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Therapeutic Use of Botox (Botulinum Toxin) for Neurologic Disorders
Botox can benefit people with neurological disorders. Dr. Parul Aneja, neurologist, discusses how botox is used in neurology.
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Learn more about Parul Aneja, MD
Parul Aneja, MD
Parul Aneja, MD, is a board-certified internal medicine physician who specializes in infectious disease.Learn more about Parul Aneja, MD
Transcription:
Bill Klaproth (Host): So, this is pretty cool. We’ve all heard of the cosmetic uses for Botox to reduce wrinkles, right? But there are therapeutic uses of Botox for neurological disorders that have nothing to do with wrinkles. So, let’s find out more Dr. Parul Aneja, a Neurologist UPMC Pinnacle. This is Healthier YOU, a podcast from UPMC Pinnacle. I’m Bill Klaproth. Dr. Aneja, let’s start here, tell us what is Botox made of and clinically, what does it do?
Parul Aneja, MD (Guest): Botulinum toxin is a powerful neurotoxin which is produced by a bacterium clostridium botulinum. And the way it works is it binds to the nerve endings at the point where the nerve joins a muscle and blocks the release of a chemical called acetylcholine which is the principal neurotransmitter at the neuromuscular junction.
Host: So, Botox basically reduces muscle spasms, so it releases the muscles to smooth everything out? That’s why it’s good for wrinkles?
Dr. Aneja: Correct. So, the result is a temporary paralysis of the muscle and I think we’re all aware of the cosmetic uses of Botox, that’s probably most people know of. But it’s the therapeutic uses that would be a good discussion and to make our patients and community aware of.
Host: Absolutely. So, let’s talk about that. What are the neurological therapeutic uses for Botox?
Dr. Aneja: So, there are several of them. But I think today we can focus on some of the neurological conditions and really the big ones are blepharospasm, cervical dystonia, chronic migraine headaches and upper and lower limb spasticity. And I can tell you a little bit about these conditions, so we understand what they entail.
Host: Yeah, please do.
Dr. Aneja: So, blepharospasm is a focal dystonia where there is excessive contraction of the muscles around the eye. This then leads to repetitive blinking of sustained closure of eyelids. And this can really get in the way of many routine activities like driving, walking, reading, watching TV. And small dosages of Botox can really make a difference here. But when we talk about a condition and treatments, and especially procedural treatments; we want to worry about a little bit of their side effects. But the side effects are somewhat procedure specific. There’s again, general side effects but also procedural specific side effects.
So, for a blepharospasm for example, we have to worry about droopy eye and dryness of eye. But again, there are other conditions as well. Cervical dystonia is another focal dystonia affecting muscles of the neck and this produces a repetitive spasmodic muscle contractions resulting in abnormal movements and postures of head and neck. And a relatively underdiagnosed condition, although quite prevalent more than 900,000 adults in the US are expected to have this condition. Side effects here usually are dysphagia, upper respiratory infections, neck pain and headache.
Host: And are there any other conditions that you use Botox to treat that we should be aware of?
Dr. Aneja: Yes, yes. There’s a few others. Chronic migraine headaches. Again, probably another underdiagnosed especially the chronic migraine part, 39 million Americans live with migraine and roughly 3.3 million of these meet the criteria for chronic migraine headaches and it’s a pretty simple straightforward criteria. Anybody who is suffering for more than or equal to 15 headache days per month of which more than or equal to eight headache days associated with migraine and the duration of the headache is more than or equal to four hours per day. And here again, the kind of side effects when botulinum toxin is used can be neck pain, headache and droopy eye.
The final neurological indication that I want to talk about is upper and lower limb spasticity. And there can be various causes for it. Some common ones are post-stroke patients, up to 58% stroke survivors experience spasticity. Multiple sclerosis, traumatic brain injury, spinal cord injury, cerebral palsy. So, those are some of the situations which can lead to spasticity.
Host: Really comprehensive list. So, there are a lot of therapeutic neurological uses for Botox. You were mentioning some of the side effects. Are there other concerns or contraindications we should be aware of?
