So, we have our last lecture of the afternoon, and we're going to be talking about cervical dystonia. And it is my pleasure to introduce Dr. Mark Clafter, D.O. So, he's actually a neurologist who graduated from the College, I'm sorry, the Chicago College of Osteopathic Medicine, and then did his neurology residency at the Cornell program. And then he went on to complete a fellowship in electromyography at the Albert Einstein College of Medicine. In addition to his subspecialty in EMG, he is a nationally recognized speaker for botulinum toxin, or Botox, for both the management of spasticity and dystonia. So he also has a practice that helps patients with movement disorders, such as Parkinson's disease. He's one of the founding members of the Neurological Services of Orlando, and he has served as a president of the Florida Society of Neurology. He was recognized in the Orlando Magazine as one of Central Florida's best physicians for his thorough and compassionate approach to care of adult neurology patients. So please join me in welcoming Dr. Clafter. Thank you so much for the kind introduction, and thank you for having me. You might recognize me. Some of you might remember from lunchtime. Some of you were at the lunchtime lecture. We talked about limb spasticity, and this kind of dovetails with that. In fact, a lot of the content today dovetails with the entire lecture series. I'm going to be talking about cervical dystonia, but we're going to hit on topics related to pain. And I have a series of slides that goes over the mechanism of how botulinums actually reduce pain. It's not just reduction of spasms and spasticity and malpositioning. It actually has a pain mechanism. Let's move on to the next slide. Is there? Oh, great. I'll advance. Green. All right. So we're going to do the clinical presentation of cervical dystonia and the mechanism of pain. Having a substantial discussion on pain, and I'll emphasize that, especially in light of some of the lectures that we've had today, kind of tie that together. We'll do treatable muscles that are involved in cervical dystonia. Which ones to go for, how to go for them, the doses that are appropriate, and then the different combinations. I also want to talk about non-botulinum treatment strategies. This is not a pharmaceutical-sponsored meeting. This is purely clinical. Remember, this is for you, not for me. This is so that you can become a better clinician, so you understand your patients better, take better care of them. With that stated, we'll have a Q&A at the end. But you know, if you want to interrupt me, by all means. In fact, if you want to talk about anything related to botulinum injections. Some of the slides that I've used have to do with botulinum injections for other reasons, not just for cervical dystonia. I do inject for the range of pathologies. Limb spasticity, limb dystonia, facial spasms, migraines, blepharospasm, cervical dystonia, and even some other indications. We're going to talk about the relevance of follow-up and then adjustments over time. We don't just shoot and back off. We actually follow them up and make some adjustments to help the patients. Before we go on to the actual anatomy, and unfortunately the slides are a little bit blurry, but I'm going to point out what muscles we're talking about. I want to go over with you, actually, the concept of dystonia, as opposed to malpositioning. So 82%, four out of five patients, have cervical dystonia that's rotatory. And almost half have some sort of head tilt. It's not just malpositioning. It's the condition that leads to that. The concept of dystonia isn't just malpositioning. It's the pulling or irrepressible movement in a direction that's abnormal. The concept of dystonia in general is overflow of feedback such that you're going into a wrong position. I'll give you an example. Somebody can have a head tilt because they have a cervical spinal injury or structural abnormality within the cord or in the spinal canal. But with true cervical dystonia, there's not just the head's position like that or rotated, but there's actually the pull. How do you demonstrate this pull? Simply, you observe the patient and you see if they're starting to turn it. You have them close their eyes. They could be turning their head. They may be positioned like this in the chair and kind of sit with their leg crossed often so it's socially acceptable that they're slightly tilted. And that may be associated with the head tilt itself. You distract them, maybe have them do finger taps, have them walk up and down the hall, and then you'll see the head starts to turn a little bit. It may not even be readily apparent. Many of my cervical dystonia cases are seen by other neurologists. They were diagnosed with a central tremor involving the head, a no-no tremor. But when you have them close their eyes, that no-no tremor doesn't become a tremor, it just kind of turns. Because what's happening with cervical dystonia is not just the position being abnormal. There's this movement in this direction. Here I'm having a torticollis to the right. And what is subconsciously happening over the course of months or years is subconsciously, socially acceptable, boom, you're moving your head in the midline. Not even thinking about it anymore. That's what creates the tremor. That's called a dystonic tremor. Sometimes it's very tricky to differentiate a dystonic tremor from a just malpositioning or a central tremor. But the difference is, if distracted, eyes closed, finger taps, walking, whatever it is, have them do math. I'll often have them close their eyes, maybe hinting at it, and then you give them a math problem. Something that doesn't have to be