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Colucci F, Pugliatti M, Casetta I, Capone JG, Diozzi E, Sensi M, Tugnoli V. Idiopathic cervical dystonia and non-motor symptoms: a pilot case-control study on autonomic nervous system. Neurol Sci 2024; 45:629-638. [PMID: 37648939 PMCID: PMC10791952 DOI: 10.1007/s10072-023-07033-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 08/21/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Non-motor symptoms, such as sleep disturbances, fatigue, neuropsychiatric manifestations, cognitive impairment, and sensory abnormalities, have been widely reported in patients with idiopathic cervical dystonia (ICD). This study aimed to clarify the autonomic nervous system (ANS) involvement in ICD patients, which is still unclear in the literature. METHODS We conducted a pilot case-control study to investigate ANS in twenty ICD patients and twenty age-sex-matched controls. The Composite Autonomic System Scale 31 was used for ANS clinical assessment. The laser Doppler flowmetry quantitative spectral analysis, applied to the skin and recorded from indices, was used to measure at rest, after a parasympathetic activation (six deep breathing) and two sympathetic stimuli (isometric handgrip and mental calculation), the power of high-frequency and low-frequency oscillations, and the low-frequency/high-frequency ratio. RESULTS ICD patients manifested higher clinical dysautonomic symptoms than controls (p < 0.05). At rest, a lower high-frequency power band was detected among ICD patients than controls, reaching a statistically significant difference in the age group of ≥ 57-year-olds (p < 0.05). In the latter age group, ICD patients showed a lower low-frequency/high-frequency ratio than controls at rest (p < 0.05) and after mental calculation (p < 0.05). Regardless of age, during handgrip, ICD patients showed (i) lower low-frequency/high-frequency ratio (p < 0.05), (ii) similar increase of the low-frequency oscillatory component compared to controls, and (iii) stable high-frequency oscillatory component, which conversely decreased in controls. No differences between the two groups were detected during deep breathing. CONCLUSION ICD patients showed ANS dysfunction at clinical and neurophysiological levels, reflecting an abnormal parasympathetic-sympathetic interaction likely related to abnormal neck posture and neurotransmitter alterations.
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Affiliation(s)
- Fabiana Colucci
- Department of Neuroscience and Rehabilitation, University of Ferrara, Via Aldo Moro, 8, 44100, Ferrara, Italy.
- Department of Clinical Neurosciences, Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Maura Pugliatti
- Department of Neuroscience and Rehabilitation, University of Ferrara, Via Aldo Moro, 8, 44100, Ferrara, Italy
| | - Ilaria Casetta
- Department of Neuroscience and Rehabilitation, University of Ferrara, Via Aldo Moro, 8, 44100, Ferrara, Italy
| | - Jay Guido Capone
- Department of Neuroscience and Rehabilitation, Azienda Ospedaliero-Universitaria S, Anna, Ferrara, Italy
| | - Enrica Diozzi
- Department of Neuroscience and Rehabilitation, Azienda Ospedaliero-Universitaria S, Anna, Ferrara, Italy
| | - Mariachiara Sensi
- Department of Neuroscience and Rehabilitation, Azienda Ospedaliero-Universitaria S, Anna, Ferrara, Italy
| | - Valeria Tugnoli
- Department of Neuroscience and Rehabilitation, Azienda Ospedaliero-Universitaria S, Anna, Ferrara, Italy
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Long-term efficacy with deep brain stimulation of the globus pallidus internus in cervical dystonia: a retrospective monocentric study. Neurol Res Pract 2022; 4:48. [PMID: 36184607 PMCID: PMC9528120 DOI: 10.1186/s42466-022-00214-8] [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: 06/24/2022] [Accepted: 08/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cervical dystonia (CD) is characterized by involuntary contractions of the cervical muscles. Data on long-term effectiveness of deep brain stimulation (DBS) are rare. The aim of this study was to evaluate the longitudinal ten years treatment efficacy of DBS in the globus pallidus internus (GPI). METHODS A retrospective single-center data analysis was performed on patients with idiopathic CD, who were treated with GPI DBS for at least 10 years. TWSTR severity score and individual sub-items were compared between pre and post DBS surgery (n = 15) over time. RESULTS There was a significant and persistent positive effect regarding the severity of TWSTRS between the conditions immediately before and 1, 5, and 10 years after establishment of GPI DBS (mean difference: 6.6-7 ± 1.6). Patients with increasing CD complexity showed a poorer response to established treatment forms, such as injection of botulinum toxin and were thus DBS candidates. Especially a predominant torticollis was significantly improved by DBS. CONCLUSION GPI DBS is an effective procedure especially in severely affected patients with a positive 10-year outcome. It should be considered in more complex CD-forms or predominant torticollis.
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Lew MF, Hauser RA, Isaacson SH, Truong D, Patel AT, Brashear A, Ondo W, Maisonobe P, Dashtipour K, Bahroo L, Wietek S. AbobotulinumtoxinA provides flexibility for the treatment of cervical dystonia with 500 U/1 mL and 500 U/2 mL dilutions. Clin Park Relat Disord 2021; 5:100115. [PMID: 34888518 PMCID: PMC8636802 DOI: 10.1016/j.prdoa.2021.100115] [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: 05/12/2021] [Revised: 10/27/2021] [Accepted: 10/29/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Cervical dystonia (CD) is a neurologic movement disorder with potentially disabling effects and significant impact on quality of life of those affected. AbobotulinumtoxinA (aboBoNT-A) was initially approved for a dilution of 500 U/1 mL and subsequently for a dilution of 500 U/2 mL, providing flexibility for clinicians to treat CD. Here, we explore the safety and efficacy of the 500 U/2 mL dilution versus 500 U/1 mL dilution of aboBoNT-A in a retrospective analysis based on published clinical trial data. METHODS The safety and efficacy of aboBoNT-A in patients with CD was evaluated in three multicenter, double-blind, randomized, placebo-controlled trials and open-label extensions. Trials 1 (NCT00257660) and 2 (NCT00288509) evaluated the 500 U/1 mL dilution in 80 and 116 patients, respectively; Trial 3 (NCT01753310) evaluated the 500 U/2 mL dilution in 125 patients. RESULTS Comparison of the adjusted mean difference in TWSTRS total scores at Week 4 from baseline for aboBoNT-A in Trial 1 (-6.0; 95% CI, -10.8, -1.3), Trial 2 (-8.8; 95% CI, -12.9, -4.7), and Trial 3 (-8.7; 95% CI, -13.2, -4.2) showed similar, significant improvements. Dysphagia and muscle weakness patterns were comparable across the three trials, indicating that an increased dilution of aboBoNT-A does not result in an increased risk of diffusion-related adverse events. CONCLUSION The results of these trials show that aboBoNT-A is similarly efficacious using either dilution, with similar safety and tolerability across trials. Having the 500 U/1 mL and 500 U/2 mL dilution volumes available provides further flexibility in administration, benefiting patient care.
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Affiliation(s)
- Mark F. Lew
- Department of Neurology, Keck/University of Southern California School of Medicine, Los Angeles, CA 90033, USA
| | - Robert A. Hauser
- University of South Florida, Parkinson’s Disease and Movement Disorders Center of Excellence, Tampa, FL 33613, USA
| | - Stuart H. Isaacson
- Parkinson’s Disease and Movement Disorders Center of Boca Raton, Boca Raton, FL 33486, USA
| | - Daniel Truong
- The Parkinson and Movement Disorder Institute, Fountain Valley, CA 92708, USA
| | - Atul T. Patel
- Kansas City Bone and Joint Clinic, Overland Park, KS 66211, USA
| | - Allison Brashear
- Department of Neurology, University of California, Davis, Sacramento, CA 95816, USA
| | - William Ondo
- Methodist Neurological Institute, Houston, TX 77030, USA
| | | | - Khashayar Dashtipour
- Department of Neurology/Movement Disorders, Loma Linda University, Loma Linda, CA 92354, USA
| | - Laxman Bahroo
- Georgetown University Hospital, Pasquerilla Healthcare Center, Washington, DC 20007, USA
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Werner C, Loudovici-Krug D, Derlien S, Rakers F, Smolenski UC, Lehmann T, Best N, Günther A. Study protocol: multimodal physiotherapy as an add-on treatment to botulinum neurotoxin type A therapy for patients with cervical dystonia: DysPT-multi-a prospective, multicentre, single-blind, randomized, controlled study. Trials 2021; 22:740. [PMID: 34696821 PMCID: PMC8547107 DOI: 10.1186/s13063-021-05705-8] [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: 04/09/2021] [Accepted: 10/08/2021] [Indexed: 11/14/2022] Open
Abstract
Background Botulinum neurotoxin (BoNT) is currently the best therapeutic option in the treatment for cervical dystonia (CD). Additional treatments like physiotherapy (PT) may even improve the results of the BoNT injection with type A (BoNT-A), but there are no definite recommendations. In the last few years, some studies showed tendencies for PT as an adjuvant therapy to benefit. However, high-quality studies are required. Methods This study is a multicentre, randomized, single-blind, controlled trial to demonstrate the effectiveness of a multimodal PT program compared to a nonspecific cupping therapy, additionally to the BoNT-A therapy. Two hundred participants will be assigned into the multimodal PT plus BoNT intervention arm or the BoNT plus cupping arm using randomization. Primary endpoint is the total Score of Toronto Western Spasmodic Rating Scale (TWSTRS). Secondary endpoints are the mobility of the cervical spine (range of motion, ROM), the TWSTRS subscales, and the quality of life (measured by questionnaires: CDQ-24 and SF-36). Patients will be single-blind assessed every 3 months according to their BoNT injection treatment over a period of 9 months. Discussion The study aims to determine the effectiveness and therefore potential benefit of an additional multimodal physiotherapy for standardized treatment with BoNT-A in patients with CD, towards the BoNT-therapy alone. This largest randomized controlled trial in this field to date is intended to generate missing evidence for therapy guidelines. Trial registration The study was registered in the German Clinical Study Register before the start of the patient recruitment (DRKS00020411; date: 21.01.2020).
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Affiliation(s)
- Christian Werner
- Department of Neurology, St. Georg Klinikum Eisenach, Eisenach, Germany
| | | | - Steffen Derlien
- Institute for Physiotherapy, Jena University Hospital, Jena, Germany
| | - Florian Rakers
- Hans-Berger-Department of Neurology, Jena University Hospital, Jena, Germany
| | | | - Thomas Lehmann
- Institute of Medical Statistics, Jena University Hospital, Jena, Germany
| | - Norman Best
- Institute for Physiotherapy, Jena University Hospital, Jena, Germany
| | - Albrecht Günther
- Hans-Berger-Department of Neurology, Jena University Hospital, Jena, Germany
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Ghit A, Assal D, Al-Shami AS, Hussein DEE. GABA A receptors: structure, function, pharmacology, and related disorders. J Genet Eng Biotechnol 2021; 19:123. [PMID: 34417930 PMCID: PMC8380214 DOI: 10.1186/s43141-021-00224-0] [Citation(s) in RCA: 109] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/08/2021] [Indexed: 02/03/2023]
Abstract
Background γ-Aminobutyric acid sub-type A receptors (GABAARs) are the most prominent inhibitory neurotransmitter receptors in the CNS. They are a family of ligand-gated ion channel with significant physiological and therapeutic implications. Main body GABAARs are heteropentamers formed from a selection of 19 subunits: six α (alpha1-6), three β (beta1-3), three γ (gamma1-3), three ρ (rho1-3), and one each of the δ (delta), ε (epsilon), π (pi), and θ (theta) which result in the production of a considerable number of receptor isoforms. Each isoform exhibits distinct pharmacological and physiological properties. However, the majority of GABAARs are composed of two α subunits, two β subunits, and one γ subunit arranged as γ2β2α1β2α1 counterclockwise around the center. The mature receptor has a central chloride ion channel gated by GABA neurotransmitter and modulated by a variety of different drugs. Changes in GABA synthesis or release may have a significant effect on normal brain function. Furthermore, The molecular interactions and pharmacological effects caused by drugs are extremely complex. This is due to the structural heterogeneity of the receptors, and the existence of multiple allosteric binding sites as well as a wide range of ligands that can bind to them. Notably, dysfunction of the GABAergic system contributes to the development of several diseases. Therefore, understanding the relationship between GABAA receptor deficits and CNS disorders thus has a significant impact on the discovery of disease pathogenesis and drug development. Conclusion To date, few reviews have discussed GABAA receptors in detail. Accordingly, this review aims to summarize the current understanding of the structural, physiological, and pharmacological properties of GABAARs, as well as shedding light on the most common associated disorders.
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Affiliation(s)
- Amr Ghit
- Department of Biology and Biotechnology, University of Pavia, Pavia, Italy. .,Department of Biotechnology, Institute of Graduate Studies and Research (IGSR), Alexandria University, Alexandria, Egypt.
| | - Dina Assal
- Department of Biotechnology, American University in Cairo (AUC), Cairo, Egypt
| | - Ahmed S Al-Shami
- Department of Biotechnology, Institute of Graduate Studies and Research (IGSR), Alexandria University, Alexandria, Egypt.,Department of Zoology, Faculty of Science, Alexandria University, Alexandria, Egypt
| | - Diaa Eldin E Hussein
- Animal Health Research Institute (AHRI), Agricultural Research Center (ARC), Port of Alexandria, Alexandria, Egypt
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Carbone F, Ellmerer P, Ritter M, Spielberger S, Mahlknecht P, Hametner E, Hussl A, Hotter A, Granata R, Seppi K, Boesch S, Poewe W, Djamshidian A. Impaired Inhibitory Control of Saccadic Eye Movements in Cervical Dystonia: An Eye-Tracking Study. Mov Disord 2021; 36:1246-1250. [PMID: 33416199 PMCID: PMC8247854 DOI: 10.1002/mds.28486] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/24/2020] [Accepted: 12/16/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The pathophysiology of cervical dystonia is still unclear. Recent evidence points toward a network disorder affecting several brain areas. The objective of this study was to assess the saccadic inhibition as a marker of corticostriatal function in cervical dystonia. METHODS We recruited 31 cervical dystonia patients and 17 matched healthy controls. Subjects performed an overlap prosaccade, an antisaccade, and a countermanding task on an eye tracker to assess automatic visual response and response inhibition. RESULTS Cervical dystonia patients made more premature saccades (P = 0.041) in the overlap prosaccade task and more directional errors in the antisaccade task (P = 0.011) and had a higher rate of failed inhibition in the countermanding task (P = 0.001). CONCLUSIONS The results suggest altered saccadic inhibition in cervical dystonia, possibly as a consequence of dysfunctional corticostriatal networks. Further studies are warranted to confirm whether these abnormalities are affected by the available therapies and whether this type of impairment is found in other focal dystonias. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Federico Carbone
- Department of NeurologyMedical University InnsbruckInnsbruckAustria
| | - Philipp Ellmerer
- Department of NeurologyMedical University InnsbruckInnsbruckAustria
| | - Marcel Ritter
- Interactive Graphics and Simulation GroupUniversity of InnsbruckInnsbruckAustria
| | | | | | - Eva Hametner
- Department of NeurologyMedical University InnsbruckInnsbruckAustria
| | - Anna Hussl
- Department of NeurologyMedical University InnsbruckInnsbruckAustria
| | - Anna Hotter
- Department of NeurologyMedical University InnsbruckInnsbruckAustria
| | - Roberta Granata
- Department of NeurologyMedical University InnsbruckInnsbruckAustria
| | - Klaus Seppi
- Department of NeurologyMedical University InnsbruckInnsbruckAustria
| | - Sylvia Boesch
- Department of NeurologyMedical University InnsbruckInnsbruckAustria
| | - Werner Poewe
- Department of NeurologyMedical University InnsbruckInnsbruckAustria
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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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Patel AT, Lew MF, Dashtipour K, Isaacson S, Hauser RA, Ondo W, Maisonobe P, Wietek S, Rubin B, Brashear A. Sustained functional benefits after a single set of injections with abobotulinumtoxinA using a 2-mL injection volume in adults with cervical dystonia: 12-week results from a randomized, double-blind, placebo-controlled phase 3b study. PLoS One 2021; 16:e0245827. [PMID: 33524060 PMCID: PMC7850472 DOI: 10.1371/journal.pone.0245827] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 01/07/2021] [Indexed: 11/18/2022] Open
Abstract
Cervical dystonia (CD) is primarily treated with botulinum toxin, at intervals of ≥ 12 weeks. We present efficacy, patient-reported outcomes (PROs), and safety in adults with CD at the last available visit after a single set of abobotulinumtoxinA (aboBoNT-A) injections versus placebo using 500 U in a 2-mL injection volume. In this 12-week, randomized, double-blind trial, patients were ≥ 18 years of age with primary idiopathic CD, had a Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) total score ≥ 20, and TWSTRS-Severity subscale score > 10 at baseline. Patients (N = 134) were randomized (2:1) to aboBoNT-A (n = 89) or placebo (n = 45), with aboBoNT-A patients treated with 500 units (U) if toxin-naïve, and 250 to 500 U based on previous onabotulinumtoxinA dose if non-naïve. Endpoints included total TWSTRS, Pain Numeric Rating Scale (NRS-Pain; 24-hour), Treatment Satisfaction Questionnaire for Medication, and other PROs for pain, depression, and global health. Results are for the intent-to-treat population, with "Week 12" (Wk12) comprising the last available post-baseline assessment (end-of-study or early withdrawal). Mean TWSTRS total scores improved from 42.5 at baseline to 35.4 at Wk12 with aboBoNT-A and 42.4 to 40.4 with placebo (treatment difference: -4.8; 95% confidence interval [CI]: -8.5, -1.1; p = 0.011). At Wk12, mean (95% CI) change from baseline in NRS-Pain was -1.0 (-1.59, -0.45) for aboBoNT-A and -0.2 (-0.96, 0.65) for placebo. AboBoNT-A demonstrated numeric improvements in other PROs. More aboBoNT-A-treated patients than patients receiving placebo reported being at least "somewhat satisfied" with treatment (60.4% vs 42.2%, respectively), symptom relief (57.0% vs 40.0%), and time for treatment to work (55.8% vs 33.3%). No new adverse events were reported. Results indicate that in patients with CD, treatment with aboBoNT-A using a 2-mL injection provided sustained improvement in the TWSTRS total score and patient-perceived benefits up to 12 weeks. Trial registration: Clinicaltrials.gov Identified: NCT01753310.
