BACKGROUND AND AIM: Clinical services were severely affected globally during the COVID-19 pandemic. This study aimed to characterize the clinical experience of using botulinum toxin (BTX) injections during the COVID-19 pandemic. METHODS: This is a retrospective chart review of patients who received BTX injections from April 2019 to January 2022. RESULTS: A total of 105 patients received an BTX injections, out of which 76 (72.4%) were men. The mean age of the patients was 47.9 ± 15.1 years. The most common indication for receiving BTX injections was dystonia (n = 79; 75.2%), followed by hemifacial spasm (n = 22; 21%) and miscellaneous movement disorders (n = 4; 3.8%). Focal dystonia (n = 45; 57%) was the most frequent form of dystonia, followed by segmental dystonia (n = 24; 30%). The percentage of generalized dystonia and hemidystonia was 12% and 1%, respectively. Cervical dystonia (44.4%), blepharospasm (17.8%), and writer’s cramp (15.6%) were the most frequent forms of focal dystonia. The miscellaneous group included four patients (3.8%) with trigeminal neuralgia, Holmes tremor, dystonic tics, and hemimasticatory spasm. The mean ages of patients in the dystonia, hemifacial spasm, and the miscellaneous groups were 47.7 ± 14.9 years, 49.2 ± 14.0 years, and 44.2 ± 26.0 years, respectively. The mean BTX dose was 131.6 ± 104.1 U. The mean BTX doses for the dystonia group, hemifacial spasm, and the miscellaneous group were 158.7 ± 105.3 U, 40.1 ± 11.3 U, and 100.0 ± 70.7 U, respectively. CONCLUSION: Most patients in our cohort had dystonia, followed by hemifacial spasm. Among the patients with dystonia, most had focal dystonia, with cervical dystonia being the most common movement disorder. The data obtained in our study is important to increase awareness of the effectiveness of BTX injections in patients with chronic disorders.
Keywords: Botulinum toxin, COVID-19, dystonia, hemifacial spasm, movement disorder
|How to cite this URL:|
Nandwani S, Mishra A, Majigoudra G, Pandey S. Botulinum toxin injections during the COVID-19 epidemic: A retrospective chart review. Ann Mov Disord [Epub ahead of print] [cited 2023 Mar 23]. Available from: https://www.aomd.in/preprintarticle.asp?id=368618
| Introduction|| |
Botulinum toxin (BTX) is produced by the anaerobic bacteria Clostridium botulinum. It is a type of bacterial exotoxin that targets intracellular substrates. BTX acts at the presynaptic cholinergic nerve terminal by cleaving and inactivating soluble N-ethylmaleimide-sensitive-factor attachment protein receptor or SNARE proteins. Therefore, it inhibits the release of acetylcholine, which suppresses muscle contractions and results in local weakness and paralysis.
Eight strains of C. botulinum, producing eight immunologically distinct serotypes (types A–H), have been identified. These serotypes contain botulinum neurotoxin complexes with several neurotoxin-associated proteins. Serotypes A and B have been approved for human use. Currently, there are four FDA-approved BTX formulations: three types of BTX type A and one type of BTX type B. The available BTX type A formulations are onabotulinumtoxinA, abobotulinumtoxinA, and incobotulinumtoxinA, while the only currently available BTX type B formulation is rimabotulinumtoxinB. BTX is currently being used for several medical and aesthetic conditions. The first therapeutic use of BTX was to treat strabismus in monkeys and humans., Regular BTX injections are the mainstay treatment for cervical dystonia (high-quality evidence) and blepharospasm (moderate-quality evidence), with randomized controlled trials showing that BTX injections improve dystonia and quality of life. Hallett et al. evaluated the efficacy of BTX in movement disorders, and the level of its efficacy for the treatment of hemifacial spasm was designated as B (probably effective). Due to strict lockdown rules worldwide during the COVID-19 pandemic, several patients with disabilities were unable to access their required doses on time., Although our institute continued to provide services, many patients were unavailable to avail the same due to the lockdown. Here, we present the data from our BTX clinic during the COVID-19 pandemic.
| Methods|| |
We conducted a retrospective chart review of patients who received BTX injections during the COVID-19 pandemic (April 2019–January 2022) at our hospital. We included all patients consecutively admitted to our hospital for BTX injections during this period. All participants were informed about the procedure and written consent was obtained before the injections. All patients had received onabotulinumtoxinA. The demographic profiles and medical records of the patients were retrospectively collected from the hospital registry. All the data were analyzed using the SPSS software (ver 19.0). Statistical analyses were performed using descriptive analysis. Descriptive statistics are calculated as mean ± standard deviation or median (mean–max), and frequency and percentage are calculated as appropriate.
| Results|| |
Demographic details of the patients
A total of 105 patients received BTX injections, out of which 76 (72.4%) were men. Patients were divided into the following three broad categories: dystonia, hemifacial spasm, and miscellaneous. The overall mean age of the patients was 47.9 ± 15.1 years. The mean ages of patients in the dystonia, hemifacial spasm, and the miscellaneous groups were 47.7 ± 14.9 years, 49.2 ± 14.0 years, and 44.2 ± 26.0 years, respectively.
