1
|
Classification of Dystonia. Life (Basel) 2022; 12:life12020206. [PMID: 35207493 PMCID: PMC8875209 DOI: 10.3390/life12020206] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/15/2022] [Accepted: 01/24/2022] [Indexed: 12/23/2022] Open
Abstract
Dystonia is a hyperkinetic movement disorder characterized by abnormal movement or posture caused by excessive muscle contraction. Because of its wide clinical spectrum, dystonia is often underdiagnosed or misdiagnosed. In clinical practice, dystonia could often present in association with other movement disorders. An accurate physical examination is essential to describe the correct phenomenology. To help clinicians reaching the proper diagnosis, several classifications of dystonia have been proposed. The current classification consists of axis I, clinical characteristics, and axis II, etiology. Through the application of this classification system, movement disorder specialists could attempt to correctly characterize dystonia and guide patients to the most effective treatment. The aim of this article is to describe the phenomenological spectrum of dystonia, the last approved dystonia classification, and new emerging knowledge.
Collapse
|
2
|
Zakin E, Simpson DM. Botulinum Toxin Therapy in Writer's Cramp and Musician's Dystonia. Toxins (Basel) 2021; 13:toxins13120899. [PMID: 34941736 PMCID: PMC8708945 DOI: 10.3390/toxins13120899] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/10/2021] [Accepted: 12/10/2021] [Indexed: 11/18/2022] Open
Abstract
Task-specific focal dystonia is characterized by muscle contraction(s) during a specific task, resulting in abnormal postures or movements. Specifically, writer’s cramp involves the upper extremity during the act of writing. Musician’s dystonia has a highly variable presentation, and thus makes therapeutic options more limited. Treatments include oral pharmacologic agents, neuromodulation, surgery and, most often, botulinum toxin (BoNT) injection. Selection of target muscles for toxin injection continues to be an area of active research for these task-specific movements. We present a review of the literature selected from a predefined search of the MEDLINE and ClinicalTrials.gov databases. We include six controlled studies of botulinum toxin for the management of writer’s cramp and focal task-specific dystonia (FTSD), including musician’s dystonia. Overall, 139 patients were included across all studies, with 99 individuals injected for writer’s cramp and the remaining 40 individuals with FTSD. The age range of all patients was 18–80 years old. We included studies that utilized only the BoNT-A serotype. These studies utilized various severity scales to quantify response to toxin injection, with ratings of instrument or pen control included as subjective ratings. Of the included 139 patients in this review, pooled data for toxin response show that 73% of patients who received the drug demonstrated improvement. Specific techniques for muscle localization and targeting were difficult to study as variable methods were employed. This remains an area of ongoing exploration.
Collapse
Affiliation(s)
- Elina Zakin
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10017, USA
- Correspondence:
| | - David M. Simpson
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
| |
Collapse
|
3
|
Tambasco N, Filidei M, Nigro P, Parnetti L, Simoni S. Botulinum Toxin for the Treatment of Hemifacial Spasm: An Update on Clinical Studies. Toxins (Basel) 2021; 13:toxins13120881. [PMID: 34941718 PMCID: PMC8706367 DOI: 10.3390/toxins13120881] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/25/2021] [Accepted: 12/02/2021] [Indexed: 11/16/2022] Open
Abstract
Hemifacial spasm (HFS) is a movement disorder characterized by involuntary contractions of the facial muscles innervated by the seventh cranial nerve. Generally, it is associated with a poor quality of life due to social embarrassment and can lead to functional blindness. Moreover, it is a chronic condition, and spontaneous recovery is rare. Intramuscular injections of Botulinum Toxin (BoNT) are routinely used as HFS treatment. METHODS We reviewed published articles between 1991 and 2021 regarding the effectiveness and safety of BoNT in HFS as well as any reported differences among BoNT formulations. RESULTS The efficacy of BoNT for HFS treatment ranged from 73% to 98.4%. The mean duration of the effect was around 12 weeks. Effectiveness did not decrease over time. Adverse effects were usually mild and transient. The efficacy and tolerability of the different preparations appeared to be similar. Among the studies, dosage, injected muscles, intervals of treatment, and rating scales were variable, thus leading to challenges in comparing the results. CONCLUSIONS BoNT was the treatment of choice for HFS due to its efficacy and safety profile. Further studies are needed to investigate the factors that influence the outcome, including the optimal timing of treatment, injection techniques, dosage, and the best selection criteria for formulations.
Collapse
Affiliation(s)
- Nicola Tambasco
- Movement Disorders Center, Neurology Department, Perugia General Hospital and University of Perugia, 06129 Perugia, Italy;
- Neurology Department, Perugia General Hospital and University of Perugia, 06129 Perugia, Italy; (M.F.); (L.P.); (S.S.)
- Correspondence:
| | - Marta Filidei
- Neurology Department, Perugia General Hospital and University of Perugia, 06129 Perugia, Italy; (M.F.); (L.P.); (S.S.)
| | - Pasquale Nigro
- Movement Disorders Center, Neurology Department, Perugia General Hospital and University of Perugia, 06129 Perugia, Italy;
| | - Lucilla Parnetti
- Neurology Department, Perugia General Hospital and University of Perugia, 06129 Perugia, Italy; (M.F.); (L.P.); (S.S.)
| | - Simone Simoni
- Neurology Department, Perugia General Hospital and University of Perugia, 06129 Perugia, Italy; (M.F.); (L.P.); (S.S.)
| |
Collapse
|
4
|
Gupta N, Pandey S. Treatment of focal hand dystonia: current status. Neurol Sci 2021; 42:3561-3584. [PMID: 34213695 DOI: 10.1007/s10072-021-05432-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/23/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Focal hand dystonia (FHD) is usually adult-onset focal dystonia that can be associated with marked occupational and functional disability leading to reduced quality of life. METHODS Relevant studies on treatment options for FHD, their limitations, and current recommendations were reviewed using the PubMed search until March 31, 2021. Besides, the reference lists of the retrieved publications were manually searched to explore other relevant studies. RESULTS and conclusion Currently, botulinum toxin has the best evidence for treatment of FHD, and 20-90% of patients experience symptomatic improvement. However, its benefit is often limited by the reduction of muscle tonus acting on the muscle spindle. Different surgical modalities that have been used to treat focal hand dystonia include lesional surgery, deep brain stimulation, and magnetic resonance-guided focused ultrasound thalamotomy. Recent studies exploring the role of behavioral techniques, sensorimotor training, and neuromodulation for the treatment of focal hand dystonia have reported good outcomes, but larger studies are required before implementing these interventions in practice.
Collapse
Affiliation(s)
- Navnika Gupta
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Sanjay Pandey
- Department of Neurology, Govind Ballabh Pant Postgraduate Institute of Medical Education and Research, New Delhi, 110002, India.
| |
Collapse
|
5
|
Bledsoe IO, Viser AC, San Luciano M. Treatment of Dystonia: Medications, Neurotoxins, Neuromodulation, and Rehabilitation. Neurotherapeutics 2020; 17:1622-1644. [PMID: 33095402 PMCID: PMC7851280 DOI: 10.1007/s13311-020-00944-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2020] [Indexed: 02/24/2023] Open
Abstract
Dystonia is a complex disorder with numerous presentations occurring in isolation or in combination with other neurologic symptoms. Its treatment has been significantly improved with the advent of botulinum toxin and deep brain stimulation in recent years, though additional investigation is needed to further refine these interventions. Medications are of critical importance in forms of dopa-responsive dystonia but can be beneficial in other forms of dystonia as well. Many different rehabilitative paradigms have been studied with variable benefit. There is growing interest in noninvasive stimulation as a potential treatment, but with limited long-term benefit shown to date, and additional research is needed. This article reviews existing evidence for treatments from each of these categories. To date, there are many examples of incomplete response to available treatments, and improved therapies are needed.