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Affiliation(s)
- Atul T. Patel
- Kansas City Bone and Joint Clinic, Overland Park, KS, United States of America
| | - Mark F. Lew
- Department of Neurology, Keck/University of Southern California School of Medicine, Los Angeles, CA, United States of America
| | - Khashayar Dashtipour
- Department of Neurology/Movement Disorders, Loma Linda University, Loma Linda, CA, United States of America
| | - Stuart Isaacson
- Parkinson’s Disease and Movement Disorders Center of Boca Raton, Boca Raton, FL, United States of America
| | - Robert A. Hauser
- University of South Florida Health Byrd Institute, Parkinson’s Disease and Movement Disorders Center of Excellence, Tampa, FL, United States of America
| | - William Ondo
- Methodist Neurological Institute, Houston, TX, United States of America
| | | | - Stefan Wietek
- Formerly of Ipsen, Cambridge, MA, United States of America
- * E-mail:
| | - Bruce Rubin
- Formerly of Ipsen, Cambridge, MA, United States of America
| | - Allison Brashear
- University of California Davis School of Medicine, Sacramento, CA, United States of America
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9
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Abstract
Introduction: Symptoms of cervical dystonia (CD) can vary in severity and cause significant pain. OnabotulinumtoxinA is an approved treatment for CD. This study assessed health-related quality of life (HRQoL) in patients with CD who received multiple onabotulinumtoxinA treatments. Methods: This prospective, observational standard-of-care study was conducted at multiple neurology centers in Québec, Canada. Patients reported the health impact of CD using the Cervical Dystonia Impact Profile (CDIP)-58, before and after up to eight onabotulinumtoxinA treatments. Other measures included the Cervical Dystonia Severity Rating Scale by physician, employment status using the Work Productivity Questionnaire and pain using the Pain Numeric Rating Scale (PNRS). Adverse events (AEs) were recorded. Results: Sixty-two patients were enrolled (safety population, n = 61; modified efficacy population, n = 58). Participants were mostly females who were employed; most (79.3%) had torticollis. In all, 21/62 patients (33.9%) discontinued the study. At the final visit, there was a statistically significant (p < 0.001) improvement in all eight CDIP-58 subscales, particularly head and neck symptoms (−31.0) and psychosocial functioning (−28.2). Employment increased from baseline (55%) to the end of the study (64%), and there was improvement in work productivity. There was a significant (p < 0.0001) reduction in pain measured by the PNRS, from −0.5 post-treatment 1 to −2.4 at end of study. AEs (neck pain, muscular weakness, dysphagia, nausea) were consistent with onabotulinumtoxinA use. Conclusion: These real-world data indicate that after repeated, long-term use, onabotulinumtoxinA continues to be a safe and effective treatment for CD, improving HRQoL and work productivity.
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Druzhinina OA, Zhukova NG, Shperling LP. [Non-motor conditions in patients with cervical dystonia]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:7-13. [PMID: 33244951 DOI: 10.17116/jnevro20201201017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To study non-motor conditions in people with diabetes in comparison with patients with cervicalgia. MATERIAL AND METHODS The study included 170 people. The main group consisted of 120 respondents with cervical dystonia (CD) aged 27 to 82 years. The diagnosis of CD was based on the Clinical guidelines for the diagnosis and treatment of dystonia adopted by the European Federation of Neurological Societies, the Society for Movement Disorders and the All-Russian Society of Neurologists. The control group included 50 patients, aged 25 to 82 years, with pain in the cervical spine due to muscle-tonic and myofascial syndromes. A Visual Analogue scale, the Hospital Anxiety and Depression Scale (HADS), the Multidimensional Fatigue Inventory (MFI-20), the Pittsburgh Sleep Quality Index (PSQI) were administered to study the asthenic syndrome in all patients. RESULTS AND CONCLUSION Pain, anxiety, depression, asthenic syndrome, insomnia are statistically significant non-motor conditions in patients with CD compared with patients with cervicalgia. CD significantly affects the physical and psychological aspects, worsening the quality of life of these patients. The following gender differences are identified: in women with CD, non-motor disorders (anxiety, depression, general and physical asthenia, insomnia) are significantly more pronounced and the quality of life is significantly reduced compared to men with CD. For the successful treatment of CD, a multimodal approach is needed that provides the treatment of not only motor, but also non-motor disorders. Early detection and treatment of comorbid conditions is an important step in the treatment of CD.
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Affiliation(s)
| | - N G Zhukova
- Siberian State Medical University, Tomsk, Russia
| | - L P Shperling
- Regional Center for Extrapyramidal Diseases with Botulinum Therapy Room, Novosibirsk, Russia
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11
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Rodrigues FB, Duarte GS, Marques RE, Castelão M, Ferreira J, Sampaio C, Moore AP, Costa J. Botulinum toxin type A therapy for cervical dystonia. Cochrane Database Syst Rev 2020; 11:CD003633. [PMID: 33180963 PMCID: PMC8106615 DOI: 10.1002/14651858.cd003633.pub4] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND This is an update of a Cochrane Review first published in 2005. Cervical dystonia is the most common form of focal dystonia, and is a highly disabling movement disorder, characterised by involuntary, usually painful, head posturing. Currently, botulinum toxin type A (BtA) is considered the first line therapy for this condition. OBJECTIVES To compare the efficacy, safety, and tolerability of BtA versus placebo, in people with cervical dystonia. SEARCH METHODS We searched Cochrane Movement Disorders' Trials Register, CENTRAL, MEDLINE, Embase, reference lists of articles, and conference proceedings in July 2020. All elements of the search, with no language restrictions, were last run in July 2020. SELECTION CRITERIA Double-blind, parallel, randomised, placebo-controlled trials (RCTs) of BtA versus placebo in adults with cervical dystonia. DATA COLLECTION AND ANALYSIS Two review authors independently assessed records, selected included studies, extracted data using a paper pro forma, and evaluated the risk of bias. We resolved disagreements by consensus or by consulting a third review author. We performed meta-analyses using a random-effects model, for the comparison of BtA versus placebo, to estimate pooled effects and corresponding 95% confidence intervals (95% CI). We performed preplanned subgroup analyses according to BtA dose used, the BtA formulation used, and the use (or not) of guidance for BtA injections. The primary efficacy outcome was improvement in cervical dystonia-specific impairment. The primary safety outcome was the proportion of participants with any adverse event. MAIN RESULTS We included nine RCTs, with moderate, overall risk of bias, that included 1144 participants with cervical dystonia. Seven studies excluded participants with poorer responses to BtA treatment, therefore, including an enriched population with a higher probability of benefiting from this therapy. Only one trial was independently funded. All RCTs evaluated the effect of a single BtA treatment session, using doses from 150 U to 500 U of onabotulinumtoxinA (Botox), 120 U to 240 U of incobotulinumtoxinA (Xeomin), and 250 U to 1000 U of abobotulinumtoxinA (Dysport). BtA resulted in a moderate to large improvement from the participant's baseline clinical status, assessed by the investigators, with a mean reduction of 8.09 points in the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS total score) at week four after injection (95% CI 6.22 to 9.96; I² = 0%) compared to placebo. This corresponded, on average, to a 18.4% improvement from baseline. The mean difference (MD) in TWSTRS pain subscore at week four was 2.11 (95% CI 1.38 to 2.83; I² = 0%) compared to placebo. Overall, both participants and clinicians reported an improvement of subjective clinical status. It was unclear if dropouts due to adverse events differed (risk ratio (RR) 2.51; 95% CI 0.42 to 14.94; I² = 0%) However, BtA treatment increased the risk of experiencing an adverse event (R) 1.23; 95% CI 1.05 to 1.43; I² = 28%). Neck weakness (14%; RR 3.40; 95% CI 1.19 to 9.71; I² = 15%), dysphagia (11%; RR 3.19; 95% CI 1.79 to 5.70; I² = 0%), and diffuse weakness or tiredness (8%; RR 1.80; 95% CI 1.10 to 2.95; I² = 0%) were the most common treatment-related adverse events. Treatment with BtA resulted in a decreased risk of dropouts. We have moderate certainty in the evidence across all of the aforementioned outcomes, with the exception of subjective assessment and tolerability, in which we have high confidence in the evidence. We found no evidence supporting the existence of a clear dose-response relationship between BtA and improvement in cervical dystonia-specific impairment, a destinction between BtA formulations, or a variation with use of EMG-guided injection for efficacy outcomes. Due to clinical heterogeneity, we did not pool health-related quality of life data, duration of clinical effect, or the development of secondary non-responsiveness. AUTHORS' CONCLUSIONS We are moderately certain in the evidence that a single BtA treatment session resulted in a clinically relevant reduction of cervical dystonia-specific impairment, and pain, and highly certain that it is well tolerated, compared with placebo. There is moderate-certainty evidence that people treated with BtA are at an increased risk of developing adverse events, most notably, dysphagia, neckweakness and diffuse weakness or tiredness. There are no data from RCTs evaluating the effectiveness and safety of repeated BtA injection cycles. There is no evidence from RCTs to allow us to draw definitive conclusions on the optimal treatment intervals and doses, the usefulness of guidance techniques for injection, the impact on quality of life, or the duration of treatment effect.
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Affiliation(s)
- Filipe B Rodrigues
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Gonçalo S Duarte
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Raquel E Marques
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Ophthalmology University Clinic, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Mafalda Castelão
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Joaquim Ferreira
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | | | | | - João Costa
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
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Emotional well-being and pain could be a greater determinant of quality of life compared to motor severity in cervical dystonia. J Neural Transm (Vienna) 2020; 128:305-314. [PMID: 33146753 PMCID: PMC7969693 DOI: 10.1007/s00702-020-02274-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 10/19/2020] [Indexed: 11/23/2022]
Abstract
Non-motor symptoms (NMS) occur in patients with cervical dystonia (CD) but with variable frequencies and impact on health-related quality of life (HRQoL). To define non-motor and motor profiles and their respective impact on HRQoL in CD patients using the newly validated Dystonia Non-Motor Symptoms Questionnaire (DNMSQuest). In an observational prospective multicentre case–control study, we enrolled 61 patients with CD and 61 age- and sex-matched healthy controls (HC) comparing demographic data, motor and non-motor symptoms and HRQoL measurements. 95% CD patients reported at least one NMS. Mean total NMS score was significantly higher in CD patients (5.62 ± 3.33) than in HC (1.74 ± 1.52; p < 0.001). Pain, insomnia and stigma were the most prevalent NMS and HRQoL was significantly impaired in CD patients compared to HC. There was strong correlation of NMS burden with HRQoL (CDQ-24: r = 0.72, EQ-5D: r = − 0.59; p < 0.001) in CD patients. Regression analysis between HRQoL and NMS suggested that emotional well-being (standardized beta = − 0.352) and pain (standardized beta = − 0.291) had a major impact on HRQoL while, in contrast motor severity had no significant impact in this model. Most NMS with the exception of pain, stigma and ADL did not correlate with motor severity. NMS are highly prevalent in CD patients and occur independent of age, sex, disease duration, duration of botulinum neurotoxin therapy and socio-economic status. Specific NMS such as emotional well-being and pain have a major impact on HRQoL and are more relevant than motor severity.
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Abstract
Background: Myoclonus-Dystonia (M-D) is a pleiotropic neuropsychiatric disorder of variable penetrance. Pathogenic variants in SGCE, a maternally imprinted gene, are the most frequent known genetic cause of M-D. The population prevalence of SGCE-linked M-D is unknown, the pathogenicity of SGCE variants identified in patients with M-D may be indeterminant, and SGCE variants predicted to be deleterious by in silico analysis may appear in patients undergoing whole-exome or whole-genome sequencing for seemingly unrelated disorders. The Genome Aggregation Database (gnomAD) v2 provides variant data on 125,748 exomes and 15,708 genomes from unrelated individuals sequenced as part of various disease-specific and population genetic studies. Methods: SGCE variants included in the gnomAD v2 dataset were analyzed with Combined Annotation Dependent Depletion (CADD), and database for nonsynonymous single nucleotide polymorphisms’ functional predictions (dbNSFP). We determined the frequency of annotated SGCE variants, ranked by scores of deleteriousness, within the gnomAD v2 dataset. Deleteriousness scores were compared to a subset of published disease associated SGCE pathogenic variants. Results: Within gnomAD v2, there were 56, 408, and 1250 alleles harboring SGCE variants with CADD scores greater than 30, 25, and 20, respectively. We estimate that approximately 1/348 individuals in the United States population harbors an SGCE variant with a CADD score ≥ 25. Discussion: SGCE M-D may be underdiagnosed due to pleiotropy, mild phenotypes, variable penetrance, and impaired access to genetic testing. Due to the high population prevalence of deleterious SGCE variants, caution should be used when asserting pathogenicity without co-segregation analyses and expert neurological examination of phenotypes within pedigrees. Highlights In silico analyses of a large population database of genetic variants revealed that over 0.2% of individuals in the United States harbor a highly deleterious SGCE variant. This finding suggests that M-D and minor phenotypic variants such as mild isolated myoclonus may be underdiagnosed.
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Farrell M, Karp BI, Kassavetis P, Berrigan W, Yonter S, Ehrlich D, Alter KE. Management of Anterocapitis and Anterocollis: A Novel Ultrasound Guided Approach Combined with Electromyography for Botulinum Toxin Injection of Longus Colli and Longus Capitis. Toxins (Basel) 2020; 12:toxins12100626. [PMID: 33008043 PMCID: PMC7650774 DOI: 10.3390/toxins12100626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 09/24/2020] [Accepted: 09/27/2020] [Indexed: 11/16/2022] Open
Abstract
Chemodenervation of cervical musculature using botulinum neurotoxin (BoNT) is established as the gold standard or treatment of choice for management of Cervical Dystonia (CD). The success of BoNT procedures is measured by improved symptomology while minimizing side effects and is dependent upon many factors including: clinical pattern recognition, identifying contributory muscles, BoNT dosage, and locating and safely injecting target muscles. In patients with CD, treatment of anterocollis (forward flexion of the neck) and anterocaput (anterocapitis) (forward flexion of the head) are inarguably challenging. The longus Colli (LoCol) and longus capitis (LoCap) muscles, two deep cervical spine and head flexor muscles, frequently contribute to these patterns. Localizing and safely injecting these muscles is particularly challenging owing to their deep location and the complex regional anatomy which includes critical neurovascular and other structures. Ultrasound (US) guidance provides direct visualization of the LoCol, LoCap, other cervical muscles and adjacent structures reducing the risks and side effects while improving the clinical outcome of BoNT for these conditions. The addition of electromyography (EMG) provides confirmation of muscle activity within the target muscle. Within this manuscript, we present a technical description of a novel US guided approach (combined with EMG) for BoNT injection into the LoCol and LoCap muscles for the management of anterocollis and anterocaput in patients with CD.