Spectrum of movement disorders
The most common indication for BTX injection was dystonia [n = 79; (75.2%)], followed by hemifacial spasm [22 patients (21%)] and miscellaneous disorders [n = 4; (3.8%)] ([Figure 1]). Focal dystonia [n = 45; (57%)] was the most frequent form of dystonia, followed by segmental dystonia [n = 24; (30%)]. The proportion of generalized dystonia and hemidystonia was 12% and 1%, respectively ([Figure 2]). Cervical dystonia (44.4%), blepharospasm (17.8%), and writer’s cramp (15.6%) were the most frequent forms of focal dystonia. The frequency of the types of focal dystonia is described in [Table 1]. Craniocervical dystonia (70.8%) was the most frequent form of segmental dystonia. The frequency distribution of segmental dystonia is described in [Table 2]. The miscellaneous group included four (3.8%) patients with trigeminal neuralgia, Holmes tremor, dystonic tics, and hemimasticatory spasm.
Number of botulinum toxin sessions and doses for various disorders
The median number of BTX sessions at our clinic was four. The median number of sessions was the highest for hemifacial spasm (median, 7) among all the groups ([Table 3]). The mean BTX dose was 131.6 ± 104.1 U. The mean BTX doses for the dystonia group, hemifacial spasm, and the miscellaneous group were 158.7 ± 105.3 U, 40.1 ± 11.3 U, and 100.0 ± 70.7 U, respectively. In the focal dystonia group, the mean BTX doses for cervical dystonia, blepharospasm, writer’s cramp, and oromandibular dystonia were 200.5 ± 101.3 U, 37 ± 8.1 U, 47.85 ± 9.0 U, and 116.6 ± 28.86 U, respectively. The mean dose for craniocervical and craniocervicobrachial dystonia was 228.6 ± 64.2 U.
|Table 3: Mean and median number of sessions for movement disorder groups|
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| Discussion|| |
Healthcare systems have faced several challenges during the COVID-19 pandemic. Strict lockdowns imposed by governments have been a major challenge for the health sector during this period. Many patients were unable to access healthcare services due to these strict lockdown rules. While many patients across the country could avail telemedicine support, the same was not possible for patients receiving botulinum therapy. BTX is the treatment of choice for focal dystonia and other movement disorders. In our study, most patients had dystonia, followed by hemifacial spasm; cervical dystonia was the most common form of focal dystonia. In addition, the data from different BTX studies demonstrate similar results.,,, Some studies have shown a higher proportion of patients with hemifacial spasm than dystonia., The mean onabotulinumtoxinA dose used in our study for various indications was similar to that found in a national Indian survey; however, a slightly higher mean dose was used for cervical and craniocervical dystonia in our study. The maximum number of sessions was by patients with hemifacial spasm, followed by dystonia. Patients with hemifacial spasm received maximum repetitive injections, which could be because of the severity of their disability or that they had a good response to BTX. However, despite frequent visits by patients with hemifacial spasm, the maximum number of visits were by patients with dystonia (75%). This may be because worsening of dystonia is more painful and leads to a decrease in the quality of life. A previous study has shown that pain perception is higher in cervical dystonia. In addition to pain, psychiatric comorbidities such as anxiety and depression are higher in patients with dystonia than in healthy people,; therefore, patients with dystonia have a poor quality of life. Moreover, the COVID-19 pandemic has exacerbated anxiety and depression among populations. A study showed that 66% of the patients regarded receiving BTX injections as more important during the COVID-19 pandemic compared to that in the pre-COVID-19 era. Despite these promising findings, our study has several limitations such as its retrospective design. Furthermore, no measurement scale was used to describe the severity of disorders. In addition, we did not have the data for the delay in patients receiving BTX injections during the pandemic. However, we believe that our sample size was large enough, which emphasized the strength as well as significance of such a study during the pandemic.
| Conclusion|| |
Our study showed that most patients with dystonia visited our clinic for BTX injections, despite the restrictions imposed during the COVID-19 pandemic. In addition, our study reveals the high percentage of patient disabilities due to movement disorders. Furthermore, our study highlights the continued need of these patients during the pandemic and emphasizes the importance of access to heathcare for such chronic disorders.
All authors have contributed equally in data collection and drafting the manuscript.
This is a retrospective chart review, so ethical approval was not required.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Department of Neurology, Academic block, Room no 503, Govind Ballabh Pant Postgraduate Institute of Medical Education and Research, New Delhi - 110002
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]