of crystalline toxin, evenly dispersed and inhaled, can kill more than one million people. The basis of the phenomenal potency of botulinum toxin (BT) is enzymatic; the toxin is a zinc proteinase that cleaves neuronal vesicle-associated proteins responsible for acetylcholine release into the neuromuscular junction. A fascinating aspect of BT research in recent years has been the development of the most potent toxin into a molecule of significant therapeutic utility. It is the first biological toxin which is licensed for the treatment of human diseases. The present review focuses on both warfare potential as well as medical uses of botulinum neurotoxin.
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Affiliation(s)
- Shubha Ranjan Dutta
- Department of Oral and Maxillofacial Surgery, MB Kedia Dental College, Birgunj, Nepal
| | - Deepak Passi
- Department of Oral and Maxillofacial Surgery, ESIC Dental College and Hospital, New Delhi, India
| | - Mahinder Singh
- Department of Oral and Maxillofacial Surgery, Uttaranchal Dental and Medical Research Institute, Dehradun, Uttarakhand, India
| | - Purnima Singh
- Department of Physiology, MB Kedia Dental College, Birgunj, Nepal
| | - Sarang Sharma
- Department of Conservative Dentistry and Endodontics, ESIC Dental College and Hospital, New Delhi, India
| | - Abhimanyu Sharma
- Department of Conservative Dentistry and Endodontics, ESIC Dental College and Hospital, New Delhi, India
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Dressler D, Altenmueller E, Bhidayasiri R, Bohlega S, Chana P, Chung TM, Frucht S, Garcia-Ruiz PJ, Kaelin A, Kaji R, Kanovsky P, Laskawi R, Micheli F, Orlova O, Relja M, Rosales R, Slawek J, Timerbaeva S, Warner TT, Saberi FA. Strategies for treatment of dystonia. J Neural Transm (Vienna) 2015; 123:251-8. [PMID: 26370676 DOI: 10.1007/s00702-015-1453-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 09/01/2015] [Indexed: 12/01/2022]
Abstract
Treatment of dystonias is generally symptomatic. To produce sufficient therapy effects, therefore, frequently a multimodal and interdisciplinary therapeutic approach becomes necessary, combining botulinum toxin therapy, deep brain stimulation, oral antidystonic drugs, adjuvant drugs and rehabilitation therapy including physiotherapy, occupational therapy, re-training, speech therapy, psychotherapy and sociotherapy. This review presents the recommendations of the IAB-Interdisciplinary Working Group for Movement Disorders Special Task Force on Interdisciplinary Treatment of Dystonia. It reviews the different therapeutic modalities and outlines a strategy to adapt them to the dystonia localisation and severity of the individual patient. Hints to emerging and future therapies will be given.
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Affiliation(s)
- Dirk Dressler
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany.
| | - Eckart Altenmueller
- Institute of Music Physiology and Musicians' Medicine, Hanover University of Music, Drama and Media, Hannover, Germany
| | - Roongroj Bhidayasiri
- Chulalongkorn Centre for Excellence on Parkinson's Disease and Related Disorders, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Saeed Bohlega
- Department of Neurology, King Faisal Specialist Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Pedro Chana
- Centro de Estudios de Trastornos del Movimiento, University of Santiago, Santiago de Chile, Chile
| | - Tae Mo Chung
- Hospital Sao Joaquim Beneficencia Portuguesa, Sao Paulo, Brazil
| | - Steven Frucht
- Department of Neurology, Mount Sinai Medical Center, New York, NY, USA
| | | | - Alain Kaelin
- Neurocentro della Svizzera Italiana, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Ryuji Kaji
- Department of Neurology, University of Tokushima, Tokushima, Japan
| | - Petr Kanovsky
- Department of Neurology, Palacky University, Olomouc, Czech Republic
| | - Rainer Laskawi
- Department of Ear-, Nose and Throat, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Federico Micheli
- Department of Neurology, Hospital de Clínicas José de San Martín, University of Buenos Aires, Buenos Aires, Argentina
| | | | - Maja Relja
- Department of Neurology, University of Zagreb, Zagreb, Croatia
| | - Raymond Rosales
- Department of Neurology, University of Santo Tomas, Manila, Philippines
| | - Jaroslaw Slawek
- Department of Neurological-Psychiatric Nursing, Medical University of Gdansk, Gdansk, Poland
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Del Sorbo F, Albanese A. Botulinum neurotoxins for the treatment of focal dystonias: Review of rating tools used in clinical trials. Toxicon 2015; 107:89-97. [PMID: 26365917 DOI: 10.1016/j.toxicon.2015.09.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 08/26/2015] [Accepted: 09/08/2015] [Indexed: 12/14/2022]
Abstract