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Affiliation(s)
- Michael Farrell
- MedStar/Georgetown University National Rehabilitation Hospital, Washington, DC 20010, USA;
| | - Barbara I. Karp
- National Institutes of Neurological Disorders and Stroke, Bethesda, MD 20892 USA; (B.I.K.); (P.K.); (D.E.)
| | - Panagiotis Kassavetis
- National Institutes of Neurological Disorders and Stroke, Bethesda, MD 20892 USA; (B.I.K.); (P.K.); (D.E.)
| | - William Berrigan
- Emory School of Medicine, Emory University, Atlanta, GA 30322, USA;
| | - Simge Yonter
- Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892-1604, USA;
| | - Debra Ehrlich
- National Institutes of Neurological Disorders and Stroke, Bethesda, MD 20892 USA; (B.I.K.); (P.K.); (D.E.)
| | - Katharine E. Alter
- Functional and Applied Biomechanics Section, Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 20892-1604, USA
- Correspondence:
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Dey S, Ghosh S. Cervical Dystonia Refractory to Botulinum Toxin Responding to Radiofrequency Ablation: A Case Report. J Pain Res 2020; 13:2313-2316. [PMID: 32982394 PMCID: PMC7509331 DOI: 10.2147/jpr.s271945] [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: 07/15/2020] [Accepted: 08/18/2020] [Indexed: 11/23/2022] Open
Abstract
A 62-year-old male diagnosed with cervical dystonia (CD) and chronic right-sided neck pain presented to the Pain Clinic after his pain and CD symptoms failed to resolve with botulinum toxin therapy. During clinical examination, right C3-C4 and C4-C5 facet arthropathy was suspected. After two sets of diagnostic right cervical, C3, C4, and C5 medial branch blocks provided >80% pain relief; cervical radiofrequency ablation (CRFA) was performed. Post CRFA, the patient was followed for 12 months. Till the last follow-up, he was not only experiencing 90% pain relief, but also had significant improvement in his CD symptoms to the point that he no longer needed botulinum toxin and other CD-related therapy. This report suggests that large-scale research is required to postulate whether CD patients, whose symptoms are refractory to botulinum toxin, should be routinely screened for cervical facet arthropathy. This is the first reported case of improvement in CD symptoms with CRFA. This effect could be explained by the fact that certain deep cervical muscles, which are affected in CD, are innervated by medial branch nerves.
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Affiliation(s)
- Saugat Dey
- Benefis Health System, Great Falls, MT, USA
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Dashtipour K, Wietek S, Rubin B, Maisonobe P, Bahroo L, Trosch R. AbobotulinumtoxinA using 2-mL dilution (500 U/2-mL) maintains durable improvement across multiple treatment cycles. JOURNAL OF CLINICAL MOVEMENT DISORDERS 2020; 7:8. [PMID: 32884828 PMCID: PMC7457764 DOI: 10.1186/s40734-020-00090-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/10/2020] [Indexed: 03/10/2023]
Abstract
Background Cervical dystonia (CD), the most common focal dystonia, is a chronic neurological movement disorder characterized by sustained involuntary contractions of the neck muscles, leading to abnormal postures. AbobotulinumtoxinA (aboBoNT-A) was approved in the US initially as a 500 U per 1-mL dilution and subsequently, as a 500 U/2-mL dilution (or 250 U/mL), thereby providing clinicians with more flexible dosing options to better meet individual patient needs. The objective of this open-label extension study was to evaluate the longer term safety and efficacy of repeat treatments with aboBoNT-A using 2-mL dilutions in adults with cervical dystonia. Methods Patients (N = 112) from a 12-week, double-blind lead-in study (NCT01753310) received up to three additional treatments of aboBoNT-A, with re-treatment every 12–16 weeks based on clinical judgment. Safety was assessed through treatment-emergent adverse events (TEAEs). The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) total and subscale scores were measured at day 1 of each treatment cycle (C), 4 weeks after each treatment, and 12 weeks after the third treatment. Descriptive statistics were used for all analyses. Results In cycles 1, 2, 3, and 4, respectively, 35.7, 25.9, 30.2, and 22.8% of patients reported TEAEs. Dysphagia, muscular weakness, and neck pain were each reported by 10.7% of patients, over the full study duration. Mean TWSTRS total score decreased from 37.7 (SD 13.6 [C1, day 1]) to 30.1 (SD 12.8 [C3, week 12]). In each cycle, TWSTRS total and subscale scores decreased from day 1 to week 4 and increased between weeks 4 and 12, though the week 12 scores remained lower than day 1 scores. Conclusion Extended treatment of cervical dystonia with aboBoNT-A (up to 3 additional treatment cycles) using a 2-mL dilution is effective, with a positive risk-benefit profile. Trial registration ClinicalTrials.gov Identifier: NCT01753336. Registered 17 Dec 2012.
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Affiliation(s)
| | | | | | | | - Laxman Bahroo
- Georgetown University Hospital, Washington, DC 20007 USA
| | - Richard Trosch
- Parkinson's and Movement Disorders Center, Farmington Hills, MI 48334 USA
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Fasano A, Paramanandam V, Jog M. Use of AbobotulinumtoxinA in Adults with Cervical Dystonia: A Systematic Literature Review. Toxins (Basel) 2020; 12:toxins12080470. [PMID: 32722133 PMCID: PMC7472382 DOI: 10.3390/toxins12080470] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/09/2020] [Accepted: 07/11/2020] [Indexed: 01/20/2023] Open
Abstract
Cervical dystonia (CD) is a neurological movement disorder characterized by sustained involuntary muscle contractions. First-line therapy for CD is intramuscular injections of botulinum neurotoxin (e.g., abobotulinumtoxinA) into the affected muscles. The objective of this systematic literature review is to assess the clinical evidence regarding the effects of abobotulinumtoxinA for treatment of CD in studies of safety, efficacy, patient-reported outcomes, and economic outcomes. Using comprehensive electronic medical literature databases, a search strategy was developed using a combination of Medical Subject Heading terms and keywords. Results were reviewed by two independent reviewers who rated the level of evidence. The search yielded 263 publications, of which 232 were excluded for being duplicate publications, not meeting the selection criteria, or failing to meet predefined eligibility criteria, leaving a total of 31 articles. Clinical efficacy, patient-reported outcomes, and safety data were in 6 placebo-controlled trials (8 articles), 6 active-controlled trials, and 16 observational studies (17 articles). Data on health economic outcomes were provided in one of the clinical trials, in two of the observational studies, and in one specific cost-analysis publication. This review demonstrated that the routine use of abobotulinumtoxinA in CD is well-established, effective, and generally well-tolerated, with a relatively low cost of treatment.
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Affiliation(s)
- Alfonso Fasano
- Edmond J. Safra Program in Parkinson’s Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, ON M5T2S8, Canada;
- Division of Neurology, University of Toronto, Toronto, ON M5S 3H2, Canada
- Krembil Brain Institute, Toronto, ON M5T 1M8, Canada
- Correspondence:
| | - Vijayashankar Paramanandam
- Edmond J. Safra Program in Parkinson’s Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, ON M5T2S8, Canada;
- Division of Neurology, University of Toronto, Toronto, ON M5S 3H2, Canada
| | - Mandar Jog
- Lawson Health Research Institute, London, ON N6A 4V2, Canada;
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Marciniec M, Szczepańska-Szerej A, Rejdak K. Cervical dystonia: factors deteriorating patient satisfaction of long-term treatment with botulinum toxin. Neurol Res 2020; 42:987-991. [PMID: 32693754 DOI: 10.1080/01616412.2020.1796430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Botulinum toxin (BoNT) is an effective first-line treatment for cervical dystonia (CD). Despite generally good therapeutic efficacy, approximately 20-40% of CD patients do not achieve acceptable relief of the dystonic symptoms. The aim of this study was to identify factors of low patient satisfaction of long-term BoNT therapy for CD. METHODS In this case-control study CD patients treated with BoNT intramuscular injections for up to 24 years were assessed by two independent assessors in three validated scales: TWSTRS, Tsui and VAS for pain measurement. Data on received BoNT doses and treatment duration were obtained from medical history. All of participants rated their long-term treatment satisfaction compared to the therapy onset on a 0-3 scale. RESULTS Study was completed by 58 participants who were treated with BoNT for 9.0 ± 6.3 years and received a median of 19 injection cycles. None/low therapy satisfaction was reported by 20.7% of participants. Compared to moderate/good treatment satisfaction, CD patients with none/low BoNT efficacy had increased incidence of cervical pain (p =.018), enhanced mean VAS score for pain (p =.037) and had higher coexistence of oromandibular dystonia (p =.018). In addition, worse treatment satisfaction correlated with shorter time intervals between treatment cycles, enhanced scores of Tsui total, TWSTRS total, as well as TWSTRS subscales: severity, disability and pain. CONCLUSION Cervical pain and coexistence of oromandibular dystonia deteriorated long-term treatment satisfaction in CD patients. Higher scores of Tsui and TWSTRS subscales were correlated with worse subjective BoNT treatment response.
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Affiliation(s)
- Michał Marciniec
- Chair and Department of Neurology, Medical University of Lublin , Lublin, Poland
| | | | - Konrad Rejdak
- Chair and Department of Neurology, Medical University of Lublin , Lublin, Poland
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Berman BD, Groth CL, Shelton E, Sillau SH, Sutton B, Legget KT, Tregellas JR. Hemodynamic responses are abnormal in isolated cervical dystonia. J Neurosci Res 2020; 98:692-703. [PMID: 31692015 PMCID: PMC7015799 DOI: 10.1002/jnr.24547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 10/10/2019] [Accepted: 10/10/2019] [Indexed: 01/04/2023]
Abstract
Neuroimaging studies using functional magnetic resonance imaging (fMRI), which measures brain activity by detecting the changes in blood oxygenation levels, are advancing our understanding of the pathophysiology of dystonia. Neurobiological disturbances in dystonia, however, may affect neurovascular coupling and impact the interpretability of fMRI studies. We evaluated here whether the hemodynamic response patterns during a behaviorally matched motor task are altered in isolated cervical dystonia (CD). Twenty-five CD patients and 25 healthy controls (HCs) underwent fMRI scanning during a paced finger tapping task (nondystonic task in patients). Imaging data were analyzed using a constrained principal component analysis-a statistical method that combines regression analysis and principal component analysis and enables the extraction of task-related functional networks and determination of the spatial and temporal hemodynamic response patterns associated with the task performance. Data from three patients and two controls were removed due to excessive movement. No significant differences in demographics or motor performance were observed. Three task-associated functional brain networks were identified. During task performance, reduced hemodynamic responses were seen in a sensorimotor network and in a network that included key nodes of the default mode, executive control and visual networks. During rest, reductions in hemodynamic responses were seen in the cognitive/visual network. Lower hemodynamic responses within the primary sensorimotor network in patients were correlated with the increased dystonia severity. Pathophysiological disturbances in isolated CD, such as alterations in inhibitory signaling and dopaminergic neurotransmission, may impact neurovascular coupling. Not accounting for hemodynamic response differences in fMRI studies of dystonia could lead to inaccurate results and interpretations.
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Affiliation(s)
- Brian D. Berman
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO
- Neurology Section, Denver VA Medical Center, Aurora, CO, USA
| | - Christopher L. Groth
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Erica Shelton
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO
| | - Stefan H. Sillau
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO
| | - Brianne Sutton
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO
| | - Kristina T. Legget
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO
| | - Jason R. Tregellas
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO
- Research Service, Denver VA Medical Center, Aurora, CO USA
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[Dystonia Non-Motor Symptoms Questionnaire (DNMSQuest) for assessment of non-motor symptoms in dystonia : Intercultural adaptation in the German language]. DER NERVENARZT 2020; 91:337-342. [PMID: 32144450 DOI: 10.1007/s00115-020-00885-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Non-motor symptoms (NMS) in patients with dystonia have a relevant impact on health-related quality of life; however, a comprehensive easy to use NMS assessment tool for clinical bedside use is currently not available. OBJECTIVE The validated German version of the dystonia non-motor symptoms questionnaire (DNMSQuest) for assessing NMS in craniocervical dystonia is presented. METHODS The DNMSQuest in the German language was developed based on internationally recognized standards for intercultural adaptation of self-completed patient questionnaires. Translation of the original English questionnaire into the German language as well as back translation to English was carried out independently by four bilingual specialists in neurological movement disorders. In each case a consensus version accepted by each translator was created by another neurologist. The back translated English version was compared with the original English questionnaire for relevant linguistic and content discrepancies by a neurologist who was significantly involved in the development of the original questionnaire. The final German version was used in 130 patients with cervical dystonia and 48 healthy controls in an international, multicenter validation study. RESULTS An interculturally adapted validated version of the DNMSQuest in the German and English languages was developed for rapid bedside assessment and evaluation of NMS in cervical dystonia. CONCLUSION The DNMSQuest successfully bridges the current gap of a validated disease-specific, patient self-administered, short, comprehensive questionnaire for NMS assessment in routine clinical practice in craniocervical dystonia. It is envisaged that this tool will be useful for the clinical practice and trials.
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Conte A, Defazio G, Mascia M, Belvisi D, Pantano P, Berardelli A. Advances in the pathophysiology of adult-onset focal dystonias: recent neurophysiological and neuroimaging evidence. F1000Res 2020; 9. [PMID: 32047617 PMCID: PMC6993830 DOI: 10.12688/f1000research.21029.2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2020] [Indexed: 12/28/2022] Open
Abstract
Focal dystonia is a movement disorder characterized by involuntary muscle contractions that determine abnormal postures. The traditional hypothesis that the pathophysiology of focal dystonia entails a single structural dysfunction (i.e. basal ganglia) has recently come under scrutiny. The proposed network disorder model implies that focal dystonias arise from aberrant communication between various brain areas. Based on findings from animal studies, the role of the cerebellum has attracted increased interest in the last few years. Moreover, it has been increasingly reported that focal dystonias also include nonmotor disturbances, including sensory processing abnormalities, which have begun to attract attention. Current evidence from neurophysiological and neuroimaging investigations suggests that cerebellar involvement in the network and mechanisms underlying sensory abnormalities may have a role in determining the clinical heterogeneity of focal dystonias.
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Affiliation(s)
- Antonella Conte
- Department of Human Neurosciences, Sapienza, University of Rome, Rome, Italy.,IRCCS Neuromed, Pozzilli (IS), Italy
| | - Giovanni Defazio
- Department of Medical Sciences and Public Health, Neurology Unit, University of Cagliari and AOU Cagliari, Monserrato, Cagliari, Italy
| | - Marcello Mascia
- Department of Medical Sciences and Public Health, Neurology Unit, University of Cagliari and AOU Cagliari, Monserrato, Cagliari, Italy
| | | | - Patrizia Pantano
- Department of Human Neurosciences, Sapienza, University of Rome, Rome, Italy.,IRCCS Neuromed, Pozzilli (IS), Italy
| | - Alfredo Berardelli
- Department of Human Neurosciences, Sapienza, University of Rome, Rome, Italy.,IRCCS Neuromed, Pozzilli (IS), Italy
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Pan P, Wei S, Ou Y, Jiang W, Li W, Lei Y, Liu F, Guo W, Luo S. Reduced Global-Brain Functional Connectivity and Its Relationship With Symptomatic Severity in Cervical Dystonia. Front Neurol 2020; 10:1358. [PMID: 31998218 PMCID: PMC6965314 DOI: 10.3389/fneur.2019.01358] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 12/09/2019] [Indexed: 01/17/2023] Open
Abstract
Background: Altered functional connectivity (FC) is related to pathophysiology of patients with cervical dystonia (CD). However, inconsistent results may be obtained due to different selected regions of interest. We explored voxel-wise brain-wide FC changes in patients with CD at rest in an unbiased manner and analyzed their correlations with symptomatic severity using the Tsui scale. Method: A total of 19 patients with CD and 21 sex- and age-matched healthy controls underwent resting-state functional magnetic resonance imaging scans. Global-brain FC (GFC) was applied to analyze the images. Support vector machine was used to distinguish the patients from the controls. Results: Patients with CD exhibited decreased GFC in the right precentral gyrus and right supplementary motor area (SMA) that belonged to the M1-SMA motor network. Significantly negative correlation was observed between GFC values in the right precentral gyrus and symptomatic severity in the patients (r = −0.476, p = 0.039, uncorrected). Decreased GFC values in these two brain regions could be utilized to differentiate the patients from the controls with good accuracies, sensitivities and specificities (83.33, 85.71, and 80.95% in the right precentral gyrus; and 87.59, 89.49, and 85.71% in the right SMA). Conclusions: Our investigation suggests that patients with CD show reduced GFC in brain regions of the M1-SMA motor network and provides further insights into the pathophysiology of CD. GFC values in the right precentral gyrus and right SMA may be used as potential biomarkers to recognize the patients from the controls.
