Practical guidance for CD management involving treatment of botulinum toxin: a consensus statement

Abstract

Cervical dystonia is a neurological movement disorder causing abnormal posture of the head. It may be accompanied by involuntary movements which are sometimes tremulous. The condition has marked effects on patients’ self-image, and adversely affects quality of life, social relationships and employment. Botulinum neurotoxin (BoNT) is the treatment of choice for CD and its efficacy and safety have been extensively studied in clinical trials. However, current guidelines do not provide enough practical information for physicians who wish to use this valuable treatment in a real-life setting. In addition, patients and physicians may have different perceptions of what successful treatment outcomes should be. Consequently, an international group of expert neurologists, experienced in BoNT treatment, met to review the literature and pool their extensive clinical experience to give practical guidance about treatment of CD with BoNT. Eight topic headings were considered: the place of BoNT within CD treatment options; patient perspectives and desires for treatment; assessment and goal setting; starting treatment with BoNT-A; follow-up sessions; management of side effects; management of non-response; switching between different BoNT products. One rapporteur took responsibility for summarising the current literature for each topic, while the consensus statements were developed by the entire expert group. These statements are presented here along with a discussion of the background information.

How Effective and Safe is Botulinum Toxin Therapy in Cervical Dystonia: The Current Stand

“…One has to identify the primary muscles involved as opposed to compensatory activity as well as dose selection by the injector [8,11].…”

“…When examining the patient, dystonic muscles are best assessed when the neck is at rest or in submaximal contraction [8,12]. More often than not, the dystonic muscles will show hypertrophy and are quite prominent.…”

“…summary of involved muscles in the four general planes and some compound movements is seen in Table . Figure . The use of equipment such as electromyography (EMG), ultrasonography, endoscopic/ luoroscopic, and even computed tomography guidance may help to locate the target muscles and thus lessen occurrence of unintended weakness of uninjected muscles [8,[13][14][15][16]. This is discussed in another chapter.…”

“…"oNT has been approved for use in many countries and remains the treatment of choice for CD [8,18,26,27]. Recent studies also provided level " evidence supporting for the treatment of CD [28].…”

“…Scoring at baseline, at the time of peak efect (approximately 1 month after injection) and before retreatment would allow the injectors to assess the outcome of the previous injection and make the necessary adjustment in the dosing and targeting in the next injection cycle [8]. The most frequently used instrument to assess the response to therapeutic interventions in patients with CD is the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) [9].…”