too frustrating, but something in which they're concentrating. Spell the word world forward, now spell it backward. Then they have to think about spelling it backward. And because they're concentrating on that, the head's kind of turning. So let's move on. I'm going to talk about the muscles, and we'll get to all of these, but I do want to discuss how posterior cervical muscles are very important. Splenius capitis is going to be a major player. Levator scapulae is a rotator and as a shoulder elevator. Longissimus, as the little cousin of splenius capitis, and splenius services, lower down. Those are major players. Before we go on, I want you to think about the bulk of muscle that you have in your neck. Most of it's back here. Yeah, it's the traps, of course. We all know the traps. There's still a ton of stuff. You know this. This is week one of anatomy class. When you're dissecting that cadaver, they're face down, you're starting at the neck. I remember tons of muscles. We never thought we were going to have to worry about those. Let's get through those so we can get to the other ones that we're going to be thinking about. Well, now's that time. We're thinking about those muscles in the posterior cervical region. Contralaterally for rotation, sternocleidomastoid, right? It's obvious. It's low-hanging fruit, so you're going to be thinking of injecting that. You're going to be excited because you see that muscle, you want to inject it. Remember, that's one muscle, and we're going to talk about some pitfalls of giving too much into the sternocleidomastoid. Most patients in whom I'm taking over the care of a cervical dystonia patient because things aren't working out perfectly well, I'm lowering or adjusting the location of the sternocleidomastoid injections and emphasizing muscles posteriorly on the opposite side, on the ipsilateral side to the rotation. And briefly, a couple of other muscles I don't want to talk too much about, okay? But basically, anterior scalenes will pull you on the opposite direction, and upper trapezius, very weak rotator to the contralateral side. Who would have thought, right? You know this if you do EMGs. I usually give very small amounts into the trapezii. Trapezii are overrated. Splenius capitis is underrated, okay? Levator scapulae is kind of underrated. It's under the traps. A lot of people think that they're injecting the traps. You put the needle in, kind of quiet. You go further down, it really starts getting loud because that's the levator scapulae, okay? We're going to talk a little bit about head tilt, and we'll go a little bit more into the anatomy and the locations, but I just want to give you the positions just for now. On head tilt, right over here, there's a dichotomy in what head tilt is. Most of these muscles that rotate in that direction also tilt in that direction. So think of all the players that I told you about, splenius capitis, splenius cervicis, longissimus, levator scapulae, they all tilt in this way. They anchor up here except for splenius cervicis. But there's another concept. This is kind of an abstract concept for a lot of people. It's head shift, okay, shift, all right? So you'll see patients with head shift and rotation the opposite side. Sometimes you see that. That's pretty tricky. The head shift is because there are some muscles that aren't that involved in tilting the head this way. You can get head shift and tilt in the same direction, don't get me wrong. But just be on the lookout for another series of muscles which is also underrated, which is the scalenes, okay? The scalenes do not mount into the head. These other muscles mount into the head, okay? And because they do, they're head tilt. And because scalenes are not mounting into the head, they're head shift, okay? So that's an important distinction and a very common mistake that's made. A next position that I want to tell you about is anterocolus, which is just a quarter patients. And barely more than a quarter is retrocolus. I'll start with retrocolus here because retrocolus, these are the same muscles we just talked about, okay? Spineus capitis, splenius services, longissimus, levator scapulae, trapezius to some extent, and one more muscle. There's only one more muscle that's not a rotator. It's an extensor. It's actually a slight rotator if it's unilateral. But all these muscles I just told you about that are rotators, posteriorly, activate both sides and they're extensors, okay? One more. That's semispineus capitis, okay? And we'll talk about nailing it, getting that muscle, and getting the other muscles so that you can get in there and get the accurate muscles, okay? Retrocolus, all right? So less than a third of patients have retrocolus as part of their disease. Now you think about, wait, I'm doing the math here. This is over 100 percent because a lot of people have combination movements. And then the absolute most frustrating dystonia that I don't even, I bemoan when a patient comes in like this because I feel bad for them because I can't really help them, which is anterocolus, okay? Two kinds of anterocolus, too, by the way, all right? Two kinds of anterocolus, this one and this one, all right? So this one, ain't much you're going to do, okay? Many people who have anterocolus by diagnosis actually have anterocolus not as a dystonia, but just as a malpositioning. Perfect example, Parkinson's patients. It's not that dystonia with Parkinson's that's anterocolus is usually not a dystonia. It's just a matter of their motor dysfunction and they're actually developing a contracture. And that's not responsive usually, Parkinson's patients. Now you're going to be, you would inject muscles retro esophageal