Botulinum neurotoxins (BoNTs) are used to achieve therapeutic benefit in focal dystonia. An expert panel recently reviewed published evidence on the efficacy of BoNTs for the treatment of focal dystonias and produced recommendations for clinical practice. Another panel reviewed the clinimetric properties of rating scales for dystonia and produced recommendations for current usage and future directions. Considering that the strength of evidence derives not only from the quality of the study design, but also from usage of validated outcome measures, we combined the information provided by these two recent reviews and assessed the appropriateness of the rating instruments used in clinical trials on BoNT treatment in focal dystonia. Data sources included all the publications on BoNT treatment for focal dystonias reviewed by the recent evidence-based analysis. We reviewed all rating instruments used to assess primary and secondary outcome following BoNT treatment. The publications were allocated into five topics according to the focal dystonia type reviewed in the meta-analysis: blepharospasm, oromandibular dystonia, cervical dystonia, upper limb dystonia, and laryngeal dystonia. For each topic, papers were divided, according to the terminology used in the meta-analysis, into placebo-controlled, active comparator and methodological or uncontrolled. For each topic we identified the rating tools used in each study class and annotated which were the mostly used in each focal dystonia type. Outcome measures included tools related to motor and non-motor features, such as pain and depression, and functional as well as health-related quality of life features. Patient- and investigator-reported outcomes were also included. Rating instruments were classified as recommended, suggested, listed or not included, based on recommendations produced by the rating scale task force. Both primary and secondary outcome measures were assessed. As a final step we compared current practice, as summarized by the meta-analysis, with the recommendations of the rating scales panel. For blepharospasm, three placebo-controlled trials used suggested scales, one active-comparator study used a recommended scale and three active-comparator studies used suggested scales. For oromandibular dystonia, one placebo-controlled study used a suggested scale. For cervical dystonia, six placebo-controlled trials used a recommended scale, four active-comparator trials used a recommended scale and one active-comparator study used a suggested scale. For upper limb and laryngeal dystonia, no trial used validated instruments. Appropriately designed studies should be based on recommended rating instruments. Therapeutic trials not using clinimetrically tested rating measures do not provide sufficient information on efficacy of BoNT treatment, even if the study design is robust. Further research is needed to develop and validate new tools to assess all types of focal dystonia and to apply them in prospective placebo-controlled clinical trials.
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Affiliation(s)
| | - Alberto Albanese
- Istituto di Neurologia, Istituto Clinico Humanitas, Rozzano, Milano, Italy; Istituto di Neurologia, Università Cattolica del Sacro Cuore, 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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Asha SE, Kerr A, Jones K, McAlpine A. Benztropine for the relief of acute non-traumatic neck pain (wry neck): a randomised trial. Emerg Med J 2014; 32:616-9. [PMID: 25414475 DOI: 10.1136/emermed-2014-204317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 11/01/2014] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The aim of this study was to determine the effect of intra-muscular benztropine on pain and range of motion in patients presenting to the emergency department with acute, non-traumatic neck pain (wry neck). METHODS In this two-centre randomised, double-blind, placebo-controlled, parallel-group superiority trial, participants were allocated to receive 2 mg intramuscular benztropine or normal saline. Participants were aged 16-65 years, no history of neck disorders and no use of medication that cause dystonia. Randomisation was computer generated, with allocation concealment by opaque sequentially numbered sealed envelopes. Pain scores and neck range of motion were measured immediately before drug administration, and 30 min after. Pain scores, range of motion and adverse effects were compared between the groups. No funding was received. The trial was registered. RESULTS Thirty participants were enrolled, 15 randomised to placebo and 15 to benztropine. Pain scores at 30 min were lower in those allocated to benztropine, but the difference was neither statistically nor clinically significant (0.6 points, 95% CI -0.8 to 1.8, p=0.40). The range of motion of the cervical spine was greater in those receiving benztropine, but the differences were very small and not statistically significant. Adverse events were more common in those receiving benztropine. CONCLUSIONS Benztropine was ineffective for reducing pain or improving range of motion of the cervical spine in patients suffering from acute, non-traumatic neck pain, but frequently caused anticholinergic side effects. However, as the CI for the primary outcome included the minimum difference considered clinically significant, an important effect of benztropine cannot be ruled out. TRIAL REGISTRATION NUMBER ANZCTR#12612000354886.
