From Stroke to Dystonia to Migraines, Botulinum Toxin Injections Bring Comfort

At the University of Cincinnati Gardner Neuroscience Institute, the beauty of widely used wrinkle-vanishing injections is more than skin deep. Specialists are injecting drugs best known for their cosmetic uses to help patients live better and more comfortably with conditions as wide-ranging as stroke, cervical dystonia, multiple sclerosis, cerebral palsy and chronic migraine. In the hands of neuroscience specialists, the injections can ease disruptive and even painful spasms in the legs, arms, hands, feet and neck.

The family of drugs come from a protein derived from the neurotoxin-producing bacterium Clostridium botulinum (pronounced botch-oo-LINE-um), an organism that can cause life-threatening botulism. The four available brands are Botox (marketed by Allergan), Dysport (Ipsen Biopharm), Xeomin (Merz Pharma) and Myobloc (USWorldMeds).

“Lots of people have heard about botulism and that it can be very bad for you as a disease process, because it can paralyze your whole body and cause you to eventually stop breathing,” says Jessica Colyer, MD, a rehabilitation specialist and member of the UC Comprehensive Stroke Center. “Pharmaceutical companies have taken a portion of the protein found in that toxin and use only a fragment for clinical purposes.”

The botulinum toxins are approved by the FDA for many uses, including upper-limb spasticity in people who have suffered a stroke; abnormal head position and neck pain in people with cervical dystonia; and chronic migraine in people who suffer 15 or more days a month of pain. Neuroscience specialists also offer the injections off-label in the lower extremities to help patients who have walking impairments after a stroke or spasticity caused by multiple sclerosis (MS) or cerebral palsy.

While cosmetic use of botulinum toxin requires tiny injections that paralyze muscles and eliminate wrinkles in the forehead and “crow’s feet” around the eyes, rehabilitation physicians like Dr. Colyer use larger doses to treat spasticity in muscles in the arms, legs and neck.

Spasticity is a spinal reflex that fires when it shouldn’t, Dr. Colyer explains. “In a healthy, working brain, the brain sends a signal back down to the muscles to say, ‘This reflex is not needed now; you do not need to be flexing now.’ After a stroke, however, that signal can be cut off.

“Stroke survivors start to have an increase in what we call flexor tone,” Dr. Colyer continues. “They curl up and flex their biceps, flex their wrist, or curl their fingers into a flexed fist. These are not functional positions. They prevent you from performing activities of daily living, such as dressing, grooming, brushing your teeth or even putting on deodorant.”

Treatment for dystonia & dysphonia

The James J. and Joan A. Gardner Family Center for Parkinson’s Disease and Movement Disorders includes a clinic for patients who receive injections of botulinum toxin to treat dystonia and spasticity. The injections can help even in cases where patients experience extreme neck discomfort and deformity, says Alberto Espay, MD, a movement disorders specialist.

The Gardner Center also collaborates with otolaryngologists who can provide injections in the vocal cords to improve voice and swallowing problems. Botulinum toxin helps patients with spasmodic dysphonia, also known as laryngeal dystonia, a neurological disorder that affects voice muscles in the larynx, or voice box. It can help patients with adductor spasmodic dysphonia, the most common type of dysphonia, more than 95 percent of the time, according to Sid Khosla, MD, an otolaryngologist and voice specialist at the UC Neurosensory Disorders Center. “Injections also can help about 50 percent of patients with voice tremor,” Dr. Khosla says. “And it can be used to help people who cannot swallow their saliva (hypersalivation) and who experience constant drooling as a result.”

Treatment for migraine

At the UC Health Headache & Facial Pain Program, botulinum toxin is prescribed for the treatment of chronic migraine. Chronic migraine is one of the most disabling forms of migraine and is diagnosed when patients experience 15 or more days of headache and have a diagnosis of migraine headache.

“To treat this condition, 155 units of Botox are injected into 31 sites in the head, neck and shoulders,” explains Vincent Martin, Co-Director of the Headache & Facial Pain Program. “It must be injected every three months, as the effects wear off after several months. Insurance will not pay for the medication unless you have had a poor response to three or more past medications used to prevent migraines.”

The average patient experiences an 8- to 10-day reduction in the frequency of headaches per month after administration of botulinum toxin. “It is an excellent therapy for the treatment of chronic migraine and is beneficial in about two out of three patients,” Dr. Martin says. “Those migraines that do occur tend to be far less disabling.”

Treatment for multiple sclerosis

Dr. Colyer collaborates with the Waddell Center for Multiple Sclerosis to help patients with MS, who can experience spasticity in any of their affected limbs. Patients can have symptoms in the arms similar to those experienced by stroke survivors; they can have spasms in their feet, causing the feet to curl; and they can experience increased tone in their thigh or calf muscles, which prevents normal knee or ankle movements. After getting botulinum toxin injections in their feet flexor muscles, Dr. Colyer says, her patients are able to walk on a normal, flat foot.  Injections in the thigh or ankle muscles can eliminate or reduce the spasm and allow for easier walking.

Physicians can prescribe other medicines, such as baclofen or tizanidine (Zanaflex), to treat spasticity. But those medications pervade the entire body and cause side-effects, including reduced alertness. The beauty of botulinum toxin, Dr. Colyer says, is that it works only in the muscles that are injected, without creating cognitive side-effects.

Botulinum toxin can be injected every three months at most, or four times a year. More frequent injections could lead to the development of antibodies against the protein, which would prevent the medication from being effective. Research is ongoing at various centers, including UC, to determine whether a protein-free toxin formulation may allow more frequent injections without any safety concerns.

— Cindy Starr

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