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Affiliation(s)
- Pan Pan
- Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, China.,National Clinical Research Center on Mental Disorders, Changsha, China
| | - Shubao Wei
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yangpan Ou
- Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, China.,National Clinical Research Center on Mental Disorders, Changsha, China
| | - Wenyan Jiang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Wenmei Li
- Department of Radiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yiwu Lei
- Department of Radiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Feng Liu
- Department of Radiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Wenbin Guo
- Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, China.,National Clinical Research Center on Mental Disorders, Changsha, China
| | - Shuguang Luo
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Loram I, Siddique A, Sanchez MB, Harding P, Silverdale M, Kobylecki C, Cunningham R. Objective Analysis of Neck Muscle Boundaries for Cervical Dystonia Using Ultrasound Imaging and Deep Learning. IEEE J Biomed Health Inform 2020; 24:1016-1027. [PMID: 31940567 DOI: 10.1109/jbhi.2020.2964098] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To provide objective visualization and pattern analysis of neck muscle boundaries to inform and monitor treatment of cervical dystonia. METHODS We recorded transverse cervical ultrasound (US) images and whole-body motion analysis of sixty-one standing participants (35 cervical dystonia, 26 age matched controls). We manually annotated 3,272 US images sampling posture and the functional range of pitch, yaw, and roll head movements. Using previously validated methods, we used 60-fold cross validation to train, validate and test a deep neural network (U-net) to classify pixels to 13 categories (five paired neck muscles, skin, ligamentum nuchae, vertebra). For all participants for their normal standing posture, we segmented US images and classified condition (Dystonia/Control), sex and age (higher/lower) from segment boundaries. We performed an explanatory, visualization analysis of dystonia muscle-boundaries. RESULTS For all segments, agreement with manual labels was Dice Coefficient (64 ± 21%) and Hausdorff Distance (5.7 ± 4 mm). For deep muscle layers, boundaries predicted central injection sites with average precision 94 ± 3%. Using leave-one-out cross-validation, a support-vector-machine classified condition, sex, and age from predicted muscle boundaries at accuracy 70.5%, 67.2%, 52.4% respectively, exceeding classification by manual labels. From muscle boundaries, Dystonia clustered optimally into three sub-groups. These sub-groups are visualized and explained by three eigen-patterns which correlate significantly with truncal and head posture. CONCLUSION Using US, neck muscle shape alone discriminates dystonia from healthy controls. SIGNIFICANCE Using deep learning, US imaging allows online, automated visualization, and diagnostic analysis of cervical dystonia and segmentation of individual muscles for targeted injection.
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Chen S, Issa MD, Wang C, Feng L, Teng F, Li B, Pan Y, Zhang X, Xu Y, Zhang Z, Su J, Ma H, Jin L. [ 99mTc]MIBI SPECT/CT for Identifying Dystonic Muscles in Patients with Primary Cervical Dystonia. Mol Imaging Biol 2019; 22:1054-1061. [PMID: 31721006 DOI: 10.1007/s11307-019-01436-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE This study aimed to evaluate the usefulness of [99mTc]sestamibi ([99mTc]MIBI) single photon emission computed tomography (SPECT)/X-ray computed tomography (CT) imaging for the identification of dystonic muscles in primary cervical dystonia (PCD) patients who underwent botulinum neurotoxin type A (BoNT-A) therapy. PROCEDURES Thirty-six patients with PCD and 10 healthy subjects (control group) who underwent [99mTc]MIBI SPECT/CT were enrolled. The image characteristics of dystonic muscles and normal muscles were evaluated. Muscle/background ratio (MBR) of six representative muscles was calculated for dystonic muscles in PCD group and normal muscles in control group. In PCD patients, target muscles injected with BoNT-A were selected by clinical evaluations and the results of needle electromyography (EMG) were considered as the gold standard. The sensitivity, specificity, and diagnostic efficacy of SPECT/CT were obtained from the receiver operator characteristic (ROC) curve. RESULTS Twenty-four PCD patients were included in our study eventually, because three PCD patients whose follow-up were lost and 9 PCD patients whose maximum reduction of Tsui scale scores was < 80 % were ruled out. Normal muscles of healthy subjects showed mild symmetrical radioactivity distribution, while in PCD patients, [99mTc]MIBI uptake in dystonic muscles abnormally increased. The mean MBRs of dystonic muscles were significantly higher than those of normal muscles. The sensitivity, specificity, and area under the curve (AUC) of SPECT/CT were 93.2 %, 88.5 %, and 0.908, respectively. CONCLUSIONS Our study indicated that [99mTc]MIBI SPECT/CT may be a useful method for identifying dystonic muscles and a guide to BoNT-A therapy in PCD patients.
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Affiliation(s)
- Shuzhen Chen
- Department of Nuclear Medicine, Tongji Hospital, Tongji University School of Medicine, No.389 Xincun Road, Putuo District, Shanghai, 200065, China
| | - Malam Djibo Issa
- Department of Neurology, Tongji Hospital, Tongji University School of Medicine, No.389 Xincun Road, Putuo District, Shanghai, 200065, China
| | - Chenghong Wang
- Department of Nuclear Medicine, Tongji Hospital, Tongji University School of Medicine, No.389 Xincun Road, Putuo District, Shanghai, 200065, China
| | - Liang Feng
- Department of Neurology, Tongji Hospital, Tongji University School of Medicine, No.389 Xincun Road, Putuo District, Shanghai, 200065, China
| | - Fei Teng
- Department of Neurology, Tongji Hospital, Tongji University School of Medicine, No.389 Xincun Road, Putuo District, Shanghai, 200065, China
| | - Bing Li
- Department of Neurology, Tongji Hospital, Tongji University School of Medicine, No.389 Xincun Road, Putuo District, Shanghai, 200065, China
| | - Yougui Pan
- Department of Neurology, Tongji Hospital, Tongji University School of Medicine, No.389 Xincun Road, Putuo District, Shanghai, 200065, China
| | - Xiaolong Zhang
- Department of Neurology, Tongji Hospital, Tongji University School of Medicine, No.389 Xincun Road, Putuo District, Shanghai, 200065, China
| | - Yifei Xu
- Department of Neurology, Tongji Hospital, Tongji University School of Medicine, No.389 Xincun Road, Putuo District, Shanghai, 200065, China
| | - Zhuoyu Zhang
- Department of Neurology, Tongji Hospital, Tongji University School of Medicine, No.389 Xincun Road, Putuo District, Shanghai, 200065, China
| | - Junhui Su
- Department of Neurology, Tongji Hospital, Tongji University School of Medicine, No.389 Xincun Road, Putuo District, Shanghai, 200065, China
| | - Hongxing Ma
- Department of Nuclear Medicine, Tongji Hospital, Tongji University School of Medicine, No.389 Xincun Road, Putuo District, Shanghai, 200065, China.
| | - Lingjing Jin
- Department of Neurology, Tongji Hospital, Tongji University School of Medicine, No.389 Xincun Road, Putuo District, Shanghai, 200065, China.
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25
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Klingelhoefer L, Chaudhuri KR, Kamm C, Martinez-Martin P, Bhatia K, Sauerbier A, Kaiser M, Rodriguez-Blazquez C, Balint B, Untucht R, Hall LJ, Mildenstein L, Wienecke M, Martino D, Gregor O, Storch A, Reichmann H. Validation of a self-completed Dystonia Non-Motor Symptoms Questionnaire. Ann Clin Transl Neurol 2019; 6:2054-2065. [PMID: 31560179 PMCID: PMC6801169 DOI: 10.1002/acn3.50900] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 08/19/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To develop and validate a novel 14-item self-completed questionnaire (in English and German) enquiring about the presence of non-motor symptoms (NMS) during the past month in patients with craniocervical dystonia in an international multicenter study. METHODS The Dystonia Non-Motor Symptoms Questionnaire (DNMSQuest) covers seven domains including sleep, autonomic symptoms, fatigue, emotional well-being, stigma, activities of daily living, sensory symptoms. The feasibility and clinimetric attributes were analyzed. RESULTS Data from 194 patients with CD (65.6% female, mean age 58.96 ± 12.17 years, duration of disease 11.95 ± 9.40 years) and 102 age- and sex-matched healthy controls (66.7% female, mean age 55.67 ± 17.62 years) were collected from centres in Germany and the UK. The median total NMS score in CD patients was 5 (interquartile range 3-7), significantly higher than in healthy controls with 1 (interquartile range 0.75-2.25) (P < 0.001, Mann-Whitney U-test). Evidence for intercorrelation and convergent validity is shown by moderate to high correlations of total DNMSQuest score with motor symptom severity (TWSTRS: rs = 0.61), clinical global impression (rs = 0.40), and health-related quality of life measures: CDQ-24 (rs = 0.74), EQ-5D index (rs = -0.59), and scale (rs = -0.49) (all P < 0.001). Data quality and acceptability was very satisfactory. INTERPRETATION The DNMSQuest, a patient self-completed questionnaire for NMS assessment in CD patients, appears robust, reproducible, and valid in clinical practice showing a tangible impact of NMS on quality of life in CD. As there is no specific, comprehensive, validated tool to assess the burden of NMS in dystonia, the DNMSQuest can bridge this gap and could easily be integrated into clinical practice.
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Affiliation(s)
| | - Kallol R Chaudhuri
- National Parkinson Foundation International Centre of Excellence, Department of Neurology, King's College Hospital, London, United Kingdom
| | - Christoph Kamm
- Department of Neurology, University of Rostock, Rostock, Germany.,German Centre for Neurodegenerative Diseases (DZNE) Rostock/Greifswald, Rostock, Germany
| | - Pablo Martinez-Martin
- National Centre of Epidemiology and CIBERNED, Carlos III Institute of Health, Madrid, Spain
| | - Kailash Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, United Kingdom
| | - Anna Sauerbier
- National Parkinson Foundation International Centre of Excellence, Department of Neurology, King's College Hospital, London, United Kingdom
| | - Maximilian Kaiser
- Department of Neurology, Technical University Dresden, Dresden, Germany
| | | | - Bettina Balint
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, United Kingdom.,Department of Neurology, University Hospital, Heidelberg, Germany
| | - Robert Untucht
- Department of Neurology, Technical University Dresden, Dresden, Germany
| | - Lynsey J Hall
- National Parkinson Foundation International Centre of Excellence, Department of Neurology, King's College Hospital, London, United Kingdom
| | | | - Miriam Wienecke
- Department of Neurology, Technical University Dresden, Dresden, Germany
| | - Davide Martino
- Department of Clinical Neurosciences, University of Calgary & Hotchkiss Brain Institute, Calgary, Canada
| | - Olaf Gregor
- Department of Neurology, Klinikum Chemnitz, Chemnitz, Germany
| | - Alexander Storch
- Department of Neurology, University of Rostock, Rostock, Germany.,German Centre for Neurodegenerative Diseases (DZNE) Rostock/Greifswald, Rostock, Germany
| | - Heinz Reichmann
- Department of Neurology, Technical University Dresden, Dresden, Germany
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26
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Colosimo C, Charles D, Misra VP, Maisonobe P, Om S. How satisfied are cervical dystonia patients after 3 years of botulinum toxin type A treatment? Results from a prospective, long-term observational study. J Neurol 2019; 266:3038-3046. [PMID: 31501975 PMCID: PMC6851034 DOI: 10.1007/s00415-019-09527-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/02/2019] [Accepted: 09/03/2019] [Indexed: 01/21/2023]
Abstract
Background Patients with cervical dystonia (CD) typically require regular injections of botulinum toxin to maintain symptomatic control. We aimed to document long-term patient satisfaction with CD symptom control in a large cohort of patients treated in routine practice. Methods This was a prospective, international, observational study (NCT01753349) following the course of adult CD treated with botulinum neurotoxin type A (BoNT-A) over 3 years. A comprehensive clinical assessment status was performed at each injection visit and subjects reported satisfaction in two ways: satisfaction with symptom control at peak effect and at the end of treatment cycle. Results Subject satisfaction remained relatively stable from the first to the last injection visit. At 3 years, 89.9% of subjects reported satisfaction with symptom control at peak effect and 55.6% reported satisfaction with symptom control at end of treatment cycle. By contrast, objective ratings of CD severity showed an overall reduction over 3 years. Mean ± SD Toronto Western Spasmodic Rating Scale (TWSTRS) Total scores (clinician assessed at end of treatment cycle) decreased from 31.59 ± 13.04 at baseline to 24.49 ± 12.43 at 3 years (mean ± SD reduction from baseline of − 6.97 ± 11.56 points). Tsui scale scores also showed gradual improvement; the percent of subjects with a tremor component score of 4 reduced from 12.4% at baseline to 8.1% at 3 years. Conclusions Despite objective clinical improvements over 3 years, subject satisfaction with symptom control remained relatively constant, indicating that factors other than symptom control also play a role in patient satisfaction. Electronic supplementary material The online version of this article (10.1007/s00415-019-09527-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Carlo Colosimo
- Department of Neurology, Santa Maria University Hospital, Viale Tristano di Joannuccio 1, 05100, Terni, Italy.
| | - David Charles
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Vijay P Misra
- Department of Neurology, Imperial College Healthcare NHS Trust, London, UK
| | | | - Savary Om
- Ipsen Pharma, Boulogne-Billancourt, France
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Louis ED, Eliasen EH, Kim CY, Ferrer M, Gaini S, Petersen MS. High Prevalence of Dystonia in the Faroe Islands: A Population-Based Study. Neuroepidemiology 2019; 53:220-224. [PMID: 31430749 DOI: 10.1159/000502455] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 07/27/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND There are fewer than 5 population-based studies of dystonia worldwide. Only one utilized a movement disorders neurologist. Given the potential for founder effects, and the highly genetic nature of dystonia, the Faroe Islands provide a particularly interesting setting to study the prevalence of dystonia. OBJECTIVE To estimate the prevalence of dystonia. METHODS We used a 2-phase, population-based design, screening 1,334 randomly selected Faroese individuals aged ≥40 years from which a subsample of 227 participated in an in-person clinical evaluation. Dystonia was assessed by 2 movement disorder neurologists using videotaped examinations. RESULTS Two of 227 (0.88%, 95% CI -0.33 to 2.09%) were diagnosed with cervical or segmental dystonia. An unusual form of thumb flexion dystonia was noted in 75 more, yielding a combined prevalence of 33.92% (95% CI 27.73-40.11%). CONCLUSIONS The prevalence of cervical or segmental dystonia was as high as in one prior population-based study using similar methods. Furthermore, an unusual form of thumb flexion dystonia was uncovered, which yielded an extraordinarily high prevalence of dystonia in this population. Although our methods likely contributed to more complete capture of subtle dystonia, founder effects are highly likely to have been an additional major contributor to these findings.
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Affiliation(s)
- Elan D Louis
- Department of Neurology, Yale School of Medicine, Yale University, New Haven, Connecticut, USA, .,Department of Chronic Disease Epidemiology, Yale School of Public Health, Yale University, New Haven, Connecticut, USA, .,Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, Yale University, New Haven, Connecticut, USA,
| | - Eina H Eliasen
- Department of Occupational Medicine and Public Health, The Faroese Hospital System, Tórshavn, Faeroe Islands
| | - Christine Y Kim
- Department of Neurology, Yale School of Medicine, Yale University, New Haven, Connecticut, USA.,Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Monica Ferrer
- Department of Neurology, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Shahin Gaini
- Centre for Health Science, Faculty of Health Sciences, University of the Faroe Islands, Tórshavn, Faeroe Islands.,Division of Infectious Diseases, National Hospital Faroe Islands, Tórshavn, Faeroe Islands.,Department of Infectious Diseases, Odense University Hospital/University of Southern Denmark, Odense, Denmark
| | - Maria Skaalum Petersen
- Department of Occupational Medicine and Public Health, The Faroese Hospital System, Tórshavn, Faeroe Islands.,Centre for Health Science, Faculty of Health Sciences, University of the Faroe Islands, Tórshavn, Faeroe Islands
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28
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Graupman P, Feyma T, Sorenson T, Nussbaum ES. Microvascular decompression with partial occipital condylectomy in a case of pediatric spasmodic torticollis. Childs Nerv Syst 2019; 35:1263-1266. [PMID: 30701298 DOI: 10.1007/s00381-019-04065-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 01/16/2019] [Indexed: 10/27/2022]
Abstract
Spasmodic torticollis is a rare, neurologic disorder that is caused by abnormal nerve compression of the 11th cranial nerve by blood vessels or bony protrusions. It is typically treated pharmacologically and, if necessary, with surgical intervention. We report a unique case of spasmodic torticollis in a 15-year-old female that involved abnormal compression of the left 11th cranial nerve (CN) by the left vertebral artery, displaced by a hypertrophic left occipital condyle. After treatment with Botox was unsuccessful, the patient was treated with microvascular decompression and occipital condylectomy that adequately relieved the abnormal compression of CN XI. Mild symptoms persisted, and the patient underwent a partial section of the sternocleidomastoid muscle 1 year later, after which torticollis symptoms resolved.