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Affiliation(s)
- Stephen Edward Asha
- Emergency Department, St George Hospital, Sydney, New South Wales, Australia Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew Kerr
- Emergency Department, St George Hospital, Sydney, New South Wales, Australia
| | - Keryn Jones
- Emergency Department, St George Hospital, Sydney, New South Wales, Australia Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Ann McAlpine
- Emergency Department, The Sutherland Hospital, Sydney, New South Wales, Australia
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Pallidal neurostimulation in patients with medication-refractory cervical dystonia: a randomised, sham-controlled trial. Lancet Neurol 2014; 13:875-84. [PMID: 25127231 DOI: 10.1016/s1474-4422(14)70143-7] [Citation(s) in RCA: 226] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cervical dystonia is managed mainly by repeated botulinum toxin injections. We aimed to establish whether pallidal neurostimulation could improve symptoms in patients not adequately responding to chemodenervation or oral drug treatment. METHODS In this randomised, sham-controlled trial, we recruited patients with cervical dystonia from centres in Germany, Norway, and Austria. Eligible patients (ie, those aged 18-75 years, disease duration ≥3 years, Toronto Western Spasmodic Torticollis Rating Scale [TWSTRS] severity score ≥15 points) were randomly assigned (1:1) to receive active neurostimulation (frequency 180 Hz; pulse width 120 μs; amplitude 0·5 V below adverse event threshold) or sham stimulation (amplitude 0 V) by computer-generated randomisation lists with randomly permuted block lengths stratified by centre. All patients, masked to treatment assignment, were implanted with a deep brain stimulation device and received their assigned treatment for 3 months. Neurostimulation was activated in the sham group at 3 months and outcomes were reassessed in all patients after 6 months of active treatment. Treating physicians were not masked. The primary endpoint was the change in the TWSTRS severity score from baseline to 3 months, assessed by two masked dystonia experts using standardised videos, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00148889. FINDINGS Between Jan 19, 2006, and May 29, 2008, we recruited 62 patients, of whom 32 were randomly assigned to neurostimulation and 30 to sham stimulation. Outcome data were recorded in 60 (97%) patients at 3 months and 56 (90%) patients at 6 months. At 3 months, the reduction in dystonia severity was significantly greater with neurostimulation (-5·1 points [SD 5·1], 95% CI -7·0 to -3·5) than with sham stimulation (-1·3 [2·4], -2·2 to -0·4, p=0·0024; mean between-group difference 3·8 points, 1·8 to 5·8) in the intention-to-treat population. Over the course of the study, 21 adverse events (five serious) were reported in 11 (34%) of 32 patients in the neurostimulation group compared with 20 (11 serious) in nine (30%) of 30 patients in the sham-stimulation group. Serious adverse events were typically related to the implant procedure or the implanted device, and 11 of 16 resolved without sequelae. Dysarthria (in four patients assigned to neurostimulation vs three patients assigned to sham stimulation), involuntary movements (ie, dyskinesia or worsening of dystonia; five vs one), and depression (one vs two) were the most common non-serious adverse events reported during the course of the study. INTERPRETATION Pallidal neurostimulation for 3 months is more effective than sham stimulation at reducing symptoms of cervical dystonia. Extended follow-up is needed to ascertain the magnitude and stability of chronic neurostimulation effects before this treatment can be recommended as routine for patients who are not responding to conventional medical therapy. FUNDING Medtronic.
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Albanese A, Sorbo FD, Comella C, Jinnah HA, Mink JW, Post B, Vidailhet M, Volkmann J, Warner TT, Leentjens AFG, Martinez-Martin P, Stebbins GT, Goetz CG, Schrag A. Dystonia rating scales: critique and recommendations. Mov Disord 2014; 28:874-83. [PMID: 23893443 DOI: 10.1002/mds.25579] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 05/22/2013] [Indexed: 01/04/2023] Open
Abstract
Many rating scales have been applied to the evaluation of dystonia, but only few have been assessed for clinimetric properties. The Movement Disorders Society commissioned this task force to critique existing dystonia rating scales and place them in the clinical and clinimetric context. A systematic literature review was conducted to identify rating scales that have either been validated or used in dystonia. Thirty-six potential scales were identified. Eight were excluded because they did not meet review criteria, leaving 28 scales that were critiqued and rated by the task force. Seven scales were found to meet criteria to be "recommended": the Blepharospasm Disability Index is recommended for rating blepharospasm; the Cervical Dystonia Impact Scale and the Toronto Western Spasmodic Torticollis Rating Scale for rating cervical dystonia; the Craniocervical Dystonia Questionnaire for blepharospasm and cervical dystonia; the Voice Handicap Index (VHI) and the Vocal Performance Questionnaire (VPQ) for laryngeal dystonia; and the Fahn-Marsden Dystonia Rating Scale for rating generalized dystonia. Two "recommended" scales (VHI and VPQ) are generic scales validated on few patients with laryngeal dystonia, whereas the others are disease-specific scales. Twelve scales met criteria for "suggested" and 7 scales met criteria for "listed." All the scales are individually reviewed in the online information. The task force recommends 5 specific dystonia scales and suggests to further validate 2 recommended generic voice-disorder scales in dystonia. Existing scales for oromandibular, arm, and task-specific dystonia should be refined and fully assessed. Scales should be developed for body regions for which no scales are available, such as lower limbs and trunk.
