Neurotoxin Treatment Research Articles

Incidence of Dysphagia and Comorbidities in Patients with Cervical Dystonia, Analyzed by Botulinum Neurotoxin Treatment Exposure (P1-3.017)

Incidence of Dysphagia and Comorbidities in Patients with Cervical Dystonia, Analyzed by Botulinum Neurotoxin Treatment Exposure (P1-3.017)

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.

Botulinum Neurotoxin Treatment Combined With Motor Learning Exercises for Pisa Syndrome in Parkinson’s Disease – A Case Study

Botulinum Neurotoxin Treatment Combined With Motor Learning Exercises for Pisa Syndrome in Parkinson’s Disease – A Case Study

Does Diagnostic Nerve Block Predict the Outcome of Botulinum Neurotoxin Treatment?

Does Diagnostic Nerve Block Predict the Outcome of Botulinum Neurotoxin Treatment?

Incidence of Dysphagia and Comorbidities in Patients With Cervical Dystonia, Analyzed by Botulinum Neurotoxin Treatment Exposure

Incidence of Dysphagia and Comorbidities in Patients With Cervical Dystonia, Analyzed by Botulinum Neurotoxin Treatment Exposure

Evaluation of nerve innervation distribution of orbicularis oculi muscle for botulinum neurotoxin application using Sihler's method

BackgroundBlepharospasm is the involuntary and forced closure of the eyelids due to spasm-like contraction of the orbicularis oculi muscle around the eye. The study aimed to reveal the nerve innervation of the orbicularis oculi muscle for Botulinum neurotoxin (BoNT) treatment of blepharospasm by Sihler’s staining technique. MethodsThis study used six cephalus (12 orbicularis oculi muscles) with an average age of 69,6 (62−88) years. Then, the orbicularis oculi muscles were removed by dissection, and Sihler's staining technique was applied to the muscles. The limit for dissection of the muscle is the orbital opening level, where the nerves enter the muscle, and the muscle attaches to the bone. ResultsIn the region above the palpebral fissure, the nerves entering the muscle were densely located in the superolateral quadrant between 9 and 12 o′clock in the right eye and between 12 and 3 o′clock in the left eye. In the region under the palpebral fissure, the nerves’ density in the orbicularis oculi muscle was higher between 4 and 7 o′clock in the right eye and between 5 and 8 o′clock in the left eye. ConclusionThis study unveiled the nerve branches associated with the orbicularis oculi muscle. It pinpointed precise crossing points of these nerve branches, which can be targeted for applying BoNT in treating blepharospasm. Consequently, by utilizing minimal BoNT, it is anticipated that the quantity of toxin administered will decrease, leading to more efficient outcomes and reduced expenses. Furthermore, this approach can aid in averting potential undesired complications during BoNT administration.

A practical guide to botulinum neurotoxin treatment of teres major muscle in shoulder spasticity: Intramuscular neural distribution of teres major muscle in cadaver model.

Botulinum neurotoxin treatment typically focuses on the teres major muscle as a primary target for addressing shoulder spasticity. The muscle is located deep within a large muscle group and optimal injection locations have not been identified. To identify the preferred location for administering botulinum toxin injections in the teres major muscle. Teres major specimens were removed from 18 cadaveric models and stained with Sihler's method to reveal the neural distribution within the muscle. The muscles were systematically divided into equal lengths from origin to insertion. The neural density in each section was evaluated to determine the location that would be likely to increase effectiveness of the injection. The greatest density of intramuscular nerve endings was located in the middle 20% of the muscle. The tendinous portion was observed at the ends of the muscle. The results suggest that botulinum neurotoxin should be delivered in the middle 20% of the teres major muscle.

Effectiveness of Serial Casting Alone and in Combination with Botulinum Neurotoxin in Pediatric Spastic Cerebral Palsy Patients

Purpose This study evaluated the changes in gait of pediatric cerebral palsy patients after serial casting alone and serial casting in conjunction with botulinum neurotoxin treatments. Methods Retrospective data of 31 children were investigated. Sixteen children were treated with serial casting combined with BoNT injection and 15 children were treated only with serial casting treatment. GAITRite was used to collect velocity, cadence, swing %, stance %, step length, stride length, and step time parameters to compare the outcomes of the treatments. Results Combined treatment group unaffected side swing % showed a statistically significant difference at completion (M = 35.16 ±1.21; M = 32.46 ± 1.38; t (15) = 2.12, p = 0.049). Unaffected side stance % at pre-intervention was statistically different for serial casting only and the combined treatment groups (M = 61.69± 0.73; M = 64.88±1.20; t (14) = -2.273, p = 0.039). Pre- and post-intervention hemiplegic side swing % comparison was statistically significant for the serial casting only group (M = 40.87± 0.57; M = 42.39±0.79, t (14) = -0.151, p = 0.032). The baseline velocity of the combined treatment group was slower than the serial casting-only group (88±11.2 vs. 107±14.4 (cm/s), p=0.007). Conclusions This investigation suggests that for patients, who have poor ambulation quality, abnormal spatiotemporal gait parameters, and significant spasticity at pre-intervention, BoNT in conjunction with serial casting is more effective for improving ambulation quality. Serial casting can be used in conjunction with botulinum neurotoxin, which is efficient in muscle morphology and function regulation by reducing spasticity.

