Dose Of Botulinum Toxin Research Articles

Doses of Botulinum Toxin in Cervical Dystonia: Does Ultrasound Guidance Change Injection Practices?

Cervical dystonia is widely understood to benefit from botulinum toxin injections. The injection practices may be influenced by specific factors, including the method of injection. Three main guidance methods can be used: palpation of anatomical landmarks, ultrasound, and electromyography. We investigated how target muscles and doses of botulinum toxin were modified after the transition from surface anatomy (non-guided) to ultrasound (US-guided), in patients with cervical dystonia. We also determined the long-term dose trend. We studied a group of 82 patients, who received non-guided injections (median: 16.5 cycles/5.1 years) followed by US-guided injections (median: 12.0 cycles/3.8 years). More muscles, and especially deep muscles, were injected during the US-guided period. The total dose and number of injected muscles were higher when US guidance was used, but the mean dose per muscle was lower. Over the long term, the total dose stabilized, and the mean dose per muscle decreased during the US-guided period. According to our results, the guidance method has a strong impact on the botulinum toxin injection strategy in cervical dystonia (target muscles and dose). Also, the treatment appeared more stable when using US guidance; this could be explained by the good precision of such injections.

Effectiveness of combined botulinum toxin and fissurectomy on chronic anal fissures - a systematic review.

Anal fissures are a debilitating benign condition, thought to be due to the hypertonicity of the internal anal sphincter resulting in localized ischaemia inhibiting healing. There are several surgical and non-surgical treatment options for chronic anal fissures. Clinical practice surveys report a trend toward sphincter-sparing options, reserving the more successful treatment of lateral sphincterotomy, with an incontinence rate up to 10%, for refractory fissures. A search of MEDLINE, Cochrane Database of Systematic Reviews and EMBASE for studies assessing sphincter-sparing treatment with botulinum toxin and fissurectomy was performed following PRISMA guidelines. Outcomes assessed included healing rate, persistence, recurrence, re-intervention and incontinence rates. Fifteen non-randomized studies assessed 978 patients managed with botulinum toxin and fissurectomy. The mean age was 40.8 years with a female predominance of 58.9%. Healing rate was reported on 14 of the 15 studies, with a healing rate of 81% (95% CI:0.67, 0.90). Persistence rate was reported as 15% (95% CI:0.07, 0.28) and a recurrence rate of 6% (95% CI: 0.01, 0.19). Re-intervention was required in 8% of patients with 55.1% requiring a repeat dose of botulinum toxin with or without fissurectomy. Incontinence appears to be transient with studies reporting a rate of 1% with median long-term follow up 23 months (range: 5-60 months). Combination fissurectomy and botulinum toxin is a safe and viable sphincter sparing treatment option, with moderate success rate and negligible complications. Randomized controlled trials are required to further strengthen the evidence for its use in chronic anal fissures.

Antipsychotics and chronic dystonia at a Botulinum Toxin clinic.

Chronic dystonia, characterised by sustained muscle contractions and abnormal postures, poses clinical challenges, especially when associated with antipsychotic medication use. To delineate the demographic and clinical profiles of adults with dystonia and examine the association with antipsychotic medication. Botulinum Toxin Clinic at Tygerberg Hospital, Cape Town, South Africa. We conducted a retrospective cohort study of adult patients seen at the Botulinum Toxin Clinic between January 2018 and June 2022. Of the 119 patients studied, those assessed with antipsychotic-induced dystonia (32.69%) presented at a younger age (p < 0.001), were more likely female (p = 0.04), received higher average dose of Botulinum toxin (p < 0.001), and incurred a higher estimated Botulinum toxin treatment cost (p = 0.01) compared to those with primary dystonia. Logistic regression identified age and Botulinum toxin dose as factors associated with psychotropic-related dystonia (p = 0.005 and p = 0.012, respectively). Clinical and demographic factors are associated with dystonia in adults taking antipsychotic medication. These patients generally manifested symptoms at an earlier age, had a higher male prevalence, and required prolonged treatment with Botulinum toxin, leading to increased costs. In those assessed with antipsychotic-induced dystonia, a comorbid diagnosis of a mood disorder was more common than that of a psychotic disorder. By identifying the demographic and clinical profile of individuals with dystonia because of antipsychotic medication, this study provides a basis for preventative strategies and enhanced patient care.

