Toronto Western Spasmodic Torticollis Rating Research Articles

Combination of anodal tDCS of the cerebellum with a goal-oriented motor training to treat cervical dystonia: a pilot case series.

Transcranial Direct Current Stimulation (tDCS) of the cerebellum shows promise for the treatment of dystonia. Specific motor rehabilitation programs have also been developed in this context. However, the combination of these two approaches has not yet been evaluated to determine their therapeutic potential. We report a series of 5 patients with cervical dystonia (CD) poorly controlled by botulinum toxin injections. They were initially treated by a protocol of repeated daily sessions (for 3 or 5 days) of cerebellar anodal tDCS (cer-atDCS) applied alone. In a second time, additional protocols of cer-atDCS were performed in combination with a program of goal-oriented motor training exercises (Mot-Training), specifically developed for the treatment of CD. The clinical impact of the procedures was assessed on the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS). Compared to baseline, the maximum percentage of TWSTRS total score improvement was 37% on average after cer-atDCS performed alone (p = 0.147, not significant) and 53% on average after cer-atDCS combined with Mot-Training (p = 0.014, significant). The TWSTRS pain and functional handicap subscores also improved after the combined protocol. A score of (+3) to (+5) was rated on the TWSTRS response scale after cer-atDCS performed alone or the combined protocol, corresponding to a moderate to striking improvement on dystonia and pain. This improvement lasted longer after the combined protocol than after cer-atDCS alone (3.4 vs. 1.4 months on average, p = 0.011). The combination of cer-atDCS with Mot-Training produced a greater and more prolonged improvement than the application of cer-atDCS alone. Such a combined therapeutic procedure is easy to perform and opens important perspectives in the long-term treatment of CD. These results remain to be confirmed by a randomized sham-controlled trial on a larger sample.

Sensitization-Associated Symptoms and Neuropathic-like Features in Patients with Cervical Dystonia and Pain.

Background: This exploratory study evaluated the presence of sensitization-associated and neuropathic-like symptoms and identified their association with pressure sensitivity, pain, and disability in patients with cervical dystonia (CD). Methods: Thirty-one patients with CD (74.2% women, age: 61.2 years, SD 10.1) participated. Data collected included clinical variables, the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), the Central Sensitization Inventory (CSI), the Self-administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS), the Hospital Anxiety and Depression Scale (HADS) and the Pittsburgh Sleep Quality Index (PSQI), as well as widespread pressure pain thresholds (PPTs). Results: Patients with CD with pain (n = 20, 64.5%) showed higher scores on the TWSTRS disability subscale and the CSI (p < 0.001), and lower PPTs (p < 0.05). Fifteen patients (15/31, 48%) showed sensitization-associated symptoms (CSI ≥ 40), whereas five of the patients with pain (5/20, 25%) exhibited neuropathic-like symptoms (S-LANSS ≥ 12). The CSI and S-LANSS were positively associated with the TWSTRS, HADS-A and HADS-D, and negatively associated with PPTs. HADS-D and S-LANSS explained 72.5% of the variance of the CSI (r2: 0.725), whereas CSI explained 42.3% of the variance of the S-LANSS (r2: 0.423). Conclusions: Pain is an important source of disability in CD, and may be a consequence of different mechanisms, including sensitization.

Bridging the gap between statistical significance and clinical relevance: A systematic review of minimum clinically important difference (MCID) thresholds of scales reported in movement disorders research