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Affiliation(s)
- Alberto Albanese
- Istituto di Neurologia, Università Cattolica del Sacro Cuore, Milano, Italy; Neurologia I, Istituto Neurologico Carlo Besta, Milano, Italy.
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Contarino MF, Van Den Munckhof P, Tijssen MAJ, de Bie RMA, Bosch DA, Schuurman PR, Speelman JD. Selective peripheral denervation: comparison with pallidal stimulation and literature review. J Neurol 2013; 261:300-8. [PMID: 24257834 DOI: 10.1007/s00415-013-7188-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 10/25/2013] [Accepted: 11/07/2013] [Indexed: 11/30/2022]
Abstract
Patients with cervical dystonia who are non-responders to Botulinum toxin qualify for surgery. Selective peripheral denervation (Bertrand's procedure, SPD) and deep brain stimulation of the globus pallidus (GPi-DBS) are available surgical options. Although peripheral denervation has potential advantages over DBS, the latter is nowadays more commonly performed. We describe the long-term outcome of selective peripheral denervation as compared with GPi-DBS, along with the findings of literature review. Twenty patients with selective peripheral denervation and 15 with GPi-DBS were included. Tsui scale, a visual analogue scale, and the global outcome score of the Toronto Western Spasmodic Torticollis Rating Scale were used to define a "combined global surgical outcome". The "combined global surgical outcome" for patients with selective peripheral denervation or pallidal stimulation was respectively "bad" for 65 and 13.3 %, "fair-to-good" for 30 and 26.7 %, and "marked" improvement for 5 and 60 % (p < 0.001). Improvement on visual analogue scale (p < 0.002), global outcome score (p < 0.002), and Tsui score (p < 0.000) was larger for the pallidal stimulation group. Seventy-five percent of patients with selective peripheral denervation and 60 % of patients with pallidal stimulation reported side effects. Seven patients with selective peripheral denervation successively underwent GPi-DBS, with a further significant improvement in the Tsui score (-48.6 ± 17.4 %). GPi-DBS is to be preferred to selective peripheral denervation for the treatment of cervical dystonia because it produces larger benefit, even if it can have more potentially severe complications. GPi-DBS is also a valid alternative in case of failure of SPD.
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Affiliation(s)
- Maria Fiorella Contarino
- Department of Neurology/Clinical Neurophysiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands,
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Woopen C, Pauls KAM, Koy A, Moro E, Timmermann L. Early application of deep brain stimulation: Clinical and ethical aspects. Prog Neurobiol 2013; 110:74-88. [DOI: 10.1016/j.pneurobio.2013.04.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 04/10/2013] [Accepted: 04/16/2013] [Indexed: 11/25/2022]
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van den Dool J, Visser B, Koelman JHTM, Engelbert RHH, Tijssen MAJ. Cervical dystonia: effectiveness of a standardized physical therapy program; study design and protocol of a single blind randomized controlled trial. BMC Neurol 2013; 13:85. [PMID: 23855591 PMCID: PMC3718643 DOI: 10.1186/1471-2377-13-85] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 06/20/2013] [Indexed: 11/18/2022] Open
Abstract
Background Cervical dystonia is characterized by involuntary muscle contractions of the neck and abnormal head positions that affect daily life activities and social life of patients. Patients are usually treated with botulinum toxin injections into affected neck muscles to relief pain and improve control of head postures. In addition, many patients are referred for physical therapy to improve their ability to perform activities of daily living. A recent review on allied health interventions in cervical dystonia showed a lack of randomized controlled intervention studies regarding the effectiveness of physical therapy interventions. Methods/design The (cost-) effectiveness of a standardized physical therapy program compared to regular physical therapy, both as add-on treatment to botulinum toxin injections will be determined in a multi-centre, single blinded randomized controlled trial with 100 cervical dystonia patients. Primary outcomes are disability in daily functioning assessed with the disability subscale of the Toronto Western Spasmodic Torticollis Rating Scale. Secondary outcomes are pain, severity of dystonia, active range of motion of the head, quality of life, anxiety and depression. Data will be collected at baseline, after six months and one year by an independent blind assessor just prior to botulinum toxin injections. For the cost effectiveness, an additional economic evaluation will be performed with the costs per quality adjusted life-year as primary outcome parameter. Discussion Our study will provide new evidence regarding the (cost-) effectiveness of a standardized, tailored physical therapy program for patients with cervical dystonia. It is widely felt that allied health interventions, including physical therapy, may offer a valuable supplement to the current therapeutic options. A positive outcome will lead to a greater use of the standardized physical therapy program. For the Dutch situation a positive outcome implies that the standardized physical therapy program forms the basis for a national treatment guideline for cervical dystonia. Trial registration Number Dutch Trial registration (Nederlands Trial Register): NTR3437