to get to those. You're not going to inject those. You can do the anterior scalenes, but there's something called the carotid arteries right there. And then you could do the sternocleidomastoid. And that's usually where people go with disappointment, with disappointment. The sternocleidomastoid is one of the most complex muscles for injecting. If you're a botulinum injector, I'm not going to say Botox injector, Botox sponsored me over the lunch break and I do, majority of my injections are Botox. Very comfortable with that, but botulinum because there are others that I also use for different situations. So a distinction that's really important to make on the sternocleidomastoid is what it does depending on what part of the sternocleidomastoid. So you've got the lower portion that's more directed toward forward flexion. Well that's terrible because you've got the esophagus underneath that and you also got the carotid artery. But you've got the upper part, not so bad. The upper part is a very active part and that's your forward shift. You can even do this on yourself. Feel back here, get that sternocleidomastoid, trace it up, and then shift forward and there it is, activating. That's forward translation. That also is associated with rotation of the head. Rotation of the head, contralateral. When you turn your head and forward shift, guess what? That thing is coming out big time. We'll talk about techniques how to hit that. And then of course there's combination. And this is a very, very common combination. This is really the majority of patients. So this is larger. You can see the muscles that we just talked about now should be able to transmit. Hopefully you can. But in this case, you can see that there's right torticollis. Think about all the muscles we just went over. Left sternocleidomastoid, right up here, not there. You can inject there if you want, esophagus is underneath. You can do upper trapezius, it's a little bit elevated, not much, way overrated. You can do anterior scalenes, of course carotid arteries there. By the way, the question of ultrasound comes up. You can do anterior scalenes, that's when, not a carotid ultrasound, just ultrasound. Vascular structures, that's where ultrasound comes in. And then ipsilaterally, these are the biggies, splenius capitis. I'll often give like 35%, 40% of the overall injection of medicine into the splenius capitis. It's a strong muscle in terms of rotation. It is truly the major rotator. And I'm telling you that from 25 years of experience. Splenius services goes along with it. And then levator scapulae, okay? Levator scapulae, even though that side's elevated. The levator scapulae does elevate the scapula, but it also rotates ipsilaterally. And I would add to that, guess what? You can parse out the scalenes, posterior scalenes, posterior scalenes. Middle scalenes is a shift. It's almost a pure shift. Anterior scalenes, which we don't inject, is a shift and rotate contralaterally. Middle scalenes is a shift. Posterior scalenes is a shift and slight backward rotation. And then also longissimus, okay? And then we have the lateral collis, the different muscles that can be injected that tilt the head to that side. Now, before we go on, I'm going to say you have to prioritize what you want to do. Because you often don't have to give the same muscle group on each side. As a rule of thumb, unless somebody's getting very low dose and slash or large muscles, I'm not injecting the same muscle on each side. That's where head drop comes in, okay? And with head drop comes pain, too, by the way. So one of the most common reasons for post-injection pain is head drop. Why is that? Because they're straining to keep their neck up. It's a different kind of pain. Fortunately, that's transient, okay? All right. Pain is a common presenting symptom. And it does respond to treatment with botulinums. Not the head drop pain, but the pain inherent to this malpositioning. It's absolutely an abnormal occurrence. This positioning, you lived, say, 45 years without this problem. 45 and a half, you start to develop it. You're presenting to your doctor at 47. Eventually, you get to see a neurologist at 49, 50. He or she is finally injecting. Okay? You know, five years, you've had this abnormal positioning that the majority of your life you didn't have. Of course, that's going to hurt. What I'm going to present to you is a series of slides. I presented to the American Academy of Neurology in July of 2009. Botox was not FDA approved yet for migraines. I had been injecting Botox for migraines since 99. We knew it wasn't for relaxation of the muscle because if it was, tension headache would have been the one, okay? But tension headache doesn't really respond. How about low back pain? It was a failure, New England Journal of Medicine right around that time. So there's something else. We were looking at neurochemistry. We all know how that went. October of 2010, Botox was FDA approved for chronic migraines and it works. It really works. The next series of slides that I'm about to show you apply to that. They apply to cervical dystonia and they apply to what Dr. Kramer was talking about in terms of pain for Parkinson's. When you have a local area of pain, I don't care if it's a cut, you got bashed somewhere, you have cervical dystonia, you got migraines, it can become chronic. But this is where it starts. Response to a stimulus, the secular release of mediators, they stimulate nociceptors. You know that, nociceptors. So it's there. With that is an ionic change, potassium ions, okay, and other ions localized that result in an increase in excitability of the peripheral nociceptors, right where that source is, okay? As