Update: Prevention and Treatment of Parotid/Submandibular Gland Fistula/Sialocele Following Rhytidectomy with Botulinum Toxin A.

Dissecting deep to the superficial musculoaponeurotic system, SMAS, a popular option for facelifts, has the potential for injury to the parotid gland leading to post operative sialoceles and fistulas. Similarly, deep plane procedures in the neck which include partial submandibular gland resection may lead to salivary gland leaks. We previously described the management of sialocele following rhytidectomy.1 Since then, administration of Botulinum toxin A has emerged as the primary treatment and prevention of this rare complication. The technique of administration and dosage of botulinum toxin in the treatment algorithm is not well-defined. We present a literature review and our current protocol of the most efficacious injection technique and dosing to prevent and treat injury to the parotid and submandibular glands.

Mitigating Immunogenicity by Coordinating Botulinum Toxin Treatments Between Aesthetics and Therapeutics.

Aesthetic use of botulinum toxin (BoNT) has expanded greatly beyond conventional low-dose (20 U) treatments, leading to some patients receiving doses previously reserved for therapeutic uses. The resulting risks are compounded in patients who receive BoNT for both aesthetic and therapeutic indications. Implementing tools for risk management is a high priority to prevent reduced treatment duration and effectiveness. To highlight the immunogenic risks of higher doses, with special attention to the compounding risks of resistance in patients with overlapping BoNT treatments from aesthetic and therapeutic indications. Authors examined the literature on current practices to provide a side-by-side comparison of BoNT doses for aesthetic and therapeutic indications. Aesthetic BoNT doses used in combination treatments of multiple areas or single treatments of large muscle areas can meet or exceed those observed in therapeutic treatments. Physicians have a responsibility to incorporate risk management and open dialog into their BoNT treatment plans to maximize effectiveness and longevity of treatments.

Comparison of the Efficacy of 2 Different Botulinum Toxin Injection Techniques in Gastrocnemius Muscle Spasticity in Hemiplegic Patients: A Randomized Double-Blind Controlled Study

ObjectiveTo compare the efficacy of the innervation zone–targeted injection technique (EUROMUSCULUS/USPRM (Ultrasound Study Group of the International Society of Physical and Rehabilitation Medicine) spasticity approach) and the injection technique along the muscle length. DesignA double-blind randomized controlled trial. SettingDepartment of rehabilitation medicine of a medical center. ParticipantsOne hundred patients with stroke experiencing ankle plantar flexor spasticity. InterventionsIn addition to conventional rehabilitation, eligible patients were randomly assigned to 2 groups. The experimental group was injected with botulinum toxin along the length of the muscle, whereas the control group was injected with the same dose and volume of botulinum toxin 25%-35% proximal to the medial head and 20%-30% proximal to the lateral aspect of the head of the gastrocnemius muscle. Main Outcome MeasuresModified Ashworth scale, modified Tardieu scale, ankle range of motion measurement, and 10-meter walk test were used before and 1 month after injection. ResultsThe study was completed by 60 participants with a mean age of 59.96±12.15 years. Both injection methods were found to be effective on range of motion, spasticity level, ambulation, and walking speed. There was no statistically significant difference between injection methods. ConclusionsBoth injection methods of botulinum toxin A produce similar clinical effects.

Evaluating Headache Incidence and Characteristics After Botulinum Toxin Treatment in Blepharospasm and Hemifacial Spasm Patients: A Retrospective Cohort Clinical Study.

The aim of the study is to assess the prevalence and clinical features of headache in patients treated with botulinum toxin for blepharospasm and hemifacial spasm. In addition, our secondary aim was to identify potential factors influencing the development of these headaches. A total of 70 patients who were treated with on a botulinum toxin A for dystonia treatment in our clinic between January 2023 and March 2023 were retrospectively screened, and the clinical and demographic characteristics of the patients who reported headache complaints after the last botulinum toxin treatment were examined. Headache was reported in 8 (%11.4) of the 70 patients included in the study. Of the 8 patients who reported headaches, 6 (%75) had the onset of the complaint within the first 24 hours. There was no significant correlation between headache occurrence and factors like age, gender, diagnosis, botulinum toxin dosage, application site, comorbid diseases, or hypertension. However, a statistically significant link was observed between the intensity of pain experienced during treatment and the frequency of headaches after the treatment. Botulinum toxin treatment can lead to short-term headaches in some patients, starting early after the procedure. The significant link between the frequency of these headaches and the pain experienced during injection highlights the need to examine factors like the volume and dilution rate of the toxin, the solvent used, treatment area, treatment purpose, patient characteristics, and the physician's technique. It is important to study these aspects by comparing them across a large patient group and control subjects.