Dr. Aneja: Yes, excellent question Bill. So, those were the procedure specific side effects that I kind of went over. But there are some contraindications, although not very many. If somebody does develop hypersensitivity to this product; which is possible; then obviously you don’t want to continue the use. Any infection at the proposed injection site is a contraindication. And there are certain pre-existing neuromuscular conditions because that’s where this medication works such as ALS or myasthenia gravis where we have to be careful because the clinical effects of botulinum toxin can be exacerbated. And while we’re on the topic, I think we should also make our audience aware of a box warning that is regarding distant spread of the toxin which was seen in some post-marketing reports where the spread of the product was seen away from the injection site and there were some side effects like generalized muscle weakness, double vision, droopy eye, swallowing difficulties, breathing difficulties and these were actually reported hours to weeks after the injection.
Again, handled properly, done in the right hand; most of the side effects can be either avoided or minimized.
Host: Really good information to know. So, we do know that Botox generally wears off after three or four or five months; what happens then? Are the treatments often repeated? And if someone does suffer a side effect like a droopy eye; in time, does that go away too?
Dr. Aneja: So, I think that the answer to both of the questions is in the fact that it does wear off and that is why patients do come back typically three to four months depending on the condition. For most conditions, we end up repeating the injections in three months from the previous injection. And since the effects of botulinum toxin wear off, the side effects also typically will wear off and they tend to be more in the prime time, when the medication is highly effective before it starts to wear off, that’s when most of the side effects are noticed and then they also do get better as the medication wears off.
Host: So, this sounds so good, I can imagine someone thinking heh, I’m getting this. But it may not be right for everyone. So, how do you know who is a good candidate for a neurological use of Botox?
Dr. Aneja: Like I said, for some conditions; the chronic migraine, I think that’s the most straightforward in the sense it has clear criteria, so this is somebody who is really suffering from very many migraines and they fit the right criteria. So, to me, that’s the most common indication, perhaps the most commonly treated indication and if you are aware of the criteria, very easy to diagnose and the patients could be seeking a neurologist directly or their family doctors could be making the referral. Dystonia and blepharospasm I think the more we are aware of these conditions and recognize them and we are aware that Botox is a treatment; I think that helps. And then spasticity also, it can be seen in various different settings. Now sometimes spasticity can be there for a very long time and contractures which are sort of fixed contractions of the tendons and the muscles; when that forms, botulinum toxin is not as effective so that needs some history taking and recognition in those situations. But most other spasticity conditions will benefit from getting some relief with this medication.
Host: And this is an outpatient procedure, right? It’s a quick injection.
Dr. Aneja: Yes. The time depends on the condition and how many injections and the amount of the dosage. So, that’s what determines the time. But fairly quick procedure. It’s typically not more than your routine doctor visit appointment. It’s usually done in the office setting. There is not much downtime unless there might be a concern for a side effect, and you can pretty much go back to mostly your normal routine the same day or the next day.
Host: And last question Dr. Aneja, for someone listening who now feels Botox may provide them some relief; what’s your best advice? Should they go to their family physician first or if they feel this is really going to help them; go directly to the neurologist such as yourself?
Dr. Aneja: Absolutely and while we are on the topic, sometimes there is concern about this medication or because I think we also are aware of botulinum toxin when it was first discovered and the way it was discovered, and it is a powerful neurotoxin. But for medical purposes, very small concentrations are injected in appropriate muscles. So, that’s what kind of makes it safe and absolutely have an open mind to this treatment. This is really the main treatment for a lot of these conditions and the medications don’t really provide much relief. So, it can make a big difference and absolutely feel free to contact the neurologist and they should be able to help you with this.
Host: Dr. Aneja, this has been fascinating. Thank you so much for your time and talking with us today about the therapeutic uses of Botox.
Dr. Aneja: Well thank you Bill for this opportunity to make our patients aware of the availability of this treatment. Thank you.