A practical guide to botulinum neurotoxin treatment of shoulder spasticity 2: Injection techniques, outcome measurement scales, and case studies.

Botulinum neurotoxin type A (BoNT-A) is a first-line treatment option for post-stroke spasticity, reducing pain and involuntary movements and helping to restore function. BoNT-A is frequently injected into the arm, the wrist, the hand, and/or the finger muscles but less often into the shoulder muscles, despite clinical trials demonstrating improvements in pain and function after shoulder BoNT-A injection. In part 2 of this two-part practical guide, we present an experts' consensus on the choice of outcome measurement scales and goal-setting recommendations for BoNT-A in the treatment of shoulder spasticity to increase awareness of shoulder muscle injection with BoNT-A, alongside the more commonly injected upper limb muscles. Expert consensus was obtained from five European experts with a cumulative experience of more than 100 years of BoNT-A use in post-stroke spasticity. Case studies are included as examples of approaches taken in the treatment of shoulder spasticity. Although the velocity-dependent increase in muscle tone is often a focus of patient assessment, it is only one component of spasticity and should be assessed as part of a wider range of measurements. For outcome measurement following BoNT-A injection in shoulder muscles, shoulder-specific scales are recommended. Other scales to be considered include Pain Numerical Rating and/or global functioning, as well as the quality of life and global perception of benefit scores.Goal setting is an essential part of the multidisciplinary management process for spasticity; goals should be patient-centric, realistic, and achievable; functional-focused goal statements and a mixture of short- (3-6 month) and long-term (9-18 month) goals are recommended. These can be grouped into symptomatic, passive function, active function, involuntary movement, and global mobility.Clinical evaluation tools, goal setting, and outcome expectations for the multipattern treatment of shoulder spasticity with BoNT-A should be defined by the whole multidisciplinary team, ensuring patient and caregiver involvement. These recommendations will be of benefit to clinicians who may not be experienced in evaluating and treating spastic shoulders.

Frequency of Hemorrhagic Side Effects of Botulinum Neurotoxin Treatment in Patients with Blepharospasm and Hemifacial Spasm on Antithrombotic Medication.

The aim of this study was to investigate the frequency of hemorrhagic side effects of botulinum neurotoxin A injections (BoNT/A) for the treatment of benign essential blepharospasm (BEB) and hemifacial spasm (HFS) in patients taking antithrombotic drugs (ATD). A total of 140 patients were included (female: 65%; BEB: 75%; mean age: 70 ± 12 years). According to their current antithrombotic medication, participants were either assigned to the ATD group (41%), or to the control group (59%). The ATD group was further divided into subgroups depending on the medication administered: acetylsalicylic acid, ADP receptor antagonists, direct oral anticoagulants, vitamin-K antagonists, or dual antiplatelet therapy. The frequency of hemorrhagic side effects was recorded by retrospective analysis of past treatments as documented in the patient's file set in relation to the number of past treatments (hematoma frequency of past treatments, HFretro) as well as by a prospective survey capturing the side effects of one single treatment (hematoma frequency of actual treatment, HFactual). There was no significant difference in hematoma frequency between the ATD group and the control group, neither for past (HFretro: ATD: 2%; 45/2554; control: 4%; 109/2744) nor for the current BoNT/A treatments (HFactual: ATD: 30%; 16/53; control: 31%; 22/72). Even between ATD subgroups, hematoma frequency did not differ significantly. Overall, hemorrhagic side effects of the BoNT/A treatment for BEB and HFS were mild and non-disabling.