Comparison of Two Doses of Botulinum Toxin A for Dry Eye Treatment by Injection into the Medial Lower Eyelid: A Randomized, Comparative Pilot Study

Comparison of Two Doses of Botulinum Toxin A for Dry Eye Treatment by Injection into the Medial Lower Eyelid: A Randomized, Comparative Pilot Study

Is Botox an Alternative to Surgery for Anal Fissure?

Objective To compare the results of the lateral internal sphincterotomy(LIS) technique and high dose botulinum toxin, which is one of the treatments applied when medical treatment is insufficient in anal fissure. Materials and methods The files and outpatient clinic notes of the patients who underwent lateral internal sphincterotomy and botulinum toxin injection due to lack of response to medical treatment due to anal fissure between May 2020 and May 2023 were examined retrospectively. Preoperative and postoperative visual analog scale (VAS) scores, five-point horizontal scale (FPHS) scores, hospitalization times, fissure locations, follow-up periods, anesthesia type, and postoperative complications of the patients were recorded. Results Total 30 LIS and 24 botulinum toxin-treated patients were included. Hospitalization time was shorter in botulinum toxin groups than in the LIS group (p&lt;0.001). First-week VAS score was lower than botulinum toxin injection group (p&lt;0.001). There was no significant difference between the groups in terms of FPHS scores, follow-up periods, and recurrence (p:0.15, p:0.07, p:0.14). Conclusion: While LIS is faster in the early period, botulinum toxin injection can be considered as an alternative to surgical treatment for long-term results.

Botulinum Toxin and Deep Brain Stimulation in Dystonia.

Deep Brain Stimulation (DBS) is a recognized treatment for different dystonia subtypes and has been approved by the Food and Drug Administration (FDA) since 2003. The European Federation of Neurological Societies (EFNS) and the International Parkinson and Movement Disorders Society (MDS) recommend DBS for dystonia after failure of botulinum toxin (BoNT) and other oral medications for dystonia treatment. In addition, several long-term studies have demonstrated the continuous efficacy of DBS on motor and quality of life (QoL) scores. However, there are only a few reports comparing the overall impact of surgical treatment in BoNT protocols (e.g., dosage and number of selected muscles before and after surgery). This retrospective multicenter chart-review study analyzed botulinum toxin total dosage and dosage per muscle in 23 dystonic patients before and after DBS surgery. The study's primary outcome was to analyze whether there was a reduction in BoNT dosage after DBS surgery. The mean BoNT dosages difference between baseline and post-surgery was 293.4 units for 6 months, 292.6 units for 12 months, and 295.2 units at the last visit. The median total dose of BoNT in the preoperative period was 800 units (N = 23). At the last visit, the median was 700 units (p = 0.05). This represents a 12.5% reduction in BoNT median dosage. In conclusion, despite the limitations of this retrospective study, there was a significant reduction in BoNT doses after DBS surgery in patients with generalized dystonia.

Botulinum Toxin Injection for Retrograde Cricopharyngeal Dysfunction: A Prospective Cohort Study.