a result of that, peripheral sensitization goes into the spinal cord and then there's a release of vasoactive mediators. Substance P, this is CGRP, I'm sorry it's not transmitting, it's blanched out. That's CGRP, Substance P, Neurokinin A. Back then, this is still 2009, we kind of were like balanced on CGRP, Substance P, Neurokinin A. CGRP has turned out to be a major player and we know that. We know that because several CGRP antagonists are now used to treat it. Now the wheels are turning. Now you're thinking, this is why it works for chronic migraines. It also works for cervical dystonia, the pain associated with dystonia. Then there's antedromic stimulation, axon potentials travel both centrally and peripherally invading the same branch and as a result, you get this vasodilation that occurs, all right? This warmth there associated with more inflammation, more release of more Substance P. Now, calcitonin gene-related peptide, dilation of arterioles, plasma leakage. Now we got this whole thing that's going on. Brain's going to start taking notice, for sure, okay? Central sensitization. Now the brain is aware of this. May have been aware of it on some level, but now it's reaching a point where there's this chronic feedback loop that keeps on going on and on. Your body is reacting to that. Your brain is reacting to that because it hurts. You're appreciating the hurt. You're then tensing up further and you're propagating more pain and, of course, the malpositioning of cervical dystonia. So where do botulinums fit in? Well, basically what they do is they inhibit the inflammatory mediators, okay? Inflammatory mediators. Yes, they have a relaxing effect, obviously help with malpositioning, but if it was because of antispasm, loosening up the muscle, then data would have been strong for a chronic, for a tension headache, for low back pain, for all these other pain syndromes that back in the 90s, early 2000s, we thought were going to pan out and didn't, okay? By 2008, 2009, we already knew. So that's the mechanism, okay? That's the mechanism. Hello? Bye? All right. Cervical dystonia anatomy. We started to go over the anatomy on a live person. And I know most of you know the anatomy, but I'm just going to point it out here. On a cutaway level, splenius capitis, posterior cervical, to the traps, just lateral to the semispinalis capitis. Longissimus comes right off of that mastoid, okay? So if you turn your head, it's kind of hard to feel because it's a really small muscle. In a patient with cervical dystonia, it feels like a rope, okay? In women, you usually don't have to push very far to get to it. You go right through it because it's For those of you who are musicians like me, I like to listen to the EMG tone. It's high-pitched because it's a smaller muscle. Lower muscles have a lower tone, okay? So you can go right through it. In a bigger dude who's got big traps, you have to go a little bit in. But basically, a couple of finger breaths down from the mastoid and one back. And then you can hit it and then you can angle it, okay? We'll talk about dosing and how to hit up the muscles and be specific where you want to go. Sternocleidomastoid, we know the anatomy there, and then the scalenes, okay? And then same thing, just from back, from behind, you can see the semispinalis capitis right underneath the traps. The traps right here, and the last time I was in a cadaver lab was in August. The traps up there are like tissue paper, okay? Right up here. It takes almost nothing to get into semispinalis capitis, okay? This is where the bulk of the traps are, as you know, okay? But semispinalis capitis, just go either side of the, for retrocollis patients, either side of the spine and you're going to hit it. And that may be, if somebody's primarily retrocollic, you may want to go bilateral on that muscle, low dose, so they don't have head drop, okay? And then splenius capitis, splenius cervicis, okay? All right, levator scapulae right there off the scapula. There's so many choices of levator scapulae. You can go low, just be careful, you don't want to drop a lung. But you're going to go through the trapezius. I usually go through the trapezius very slowly, especially the first time, okay? Very slowly. Quiet, quiet, quiet, quiet. You're in there. And then I may angle it a little bit, okay? We talk about dilution, you'll see what I mean when I say repositioning and angling it. Kind of giving a fan-like distribution, as long as you're hitting up loud areas. Considerations for muscle selection, determine which muscles are dystonic. Here's a really important tenet to be aware of, versus those that are just compensatory. I can't tell you how many, I have hundreds of Parkinson's patients. It's the most common thing that I see for follow-up. I'm in practice in the same clinic for 25 years. You take good care of Parkinson's patients, you keep them alive, they accumulate. Migraines, I try to get the better, so they don't need me anymore. They're young and they're healthy, I don't want them to have to need me. If they need me, they're back, by all means. But for chronic neurological diseases, Parkinson's disease is super common. And I will tell you that many patients who have this tendency toward anterocollis, which isn't necessarily dystonic, they have really tight traps because they're working to get those neck muscles up, the head up, all right? And I give them exercises to have them raise their arms above their head and, you know, focus further away. And they can do these things like dozens of times a day to fight it. You've got to fight it, you've got to fight it. And that's different than a dystonia. But that's a pseudo-dystonia. And if