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Affiliation(s)
- Patrick Graupman
- Gillette Children's Specialty Healthcare, 200 University Ave E, St Paul, MN, 55101, USA
| | - Timothy Feyma
- Gillette Children's Specialty Healthcare, 200 University Ave E, St Paul, MN, 55101, USA
| | - Thomas Sorenson
- National Brain Aneurysm & Tumor Center, United Hospital, 3033 Excelsior Boulevard, Suite 495, Minneapolis, MN, 55416, USA
| | - Eric S Nussbaum
- National Brain Aneurysm & Tumor Center, United Hospital, 3033 Excelsior Boulevard, Suite 495, Minneapolis, MN, 55416, USA.
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29
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Ravindran K, Ganesh Kumar N, Englot DJ, Wilson TJ, Zuckerman SL. Deep Brain Stimulation Versus Peripheral Denervation for Cervical Dystonia: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 122:e940-e946. [PMID: 30419402 DOI: 10.1016/j.wneu.2018.10.178] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 10/26/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cervical dystonia is a disabling medical condition that drastically decreases quality of life. Surgical treatment consists of peripheral nerve denervation procedures with or without myectomies or deep brain stimulation (DBS). The current objective was to compare the efficacy of peripheral denervation versus DBS in improving the severity of cervical dystonia through a systematic review and meta-analysis. METHODS A search of PubMed, MEDLINE, EMBASE, and Web of Science electronic databases was conducted in accordance with PRISMA guidelines. Preoperative and postoperative Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) total scores were used to generate standardized mean differences and 95% confidence intervals (CIs), which were combined in a random-effects model. Both mean percentage and absolute reduction in TWSTRS scores were calculated. Absolute reduction was used for forest plots. RESULTS Eighteen studies met the inclusion criteria, comprising 870 patients with 180 (21%) undergoing DBS and 690 (79%) undergoing peripheral denervation procedures. The mean follow-up time was 31.5 months (range, 12-38 months). In assessing the efficacy of each intervention, forest plots revealed significant absolute reduction in total postoperative TWSTRS scores for both peripheral denervation (standardized mean difference 1.54; 95% CI 1.42-1.66) and DBS (standardized mean difference 2.07; 95% CI 1.43-2.71). On subgroup analysis, DBS therapy was significantly associated with improvement in postoperative TWSTRS severity (standardized mean difference 2.08; 95% CI 1.66-2.50) and disability (standardized mean difference 2.12; 95% CI 1.57-2.68) but not pain (standardized mean difference 1.18; 95% CI 0.80-1.55). CONCLUSIONS Both peripheral denervation and DBS are associated with a significant reduction in absolute TWSTRS total score, with no significant difference in the magnitude of reduction observed between the 2 treatments. Further comparative data are needed to better evaluate the long-term results of both interventions.
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Affiliation(s)
- Krishnan Ravindran
- Department of Neurosurgery, Vanderbilt University Medical Center School, Nashville, Tennessee, USA
| | - Nishant Ganesh Kumar
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Dario J Englot
- Department of Neurosurgery, Vanderbilt University Medical Center School, Nashville, Tennessee, USA
| | - Thomas J Wilson
- Department of Neurosurgery, Stanford University, Stanford, California, USA
| | - Scott L Zuckerman
- Department of Neurosurgery, Vanderbilt University Medical Center School, Nashville, Tennessee, USA.
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30
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Diestro JDB, Ang MAC, Mondia MWL, Pasco PMD. Validation of a Questionnaire for Distinguishing X-Linked Dystonia Parkinsonism From Its Mimics. Front Neurol 2018; 9:830. [PMID: 30374324 PMCID: PMC6196251 DOI: 10.3389/fneur.2018.00830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 09/18/2018] [Indexed: 11/13/2022] Open
Abstract
Objectives: X-linked dystonia parkinsonism (XDP) is a neurodegenerative movement disorder endemic to the island of Panay in the Philippines. We undertook a population-based prevalence study to enumerate all cases of XDP in Panay. We first developed a 4-item questionnaire to distinguish XDP suspects from the general population. In the present study we aimed to revalidate this questionnaire to distinguish XDP from similar conditions so as to give it greater utility in the clinical setting. Patients and Methods: A total of 306 subjects (114 cases and 192 controls) were screened in from the 16 towns and 1 city of Capiz province. Their responses to the previously developed 4-item questionnaire were collected and multivariable logistic regression was performed to develop a predictive model. The accuracy of the model was determined by using it on a subset of patients; then, a scoring system based on the model coefficients was established. Results: With a cut-off score of 6, the questionnaire had an accuracy of 70.7% (95% CI 0.57-0.82), a sensitivity of 84.6 % (95% CI 0.65-0.96) and a specificity of 59.4 % (95% CI 0.41-0.76). The item on "shuffling of feet" was the strongest predictor in distinguishing XDP from its common mimics. Conclusion: We were able to revalidate a simple, four-item questionnaire that could distinguish XDP from its common mimics with fair accuracy. The questionnaire along with other clinical features can be used to determine which patients need specialty evaluation and genetic testing to verify a diagnosis of XDP.
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Affiliation(s)
- Jose Danilo B Diestro
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Mark Angelo C Ang
- Department of Laboratories, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Mark Willy L Mondia
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Paul Matthew D Pasco
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
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31
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Misra VP, Trosch RM, Maisonobe P, Om S. Spectrum of practice in the routine management of cervical dystonia with abobotulinumtoxinA: findings from three prospective open-label observational studies. JOURNAL OF CLINICAL MOVEMENT DISORDERS 2018; 5:4. [PMID: 30002865 PMCID: PMC6036690 DOI: 10.1186/s40734-018-0072-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 06/29/2018] [Indexed: 12/31/2022]
Abstract
Background Cervical dystonia is a heterogeneous disorder with several possible presentations, for which first-line therapy is often botulinum toxin (BoNT). In routine clinical practice the success of each BoNT injection is dependent on several variables, including individual presentation and injection technique. Large multicenter, observational studies provide important information on individualized administration strategies that cannot be otherwise ascertained from controlled clinical trials. In this meta-analysis of patient level data, we aimed to evaluate the clinical characteristics of patients with cervical dystonia undergoing routine treatment with botulinum toxin, specifically abobotulinumtoxinA. We also aimed to characterize current abobotulinumtoxinA injection techniques and parameters and to explore international differences in patient presentation and treatment. Methods This was a meta-analysis of baseline data from three prospective, international, multicenter, observational studies (NCT01314365, NCT00833196 and NCT01753349) of botulinum toxin treatment for the routine management of adult cervical dystonia. Results Data presented illustrate the significant heterogeneity of CD presentation in routine practice. Most subjects presented with a complex pattern of dystonic movements and the majority had additional components of shoulder elevation, tremor and/or jerk. Dosing was generally in accordance with that recommended in the abobotulinumtoxinA prescribing information, although the range of dosing also indicates that injections are tailored to individual presentation. Sub-group analyses at the country level revealed distinct differences in injection practice. Conclusions This meta-analysis is based on the largest dataset of subjects with cervical dystonia studied to date. The heterogeneity revealed in our baseline findings support the need to develop consistent, practical and comprehensive best practice guidelines.
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Affiliation(s)
- Vijay P Misra
- 1Imperial College Healthcare NHS Trust, London, UK.,4Peripheral Nerve Unit, Hammersmith Hospital, London, W12 0HS UK
| | - Richard M Trosch
- The Parkinson's and Movement Disorders Center, 32255 Northwestern Highway, Suite 40, Farmington Hills, MI 48334 USA
| | - Pascal Maisonobe
- 3Ipsen Pharma, 65 Quai Georges Gorse, 92100 Boulogne-Billancourt, France
| | - Savary Om
- 3Ipsen Pharma, 65 Quai Georges Gorse, 92100 Boulogne-Billancourt, France
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Berman BD, Pollard RT, Shelton E, Karki R, Smith-Jones PM, Miao Y. GABA A Receptor Availability Changes Underlie Symptoms in Isolated Cervical Dystonia. Front Neurol 2018; 9:188. [PMID: 29670567 PMCID: PMC5893646 DOI: 10.3389/fneur.2018.00188] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 03/12/2018] [Indexed: 11/28/2022] Open
Abstract
GABAA receptor availability changes within sensorimotor regions have been reported in some isolated forms of dystonia. Whether similar abnormalities underlie symptoms in cervical dystonia is not known. In the present study, a total of 15 cervical dystonia patients and 15 age- and sex-matched controls underwent 11C-flumazenil PET/CT scanning. The density of available GABAA receptors was estimated using a Simplified Reference Tissue Model 2. Group differences were evaluated using a two-sample T-test, and correlations with dystonia severity, as measured by the Toronto Western Spasmodic Torticollis Rating Scale, and disease duration were evaluated using a regression analysis. Voxel-based analyses revealed increased GABAA availability within the right precentral gyrus in brain motor regions previously associated with head turning and the left parahippocampal gyrus. GABAA availability within the bilateral cerebellum was negatively correlated with dystonia severity, and GABAA availability within the right thalamus and a variety of cerebellar and cortical regions were negatively correlated with disease duration. While GABAA availability changes within primary motor areas could represent a partial compensatory response to loss of inhibition within sensorimotor network, GABAergic signaling impairment within the cerebellum may be a key contributor to dystonia severity.
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Affiliation(s)
- Brian D Berman
- Department of Neurology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Department of Radiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Neurology Section, Denver VA Medical Center, Denver, CO, United States
| | - Rebecca Tran Pollard
- Department of Neurology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Erika Shelton
- Department of Neurology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Ramesh Karki
- Department of Radiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Peter M Smith-Jones
- Department of Psychiatry, School of Medicine, Stony Brook University, Stony Brook, NY, United States
| | - Yubin Miao
- Department of Radiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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Misra VP, Colosimo C, Charles D, Chung TM, Maisonobe P, Om S. INTEREST IN CD2, a global patient-centred study of long-term cervical dystonia treatment with botulinum toxin. J Neurol 2018; 265:402-409. [PMID: 29270685 PMCID: PMC5808090 DOI: 10.1007/s00415-017-8698-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/22/2017] [Accepted: 12/03/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Longitudinal cohort studies provide important information about the clinical effectiveness of an intervention in the routine clinical setting, and are an opportunity to understand how a population presents for treatment and is managed. METHODS INTEREST IN CD2 (NCT01753349) is a prospective, international, 3-year, longitudinal, observational study following the course of adult idiopathic cervical dystonia (CD) treated with botulinum neurotoxin type A (BoNT-A). The primary objective is to document long-term patient satisfaction with BoNT-A treatment. Here we report baseline data. RESULTS This analysis includes 1036 subjects (67.4% of subjects were female; mean age was 54.7 years old; mean TWSTRS Total score was 31.7). BoNT-A injections were usually given in line with BoNT-A prescribing information. The most commonly injected muscles were splenius capitis (87.3%), sternocleidomastoid (82.6%), trapezius (64.3%), levator scapulae (40.9%) and semispinalis capitis (26.9%); 35.5% of subjects were injected using a guidance technique. Most subjects (87.8%) had been previously treated with BoNT-A (median interval between last pre-study injection and study baseline was 4 months); of these 84.8% reported satisfaction with BoNT-A treatment at peak effect during their previous treatment cycle and 51.5% remained satisfied at the end of the treatment. Analyses by geographical region revealed heterogeneity in the clinical characteristics and BoNT-A injection practice of CD subjects presenting for routine treatment. CONCLUSIONS These baseline analyses provide sizeable data regarding the epidemiology and clinical presentation of CD, and demonstrate an international heterogeneity of clinical practice. Future longitudinal analyses of the full 3-year study will explore how these factors impact treatment satisfaction.
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Affiliation(s)
- Vijay P Misra
- Department of Neurology, Imperial College Healthcare NHS Trust, London, UK.
| | - Carlo Colosimo
- Department of Neurology, Santa Maria University Hospital, Terni, Italy
| | - David Charles
- Vanderbilt Neuroscience Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tae Mo Chung
- Institute of Physical Medicine and Rehabilitation, São Paulo University Hospital, Sao Paulo, Brazil
| | | | - Savary Om
- Ipsen Pharma, Boulogne-Billancourt, France
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Lew MF, Brashear A, Dashtipour K, Isaacson S, Hauser RA, Maisonobe P, Snyder D, Ondo W. A 500 U/2 mL dilution of abobotulinumtoxinA vs. placebo: randomized study in cervical dystonia. Int J Neurosci 2018; 128:619-626. [PMID: 29343142 DOI: 10.1080/00207454.2017.1406935] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Purpose/aim: AbobotulinumtoxinA (Dysport®, Ipsen Biopharmaceuticals, Inc., Basking Ridge, NJ, USA) is an acetylcholine release inhibitor and a neuromuscular blocking agent. The United States prescribing information for abobotulinumtoxinA previously indicated only one dilution for cervical dystonia: 500 U/1 mL. Clinical trial data supporting a larger volume with a 500 U/2 mL dilution would offer clinicians flexibility with injection volume to better meet patient needs. MATERIALS AND METHODS We conducted a 12-week, phase 3b, multicenter, randomized, double-blind, placebo-controlled trial (NCT01753310). Adult subjects with a primary diagnosis of cervical dystonia were randomized (2:1) to receive a single injection of either abobotulinumtoxinA, 500 U/2 mL dilution, or placebo. The primary efficacy endpoint was changed from baseline in Toronto Western Spasmodic Torticollis Rating Scale total score at Week 4. RESULTS A total of 134 subjects (abobotulinumtoxinA, n = 89; placebo, n = 45) were randomized (intent-to-treat population) and 129 (abobotulinumtoxinA, n = 84; placebo, n = 45) completed the Week 4 primary endpoint evaluation (modified intent-to-treat population). In the modified intent-to-treat population, subjects receiving abobotulinumtoxinA experienced significantly greater changes from baseline versus placebo on the primary endpoint (weighted overall treatment difference -8.3, P < 0.001). The most common treatment-emergent adverse events (TEAEs) were dysphagia, muscle weakness, neck pain and headache. Overall, TEAEs were consistent with those reported in the abobotulinumtoxinA prescribing information (1 mL dilution) for cervical dystonia patients. CONCLUSIONS This trial provides evidence that a 500 U/2 mL dilution is an effective treatment for cervical dystonia and exhibits a safety profile consistent with the known safety profile of abobotulinumtoxinA.