SERUM SICKNESS AFTER COSMETIC ONABOTULINUMTOXIN A USE

<h3>Introduction</h3> Onabotulinumtoxin A is one of the most commonly used drugs in cosmetic medicine, and neurotoxin treatment is the most common nonsurgical cosmetic procedure in all age groups of both women and men per the most recent Aesthetic Plastic Surgery National Databank statistics. This abstract will present a case report of serum sickness believed to be the first reported of this such complication with onabotulinumtoxin A. <h3>Case Description</h3> A 46 year-old woman with an unremarkable medical history including prior onabotulinumtoxin A use in Canada was seen in Michigan, US, for injectable fillers and neurotoxins on multiple occasions. She presents with interval history of onabotulinumtoxin A treatment in Canada followed 11 days later with a visit to the ER for pyrexia, symmetric arthralgias, and abdominal swelling. Two days prior to these symptoms, she developed utricaria at the injection sites. Concern about future onabotulinumtoxin A treatments were raised. Consultation with an allergist confirmed serum sickness likely due to albumin in onabotulinumtoxin A. Skin testing was performed with protein-free neurotoxin, and no reaction was noted. She has since undergone successful neurotoxin treatment. Serum sickness did not recur. <h3>Discussion</h3> Serum sickness is a Type III hypersensitivity reaction, mediated by IgE. It is reported in the product safety insert of onabotulinumtoxin A, but has never been reported in cosmetic onabotulinumtoxin A use. Discussion of this rare but reported complication is important as onabotulinumtoxin A use for cosmetic purposes is prevalent in medical spas and non-core physician practices where this complication could be overlooked.

Association of neurotoxin treatment likelihood with sex of television journalists.

Neurotoxin procedures have been increasing in popularity since they were approved for cosmetic use in 2002, with predominately women being treated. Our objectives were to determine likelihood of neurotoxin treatment in television journalists based on demographics and social media popularity. Likelihood of neurotoxin treatment was determined from by grading forehead and glabellar rhytides in videos using a standardized scale. A greater percentage of women vs. men were "likely/highly likely" to have had glabellar (23% vs. 17%, respectively) and forehead neurotoxins (42% vs. 13%, respectively) neurotoxins (both P < 0.05). A greater proportion of anchors vs. non-anchors were "likely/highly likely" to have had glabellar neurotoxins (37% vs. 11%; P < 0.05). In sum, we found that women broadcasters are more likely to pursue neurotoxin treatments compared to male broadcasters and uncovered potential gender-based aesthetic treatment biases in the media industry.

A practical guide to botulinum neurotoxin treatment of shoulder spasticity 1: Anatomy, physiology, and goal setting

Botulinum neurotoxin type A (BoNT-A) is a first-line treatment option for post-stroke spasticity, reducing pain and involuntary movements and helping to restore function. BoNT-A is frequently injected into the arm, wrist, hand and/or finger muscles, but less often into the shoulder muscles, despite clinical trials demonstrating improvements in pain and function after shoulder BoNT-A injection. In part 1 of this two-part practical guide, we present an experts' consensus on the use of BoNT-A injections in the multi-pattern treatment of shoulder spasticity to increase awareness of shoulder muscle injection with BoNT-A, alongside the more commonly injected upper limb muscles. Expert consensus was obtained from five European experts with a cumulative experience of more than 100 years of BoNT-A use in post-stroke spasticity. A patient-centered approach was proposed by the expert consensus: to identify which activities are limited by the spastic shoulder and consider treating the muscles that are involved in hindering those activities. Two patterns of shoulder spasticity were identified: for Pattern A (adduction, elevation, flexion and internal rotation of the shoulder), the expert panel recommended injecting the pectoralis major, teres major and subscapularis muscles; in most cases injecting only the pectoralis major and the teres major is sufficient for the first injection cycle; for Pattern B (abduction or adduction, extension and internal rotation of the shoulder), the panel recommended injecting the posterior part of the deltoid, the teres major and the latissimus dorsi in most cases. It is important to consider the local guidelines and product labels, as well as discussions within the multidisciplinary, multiprofessional team when deciding to inject shoulder muscles with BoNT-A. The choice of shoulder muscles for BoNT-A injection can be based on spastic pattern, but ideally should also firstly consider the functional limitation and patient expectations in order to establish better patient-centered treatment goals. These recommendations will be of benefit for clinicians who may not be experienced in evaluating and treating spastic shoulders.

Identifying and managing complications caused by cosmetic neurotoxin treatment

Any practitioner trained in using cosmetic botulinum toxin type A for on-label and off-label indications must stay informed of the possible complications from treatments. Though prevention of complications is ideal, management of adverse events, when they occur, is integral for a positive patient outcome. Major long-term complications from botulinum toxin treatment are rarely observed because the agent eventually metabolizes after 3–4 months. As such, minor complications are more commonly observed and may be problematic in the short-term. These complications seen from botulinum toxin can be organized into three main categories: (1) injection-related complications, (2) complications intrinsic to the toxin's pharmacologic properties, and (3) the practitioner's injection technique in specific anatomical locations. Common injection-related complications, such as pain, swelling, bruising, a heavy sensation, and headache, are well-tolerated and well-managed, though practitioners may consider implementing certain techniques to help mitigate these complications. Complications due to pharmacologic properties of botulinum toxin allow for an interesting discussion of complex topics, such as the genesis of the Black Box Warning on distant migration, potency and efficacy with storage conditions, lethal dose, diffusion, and immunogenicity. In addition, injection techniques for specific anatomical locations as well as recommendations for avoiding and managing complications at each location are discussed in detail.

