Botulinum Neurotoxin Injections Research Articles

Evaluation of Regio Temporalis in 3 Steps in Terms of Interventional Procedures.

Regio temporalis is a site where botulinum neurotoxin is applied for various medical reasons, such as migraine, bruxism, and myofascial pain syndrome. The region is also one of the target regions in flap surgery. This study aimed to define the region topographically. In addition, it was aimed to reveal the intramuscular nerve distribution of the temporalis.11 fixed cephalus (cadaver head) and 2 fresh cephalus were used. The lateral canthus of the eye was marked as point A, and the middle of the ear tragus as point B. The transverse and vertical distances of the branching point of the superficial temporal artery to the A and B points were measured. Transverse distances of the superficial temporal artery and superficial temporal vein to A and B points were measured. The muscle was examined in 5 equal parts (L0-L1-L2-L3-L4), and each part's vertical muscle and tendon lengths were examined. Intramuscular nerve density was demonstrated by applying the modified Sihler staining to fresh temporalis'. Superficial temporal artery had an average transverse distance of 8.56±1.9mm in women and 12.56±1.94mm in men from the middle of the ear tragus. The artery was 64.21±5.59mm posterior in females and 63.48±6.53mm in males from the lateral canthus of the eye. Our study determined that the branching point of the superficial temporal artery was below the upper level of the arcus zygomaticus in 10% of cases and above it in 90% of cases. In our study, the L2 point had the highest vertical muscle length at 45.67mm, while the L3 point had the highest vertical tendon length at 41.25mm. The point where the muscle length had the highest ratio with 1.49 compared to the tendon length, was the L2 point. The temporalis' for which the modified Sihler staining was applied was examined in 5 quadrants. It was determined that the nerve densities were in the second and third quadrants from anterior to posterior. The distance of superficial landmarks to neurovascular structures is extremely important in interventions to the regio temporalis. Considering the average distances given in our study is important in avoiding damage in surgical procedures and not injecting into vascular structures. The point where the muscle length had the highest ratio of 1.49 compared to the tendon length was the L2 point. The area in line with this point is the most suitable area for injection. The L2 point is also the most suitable area for injection as it has the highest muscle length. Since the nerve densities were observed in the modified Sihler staining applied temporalis' 2 and 3 quadrants from anterior to posterior, botulinum neurotoxin injections to these areas will give more effective results.

A prospective and randomized study comparing ultrasound-guided real time injection to conventional blind injection of botulinum neurotoxin for glabellar wrinkles.

Botulinum neurotoxin injections are the most frequently performed cosmetic procedures, but conventional blind injection for glabellar wrinkles remains to have some limitations. We intend to directly inject botulinum neurotoxin into the glabella complex guided by real time ultrasound. We aim to propose a more efficient and safer botulinum neurotoxin injection strategy for glabellar wrinkles. A total of 40 subjects with moderate to severe glabellar lines were enrolled in this study to receive botulinum neurotoxin injection, either through ultrasound-guided real time injection or conventional blind injection. Facial Wrinkle Scale (ranging from 0 = none to 3 = severe) and inter-brow distance (from 3D scanned face images) were used to evaluate the glabellar wrinkles improvement. Paired t test and two-sample t test were performed to analyze the within-group and between-group differences. The wrinkle score reduction was significant (p < 0.0001) immediately after the injection in ultrasound-guided injection group, but not in blind injection group (p = 0.163). Ultrasound-guided injection also showed a higher performance of wrinkle score reduction and more effective inter-brow distance increase over blind injection at Day 0 (p < 0.0001), Day 1 (p < 0.0001), Day 21 (p < 0.01) and Day 35 (p < 0.01) after initial treatment. The results of the study confirmed that botulinum neurotoxin injection for glabellar wrinkles under ultrasound guidance achieves quicker onset of action and better final outcomes compared to conventional blind injection.

Ultrasonographic Study of the Submandibular Gland for Botulinum Neurotoxin Injection.