Collapse
Affiliation(s)
- Ian O. Bledsoe
- Weill Institute for Neurosciences, Movement Disorder and Neuromodulation Center, University of California, San Francisco, 1635 Divisadero St., Suite 520, San Francisco, CA 94115 USA
| | - Aaron C. Viser
- Weill Institute for Neurosciences, Movement Disorder and Neuromodulation Center, University of California, San Francisco, 1635 Divisadero St., Suite 520, San Francisco, CA 94115 USA
| | - Marta San Luciano
- Weill Institute for Neurosciences, Movement Disorder and Neuromodulation Center, University of California, San Francisco, 1635 Divisadero St., Suite 520, San Francisco, CA 94115 USA
| |
Collapse
|
6
|
Spiegel LL, Ostrem JL, Bledsoe IO. FDA Approvals and Consensus Guidelines for Botulinum Toxins in the Treatment of Dystonia. Toxins (Basel) 2020; 12:E332. [PMID: 32429600 PMCID: PMC7290737 DOI: 10.3390/toxins12050332] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/01/2020] [Accepted: 05/13/2020] [Indexed: 11/17/2022] Open
Abstract
In 2016, the American Academy of Neurology (AAN) published practice guidelines for botulinum toxin (BoNT) in the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache. This article, focusing on dystonia, provides context for these guidelines through literature review. Studies that led to Food and Drug Administration (FDA) approval of each toxin for dystonia indications are reviewed, in addition to several studies highlighted by the AAN guidelines. The AAN guidelines for the use of BoNT in dystonia are compared with those of the European Federation of the Neurological Societies (EFNS), and common off-label uses for BoNT in dystonia are discussed. Toxins not currently FDA-approved for the treatment of dystonia are additionally reviewed. In the future, additional toxins may become FDA-approved for the treatment of dystonia given expanding research in this area.
Collapse
Affiliation(s)
| | | | - Ian O. Bledsoe
- Movement Disorders and Neuromodulation Center, Department of Neurology, University of California, San Francisco, CA 94115, USA; (L.L.S.); (J.L.O.)
| |
Collapse
|
7
|
Ashworth N, Aidoo H, Doroshenko A, Antle D, Els C, Flaschner DM, Gross DP, Guptill C, Potter P, Tan MC, Straube S. Botulinum Toxin for the Treatment of Focal Task-Specific Hand Dystonias: Systematic Review and Meta-Analysis. Open Neurol J 2019. [DOI: 10.2174/1874205x01913010032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective:Botulinum Toxin (BTX) has become a widely used treatment in several dystonic conditions, but the evidence for its efficacy has largely come from open trials and expert opinion. This systematic review examined the efficacy and safety of BTX in the treatment of Focal Hand Dystonia (FHD) in Randomized Controlled Trials (RCTs).Methods:We searched Ovid MEDLINE, EMBASE, Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE), Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, SPORT Discus, SCOPUS, Web of Science, PEDro, ClinicalTrials.gov, and the International Clinical Trials Registry Platform (ICTRP) for randomized, placebo-controlled trials on the use of BTX for FHD.Results:Of 1,116 publications retrieved from the databases searched, three publications were included. The evidence identified pertains to focal task-specific hand dystonias. Sixty-nine participants were involved in the three RCTs with a mean duration of symptoms of 7.5 years. Participants were assessed using a combination of self-reported and functional performance outcome measures following injections of BTX subtype A (BTX-A) or placebo. The Oxford Quality Scale was used to assess the included studies, and the three studies each scored 3/5 or above. The included studies reported no adverse events with BTX-A use, other than muscle weakness and pain at the injection sites.Conclusion:The number of participants included in these three trials is too small to draw dependable conclusions about the efficacy and safety of BTX-A for FHD. There is currently not enough evidence to recommend the routine use of BTX-A for FHD.
Collapse
|
8
|
Pain in focal dystonias – A focused review to address an important component of the disease. Parkinsonism Relat Disord 2018; 54:17-24. [DOI: 10.1016/j.parkreldis.2018.04.030] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 04/05/2018] [Accepted: 04/26/2018] [Indexed: 12/16/2022]
|
9
|
Abstract
Botulinum neurotoxins (BoNTs) are now among the most widely used therapeutic agents in clinical medicine with indications applied to the fields of movement disorders, pain disorders, and autonomic dysfunction. In this literature review, the efficacy and utility of BoNTs in the field of movement disorders are assessed using the criteria of the Guideline Development Subcommittee of the American Academy of Neurology. The literature supports a level A efficacy (established) for BoNT therapy in cervical dystonia and a level B efficacy (probably effective) for blepharospasm, hemifacial spasm, laryngeal dystonia (spasmodic dysphonia), task-specific dystonias, essential tremor, and Parkinson rest tremor. It is the view of movement disorder experts, however, that despite the level B efficacy, BoNTs should be considered treatment of first choice for blepharospasm, hemifacial spasm, laryngeal, and task-specific dystonias. The emerging data on motor and vocal tics of Tourette syndrome and oromandibular dystonias are encouraging but the current level of efficacy is U (undetermined) due to lack of published high-quality studies.
Collapse
Affiliation(s)
- Yasaman Safarpour
- Division of Nephrology, Department of Medicine, University of California, Irvine, USA
| | - Bahman Jabbari
- Division of Movement Disorders, Department of Neurology, Yale University School of Medicine, New Haven-CT, 31 Silver Pine Drive, Newport Coast, CA, 92657, USA.
| |
Collapse
|
10
|
Pirio Richardson S, Altenmüller E, Alter K, Alterman RL, Chen R, Frucht S, Furuya S, Jankovic J, Jinnah HA, Kimberley TJ, Lungu C, Perlmutter JS, Prudente CN, Hallett M. Research Priorities in Limb and Task-Specific Dystonias. Front Neurol 2017; 8:170. [PMID: 28515706 PMCID: PMC5413505 DOI: 10.3389/fneur.2017.00170] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 04/11/2017] [Indexed: 11/13/2022] Open
Abstract
Dystonia, which causes intermittent or sustained abnormal postures and movements, can present in a focal or a generalized manner. In the limbs, focal dystonia can occur in either the upper or lower limbs and may be task-specific causing abnormal motor performance for only a specific task, such as in writer’s cramp, runner’s dystonia, or musician’s dystonia. Focal limb dystonia can be non-task-specific and may, in some circumstances, be associated with parkinsonian disorders. The true prevalence of focal limb dystonia is not known and is likely currently underestimated, leaving a knowledge gap and an opportunity for future research. The pathophysiology of focal limb dystonia shares some commonalities with other dystonias with a loss of inhibition in the central nervous system and a loss of the normal regulation of plasticity, called homeostatic plasticity. Functional imaging studies revealed abnormalities in several anatomical networks that involve the cortex, basal ganglia, and cerebellum. Further studies should focus on distinguishing cause from effect in both physiology and imaging studies to permit focus on most relevant biological correlates of dystonia. There is no specific therapy for the treatment of limb dystonia given the variability in presentation, but off-label botulinum toxin therapy is often applied to focal limb and task-specific dystonia. Various rehabilitation techniques have been applied and rehabilitation interventions may improve outcomes, but small sample size and lack of direct comparisons between methods to evaluate comparative efficacy limit conclusions. Finally, non-invasive and invasive therapeutic modalities have been explored in small studies with design limitations that do not yet clearly provide direction for larger clinical trials that could support new clinical therapies. Given these gaps in our clinical, pathophysiologic, and therapeutic knowledge, we have identified priorities for future research including: the development of diagnostic criteria for limb dystonia, more precise phenotypic characterization and innovative clinical trial design that considers clinical heterogeneity, and limited available number of participants.
Collapse
Affiliation(s)
- Sarah Pirio Richardson
- Department of Neurology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Eckart Altenmüller
- Institute for Music Physiology and Musicians' Medicine (IMMM), Hannover University of Music, Drama and Media, Hannover, Germany
| | - Katharine Alter
- Functional and Applied Biomechanics Section, Rehabilitation Medicine, National Institute of Child Health and Development, National Institutes of Health, Bethesda, MD, USA
| | - Ron L Alterman
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Robert Chen
- Division of Neurology, Department of Medicine (Neurology), Krembil Research Institute, University of Toronto, Toronto, ON, Canada
| | - Steven Frucht
- Robert and John M. Bendheim Parkinson and Movement Disorders Center, Mount Sinai Hospital, New York, NY, USA
| | - Shinichi Furuya
- Musical Skill and Injury Center (MuSIC), Sophia University, Tokyo, Japan
| | - Joseph Jankovic
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - H A Jinnah
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.,Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, USA.,Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Teresa J Kimberley
- Department of Rehabilitation Medicine, Division of Physical Therapy and Rehabilitation Science, University of Minnesota, Minneapolis, MN, USA
| | - Codrin Lungu
- Division of Clinical Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Joel S Perlmutter
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.,Department of Radiology, Washington University School of Medicine, St. Louis, MO, USA.,Department of Neurosciences, Washington University School of Medicine, St. Louis, MO, USA.,Department of Physical Therapy, Washington University School of Medicine, St. Louis, MO, USA.,Department of Occupational Therapy, Washington University School of Medicine, St. Louis, MO, USA
| | - Cecília N Prudente
- Department of Rehabilitation Medicine, Division of Physical Therapy and Rehabilitation Science, University of Minnesota, Minneapolis, MN, USA
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| |
Collapse
|
11
|
Jabbari B. History of Botulinum Toxin Treatment in Movement Disorders. Tremor Other Hyperkinet Mov (N Y) 2016; 6:394. [PMID: 27917308 PMCID: PMC5133258 DOI: 10.7916/d81836s1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 10/25/2016] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The frontiers of clinical medicine constantly expand as a result of the innovative efforts of visionary researchers and keen observations of seasoned clinicians. In medicine, rarely has a therapeutic agent been found efficacious in the management of so many symptoms and in such a relatively short time as botulinum toxin. One of the most notable contributions of botulinum toxin therapy in clinical medicine is in the field of movement disorders. METHODS The English literature was searched using the Yale search engine including but not limited to PubMed and Ovid. The search includes articles from January 1 1980 to March 1 2016. RESULTS A total of 2055 articles were identified. Of these, 132 met the criteria for this review. DISCUSSION This historical review highlights early and seminal contributions that have introduced the application of botulinum toxins in the field of movement disorders and provides evidence-based contributions that have established botulinum toxin as an effective treatment for abnormal movements.
