May 13, 2021

New Consensus Guidelines for Botulinum Toxin Therapy of Dystonia and Spasticity

Professor Dirk Dressler

Botulinum toxin (BT) therapy is based on applying appropriate doses of BT into an appropriate selection of muscles. Both, the list of target muscles together with their BT doses, constitute the dosing scheme. Developing the dosing scheme for each patient individually requires considerable experience and makes BT therapy what some people might call a piece of art. To help in this process dosing tables give orientation about reasonable doses for each target muscle.

A new consensus guideline from IAB – Interdisciplinary Working Group on Movement Disorders recently published in Journal of Neural Transmission provides these dosing tables (Dressler et al. 2021). For the first time the dosing tables are based on statistical evaluation of real-life data from the botulinum toxin clinics at the Movement Disorders Section of Hannover Medical School. For each target muscle its mean dose with standard deviation and its minimum and maximum doses are reported. The mean dose describes the typical dose, the standard deviation the dose variability and the minimum and maximum doses the limits of the target muscle dosing. ‘So far dosing tables have only been reporting dose ranges coming out of group discussions. Usually they covered enormous ranges making them virtually useless for practical considerations,’ said Dressler, first author of the publication.

‘We give typical doses for each target muscle, we give variability and we give limits so that the user has all the information to decide the best target muscle dose.’ The statistical analysis was based on treatment data from 1831 BT injections in 36 different target muscles in 420 dystonia patients and 1593 BT injections in 31 different target muscles in 240 spasticity patients. ‘Also for the first time, we differentiated between dosing for dystonia and spasticity’, said Dressler. For all main dystonia and spasticity indications the paper describes the typical number of target muscles and the frequency of their usage. In a general section the currently used treatment algorithms including the short interval therapy and the high dose therapy are reviewed. ‘We are extremely grateful to our panel of 26 world class experts in BT therapy from all over the world. We are confident that this publication will be the key source for planning and dosing BT therapy in dystonia and spasticity for the years to come’, said Dressler.

References: Journal of Neural Transmission


Consensus guidelines for botulinum toxin therapy: general algorithms and dosing tables for dystonia and spasticity

Dirk Dressler, Maria Concetta Altavista, Eckart Altenmueller, Roongroj Bhidayasiri, Saeed Bohlega, Pedro Chana, Tae Mo Chung, Carlo Colosimo, Klemens Fheodoroff, Pedro J. Garcia‑Ruiz, Beomseok Jeon, Lingjing Jin, Petr Kanovsky, Ivan Milanov, Federico Micheli, Olga Orlova, Sanjay Pandey, Zvezdan Pirtosek, Maja Relja, Raymond Rosales, José Alberto Sagastegui‑Rodriguez, Gholam Ali Shahidi, Sofia Timerbaeva, Xinhua Wan, Uwe Walter, Fereshte Adib Saberi


Botulinum toxin (BT) therapy is a complex and highly individualised therapy defined by treatment algorithms and injection schemes describing its target muscles and their dosing. Various consensus guidelines have tried to standardise and to improve BT therapy. We wanted to update and improve consensus guidelines by: (1) Acknowledging recent advances of treatment algorithms. (2) Basing dosing tables on statistical analyses of real-life treatment data of 1831 BT injections in 36 different target muscles in 420 dystonia patients and 1593 BT injections in 31 different target muscles in 240 spasticity patients. (3) Providing more detailed dosing data including typical doses, dose variabilities, and dosing limits. (4) Including total doses and target muscle selections for typical clinical  entities thus adapting dosing to different aetiologies and pathophysiologies. (5) In addition, providing a brief and concise review of the clinical entity treated together with general principles of its BT therapy. For this, we collaborated with IAB—Interdisciplinary Working Group for Movement Disorders which invited an international panel of experts for the support