BackgroundMinimum clinically important difference (MCID) is the smallest change in an outcome measure that is considered clinically meaningful. Using validated MCID thresholds for outcomes powers trials adequately to detect meaningful treatment effects, aids in their interpretation and guides development of new outcome measures. ObjectivesTo provide a comprehensive summary of MCID thresholds of various symptom severity scales reported in movement disorder. MethodsWe conducted systematic review of the literature and included studies of one or more movement disorders, and reporting MCID scales. Results2763 reports were screened. Final review included 32 studies. Risk of bias (RoB) assessment showed most studies were of good quality. Most commonly evaluated scale was Unified Parkinson's Disease Rating Scale (UPDRS) (11 out of 32). Four studies assessing MDS-UPDRS had assessed its different sub-parts, reporting a change of 2.64,3.05,3.25 and 0.9 points to detect clinically meaningful improvement and 2.45,2.51,4.63 and 0.8 points to detect clinically meaningful worsening, for the Part I, II, III and IV, respectively. For Parts II + III, I + II + III and I + II + III + IV, MCID thresholds reported for clinically meaningful improvement were 5.73, 4.9, 6.7 and 7.1 points respectively; while those for clinically meaningful worsening were 4.7, 4.2, 5.2 and 6.3 points, respectively. MCID thresholds reported for other scales included Abnormal Involuntary Movement Scale (AIMS), Toronto Western Spasmodic Torticollis Rating Scale (TWSRS), and Burke-Fahn-Marsden Dystonia Scale (BFMD). ConclusionThis review summarizes all the MCID thresholds currently reported in Movement disorders research and provides a comprehensive resource for future trials, highlighting the need for standardized and validated MCID scales in movement disorder research.

MRI-Guided Focused Ultrasound in Cervical Dystonia

Introduction. MRI-guided focused ultrasound (MRgFUS) is approved for management of various movement disorders, primarily essential tremor and Parkinson’s disease (PD), with favorable long-term outcomes in numerous patients worldwide. However, few case studies describe the use of this modality for symptomatic treatment of dystonias that, as the third most common movement disorder, may be rather disabling.&#x0D; Objective: To improve outcomes in patients with cervical dystonia (CD) using MRgFUS.&#x0D; Materials and methods. We retrospectively analyzed 13 cases of various CD types managed with MRgFUS in single or multiple sessions. The mean age of the patients was 42 [39; 53] years. The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) was used to assess patients' statuses and severity of CD symptoms during therapy and the last available observation period. The targets included the pallidothalamic tract and the thalamic ventral oralis complex nucleus or their combination.&#x0D; Results. The mean follow-up period was 13.3 ± 3.4 months (July 2021 to April 2023). The mean CD severity sum score (TWSTRS score) was 22 [16; 25] before MRgFUS and 6 [4; 9] in the last observation. Therefore, we report 70.6% [55.6; 76.5] improvement (paired samples t-test p = 0.0025).&#x0D; Conclusion. Available data evidence that MRgFUS is efficient and sufficiently safe for symptomatic treatment in pharmacoresistant CD patients. A number of vital aspects of MRgFUS have to be specified in larger CD cohorts in the long-term follow-up.

An analysis of the efficacy of botulinum neurotoxin type a in treating cervical dystonia

BACKGROUND: The first-line treatment for cervical dystonia (CD) consists of repeated intramuscular injections of botulinum toxin (BoNT). However, the efficacy in some patients may be unsatisfactory and they may discontinue treatment. OBJECTIVE: To examine the factors associated with the maximum rate of remission in patients with CD after initial botulinum neurotoxin type A (or botulinum toxin type A abbreviated as BTX-A or BoNT-A) treatment. METHODS: Patients with CD who received BoNT-A injections were evaluated using the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) and the Tsui scale, with follow-up endpoints lasting until the start of the second injection. Patients who did not receive a second injection of BoNT-A were followed up for at least 5 months. The maximum remission rates were determined using the lowest Tsui and TWSTRS total scores during the follow-up period. We obtained basic information about these patients such as age, gender, duration of disease, presence of additional disease, types of torticollis, presence of anxiety, depression, tremors, single-photon emission computed tomography (SPECT) findings, injected dose, and so on from their medical records. RESULTS: A total of 70 patients with CD participated in this study, with males comprising 35.7% (25 individuals) with an average age of 45 ± 14 years old. The duration of disease was an independent risk factor for determining whether a complete remission has been attained using the Tsui scale (odds ratio [OR] = 0.978, 95% confidence interval [CI]: 0.959–0.997, P= 0.026). The optimal cut-off point for predicting patients who were unable to achieve complete remission based on duration of disease was 7.5 months (AUG = 0.711). Patients with CD with additional disease had greater difficulty achieving complete remission than those with CD alone based on TWSTRS assessments (P= 0.049). During the study, approximately 17% of all participants reported experiencing adverse reactions that lasted between 1 to 3 weeks before disappearing. CONCLUSION: BoNT is an effective and safe method for treating CD. The maximum remission rates of patients after their first injections are influenced by the duration of their disease. Thus, treatment using BoNT injections must be administered as soon as possible.

