Cervical dystonia is the most frequent form of focal dystonia. Symptoms often result in pain and functional disability. Local injections of botulinum neurotoxin are currently the treatment of choice for cervical dystonia. Although this treatment has proven effective and is widely applied worldwide, many issues still remain open in the clinical practice. We performed a systematic review of the literature on botulinum toxin treatment for cervical dystonia based on a question-oriented approach, with the aim to provide practical recommendations for the treating clinicians. Key-questions from the clinical practice were explored. Results suggest that while the beneficial effect of botulinum toxin treatment on different aspects of cervical dystonia is well established, robust evidence is still missing concerning some practical aspects, such as doseequivalence between different formulations, optimal treatment intervals, treatment approaches, and the use of supportive techniques including electromyography (EMG) or ultrasounds. Established strategies to prevent or manage common side effects (including excessive muscle weakness, pain at injection site, dysphagia) and potential contraindications to this treatment (pregnancy and lactation, use of anticoagulants, neurological comorbidities) should also be further explored.
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Objective: To evaluate the effectiveness of a specialized physical therapy (SPT) program on disability in cervical dystonia (CD) compared to regular physical therapy (RPT). Design: A single-blinded randomized controlled trial. Setting: This study was performed by a physical therapist in a primary health care setting. Measurements were performed at baseline, 6 and 12 months in the botulinum toxin (BoNT) outpatient clinic of the neurology department. Participants: Patients with primary CD and stable on BoNT treatment for 1 year (N=96). Main Outcome Measures: The primary outcome was disability assessed with the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS). Secondary outcomes were pain, anxiety, depression, quality of life (QOL), and health related costs over 12 months. Results: A total of 72 participants (30 men, 42 women) finished the study: 40 received SPT, 32 RPT. No significant between group differences were found after 12 months of treatment (P=.326). Over these 12 months both groups improved significantly (P<.001) on the TWSTRS disability scale compared to baseline (SPT 1.7 points, RPT 1.0 points). Short Form 36 (SF-36) General Health Perceptions (P=.046) and self-perceived improvement (P=.007) showed significantly larger improvements after 12 months in favor of SPT. Total health related costs after 12 months were $1373±556 for SPT compared to $1614±917 for RPT. Conclusion: SPT revealed no significant differences compared to RPT after 12 months of treatment on the TWSTRS disability scale. Both groups showed similar improvements compared to baseline. Positive results in the SPT group were higher patient perceived effects and general health perception. Treatment costs were lower in the SPT group. With lower costs and similar effects, the SPT program seems to be the preferred program to treat CD.
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BACKGROUND: Cervical dystonia (CD) is characterized by involuntary muscle contractions causing abnormal postures and/or twisting movements of the head and neck. These motor symptoms can have a major impact on disability. Treatment with botulinum toxin injections aims to reduce motor symptoms, and therefore disability. Despite motor improvements, many patients still experience difficulties with performing daily life activities. To optimize treatment, other factors that determine disability should be identified.OBJECTIVE: To explore and identify clinical characteristics that relate to disability in CD.METHODS: Data on disability, severity of dystonia, anxiety, depression, pain and quality of life of 96 CD patients was analyzed with a principal component analysis (PCA). Multiple regression analysis was performed to determine which components derived from the PCA explain most of the variance in disability.RESULTS: PCA revealed five components (disability, psychiatric features, pain, physical function and severity of dystonia), explaining 74.4% of the variance in disability. Multivariate association between disability and the other components was statistically significant (R(2) change 0.433, F change (4-86) = 22.39, p = .000). Psychiatric features had the largest contribution to disability (standardized beta = 0.555, p = 0.000) followed by pain (standardized beta = 0.232 p = 0.004). Physical functioning (standardized beta = 0.059 p = 0.507) and severity of dystonia (standardized beta = -0.001 p = 0.991) had no significant contribution.CONCLUSIONS: In CD patients, psychiatric features and pain are important determinants of disability. Interventions to reduce psychiatric problems and pain should have a more prominent role in the treatment of CD patients in order to improve disability levels.
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