Collapse
|
12
|
Bakheit A, McLellan DL, Burnett ME. Symptomatic and functional improvement of foot dystonia with medial popliteal nerve block. Clin Rehabil 2016. [DOI: 10.1177/026921559601000414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Amo Bakheit
- University Rehabilitation Research Unit, Mail Point 874, Level C, West Wing, Southampton General Hospital, Southampton SO16 6YD, UK Southampton
| | - DL McLellan
- University Rehabilitation Research Unit, Southampton General Hospital Southampton
| | - ME Burnett
- University Rehabilitation Research Unit, Southampton General Hospital Southampton
| |
Collapse
|
13
|
Affiliation(s)
- DA Skeil
- Hunters Moor Regional Rehabilitation Centre
| | - MP Barnes
- University of Newcastle upon Tyne, Newcastle upon Tyne
| |
Collapse
|
14
|
Abstract
Writer's cramp is the most common form of focal, task-specific dystonia. Symptoms frequently evolve in the setting of repetitive hand movements and increased writing demands, and clinical presentations demonstrate a variety of different dystonic patterns of the upper extremity such as while writing or holding a writing utensil. However, why writer's cramp develops still remains much of a mystery. Clinical evaluation of patients with writer's cramp and various theories regarding its pathophysiology are reviewed. Treatment can be challenging and often involves a combination of pharmacologic (e.g., oral medications, botulinum toxin injections) and non-pharmacologic approaches (e.g., neurosurgical or neurostimulatory interventions, rehabilitation therapies, adaptive devices). Management strategies for writer's cramp using both of these approaches will be discussed.
Collapse
Affiliation(s)
- Jennifer G Goldman
- Rush University Medical Center, Department of Neurological Sciences, Section of Parkinson Disease and Movement Disorders, USA.
| |
Collapse
|
15
|
Del Sorbo F, Albanese A. Botulinum neurotoxins for the treatment of focal dystonias: Review of rating tools used in clinical trials. Toxicon 2015; 107:89-97. [PMID: 26365917 DOI: 10.1016/j.toxicon.2015.09.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 08/26/2015] [Accepted: 09/08/2015] [Indexed: 12/14/2022]
Abstract
Botulinum neurotoxins (BoNTs) are used to achieve therapeutic benefit in focal dystonia. An expert panel recently reviewed published evidence on the efficacy of BoNTs for the treatment of focal dystonias and produced recommendations for clinical practice. Another panel reviewed the clinimetric properties of rating scales for dystonia and produced recommendations for current usage and future directions. Considering that the strength of evidence derives not only from the quality of the study design, but also from usage of validated outcome measures, we combined the information provided by these two recent reviews and assessed the appropriateness of the rating instruments used in clinical trials on BoNT treatment in focal dystonia. Data sources included all the publications on BoNT treatment for focal dystonias reviewed by the recent evidence-based analysis. We reviewed all rating instruments used to assess primary and secondary outcome following BoNT treatment. The publications were allocated into five topics according to the focal dystonia type reviewed in the meta-analysis: blepharospasm, oromandibular dystonia, cervical dystonia, upper limb dystonia, and laryngeal dystonia. For each topic, papers were divided, according to the terminology used in the meta-analysis, into placebo-controlled, active comparator and methodological or uncontrolled. For each topic we identified the rating tools used in each study class and annotated which were the mostly used in each focal dystonia type. Outcome measures included tools related to motor and non-motor features, such as pain and depression, and functional as well as health-related quality of life features. Patient- and investigator-reported outcomes were also included. Rating instruments were classified as recommended, suggested, listed or not included, based on recommendations produced by the rating scale task force. Both primary and secondary outcome measures were assessed. As a final step we compared current practice, as summarized by the meta-analysis, with the recommendations of the rating scales panel. For blepharospasm, three placebo-controlled trials used suggested scales, one active-comparator study used a recommended scale and three active-comparator studies used suggested scales. For oromandibular dystonia, one placebo-controlled study used a suggested scale. For cervical dystonia, six placebo-controlled trials used a recommended scale, four active-comparator trials used a recommended scale and one active-comparator study used a suggested scale. For upper limb and laryngeal dystonia, no trial used validated instruments. Appropriately designed studies should be based on recommended rating instruments. Therapeutic trials not using clinimetrically tested rating measures do not provide sufficient information on efficacy of BoNT treatment, even if the study design is robust. Further research is needed to develop and validate new tools to assess all types of focal dystonia and to apply them in prospective placebo-controlled clinical trials.
Collapse
Affiliation(s)
| | - Alberto Albanese
- Istituto di Neurologia, Istituto Clinico Humanitas, Rozzano, Milano, Italy; Istituto di Neurologia, Università Cattolica del Sacro Cuore, Milano, Italy.
| |
Collapse
|
16
|
Pandey S. A practical approach to management of focal hand dystonia. Ann Indian Acad Neurol 2015; 18:146-53. [PMID: 26019409 PMCID: PMC4445187 DOI: 10.4103/0972-2327.156563] [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] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 01/21/2015] [Accepted: 02/04/2015] [Indexed: 12/03/2022] Open
Abstract
Dystonia can be focal, segmental, multifocal, generalized, or hemidystonia. Focal dystonia is localized to a specific part of the body. Overall upper limb is more commonly involved in focal dystonia than lower limb and since it starts from hand, focal hand dystonia (FHD) is a more accepted terminology. Writer's cramp and musician dystonia are commonest types of FHD. Typically this dystonia is task specific, but in some patients this specificity may be lost over a period of time. Segmental or generalized dystonia may also start as FHD, so a detailed clinical assessment is required, which should be supplemented by relevant investigations. Treatment includes oral medications, injection botulinum toxin, neurosurgery including neurostimulation, and rehabilitation. Role of injection botulinum toxin has been extensively studied in writer's cramp patients and found to be effective; however, selection of muscles and techniques of injection are crucial in getting best results.
Collapse
Affiliation(s)
- Sanjay Pandey
- Department of Neurology, Room No. 507, Academic Block, Govind Ballabh Pant Hospital, New Delhi, India
| |
Collapse
|
17
|
Mills R, Bahroo L, Pagan F. An Update on the Use of Botulinum Toxin Therapy in Parkinson’s Disease. Curr Neurol Neurosci Rep 2014; 15:511. [DOI: 10.1007/s11910-014-0511-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
18
|
Abstract
Selecting the appropriate treatment for dystonia begins with proper classification of disease based on age, distribution, and underlying etiology. The therapies available for dystonia include oral medications, botulinum toxin, and surgical procedures. Oral medications are generally reserved for generalized and segmental dystonia. Botulinum toxin revolutionized the treatment of focal dystonia when it was introduced for therapeutic purposes in the 1980s. Surgical procedures are available for medication-refractory dystonia, markedly affecting an individual's quality of life.