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Affiliation(s)
- Mark F Lew
- a Department of Neurology , Keck/University of Southern California School of Medicine , Los Angeles , CA , USA
| | - Allison Brashear
- b Department of Neurology , Wake Forest School of Medicine , Medical Center Blvd. Winston Salem , NC , USA
| | - Khashayar Dashtipour
- c Department of Neurology/Movement Disorders , School of Medicine, Faculty Medical Offices , Loma Linda University , Loma Linda , CA , USA
| | - Stuart Isaacson
- d Parkinson's Disease and Movement Disorders Center of Boca Raton , Boca Raton , FL , USA
| | - Robert A Hauser
- e University of South Florida Health Byrd Parkinson's Disease and Movement Disorders Center of Excellence , Tampa , FL , USA
| | | | - Daniel Snyder
- g Ipsen Biopharmaceuticals , Basking Ridge , NJ , USA
| | - William Ondo
- h Methodist Neurological Institute , Houston , TX , USA
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Castelão M, Marques RE, Duarte GS, Rodrigues FB, Ferreira J, Sampaio C, Moore AP, Costa J. Botulinum toxin type A therapy for cervical dystonia. Cochrane Database Syst Rev 2017; 12:CD003633. [PMID: 29230798 PMCID: PMC6486222 DOI: 10.1002/14651858.cd003633.pub3] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND This is an update of a Cochrane Review first published in 2005. Cervical dystonia is the most common form of focal dystonia and is a highly disabling movement disorder characterised by involuntary, usually painful, head posturing. Currently, botulinum toxin type A (BtA) is considered the first line therapy for this condition. OBJECTIVES To compare the efficacy, safety, and tolerability of botulinum toxin type A (BtA) versus placebo in people with cervical dystonia. SEARCH METHODS To identify studies for this review we searched Cochrane Movement Disorders' Trials Register, CENTRAL, MEDLINE, Embase, reference lists of articles and conference proceedings. All elements of the search, with no language restrictions, were run in October 2016. SELECTION CRITERIA Double-blind, parallel, randomised, placebo-controlled trials (RCTs) of BtA versus placebo in adults with cervical dystonia. DATA COLLECTION AND ANALYSIS Two review authors independently assessed records, selected included studies, extracted data using a paper pro forma, and evaluated the risk of bias. We resolved disagreements by consensus or by consulting a third review author. We performed meta-analyses using a random-effects model for the comparison of BtA versus placebo to estimate pooled effects and corresponding 95% confidence intervals (95% CI). In addition, we performed preplanned subgroup analyses according to BtA dose used, the BtA formulation used, and the use or not of guidance for BtA injection. The primary efficacy outcome was improvement in cervical dystonia-specific impairment. The primary safety outcome was the proportion of participants with any adverse event. MAIN RESULTS We included eight RCTs of moderate overall risk of bias, including 1010 participants with cervical dystonia. Six studies excluded participants with poorer responses to BtA treatment, therefore including an enriched population with a higher probability of benefiting from this therapy. Only one trial was independently funded. All RCTs evaluated the effect of a single BtA treatment session, using doses from 150 U to 236 U of onabotulinumtoxinA (Botox), 120 U to 240 U of incobotulinumtoxinA (Xeomin), and 250 U to 1000 U of abobotulinumtoxinA (Dysport).BtA was associated with a moderate-to-large improvement in the participant's baseline clinical status as assessed by investigators, with reduction of 8.06 points in the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS total score) at week 4 after injection (95% CI 6.08 to 10.05; I2 = 0%) compared to placebo, corresponding on average to a 18.7% improvement from baseline. The mean difference (MD) in TWSTRS pain subscore at week 4 was 2.11 (95% CI 1.38 to 2.83; I2 = 0%). Overall, both participants and clinicians reported an improvement of subjective clinical status. There were no differences between groups regarding withdrawals due to adverse events. However, BtA treatment was associated with an increased risk of experiencing an adverse event (risk ratio (RR) 1.19; 95% CI 1.03 to 1.36; I2 = 16%). Dysphagia (9%) and diffuse weakness/tiredness (10%) were the most common treatment-related adverse events (dysphagia: RR 3.04; 95% CI 1.68 to 5.50; I2 = 0%; diffuse weakness/tiredness: RR 1.78; 95% CI 1.08 to 2.94; I2 = 0%). Treatment with BtA was associated with a decreased risk of participants withdrawing from trials. We have moderate certainty in the evidence across all of the aforementioned outcomes.We found no evidence supporting the existence of a clear dose-response relationship with BtA, nor a difference between BtA formulations, nor a difference with use of EMG-guided injection.Due to clinical heterogeneity, we did not pool data regarding health-related quality of life, duration of clinical effect, or the development of secondary non-responsiveness. AUTHORS' CONCLUSIONS We have moderate certainty in the evidence that a single BtA treatment session is associated with a significant and clinically relevant reduction of cervical dystonia-specific impairment, including severity, disability, and pain, and that it is well tolerated, when compared with placebo. There is also moderate certainty in the evidence that people treated with BtA are at an increased risk of developing adverse events, most notably dysphagia and diffuse weakness. There are no data from RCTs evaluating the effectiveness and safety of repeated BtA injection cycles. There is no evidence from RCTs to allow us to draw definitive conclusions on the optimal treatment intervals and doses, usefulness of guidance techniques for injection, the impact on quality of life, or the duration of treatment effect.
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Affiliation(s)
- Mafalda Castelão
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Raquel E Marques
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Gonçalo S Duarte
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Filipe B Rodrigues
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Joaquim Ferreira
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Cristina Sampaio
- CHDI Foundation155 Village BoulevardSuite 200PrincetonNJUSA08540
| | - Austen P Moore
- The Walton Centre NHS Foundation TrustLower LaneLiverpoolUKL9 7LJ
| | - João Costa
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAv. Prof. Egas MonizLisboaPortugal1649‐028
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De Pauw J, Mercelis R, Hallemans A, Michiels S, Truijen S, Cras P, De Hertogh W. Cervical sensorimotor control in idiopathic cervical dystonia: A cross-sectional study. Brain Behav 2017; 7:e00735. [PMID: 28948067 PMCID: PMC5607536 DOI: 10.1002/brb3.735] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 04/19/2017] [Accepted: 04/19/2017] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Patients with idiopathic adult-onset cervical dystonia (CD) experience an abnormal head posture and involuntary muscle contractions. Although the exact areas affected in the central nervous system remain uncertain, impaired functions in systems stabilizing the head and neck are apparent such as the somatosensory and sensorimotor integration systems. The aim of the study is to investigate cervical sensorimotor control dysfunction in patients with CD. MATERIAL AND METHODS Cervical sensorimotor control was assessed by a head repositioning task in 24 patients with CD and 70 asymptomatic controls. Blindfolded participants were asked to reposition their head to a previously memorized neutral head position (NHP) following an active movement (flexion, extension, left, and right rotation). The repositioning error (joint position error, JPE) was registered via 3D motion analysis with an eight-camera infrared system (VICON ® T10). Disease-specific characteristics of all patients were obtained via the Tsui scale, Cervical Dystonia Impact Profile (CDIP-58), and Toronto Western Spasmodic Rating Scale. RESULTS Patients with CD showed larger JPE than controls (mean difference of 1.5°, p < .006), and systematically 'overshoot', i.e. surpassed the NHP, whereas control subjects 'undershoot', i.e. fall behind the NHP. The JPE did not correlate with disease-specific characteristics. CONCLUSIONS Cervical sensorimotor control is impaired in patients with CD. As cervical sensorimotor control can be trained, this might be a potential treatment option for therapy, adjuvant to botulinum toxin injections.
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Affiliation(s)
- Joke De Pauw
- Department of Physical Therapy and Rehabilitation SciencesUniversity of AntwerpWilrijkBelgium
| | - Rudy Mercelis
- Department of NeurologyAntwerp University HospitalWilrijkBelgium
- Faculty of Medicine and Health SciencesBorn Bunge InstituteUniversity of AntwerpWilrijkBelgium
| | - Ann Hallemans
- Department of Physical Therapy and Rehabilitation SciencesUniversity of AntwerpWilrijkBelgium
- Multidisciplinary Motor Centre Antwerp (MOCEAN)WilrijkBelgium
| | - Sarah Michiels
- Department of Physical Therapy and Rehabilitation SciencesUniversity of AntwerpWilrijkBelgium
| | - Steven Truijen
- Department of Physical Therapy and Rehabilitation SciencesUniversity of AntwerpWilrijkBelgium
| | - Patrick Cras
- Department of NeurologyAntwerp University HospitalWilrijkBelgium
- Faculty of Medicine and Health SciencesBorn Bunge InstituteUniversity of AntwerpWilrijkBelgium
| | - Willem De Hertogh
- Department of Physical Therapy and Rehabilitation SciencesUniversity of AntwerpWilrijkBelgium
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Duarte GS, Castelão M, Rodrigues FB, Marques RE, Ferreira J, Sampaio C, Moore AP, Costa J. Botulinum toxin type A versus botulinum toxin type B for cervical dystonia. Cochrane Database Syst Rev 2016; 10:CD004314. [PMID: 27782297 PMCID: PMC6461154 DOI: 10.1002/14651858.cd004314.pub3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND This is an update of a Cochrane review first published in 2003. Cervical dystonia is the most common form of focal dystonia and is a disabling disorder characterised by painful involuntary head posturing. There are two available formulations of botulinum toxin, with botulinum toxin type A (BtA) usually considered the first line therapy for this condition. Botulinum toxin type B (BtB) is an alternative option, with no compelling theoretical reason why it might not be as- or even more effective - than BtA. OBJECTIVES To compare the efficacy, safety and tolerability of botulinum toxin type A (BtA) versus botulinum toxin type B (BtB) in people with cervical dystonia. SEARCH METHODS To identify studies for this review we searched the Cochrane Movement Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, reference lists of articles and conference proceedings. All elements of the search, with no language restrictions, were last run in October 2016. SELECTION CRITERIA Double-blind, parallel, randomised, placebo-controlled trials (RCTs) comparing BtA versus BtB in adults with cervical dystonia. DATA COLLECTION AND ANALYSIS Two independent authors assessed records, selected included studies, extracted data using a paper pro forma, and evaluated the risk of bias. We resolved disagreements by consensus or by consulting a third author. We performed meta-analyses using the random-effects model, for the comparison BtA versus BtB to estimate pooled effects and corresponding 95% confidence intervals (95% CI). No prespecified subgroup analyses were carried out. The primary efficacy outcome was improvement on any validated symptomatic rating scale, and the primary safety outcome was the proportion of participants with adverse events. MAIN RESULTS We included three RCTs, all new to this update, of very low to low methodological quality, with a total of 270 participants.Two studies exclusively enrolled participants with a known positive response to BtA treatment. This raises concerns of population enrichment, with a higher probability of benefit from BtA treatment. None of the trials were free of for-profit bias, nor did they provide information regarding registered study protocols. All trials evaluated the effect of a single Bt treatment session, and not repeated treatment sessions, using doses from 100 U to 250 U of BtA (all onabotulinumtoxinA, or Botox, formulations) and 5000 U to 10,000 U of BtB (rimabotulinumtoxinB, or Myobloc/Neurobloc).We found no difference between the two types of botulinum toxin in terms of overall efficacy, with a mean difference of -1.44 (95% CI -3.58 to 0.70) points lower on the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) for BtB-treated participants, measured at two to four weeks after injection. The proportion of participants with adverse events was also not different between BtA and BtB (BtB versus BtA risk ratio (RR) 1.40; 95% CI 1.00 to 1.96). However, when compared to BtA, treatment with BtB was associated with an increased risk of one adverse events of special interest, namely treatment-related sore throat/dry mouth (BtB versus BtA RR of 4.39; 95% CI 2.43 to 7.91). Treatment-related dysphagia (swallowing difficulties) was not different between BtA and BtB (RR 2.89; 95% CI 0.80 to 10.41). The two types of botulinum toxin were otherwise clinically non-distinguishable in all the remaining outcomes. AUTHORS' CONCLUSIONS The previous version of this review did not include any trials, since these were still ongoing at the time. Therefore, with this update we are able to change the conclusions of this review. There is low quality evidence that a single treatment session of BtA (specifically onabotulinumtoxinA) and a single treatment session of BtB (rimabotulinumtoxinB) are equally effective and safe in the treatment of adults with certain types of cervical dystonia. Treatment with BtB appears to present an increased risk of sore throat/dry mouth, compared to BtA. Overall, there is no clinical evidence from these single-treatment trials to support or contest the preferential use of one form of botulinum toxin over the other.
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Affiliation(s)
- Gonçalo S Duarte
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAvenida Professor Egas MonizLisboaLisboaPortugal1649‐028
- Instituto de Medicina MolecularClinical Pharmacology UnitAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Mafalda Castelão
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAvenida Professor Egas MonizLisboaLisboaPortugal1649‐028
- Instituto de Medicina MolecularClinical Pharmacology UnitAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Filipe B Rodrigues
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAvenida Professor Egas MonizLisboaLisboaPortugal1649‐028
- Instituto de Medicina MolecularClinical Pharmacology UnitAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Raquel E Marques
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAvenida Professor Egas MonizLisboaLisboaPortugal1649‐028
- Instituto de Medicina MolecularClinical Pharmacology UnitAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Joaquim Ferreira
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAvenida Professor Egas MonizLisboaLisboaPortugal1649‐028
- Instituto de Medicina MolecularClinical Pharmacology UnitAv. Prof. Egas MonizLisboaPortugal1649‐028
| | - Cristina Sampaio
- CHDI Foundation155 Village BoulevardSuite 200PrincetonNJUSA08540
| | - Austen P Moore
- The Walton Centre NHS Foundation TrustLower LaneLiverpoolUKL9 7LJ
| | - João Costa
- Faculdade de Medicina de LisboaLaboratório de Farmacologia Clínica e TerapêuticaAvenida Professor Egas MonizLisboaLisboaPortugal1649‐028
- Instituto de Medicina MolecularClinical Pharmacology UnitAv. Prof. Egas MonizLisboaPortugal1649‐028
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Thacker T, Wegele AR, Pirio Richardson S. Utility of electronic medical record for recruitment in clinical research: from rare to common disease. Mov Disord Clin Pract 2016; 3:507-509. [PMID: 27713907 PMCID: PMC5047661 DOI: 10.1002/mdc3.12318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 12/04/2015] [Accepted: 12/06/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recruitment for clinical trials is a major challenge. Movement disorders, which do not have associated diagnostic laboratory tests, may be especially prone to inaccuracy in coding. Our objective was to evaluate the accuracy of diagnostic codes such as cervical dystonia (CD) and PD in an electronic medical record. METHODS Retrospective chart review was performed to confirm the ICD-9 diagnoses of PD, CD and diabetes mellitus type 2 (DM-2), using published clinical diagnostic criteria (PD, CD) and hemoglobin A1c ≥ 6.5 (DM-2). RESULTS 421 charts (n=129, n=142, n=150 for PD, CD and DM-2, respectively) were reviewed. The accuracy rate was different between all diseases examined with an overall p<0.001. In post hoc pairwise comparisons, the accuracy of DM-2 diagnosis by ICD-9 (96.6%) was greater than CD (88.0%) and both greater than PD (55.0%) (p≤0.003). CONCLUSIONS Using an electronic medical record based screening of clinically diagnosed diseases such as CD may be more accurate than previously thought and may identify potential clinical trial participants even without confirmatory lab tests available.
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Affiliation(s)
- Tapan Thacker
- Department of NeurologyUniversity of New Mexico Health Sciences CenterAlbuquerqueNew MexicoUSA
| | - Ashley R. Wegele
- Department of NeurologyUniversity of New Mexico Health Sciences CenterAlbuquerqueNew MexicoUSA
| | - Sarah Pirio Richardson
- Department of NeurologyUniversity of New Mexico Health Sciences CenterAlbuquerqueNew MexicoUSA
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Wu C, Xue F, Chang W, Lian Y, Zheng Y, Xie N, Zhang L, Chen C. Botulinum toxin type A with or without needle electromyographic guidance in patients with cervical dystonia. SPRINGERPLUS 2016; 5:1292. [PMID: 27547666 PMCID: PMC4977261 DOI: 10.1186/s40064-016-2967-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 07/29/2016] [Indexed: 11/04/2022]
Abstract
Aim To investigate the efficacy and safety of electromyography (EMG)- and palpation-guided botulinum toxin type A injection in cervical dystonia (CD) patients. Methods In this randomized, controlled trial, 68 CD patients were randomly allocated to two groups, receiving botulinum toxin type A injections guided by either palpation (Group A) or EMG (Group B). The primary endpoint is defined as the difference in the Tsui score between groups at 16 weeks. The secondary endpoints were the visual analog scale (VAS) and Hospital Anxiety and Depression Scale (HADS) scores and Clinical and Patient Global Impression of Change (CGIC and PGIC). Results Sixty-five patients completed the study. No significant difference was observed in the Tsui score between groups A and B at 4, 8, and 12 weeks after treatment (p > 0.05). However, 16 weeks after treatment, the Tsui score of group A was significantly higher than that of group B. For both groups, the degree of pain at each time point during follow-up significantly reduced after treatment. However, no significant difference was observed in VAS scores between the two groups. Interestingly, the patient HADS score decreased without statistical significance 8 weeks following treatment. No significant difference in HADS scores was observed between the two groups. Additionally, there was no significant difference in PGIC and CGIC between the two groups. However, CGIC was significantly higher than PGIC. No significant difference in adverse reactions was observed between groups. CD patients treated with EMG guidance experienced a significantly more pain at the injection site but a significantly lower adverse event occurrence rate of dysphagia when compared to CD patients treated with palpation guidance only. Conclusions CD patients treated with EMG guidance experienced a prolonged benefit as measured by the Tsui scale when compared to CD patients treated with palpation guidance alone. EMG-guided injection resulted in a lower incidence of dysphagia and higher incidence of discomfort at the injection site than palpation-guided injection.
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Affiliation(s)
- Chuanjie Wu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 China
| | - Fang Xue
- Department of Neurology, The Second Hospital of Hebei Medical University, Shi Jiazhuang, China
| | - Wansheng Chang
- Department of Neurology, The Second People's Hospital of Liaocheng, Shandong, China
| | - Yajun Lian
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 China
| | - Yake Zheng
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 China
| | - Nanchang Xie
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 China
| | - Lu Zhang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 China
| | - Chen Chen
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 China
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Simpson DM, Hallett M, Ashman EJ, Comella CL, Green MW, Gronseth GS, Armstrong MJ, Gloss D, Potrebic S, Jankovic J, Karp BP, Naumann M, So YT, Yablon SA. Practice guideline update summary: Botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2016; 86:1818-26. [PMID: 27164716 DOI: 10.1212/wnl.0000000000002560] [Citation(s) in RCA: 348] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 12/21/2015] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To update the 2008 American Academy of Neurology (AAN) guidelines regarding botulinum neurotoxin for blepharospasm, cervical dystonia (CD), headache, and adult spasticity. METHODS We searched the literature for relevant articles and classified them using 2004 AAN criteria. RESULTS AND RECOMMENDATIONS Blepharospasm: OnabotulinumtoxinA (onaBoNT-A) and incobotulinumtoxinA (incoBoNT-A) are probably effective and should be considered (Level B). AbobotulinumtoxinA (aboBoNT-A) is possibly effective and may be considered (Level C). CD: AboBoNT-A and rimabotulinumtoxinB (rimaBoNT-B) are established as effective and should be offered (Level A), and onaBoNT-A and incoBoNT-A are probably effective and should be considered (Level B). Adult spasticity: AboBoNT-A, incoBoNT-A, and onaBoNT-A are established as effective and should be offered (Level A), and rimaBoNT-B is probably effective and should be considered (Level B), for upper limb spasticity. AboBoNT-A and onaBoNT-A are established as effective and should be offered (Level A) for lower-limb spasticity. Headache: OnaBoNT-A is established as effective and should be offered to increase headache-free days (Level A) and is probably effective and should be considered to improve health-related quality of life (Level B) in chronic migraine. OnaBoNT-A is established as ineffective and should not be offered for episodic migraine (Level A) and is probably ineffective for chronic tension-type headaches (Level B).