Hypertrophied submandibular glands provide a bulky contour to the lower face. Botulinum neurotoxin injection methods are commonly used for facial contouring; however, no studies have suggested injection points because of the lack of delicate anatomical information on the submandibular gland. The aim of this study was to determine the optimal injection site for botulinum neurotoxin injections in the submandibular gland. Anatomical considerations when injecting botulinum neurotoxin into the submandibular gland were determined using ultrasonography. The thickness of the submandibular gland, its depth from the skin surface, and the location of the vascular bundle were observed bilaterally in 42 participants. Two cadavers were dissected to measure the location of the submandibular gland corresponding to the ultrasonographic observation. The thickest part of the submandibular gland measured 11.12 ± 2.46 in width with a depth of 4.63 ± 0.76. At the point where it crosses the line of the lateral canthus, it measured 5.53 ± 1.83 in width and 8.73 ± 1.64 in depth. The authors suggest optimal injection sites based on external anatomical landmarks. These guidelines aim to maximize the effects of botulinum neurotoxin therapy by minimizing its deleterious effects, which can be useful in clinical settings.

Why do marionette lines appear? Exploring the anatomical perspectives and role of thread-based interventions.

The pathogenesis of marionette lines involves a complex interplay of anatomical, physiological, and age-related factors leading to the development of wrinkles around the oral commissures. This exploration delves into the distinct anatomical predispositions observed among different ethnicities, emphasizing the role of compact modiolus structures and muscle compositions. Notably, individuals of East Asian descent exhibit inherent facial structures that predispose them to pronounced sagging around the oral commissures during aging. The emergence of distinct facial lines, such as the commissural line and the melolabial fold, contributes to the formation of marionette lines. This specific wrinkle pattern, resembling a marionette puppet's mouth contours, is influenced by various factors like bone resorption, gravitational forces, fat compartment variations, muscle compression, ligament tethering, and skin aging. Treatment strategies for marionette lines encompass diverse interventions, including filler injections, botulinum neurotoxin, surgeries targeting fat reduction, thread lifting, and volumizing fillers. These approaches aim to address the underlying causes and mitigate the appearance of marionette lines. Botulinum neurotoxin injections, for instance, weaken specific facial muscles, reducing downward strain and aiding in tissue retraction. Anatomical considerations during procedures are crucial to avoid nerve or vascular damage. Delicate manipulation and precise entry points are essential to prevent inadvertent injuries, particularly concerning blood vessels like the facial artery and nerves like the mental nerve. Technical guidelines for procedures targeting marionette lines involve specific techniques like cogged thread reverse methods and volumizing thread placements. Attention to entry points, tissue engagement, and the direction of threads is crucial for effective treatment outcomes, minimizing complications, and ensuring patient safety.

Botulinum neurotoxin as early treatment in acute-onset lesional hemiballism.

Hemiballism (HB) and hemichorea (HC) are the most frequent secondary movement disorders, usually caused by cerebrovascular diseases. In only a minority of cases, these involuntary movements are not self-limited, and they may severely compromise patients' quality of life, so that symptomatic treatments are required. Typical and atypical neuroleptics as well as tetrabenazine are considered therapies of choice. However, anecdotal reports of antiseizures medications and botulinum neurotoxin injection effectiveness have been described. We described a case of severely disabling acute-onset lesional HB/HC, where high dosage of first- and second-line therapies was contraindicated due to patient's comorbidities. After botulin neurotoxin (BoNT) injections in his left upper limb muscles (biceps brachii, triceps brachii, teres major, and deltoid), the patient experienced gradual reduction of hyperkinetic movements. The gradual discontinuation of topiramate (TPM) did not worsen the clinical picture. The reduction of hyperkinetic movements led to rhabdomyolysis resolution as well as cutaneous injuries healing with renal function improvement, so that the patient was able to be eligible for rehabilitation, which was prevented by HB/HC itself. The clinical improvement was consistent with BoNT pharmacokinetic. The administration of BoNT early after the onset of lesional HB/HC remarkably modified the clinical management and drove toward comorbidities resolution and rehabilitation. The present case highlights the effectiveness of unconventional therapeutic options in disabling acute onset lesional HB/HC when first-line therapies are contraindicated. Particularly, this report may encourage BoNT application in the early stage of movement disorder emergencies.