you inject those traps, lights out, baby. That chin's on the chest for good. Major problem, okay? And there are other reasons why people can have anterocollis as part of a dystonic syndrome. But be aware of the muscle that is tight to try and compensate for the problem. Another example is, hey, this really hurts over here. Now, they're rotated to the right. What? Why does it hurt so much there? Because they're fighting to get it back into that side and they're straining to get that back there. You inject that, guess what? They're going even further, okay? Resist the temptation of chasing the pain. This is where guidance techniques are really important. Use your EMG. The EMG is going to tell you what's loud. And I always tell the patient, I know you're a good patient. I get it. This is where you are just supposed to let it all happen, okay? You don't have to keep still for me. I want to see naturally what's happening in your body all the time so we can treat it, okay? Select muscles that might yield a noticeable improvement after the first treatment. So I purposefully stayed away from obliquus capitis inferioris. It's a higher order muscle that we sometimes inject, all right? If you know the anatomy, you go to the Atlantis, okay, C2, just to the right, one finger breath over, one finger breath up. Not even. Half a finger breath. If you've got acromegaly, a third of a finger breath. Anyway. But, you know, it's barely there, okay? That's a good muscle to inject for rotators that are refractory to everything else. You're not going to start with obliquus capitis inferioris, okay? So you're going to go with the muscles, go with splenius capitis. You can't find longissimus? That's okay. Dullivator scapulae. Splenius cervices. Sternocleidomastoid. Perfect. Yeah, opposite sternocleidomastoid, okay? Start. Starting at too low a dose might yield a less than expected response. People get very trepidatious. This is not a limb, folks. You're injecting in the neck. We haven't even gotten into the major problems of injecting in the neck. But this is where we talk about tailoring it to your patient, all right? So the standard dilution is 200 units per 2 mL. I like simple math. If you do simple math, you've got staff coming in. They're always new. Everyone's, every patient for every disorder, 100 unit per 1 mL. That's beautiful. Math is simple that way. 100 units per 1 mL for Botox. And for Xeomin, okay? Although it's not interchangeable, the math is equivalent, okay? So for that. And then myoblock we'll talk briefly about, and we'll also even touch on briefly dysport because the math is different on those. But for Botox and Xeomin, I do 100 units per 1 cc. That way, no matter who's drawing it up for me, they're drawing it up the same, okay? That's very concentrated. How are you going to get it through the muscle? The fan-like distribution. As long as you're getting loud muscle input from each of these muscles that you're injecting, you may inject it in a fan-like distribution if you're injecting a large muscle, especially like the extremities. But even the cervical muscles, because it's loud, you're going to hear it. And I'll give you another trick and tip is if you inject it up here in the cervical region for the sternocleidomastoid, and it's concentrated, those are the two ways that you reduce this initial 19% incidence of dysphagia. It was 19%. I haven't seen dysphagia in like over 5 years. 19% incidence of dysphagia of the initial cases because they were going all over the sternocleidomastoid, okay? Stay away from that. Go concentrated and angle it up, okay? And you'll hear it loud. You're good. If you need to have them enhance it, fine. All right, so those are really some tips and tricks that are really important, okay? So and then lower dose to reduce the occurrence of dysphagia. Adult patients with more than one indication, the FDA approved is 400 units. Off-label is over 400, okay? This is not a, this is a CME lecture. Many, many, many people receive over 400 units. Not kids with cerebral palsy, big mistake. You know, you're 85 pounds, you're 80 pounds, you're getting over 400 units, we got a problem there. That's too high. But you're a big dude, you're 240 pounds, and you have stroke, spasticity, upper limb, lower limb, that might not be enough, okay? I don't inject over 400 units in anyone in my practice for cervical dystonia, but I do have some patients with cervical dystonia receiving 400, and even women. In those cases, I'm not doing bilateral same muscle, just one side. Understanding of the standard EMG techniques, that's self-explanatory, we went over that. And then clinical improvement, about two weeks, and then you have them follow up, okay? And then the warnings, we went over these over lunch, but I will briefly mention them, because if they have neuromuscular disorders to begin with, that can be worse, alright? And that includes ALS, and myasthenia gravis, or if they're taking medicines that are neuromuscular blocking agents. Dysphagia, we've already actually kind of hit on that, okay? The breathing difficulties are often dose-related, we don't get into that problem if we don't give too much, and as far as the dysphagia goes, we just talked about techniques to circumvent that problem. And then the transmission of viral diseases, that was thought to be potentially a problem, it's not. We haven't seen that. Now we're talking doses here, okay? This is important, this is where the rubber meets the road, how much? 236 is the mean Botox dose, that's pretty good. That's pretty close. A lot of my patients get about 200 to start, and they may, and this is the clinical trials, okay? And the range in the trials was 198 to 