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Affiliation(s)
- David M Simpson
- From the Department of Neurology (D.M.S., M.W.G.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke (B.P.K.), National Institutes of Health, Bethesda, MD; Department of Neurology (E.J.A.), Bronson Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, MI; Department of Neurological Sciences (C.L.C.), Rush University Medical Center, Chicago, IL; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City; Department of Neurology (M.J.A.), University of Maryland, Baltimore; Department of Neurology (D.G.), Geisinger Health System, Danville, PA; Department of Neurology (S.P.), Kaiser Permanente Los Angeles Medical Center, CA; Parkinson's Disease Center and Movement Disorders Clinic (J.J.), Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Neurology and Clinical Neurophysiology (M.N.), Klinikum Augsburg, Germany; Department of Neurology and Neurological Sciences (Y.T.S.), Stanford University, Palo Alto, CA; and Division of Physical Medicine and Rehabilitation (S.A.Y.), University of Alberta, Edmonton, Canada
| | - Mark Hallett
- From the Department of Neurology (D.M.S., M.W.G.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke (B.P.K.), National Institutes of Health, Bethesda, MD; Department of Neurology (E.J.A.), Bronson Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, MI; Department of Neurological Sciences (C.L.C.), Rush University Medical Center, Chicago, IL; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City; Department of Neurology (M.J.A.), University of Maryland, Baltimore; Department of Neurology (D.G.), Geisinger Health System, Danville, PA; Department of Neurology (S.P.), Kaiser Permanente Los Angeles Medical Center, CA; Parkinson's Disease Center and Movement Disorders Clinic (J.J.), Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Neurology and Clinical Neurophysiology (M.N.), Klinikum Augsburg, Germany; Department of Neurology and Neurological Sciences (Y.T.S.), Stanford University, Palo Alto, CA; and Division of Physical Medicine and Rehabilitation (S.A.Y.), University of Alberta, Edmonton, Canada
| | - Eric J Ashman
- From the Department of Neurology (D.M.S., M.W.G.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke (B.P.K.), National Institutes of Health, Bethesda, MD; Department of Neurology (E.J.A.), Bronson Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, MI; Department of Neurological Sciences (C.L.C.), Rush University Medical Center, Chicago, IL; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City; Department of Neurology (M.J.A.), University of Maryland, Baltimore; Department of Neurology (D.G.), Geisinger Health System, Danville, PA; Department of Neurology (S.P.), Kaiser Permanente Los Angeles Medical Center, CA; Parkinson's Disease Center and Movement Disorders Clinic (J.J.), Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Neurology and Clinical Neurophysiology (M.N.), Klinikum Augsburg, Germany; Department of Neurology and Neurological Sciences (Y.T.S.), Stanford University, Palo Alto, CA; and Division of Physical Medicine and Rehabilitation (S.A.Y.), University of Alberta, Edmonton, Canada
| | - Cynthia L Comella
- From the Department of Neurology (D.M.S., M.W.G.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke (B.P.K.), National Institutes of Health, Bethesda, MD; Department of Neurology (E.J.A.), Bronson Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, MI; Department of Neurological Sciences (C.L.C.), Rush University Medical Center, Chicago, IL; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City; Department of Neurology (M.J.A.), University of Maryland, Baltimore; Department of Neurology (D.G.), Geisinger Health System, Danville, PA; Department of Neurology (S.P.), Kaiser Permanente Los Angeles Medical Center, CA; Parkinson's Disease Center and Movement Disorders Clinic (J.J.), Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Neurology and Clinical Neurophysiology (M.N.), Klinikum Augsburg, Germany; Department of Neurology and Neurological Sciences (Y.T.S.), Stanford University, Palo Alto, CA; and Division of Physical Medicine and Rehabilitation (S.A.Y.), University of Alberta, Edmonton, Canada
| | - Mark W Green
- From the Department of Neurology (D.M.S., M.W.G.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke (B.P.K.), National Institutes of Health, Bethesda, MD; Department of Neurology (E.J.A.), Bronson Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, MI; Department of Neurological Sciences (C.L.C.), Rush University Medical Center, Chicago, IL; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City; Department of Neurology (M.J.A.), University of Maryland, Baltimore; Department of Neurology (D.G.), Geisinger Health System, Danville, PA; Department of Neurology (S.P.), Kaiser Permanente Los Angeles Medical Center, CA; Parkinson's Disease Center and Movement Disorders Clinic (J.J.), Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Neurology and Clinical Neurophysiology (M.N.), Klinikum Augsburg, Germany; Department of Neurology and Neurological Sciences (Y.T.S.), Stanford University, Palo Alto, CA; and Division of Physical Medicine and Rehabilitation (S.A.Y.), University of Alberta, Edmonton, Canada
| | - Gary S Gronseth
- From the Department of Neurology (D.M.S., M.W.G.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke (B.P.K.), National Institutes of Health, Bethesda, MD; Department of Neurology (E.J.A.), Bronson Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, MI; Department of Neurological Sciences (C.L.C.), Rush University Medical Center, Chicago, IL; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City; Department of Neurology (M.J.A.), University of Maryland, Baltimore; Department of Neurology (D.G.), Geisinger Health System, Danville, PA; Department of Neurology (S.P.), Kaiser Permanente Los Angeles Medical Center, CA; Parkinson's Disease Center and Movement Disorders Clinic (J.J.), Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Neurology and Clinical Neurophysiology (M.N.), Klinikum Augsburg, Germany; Department of Neurology and Neurological Sciences (Y.T.S.), Stanford University, Palo Alto, CA; and Division of Physical Medicine and Rehabilitation (S.A.Y.), University of Alberta, Edmonton, Canada
| | - Melissa J Armstrong
- From the Department of Neurology (D.M.S., M.W.G.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke (B.P.K.), National Institutes of Health, Bethesda, MD; Department of Neurology (E.J.A.), Bronson Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, MI; Department of Neurological Sciences (C.L.C.), Rush University Medical Center, Chicago, IL; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City; Department of Neurology (M.J.A.), University of Maryland, Baltimore; Department of Neurology (D.G.), Geisinger Health System, Danville, PA; Department of Neurology (S.P.), Kaiser Permanente Los Angeles Medical Center, CA; Parkinson's Disease Center and Movement Disorders Clinic (J.J.), Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Neurology and Clinical Neurophysiology (M.N.), Klinikum Augsburg, Germany; Department of Neurology and Neurological Sciences (Y.T.S.), Stanford University, Palo Alto, CA; and Division of Physical Medicine and Rehabilitation (S.A.Y.), University of Alberta, Edmonton, Canada
| | - David Gloss
- From the Department of Neurology (D.M.S., M.W.G.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke (B.P.K.), National Institutes of Health, Bethesda, MD; Department of Neurology (E.J.A.), Bronson Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, MI; Department of Neurological Sciences (C.L.C.), Rush University Medical Center, Chicago, IL; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City; Department of Neurology (M.J.A.), University of Maryland, Baltimore; Department of Neurology (D.G.), Geisinger Health System, Danville, PA; Department of Neurology (S.P.), Kaiser Permanente Los Angeles Medical Center, CA; Parkinson's Disease Center and Movement Disorders Clinic (J.J.), Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Neurology and Clinical Neurophysiology (M.N.), Klinikum Augsburg, Germany; Department of Neurology and Neurological Sciences (Y.T.S.), Stanford University, Palo Alto, CA; and Division of Physical Medicine and Rehabilitation (S.A.Y.), University of Alberta, Edmonton, Canada
| | - Sonja Potrebic
- From the Department of Neurology (D.M.S., M.W.G.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke (B.P.K.), National Institutes of Health, Bethesda, MD; Department of Neurology (E.J.A.), Bronson Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, MI; Department of Neurological Sciences (C.L.C.), Rush University Medical Center, Chicago, IL; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City; Department of Neurology (M.J.A.), University of Maryland, Baltimore; Department of Neurology (D.G.), Geisinger Health System, Danville, PA; Department of Neurology (S.P.), Kaiser Permanente Los Angeles Medical Center, CA; Parkinson's Disease Center and Movement Disorders Clinic (J.J.), Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Neurology and Clinical Neurophysiology (M.N.), Klinikum Augsburg, Germany; Department of Neurology and Neurological Sciences (Y.T.S.), Stanford University, Palo Alto, CA; and Division of Physical Medicine and Rehabilitation (S.A.Y.), University of Alberta, Edmonton, Canada
| | - Joseph Jankovic
- From the Department of Neurology (D.M.S., M.W.G.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke (B.P.K.), National Institutes of Health, Bethesda, MD; Department of Neurology (E.J.A.), Bronson Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, MI; Department of Neurological Sciences (C.L.C.), Rush University Medical Center, Chicago, IL; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City; Department of Neurology (M.J.A.), University of Maryland, Baltimore; Department of Neurology (D.G.), Geisinger Health System, Danville, PA; Department of Neurology (S.P.), Kaiser Permanente Los Angeles Medical Center, CA; Parkinson's Disease Center and Movement Disorders Clinic (J.J.), Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Neurology and Clinical Neurophysiology (M.N.), Klinikum Augsburg, Germany; Department of Neurology and Neurological Sciences (Y.T.S.), Stanford University, Palo Alto, CA; and Division of Physical Medicine and Rehabilitation (S.A.Y.), University of Alberta, Edmonton, Canada
| | - Barbara P Karp
- From the Department of Neurology (D.M.S., M.W.G.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke (B.P.K.), National Institutes of Health, Bethesda, MD; Department of Neurology (E.J.A.), Bronson Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, MI; Department of Neurological Sciences (C.L.C.), Rush University Medical Center, Chicago, IL; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City; Department of Neurology (M.J.A.), University of Maryland, Baltimore; Department of Neurology (D.G.), Geisinger Health System, Danville, PA; Department of Neurology (S.P.), Kaiser Permanente Los Angeles Medical Center, CA; Parkinson's Disease Center and Movement Disorders Clinic (J.J.), Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Neurology and Clinical Neurophysiology (M.N.), Klinikum Augsburg, Germany; Department of Neurology and Neurological Sciences (Y.T.S.), Stanford University, Palo Alto, CA; and Division of Physical Medicine and Rehabilitation (S.A.Y.), University of Alberta, Edmonton, Canada
| | - Markus Naumann
- From the Department of Neurology (D.M.S., M.W.G.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke (B.P.K.), National Institutes of Health, Bethesda, MD; Department of Neurology (E.J.A.), Bronson Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, MI; Department of Neurological Sciences (C.L.C.), Rush University Medical Center, Chicago, IL; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City; Department of Neurology (M.J.A.), University of Maryland, Baltimore; Department of Neurology (D.G.), Geisinger Health System, Danville, PA; Department of Neurology (S.P.), Kaiser Permanente Los Angeles Medical Center, CA; Parkinson's Disease Center and Movement Disorders Clinic (J.J.), Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Neurology and Clinical Neurophysiology (M.N.), Klinikum Augsburg, Germany; Department of Neurology and Neurological Sciences (Y.T.S.), Stanford University, Palo Alto, CA; and Division of Physical Medicine and Rehabilitation (S.A.Y.), University of Alberta, Edmonton, Canada
| | - Yuen T So
- From the Department of Neurology (D.M.S., M.W.G.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke (B.P.K.), National Institutes of Health, Bethesda, MD; Department of Neurology (E.J.A.), Bronson Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, MI; Department of Neurological Sciences (C.L.C.), Rush University Medical Center, Chicago, IL; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City; Department of Neurology (M.J.A.), University of Maryland, Baltimore; Department of Neurology (D.G.), Geisinger Health System, Danville, PA; Department of Neurology (S.P.), Kaiser Permanente Los Angeles Medical Center, CA; Parkinson's Disease Center and Movement Disorders Clinic (J.J.), Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Neurology and Clinical Neurophysiology (M.N.), Klinikum Augsburg, Germany; Department of Neurology and Neurological Sciences (Y.T.S.), Stanford University, Palo Alto, CA; and Division of Physical Medicine and Rehabilitation (S.A.Y.), University of Alberta, Edmonton, Canada
| | - Stuart A Yablon
- From the Department of Neurology (D.M.S., M.W.G.), Icahn School of Medicine at Mount Sinai, New York, NY; Human Motor Control Section (M.H.), National Institute of Neurological Disorders and Stroke (B.P.K.), National Institutes of Health, Bethesda, MD; Department of Neurology (E.J.A.), Bronson Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, MI; Department of Neurological Sciences (C.L.C.), Rush University Medical Center, Chicago, IL; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City; Department of Neurology (M.J.A.), University of Maryland, Baltimore; Department of Neurology (D.G.), Geisinger Health System, Danville, PA; Department of Neurology (S.P.), Kaiser Permanente Los Angeles Medical Center, CA; Parkinson's Disease Center and Movement Disorders Clinic (J.J.), Department of Neurology, Baylor College of Medicine, Houston, TX; Department of Neurology and Clinical Neurophysiology (M.N.), Klinikum Augsburg, Germany; Department of Neurology and Neurological Sciences (Y.T.S.), Stanford University, Palo Alto, CA; and Division of Physical Medicine and Rehabilitation (S.A.Y.), University of Alberta, Edmonton, Canada
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LeDoux MS, Vemula SR, Xiao J, Thompson MM, Perlmutter JS, Wright LJ, Jinnah HA, Rosen AR, Hedera P, Comella CL, Weissbach A, Junker J, Jankovic J, Barbano RL, Reich SG, Rodriguez RL, Berman BD, Chouinard S, Severt L, Agarwal P, Stover NP. Clinical and genetic features of cervical dystonia in a large multicenter cohort. NEUROLOGY-GENETICS 2016; 2:e69. [PMID: 27123488 PMCID: PMC4830199 DOI: 10.1212/nxg.0000000000000069] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 03/01/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To characterize the clinical and genetic features of cervical dystonia (CD). METHODS Participants enrolled in the Dystonia Coalition biorepository (NCT01373424) with initial manifestation as CD were included in this study (n = 1,000). Data intake included demographics, family history, and the Global Dystonia Rating Scale. Participants were screened for sequence variants (SVs) in GNAL, THAP1, and Exon 5 of TOR1A. RESULTS The majority of participants were Caucasian (95%) and female (75%). The mean age at onset and disease duration were 45.5 ± 13.6 and 14.6 ± 11.8 years, respectively. At the time of assessment, 68.5% had involvement limited to the neck, shoulder(s), and proximal arm(s), whereas 47.4% had dystonia limited to the neck. The remaining 31.5% of the individuals exhibited more extensive anatomical spread. A head tremor was noted in 62% of the patients. Head tremor and laryngeal dystonia were more common in females. Psychiatric comorbidities, mainly depression and anxiety, were reported by 32% of the participants and were more common in females. Family histories of dystonia, parkinsonian disorder, and tremor were present in 14%, 11%, and 29% of the patients, respectively. Pathogenic or likely pathogenic SVs in THAP1, TOR1A, and GNAL were identified in 8 participants (0.8%). Two individuals harbored novel missense SVs in Exon 5 of TOR1A. Synonymous and noncoding SVs in THAP1 and GNAL were identified in 4% of the cohort. CONCLUSIONS Head tremor, laryngeal dystonia, and psychiatric comorbidities are more common in female participants with CD. Coding and noncoding variants in GNAL, THAP1, and TOR1A make small contributions to the pathogenesis of CD.