Proteomic changes of botulinum neurotoxin injection on muscle growth in children with spastic cerebral palsy.

The study aims to explore the proteomic profile and specific target proteins associated with muscle growth in response to botulinum neurotoxin A (BoNT-A) treatment, in order to improve spasticity management in children with cerebral palsy (CP). A total of 54 participants provided 60 plasma samples for proteomic analysis. Among them, six children were sampled before and after receiving their first BoNT-A injection. In addition, 48 unrelated children were enrolled, among whom one group had never received BoNT-A injections and another group was sampled after their first BoNT-A injection. Differentially expressed proteins were identified using the data-independent acquisition (DIA) mass spectrometry approach. Gene Ontology (GO), protein-protein interaction network, and Kyoto Encyclopedia of Genes and Genome analysis were conducted to explore the function and relationship among differentially expressed proteins. The expression levels of target proteins were verified by quantitative real-time PCR and western blotting. Analysis identified significant differential expression of 90 proteins across two time points, including 48 upregulated and 42 downregulated proteins. The upregulated thioredoxin, α-actinin-1, and aggrecan, and the downregulated integrin beta-1 may affect the growth of muscles affected by spasticity 3months after BoNT-A injection. This effect is potentially mediated through the activation or inhibition of PI3K-Akt, focal adhesion, and regulation of actin cytoskeleton signaling pathways. BoNT-A injection could lead to a disruption of protein levels and signaling pathways, a condition subsequently associated with muscle growth. This finding might aid clinicians in optimizing the management of spasticity in children with CP.

Effects of botulinum neurotoxin on regularity of head oscillations in cervical dystonia

Introduction: This study explores the effects of botulinum neurotoxin (BoNT) on the relationship between dystonia and tremor, specifically focusing on cervical dystonia (CD) and its connection to head tremor.Methods: Fourteen CD patients were recruited; eight (57%) with clinically observable head oscillations were included in further analysis. A high-resolution magnetic search coil system precisely measured head movements, addressing two questions: 1) BoNT’s effects on head movement amplitude, frequency, and regularity, and 2) BoNT’s influence on the relationship between head position and head oscillations. For the first question, temporal head position measurements of three patients were analyzed before and after BoNT injection. The second question examined the effects of BoNT injections on the dependence of the oscillations on the position of the head.Results: Three distinct trends were observed: shifts from regular to irregular oscillations, transitions from irregular to regular oscillations, and an absence of change. Poincaré analysis revealed that BoNT induced changes in regularity, aligning oscillations closer to a consistent “set point” of regularity. BoNT injections reduced head oscillation amplitude, particularly in head orientations linked to high-intensity pre-injection oscillations. Oscillation frequency decreased in most cases, and overall variance in the amplitude of head position decreased post-injection.Discussion: These findings illuminate the complexity of CD but also suggest therapeutic potential for BoNT. They show that co-existing mechanisms contribute to regular and irregular head oscillations in CD, which involve proprioception and central structures like the cerebellum and basal ganglia. These insights advocate for personalized treatment to optimize outcomes that is based on individual head oscillation characteristics.

Nerve Distribution Method is Superior to the Conventional Method in BoNT-A Treatment of Trapezius Hypertrophy: A Randomized Controlled Trial.