Collapse
Affiliation(s)
- Mary Ann Thenganatt
- Parkinson’s Disease Center & Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, 6550 Fannin, Suite 1801, Houston, TX 77030 USA
| | - Joseph Jankovic
- Parkinson’s Disease Center & Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, 6550 Fannin, Suite 1801, Houston, TX 77030 USA
| |
Collapse
|
19
|
Peña E. Treatment with botulinum toxin: An update. World J Neurol 2013; 3:29-41. [DOI: 10.5316/wjn.v3.i3.29] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/10/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023] Open
Abstract
Botulinum neurotoxin (BoNT) is a potent toxin produced by the anaerobic bacterium clostridium botulinum. It causes flaccid, long-lasting, local and reversible paralysis. In addition, BoNT inhibits the secretion of the exocrine glands and could have properties in the control of pain. Thus, BoNT is useful in the treatment of many neuromuscular conditions where an increase of muscle tone is associated with the pathogenic mechanism. Furthermore, BoNT is recommended in the treatment of some hypersecretion disorders of the exocrine gland and could play a role in the treatment of migraine and other chronic pain conditions. In the BoNT therapy adverse effects are usually mild and reversible. However, repeated injections of BoNT can lead to the development of neutralizing antibodies that can subsequently inhibit the biological activity of the toxin. In this sense, many factors can influence the immunogenicity of the BoNT, such as product-related factors, the dose of BoNT used, the frequency of injection and the previous exposure to the toxin. In this review, we are going to discuss the current clinical applications of BoNT with a special focus on evidence, doses, injection technique and adverse effects for those applications more frequently used in neurology, namely spasticity, blepharospasm, hemifacial spasm, cervical dystonia and other focal dystonias, as well as chronic migraine, tremor, sialorrhea, facial palsy, neurogenic bladder and many other neurological condition.
Collapse
|
20
|
Hallett M, Albanese A, Dressler D, Segal KR, Simpson DM, Truong D, Jankovic J. Evidence-based review and assessment of botulinum neurotoxin for the treatment of movement disorders. Toxicon 2013; 67:94-114. [PMID: 23380701 DOI: 10.1016/j.toxicon.2012.12.004] [Citation(s) in RCA: 151] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 11/28/2012] [Accepted: 12/05/2012] [Indexed: 01/28/2023]
Abstract
Botulinum neurotoxin (BoNT) can be injected to achieve therapeutic benefit across a large range of clinical conditions. To assess the efficacy and safety of BoNT injections for the treatment of certain movement disorders, including blepharospasm, hemifacial spasm, oromandibular dystonia, cervical dystonia, focal limb dystonias, laryngeal dystonia, tics, and essential tremor, an expert panel reviewed evidence from the published literature. Data sources included English-language studies identified via MEDLINE, EMBASE, CINAHL, Current Contents, and the Cochrane Central Register of Controlled Trials. Evidence tables generated in the 2008 Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology (AAN) review of the use of BoNT for movement disorders were also reviewed and updated. The panel evaluated evidence at several levels, supporting BoNT as a class, the serotypes BoNT-A and BoNT-B, as well as the four individual commercially available formulations: abobotulinumtoxinA (A/Abo), onabotulinumtoxinA (A/Ona), incobotulinumtoxinA (A/Inco), and rimabotulinumtoxinB (B/Rima). The panel ultimately made recommendations for each therapeutic indication, based upon the strength of clinical evidence and following the AAN classification scale. For the treatment of blepharospasm, the evidence supported a Level A recommendation for BoNT-A, A/Inco, and A/Ona; a Level B recommendation for A/Abo; and a Level U recommendation for B/Rima. For hemifacial spasm, the evidence supported a Level B recommendation for BoNT-A and A/Ona, a Level C recommendation for A/Abo, and a Level U recommendation for A/Inco and B/Rima. For the treatment of oromandibular dystonia, the evidence supported a Level C recommendation for BoNT-A, A/Abo, and A/Ona, and a Level U recommendation for A/Inco and B/Rima. For the treatment of cervical dystonia, the published evidence supported a Level A recommendation for all four BoNT formulations. For limb dystonia, the available evidence supported a Level B recommendation for both A/Abo and A/Ona, but no published studies were identified for A/Inco or B/Rima, resulting in a Level U recommendation for these two formulations. For adductor laryngeal dystonia, evidence supported a Level C recommendation for the use of A/Ona, but a Level U recommendation was warranted for B/Rima, A/Abo, and A/Inco. For the treatment of focal tics, a Level U recommendation was warranted at this time for all four formulations. For the treatment of tremor, the published evidence supported a level B recommendation for A/Ona, but no published studies were identified for A/Abo, A/Inco, or B/Rima, warranting a Level U recommendation for these three formulations. Further research is needed to address evidence gaps and to evaluate BoNT formulations where currently there is insufficient or conflicting clinical data.
Collapse
Affiliation(s)
- Mark Hallett
- The George Washington University School of Medicine and Health Sciences, Ross Hall, Department of Neurology, 2300 Eye Street, NW Suite 713W, Washington, DC 20037, USA.
| | | | | | | | | | | | | |
Collapse
|
21
|
Thenganatt MA, Fahn S. Botulinum toxin for the treatment of movement disorders. Curr Neurol Neurosci Rep 2012; 12:399-409. [PMID: 22661378 DOI: 10.1007/s11910-012-0286-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
After botulinum toxin was initially used to treat strabismus in the 1970s, others started using it to treat movement disorders including blepharospasm, hemifacial spasm, cervical dystonia, spasmodic dysphonia, and oromandibular dystonia. It was discovered that botulinum toxin can be an effective treatment for focal movement disorders with limited side effects. Over the past three decades, various formulations of botulinum toxin have been developed and the therapeutic use of these toxins has expanded in movement disorders and beyond. We review the history and mechanism of action of botulinum toxin, as well as describe different formulations available and their potential therapeutic uses in movement disorders.
Collapse
Affiliation(s)
- Mary Ann Thenganatt
- Department of Neurology, College of Physicians and Surgeons, Columbia University, 710 West 168th Street, New York, NY 10032, USA.
| | | |
Collapse
|
22
|
Abstract
OPINION STATEMENT Dystonia is characterized by repetitive twisting movements or abnormal postures due to involuntary muscle activity. When limited to a single body region it is called focal dystonia. Examples of focal dystonia include cervical dystonia (neck), blepharospasm (eyes), oromandibular dystonia, focal limb dystonia, and spasmodic dysphonia, which are discussed here. Once the diagnosis is established, the therapeutic plan is discussed with the patients. They are informed that there is no cure for dystonia and treatment is symptomatic. The main therapeutic option for treating focal dystonias is botulinum toxin (BoNT). There have been several attempts to characterize the procedure, the type of toxin, dosage, techniques, and combination with physical measures in each of the focal dystonia forms. The general treatment principles are similar. The affected muscles are injected at muscle sites based on evidence and experience using standard dosages based on the type of toxin used. The injections are repeated after 3 to 6 months based on the individual response duration. In the uncommon event of nonresponse with BoNT, the dose and site are reassessed. Oral drug treatment could be considered as an additional option. Once the condition is thought to be medically refractory, the opinion from the deep brain stimulation (DBS) team for the suitability of the patient for DBS is taken. The successful use of DBS in cervical dystonia has led to increased acceptance for trial in other forms of focal dystonias. DBS surgery in focal dystonias other than cervical is, however, still experimental. The patients may be offered the surgery with adequate explanation of the risks and benefits. Patient education and directing the patients towards dystonia support groups and relevant websites that provide scientific information may be useful for long-term compliance and benefit.
Collapse
Affiliation(s)
- Amit Batla
- The National Hospital for Neurology and Neurosurgery Queen Square, Box 13, London, WC1N 3BG, UK
| | | | | |
Collapse
|
23
|
Delnooz CCS, van de Warrenburg BPC. Current and future medical treatment in primary dystonia. Ther Adv Neurol Disord 2012; 5:221-40. [PMID: 22783371 PMCID: PMC3388529 DOI: 10.1177/1756285612447261] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Dystonia is a hyperkinetic movement disorder, characterized by involuntary and sustained contractions of opposing muscles causing twisting movements and abnormal postures. It is often a disabling disorder that has a significant impact on physical and psychosocial wellbeing. The medical therapeutic armamentarium used in practice is quite extensive, but for many of these interventions formal proof of efficacy is lacking. Exceptions are the use of botulinum toxin in patients with cervical dystonia, some forms of cranial dystonia (in particular, blepharospasm) and writer's cramp; deep brain stimulation of the pallidum in generalized and segmental dystonia; and high-dose trihexyphenidyl in young patients with segmental and generalized dystonia. In order to move this field forward, we not only need better trials that examine the effect of current treatment interventions, but also a further understanding of the pathophysiology of dystonia as a first step to design and test new therapies that are targeted at the underlying biologic and neurophysiologic mechanisms.