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Affiliation(s)
- Mark S LeDoux
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - Satya R Vemula
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - Jianfeng Xiao
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - Misty M Thompson
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - Joel S Perlmutter
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - Laura J Wright
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - H A Jinnah
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - Ami R Rosen
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - Peter Hedera
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - Cynthia L Comella
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - Anne Weissbach
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - Johanna Junker
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - Joseph Jankovic
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - Richard L Barbano
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - Stephen G Reich
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - Ramon L Rodriguez
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - Brian D Berman
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - Sylvain Chouinard
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - Lawrence Severt
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - Pinky Agarwal
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
| | - Natividad P Stover
- Departments of Neurology and Anatomy & Neurobiology (M.S.L., S.R.V., J.X., M.M.T.), University of Tennessee Health Science Center, Memphis, TN; Department of Neurology (J.S.P., L.J.W.), Washington University School of Medicine, St. Louis, MO; Departments of Neurology (A.R.R.), Human Genetics, and Pediatrics (H.A.J.), School of Medicine, Emory University, Atlanta, GA; Department of Neurology (P.H.), Vanderbilt University, Nashville, TN; Department of Neurological Sciences (C.L.C.), Rush University, Chicago, IL; Institute of Neurogenetics (A.W., J. Junker), University of Lübeck, Germany; Department of Neurology (J. Jankovic), Baylor College of Medicine, Houston, TX; Department of Neurology (R.L.B.), University of Rochester, NY; Department of Neurology (S.G.R.), University of Maryland, Baltimore, MD; Department of Neurology (R.L.R.), University of Florida, Gainesville, FL; Department of Neurology (B.D.B.), University of Colorado Denver School of Medicine, Aurora, CO; Center of Excellence in Neuroscience (S.C.), University of Montreal, QC, Canada; Mirken Department of Neurology (L.S.), Mt. Sinai Beth Israel Medical Center, New York, NY; Booth Gardner Parkinson's Care Center (P.A.), Kirkland, WA; and Department of Neurology (N.P.S.), University of Alabama at Birmingham, AL
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Han Y, Stevens AL, Dashtipour K, Hauser RA, Mari Z. A mixed treatment comparison to compare the efficacy and safety of botulinum toxin treatments for cervical dystonia. J Neurol 2016; 263:772-80. [PMID: 26914922 PMCID: PMC4826665 DOI: 10.1007/s00415-016-8050-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 01/23/2016] [Accepted: 01/25/2016] [Indexed: 12/17/2022]
Abstract
A systematic pair-wise comparison of all available botulinum toxin serotype A and B treatments for cervical dystonia (CD) was conducted, as direct head-to-head clinical trial comparisons are lacking. Five botulinum toxin products: Dysport® (abobotulinumtoxinA), Botox® (onabotulinumtoxinA), Xeomin® (incobotulinumtoxinA), Prosigne® (Chinese botulinum toxin serotype A) and Myobloc® (rimabotulinumtoxinB) have demonstrated efficacy for managing CD. A pair-wise efficacy and safety comparison was performed for all toxins based on literature-reported clinical outcomes. Multi-armed randomized controlled trials (RCTs) were identified for inclusion using a systematic literature review, and assessed for comparability based on patient population and efficacy outcome measures. The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) was selected as the efficacy outcome measurement for assessment. A mixed treatment comparison (MTC) was conducted using a Bayesian hierarchical model allowing indirect comparison of the interventions. Due to the limitation of available
clinical data, this study only investigated the main effect of toxin treatments without explicitly considering potential confounding factors such as gender and formulation differences. There was reasonable agreement between the number of unconstrained data points, residual deviance and pair-wise results. This research suggests that all botulinum toxin serotype A and serotype B treatments were effective compared to placebo in treating CD, with the exception of Prosigne. Based on this MTC analysis, there is no significant efficacy difference between Dysport, Botox, Xeomin and Myobloc at week four post injection. Of the adverse events measured, neither dysphagia nor injection site pain was significantly greater in the treatment or placebo groups.
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Affiliation(s)
- Yi Han
- WG Consulting, 200 Fifth Avenue, New York, NY, 10010, USA.
| | | | - Khashayar Dashtipour
- Faculty of Medical Offices, School of Medicine, Loma Linda University, 11370 Anderson, Suite B-100, Loma Linda, CA, 92354, USA
| | - Robert A Hauser
- Health Byrd Institute, University of South Florida, 4001 E. Fletcher Ave, 6th Floor, Tampa, FL, 33613, USA
| | - Zoltan Mari
- School of Medicine, Johns Hopkins University, 600 N. Wolfe Street, Meyer 6-181B, Baltimore, MD, 21287, USA
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Brin MF, Kirby RS, Slavotinek A, Miller-Messana MA, Parker L, Yushmanova I, Yang H. Pregnancy outcomes following exposure to onabotulinumtoxinA. Pharmacoepidemiol Drug Saf 2015; 25:179-87. [PMID: 26635276 PMCID: PMC5063122 DOI: 10.1002/pds.3920] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 10/05/2015] [Accepted: 10/20/2015] [Indexed: 11/08/2022]
Abstract
PURPOSE To evaluate pregnancy outcomes following onabotulinumtoxinA (US Food and Drug Administration pregnancy category C product) exposure using the Allergan safety database. METHODS The Allergan Global Safety Database contains reports of onabotulinumtoxinA administration before/during pregnancy, including both prospective (reported before outcome) and retrospective (outcome already known) cases. The database was searched from 1/1/90 to 12/31/13 for eligible cases where treatment occurred during pregnancy or ≤3 months before conception. To minimize reporting bias, prevalence rates were focused on prospective cases. RESULTS Of 574 pregnancies with maternal onabotulinumtoxinA exposure, 232 were eligible with known outcomes. Patients received onabotulinumtoxinA most frequently for cosmetic indications (50.5%), movement disorders (16.8%), and pain disorders (14.2%). Of the 137 with dose information, 40.1% received <50U, 14.6% 50U to <100U, 27.7% 100U to <200U, and 17.5% ≥200U. Among 146 cases with known maternal age, 47.9% were ≥35 years. Most (96.0%) fetal exposures occurred during/before the first trimester. Of the 137 prospective cases (139 fetuses), 110 (79.1%) were live births; 29 (20.9%; 95% CI, 14.0-30.0%) ended in fetal loss (21 spontaneous, 8 induced abortions). Among live births, 106 (96.4%) were normal, with four abnormal birth outcomes (1 major fetal defect, 2 minor fetal malformations, 1 birth complication), giving a 2.7% (3/110; 95% CI, 0.6-8.0%) prevalence rate for overall fetal defects. CONCLUSIONS A 24-year retrospective review of the Allergan safety database shows that the prevalence of fetal defects in onabotulinumtoxinA-exposed mothers before/during pregnancy (2.7%) is comparable with background rates in the general population. Pregnancy outcome monitoring in onabotulinumtoxinA-exposed women continues.
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Affiliation(s)
- Mitchell F Brin
- Allergan, Inc., Irvine, CA, USA.,University of California, Irvine, CA, USA
| | | | | | | | | | | | - Huiying Yang
- Allergan, Inc., Irvine, CA, USA.,Now at the Department of Drug Safety and Pharmacovigilance, Pharmacyclics, Inc., Sunnyvale, CA, USA
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Williams LJ, Butler JS, Molloy A, McGovern E, Beiser I, Kimmich O, Quinlivan B, O'Riordan S, Hutchinson M, Reilly RB. Young Women do it Better: Sexual Dimorphism in Temporal Discrimination. Front Neurol 2015. [PMID: 26217303 PMCID: PMC4497309 DOI: 10.3389/fneur.2015.00160] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The temporal discrimination threshold (TDT) is the shortest time interval at which two sensory stimuli presented sequentially are detected as asynchronous by the observer. TDTs are known to increase with age. Having previously observed shorter thresholds in young women than in men, in this work we sought to systematically examine the effect of sex and age on temporal discrimination. The aims of this study were to examine, in a large group of men and women aged 20–65 years, the distribution of TDTs with an analysis of the individual participant’s responses, assessing the “point of subjective equality” and the “just noticeable difference” (JND). These respectively assess sensitivity and accuracy of an individual’s response. In 175 participants (88 women) aged 20–65 years, temporal discrimination was faster in women than in men under the age of 40 years by a mean of approximately 13 ms. However, age-related decline in temporal discrimination was three times faster in women so that, in the age group of 40–65 years, the female superiority was reversed. The point of subjective equality showed a similar advantage in younger women and more marked age-related decline in women than men, as the TDT. JND values declined equally in both sexes, showing no sexual dimorphism. This observed sexual dimorphism in temporal discrimination is important for both (a) future clinical research assessing disordered mid-brain covert attention in basal-ganglia disorders, and (b) understanding the biology of this sexual dimorphism which may be genetic or hormonal.
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Affiliation(s)
- Laura Jane Williams
- Department of Neurology, St. Vincent's University Hospital , Dublin , Ireland ; School of Medicine and Medical Science, University College Dublin , Dublin , Ireland
| | - John S Butler
- Trinity Centre for Bioengineering, Trinity College Dublin , Dublin , Ireland ; School of Engineering, Trinity College Dublin , Dublin , Ireland
| | - Anna Molloy
- Department of Neurology, St. Vincent's University Hospital , Dublin , Ireland ; School of Medicine and Medical Science, University College Dublin , Dublin , Ireland
| | - Eavan McGovern
- Department of Neurology, St. Vincent's University Hospital , Dublin , Ireland ; School of Medicine and Medical Science, University College Dublin , Dublin , Ireland
| | - Ines Beiser
- Department of Neurology, St. Vincent's University Hospital , Dublin , Ireland ; School of Medicine and Medical Science, University College Dublin , Dublin , Ireland
| | - Okka Kimmich
- Department of Neurology, St. Vincent's University Hospital , Dublin , Ireland ; School of Medicine and Medical Science, University College Dublin , Dublin , Ireland
| | - Brendan Quinlivan
- Trinity Centre for Bioengineering, Trinity College Dublin , Dublin , Ireland ; School of Engineering, Trinity College Dublin , Dublin , Ireland
| | - Sean O'Riordan
- Department of Neurology, St. Vincent's University Hospital , Dublin , Ireland ; School of Medicine and Medical Science, University College Dublin , Dublin , Ireland
| | - Michael Hutchinson
- Department of Neurology, St. Vincent's University Hospital , Dublin , Ireland ; School of Medicine and Medical Science, University College Dublin , Dublin , Ireland
| | - Richard B Reilly
- Trinity Centre for Bioengineering, Trinity College Dublin , Dublin , Ireland ; School of Engineering, Trinity College Dublin , Dublin , Ireland ; School of Medicine, Trinity College Dublin , Dublin , Ireland
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Iacono D, Geraci-Erck M, Peng H, Rabin ML, Kurlan R. Reduced Number of Pigmented Neurons in the Substantia Nigra of Dystonia Patients? Findings from Extensive Neuropathologic, Immunohistochemistry, and Quantitative Analyses. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2015; 5. [PMID: 26069855 PMCID: PMC4458735 DOI: 10.7916/d8t72g9g] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 03/07/2015] [Indexed: 01/05/2023]
Abstract
Background Dystonias (Dys) represent the third most common movement disorder after essential tremor (ET) and Parkinson's disease (PD). While some pathogenetic mechanisms and genetic causes of Dys have been identified, little is known about their neuropathologic features. Previous neuropathologic studies have reported generically defined neuronal loss in various cerebral regions of Dys brains, mostly in the basal ganglia (BG), and specifically in the substantia nigra (SN). Enlarged pigmented neurons in the SN of Dys patients with and without specific genetic mutations (e.g., GAG deletions in DYT1 dystonia) have also been described. Whether or not Dys brains are associated with decreased numbers or other morphometric changes of specific neuronal types is unknown and has never been addressed with quantitative methodologies. Methods Quantitative immunohistochemistry protocols were used to estimate neuronal counts and volumes of nigral pigmented neurons in 13 SN of Dys patients and 13 SN of age-matched control subjects (C). Results We observed a significant reduction (∼20%) of pigmented neurons in the SN of Dys compared to C (p<0.01). Neither significant volumetric changes nor evident neurodegenerative signs were observed in the remaining pool of nigral pigmented neurons in Dys brains. These novel quantitative findings were confirmed after exclusion of possible co-occurring SN pathologies including Lewy pathology, tau-neurofibrillary tangles, β-amyloid deposits, ubiquitin (ubiq), and phosphorylated-TAR DNA-binding protein 43 (pTDP43)-positive inclusions. Discussion A reduced number of nigral pigmented neurons in the absence of evident neurodegenerative signs in Dys brains could indicate previously unconsidered pathogenetic mechanisms of Dys such as neurodevelopmental defects in the SN.
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Affiliation(s)
- Diego Iacono
- Neuropathology Research, Biomedical Research Institute of New Jersey, BRInj, Cedar Knolls, NJ, USA ; Movement Disorders Program, Atlantic Neuroscience Institute, Overlook Medical Center, Summit, NJ, USA ; Department of Neurology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York City, NY, USA
| | - Maria Geraci-Erck
- Neuropathology Research, Biomedical Research Institute of New Jersey, BRInj, Cedar Knolls, NJ, USA
| | - Hui Peng
- Neuropathology Research, Biomedical Research Institute of New Jersey, BRInj, Cedar Knolls, NJ, USA
| | - Marcie L Rabin
- Movement Disorders Program, Atlantic Neuroscience Institute, Overlook Medical Center, Summit, NJ, USA
| | - Roger Kurlan
- Movement Disorders Program, Atlantic Neuroscience Institute, Overlook Medical Center, Summit, NJ, USA ; Department of Neurology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York City, NY, USA
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Raluy-Callado M, Gabriel S, Dinet J, Wang M, Wasiak R. A retrospective study to assess resource utilization in patients with cervical dystonia in the United Kingdom. Neuropsychiatr Dis Treat 2015; 11:647-55. [PMID: 25834443 PMCID: PMC4358415 DOI: 10.2147/ndt.s78618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Cervical dystonia (CD) is a hypertonic condition caused by damage to the central nervous system. Very few studies have assessed the overall economic burden of the disease. The objective of this study was to describe the utilization of health care resources of patients with CD in the UK primary care setting, using a large population-based database. PATIENTS AND METHODS Adults with a first diagnosis of CD between January 1, 2007 and January 31, 2011, who were registered to a general practitioner (GP) practice contributing to The Health Improvement Network (THIN), were included. Sociodemographic and clinical characteristics were assessed at the time of diagnosis. Health care resource utilization and pharmacological treatment were investigated at the end of the first and second year after diagnosis. RESULTS Overall, 4,024 newly diagnosed patients with CD were identified, with average age at diagnosis of 45 years old; 65.3% were female. Depression in the year prior to diagnosis was the most common comorbidity. Primary care utilization was high in the first year, with 99.2% of patients visiting their GP (on average 6.2 times), and 43% visiting a nurse (on average 2.5 times). Patients were most commonly referred to an orthopedic surgeon, and 15.9% reported at least one physiotherapy visit. In the second year, utilization was similar. Prescriptions of at least one of the investigated treatments were found in 82.0% and 45.3%, in the first and second year, respectively. CONCLUSION Findings suggest a high number of new CD cases are being identified in primary care, but not all will be referred to secondary care. Health care resource utilization was compared with that of all patients registered in THIN, which is representative of the UK, and the adjusted usage of primary care resources was found to be similar to that of the THIN population.
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Affiliation(s)
| | | | | | - Meng Wang
- Retrospective Observational Studies, Evidera, London, UK
| | - Radek Wasiak
- Retrospective Observational Studies, Evidera, London, UK
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Patel N, Hanfelt J, Marsh L, Jankovic J. Alleviating manoeuvres (sensory tricks) in cervical dystonia. J Neurol Neurosurg Psychiatry 2014; 85:882-4. [PMID: 24828895 PMCID: PMC4871143 DOI: 10.1136/jnnp-2013-307316] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND There is limited information on the phenomenology, clinical characteristics and pathophysiology of alleviating manoeuvres (AM), also called 'sensory tricks' in cervical dystonia (CD). METHODS Individual data, collected from 10 sites participating in the Dystonia Coalition (http://clinicaltrials.gov/show/NCT01373424), included description of localisation and phenomenology of AM collected by systematic review of standardised video examinations. Analyses correlated demographic, neurologic, and psychiatric features of CD patients with or without effective AM. RESULTS Of 154 people studied, 138 (89.6%) used AM, of which 60 (43.4%) reported partial improvement, 55 (39.8%) marked improvement, and 4 (0.03%) no effect on dystonic posture. Light touch, usually to the lower face or neck, was used by >90%. The presence or location of AM did not correlate with the severity of the dystonia. CONCLUSIONS In this large and comprehensive study of CD, we found no clinical predictors of effective AM. Further studies of sensorimotor integration in dystonia are needed to better understand the pathophysiology of AM.
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Affiliation(s)
- Neepa Patel
- Department of Neurology and Neurotherapeutics, Center for Movement Disorders, University of Texas Southwestern, Dallas, Texas, USA
| | - John Hanfelt
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia, USA
| | - Laura Marsh
- Departments of Psychiatry and Neurology, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
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