A randomized study of botulinum toxin versus botulinum toxin plus physical therapy for treatment of cervical dystonia

Wei Hu, Valerie Rundle-Gonzalez, Shankar J. Kulkarni, Daniel Martinez-Ramirez, Leonardo Almeida, Michael S. Okun, Aparna Wagle Shukla

Research output: Contribution to journalArticlepeer-review

17 Scopus citations

Abstract

Background: Physical therapy (PT) for cervical dystonia is not well studied, and the underlying physiological effects are not known. Methods: We enrolled 26 subjects comprising of 16 cervical dystonia and 10 healthy controls for normative physiological data. We randomized cervical dystonia patients who reported suboptimal benefits on botulinum toxin (BoNT) injections to BoNT alone (BoNT arm) or BoNT plus PT (PT-BoNT arm). PT-BoNT arm received manual PT on the injection day followed by six weeks of home-exercise program. Home-exercise program comprised of stretching, range-of-motion and isometric exercises. The primary outcome was change from baseline in Toronto Western spasmodic torticollis rating scale (TWSTRS) that was recorded six weeks after exercise program. TWSTRS was video evaluated by blinded raters. We probed sensorimotor plasticity with transcranial magnetic stimulation (TMS) using a paired associative stimulation (PAS) paradigm. Results: TWSTRS score improved (severity 31%, p = 0.002; pain 28%, p = 0.01) and PAS plasticity decreased (p = 0.01) in PT-BoNT arm compared to BoNT arm. PAS values for PT-BoNT arm were found to approach values of healthy control values. Change in PAS measure correlated significantly with TWSTRS change (severity, r = 0.56, p = 0.04; pain, r = 0.61, p = 0.03. TWSTRS disability score only approached significance (p = 0.14) when comparing the two treatment arms. Conclusion: PT is a potential adjunct in patients with cervical dystonia who report suboptimal benefits with BoNT therapy. PT related benefits in cervical dystonia are likely mediated through modulation of sensorimotor plasticity.

Original languageEnglish (US)
Pages (from-to)195-198
Number of pages4
JournalParkinsonism and Related Disorders
Volume63
DOIs
StatePublished - Jun 2019
Externally publishedYes

Bibliographical note

Funding Information:
Drs. Wei Hu and Valerie Rundle-Gonzalez are the recipients of American Brain Foundation Clinical Research Training Fellowship in the Neurological Application of Neurotoxins Funded by the Allergan Foundation.Dr. Michael S. Okun ? Serves as consultant for the National Parkinson's Foundation, and has received research grants from the National Institutes of Health, National Parkinson's Foundation, Michael J. Fox Foundation, Parkinson Alliance, Smallwood Foundation, Bachmann-Strauss Foundation, Tourette Syndrome Association, and UF Foundation. Dr. Okun has previously received honoraria, but in the past >60 months has received no support from industry. Dr. Okun has received royalties for publications with Demos, Manson, Amazon, Smashwords, Books4Patients, and Cambridge (movement disorders books). Dr. Okun is an associate editor for New England Journal of Medicine Journal Watch Neurology. Dr. Okun has participated in CME and educational activities on movement disorders (in the last 36 months) sponsored by PeerView, Prime, Quantia, Henry Stewart, and the Vanderbilt University. The institution and not Dr. Okun receives grants from Medtronic, Abbvie, and ANS/St. Jude, and the PI has no financial interest in these grants. Dr. Okun has participated as a site PI and/or co-I for several NIH, foundation, and industry sponsored trials over the years but has not received honoraria. Dr.Aparna Wagle Shukla ? Reports grants from the NIH and has received grant support from Benign Essential Blepharospasm Research Foundation, Dystonia coalition, Dystonia Medical Research Foundation, National Organization for Rare Disorders and grant support from NIH (KL2 and K23 NS092957-01A1).

Funding Information:
Dr. Michael S. Okun – Serves as consultant for the National Parkinson’s Foundation , and has received research grants from the National Institutes of Health , National Parkinson's Foundation , Michael J. Fox Foundation , Parkinson Alliance , Smallwood Foundation , Bachmann-Strauss Foundation , Tourette Syndrome Association , and UF Foundation . Dr. Okun has previously received honoraria, but in the past >60 months has received no support from industry. Dr. Okun has received royalties for publications with Demos, Manson, Amazon, Smashwords, Books4Patients, and Cambridge (movement disorders books). Dr. Okun is an associate editor for New England Journal of Medicine Journal Watch Neurology. Dr. Okun has participated in CME and educational activities on movement disorders (in the last 36 months) sponsored by PeerView, Prime, Quantia, Henry Stewart, and the Vanderbilt University. The institution and not Dr. Okun receives grants from Medtronic, Abbvie, and ANS/St. Jude, and the PI has no financial interest in these grants. Dr. Okun has participated as a site PI and/or co-I for several NIH, foundation, and industry sponsored trials over the years but has not received honoraria. Dr.

Funding Information:
Aparna Wagle Shukla – Reports grants from the NIH and has received grant support from Benign Essential Blepharospasm Research Foundation , Dystonia coalition , Dystonia Medical Research Foundation , National Organization for Rare Disorders and grant support from NIH ( KL2 and K23 NS092957-01A1 ).

Funding Information:
Drs. Wei Hu and Valerie Rundle-Gonzalez are the recipients of American Brain Foundation Clinical Research Training Fellowship in the Neurological Application of Neurotoxins Funded by the Allergan Foundation.Dr. Michael S. Okun – Serves as consultant for the National Parkinson's Foundation, and has received research grants from the National Institutes of Health, National Parkinson's Foundation, Michael J. Fox Foundation, Parkinson Alliance, Smallwood Foundation, Bachmann-Strauss Foundation, Tourette Syndrome Association, and UF Foundation. Dr. Okun has previously received honoraria, but in the past >60 months has received no support from industry. Dr. Okun has received royalties for publications with Demos, Manson, Amazon, Smashwords, Books4Patients, and Cambridge (movement disorders books). Dr. Okun is an associate editor for New England Journal of Medicine Journal Watch Neurology. Dr. Okun has participated in CME and educational activities on movement disorders (in the last 36 months) sponsored by PeerView, Prime, Quantia, Henry Stewart, and the Vanderbilt University. The institution and not Dr. Okun receives grants from Medtronic, Abbvie, and ANS/St. Jude, and the PI has no financial interest in these grants. Dr. Okun has participated as a site PI and/or co-I for several NIH, foundation, and industry sponsored trials over the years but has not received honoraria. Dr.Aparna Wagle Shukla – Reports grants from the NIH and has received grant support from Benign Essential Blepharospasm Research Foundation, Dystonia coalition, Dystonia Medical Research Foundation, National Organization for Rare Disorders and grant support from NIH (KL2 and K23 NS092957-01A1).

Publisher Copyright:
© 2019 Elsevier Ltd

Keywords

  • Botulinum toxin
  • Cervical dystonia
  • Dystonia
  • Physical therapy

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