An Empirical Comparison of Commonly Used Universal Rating Scales for Dystonia.

There are several widely used clinical rating scales for documenting the severity and distribution of various types of dystonia. The goal of this study was to evaluate the performance of the most commonly used scales in a large group of adults with the most common types of isolated dystonia. Global Dystonia Rating Scale (GDRS) and the Burke-Fahn-Marsden Dystonia Rating Scale (BFM) scores were obtained for 3067 participants. Most had focal or segmental dystonia, with smaller numbers of multifocal or generalized dystonia. These scales were also compared for 209 adults with cervical dystonia that had Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) scores and 210 adults with blepharospasm that had Blepharospasm Severity Scale (BSRS) scores. There were strong correlations between the GDRS and BFM total scores (r = 0.79) and moderate correlations for their sub scores (r > 0.5). Scores for both scales showed positive skew, with an overabundance of low scores. BFM sub-scores were not normally distributed, due to artifacts caused by the provoking factor. Relevant sub-scores of the GDRS and BFM also showed moderate correlations with the TWSTRS (r > 0.5) for cervical dystonia and the BSRS (r > 0.5) for blepharospasm. The BFM is more widely used than the GDRS, but these results suggest the GDRS may be preferable for focal and segmental dystonias. The overabundance of very low scores for both scales highlights challenges associated with discriminating very mild dystonia from other abnormal movements or variants of normal behavior.

A Case Report of Korean Medicine Treatment for a Patient with Cervical Dystonia

The purpose of this study is to report a case of cervical dystonia and the effects of a series of traditional Korean medicine treatments applied to the patient. The patient was treated with conventional treatment and traditional Korean medicine consisting of acupuncture, moxa, chuna therapy, and herbal medicine (&lt;i&gt;Hoesu-san-gami&lt;/i&gt;) for 48 days. Progress was measured by Tsui’s score, the Toronto Western Spasmodic Torticollis Rating Scale, and the Neck Disability Index. We observed some improvements in the patient’s symptoms: Tsui’s score of 15 to 11, TWSTRS of 63.3 to 47.8, and NDI of 24 to 17. These findings indicate that the application of traditional Korean medicine to cervical dystonia can yield decent clinical outcomes.

Comprehensive diagnosis of cervical dystonia and the efficacy of long-term (three-year) botulinum therapy

Cervical dystonia (CD) is common in outpatient practice but in many cases is diagnosed at late stages. The efficacy of long-term botulinum therapy (BT) in CD has been poorly studied.Objective: to analyse the typical practice of treating patients with CD and the efficacy of long-term BT therapy (three years).Material and methods. Sixty-three patients (43 women and 20 men) diagnosed with CD (mean age 51 [42; 63] years) participated in the study. We performed an analysis of typical practice of managing patients with CD before starting BT. The mean duration of disease at the time of referral was 6 [4; 10] years. Patients received repeated injections of BT at 10–20 week intervals; BT was administered under electromyographic control and ultrasound navigation. The severity of CD was assessed using the Toronto Western Spasmodic Torticollis Rating Scale (TWRSTW), quality of life using the EuroQol-5D questionnaire (EQ-5D) questionnaire, and anxiety level using the Generalized Anxiety Disorder Questionnaire scale-7, GAD-7). Patients' condition was assessed at baseline, 1 month after BT, and after 3 years against the background of regular BT. The severity of the disease before BT was 36.71±3.6 points. The control group consisted of 46 healthy subjects (39 women and 7 men, mean age 53.8±12.3 years).Results. The diagnosis of CD was made on average 2.3±1.1 years after the onset of the first symptoms, BT was started on average 5±2.6 years after diagnosis. At the first visit to the physician, CD was detected in only 32% of cases. In the CD group there was an increase in the severity of anxiety up to 9.93±4.7 points (in the control group – 4.28±3.5 points; p≤0.05) and a decrease in quality of life down to 62.53±12.1 points (in the control group – 86.38±6.4 points; p≤0.05). One month after BT, a significant decrease in the severity of the disease was observed – from 36.7±13.6 to 13.3±10.8 points (p≤0.05). After three years of regular BT the severity of the disease decreased to 12.7±10.5 points (p≤0.05), the level of anxiety decreased to 5.2±3.7 points (p≤0.05), the patients' quality of life increased up to 77.93±8.4 points (p≤0.05).Conclusion. CD is still underdiagnosed in practice, and BT is not prescribed until several years after the onset of the disease. Regular and longterm use of BT not only reduces the severity of CD, but also reduces the severity of anxiety disorders and improves patients' quality of life.