300. But, you know, 236 is a pretty good amount. I will try to keep it under 200, just because you don't want to crack another open, but hey, sometimes they need 300, sometimes they need over 300, okay? And then you can see the doses now. Levator scapulae, a healthy amount. Scalenes, less. Sternocleidomastoid, probably too much. I have nobody in my entire practice getting 800 units. Trapezius, not very much, way overrated. Longissimus, underrated. That might get 40 units. So splenius capitis might get 70, and splenius cervusus, 30. Something like that, okay? Between those two, a good, healthy amount, okay? So that's an example of somebody with spasmodic torticollis, the rotatory, because that's far and away the most common pattern. The brands are not interchangeable, as I mentioned, and these are the ones, okay? So onabotulinum, toxin type A Botox, by Allergan, AbbVie bought them. Abobotulinum toxin, Dysport. Dysport is also known as the British Botox, came out in 1989, it's like Botox, UK, United States, 1989, both approved, and the ratio there is 5 to 2, okay? 5 to 2. So Dysport 500 units is the functional equivalent, and again, they're not interchangeable technically, but in practice they often are. 500 units is 200 of Botox, okay? Xeomin is simple. I love simple. Simple math is beautiful, okay? 100 units. Xeomin has the advantage of being available in 50 for facial spasm. I inject a lot of faces. Very rewarding thing to do, inject somebody's face and reduce their spasms so they can look normal for the world and they can basically drive their car. But that comes in 50s, so that's the advantage of Incobotulinum toxin, Xeomin, which has been around since about 2009. And then Remabotulinum toxin, type B. If they seem like they're failures, it's like you think they're rejecting the medicine. Shift to B, okay? the math is horrid. The math is horrid. They really, they forgot, they're dealing with movement disorder specialists. Movement disorder specialists are usually artsy people, and once you start with math, that's it, they're out. So it was a, you know, see I'm already struggling with it, and I use it quite a bit too. 2,500 units per 0.5 cc, 5,000 units per 1 cc, pre-mixed, right? We thought pre-mixed is awesome, pre-mixed is painful, because they put a stabilizer in it, it's not saline, so it actually burns more. So when you inject, say, myoblock, it's injected for cosmesis, for example, you inject like on the forehead, they hate you, okay? So I'm not a huge fan, as you can tell, for those reasons. I have staff mixing it anyway, drawing it up, okay? But it's pre-mixed, they miscalculated on a couple of fronts. But it does work, and it's a great option for patients that you could swear, Botox, you're getting antibodies. There used to be that place in Worcester, Mass., that charges crazy amounts of money for genetic tests and whatnot. There used to be a test, that lab ran it, and they don't run that lab test anymore, because the second batch of Botox, there was an 89 batch, and then they reformulated it in 97. And the 97 to present batch is not very antibody-laden. There are still some antibodies out there, so if you could swear that they're failing, or if they're fading, fading, fading, fading, and because it worked, now it doesn't work anymore, maybe they're developing antibodies, that's a time to switch to B, okay? Or if somebody has absolutely no confidence in the Botox injections, they've seen somebody else in your town, and you want to save face for them, and you want to inject, but you don't want to make that other doctor feel bad by injecting Botox again and just using different technique, you could switch over to Myoblock, all right? So you're saving face on that front, because it's the same type of medicine, okay? So but there are different strategies, different reasons to go over to the Bs, but almost always I'm in between Botox and Xeomin. A lot of the insurances are asking for a switch to Xeomin. Really? Switch to Xeomin? Why do we have to switch to Xeomin? Right? Guess why? It's a little cheaper, yeah. Honestly, I think it's just about as good anyway, but you know, it is, it is, but they're not pushing that yet. The emphasis is on the word yet. I don't know the difference between Xeomin and Dysport, but I know it's cheaper than Botox. Dysport actually often ends up wasting more money, because you have to do the 200, the equivalent of 200, okay? So what if you want to inject the equivalent of 250 or 300 of Botox, then you got to go through two of the Xeomin, which is the equivalent of 400, a thousand of, not Xeomin, of Dysport, okay? So yeah, it's because of cost. I also wanted to say something about cost while somebody brought it up. It's really worthwhile mentioning. I don't buy any of this stuff. I have insured patients. We go through the insurance, got to get it approved by the insurance, they dictate. But if you buy the medicine, you can bill for it. 19 times out of 20, you'll probably get repaid for it. Even if you get a prior off, there's always a chance that you don't get paid. Well, you just injected 300 units of Botox, that's whatever, 640 times 3, do the math, and you didn't get reimbursed for the money that you put in for the medicine to help someone. That person is gone, and you're out 2,000 bucks for being a nice guy. Just something to think about. Not a lot, but every now and then it was happening, okay? So people have lost hundreds of thousands of dollars in buying and billing, because it takes a while to pick up on the pattern. Tons of money's coming in, because you're billing and collecting for the medicine, but you'll realize here and there it's not coming in. So for the Medicare patients, I'm