Retrograde Cricopharyngeal Dysfunction (RCPD) is treated by botulinum toxin (BTX) injection into the cricopharyngeus. This prospective study compares the effectiveness and side effects of operating room (OR) and in-office (IO) injections. Patients over 18 years of age with inability to burp, abdominal, thoracic, or cervical gurgling sounds, bloating, and excessive flatulence were diagnosed with RCPD and included in the study. Injections were performed in the OR (80U) or IO (30U) by the senior author. An RCPD questionnaire quantifying major and minor symptoms on a Likert scale, Eating Assessment Tool-10 (EAT-10), and Generalized Anxiety Score-7 (GAD-7), were completed preinjection; at 1, 2, and 3 weeks; and 3 months postoperatively. Linear mixed models were used to analyze effects of BTX injection on RCPD symptoms, the EAT-10, and the GAD-7. 108 (55 M/53F) patients completed the pretreatment survey, 53 (31 OR vs. 22 IO) completed the 3-week follow-up, and 36 (22 OR vs. 14 IO) completed the 3-month questionnaire. Average posttreatment RCPD scores were significantly lower in both groups at 3 weeks and 3 months (p < 0.0001), There was no difference between IO or OR (p = 0.4924). GAD-7 scores were significantly lower in both groups at week 3 (p = 0.0018) and month 3 (p = 0.0012). Postinjection EAT-10 scores were significantly higher in OR compared with IO (p = 0.0379). OR and IO injections are equally effective in the treatment of RCPD. Postinjection dysphagia is more severe after the OR injections which may be related to higher doses of BTX used. General anxiety levels decrease with treatment. 2 Laryngoscope, 134:4614-4619, 2024.

Do lower doses of botulinum toxin offer a longer duration of effect and superior efficacy in patients with cervical dystonia?

Do lower doses of botulinum toxin offer a longer duration of effect and superior efficacy in patients with cervical dystonia?

Evaluation of Botulinum Toxin Applications in a Tertiary Cosmetic Department

Aim: Botulinum toxin type A (BTX-A) treatment for facial rejuvenation has&#x0D; been started to used widely and become the most common aesthetic procedure. The aim in&#x0D; this study to evaluate the patients features and outcomes who had Onabotulinumtoxin A.&#x0D; Material and Method: The data of the BTX-A patient’s gender, age, occupation, history of cosmetic&#x0D; procedures, history of disease, doses of the first and control injections, complications and&#x0D; expectations from the therapy collected from the medical records. The patients were divided&#x0D; into two groups as under the age of 45 and age of 45 and older. These groups were compared&#x0D; with each other in terms of mentioned variables.&#x0D; Results: A total of 200 patients included in this study. The mean botulinum toxin dose was&#x0D; 33.7 units and the mean control dose was 4.5 units. Three (1.5%) of the patients developed a&#x0D; complication, all of them were eyelid ptosis. Most common expectation from the toxin&#x0D; injection was to look more young (69%) and vigorous (75.5%). There were no significant&#x0D; difference between the under the age of 45 and 45 and older group in terms of total BTX-A&#x0D; dose and control dose and complication rate (p=0.8, p=0.5, p=0.6). Expectation of looking&#x0D; less angry and less saggy were significantly higher in the 45 year and older group (p=0.02,&#x0D; p=0.02).&#x0D; Conclusion: It is important to evaluate the patient’s gender, age and expectations from the&#x0D; botulinum toxin injection to get the highest efficiency from BTX-A injection.

Comparative effectiveness of two different doses of botulinum toxin A for the treatment of mild to moderate depression

ObjectiveBotulinum toxin A has been shown to be effective in managing depression. This study aimed to evaluate the antidepressant and antianxiety effects of two different doses of botulinum toxin A in patients with mild to moderate depression. MethodsA total of 140 patients diagnosed with mild to moderate depression at the Department of Neurology of the Second Affiliated Hospital of Soochow University from September 2020 to September 2021 were enrolled for the study. The patients were allocated into two groups and treated with two different doses of botulinum toxin A (50 units or 100 units). Depression scores (HAMD, HAMA, SDS, and SAS) were evaluated at baseline and 1, 2, 4, 8, and 12 weeks after treatment. ResultsThere was a significant improvement in the depressive and anxiety symptoms following treatment with the botulinum toxin A after 12 weeks compared to the baseline. However, there were no significant differences between the two groups. Further, the factor scores of anxiety/somatization, blocking, sleep disorder, and cognitive disorder were significantly decreased after 12 weeks of treatment with 50 units of botulinum toxin A compared to the baseline (P < 0.05). Further, the factor scores of somatic and mental anxiety were significantly decreased at different time points after treatment with 50 units of botulinum toxin A compared to the baseline (P < 0.05). ConclusionLocal injections of 50 units and 100 units of botulinum toxin A shows equal efficacy. Therefore, 50 units of botulinum toxin A could be used clinically to manage mild to moderate depression.