Collapse
Affiliation(s)
- Cathérine C S Delnooz
- Radboud University Nijmegen Medical Centre, Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, the Netherlands
| | | |
Collapse
|
24
|
Jabeen A, Kandadai RM, Kannikannan MA, Borgohain R. Guidelines for the use of botulinum toxin in movement disorders and spasticity. Ann Indian Acad Neurol 2011; 14:S31-4. [PMID: 21847327 PMCID: PMC3152173 DOI: 10.4103/0972-2327.83099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2010] [Indexed: 11/26/2022] Open
Affiliation(s)
- Afshan Jabeen
- Department of Neurology, NIMS, Punjagutta, Hyderabad, Andhra Pradesh, India
| | | | | | | |
Collapse
|
25
|
Lungu C, Karp BI, Alter K, Zolbrod R, Hallett M. Long-term follow-up of botulinum toxin therapy for focal hand dystonia: outcome at 10 years or more. Mov Disord 2011; 26:750-3. [PMID: 21506157 DOI: 10.1002/mds.23504] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Revised: 07/23/2010] [Accepted: 10/03/2010] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Previous studies have explored the efficacy and safety of botulinum neurotoxin (BoNT) treatment for Focal hand dystonia (FHD), but none have followed a large number of patients for 10 years or more. METHODS Retrospective study, with benefit and weakness assessed on a 0 to 4 subjective scale. Demographic, clinical and treatment characteristics were analyzed using t tests and Pearson correlations. RESULTS Twenty FHD patients had 10 years or longer treatment. Interinjection intervals were variable. Musicians were more likely to wait longer between injections and had less complex dystonia. There was a trend for larger benefit in women and with shorter intervals. The dose increased over time. Dystonia characteristics did not predict response or side-effects, but benefit magnitude predicted longer compliance. No serious side-effects or antibody-mediated resistance occurred. CONCLUSION This is the longest reported period of BoNT treatment in the largest FHD cohort. BoNT therapy for FHD remains safe and effective after more than a decade of treatment.
Collapse
Affiliation(s)
- Codrin Lungu
- Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | | | | | | | | |
Collapse
|
26
|
Abstract
Dystonia is defined as involuntary sustained muscle contractions producing twisting or squeezing movements and abnormal postures. The movements can be stereotyped and repetitive and they may vary in speed from rapid to slow; sustained contractions can result in fixed postures. Dystonic disorders are classified into primary and secondary forms. Several types of adult-onset primary dystonia have been identified but all share the characteristic that dystonia (including tremor) is the sole neurologic feature. The forms most commonly seen in neurological practice include cranial dystonia (blepharospasm, oromandibular and lingual dystonia and spasmodic dysphonia), cervical dystonia (also known as spasmodic torticollis) and writer's cramp. These are the disorders that benefit most from botulinum toxin injections. A general characteristic of dystonia is that the movements or postures may occur in relation to specific voluntary actions by the involved muscle groups (such as in writer's cramp). Dystonic contractions may occur in one body segment with movement of another (overflow dystonia). With progression, dystonia often becomes present at rest. Dystonic movements typically worsen with anxiety, heightened emotions, and fatigue, decrease with relaxation, and disappear during sleep. There may be diurnal fluctuations in the dystonia, which manifest as little or no involuntary movement in the morning followed by severe disabling dystonia in the afternoon and evening. Morning improvement (or honeymoon) is seen with several types of dystonia. Patients often discover maneuvers that reduce the dystonia and which involve sensory stimuli such as touching the chin lightly in cervical dystonia. These maneuvers are known as sensory tricks, or gestes antagonistes. This chapter focuses on adult-onset focal dystonias including cranial dystonia, cervical dystonia, and writer's cramp. The chapter begins with a review of the epidemiology of focal dystonias, followed by discussions of each major type of focal dystonia, covering clinical phenomenology, differential genetics, and diagnosis. The chapter concludes with discussions of the pathophysiology, the few pathological cases published of adult-onset focal dystonia and management options, and a a brief look at the future.
Collapse
Affiliation(s)
- Marian L Evatt
- Department of Neurology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | | | | |
Collapse
|
27
|
|
28
|
Fock J, Galea MP, Stillman BC, Rawicki B, Clark M. Functional outcome following Botulinum toxin A injection to reduce spastic equinus in adults with traumatic brain injury. Brain Inj 2009; 18:57-63. [PMID: 14660236 DOI: 10.1080/0269905031000149498] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PRIMARY OBJECTIVE The aim of this study was to assess the effect of Botulinum toxin A in the management of spastic equinus resulting from traumatic brain injury. RESEARCH DESIGN A before-after intervention design was used without controls. METHODS AND PROCEDURES Subjects were seven patients suffering from traumatic brain injury of average duration 14 (4-38) months as a result of motor vehicle trauma, who had spastic equinus interfering with gait. EXPERIMENTAL INTERVENTION The patients were treated with injections of Botulinum toxin A into the spastic calf muscles: gastrocnemius, soleus and tibialis posterior. Assessments were made pre-injection and at 2 weeks and 3 months post-injection. MAIN OUTCOME AND RESULTS At the end of the 3-month period, all patients showed a significant improvement in gait velocity, cadence and stride length. CONCLUSIONS The findings suggest that Botulinum toxin A may be useful in the management of spastic equinus following traumatic brain injury.
Collapse
Affiliation(s)
- Jimy Fock
- Brighton Rehabilitation Centre, Victoria, Australia
| | | | | | | | | |
Collapse
|
29
|
Hallett M, Benecke R, Blitzer A, Comella CL. Treatment of focal dystonias with botulinum neurotoxin. Toxicon 2008; 54:628-33. [PMID: 19103214 DOI: 10.1016/j.toxicon.2008.12.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2008] [Accepted: 12/09/2008] [Indexed: 01/28/2023]
Abstract
This is a review on the use of injections of botulinum toxin for the treatment of focal dystonias. Disorders covered include cranial dystonia, cervical dystonia, spasmodic dysphonia, and focal hand dystonia. Considered are clinical aspects, alternative treatment strategies and principles of use of botulinum toxin injections.
Collapse
Affiliation(s)
- Mark Hallett
- Human Motor Control Section, NINDS, NIH, Building 10, Room 7D37, 10 Center Dr MSC 1428, Bethesda, MD 20892-1428, USA.
| | | | | | | |
Collapse
|
30
|
Simpson DM, Blitzer A, Brashear A, Comella C, Dubinsky R, Hallett M, Jankovic J, Karp B, Ludlow CL, Miyasaki JM, Naumann M, So Y. Assessment: Botulinum neurotoxin for the treatment of movement disorders (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2008; 70:1699-706. [PMID: 18458230 PMCID: PMC5565261 DOI: 10.1212/01.wnl.0000311389.26145.95] [Citation(s) in RCA: 283] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To perform an evidence-based review of the safety and efficacy of botulinum neurotoxin (BoNT) in the treatment of movement disorders. METHODS A literature search was performed including MEDLINE and Current Contents for therapeutic articles relevant to BoNT and selected movement disorders. Authors reviewed, abstracted, and classified articles based on American Academy of Neurology criteria (Class I-IV). RESULTS The highest quality literature available for the respective indications was as follows: blepharospasm (two Class II studies); hemifacial spasm (one Class II and one Class III study); cervical dystonia (seven Class I studies); focal upper extremity dystonia (one Class I and three Class II studies); focal lower extremity dystonia (one Class II study); laryngeal dystonia (one Class I study); motor tics (one Class II study); and upper extremity essential tremor (two Class II studies). RECOMMENDATIONS Botulinum neurotoxin should be offered as a treatment option for the treatment of cervical dystonia (Level A), may be offered for blepharospasm, focal upper extremity dystonia, adductor laryngeal dystonia, and upper extremity essential tremor (Level B), and may be considered for hemifacial spasm, focal lower limb dystonia, and motor tics (Level C). While clinicians' practice may suggest stronger recommendations in some of these indications, evidence-based conclusions are limited by the availability of data.
