Abstract
Botulinum toxin-A (BoNT-A) is an effective treatment for cervical dystonia (CD) and spastic paresis (SP), but it requires in-depth knowledge of anatomy and injection techniques. The Ixcellence Network® is an educational programme to provide neurology, neuropaediatrics, and physical medicine and rehabilitation (PMR) specialists with access to best clinical practices and innovations regarding SP and CD management with BoNT-A. To assess the benefits of such educational programmes and identify unmet needs, a multidisciplinary scientific committee designed INPUT (INjection Practice, Usage & Training), an international multicentric survey describing training and practices among this trained and experienced population. A self-completed questionnaire was sent online to 553 trainees and 14 trainers from the Ixcellence Network®. Among the 131 respondents, 92% specialized in PMR (48%) or neurology (44%), with a mean experience of 15.5 years in their clinical fields and 10.9 years of BoNT-A injection. Most of them (98%) reported having received training before performing their first BoNT-A injection and attending specific courses on how to perform it without any instrumental guidance (76%), and with ultrasound (73%), electrical stimulation (44%) or electromyography (41%). In terms of practices, 92% of respondents reported using at least one guidance technique while injecting, with ultrasound being the most used technique (48%). Attending specific courses was significantly associated with greater self-confidence and use, e.g. for injection with ultrasound, mean self-confidence, on a scale from 1 (not confident) to 10 (fully confident), was 7.9 for trained respondents (vs 4.0 for untrained respondents, p < 0.001) of whom 70% stated that they used this technique regularly or systematically (vs. 11% of untrained healthcare professionals (HCPs), p < 0.0001). Moreover, 84% of respondents reported having trained colleagues, residents or fellows through theoretical (70%) or practical teaching in individuals (80%) or in small groups (65%). Overall, 86% of respondents reported a notable increase over the past 5 years of the number of patients treated with BoNT-A. INPUT is the first international survey describing training and practices in SP and CD management of physicians who attended a dedicated educational programme. The results highlighted the importance of training for self-confidence, and the use of specific techniques and new approaches.
Highlights
Botulinum toxin-A (BoNT-A), a neurotoxin produced by an anaerobic bacterium Clostridium botulinum, is a well-established and effective treatment for a number of neurological movement disorders associated with muscle hyperactivity, including adult spastic paresis (SP) from stroke, multiple sclerosis, traumatic brain or spinal cord injury, pediatric SP from cerebral palsy and adult cervical dystonia (CD) [1,2,3,4,5,6]
The following parameters were collected: [1] general information: country of practice, experience in their field and in BoNT-A injection, training on different approaches/techniques, confidence in using these approaches, trainer activity; [2] clinic organization: time dedicated to BoNT-A injection, number of injectors in the department, waiting time for appointments, usage of guidance techniques for BoNT-A injection; [3] patient profile and management: type of patients treated and specific information related to each indication; [4] how their clinical practice evolved over the past 5 years (Supplementary Figure 1)
For patient profile and management results, only adult SP and CD data were reported in this publication, which focuses on adult SP and CD management
Summary
BoNT-A is administered by local injections into the muscles involved in the movement disorder. Its effectiveness depends on several factors including the injector’s skills and knowledge, since accurate muscle selection, injection site selection and adequate drug dosage are key to achieving the best results [7,8,9,10]. Palpation or instrumentally guided injection with ultrasound (US), electrical stimulation (ES) or electromyography (EMG) are commonly used to identify targeted muscles for injection in SP and CD treatment [12]. Use of these targeting techniques is very much dependent on injector’s prior training, confidence and the availability of equipment
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