PAllidal versus SubThalamic deep brain Stimulation for Cervical Dystonia (PASTS-CD): study protocol for a multicentre randomised controlled trial

IntroductionDeep brain stimulation (DBS) has been validated as a safe and effective treatment for refractory cervical dystonia (CD). Globus pallidus internus (GPi) and subthalamic nucleus (STN) are the two main...

GPi-DBS-induced brain metabolic activation in cervical dystonia

BackgroundDeep brain stimulation (DBS) of the globus pallidus interna (GPi) is a highly efficacious treatment for cervical dystonia, but its mechanism of action is not fully understood. Here, we investigate...

Therapeutic Benefit of Sensory Trick in Cervical Dystonia.

Sensory tricks (STs) are voluntary maneuvers that dampen the abnormal movement in cervical dystonia (CD). To investigate the effect of ST on CD severity and treatment. Data on 1039 individuals with a modified Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) score were extracted from the CD Patient Registry for Observation of OnabotulinumtoxinA (onabotA) Efficacy study. Univariate and multivariate models evaluated the direct and indirect impact of ST on CD severity and treatment, while controlling for confounds. Complete ST was associated with a 10% lower mean onabotA dose. Absence of complete ST was associated with a higher onabotA dose after controlling for dystonia severity (OR = 1.37, P = 0.04). ST moderated the relationship between dystonia severity and toxin dose (β = -0.16, P = 0.02). ST is related to lower CD severity and toxin dose. It may have a direct effect on lowering toxin dose, independent of CD severity.

Efficacy and safety of abobotulinum injection in patients with focal dystonia

Objectives: To investigate the clinical features of focal dystonia and evaluate the efficacy and safety of Abobotulinum injection on these patients. Subjects and methods: A prospective cross-sectional descriptive study on 59 patients and 114 injection sessions of focal dystonia at the Functional Exploration Unit, Hue University of Medicine and Pharmacy Hospital from July 2020 to June 2023. We recorded the dystonia severity by corresponding scale and followed up every one month after the injection to document the maximal subjective improvement and side effects of the injection. Results: The number of patients with hemifacial spasm: blepharospasm: cervical dystonia: limb dystonia: oromandibular dystonia are 17: 12: 20: 8: 2, respectively. Regarding to hemifacial spasm, the primary cause accounted for 82.4%, the average grading scale was 6.1 ± 0.5; the average dose was 80.9 ± 29.9 U Abobotulinum; the proportion of complete and &gt; 50% improvement was 83.9% of injections; the most common adverse effect was facial weakness in 47.0% of patients and 41.9% of injections. In terms of blepharospasm, the mean severity was 5.5 ± 0.9 on the Jankovic’s scale; the average therapeutic dose of 68.1 ± 27.6 helped 90.5% improve &gt; 50% and completely; 1/3 of patients had lagophthalmos, only 2 patient had bruising but no one had ptosis. Cervical dystonia patients had mean Toronto Western Spasmodic Torticollis Rating Scale of 26.3 ± 9.6; using an average dose of 406.1 ± 225.2, which improved 97.8% of injections. The most notable adverse events reported were 1 patient with vasovagal syncope and 1 patient with flu-like symptoms after injection. Limb dystonia data recorded subjective improvement in all patients, and only 1 patient had focal weakness. In 2 cases of closed jaw LTLC, both improved and had no side effects. All of the above side effects were transient and mild. Conclusion: Dystonia involves predominantly the facial and neck muscles, mainly of idiopathic origin. Research has demonstrated its effectiveness in improving symptoms of muscle dystonia, similar to studies conducted worldwide in hemifacial spasm, blepharospasm, and cervical dystonia, with less effectiveness in arm dystonia. Local side effects are quite common in hemifacial spasm and blepharospasm, while they are rare in other forms. Key words: focal dystonia, Abobotulinum, Botulinum toxin injection, cervical dystonia, blepharospasm, hemifacial spasm, oromandibular dystonia, limb dystonia.