Collapse
Affiliation(s)
- D M Simpson
- Department of Neurology, Mount Sinai Medical Center, New York, NY, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Kruisdijk JJM, Koelman JHTM, Ongerboer de Visser BW, de Haan RJ, Speelman JD. Botulinum toxin for writer's cramp: a randomised, placebo-controlled trial and 1-year follow-up. J Neurol Neurosurg Psychiatry 2007; 78:264-70. [PMID: 17185301 PMCID: PMC2117645 DOI: 10.1136/jnnp.2005.083170] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Botulinum toxin type A (BoNT-A) has become the treatment of choice for most types of focal dystonia. OBJECTIVE To investigate the efficacy of BoNT-A injections in patients with writer's cramp in a double-blind, randomised, placebo-controlled trial and to evaluate the follow-up results. METHODS Forty participants were randomised to treatment with either BoNT-A or placebo injections in two sessions. Trial duration was 12 weeks. The primary outcome measure was the patients' choice to continue with the treatment, despite its possible disadvantages. Secondary outcome measures included several clinical rating scales on the levels of impairment and disability. Assessments were made at baseline and 2 months (secondary outcomes) and 3 months (primary outcome). Duration of follow-up was 1 year. RESULTS 39 patients completed the trial. Fourteen of 20 patients (70%) receiving BoNT-A reported a beneficial effect and chose to continue treatment, versus 6 of 19 patients (31.6%) in the placebo group (p = 0.03). The changes on most of the clinical rating scales were significantly in favour of BoNT-A. Side effects reported were hand weakness, which was mostly mild and always transient, and pain at the injection site. After 1 year, 20 of 39 patients were still under treatment with a positive effect. CONCLUSION Treatment with BoNT-A injections led to a significantly greater improvement compared with placebo, according to patients' opinion and clinical assessment scales. Weakness in the hand is an important side effect of BoNT-A injections, but despite this disadvantage, most patients preferred to continue treatment. About 50% of our patients were still under treatment after 1 year.
Collapse
Affiliation(s)
- J J M Kruisdijk
- Department of Neurology and Clinical Neurophysiology, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | | | | | | | | |
Collapse
|
32
|
Abstract
Dystonia may be a sign or symptom, that is comprised of complex abnormal and dynamic movements of different etiologies. A specific cause is identified in approximately 28% of patients, which only occasionally results in specific treatment. In most cases, treatment is symptomatic and designed to relieve involuntary movements, improve posture and function and reduce associated pain. Therapeutic options are dictated by clinical assessment of the topography of dystonia, severity of abnormal movements, functional impairment and progression of disease and consists of pharmacological, surgical and supportive approaches. Several advances have been made in treatment with newer medications, availability of different forms of botulinum toxin and globus pallidus deep brain stimulation (DBS). For patients with childhood-onset dystonia, the majority of whom later develop generalized dystonia, oral medication is the mainstay of therapy. Recently, DBS has emerged as an effective alternative therapy. Botulinum toxin is usually the treatment of choice for those with adult-onset primary dystonia in which dystonia usually remains focal. In patients with secondary dystonia, treatment is challenging and efficacy is typically incomplete and partially limited by side effects. Despite these treatment options, many patients with dystonia experience only partial benefit and continue to suffer significant disability. Therefore, more research is needed to better understand the underlying cause and pathophysiology of dystonia and to explore newer medications and surgical techniques for its treatment.
Collapse
Affiliation(s)
- Roongroj Bhidayasiri
- Chulalongkorn University Hospital, Chulalongkorn Comprehensive Movement Disorders Center, Division of Neurology, 1873 Rama 4 Road Bangkok 10330, Thailand.
| | | |
Collapse
|
33
|
Abstract
The pathophysiology and management of writer's cramp is one of the most challenging amongst the various forms of focal dystonias. Frequently, the dystonic postures are confounded by compensatory muscle activity. Correct identification of target muscles for botulinum toxin (BT) injections determines the treatment success. The dosages of different preparations vary, with 1 unit of Botox roughly equalling 3.5 units of Dysport. Electromyographic guided injections yield better results and may also decrease the amount of toxin required. Weakness of target muscles interfering with other non-writing activities is a frequently encountered adverse effect. Studies have shown that BT is a safe long-term therapy option.
Collapse
Affiliation(s)
- C P Das
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chadigarh, India.
| | | | | |
Collapse
|
34
|
Singer C, Papapetropoulos S. Adult-onset primary focal foot dystonia. Parkinsonism Relat Disord 2006; 12:57-60. [PMID: 16154790 DOI: 10.1016/j.parkreldis.2005.07.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2005] [Accepted: 07/18/2005] [Indexed: 11/25/2022]
Abstract
Although primary focal hand dystonia has been well characterized, primary focal foot dystonia in adults has rarely been reported. Our objective was to describe the clinical phenotype and treatment outcomes in patients with primary, adult-onset focal foot dystonia. To this end we conducted a retrospective study of four consecutive patients (59.5+/-13.5 years, range 44-67) diagnosed over a period of 6 years and followed-up for at least 5 years. Focal foot dystonia resulted in variable physical impairment. Anti-dystonic agents were mildly effective whereas botulinum toxin injections provided substantial benefit when used. Focal primary focal foot dystonia seems to be a rare form of focal dystonia with distinct clinical features that may benefit from treatment with botulinum toxin.
Collapse
Affiliation(s)
- Carlos Singer
- Department of Neurology, Miller School of Medicine, University of Miami, 1501 NW 9th Avenue, Miami, FL 33136, USA.
| | | |
Collapse
|
35
|
Djebbari R, du Montcel ST, Sangla S, Vidal JS, Gallouedec G, Vidailhet M. Factors predicting improvement in motor disability in writer's cramp treated with botulinum toxin. J Neurol Neurosurg Psychiatry 2004; 75:1688-91. [PMID: 15548483 PMCID: PMC1738875 DOI: 10.1136/jnnp.2003.032227] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To identify factors predicting improvement in motor disability in writer's cramp treated with botulinum toxin (BTX). METHODS 47 patients with writer's cramp were treated with BTX and were evaluated by the same neurologists at initial referral, after each BTX injection, and when the effect of BTX was maximal at the time of the study. Patients and examiners simultaneously and independently rated the efficacy of BTX injections. Self assessment was a global clinical impression of the impact of treatment on writing quality, writing speed, writing errors, and legibility of handwriting; for objective assessment, the examiners used the Burke-Fahn-Marsden (BFM) scale. RESULTS On the BFM scale, there was a significant improvement (p<0.0001) in both severity and disability scores. Patients with a pronation/flexion pattern of dystonia showed the best and the most sustained improvement. Primary writing tremor was little improved. There was a correlation between the self assessment score and the Burke-Fahn-Marsden score. Benefit was maintained over time CONCLUSIONS These results have implications for the identification of patients most likely to benefit from BTX injections.
Collapse
Affiliation(s)
- R Djebbari
- Department of Neurology, Hôpital Saint Antoine, Paris, France
| | | | | | | | | | | |
Collapse
|
36
|
Balash Y, Giladi N. Efficacy of pharmacological treatment of dystonia: evidence-based review including meta-analysis of the effect of botulinum toxin and other cure options. Eur J Neurol 2004; 11:361-70. [PMID: 15171731 DOI: 10.1111/j.1468-1331.2004.00845.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The treatment of both generalized and focal dystonia is symptomatic. There is no evidence-based information about the efficacy of the different methods of the pharmacological therapeutic options currently being applied in dystonia. The specific questions addressed by this study were which treatments for dystonia have proven efficacy and which of them have unproven results. Following evidence-based principles, a literature review based on MEDLINE and the Cochrane Library, augmented by manual search of the most important journals was performed to identify the relevant publications issued between 1973 and 2003. All articles appearing in the professional English literature, including case reports, were considered. In the presence of comparable studies the meta-analysis was performed to obtain pooled information and make a reasonable inference. Based on this review, we conclude: (i) botulinum toxin has obvious benefit (level A, class I-II evidence) for the treatment of cervical dystonia and blepharospasm; (ii) trihexyphenidyl in high dosages is effective for the treatment of segmental and generalized dystonia in young patients (level A, class I-II evidence); (iii) all other methods of pharmacological intervention for generalized or focal dystonia, including botulinum toxin injections, have not been confirmed as being effective according to accepted evidence-based criteria (level U, class IV studies).
Collapse
Affiliation(s)
- Y Balash
- Movement Disorders Unit, Department of Neurology, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | | |
Collapse
|
37
|
Abstract
BTs seem to be a useful treatment in refractory MPS and headache. Presumably BTs work by breaking the spasm or pain cycle giving the patient a "window of opportunity" for traditional conservative measures to have a greater beneficial impact, but several studies suggest that a direct antinociceptive effect distinct from any reduction in muscle spasm may be at play. The major benefit of BTs compared with standard therapies is duration of response. We do not advocate that BTs be used as a first line treatment for MPS or headache. However, in refractory cases where nothing else has worked, it may offer a chance for improvement or cure not otherwise available. For now, it remains an off label, but increasingly accepted, approach in-patients with refractory myofascial pain and headache, who despite multidisciplinary approaches, continue to suffer.