Influence of vitamin D on muscle strength and botulinum toxin dosage through surface electromyography.

To evaluate the influence of patients' serum vitamin D levels on muscle strength characteristics and whether it impacts the durability of botulinum toxin (BT) treatment. The muscle strength of the frontal and corrugator muscles was evaluated before and after the application of TB with pre- and post-application control measurements, and at weeks 2, 5 and 12. The effect of vitamin D on muscle strength and its interaction with BT were investigated in 20 patients. The muscle contraction force was measured by surface electromyography. The results revealed statistically significant differences between the frontal measurement groups at weeks 2 and 5, as well as for the corrugator in the same weeks and at week 12. Regarding vitamin D, significant differences were observed only in the initial group with vitamin D > 30 ng/mL compared to < 30 ng/mL for the frontal muscles. Patients with higher levels of vitamin D had higher average muscle strength compared to those with lower levels in all evaluations. It was observed that vitamin D influences muscle strength and the necessary dosage of BT.

Assessing the Efficacy and Safety of Intradermal Injection of Different Doses of Botulinum Toxin Type A: A Randomized, Double‐Blind, Placebo‐Controlled, Split‐Face Pilot Study in Rosacea Patients with Erythematic Telangiectasia

Introduction. Rosacea is a common chronic inflammatory skin disease of the central facial skin with unknown origin, significantly impacting quality of patient’s life and causing various psychosocial problems. Erythematotelangiectatic rosacea (ETR) is characterized by paroxysmal flushing that occurs repeatedly and is easily resistant to therapeutic drugs. While microinjection of type A botulinum toxin (BTX) can treat ETR, there is no consensus on the injection dose, and strong evidence to verify its efficacy and safety is lacking. This randomized, double‐blind, split‐face clinical study aimed to investigate the efficacy, safety, and optimal dose of two different single‐point injection doses (0.5 U and 1 U) of BTX in the treatment of rosacea. Methods. Twenty‐six patients with ETR were randomly assigned to receive different single‐point injections of BTX (0.5 U and 1 U, respectively) every 1 cm on one half of the face. The Clinical Erythema Score (CEA), VISIA red area absolute value, Global Aesthetic Improvement Scale Score (GAIS), and recurrence at 12‐week follow‐up were evaluated at baseline, 2,4, 8, and 12 weeks after injection. Additionally, the Dermatological Quality of Life Index (DLQI) questionnaire survey and adverse reactions were also recorded. Results. All twenty‐six patients completed the follow‐up visits and were included in the analysis. Compared to the 0.5 UBTX‐treated side, the CEA score showed significantly improvement in erythema and flushing at 2, 4, and 8 weeks after injection on the 1 U BTX‐treated side (P &lt; 0.05). The mean absolute value of the red area of VISIA was ‐19.12 ± 51.91 on 1 U BTX‐treated side and 2.5 ± 42.08, on 0.5 UBTX‐treated side at 4 weeks after treatment, showing significant improvement on the 1 U side (P &lt; 0.05). GAIS and DLQI were also significantly improved from Week 4 to Week 12 and Week 2 to Week 12, respectively (P &lt; 0.05). There was no recurrence of symptoms with either 0.5 U or 1 U injection by 12 weeks. Apart from one patient who experienced facial tightness and three patients who had temporary aggravation of erythema, all of which resolved without treatment, 22 patients did not report any side effects except for injection pain during the procedure. Conclusions. BTX‐A can significantly improves symptoms and quality of life in patients with refractory rosacea with few side effects. A single‐point injection of 1 U was more effective. This trial is registered with NCT06282679.

Comparison of the Effects of Botulinum Toxin Doses on Nerve Regeneration in Rats with Experimentally Induced Sciatic Nerve Injury.