Individual Response to Botulinum Toxin Therapy in Movement Disorders: A Time Series Analysis Approach.

On a group level, satisfaction with botulinum neurotoxin (BoNT) treatment in neurological indications is high. However, it is well known that a relevant amount of patients may not respond as expected. The aim of this study is to evaluate the BoNT treatment outcome on an individual level using a statistical single-case analysis as an adjunct to traditional group statistics. The course of the daily perceived severity of symptoms across a BoNT cycle was analyzed in 20 cervical dystonia (CD) and 15 hemifacial spasm (HFS) patients. A parametric single-case autoregressive integrated moving average (ARIMA) time series analysis was used to detect individual responsiveness to BoNT treatment. Overall, both CD and HFS patients significantly responded to BoNT treatment with a gradual worsening of symptom intensities towards BoNT reinjection. However, only 8/20 CD patients (40%) and 5/15 HFS patients (33.3%) displayed the expected U-shaped curve of BoNT efficacy across a single treatment cycle. CD (but not HFS) patients who followed the expected outcome course had longer BoNT injection intervals, showed a better match to objective symptom assessments, and were characterized by a stronger certainty to control their somatic symptoms (i.e., internal medical locus of control). In addition to standard evaluation procedures, patients should be identified who do not follow the mean course-of-treatment effect. Thus, the ARIMA single-case time series analysis seems to be an appropriate addition to clinical treatment studies in order to detect individual courses of subjective symptom intensities.

Short- and Long-term Central Action of Botulinum Neurotoxin Treatment in Laryngeal Dystonia.

Background and ObjectivesLaryngeal dystonia (LD) is isolated task-specific focal dystonia selectively impairing speech production. The first choice of LD treatment is botulinum neurotoxin (BoNT) injections into the affected laryngeal muscles. However, whether BoNT has a lasting therapeutic effect on disorder pathophysiology is unknown. We investigated short-term and long-term effects of BoNT treatment on brain function in patients with LD.MethodsA total of 161 participants were included in the functional MRI study. Statistical analyses examined central BoNT effects in patients with LD who were stratified based on the effectiveness and duration of treatment.ResultsPatients with LD who were treated and benefited from BoNT injections had reduced activity in the left precuneus compared with BoNT-naive and treatment nonbenefiting patients. In addition, BoNT-treated patients with adductor LD had decreased activity in the right thalamus, whereas BoNT-treated abductor patients with LD had reduced activity in the left inferior frontal cortex. No statistically significant differences in brain activity were found between patients with shorter (1–5 years) and longer (13–28 years) treatment durations. However, patients with intermediate treatment duration of 6–12 years showed reduced activity in the right cerebellum compared with patients with both shorter and longer treatment durations and reduced activity in the right prefrontal cortex compared with patients with shorter treatment duration.DiscussionOur findings suggest that the left precuneus is the site of short-term BoNT central action in patients with LD, whereas the prefrontal-cerebellar axis is engaged in the BoNT response in patients with intermediate treatment duration of 6–12 years. Involvement of these structures points to indirect action of BoNT treatment on the dystonic sensorimotor network through modulation of motor sequence planning and coordination.

An Observational Cross-Sectional Study of Gender and Disability as Determinants of Person-Centered Medicine in Botulinum Neurotoxin Treatment of Upper Motoneuron Syndrome.

The motor behaviour of patients with Upper Motor Neuron Syndrome (UMNS) is characterised by spasticity. The first-line treatment for this clinical condition is Botulinum neurotoxin A (BoNTA), but the number and key locations of muscles which need to be treated is not much discussed in the literature. Cross-sectional analysis of outpatient cohort with UMNS spasticity, who were potential candidates for BoNTA treatment, was performed. Between November 2020 and November 2021, all consecutive adult patients eligible for BoNTA treatment were enrolled. The inclusion criteria encompass UMNS spasticity (onset being ≥6 months), with disabling muscles hypertonia. Patients underwent a clinical evaluation, a comprehensive assessment with the Modified Ashworth Scale, with the Modified Rankin Scale, and a patients’ perception-centred questionnaire. In total, 68 participants were enrolled in the study, among them 40 (58.8%) were male; mean age 57.9 ± 15.1. In women, BoNTA was more frequently required for adductor group muscles, independently from potential confounders (OR = 7.03, 95%CI: 1.90–25.97). According to the pattern of disability, patients with hemiparesis more frequently need to be treated in the upper limb, whereas the diplegia/double-hemiparesis group needed to be treated more frequently at the adductor and crux muscles compared to their counterparts. UMNS spasticity in women could require more attention to be paid to the treatment of adductor muscle spasticity, potentially because the dysfunction of those muscles could influence sphincteric management, required for perineal hygiene and/or sexual life.