Collapse
Affiliation(s)
- P Prithvi Raj
- Texas Tech University Health Sciences Center, International Pain Institute, 4430 South Loop 289, Lubbock, TX 79413, USA.
| |
Collapse
|
38
|
Abstract
Botulinum toxins are among the most potent neurotoxins known to humans. In the past 25 years, botulinum toxin has emerged as both a potential weapon of bioterrorism and as a powerful therapeutic agent, with growing applications in neurological and non-neurological disease. Botulinum toxin is unique in its ability to target peripheral cholinergic neurons, preventing the release of acetylcholine through the enzymatic cleavage of proteins involved in membrane fusion, without prominent central nervous system effects. There are seven serotypes of the toxin, each with a specific activity at the molecular level. Currently, serotypes A (in two preparations) and B are available for clinical use, and have been shown to be safe and effective for the treatment of dystonia, spasticity, and other disorders in which muscle overactivity gives rise to symptoms. This review focuses on the pharmacology, electrophysiology, immunology, and application of botulinum toxin in selected neurological disorders.
Collapse
Affiliation(s)
- Cynthia L Comella
- Department of Neurological Sciences, Rush University Medical Center, 1725 West Harrison, Chicago, Illinois 60612, USA.
| | | |
Collapse
|
39
|
Hyman N, Barnes M, Bhakta B, Cozens A, Bakheit M, Kreczy-Kleedorfer B, Poewe W, Wissel J, Bain P, Glickman S, Sayer A, Richardson A, Dott C. Botulinum toxin (Dysport) treatment of hip adductor spasticity in multiple sclerosis: a prospective, randomised, double blind, placebo controlled, dose ranging study. J Neurol Neurosurg Psychiatry 2000; 68:707-12. [PMID: 10811692 PMCID: PMC1736956 DOI: 10.1136/jnnp.68.6.707] [Citation(s) in RCA: 142] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To define a safe and effective dose of Dysport for treating hip adductor spasticity. METHODS Patients with definite or probable multiple sclerosis, and disabling spasticity affecting the hip adductor muscles of both legs, were randomised to one of four treatment groups. Dysport (500, 1000, or 1500 Units), or placebo was administered by intramuscular injection to these muscles. Patients were assessed at entry, and 2, 4 (primary analysis time-point), 8, and 12 weeks post-treatment. RESULTS A total of 74 patients were recruited. Treatment groups were generally well matched at entry. The primary efficacy variables-passive hip abduction and distance between the knees-improved for all groups. The improvement in distance between the knees for the 1500 Unit group was significantly greater than placebo (p = 0.02). Spasm frequency was reduced in all groups, but muscle tone was reduced in the Dysport groups only. Pain was reduced in all groups, but improvements in hygiene scores were evident only in the 1000 Unit and 1500 Unit groups. Duration of benefit was significantly longer than placebo for all Dysport groups (p<0.05). Adverse events were reported by 32/58 (55%) Dysport patients, and by 10/16 (63%) placebo patients. Compared with the two lower dose groups, twice as many adverse events were reported by the 1500 Unit group (2.7/patient). The incidence of muscle weakness was higher for the 1500 Unit group (36%) than for placebo (6%). The response to treatment was considered positive by two thirds of the patients in the 500 Unit group, and by about half the patients in the other groups. CONCLUSION Dysport reduced the degree of hip adductor spasticity associated with multiple sclerosis, and this benefit was evident despite the concomitant use of oral antispasticity medication and analgesics. Although evidence for a dose response effect was not statistically significant, there was a clear trend towards greater efficacy and duration of effect with higher doses of Dysport. Dysport treatment was well tolerated, with no major side effects seen at doses up to 1500 Units. The optimal dose for hip adductor spasticity seems to be 500-1000 Units, divided between both legs.
Collapse
Affiliation(s)
- N Hyman
- Radcliffe Infirmary, Oxford, UK
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Abstract
Advances in the clinical use of botulinum neurotoxins continue. Of interest to the neurologist is the advanced practice in the treatment of focal dystonia and the new developments on other dyskinesias and on autonomic control of smooth muscle motility. New toxin serotypes are now being tested; their availability will improve clinical practice and will possibly lead to combined treatments. Indications in spasticity and in juvenile cerebral palsy are now under scrutiny. The combination of focal chemodenervation with specific rehabilitation procedures enables new development in this field.
Collapse
|
41
|
Abstract
Dystonia is a movement disorder characterized by increased muscular tone for which surgical treatment has met with less than ideal results. Surgical treatment in patients with dystonia is often avoided due to the relative success of medical therapy. However, if expectations stay realistic and if the patient with dystonia is continuously evaluated, appropriate surgical measures may be taken when necessary to optimize patient satisfaction. The authors present a case of successful surgical treatment in a patient with a relatively static but crippling lower extremity deformity. A review of dystonia is included with successful surgical treatment of this compound neurologic disease causing lower extremity deformity in a young female. Diagnosis and treatment options including surgical planning and principles in the dystonic patient are highlighted.
Collapse
Affiliation(s)
- C G Kissel
- Department of Surgery, Hutzel Hospital/Detroit Medical Center, MI, USA
| | | |
Collapse
|
42
|
Chen R, Karp BI, Goldstein SR, Bara-Jimenez W, Yaseen Z, Hallett M. Effect of muscle activity immediately after botulinum toxin injection for writer's cramp. Mov Disord 1999; 14:307-12. [PMID: 10091625 DOI: 10.1002/1531-8257(199903)14:2<307::aid-mds1016>3.0.co;2-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Animal and human studies have shown that nerve stimulation enhances some effects of botulinum toxin (btx A) injection. Voluntary muscle activity might work similarly and would focus the effect of an injection into the active muscles. We studied the effects of exercise immediately after btx A injection in eight patients with writer's cramp with established response to btx A over two injection cycles with a single-blinded, randomized, crossover design. Immediately after the first study injection, they were randomly assigned to write continuously for 30 min or have their hand and forearm immobilized for 30 min. Following the second injection, they were assigned the alternate condition. Patients were assessed just before each injection, and at 2 weeks, 6 weeks, and 3 months post-injection. Assessment included objective strength testing, self-reported rating of benefit and weakness, and blinded evaluation of videotapes and writing samples of the patients writing a standard passage. Strength testing showed that the maximum weakness occurred at 2 weeks post-injection, but the benefit was maximum at 6 weeks post-injection. The "write" condition resulted in greater reduction in strength than the "rest" condition. Btx A treatment led to improvement in self-reported ratings, writer's cramp rating scale scores by blinded raters, and reduction in writing time, but the differences between the "write" and "rest" conditions were not significant. We conclude that voluntary muscle activity immediately after btx A injection leads to greater reduction in muscle strength. Our findings raise the possibility that voluntary muscle activation may allow reduction of btx A doses and favorably alter the balance of benefit and side effects of btx A injections.
Collapse
Affiliation(s)
- R Chen
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland 20892-1428, USA
| | | | | | | | | | | |
Collapse
|
43
|
Sherman AL, Willick SP, Cardenas DD. Management of focal dystonia of the extensor hallucis longus muscle with botulinum toxin injection: a case report. Arch Phys Med Rehabil 1998; 79:1303-5. [PMID: 9779689 DOI: 10.1016/s0003-9993(98)90280-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Recently botulinum toxin has been used with increasing frequency as a safe and effective treatment for many previously refractory conditions associated with excessive muscle activity. The indications for use of botulinum toxin injection continue to expand. This report describes the case of an 83-year-old woman with a history of diabetes mellitus and lumbar spinal stenosis who developed a severe focal dystonia of the left great toe, such that the toe maintained the extended position. Functionally, the resultant deformity prevented the patient from wearing shoes. In addition, the patient had significant pain in the left great toe. Under needle electromyographic localization, 50 units of botulinum toxin were injected into the left extensor hallucis longus muscle. Two weeks after the injection the patient was symptom free and could place her left foot into a shoe. Seven months later, she remained symptom free. This case illustrates that localized injection of botulinum toxin to a specific lower limb muscle can effectively result in decreased muscle activity and functional improvement.