This study was designed to compare the effects of various doses of botulinum neurotoxin A (BoNT/A) on nerve regeneration. Sixty-five six-week-old rats with sciatic nerve injury were randomly allocated to three experimental groups, a control group, and a sham group. The experimental groups received a single session of intraneural BoNT/A (3.5, 7.0, or 14 U/kg) injection immediately after nerve-crushing injury. The control group received normal intraneural saline injections after sciatic nerve injury. At three, six, and nine weeks after nerve damage, immunofluorescence staining, an ELISA, and toluidine blue staining was used to evaluate the regenerated nerves. Serial sciatic functional index analyses and electrophysiological tests were performed every week for nine weeks. A higher expression of GFAP, S100β, GAP43, NF200, BDNF, and NGF was seen in the 3.5 U/kg and 7.0 U/kg BoNT/A groups. The average area and myelin thickness were significantly greater in the 3.5 U/kg and 7.0 U/kg BoNT/A groups. The sciatic functional index and compound muscle action potential amplitudes exhibited similar trends. These findings indicate that the 3.5 U/kg and 7.0 U/kg BoNT/A groups exhibited better nerve regeneration than the 14 U/kg BoNT/A and control group. As the 3.5 U/kg and the 7.0 U/kg BoNT/A groups exhibited no statistical difference, we recommend using 3.5 U/kg BoNT/A for its cost-effectiveness.

31. The Effects of a Reduced Dose of Botulinum Toxin A in the Management of Myofascial Pain

31. The Effects of a Reduced Dose of Botulinum Toxin A in the Management of Myofascial Pain

Time course of surface electromyography during walking of children with spastic cerebral palsy treated with botulinum toxin type a and its rehabilitation implications

BackgroundThe timing of the effects of botulinum toxin A on spastic muscles is not yet fully clarified. The goal of this study was to follow the temporal changes of surface electromyographic activity of lower limb muscles during walking, after a therapeutic dose of botulinum toxin A injected into the calf muscles of children with spastic cerebral palsy. MethodsA group of children with spastic equinus foot was administered botulinum toxin A into the gastrocnemius medialis and lateralis muscles. Surface electromyographic activity of the tibialis anterior, gastrocnemius medialis, rectus femoris and medial hamstrings, was recorded before botulinum toxin A injections and after 4, 8, and 16 weeks. Children walked on ground and on a treadmill at an incline of 0% and 12%. The area of electromyographic activity and the index of muscle co-contraction were calculated for specific segments of gait cycle. FindingsBotulinum toxin A did not modify the speed of gait on ground. ANOVA showed significant differences in electromyography during the stance phase segments with a maximum decrease between 4 and 8 weeks' post botulinum toxin A and a full recovery at 16 weeks. A significant co-contraction of rectus femoris/gastrocnemius medialis, between 0 and 20% and 35–50% of the gait cycle, was observed from the 4th to the 8th week post- botulinum toxin A for both treadmill settings. InterpretationThe temporal identification of deterioration/recovery of electromyographic activity as well as of muscle co-contractions, could be key elements in a rehabilitation program planning combined with botulinum toxin A.

The role of botulinum toxin in management of infantile esotropia

Purpose: To find out the effect of a single dose botulinum toxin injection. Methods: This study is an observational case series. Data of patients with infantile esotropia who received a single dose of botulinum toxin in 6th-9th month of their age were retrospectively reviewed during the period from February 2013 to January 2015. Botulinum toxin was injected in each of medial recti with a dose of 5 IU/0,05 mL without Electromyography (EMG) control. Five patients were included in the study. Complications reletad to injection and to the toxin were recorded. During their regular follow-ups, the parents were instructed to patch the dominant eye if there is fixation preference either in exotropia or esotropia phases. Patients were examined between their 72nd to 96th month to find out their current visual acuity and to observe if they had any late term accompanying squints, nystagmus and amblyopia. Snellen optotypes or pictures were used for detecting best-corrected visual acuity. Results: Orthophoria was the main outcome for 3 of the 5 patients. Dissociated deviations and latent nystagmus did not develop on any patient. On the last examination, patients’ visual acuities were assesed. Orthophoric ones: One patient had 1.0/1.0 visual acuity, one patient had 0.4/0.6 visual acuity, one patient had 0.2/0.2 visual acuity. Monocular esotropia ones: On the strabismic eye 0.1, on the dominant eye 1.0 visual acuity was detected. Inferior oblique muscle hyperfunction developed post injection on all the patients. Conclusions: Botulinum toxin injection caused infantile esotropia to change into a more manageble form.