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Affiliation(s)
- Joost van den Dool
- Department of Neurology, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands
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[Applications of botulinum toxin in Neurology]. Med Clin (Barc) 2013; 141:33-6. [PMID: 23434466 DOI: 10.1016/j.medcli.2012.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 12/16/2012] [Accepted: 12/20/2012] [Indexed: 11/24/2022]
Abstract
At present, botulinum toxin (BT) is one of the most fundamental available drugs in Neurology, only comparable with levodopa. BT is currently used in those entities characterized by excessive muscle contraction, including dystonia and spasticity. In addition, BT has been used to control pain associated with increased muscle contraction in dystonia and spasticity, but also is useful to control chronic pain not associated with muscle contraction, such as chronic daily headache. Finally, BT is useful in sialorrhoea and bruxism. The mechanism of action is complex, mainly acting on terminal neuromuscular junction, but also exhibiting analgesic properties, probably through inhibition of pain neurotransmitters release.
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Hallett M, Albanese A, Dressler D, Segal KR, Simpson DM, Truong D, Jankovic J. Evidence-based review and assessment of botulinum neurotoxin for the treatment of movement disorders. Toxicon 2013; 67:94-114. [PMID: 23380701 DOI: 10.1016/j.toxicon.2012.12.004] [Citation(s) in RCA: 151] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 11/28/2012] [Accepted: 12/05/2012] [Indexed: 01/28/2023]
Abstract
Botulinum neurotoxin (BoNT) can be injected to achieve therapeutic benefit across a large range of clinical conditions. To assess the efficacy and safety of BoNT injections for the treatment of certain movement disorders, including blepharospasm, hemifacial spasm, oromandibular dystonia, cervical dystonia, focal limb dystonias, laryngeal dystonia, tics, and essential tremor, an expert panel reviewed evidence from the published literature. Data sources included English-language studies identified via MEDLINE, EMBASE, CINAHL, Current Contents, and the Cochrane Central Register of Controlled Trials. Evidence tables generated in the 2008 Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology (AAN) review of the use of BoNT for movement disorders were also reviewed and updated. The panel evaluated evidence at several levels, supporting BoNT as a class, the serotypes BoNT-A and BoNT-B, as well as the four individual commercially available formulations: abobotulinumtoxinA (A/Abo), onabotulinumtoxinA (A/Ona), incobotulinumtoxinA (A/Inco), and rimabotulinumtoxinB (B/Rima). The panel ultimately made recommendations for each therapeutic indication, based upon the strength of clinical evidence and following the AAN classification scale. For the treatment of blepharospasm, the evidence supported a Level A recommendation for BoNT-A, A/Inco, and A/Ona; a Level B recommendation for A/Abo; and a Level U recommendation for B/Rima. For hemifacial spasm, the evidence supported a Level B recommendation for BoNT-A and A/Ona, a Level C recommendation for A/Abo, and a Level U recommendation for A/Inco and B/Rima. For the treatment of oromandibular dystonia, the evidence supported a Level C recommendation for BoNT-A, A/Abo, and A/Ona, and a Level U recommendation for A/Inco and B/Rima. For the treatment of cervical dystonia, the published evidence supported a Level A recommendation for all four BoNT formulations. For limb dystonia, the available evidence supported a Level B recommendation for both A/Abo and A/Ona, but no published studies were identified for A/Inco or B/Rima, resulting in a Level U recommendation for these two formulations. For adductor laryngeal dystonia, evidence supported a Level C recommendation for the use of A/Ona, but a Level U recommendation was warranted for B/Rima, A/Abo, and A/Inco. For the treatment of focal tics, a Level U recommendation was warranted at this time for all four formulations. For the treatment of tremor, the published evidence supported a level B recommendation for A/Ona, but no published studies were identified for A/Abo, A/Inco, or B/Rima, warranting a Level U recommendation for these three formulations. Further research is needed to address evidence gaps and to evaluate BoNT formulations where currently there is insufficient or conflicting clinical data.