Clinical Results of Sevoflurane Inhalation Anesthesia for Botulinum Neurotoxin Treatment in Children with Cerebral Palsy

Objective: The botulinum neurotoxin type A (BoNT-A) intramuscular injection is a safe and reliable method to treat increased spasticity in spastic cerebral palsy (CP). Although BNT-A injections may be administered under local anesthesia, many clinicians prefer injections under general anesthesia in the operating room, especially for children. The purpose of the present study was to evaluate the safety and efficacy of administering BNT-A injections to children with spastic CP under sevoflurane mask anesthesia. Materials and Methods: Files of 61 children with CP who received 191 BoNT-A injections under sevoflurane mask anesthesia were analyzed retrospectively. The time from the beginning of anesthesia to the end of the procedure was recorded. The BNT-A dose per muscle was 3–6 IU/kg body weight for lower extremity muscles and 1–3 IU/kg body weight for upper extremity muscles. Results: The mean age of the children was 42 months. The mean procedure time was 15 min. There were no complications related to anesthesia or the BTN-A injection procedure. Conclusion: BTN-A injections in children with spastic CP may be safely and effectively administered under sevoflurane mask anesthesia without any procedural or anesthetic complications.

A Retrospective and Anatomical Study Describing the Injection of Botulinum Neurotoxins in the Depressor Anguli Oris.

The depressor anguli oris acts to lower the lateral corners of the mouth and can cause an individual to appear sad or angry and contribute to the development of the labiomental folds. Many patients can benefit from the injection of small amounts of botulinum neurotoxin into the depressor anguli oris to enable the lip elevators to reposition the corners of the mouth. Although effective, the procedure is off-label, and the proximity of the depressor anguli oris to the depressor labii inferioris, particularly inferiorly, can lead to inadvertent treatment of the latter, resulting in lip asymmetry. The authors have taken a threefold approach to establish a depressor anguli oris injection technique that provides optimal aesthetic outcomes with a low incidence of adverse events. This involved, first, reviewing the limited existing literature for studies discussing depressor anguli oris anatomy and botulinum neurotoxin treatment technique; second, supplementing information from the published literature with information from cadaver dissections to demonstrate the relationship between the depressor anguli oris and surrounding anatomical structures; and third, performing a retrospective chart review of 275 patients treated with the authors' three-point injection technique. Combining data from published studies, cadaver dissections, and clinical experience, the authors demonstrate that a three-point technique performed in the upper half of the depressor anguli oris is associated with good clinical outcome and avoids common side effects related to injection or spread of neurotoxin to adjacent muscles. Therapeutic, IV.

Intraoperative findings of abnormal muscle response for hemifacial spasm following botulinum neurotoxin treatment.

This study aimed to investigate the effect of preoperative botulinum toxin (BTX) injection on intraoperative abnormal muscle response (AMR) in patients with hemifacial spasm (HFS). A total of 104 patients (32 men, 72 women) who underwent microvascular decompression (MVD) for HFS were included in this study. A total of 62 patients without and 42 patients with preoperative BTX treatments were assigned to group A and group B, respectively. AMR recordings were obtained from the orbicularis oculi and mentalis muscles by stimulation of the marginal mandibular branch and zygomatic branch of the facial nerve, respectively. The intraoperative AMR monitoring findings and therapeutic effects were compared between groups A and B. The rates of the patients with unavailable AMRs recorded from the orbicularis oculi muscles in group B (38.1%) were significantly higher than those in group A (14.5%, p = 0.006). Moreover, in cases with over 4 times BTX injection, the recordings of AMR from the orbicularis oculi muscles were poorer than the cases with less BTX injection (p = 0.001). There were no significant differences in the rates of the patients with unavailable AMRs recorded from the mentalis muscles between the two groups. There were no significant differences in the surgical results obtained between the two groups. Preoperative BTX injections should be less than 4 times to ensure effective AMR monitoring. MVD using AMR monitoring is useful for patients with HFS who were previously treated by BTX as well as those who were not treated.