The contour of the neck and shoulder is defined by the trapezius muscle (TM). Beyond facial procedures, botulinum toxin A (BoNT-A) injections has been increasingly adopted to create a smooth shoulder line. Several studies described the intramuscular nerve branching and the pattern of perforating branch of the accessory nerve in the trapezius muscle, providing essential information for botulinum neurotoxin injection. To this date, research groups seldom perform clinical investigations, especially randomized controlled trials, that demonstrates whether BoNT-A injections using the nerve distribution method for aesthetic purposes is more effective. Patients met the criteria for inclusion were randomized to either the Nerve Distribution group (ND group) or control group. Control group patients received injection using the conventional method while ND group patients received the nerve distribution method. Photographic and ultrasonographic evaluations were carried out at baseline, one month, three months, and six months after the procedure. Patients were also required to complete a questionnaire to evaluate their feedbacks to the injection. After screening, 30 healthy young Chinese women were included. At one-month follow-up, no statistically significant difference was observed between the two methods. At the three-month follow-up, the reduction of the TM thickness for the ND group (0.21 ± 0.09 cm) was more than that for the control group (0.27 ± 0.08 cm), with p = 0.047*. Similar differences were observed for the reduction of the shoulder area proportion (p = 0.031*) and the shoulder angle (p = 0.035*). At the six-month follow-up, the reduction in TM thickness in the ND group (0.2 ± 0.09 cm) was more than that of the control group (0.28 ± 0.06 cm), with p = 0.041*. The global aesthetic improvement scale feedbacks of the two methods showed no significant difference (3.4 ± 0.71 vs 3.8 ± 0.91, p = 0.207). The patients did not experience severe side effects. Compared to the conventional injection method, the nerve distribution method is more effective in reducing the trapezius muscle thickness, shoulder area proportion, and shoulder angle at three months, and shows longer lasting effects. The results of this study introduce unique insights into the design and tailoring of treatment protocols for shoulder-line contouring using BoNT-A.Level of Evidence I This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Intensive Voice Treatment following Botulinum Neurotoxin Injection for a Speaker with Abductor Laryngeal Dystonia: An Exploratory Case Study.

Abductor laryngeal dystonia (ABLD) is a rare neurological voice disorder which results in sporadic opening of the vocal folds during speech. Etiology is unknown, and to date there is no identified effective behavioral treatment for it. It is hypothesized that LSVT LOUD®, which was developed to treat dysphonia secondary to Parkinson's disease, may have application to speakers with ABLD to improve outcomes beyond that with botulinum neurotoxin (BoNT) treatment alone. The participant received one injection of BoNT in each vocal fold 2 to 3 months prior to initiating intensive voice therapy via teletherapy. Objective measures of vocal loudness (dB sound pressure level), maximum phonation time, and high/low pitch frequency (Hz) were recorded in all treatment sessions and follow-up sessions. Over the course of treatment, the participant showed steady gains in phonation time, volume, pitch range, and vocal quality with a substantial reduction in aphonic voice breaks by the end of the treatment program. Perceptual symptoms of ABLD were nearly undetectable by the participant and the clinicians up to 12 months posttreatment, with no additional BoNT injections. The results suggest that LSVT LOUD® following BoNT was effective, with long-lasting improvement in vocal function, for this speaker with ABLD.

Sonographic observation of the paradoxical masseteric bulging and clinical implication of functional compartment.

Masseter are commonly botulinum neurotoxin targeted muscle for facial contouring in aesthetic field. However, paradoxical masseteric bulging is common adverse effect that has not been discussed with ultrasonographic observations. Retrospective study has been conducted from October, 2021 to January, 2023, out of 324 patients have done blinded botulinum neurotoxin injection in the masseter at the middle and lower portion of the masseter with each side of 25 units (letibotulinum neurotoxin type A), 3 patients demonstrated paradoxical masseteric bulging has been reported and the image observed by ultrasonography by physician. Based on the observations made, we can infer that the function of the moving muscle involves twisting of the muscle fibers during contraction, along with the twisting of the deep inferior tendon, which causes the muscle to be divided into anterior and posterior compartments rather than into superficial and deep compartments of masseter. In ultrasonographic observe the skin surface of a patient with paradoxical masseteric bulging, it is observable that either the anterior or posterior part contracts significantly. The functional units of anterior and posterior compartment are observable as muscular contraction of inward movement of the muscle from either the anterior or posterior functional unit.

Effect of refractive errors on the results of botulinum neurotoxin administration in patients with infantile esotropia.