Collapse
Affiliation(s)
- A L Sherman
- Department of Rehabilitation Medicine, University of Washington, Seattle 98105, USA
| | | | | |
Collapse
|
44
|
Abstract
Leigh syndrome is a form of neurodegenerative disease which is associated with intracranial infarcts. The diagnosis is made by finding hyperlactacidaemia together with cerebral infarcts on neuroimaging. We report a 4-year-old Chinese girl with Leigh syndrome who had several atypical features. She presented with generalized dystonia and developmental regression. In addition, she suffered from an unusual feature of bladder dystonia. This patient appeared to be suffering from respiratory chain complex I deficiency from studies on cultured skin fibroblasts. Assays for respiratory chain enzymes as well as mitochondrial DNA point mutations and major deletions in muscle were normal. Dystonia persisted despite treatments with muscle relaxants and a ketogenic diet. Intramuscular botulinum toxin resulted in significant relief of dystonia.
Collapse
Affiliation(s)
- T F Leung
- Department of Paediatrics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong.
| | | | | | | |
Collapse
|
45
|
Abstract
Six surgical procedures, consisting of tendon transfers and releases, were performed in five patients with idiopathic focal dystonia involving the lower extremity. All patients were female. Surgical management was performed to correct clinically significant foot abnormalities. The goal of each procedure was functional improvement and obtaining a plantigrade foot. The SPLATT (split anterior tibial tendon transfer) procedure was performed in each foot with a flexible equinovarus foot abnormality. Follow up at a mean of 27.2 months (range, 8-40 months) yielded satisfactory clinical results without significant complications. Clinical equinovarus has not recurred after this procedure. All patients remain brace-free ambulators.
Collapse
Affiliation(s)
- T J Moore
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia 30308, USA
| | | | | |
Collapse
|
46
|
Bickerton LE, Agur AM, Ashby P. Flexor digitorum superficialis: locations of individual muscle bellies for botulinum toxin injections. Muscle Nerve 1997; 20:1041-3. [PMID: 9236799 DOI: 10.1002/(sici)1097-4598(199708)20:8<1041::aid-mus18>3.0.co;2-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Twenty-two Flexor Digitorum Superficialis (FDS) muscles from 18 cadavers were dissected to find the "Optimal Injection Site" (OIS) for botulinum toxin injections to individual bellies of FDS. Coordinates are given as a percentage of the distance along a landmarking line from the medial epicondyle to the pisiform and in millimetres (mm) lateral to it. The OIS were: FDS2: 72%, 14 mm; FDS3: 54%, 17mm; FDS4: 49%, 7mm; FDS5: 76%, 6mm. OIS measurements guide the electromyographer to localize the targeted muscle belly.
Collapse
Affiliation(s)
- L E Bickerton
- Department of Physical Therapy, Faculty of Medicine, University of Toronto, Ontario, Canada
| | | | | |
Collapse
|
47
|
Ross MH, Charness ME, Sudarsky L, Logigian EL. Treatment of occupational cramp with botulinum toxin: diffusion of toxin to adjacent noninjected muscles. Muscle Nerve 1997; 20:593-8. [PMID: 9140366 DOI: 10.1002/(sici)1097-4598(199705)20:5<593::aid-mus8>3.0.co;2-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Over a 5-year period, 40 patients, 11 with musician's and 29 with writer's cramp, were treated with botulinum toxin A using a precise injection technique in which the hollow-bore electromyography (EMG) needle was positioned by both standard EMG and by muscle twitch evoked by stimulating current passed through it. Moderate to complete improvement in dystonia occurred in 28 patients (70%) after the first injection and in 34 patients (85%) after the second injection with better outcome in nonmusicians than in musicians. Of note, weakness of uninjected muscles, immediately adjacent to those injected, was found in 25/40 patients (63%). The most common patterns of toxin spread were from flexor digitorum sublimis to profundus, extensor carpi radialis to extensor digitorum communis, and extensor indicis proprius to extensor pollicis brevis. Spread to, and weakness of, adjacent uninjected muscles was a major factor contributing to suboptimal outcome in 6/39 (15%) such patients.
Collapse
Affiliation(s)
- M H Ross
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
| | | | | | | |
Collapse
|
48
|
Wissel J, Kabus C, Wenzel R, Klepsch S, Schwarz U, Nebe A, Schelosky L, Scholz U, Poewe W. Botulinum toxin in writer's cramp: objective response evaluation in 31 patients. J Neurol Neurosurg Psychiatry 1996; 61:172-5. [PMID: 8708685 PMCID: PMC1073991 DOI: 10.1136/jnnp.61.2.172] [Citation(s) in RCA: 96] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES To quantify the treatment effect of local botulinum toxin injections in writer's cramp a newly developed rating scale of writing performance and a computer assisted analysis of writing speed were used in 31 patients undergoing botulinum toxin therapy. METHODS Baseline data of the writer's cramp rating scale (WCRS, see appendix) and computer based writing speed analysis were compared with those obtained at the time of subjective best response as recorded during follow up visits. RESULTS The mean dose injected per session was 133.2 units Dysport divided between two forearm muscles. Of all 124 injection sessions during mean follow up of one year 76% produced a good improvement. The most common side effect was weakness (72% of the follow up visits). The WCRS scores as assessed by a blinded videotape review by four independent raters showed good reliability between raters and a significant improvement after treatment (P < 0.001). The speed of pen movements showed a significant (P < 0.05) increase after treatment at subjective best effect recordings and a significant correlation with WCRS subscores, documenting the validity of the scale. CONCLUSION The present study is the first to show significant effects of botulinum toxin treatment in patients with writer's cramp on the basis of a quantifiable scale for writing performance which correlates significantly with writing speed measurements. The WCRS as employed in this study might therefore prove a useful rating instrument in other studies assessing severity and treatment response in patients with writer's cramp.
Collapse
Affiliation(s)
- J Wissel
- Department of Neurology, Virchow Klinikum, Berlin, Germany
| | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Geenen C, Consky E, Ashby P. Localizing muscles for botulinum toxin treatment of focal hand dystonia. Can J Neurol Sci 1996; 23:194-7. [PMID: 8862841 DOI: 10.1017/s0317167100038506] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is currently no consensus on the best way to localize muscles in the forearm for botulinum toxin (BTX) injection. We devised a study to compare electromyography (EMG) with local stimulation through a cannula for localizing forearm muscles for botulinum toxin (BTX) injection, and for predicting the risk of unwanted weakness in non-target muscles. METHODS In 12 patients with focal hand dystonia a single "target" muscle, determined by clinical examination to contribute most to the dystonic hand posture, was selected for botulinum toxin injection. The patients were randomized into 2 treatment groups, one in which the target muscle was localized by recording the EMG signals during voluntary contractions (8 patients) and the other in which the target muscle was localized by local electrical stimulation (4 patients). The target muscle was then injected with a standardized dose of BTX. RESULTS At follow-up 3 weeks after BTX injection the target muscle was weakened in 7/12 patients (4/8 of the EMG group, and 3/4 of the stimulation group). Additional noninjected muscles, adjacent to the target muscle, were weakened in 5 of these 7 patients, presumably from diffusion of the toxin. CONCLUSIONS Localization by stimulation is probably at least as good as EMG. Each technique has certain advantages. Weakness of "non-target" muscles was not consistently predicted by either EMG or stimulation suggesting that BTX diffuses farther than the volume conduction of EMG signals or the spread of effective stimulus current.
Collapse
Affiliation(s)
- C Geenen
- Division of Neurology, Toronto Hospital, Ontario, Canada
| | | | | |
Collapse
|
50
|
Quirk JA, Sheean GL, Marsden CD, Lees AJ. Treatment of nonoccupational limb and trunk dystonia with botulinum toxin. Mov Disord 1996; 11:377-83. [PMID: 8813216 DOI: 10.1002/mds.870110405] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
We report the results of treatment of 16 patients (14 women, two men; 18-81 years old) with nonoccupational limb and trunk dystonia with botulinum toxin A (BTX; Dysport). A total of 18 clinical problems were identified. Outcomes were assessed in terms of pain relief and improvement in posture and function by the combined observations of the patient and physician. Patients' satisfaction with treatment was high--the benefit in 15 of 18 problems was rated as good to excellent. Reduction in pain was achieved in nine of 10 painful problems, with total relief in four cases. Some normalisation of posture was obtained in 17 of 18; it was complete in three cases. Functional improvement was less common (10 of 18). Excessive weakness was the most common side effect, affecting five patients, but it was disabling in only two. We conclude that BTX can provide substantial benefit with minimal side effects in the majority of patients with these conditions, particularly with pain relief and postural improvements.
Collapse
Affiliation(s)
- J A Quirk
- National Hospital for Neurology and Neurosurgery, London, England
| | | | | | | |
Collapse
|