Assessing the Severity of Cervical Dystonia: Ask the Doctor or Ask the Patient?

Assessing disease severity can be performed using either clinician-rated scales (CRS) or patient-rated outcome (PRO) tools. These two measures frequently demonstrate poor correlations. To determine if the correlation between a CRS and PRO for motor features of cervical dystonia (CD) improves by accounting for non-motor features. Subjects with CD (N = 209) were evaluated using a CRS (Toronto Western Spasmodic Torticollis Rating Scale, TWSTRS) and a PRO (Cervical Dystonia Impact Profile, CDIP-58). Linear regression revealed a weak correlation between the two measures, even when considering only the motor subscales of each. The strength of this relationship improved with a regression model that included non-motor symptoms of pain, depression, and disability. These results argue that the results of motor assessments in a PRO for CD cannot be fully appreciated without simultaneous assessment of non-motor co-morbidities. This conclusion might apply to other disorders, especially those with frequent non-motor co-morbidities.

The effect of botulinum toxin on anxiety in cervical dystonia: A prospective, observational study

IntroductionAnxiety is present in 30–40% of patients with cervical dystonia (CD). It has been ascribed to a direct effect of the state of motor symptoms on related pain, disability, and disfigurement. Accordingly, any reported benefit of botulinum toxin (BoNT) on anxiety is thought to be secondary to its effect on the same. We sought to evaluate the distinctive impact of botulinum toxin (BoNT) on anxiety in cervical dystonia (CD). MethodsIn this prospective observational study, 60 participants with idiopathic isolated CD were recruited from clinic. We assessed motor and anxiety burden using Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) parts I-III and State-Trait Anxiety Inventory (STAI). Assessments were done at time of BoNT (baseline) and at 6 weeks post-injection. ResultsSTAI and motor severity TWSTRS scores poorly correlated at the baseline visit (rho = −0.30, p = 0.411). Both, motor TWSTRS (Mdifference = −1.46, p < 0.024) and STAI (Mdifference = −10.37, p = 0.007) improved from baseline to 6 weeks (peak effect). The change in motor TWSTRS poorly correlated with change in anxiety scores from baseline visit to 6 weeks (rho = −0.14, p > 0.999). Of these measures of anxiety, improvement in STAI-T had the largest effect size (rank biserial = 0.52). ConclusionBoNT improves both motor severity and anxiety in CD. Poor correlation between motor severity and anxiety at both the time of injection and during the time of peak effect, and improvement in trait anxiety suggests that BoNT has a direct beneficial effect on anxiety.

Bilateral globus pallidus internus (GPi) deep brain stimulation for cervical dystonia: Effects on motor and non-motor symptoms within 5 years follow

