[Treatment goals in patients with post-stroke upper limb spasticity following injection of botulinum toxin A : Results of the German-Austrian subgroup of the ULIS-II study]

BACKGROUND

The ULIS-II was an international cohort study (NCT01020500) evaluating current treatment of upper limb spasticity in post-stroke adult patients with botulinum toxin A (BoNT-A) in real-life practice.

OBJECTIVE

Post hoc analysis to compare current management of post-stroke adult patients regarding goal setting and attainment with BoNT-A in Germany (D) and Austria (A) with the full cohort of ULIS-II.

MATERIAL AND METHODS

The ULIS-II was a global, open-label, prospective, multicenter observational study with 2 visits conducted in 84 centers worldwide. A total of 468 patients aged ≥18 years with post-stroke upper limb spasticity were included. The primary outcome measure was the responder rate defined as achievement of a goal attainment scale (GAS) score of 0, 1 or 2 after 1 cycle of BoNT-A.

RESULTS

A total of 57 patients from D/A were included in the efficacy analysis. The number of patients in D/A and the full cohort achieving the primary (78.9% vs. 79.6%) and secondary treatment goal (76.8% vs. 75.6%), respectively, was comparable. Deviating from the full cohort, the most common primary treatment goal in D/A was related to impairment (33.3%). Compared to baseline there was a marked reduction in concomitant therapies at the follow-up visit after 3-5 months in the D/A group: patients receiving oral anti-spastic medication 61.4% vs. 40.4%, positioning 50.9% vs. 36.8% and splinting 43.9% vs. 31.6%. Injection control techniques were less frequently used in the D/A group compared to the global study cohort (electrical stimulation: 26.3% vs. 45.8% and electromyography: 12.3% vs. 29.2%). No adverse events were documented in the D/A cohort.

CONCLUSION

A single injection of BoNT-A in adult patients with post-stroke spasticity of the arm led to a high response rate of approximately 80% in both cohorts. The BoNT-A injections in post-stroke adult patients contributed to an improvement in the daily life of patients and their carers beyond simple reduction of muscle tone or spasticity.

An open-label cohort study of the improvement of quality of life and pain in de novo cervical dystonia patients after injections with 500 U botulinum toxin A (Dysport)

OBJECTIVES

It remains to be determined whether the benefits of botulinum toxin type A (BoNT-A) on cervical dystonia (CD) motor symptoms extend to improvements in patient's quality of life (QoL). This analysis of a large, multicentre study was conducted with the aim of investigating changes in QoL and functioning among de novo patients receiving 500 U BoNT-A (abobotulinumtoxinA; Dysport) for the treatment of the two most frequent forms of CD, predominantly torticollis and laterocollis.

DESIGN

A prospective, open-label study of Dysport (500 U; Ipsen Biopharm Ltd) administered according to a defined intramuscular injection algorithm.

SETTING

German and Austrian outpatient clinics.

PARTICIPANTS

516 male and female patients (aged ≥18 years) with de novo CD. The majority of patients had torticollis (78.1%). 35 patients had concomitant depression (MedDRA-defined).

MAIN OUTCOME MEASURES

Change from baseline to weeks 4 and 12 in Craniocervical Dystonia Questionnaire (CDQ-24) total and subscale scores, patient diary items ('day-to-day capacities and activities', 'pain' and 'duration of pain') and global assessment of pain.

RESULTS

Significant improvements were observed in CDQ-24 total and subscale scores at week 4 and were sustained up to week 12 (p<0.001). Changes in CDQ-24 scores did not significantly differ between the torticollis and laterocollis groups or between patients with or without depression. There were also significant reductions in patient diary item scores for activities of daily living, pain and pain duration at weeks 4 and 12 (p<0.001). Pain relief (less or no pain) was reported by 66% and 74.1% of patients at weeks 4 and 12, respectively. Changes in pain parameters demonstrated a positive relationship with change in Tsui score.