Host: That’s Dr. Parul Aneja, a Neurologist at UPMC Pinnacle. And to learn more, please visit www.upmcpinnacle.com/neurology. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Healthier YOU, a podcast from UPMC Pinnacle. I’m Bill Klaproth. Thanks for listening.
Bill Klaproth (Host): So, this is pretty cool. We’ve all heard of the cosmetic uses for Botox to reduce wrinkles, right? But there are therapeutic uses of Botox for neurological disorders that have nothing to do with wrinkles. So, let’s find out more Dr. Parul Aneja, a Neurologist UPMC Pinnacle. This is Healthier YOU, a podcast from UPMC Pinnacle. I’m Bill Klaproth. Dr. Aneja, let’s start here, tell us what is Botox made of and clinically, what does it do?
Parul Aneja, MD (Guest): Botulinum toxin is a powerful neurotoxin which is produced by a bacterium clostridium botulinum. And the way it works is it binds to the nerve endings at the point where the nerve joins a muscle and blocks the release of a chemical called acetylcholine which is the principal neurotransmitter at the neuromuscular junction.
Host: So, Botox basically reduces muscle spasms, so it releases the muscles to smooth everything out? That’s why it’s good for wrinkles?
Dr. Aneja: Correct. So, the result is a temporary paralysis of the muscle and I think we’re all aware of the cosmetic uses of Botox, that’s probably most people know of. But it’s the therapeutic uses that would be a good discussion and to make our patients and community aware of.
Host: Absolutely. So, let’s talk about that. What are the neurological therapeutic uses for Botox?
Dr. Aneja: So, there are several of them. But I think today we can focus on some of the neurological conditions and really the big ones are blepharospasm, cervical dystonia, chronic migraine headaches and upper and lower limb spasticity. And I can tell you a little bit about these conditions, so we understand what they entail.
Host: Yeah, please do.
Dr. Aneja: So, blepharospasm is a focal dystonia where there is excessive contraction of the muscles around the eye. This then leads to repetitive blinking of sustained closure of eyelids. And this can really get in the way of many routine activities like driving, walking, reading, watching TV. And small dosages of Botox can really make a difference here. But when we talk about a condition and treatments, and especially procedural treatments; we want to worry about a little bit of their side effects. But the side effects are somewhat procedure specific. There’s again, general side effects but also procedural specific side effects.
So, for a blepharospasm for example, we have to worry about droopy eye and dryness of eye. But again, there are other conditions as well. Cervical dystonia is another focal dystonia affecting muscles of the neck and this produces a repetitive spasmodic muscle contractions resulting in abnormal movements and postures of head and neck. And a relatively underdiagnosed condition, although quite prevalent more than 900,000 adults in the US are expected to have this condition. Side effects here usually are dysphagia, upper respiratory infections, neck pain and headache.
Host: And are there any other conditions that you use Botox to treat that we should be aware of?
Dr. Aneja: Yes, yes. There’s a few others. Chronic migraine headaches. Again, probably another underdiagnosed especially the chronic migraine part, 39 million Americans live with migraine and roughly 3.3 million of these meet the criteria for chronic migraine headaches and it’s a pretty simple straightforward criteria. Anybody who is suffering for more than or equal to 15 headache days per month of which more than or equal to eight headache days associated with migraine and the duration of the headache is more than or equal to four hours per day. And here again, the kind of side effects when botulinum toxin is used can be neck pain, headache and droopy eye.
The final neurological indication that I want to talk about is upper and lower limb spasticity. And there can be various causes for it. Some common ones are post-stroke patients, up to 58% stroke survivors experience spasticity. Multiple sclerosis, traumatic brain injury, spinal cord injury, cerebral palsy. So, those are some of the situations which can lead to spasticity.
Host: Really comprehensive list. So, there are a lot of therapeutic neurological uses for Botox. You were mentioning some of the side effects. Are there other concerns or contraindications we should be aware of?