BackgroundCervical Dystonia (“CD”) is a movement disorder characterised by sustained muscle contractions in the neck, causing involuntary posturing. Deep brain stimulation (“DBS”) of the globus pallidal internus (GPi) is advanced treatment for pharmaco-refractory patients. As CD is a rare disease, cohort studies are often limited to patients of heterogenous disease profile, small sample size or short follow-up. This study firstly aimed to measure the efficacy of GPi-DBS on motor and non-motor symptoms of CD. A secondary aim was to evaluate if clinical factors – such as age, disease duration and baseline disease severity – influence variability of motor outcomes. Methods37 idiopathic CD patients were recruited from movement disorders clinics at The Walton NHS Foundation Trust, Liverpool, UK. Patients were assessed pre-operatively, and 1 year, 3 years and 5 years post-operatively with the following clinical scales: Toronto Western Spasmodic Torticollis Rating Scale (“TWSTRS”), Hospital Anxiety and Depression Scale and EuroQuol-5D. ResultsGPI-DBS significantly improved overall TWSTRS scores by 57% from baseline to 5Y FU (p < 0.001). It also significantly improved TWSTRS severity, disability, and pain sub-scores by 72%, 59% and 46% respectively. We did not find a significant improvement in mood or quality of life scores at 5 years. Similarly, clinical factors at baseline did not correlate with variability in motor outcome. ConclusionWe concluded that GPi-DBS is an effective treatment for motor symptoms and pain in CD. There was limited effect on mood and QoL, and no clinical predictive factors of outcome were identified.

Subthalamic deep brain stimulation for primary dystonia: defining an optimal location using the medial subthalamic nucleus border as anatomical reference.

Although the subthalamic nucleus (STN) has proven to be a safe and effective target for deep brain stimulation (DBS) in the treatment of primary dystonia, the rates of individual improvement vary considerably. On the premise of selecting appropriate patients, the location of the stimulation contacts in the dorsolateral sensorimotor area of the STN may be an important factor affecting therapeutic effects, but the optimal location remains unclear. This study aimed to define an optimal location using the medial subthalamic nucleus border as an anatomical reference and to explore the influence of the location of active contacts on outcomes and programming strategies in a series of patients with primary dystonia. Data from 18 patients who underwent bilateral STN-DBS were retrospectively acquired and analyzed. Patients were assessed preoperatively and postoperatively (1 month, 3 months, 6 months, 1 year, 2 years, and last follow-up after neurostimulator initiation) using the Toronto Western Spasmodic Torticollis Rating Scale (for cervical dystonia) and the Burke-Fahn-Marsden Dystonia Rating Scale (for other types). Optimal parameters and active contact locations were determined during clinical follow-up. The position of the active contacts relative to the medial STN border was determined using postoperative stereotactic MRI. The clinical improvement showed a significant negative correlation with the y-axis position (anterior-posterior; A+, P-). The more posterior the electrode contacts were positioned in the dorsolateral sensorimotor area of the STN, the better the therapeutic effects. Cluster analysis of the improvement rates delineated optimal and sub-optimal groups. The optimal contact coordinates from the optimal group were 2.56 mm lateral, 0.15 mm anterior, and 1.34 mm superior relative to the medial STN border. STN-DBS was effective for primary dystonia, but outcomes were dependent on the active contact location. Bilateral stimulation contacts located behind or adjacent to Bejjani's line were most likely to produce ideal therapeutic effects. These findings may help guide STN-DBS preoperative planning, stimulation programming, and prognosis for optimal therapeutic efficacy in primary dystonia.

The Pain in Dystonia Scale (PIDS)-Development and Validation in Cervical Dystonia.

A better understanding of pain in adult-onset idiopathic dystonia (AOID) is needed to implement effective therapeutic strategies. To develop a new rating instrument for pain in AOID and validate it in cervical dystonia (CD). Development and validation of the Pain in Dystonia Scale (PIDS) comprised three phases. In phase 1, international experts and participants with AOID generated and evaluated the preliminary items for content validity. In phase 2, the PIDS was drafted and revised by the experts, followed by cognitive interviews to ensure self-administration suitability. In phase 3, the PIDS psychometric properties were assessed in 85 participants with CD and retested in 40 participants. The final version of PIDS evaluates pain severity (by body-part), functional impact, and external modulating factors. Test-retest reliability showed a high-correlation coefficient for the total score (0.9, P < 0.001), and intraclass correlation coefficients were 0.7 or higher for all items in all body-parts subscores. The overall PIDS severity score showed high internal consistency (Cronbach's α, 0.9). Convergent validity analysis revealed a strong correlation between the PIDS severity score and the Toronto Western Spasmodic Torticollis Rating Scale pain subscale (0.8, P < 0.001) and the Brief Pain Inventory-short form items related to pain at time of the assessment (0.7, P < 0.001) and impact of pain on daily functioning (0.7, P < 0.001). The PIDS is the first specific questionnaire developed to evaluate pain in all patients with AOID, here, demonstrating high-level psychometric properties in people with CD. Future work will validate PIDS in other forms of AOID. © 2023 International Parkinson and Movement Disorder Society.

