The Impact of SARS-CoV-2 Pandemic Lockdown on a Botulinum Toxin Outpatient Clinic in Germany

Abstract

Botulinum neurotoxin type A (BoNT/A) injections have to be administered repeatedly to achieve a rather stable, high level of improvement. This study aimed to take a look at changes in the daily routine of a BoNT/A outpatient clinic due to the SARS-CoV-2 pandemic lockdown, analyze the impact of SARS-CoV-2-induced re-injection delay on outcomes in patients with cervical dystonia (CD) (n = 36) and four other disease entities (n = 58), and study the influence of covariables, including previous injections and doses. For the present observational study, the first 100 patients who were scheduled to have an appointment between April 20 and May 18 during the partial lockdown and also had been treated regularly before the lockdown were recruited. Clinical and demographical characteristics and treatment-related data from the previous visits were extracted from charts. Time delay, symptom severity assessment, and TSUI score (if applicable) were gathered at the first coronavirus pandemic lockdown emergency visit for each patient. Of the 94 patients who could come to the clinic, 48 reported a delay and 44 reported worsening during the delay. Delays ranged from 1 to 63 days, the mean delay was 23 days, and the mean worsening was 26% compared to the previous visit. A significant correlation was found between the duration of the delay and the patient’s rating of worsening (PwP). In CD patients, the physician´s rating of CD worsening by the TSUI score (ATUSI-PTSUI) was significantly correlated with general worsening (DwP) and the TSUI at the last visit (PTSUI). A small delay of a few weeks led to a similar worsening of symptoms in CD and all other disease entities and to relapse on a higher level of severity. This relapse can only be compensated by continuous treatment up to at least 1 year until patients reach the same level of treatment efficacy as that before the SARS-CoV-2 pandemic.

COVID-19-related delays of botulinum toxin injections have a negative impact on the quality of life of patients with dystonia and spasticity: a single-center ambulatory care study

“…In a German cohort, 44 of 48 (92%) patients reported a worsening of symptoms after delays in reinjection. This is comparable to the 97% found in our study (Samadzadeh et al 2021 ). The authors calculated that on average, 1 day of delay caused 1% of worsening compared to the previous visit, with a mean delay of 23 days corresponding to a mean worsening of 26%.…”

“…This survey shows how strongly the closure of a botulinum toxin outpatient clinic in Austria and thereby prolonged interinjection intervals affected patients’ symptom reoccurrence and their QoL. Case reports and surveys from Italy, the USA, Germany, and the Philippines have already shown the negative influence of COVID-19-related delays of BoNT-A injections on patients suffering from dystonia, spasticity, or migraine (Dressler and Adib Saberi 2020 ; Ali 2020 ; Ranza et al 2020 ; Erro et al 2021 ; Santamato et al 2021 ; Tarantino et al 2021 ; Samadzadeh et al 2021 ; Pajo et al 2021 ). This is underlined by 75–91% of patients perceiving the security of long-term BoNT-A therapy as very important and 76–98% which felt their patient rights not respected by COVID-19 counter measures (this study, Dressler and Adib Saberi 2020 ; Tarantino et al 2021 ).…”

Continuous Increase of Efficacy under Repetitive Injections of Botulinum Toxin Type/A beyond the First Treatment for Adult Spastic Foot Drop

“…Assessment of the worsening during this delay by patients and treating physicians revealed a worsening by 1%/1 day, summing up to a clinically highly relevant worsening of 30% after one month. This was observed across all indications (patients with focal dystonia, patients with spasticity, patients with pain syndromes; for details see [ 32 ]). This underlines the gradual benefit patients have when they are reinjected before the clinical effect of the previous injection has completely vanished.…”

“…Here we demonstrate that with repeated injections every three months the effect on adult lower limb spasticity will increase far beyond the peak effect of the first cycle. This is similar to BoNT treatment of focal cervical dystonia where injections every three months will lead to a mean improvement of baseline severity (before the next injection) of more than 50% [ 31 , 32 ].…”

“…Patients’ assessment continuously increased with duration of BoNT/A therapy. Improvement of pain was not addressed, but may have considerably influenced [ 32 ] patient’s assessment of the efficacy of BoNT/A treatment. The problem of impaired motor learning has not been analyzed, but may be relevant to explain why some patients experience a better improvement of gait than others.…”