To investigate the effect of refractive errors on the results of patients followed up with infantile esotropia (IE) and treated with botulinum neurotoxin (BNT) injection. The files of patients with IE who presented to the ophthalmology pediatric ophthalmology unit and underwent BNT injection into both medial rectus muscles between 2019 and 2021 were reviewed retrospectively. Sixty eyes of 30 patients were included in the study. Patients with additional systemic or ocular diseases and those with a history of ocular surgery were excluded. Distance and near deviations were measured (with the prism cover test or Krimsky method) before and at the first, third, and sixth months after BNT injection. In Group 1 (n = 20) with a spherical equivalent of + 2.0 diopters (D) or less, the mean near and distance deviation value was both 36.8 ± 12.7 prism diopter (PD) before injection. In Group 2 (n = 10) with a spherical equivalent of above + 2.0 D, the near deviation was measured as 35.0 ± 7.1 PD and distance deviation as 31.8 ± 7.9. At six months after BNT injection, the near and distance deviation values were 20.6 ± 12.3 and 20.6 ± 11.6 PD, respectively in Group 1 and 10.1 ± 10.3 and 8.8 ± 10.8 PD, respectively in Group 2. The change in deviation did not statistically significantly differ between the groups (p > 0.05), but the distance and near deviation values were lower in Group 2 at sixth months after BNT injection. BNT injection is a preferred method in IE. Higher hypermetropic values seem to increase the success of BNT injection.

BOTULINUM TOXIN A FOR BLEPHAROSPASM WITH DRY EYE: A SYSTEMATIC REVIEW

Introduction &amp; Objectives : Essential blepharospasm is a neurological condition that is defined by uncontrolled and abnormal eyelid closure from a central cerebral disorder. Between 40%-85% of blepharospasm occurs in conjunction with dry eye symptoms. Botulinum neurotoxin (BoNT) injections are commonly used treatment for reducing spasms in blepharospasm. Furthermore, it is often suggested for dry eye therapy due to their ability to reduce lacrimal drainage. The purpose of this review is to assess the effectiveness of BoNT treatment for blepharospasm with dry eye symptoms.&#x0D; Methods : A literature research was conducted on online databases such as PubMed, Cochrane library and Google scholar. All studies of BoNT and dry eye with full-text journals published in English within the last 10 years were included. We assessed Tear Breakup Time (TBUT), Schirmer Test, and Blepharospasm Disability Index (BSDI).&#x0D; Results : 204 patients from 6 publications were analyzed. In five trials, the BoNT treatment statistically significant increased TBUT (p&lt;0,5), with mean final TBUT 5,7 ±1.1 s. Furthermore, the Schirmer test also increased with the mean final score 6,29 ± 4,6 mm. The mean BSDI score dropped by 6,05 ± 3,7 in two studies.&#x0D; Conclusion : It is confirmed that BoNT injection is an effective treatment for essential blepharospasm with dry eye symptoms. Clinicians should be screened for dry eye in all blepharospasm patients prior to BoNT treatment.

Impact on Hygiene and Function of the Post-Stroke Spastic Hemiplegic Upper Limb of Constraint-Induced Movement Therapy Preceded by Botulinum Neurotoxin Injections

Impact on Hygiene and Function of the Post-Stroke Spastic Hemiplegic Upper Limb of Constraint-Induced Movement Therapy Preceded by Botulinum Neurotoxin Injections

Choice of shoulder muscles for the multi-pattern treatment of upper limb spasticity with botulinum neurotoxin injections

Choice of shoulder muscles for the multi-pattern treatment of upper limb spasticity with botulinum neurotoxin injections

Do repetitive botulinum neurotoxin injections induce muscle fibrosis? Sonographic observation of the masseter muscle.

In the esthetic field, the masseter muscle is commonly targeted by botulinum neurotoxin for facial contouring. However, multiple botulinum neurotoxin injections have been reported to cause muscle fibrosis. Ultrasonography can be useful for clinical consideration in such cases. This study presents nine cases of masseteric fibrosis caused by repeated botulinum neurotoxin injections with ultrasonographic analysis of full and partial masseteric fibrosis. Repetitive botulinum neurotoxin injections resulted in reduced masseter muscle volume, which frequently appeared hyperechoic on ultrasonography. The hyperechoic region was mostly located in the deep and posterior portions; however, in some cases, it was observed throughout the muscle, including the superficial, deep, or both areas. The fibrotic masseter muscles appear hyperechoic, and ultrasonography is necessary to analyze the degree and location of fibrosis. Predictions can be made for cases in which botulinum neurotoxin injections may have less of an effect after ultrasonography. Because muscle fibrosis can be localized, it is necessary to confirm the degree and location of fibrosis before determining the effective area of injection. In clinical practice, muscle fibrosis may be visible in a specific area where blind injections are administered.

