Vol 55, No 2 (2021)
Research Paper
Published online: 2021-01-20

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Dose per muscle in cervical dystonia: pooled data from seven movement disorder centres

Wolfgang H. Jost1, Artur Drużdż2, Sanjay Pandey3, Bo Biering-Sørensen4, Alexandre Kreisler5, Laurent Tatu6, Christian F. Altmann1, Jarosław Sławek7
Pubmed: 33471347
Neurol Neurochir Pol 2021;55(2):174-178.


Aim of study. Botulinum neurotoxin type A (BoNT/A) injections are the established treatment in cervical dystonia (CD). But clinical practice regarding the choice of muscles into which injections are made varies between centres. Until now, there have been no dose-per-muscle recommendations based on ‘searching the dose’ clinical trial data.

Clinical rationale for study. We therefore examined the dosages under real world conditions at seven international movement disorders centres, using an identical clinical approach.

Results. We examined 305 patients with CD (55.6 ± 13.2 years, 204 female). The most commonly injected muscles were the splenius capitis (84.9%), sternocleidomastoid (80.3%), trapezius (59.7%), levator scapulae (49.8%), semispinalis capitis (39%), and obliquus capitis inferior (36.7%). The mean total dose per treatment session with aboBoNT/A was 652.5 (SD = 285.5), with onaBoNT/A it was 159.5 (SD = 62.4), and with incoBoNT/A it was 173.4 (SD = 99.2) units. The doses injected into each muscle in the ona- or incoBoNT/A groups were between 19.7 and 48.2 units, with the highest dose for the splenius capitis with 49.2 ± 26.0 units. The doses in the aboBoNT/A group were between 69.6 and 146.4 units, and the highest dose being injected into the splenius capitis (139.6 ± 80.7 units).

Conclusions and clinical implications. In clinical trials the doses per muscle are based on an arbitrary decision. In our study, the doses were lower than in other studies, which may be due to the number of muscles per session, the use of ultrasound guidance (and therefore more precise injections), as well as the use of the Col-Cap concept. Our results exemplify everyday practice, and may help as the basis for recommendations and further investigations.

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  1. Bentivoglio AR, Bagella CF, Albanese A. Botulinum toxin in movement disorders. In: Jankovic J, Tolosa E (eds) Parkinson’s disease & Movement Disorders 2015, 6th edn. Wolters Kluver, Philadelphia, pp. : 480–495.
  2. Camargo CH, Teive HA, Becker N, et al. Botulinum toxin type A and cervical dystonia: a seven-year follow-up. Arq Neuropsiquiatr. 2011; 69(5): 745–750.
  3. Castelão M, Marques R, Duarte G, et al. Botulinum toxin type A therapy for cervical dystonia. Cochrane Database of Systematic Reviews. 2017.
  4. Albanese A, Abbruzzese G, Dressler D, et al. Practical guidance for CD management involving treatment of botulinum toxin: a consensus statement. J Neurol. 2015; 262(10): 2201–2213.
  5. Jost WH, Tatu L, Pandey S, et al. Frequency of different subtypes of cervical dystonia: a prospective multicenter study according to Col-Cap concept. J Neural Transm (Vienna). 2020; 127(1): 45–50.
  6. Reichel G, Stenner A, Jahn A. The phenomenology of cervical dystonia Proposed New treatment strategy with botulinum toxin. Fortschr Neurol Psychiat. 2009; 77: 272–277.
  7. Jost WH, Tatu L. Selection of Muscles for Botulinum Toxin Injections in Cervical Dystonia. Mov Disord Clin Pract. 2015; 2(3): 224–226.
  8. Pandey S, Kreisler A, Drużdż A, et al. Tremor in Idiopathic Cervical Dystonia - Possible Implications for Botulinum Toxin Treatment Considering the Col-Cap Classification. Tremor Other Hyperkinet Mov (N Y). 2020; 10: 13.
  9. Tyślerowicz M, Kiedrzyńska W, Adamkiewicz B, et al. Cervical dystonia - improving the effectiveness of botulinum toxin therapy. Neurol Neurochir Pol. 2020; 54(3): 232–242.
  10. Charles D, Brashear A, Hauser RA, et al. CD 140 Study Group. Efficacy, tolerability, and immunogenicity of onabotulinumtoxina in a randomized, double-blind, placebo-controlled trial for cervical dystonia. Clin Neuropharmacol. 2012; 35(5): 208–214.
  11. Comella C, Jankovic J, Truong D, et al. Efficacy and safety of incobotulinumtoxinA (NT 201, XEOMIN®, botulinum neurotoxin type A, without accessory proteins) in patients with cervical dystonia. Journal of the Neurological Sciences. 2011; 308(1-2): 103–109.
  12. Truong D, Duane DD, Jankovic J, et al. Efficacy and safety of botulinum type A toxin (Dysport) in cervical dystonia: results of the first US randomized, double-blind, placebo-controlled study. Mov Disord. 2005; 20(7): 783–791.
  13. Truong D, Brodsky M, Lew M, et al. Global Dysport Cervical Dystonia Study Group. Long-term efficacy and safety of botulinum toxin type A (Dysport) in cervical dystonia. Parkinsonism Relat Disord. 2010; 16(5): 316–323.
  14. Poewe W, Deuschl G, Nebe A, et al. What is the optimal dose of botulinum toxin A in the treatment of cervical dystonia? Results of a double blind, placebo controlled, dose ranging study using Dysport. German Dystonia Study Group. J Neurol Neurosurg Psychiatry. 1998; 64(1): 13–17.
  15. Wissel J, Kanovsky P, Ruzicka E, et al. Efficacy and safety of a standardised 500 unit dose of Dysport in heterogeneous cervical dystonia population: result of a prospective, multicentre, randomised, double-blind, placebo-controlled, parallel group study. J Neurol. 2001; 248: 1073–1078.
  16. Poewe W, Burbaud P, Castelnovo G, et al. Efficacy and safety of abobotulinumtoxinA liquid formulation in cervical dystonia: A randomized-controlled trial. Mov Disord. 2016; 31(11): 1649–1657.
  17. Jost WH, Biering-Sørensen Bo, Drużdż A, et al. Preferred muscles in cervical dystonia. Neurol Neurochir Pol. 2020; 54(3): 277–279.

Neurologia i Neurochirurgia Polska