CONCLUSIONS

After standardised open-label treatment with Dysport 500 U, improvements in QoL and pain intensity up to 12 weeks in patients with CD were observed.

[Cervical dystonia: clinical-radiological correlations and recommendations for the correction of botulinum therapy]

Seventy-eight patients with confirmed primary cervical dystonia CD were studied. All patients underwent CT of the soft tissues of the neck using slices at cervical vertebrae and MRI images of the cervical spine and of soft tissues. MRI images of 50 patients who did not have CD were used for comparison. This was followed by measuring the largest diameter along with the description of the shape of all observable muscles including the small muscles of the occipital area. In lateral flexion and rotation, 19% of patients showed disorders of muscles acting on head joints (laterocaput/torticaput). Muscles that act on the cervical spine were affected (laterocollis/torticollis) in 20% of patients. Both types of the disorder, but with various degrees of the caput- and collis- involvement, were presented in 61% of patients. Consequently, the ratio for these forms was approximately estimated as 1:1:3. The following conclusions have been made: In lateral flexion, clinical differentiation between laterocollis and laterocaput is possible. Lateral shift is always a result of laterocollis on one side and laterocaput on the opposite side. In rotation, clinical differentiation between torticollis and torticaput is not always possible. CT slices at levels C1 and C2 are advisable in these cases. Comparing the positions of vertebrae on both levels will provide a safe differentiation between torticollis and torticaput. Analysis of forward flexion (differentiation between antecollis and antecaput) can be accomplished by lateral observation of the angles between the cervical spine and the thoracic spine, respectively, and between the cervical spine and the base of skull. The same applies to the analysis of backward flexion (differentiation between retrocollis and retrocaput). Sagittal shift forwards usually does not require further diagnosis: it is almost always caused by bilateral dystonic activities of the Mm. sternocleidomastoidei.

[The phenomenology of cervical dystonia]

BACKGROUND

Cervical dystonia is the most common form of focal dystonia. Most cases of cervical dystonia are idiopathic and generally it is a life-long disorder. In recent years, Botulinum toxin type A (BtA) has become the first line therapy. However, some patients are resistant to it. This problem leads to the study of the clinical forms of cervical dystonias with the help of CT and MRI.

PATIENTS AND METHODS

78 patients with diagnosed primary cervical dystonia were examined. All underwent CT of the soft tissues of the neck with the aid of slices at the level of cervical vertebra 3 and 7. The cervical spine and the soft tissues of the neck were examined using magnetic resonance tomography in T 1 and T 2 with a slice thickness of 2 mm and in T 1 tilted towards the deep neck muscles. For comparison the MRT image data of 50 patients who had no cervical dystonia was analysed. The largest diameters were measured and the shape of all muscles captured in the neck region was described, including the small neck muscles.

RESULTS

It was shown that in lateral flexion and in rotation, in 1 / 5 of patients the disorder affected only muscles which work on atlanto-occipital joints (latero- or torticaput), and in a further 1 / 5 it affected only muscles which work on the cervical spine (latero- or torticollis). 3 / 5 showed both disorders, but with a different degree of caput and collis involvement. Thus a ration of 1:1:3 was obtained in relation to this.

CONCLUSIONS

1. In lateral tilt, differentiation between laterocollis and laterocaput is clinically possible. 2. Lateral shift always occurs when laterocollis is present on one side and laterocaput on the other. 3. In rotation, clinical differentiation between torticollis and torticaput is not always possible. In this case CT sections at levels C 3 and C 7 are recommended. By comparing the vertebral position at the two levels it is possible to differentiate reliably between torticollis and torticaput. 4. Anteflexion--differentiation between anterocollis and anterocaput--is analysed by lateral inspection of the angle between the cervical spine and the thoracic spine or between the cervical spine and the base of the skull. The same applies for the analysis of retroflexion, the differentiation between retrocollis and retrocaput. 5. A posteroanterior sagittal shift requires no further diagnosis: it is often caused by bilateral dystonic activity of the sternocleidomastoid muscles.