doing those at the hospital, the neurodiagnostics unit, and the neurodiagnostics unit, they charge obscene amounts. The hospital pays extra charge fees for a hospital fee, because a hospital's a special place, and then they don't collect every time, but that's worked into the math. They accept that they're not going to collect every time, but they make so much more on the other cases that they do collect on. So their math works, okay? But at the end of the day, we're helping people, okay? And it's a beautiful thing. The most frequent side effects are swallowing difficulties we talked about, pain, and sometimes neck weakness. We talked about ways to reduce all of these, and the neck weakness and pain post-injection go hand in hand. The pain sometimes post-injection, immediately after injection, can happen, okay? That's because the needle hurts, okay? All right. PT, range of motion exercises, consider heat. You guys know this better than I do, probably. Warm things up, they're more malleable. Manipulation, that includes manipulation by the therapist, but also physical therapy, I mean also osteopathic manipulation, and I have referred patients for that. And then let's not forget other forms of exercise, which we'll get to in a moment. You reassess them, have them come back one month, okay? Range of motion, ask them about those side effects, and then adjust the dose. Let's talk a moment about other medicines. I do have some patients, having been injecting some of the patients since the late 90s, and they've kind of plateaued, and they're perfectly happy, and they find, you know, it's not so bad anymore. Do I have to come in every three months for injections? And I had already put them on, I was using a greater amount of other medicines. That's on the next slide. And then if they plateaued, and they don't feel like they need it anymore, you can continue them on some medicines. Or while you're waiting for approval, you can put them on some medicines. Or to act as an adjunct, you'll use some medicines. So what are the medicines? What are they? Here they are. The vast majority of my patients with cervical dystonia are on either this one or this one. Different mechanisms. Ever think of why patients have dystonia? We talked about what happens, this feedback loop. What's the chemical? Acetylcholine, the chemical of movement. Some dopamine, but that's for patients who have DRD, dopa-responsive dystonia. So if somebody has a diffuse dystonic syndrome, and they're young, you should think of dopa-responsive dystonia, and you can throw some Carb-Levo at them. But if they truly have late-onset isolated cervical dystonia, try hexafenadil, two milligrams. Start with one tab, one half tab, at bedtime. You're not too sleepy? Try it with dinner. You're not sleepy in the evening? Great. Movements are still a problem? Take a half in the morning also. Then a week later, you can go up to a full two milligram tab at night. Too sleepy, but functioning well enough? Great. Half a pill in the morning, one at night. You can march your way up. Kids tolerate it very well. How do I analogize trihexafenadil? It's Benadryl. It's an anticholinergic. Dry mouth, sleepiness. If they have angle-closure glaucoma, they shouldn't be on it. Clonazepam, I also use a fair amount. I find it to not be addicting, because it doesn't give you that hypnotic effect. And that enhances, it's usually an enhancer of the cervical dystonia management with the botch line of injections. But there are others. Surgical treatments, I'll briefly touch on. Very few people get cervical treatments. Now, remember, Botox was only approved in 89. That seems like a long time ago, but along the range of history, the annals of medicine, that's not very long. People were using those medicines that we just talked about. And they were also using peripheral neurosurgical intervention. Active peripheral denervation. So if you have this abnormal positioning, a surgeon can cut those nerves. And so you're not having that malpositioning anymore, to the same degree. There's a major problem, though, that gets in the way of the efficacy of the botulinums, which is also denervating it, right? So it basically reduces the likelihood that they're going to have any response to any of the botulinums, okay? And the efficacy is not quite as good. So I'm not a huge fan of that. And I haven't referred for that in over 20 years. But DBS, for somebody who has enterocolis, is an option if the enterocolis is truly dystonic and if it's driving them nuts. Because you don't want to inject into the anterior scalenes, and you're going to be piddling if you're injecting into the sternocleidomastoid bilaterally, okay? So for enterocolis, that's a viable option. For patients who are refractory, it's an option. I have not had to refer anyone other than enterocolis. It's doable. If you can't work out the cervical dystonia, you can always ask another injector to try. This is not easy stuff. Adjustments are needed over time. Other exercises are also worthwhile, right? We're telling our patients to do exercises. If you want to be a good example of yourself, you should exercise, keep yourself in shape, and that way your credibility is there because you exercise, they exercise, they believe you. Walking, jogging, okay? So symmetrical movements, swimming, it's all good. I try not to have them do, if they have cervical dystonia, the, you know I don't do this, right? When they're, the one where they're like with a group of people and they get all excited. Spinning, yeah, right, right, because spinning, right, so it's you're bending forward, right? And you're extending at the neck, right? That's less than ideal, okay? So if it's