Mapping the Vascular and Muscular Topography of the Glabellar Region: Implication for Improving Safety and Efficacy of the Glabellar Injections.

Botulinum neurotoxin (BoNT) and filler injections into the highly vascularized glabellar region for aesthetical purposes are extremely common. Injections into the glabellar region without precise anatomical knowledge of its vascular and muscular topography may pose the risk of severe complications. We aimed to improve the safety and efficacy of the glabellar injections by mapping the regional muscles and vasculature in relation to the medial canthus and the defined reference lines. Meticulous dissection was performed to reveal glabellar region muscles and arteries under surgical microscope, in 16 hemifaces of whom arteries are injected with red-dyed latex. Location of the angular artery (AA) along with its branches was noted in relation to glabellar muscles. The AA was always located superficial to the levator labii superioris alaeque nasi muscle (LLSAN) and then coursed toward the medial canthus to anastomose with the supratrochlear artery deep to the origin of the depressor supercilii (DS). The AA gave subcutaneously located central and paracentral branches coursing close to the mid-face line in 14 out of 16 hemifaces. Variable muscular connections were also present between the LLSAN, the DS and the procerus (P) muscles. No arteries were detected at the base of the medial eyebrow to which the DS, the P, and the frontalis (F) inserted. This study provides a detailed map of muscular and vascular anatomy of the glabellar region to facilitate safe and efficient filler and BoNT injections without complications. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

"Pseudo"-Secondary Treatment Failure Explained via Disease Progression and Effective Botulinum Toxin Therapy: A Pilot Simulation Study.

The objective of this study was to provide evidence from a simple simulation. In patients with focal dystonia, an initial good response to botulinum neurotoxin (BoNT) injections followed by a secondary worsening does not necessarily arise from an antibody-induced secondary treatment failure (NAB-STF), but may stem from a "pseudo"-secondary treatment failure (PSEUDO-STF). The simulation of the outcome after BoNT long-term treatment was performed in four steps: 1. The effect of the first single BoNT injection (SI curve) was displayed as a 12-point graph, corresponding to the mean improvement from weeks 1 to 12. 2. The remaining severity of the dystonia during the nth injection cycle was calculated by subtracting the SI curve (weighted by the outcome after n - 1 cycles) from the outcome after week 12 of the (n - 1)th cycle. 3. A graph was chosen (the PRO curve), which represents the progression of the severity of the underlying disease during BoNT therapy. 4. The interaction between the outcome during the nth BoNT cycle and the PRO curve was determined. When the long-term outcome after n cycles of BoNT injections (applied every 3 months) was simulated as an interactive process, subtracting the effect of the first cycle (weighted by the outcome after n - 1 cycles) and adding the progression of the disease, an initial good improvement followed by secondary worsening results. This long-term outcome depends on the steepness of the progression and the duration of action of the first injection cycle. We termed this response behavior a "pseudo"-secondary treatment failure, as it can be compensated via a dose increase. A secondary worsening following an initial good response in BoNT therapy of focal dystonia might not necessarily indicate neutralizing antibody induction but could stem from a "PSEUDO"-STF (a combination of good response behavior and progression of the underlying disease). Thus, an adequate dose adaptation must be conducted before diagnosing a secondary treatment failure in the strict sense.