Dr. Aneja: Yes, excellent question Bill. So, those were the procedure specific side effects that I kind of went over. But there are some contraindications, although not very many. If somebody does develop hypersensitivity to this product; which is possible; then obviously you don’t want to continue the use. Any infection at the proposed injection site is a contraindication. And there are certain pre-existing neuromuscular conditions because that’s where this medication works such as ALS or myasthenia gravis where we have to be careful because the clinical effects of botulinum toxin can be exacerbated. And while we’re on the topic, I think we should also make our audience aware of a box warning that is regarding distant spread of the toxin which was seen in some post-marketing reports where the spread of the product was seen away from the injection site and there were some side effects like generalized muscle weakness, double vision, droopy eye, swallowing difficulties, breathing difficulties and these were actually reported hours to weeks after the injection.
Again, handled properly, done in the right hand; most of the side effects can be either avoided or minimized.
Host: Really good information to know. So, we do know that Botox generally wears off after three or four or five months; what happens then? Are the treatments often repeated? And if someone does suffer a side effect like a droopy eye; in time, does that go away too?
Dr. Aneja: So, I think that the answer to both of the questions is in the fact that it does wear off and that is why patients do come back typically three to four months depending on the condition. For most conditions, we end up repeating the injections in three months from the previous injection. And since the effects of botulinum toxin wear off, the side effects also typically will wear off and they tend to be more in the prime time, when the medication is highly effective before it starts to wear off, that’s when most of the side effects are noticed and then they also do get better as the medication wears off.
Host: So, this sounds so good, I can imagine someone thinking heh, I’m getting this. But it may not be right for everyone. So, how do you know who is a good candidate for a neurological use of Botox?
Dr. Aneja: Like I said, for some conditions; the chronic migraine, I think that’s the most straightforward in the sense it has clear criteria, so this is somebody who is really suffering from very many migraines and they fit the right criteria. So, to me, that’s the most common indication, perhaps the most commonly treated indication and if you are aware of the criteria, very easy to diagnose and the patients could be seeking a neurologist directly or their family doctors could be making the referral. Dystonia and blepharospasm I think the more we are aware of these conditions and recognize them and we are aware that Botox is a treatment; I think that helps. And then spasticity also, it can be seen in various different settings. Now sometimes spasticity can be there for a very long time and contractures which are sort of fixed contractions of the tendons and the muscles; when that forms, botulinum toxin is not as effective so that needs some history taking and recognition in those situations. But most other spasticity conditions will benefit from getting some relief with this medication.
Host: And this is an outpatient procedure, right? It’s a quick injection.
Dr. Aneja: Yes. The time depends on the condition and how many injections and the amount of the dosage. So, that’s what determines the time. But fairly quick procedure. It’s typically not more than your routine doctor visit appointment. It’s usually done in the office setting. There is not much downtime unless there might be a concern for a side effect, and you can pretty much go back to mostly your normal routine the same day or the next day.
Host: And last question Dr. Aneja, for someone listening who now feels Botox may provide them some relief; what’s your best advice? Should they go to their family physician first or if they feel this is really going to help them; go directly to the neurologist such as yourself?
Dr. Aneja: Absolutely and while we are on the topic, sometimes there is concern about this medication or because I think we also are aware of botulinum toxin when it was first discovered and the way it was discovered, and it is a powerful neurotoxin. But for medical purposes, very small concentrations are injected in appropriate muscles. So, that’s what kind of makes it safe and absolutely have an open mind to this treatment. This is really the main treatment for a lot of these conditions and the medications don’t really provide much relief. So, it can make a big difference and absolutely feel free to contact the neurologist and they should be able to help you with this.
Host: Dr. Aneja, this has been fascinating. Thank you so much for your time and talking with us today about the therapeutic uses of Botox.
Dr. Aneja: Well thank you Bill for this opportunity to make our patients aware of the availability of this treatment. Thank you.
Host: That’s Dr. Parul Aneja, a Neurologist at UPMC Pinnacle. And to learn more, please visit www.upmcpinnacle.com/neurology. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Healthier YOU, a podcast from UPMC Pinnacle. I’m Bill Klaproth. Thanks for listening.