malpositioning, if it's recumbent bike, fantastic, swimming, fantastic, jogging if they're young and they are able-bodied, walking, those types of things, they're great. They basically take the pressure off the neck. Snorkel swimming? Oh yeah, yeah, yeah, that's good and also that, that board, the body board is good. Elementary backstroke, okay, is good. Regular backstroke if you're really up for it and forward swimming, body board, kick, kick, kick, kick, good stuff, okay? Keeps them nice and light too. Again the anatomy, I'm not going to go back to it because we actually went over it in considerable detail, all right, and these are the players we're talking about and so I blew this up so you have the anatomy again, circling back, making sure we're comfortable with the muscles that we're injecting, okay, contralateral, sternocleidomastoid, especially trapezius, a little bit anterior scalenes we stay away from, and then the muscles ipsilaterally, that's going to be the majority of your injection. So just say this is a guy, okay, this is a pretty big dude, he'll probably be over 200 units, he may be about 250, 260 units, and then at least 100 of that is going to be the splenius muscles, maybe like 70 of splenius capitis and 30 of splenius services or maybe 70 of splenius capitis and 50 of splenius services, so you'll finish up that first 30 on another muscle, okay, and so levator scapulae may be 50 or 60, longissimus will be about 40, sternocleidomastoid will be maybe 40, and then trapezius will be maybe just 20. And we're a little over 200 on that guy, okay, mid-200s, and then adjust it. And then sidebending, circling back on that too, okay, and if you're sidebent, you can go for broke, man, because you're injecting a ton over here, you're not injecting anything over there at all, if you're not injecting bilaterally, you're in good shape, okay. So the key takeaways, for over 20 years, botulinums have been proven treatment for cervical dystonia, and clinically, if you're talking about places like Columbia and other places in New York, they're basically doing it since the 80s, even before 89, before it was approved. Assess the affected anatomy contributing to the patient's dystonia and treat those muscles first, and then you could adjust over time, you don't have to get too fancy. Consider other treatment modalities, we talked about some of those treatment modalities. It's okay to use the other medicines, the medicines are a good adjunct, you give it a try, if they start doing really well, you can start tapering them. Remember about the neck stretches, we talked a lot at the noon talk with spasticity, the importance of exercise, they go back to the physical therapist and all that other treatment, and then they come back to you after four weeks. Same thing holds for here. I almost mandatorily, after the first set of injections, refer them to physical therapy, just the first time. I explain to them, this is like you're driving new wheels, you're used to driving this kind of car, now we've changed it a little bit. You got so used to this, and the longer that they're in this position, the more likely they are to have adjustment pain. Just because they're in this position. The pain could be because of the needle, that's immediate. The pain could be because of weakness, hopefully you'll avoid that because we went over all kinds of techniques to avoid weakness of neck extension. Or the pain could just be because they got so settled into a certain position, you've now changed it, for the better, in the long run, but immediately, and when I say immediately, I mean like the first month or so, they may go through this transition. So it's good to have physical therapy to help them with their biomechanics, because their biomechanics will improve. You want to enhance that. So it is a combination of factors, and you really can make a difference on these patients. It's been extremely rewarding, and there's no reason why these patients have to just be neurological patients. PM&Rs, definitely, I highly recommend that you go ahead and consider injecting these patients. And if you need help from your neurological colleagues, by all means. Allergan, AbbVie now, probably the best of the four, in terms of getting the support. So you can do, we talk about preceptorships, in which you observe a doctor doing these injections on his or her own. And then proctorships, where you're now ready to do it, or you may have had some patients that you've been doing, and you just want to make sure you're doing it right, you can get that doctor to come and visit you. That's on Allergan's dime, okay? And that way you're better at what you're doing. The models, all right, the models aren't part of this lecture, because it's not a pharmaceutical sponsor, but just like the models we saw over the lunch hour for the extremities, there are models that you can work on for the neck. I think it's called Elvis, if I recall. So I very much appreciate being invited. It's really been an honor. I'll say, Michael and I go back to the 1990s. My first lecture was 99, and it's great to always come back periodically. And you guys are, you're awesome. Thank you so much. Do we have any questions? Matt, I don't know if you can see the chat. I didn't see, Betsy didn't tell me there was anybody, but... I'm so glad you didn't tell me that this is online. I would have gotten so nervous. It's the end of the day. Yeah. Well, thank you so much again, Dr. Clafter. That was excellent. My pleasure. Thank you so much for having me.

cervical dystonia

involuntary muscle contractions

botulinum toxin

electromyography

dysphagia

anticholinergics

physical therapy

surgical options

patient outcomes