Longitudinal predictors of health-related quality of life in isolated dystonia

ObjectiveTo determine longitudinal predictors of health-related quality of life (HR-QoL) in an international multicenter cohort of patients with isolated dystonia.MethodsOut of 603 dystonia patients prospectively enrolled in the Natural History Dystonia Coalition study, 155 were assessed three times within 2 years for HR-QoL, symptoms of depression, generalized anxiety disorder (GAD), and social anxiety disorder (SAD), as well as dystonia severity and dystonic tremor. In addition, the impact of botulinum neurotoxin (BoNT) injections on HR-QoL was evaluated after 1 year.ResultsDepressive symptoms at baseline predicted lower HR-QoL on all subscales after 2 years (all p ≤ 0.001). Higher GAD scores at baseline predicted lower HR-QoL related to general health, pain and emotional well-being, whereas higher SAD scores predicted higher pain-related QoL after 2 years (all p ≤ 0.006). Dystonia severity at baseline predicted social functioning (p = 0.002). Neither dystonic tremor, age, or sex predicted HR-QoL at 2 years. Two latent categories were revealed across the three-time points: Category 1 with higher total HR-QoL scores (mean HR-QoL = 74.4% ± 16.1), susceptible to symptoms of depression and SAD, and Category 2 with lower total HR-QoL scores (mean HR-QoL = 45.5% ± 17.6), susceptible to symptoms of GAD. HR-QoL improved over the course of 1 year irrespective of the use of BoNT.ConclusionThe longitudinal impact of psychiatric symptoms on HR-QoL emphasizes the importance of incorporating mental health treatment, in particular also the therapy of anxiety disorders, into treatment regimens for dystonia.

Botulinum toxin and conservative treatment strategies in people with cervical dystonia: an online survey

Isolated cervical dystonia is a focal, idiopathic dystonia affecting the neck muscles. Treatment usually consists of botulinum neurotoxin (BoNT) injections into the dystonic muscles. Our aim is to investigate the use of BoNT treatment and conservative treatments by people living with cervical dystonia. An online survey in English was conducted between June and August 2022. Participants were eligible to participate if they were living with cervical dystonia, were over 18 years old and could read and understand English. The survey consisted of demographic questions, characteristics of dystonia, questions relating to BoNT use and the perceived utility of conservative treatments. The data were analysed descriptively, and open-ended questions were grouped into similar topics represented by direct quotes. We received 128 responses from people with cervical dystonia, with an average age of 59 years and 77% women. Most participants (52%) described their cervical dystonia as mild to moderate with an average pain score of 5/10. Eighty-two (64%) participants were having regular BoNT injections, with overall positive perceived effects. Common activities reported to improve the symptoms were the use of heat packs, massage, relaxation, physiotherapy and participation in general exercise. Common coping strategies reported were getting sufficient rest, having the support of friends and family, and remaining engaged in enjoyable hobbies. We found that most participants received regular BoNT injections and that heat packs, exercise, massage, physiotherapy and relaxation were mostly perceived as effective in reducing the symptoms of cervical dystonia.

Deep Brain Stimulation for Focal or Segmental Craniocervical Dystonia in Patients Who Have Failed Botulinum Neurotoxin Therapy-A Narrative Review of the Literature.

(1) Background: The first-line treatment for patients with focal or segmental dystonia with a craniocervical distribution is still the intramuscular injection of botulinum neurotoxin (BoNT). However, some patients experience primary or secondary treatment failure from this potential immunogenic therapy. Deep brain stimulation (DBS) may then be used as a backup strategy in this situation. (2) Methods: Here, we reviewed the current study literature to answer a specific question regarding the efficacy and safety of the use of DBS, particularly for cervical dystonia (CD) and Meige syndrome (MS) in patients with documented treatment failure under BoNT. (3) Results: There are only two studies with the highest level of evidence in this area. Despite this clear limitation, in the context of the narrowly defined research question of this paper, it is possible to report 161 patients with CD or MS who were included in studies that were able to show a statistically significant reduction in dystonic symptoms using DBS. Safety and tolerability data appeared adequate. However, much of the information is based on retrospective observations. (4) Conclusions: The evidence base in this area is in need of further scientific investigation. Most importantly, more randomized, controlled and double-blind trials are needed, possibly including a head-to-head comparison of DBS and BoNT.