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Affiliation(s)
- Mark Hallett
- The George Washington University School of Medicine and Health Sciences, Ross Hall, Department of Neurology, 2300 Eye Street, NW Suite 713W, Washington, DC 20037, USA.
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Hong JS, Sathe GG, Niyonkuru C, Munin MC. Elimination of dysphagia using ultrasound guidance for botulinum toxin injections in cervical dystonia. Muscle Nerve 2012; 46:535-9. [PMID: 22987694 DOI: 10.1002/mus.23409] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Dysphagia is a common side effect after botulinum toxin injections for cervical dystonia, with an incidence of 10-40%, depending upon the study and dose used. METHODS Our study consisted of 5 preselected women who met criteria for cervical dystonia and subsequent dysphagia after electromyography (EMG)-guided injections. Injections were performed with ultrasound (US) imaging, and the effects on swallowing were examined. Separately, sternocleidomastoid (SCM) thickness in healthy controls and treated patients was measured. RESULTS There were 34 episodes of dysphagia over 98 injection sessions using EMG guidance for a cumulative rate of 34.7%. Using US plus EMG guidance, there was 0% dysphagia across 27 injection sessions. SCM thickness was <1.1 cm. CONCLUSION US combined with EMG guidance eliminated recurrent dysphagia after botulinum toxin treatment, possibly by keeping the injectate within the SCM.
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Affiliation(s)
- Justin S Hong
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, 201 Kaufmann Building, 3471 Fifth Avenue, Pittsburgh, Pennsylvania 15213, USA
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Thenganatt MA, Fahn S. Botulinum toxin for the treatment of movement disorders. Curr Neurol Neurosci Rep 2012; 12:399-409. [PMID: 22661378 DOI: 10.1007/s11910-012-0286-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
After botulinum toxin was initially used to treat strabismus in the 1970s, others started using it to treat movement disorders including blepharospasm, hemifacial spasm, cervical dystonia, spasmodic dysphonia, and oromandibular dystonia. It was discovered that botulinum toxin can be an effective treatment for focal movement disorders with limited side effects. Over the past three decades, various formulations of botulinum toxin have been developed and the therapeutic use of these toxins has expanded in movement disorders and beyond. We review the history and mechanism of action of botulinum toxin, as well as describe different formulations available and their potential therapeutic uses in movement disorders.
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Affiliation(s)
- Mary Ann Thenganatt
- Department of Neurology, College of Physicians and Surgeons, Columbia University, 710 West 168th Street, New York, NY 10032, USA.
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Abstract
OPINION STATEMENT Dystonia is characterized by repetitive twisting movements or abnormal postures due to involuntary muscle activity. When limited to a single body region it is called focal dystonia. Examples of focal dystonia include cervical dystonia (neck), blepharospasm (eyes), oromandibular dystonia, focal limb dystonia, and spasmodic dysphonia, which are discussed here. Once the diagnosis is established, the therapeutic plan is discussed with the patients. They are informed that there is no cure for dystonia and treatment is symptomatic. The main therapeutic option for treating focal dystonias is botulinum toxin (BoNT). There have been several attempts to characterize the procedure, the type of toxin, dosage, techniques, and combination with physical measures in each of the focal dystonia forms. The general treatment principles are similar. The affected muscles are injected at muscle sites based on evidence and experience using standard dosages based on the type of toxin used. The injections are repeated after 3 to 6 months based on the individual response duration. In the uncommon event of nonresponse with BoNT, the dose and site are reassessed. Oral drug treatment could be considered as an additional option. Once the condition is thought to be medically refractory, the opinion from the deep brain stimulation (DBS) team for the suitability of the patient for DBS is taken. The successful use of DBS in cervical dystonia has led to increased acceptance for trial in other forms of focal dystonias. DBS surgery in focal dystonias other than cervical is, however, still experimental. The patients may be offered the surgery with adequate explanation of the risks and benefits. Patient education and directing the patients towards dystonia support groups and relevant websites that provide scientific information may be useful for long-term compliance and benefit.
