Quality of life in individuals with cervical dystonia before botulinum toxin injection in a Brazilian tertiary care hospital

Article Arq Neuropsiquiatr 2011;69(6):900-904 Quality of life in individuals with cervical dystonia before botulinum toxin injection in a Brazilian tertiary care hospital Mariana Ribeiro Queiroz1, Hsin Fen Chien2, Egberto Reis Barbosa2 ABSTRACT Objective: The purpose of this study was to evaluate quality of life (QoL) in a Brazilian population of individuals with cervical dystonia (CD) without effect of botulinum toxin (BTx) or with only residual effect of BTx, and identify possible physical and social aspects that affect their QoL. Method: Sixty five out of sixty seven consecutive patients with CD were assessed with two instruments: Short-form Health Survey with 36 questions (SF-36) and Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS). Results: Severity of CD (TWSTRS) correlated moderately with two SF-36 subscale: role-physical (r= –0.42) and body pain (r= –0.43). Women also scored worse in two subscale of SF-36: vitality (p<0.05) and mental-health (p<0.005). Conclusion: Severity of CD and gender (female) were the main factors related to a worse QoL perception. These findings may help health professionals to predict which characteristics could lead to worse QoL, and therefore, better target their interventions to lessen the burden caused by CD. Key words: cervical dystonia, quality of life, botulinum neurotoxin type-A, Toronto Western Spasmodic Torticollis Rating Scale, Short-form Health Survey. Qualidade de vida em indivíduos com distonia cervical antes da aplicação de toxina botulínica em um hospital terciário brasileiro Correspondence Mariana Araújo Ribeiro Queiroz Rua Andirá 195 / 81 86020-520 Londrina PR - Brasil E-mail: Conflicts of interest The authors report no conflicts of interest Received 18 April 2011 Received in final form 10 June 2011 Accepted 17 June 2011 900 RESUMO Objetivo: O objetivo deste estudo foi avaliar a qualidade de vida (QV) em uma população brasileira de indivíduos com distonia cervical (DC), que estavam sem o efeito da toxina botulínica ou com efeito residual da mesma, e identificar os possíveis aspectos físicos e sociais que afetam sua QV. Método: Sessenta e cinco de sessenta e sete pacientes consecutivos com DC foram avaliados com dois instrumentos: Short-form Health Survey com 36 questões (SF-36) e Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS). Resultados: A gravidade da DC (TWSTRS) correlacionou-se moderadamente com duas sub-escalas da SF-36: aspectos físicos (r= –0,42) e dor (r= –0,43). Mulheres apresentaram piores pontuações em duas sub-escalas da SF-36: vitalidade (p<0,05) e saúde mental (p<0,005). Conclusão: Gravidade da DC e gênero (feminino) foram os principais fatores relacionados à pior percepção de QV. Estes achados podem auxiliar profissionais da saúde a identificarem quais características poderiam levar a uma pior QV, e assim direcionar melhor suas intervenções, atenuando os danos causados pela DC. Palavras-Chave: distonia cervical, qualidade de vida, toxina botulínica do tipo-A, Toronto Western Spasmodic Torticollis Rating Scale, Short-form Health Survey. 1 Physical therapist, Movement Disorders Clinic of the Division of Neurology, Hospital das Clínicas of the University of São Paulo School of Medicine, São Paulo SP, Brazil; 2Clinical Neurology, Movement Disorders Clinic of the Division of Neurology, Hospital das Clínicas of the University of São Paulo School of Medicine, São Paulo SP, Brazil. Arq Neuropsiquiatr 2011;69(6) Cervical dystonia (CD) is the most common form of focal dystonia and its prevalence is estimated to be 11.5 cases per 100,000 individuals1,2. CD is characterized by involuntary contractions of cervical region muscles, leading to awkward posture of the head and neck. Most of the cases have idiopathic origin3. The most debilitating symptoms in this condition are: pain, head abnormal posture, and tremor4. The pain, present in two third of patients, is the most disabling one5. Mental stress resulting from the disease may also contribute for the high level of dysfunction and interferes in important aspects of daily living such as professional and social activities6. Its effect on patient’s health is comparable to progressive and generalized neurological degenerative diseases which are more severe than CD1. Botulinum toxin (BTx) is the most effective treatment option for focal dystonias, which includes CD. It leads to symptoms relief, specially pain, and significant postural improvement7. Many studies show improvement of quality of life (QoL) after BTx injections1,8,9. Other authors10,11, on the other hand, disagree with this point of view since their patients did not have significant improvement of QoL after BTx injections. Some reasons may partially explain these conflicting opinions: the effect of the treatment changes over time reaching a plateau after the injection and decreasing soon after it; not all injections achieve the same results; it is a long-term treatment and the procedure has to be repeated frequently. These facts discourage the patients and leads to negative impact in their QoL. Although many studies1,8,10,12 have demonstrated that CD impacts negatively in the patient’s QoL there are no agreements about which individual or social aspects are the most troublesome. Furthermore, there are few data about patients QoL without the effect of BTx treatment or with only residual effects, since in most studies the authors assess the QoL exclusively during the period of action of BTx without an adequate control10, or do not even mention when they interviewed their patients1,12. The purpose of the present study was to evaluate QoL in a Brazilian population of individuals with CD without the effect of BTx or with only residual effect of BTx, and identify possible clinical and social aspects that affect their QoL that can be targeted by specific interventions. METHOD Sixty five out of sixty seven consecutive CD patients treated at the Movement Disorder Clinic of the Division of Neurology of the Hospital das Clínicas of the University of São Paulo School of Medicine were initially evaluated by one physiotherapist during the period of November 2007 to September 2009. The patients were assessed by Short-form Health Survey with 36 questions QoL: cervical dystonia Queiroz et al. (SF-36) and the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), at the day they would receive BTx injection, before the procedure. The study was approved by the hospital ethics committee. All patients had signed the informed consent form prior to their inclusion to the study. The SF-36 health survey questionnaire yields an eight scale profile and they are hypothesized to form two distinct higher-ordered clusters: physical and mental health. The physical health domain comprehends the following items: physical functioning, role-physical, body pain, and general health. The mental health domain measures the following areas: vitality, social functioning, role-emotional, and mental health. The sc (...truncated)