Pain Reduction in Cervical Dystonia Following Treatment with IncobotulinumtoxinA: A Pooled Analysis.

This analysis pooled pain severity data from four phase 3 and 4 studies of incobotulinumtoxinA (incoBoNT-A) for the treatment of cervical dystonia (CD) in adults. CD-related pain severity was assessed at baseline, each injection visit, and 4 weeks after each injection of incoBoNT-A using the Toronto Western Spasmodic Torticollis Rating Scale pain severity subscale or a pain visual analog scale. Both were analyzed using a score range of 0-10 and pain was categorized as mild, moderate, or severe. Data for 678 patients with pain at baseline were assessed and sensitivity analyses evaluated pain responses in the subgroup not taking concomitant pain medication (n = 384 at baseline). At Week 4 after the first injection, there was a mean change of -1.25 (standard deviation 2.04) points from baseline pain severity (p < 0.0001), with 48.1% showing ≥ 30% pain reduction from baseline, 34.4% showing ≥50% pain reduction from baseline, and 10.3% becoming pain free. Pain responses were sustained over five injection cycles with a trend to incremental improvements with each successive cycle. Pain responses in the subgroup not taking concomitant pain medication demonstrated the lack of confounding effects of pain medications. These results confirmed the pain relief benefits of long-term treatment with incoBoNT-A.

Cervical Dystonia in a Headache Population: General Medical Education (GME) Training to Standardize Screening (P11-12.005)

<h3>Objective:</h3> To highlight the importance of GME training on screening for cervical dystonia in patients presenting for headaches or cervicalgia. <h3>Background:</h3> Cervical dystonia (CD) is a condition of involuntary overactivation of the cervical musculature resulting in abnormal head posture. Notably, comorbid headache in CD is present in up to 75% of patients. Although the prevalence of CD is reported to be quite low, underdiagnosis or misdiagnosis is common. This is likely due to the challenging physical diagnosis often requiring a movement disorder specialist, and the lack of focused training in neurology residency programs. Although CD can improve with Botulinum toxin (BT), greater than 50% of patients remain untreated. <h3>Design/Methods:</h3> From 2017–2020, an IRB-reviewed Quality Improvement Project was initiated by a Movement Disorder Neurologist in a GME-Residency program. Chart review was performed on all patients presenting for headache, migraine, or cervicalgia, and the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) was performed to assess for comorbid cervical dystonia. <h3>Results:</h3> During this timeframe, 6455 patients presented for headache, migraine, cervical dystonia, or cervicalgia. 306 patients were diagnosed with both cervicalgia and headache. Of those patients, 5% were ultimately diagnosed with cervical dystonia. All diagnoses of cervical dystonia were made by a Movement Disorder Neurologist or resident trained in this screening approach. All patients diagnosed with cervical dystonia had chronic headaches, and most had daily headaches. Of patients diagnosed with cervical dystonia, 86% were started on treatment with BT, with a 91% success rate. <h3>Conclusions:</h3> Patients with cervical dystonia commonly present to Neurology for headache or migraine, as comorbid pain is frequent. Underdiagnosis of dystonia may lead to suboptimal treatment choices. Formalized training of residents to use TWSTRS on patients with headache and cervicalgia may enhance diagnosis and improve treatment outcomes. <b>Disclosure:</b> Dr. Inoue has nothing to disclose. Dr. Dalton has nothing to disclose. Dr. Hack has nothing to disclose. Dr. Baker has nothing to disclose.