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Affiliation(s)
- Amit Batla
- The National Hospital for Neurology and Neurosurgery Queen Square, Box 13, London, WC1N 3BG, UK
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Rating scales for cervical dystonia: a critical evaluation of tools for outcome assessment of botulinum toxin therapy. J Neural Transm (Vienna) 2012; 120:487-96. [PMID: 22899277 PMCID: PMC3575559 DOI: 10.1007/s00702-012-0887-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2012] [Accepted: 07/08/2012] [Indexed: 10/28/2022]
Abstract
Botulinum neurotoxin is the therapy of choice for all forms of cervical dystonia (CD), but treatment regimens still vary considerably. The interpretation of treatment outcome is mainly based on the clinical experience and on the scientific value of the rating scales applied. The aim of this review is to describe the historical development of rating scales for the assessment of CD and to provide an appraisal of their advantages and drawbacks. The Tsui score and the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) have been widely employed in numerous clinical studies as specific instruments for CD. The obvious advantage of the Tsui score is its simplicity so that it can be easily implemented in clinical routine. The TWSTRS allows a more sophisticated assessment of functional features of CD, but only the Tsui score includes a rating for tremor. Other benefits of the TWSTRS are the disability and pain subscales, but despite its value in clinical trials, it might be too complex for routine clinical practice. None of the rating scales used at present has been rigorously tested for responsiveness to detect significant changes in clinical status after therapeutic interventions. Moreover, clinical data support a new classification of CD leading to a differentiation between head and neck subtypes. As the current rating scales are not able to cover all these aspects of the disorder, further research is needed to develop a valid and reliable instrument which considers the most current classification of CD.
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Delnooz CCS, van de Warrenburg BPC. Current and future medical treatment in primary dystonia. Ther Adv Neurol Disord 2012; 5:221-40. [PMID: 22783371 PMCID: PMC3388529 DOI: 10.1177/1756285612447261] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Dystonia is a hyperkinetic movement disorder, characterized by involuntary and sustained contractions of opposing muscles causing twisting movements and abnormal postures. It is often a disabling disorder that has a significant impact on physical and psychosocial wellbeing. The medical therapeutic armamentarium used in practice is quite extensive, but for many of these interventions formal proof of efficacy is lacking. Exceptions are the use of botulinum toxin in patients with cervical dystonia, some forms of cranial dystonia (in particular, blepharospasm) and writer's cramp; deep brain stimulation of the pallidum in generalized and segmental dystonia; and high-dose trihexyphenidyl in young patients with segmental and generalized dystonia. In order to move this field forward, we not only need better trials that examine the effect of current treatment interventions, but also a further understanding of the pathophysiology of dystonia as a first step to design and test new therapies that are targeted at the underlying biologic and neurophysiologic mechanisms.
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Affiliation(s)
- Cathérine C S Delnooz
- Radboud University Nijmegen Medical Centre, Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, the Netherlands
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Muscle selection for treatment of cervical dystonia with botulinum toxin--a systematic review. Parkinsonism Relat Disord 2012; 18:731-6. [PMID: 22575237 DOI: 10.1016/j.parkreldis.2012.04.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Revised: 03/30/2012] [Accepted: 04/04/2012] [Indexed: 12/19/2022]
Abstract
RATIONALE Cervical dystonia, also called spasmodic torticollis, is the most common form of (primary) dystonia. Intramuscular injections with botulinum toxin are the first line of treatment for cervical dystonia. To optimise the treatment response to botulinum toxin correct muscles should be selected. Clinical evaluation is important for muscle selection but the value of additional tests to identify dystonic muscles remains unclear. OBJECTIVE To evaluate all relevant literature regarding the best approach to select dystonic muscles for treatment with botulinum toxin. METHODS We conducted a systematic review of studies that had investigated methods of selecting muscles for treatment with botulinum toxin. In addition, we compared all prospective botulinum toxin trials using either clinical evaluation or polymyographic electromyography for muscle selection. RESULTS Forty relevant studies were included and polymyographic electromyography recordings were most often employed. In several studies, polymyographic electromyography revealed a different pattern of muscle involvement compared to that found during clinical evaluation. In one randomized controlled trial polymyographic electromyography significantly improved the outcome of botulinum toxin treatment. A limited number of studies used positron emission tomography -computed tomography imaging or frequency analysis of the electromyography signal to identify dystonic muscles but their effect on the outcome of treatment has never been studied. CONCLUSION Polymyographic electromyography may improve the outcome of botulinum toxin treatment in cervical dystonia, but evidence is limited and larger studies are needed.