Characteristics and Treatment Response to OnabotulinumtoxinA of Patients From CD-PROBE With Anterocollis and Retrocollis (P12-11.005)

<h3>Objective:</h3> To describes baseline characteristics and treatment response of these cervical dystonia (CD) subtypes. <h3>Background:</h3> CD-PROBE included patients with anterocollis (AC) and retrocollis (RC) treated with onabotulinumtoxinA (onabotA). <h3>Design/Methods:</h3> CD PROBE was an observational, prospective study designed to identify real-world outcomes in patients with CD after onabotA treatment; patients from 82 US sites with CD diagnosis who were candidates for onabotA therapy, new to treatment, or not previously treated in a clinical trial in ≥16 weeks, and completed 3 onabotA treatments. Treatment benefit was measured using the Patient’s Global Impression of Change (PGI-C), Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), Cervical Dystonia Impact Profile (CDIP-58), Clinician’s Global Impression of Change (CGI-C), and physician assessments of CD severity. <h3>Results:</h3> Patients with AC (n=59) and RC (n=55) were older and more disabled, with a shorter time to diagnosis and treatment, than patients with laterocollis (LC) or torticollis (TC). From PGI-C responses, 58.4% of RC vs 47.8% of AC patients reported being much/very much improved by onabotA post-injection 3 (final visit). CGI-C responses similarly improved over this timeframe; 82.6% of RC and 60.9% of AC patients reporting much/very much improved. The mean total TWSTRS score decreased for AC and RC patients from injection 1 (46 [AC]; 40 [RC]) to final visit (36 [AC]; 32 [RC]); CDIP-58 scores also decreased over time. The proportion of patients with physician-assessed severe CD decreased from injection 1 (28.8% [AC]; 21.8% [RC]) to final visit (21.7% [AC]; 4.3% [RC]); most patients shifted to lower symptom severity. OnabotA dose generally increased per visit, with AC patients having lowest doses (153.5–195.4U) and RC patients the highest (184.0–213.4U). Adverse event of dysphagia reported in 4 AC and 7 RC patients. No new safety signals were identified. <h3>Conclusions:</h3> CD PROBE data indicates real-world treatment with onabotA relieves CD symptoms in patients with anterocollis and retrocollis. <b>Disclosure:</b> Dr. Dashtipour has received personal compensation in the range of $100,000-$499,999 for serving as a Consultant for Amneal, Abbvie, Acorda, Acadia, Ipsen, Supernus, Sunovion, Neurocrine, Teva. Dr. Dashtipour has received personal compensation in the range of $100,000-$499,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Amneal, Abbvie, Acadia, Supernus. Dr. Dashtipour has received personal compensation in the range of $100,000-$499,999 for serving on a Speakers Bureau for Amneal, Acorda, Abbvie, Ipsen, Teva, Neurocrine, SupernusPD, sunovion . Dr. Jankovic has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Revance. Dr. Jankovic has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Revance, Allergan. The institution of Dr. Jankovic has received research support from Baylor College of Medicine. Dr. Jankovic has received research support from Abbvie. The institution of Dr. Jankovic has received research support from Abbvie. Dr. Charles has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Supernus. Dr. Charles has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Revance. Dr. Charles has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Merz. Dr. Charles has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Newronika. Dr. Charles has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Ipsen. Dr. Charles has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Iota. Dr. Charles has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Abbott. Dr. Charles has received personal compensation in the range of $500-$4,999 for serving as a Consultant for AbbVie. Dr. Charles has stock in Arena Therapeutics. The institution of Dr. Charles has received research support from Pharma 2 B. The institution of Dr. Charles has received research support from Intec. The institution of Dr. Charles has received research support from Merz. The institution of Dr. Charles has received research support from Novartis. The institution of Dr. Charles has received research support from Aeon. The institution of Dr. Charles has received research support from Impax. Dr. Mehta has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Adamas Pharma. Dr. Mehta has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Abbott. Dr. Mehta has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for CNS Ratings. Marc Schwartz has nothing to disclose. Dr. Sadeghi has received personal compensation for serving as an employee of AbbVie. Dr. Sadeghi has stock in Abbvie/Abbott.