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Zoons E, Dijkgraaf MGW, Dijk JM, van Schaik IN, Tijssen MA. Botulinum toxin as treatment for focal dystonia: a systematic review of the pharmaco-therapeutic and pharmaco-economic value. J Neurol 2012; 259:2519-26. [PMID: 22552527 PMCID: PMC3506193 DOI: 10.1007/s00415-012-6510-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 03/30/2012] [Accepted: 04/02/2012] [Indexed: 10/28/2022]
Abstract
Focal dystonia is a common, invalidating neurologic condition characterized by involuntary, sustained muscle contractions causing twisting movements and abnormal postures in one body part. Currently, botulinum toxin is the treatment of first choice. We performed a systematic review towards the pharmaco-therapeutic and pharmaco-economic value of botulinum toxin as treatment for focal dystonia, which yielded the following results. Botulinum toxin is the most effective treatment for reducing dystonic symptoms measured with dystonia-specific and general questionnaires, and pain in patients with focal dystonia. Seventy-one percent of patients with cervical dystonia had a reduction in neck pain compared to 12 % in placebo groups. Adverse events occur in 58 % of patients during treatment with botulinum toxin compared to 46 % treated with placebo. Especially dry mouth, neck weakness, dysphagia, and voice changes are common. Adverse events are usually mild and self-limiting. Health-related quality of life, measured with the SF-36 is 20-50 points lower in patients with focal dystonia compared to controls and the effect of botulinum toxin on health-related quality of life is unclear. Botulinum toxin treatment is expensive because the drug itself is expensive. Yearly costs for treating a patient with focal dystonia with botulinum toxin range from EUR 347 to EUR 3,633 and the gain in QALYs with BTX treatment is small. Focal dystonia impairs the productivity and the ability to work. At start of botulinum toxin treatment only 47-50 % was working. Botulinum toxin partly improves this. Overall, we conclude that botulinum toxin is an expensive drug with good effects. From a societal perspective, the costs may well weigh up to the regained quality of life. However, the available literature concerning costs, health-related quality of life and labor participation is very limited. An extensive cost-effectiveness study should be performed incorporating all these aspects.
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Affiliation(s)
- E Zoons
- Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands
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Truong D. Botulinum toxins in the treatment of primary focal dystonias. J Neurol Sci 2012; 316:9-14. [PMID: 22336699 DOI: 10.1016/j.jns.2012.01.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 01/05/2012] [Accepted: 01/19/2012] [Indexed: 11/18/2022]
Abstract
Focal dystonia, such as cervical dystonia, blepharospasm, oromandibular dystonia, laryngeal dystonia, and limb dystonia, is often observed in adult-onset primary dystonia syndromes that affect a specific area of the body and tend to have little or no spread. This review will examine the past, present, and future approaches to the treatment of focal dystonia. Botulinum toxin (BoNT) has emerged as the treatment of choice for the majority of focal dystonias. Currently four products are widely available commercially, three of BoNT/A type and one of BoNT/B type. Each has important pharmacological differences that give rise to markedly different dosing recommendations. The four approved BoNTs are safe and effective for treating focal dystonias, including long-term treatment. Adverse events are limited and transient and, for the most part, mild in severity. Potential problems with the use of BoNT agents are diffusion and neutralizing antibody formation; the latter can lead to treatment resistance. Because each BoNT product is developed from distinct purification and manufacturing procedures and has varying toxin complex size and structures, physicians need to be aware of these differences when choosing an agent.
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Affiliation(s)
- Daniel Truong
- Parkinson's and Movement Disorder Institute, 9940 Talbert Avenue, Suite 204, Fountain Valley, CA 92708, USA.
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Jenkins ME, Miyasaki JM, Suchowersky O. Movement Disorders. Neurology 2012. [DOI: 10.1007/978-0-387-88555-1_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Marvulli R, Ianieri G, Megna G, Lancioni G, Saggini R, Ranieri M, Cristella G, Megna M. Botulinum Toxin Type a in Cervical Dystonia. Int J Immunopathol Pharmacol 2012; 25:23S-28S. [PMID: 22652158 DOI: 10.1177/03946320120250s104] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- R. Marvulli
- Neuroscience and Sense Organs Department Physical Medicine and Rheabilitation Bari “Aldo Moro” University - Italy
| | - G. Ianieri
- Neuroscience and Sense Organs Department Physical Medicine and Rheabilitation Bari “Aldo Moro” University - Italy
| | - G. Megna
- Neuroscience and Sense Organs Department Physical Medicine and Rheabilitation Bari “Aldo Moro” University - Italy
| | - G. Lancioni
- Neuroscience and Sense Organs Department Physical Medicine and Rheabilitation Bari “Aldo Moro” University - Italy
| | - R. Saggini
- Department of Physical Medicine and Rehabilitation “G. D'annunzio” University - Chieti, Italy
| | - M. Ranieri
- Neuroscience and Sense Organs Department Physical Medicine and Rheabilitation Bari “Aldo Moro” University - Italy
| | - G. Cristella
- Osmairm Neuropsychomotor Rehabilitation Center Laterza (Ta) Italy
| | - M. Megna
- Neuroscience and Sense Organs Department Physical Medicine and Rheabilitation Bari “Aldo Moro” University - Italy
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