Chemodenervation (Botulinum) Clinic
Chemodenervation is a process, in which signals from the nerves to the muscles are modified using various medications. There are various medications which include chemicals and neurotoxins used in a controlled manner to achieve a desired action. This effect is used to control unwanted and excessive muscular contractions due to various etiologies and disease process. Chemodenervation using Botulinum toxin, is currently a well-recognized and accepted treatment in management of various medical disorders. Even though there are various therapeutic indications for Botulinum toxin injections, in neurology it commonly used for dystonia, spasticity (stiffness of muscle following stroke), and chronic migraine. Movement disorders clinic provides Botulinum toxin injections to these common neurological problems, especially in relation to movement disorders. The following are the commonly asked questions about the usage of Botulinum toxin injections.
- What is Botulinum toxin?
Botulinum Neurotoxin, is a biological product which has revolutionized the treatment of various neurological symptoms since its recognition in late 1980’s. Botulinum neurotoxin is derived from the bacterium Clostridium botulinum.
- How does Botulinum toxin work?
Botulinum toxin (Botox) is a nerve "blocker" that binds to the nerves that lead to the muscle and prevents the release of acetylcholine, a neurotransmitter that activates muscle contractions. If the message is blocked, muscle spasms are significantly reduced or eliminated.
- Is it a newly recognized medical treatment?
No. Botox treatment is a well-recognized therapeutic option available since early 1980’s. In last 30 years, it has itself established as a well-accepted treatment for various disorders based upon scientific publications and observations.
- What are the common conditions where Botulinum toxin is used for?
Botulinum toxin in neurological conditions is commonly used for treatment of dystonias, spasticity, Hemifacial spasms, Tremors, and Chronic migraine.
- What are the indications for Botulinum therapy?
Botox is used in various medical conditions and include
a. Focal dystonias - Involuntary, sustained, or spasmodic patterned muscle activity, Cervical dystonia (spasmodic torticollis), Blepharospasm (eyelid closure), Laryngeal dystonia (spasmodic dysphonia), Limb dystonia (writer's cramp), Oromandibular dystonia, Orolingual dystonia, Truncal dystonia
b. Spasticity - following Stroke, Traumatic brain injury, Cerebral palsy, Multiple sclerosis, Spinal cord injury
c. Nondystonic disorders of involuntary muscle activity, Hemifacial spasm, Tremor, Tics, myokymia and synkinesis, Myoclonus (tensor veli palatini muscle [middle ear], causing tinnitus), Hereditary muscle cramps, Nocturnal bruxism,
d. Trismus, Strabismus (disorder of conjugate eye movement) and nystagmus
e. Chronic pain and disorders of localized muscle spasms, Chronic low back pain, Myofascial pain syndrome
f. Tension headache, Chronic migraine headache, Medication overuse headache
g. Lateral epicondylitis, Knee pain, Shoulder pain,
h. Neuropathic pain
i. Smooth muscle hyperactive disorders, Neurogenic bladder – Detrusor hyperreflexia, Detrusor-sphincter dyssynergia, Benign prostatic hypertrophy, Achalasia cardia, Hirschsprung disease, Sphincter of Oddi dysfunctions
j. Cosmetic use: Hyperkinetic facial lines (glabellar frown lines, crow's feet), Hypertrophic platysma muscle bands, Sweating, salivary, and allergy disorders
k. Axillary and palmar hyperhidrosis
l. Drooling in cerebral palsy and other neurological disorders
- Is there a difference in various brands available in market?
Even though the end product used is Botulinum toxin, the drug has been differentiated based upon the type of Botulinum toxin used (commonly type A and type B). In addition various botulinum toxins possess individual potencies, and care is required to assure proper use and avoid medication errors. Recent changes to the established drug names by the FDA were intended to reinforce these differences and prevent medication errors. The products and their approved indications include the following:
a. OnabotulinumtoxinA (Brand names : Botox, Botox Cosmetic)
b. AbobotulinumtoxinA (Brand names : Dysport)
c. IncobotulinumtoxinA (Brand name : Xeomin)
d. Rimabotulinumtoxin B (Brand name: Myobloc)
An important difference between the different brands of botulinum neurotoxin is the number of units needed for treatment and how much toxin is in a 'unit' of each product. The units used to measure dosage are not consistent among the commercially produced toxins, and the products are not interchangeable.
- Where and how is Botulinum toxin injected?
The medication is directly injected into the area of the body where benefit is intended for. E.g., in to cervical muscles in cervical dystonia and ocular muscles for blepharospasm. For selected areas of the body, and particularly when injecting muscles that are difficult or impossible to palpate, guidance using an electromyograph (EMG) may be necessary. For instance, when injecting the deep muscles of the jaw, neck, or vocal cords, an EMG-guided injection may improve precision since these muscles cannot be readily palpated. An EMG measures and records muscle activity and may help the physician locate overactive muscles.
- Is it a very uncomfortable procedure?
The procedure is done with a very fine needle and most of the people do not complain of any discomfort. At most the pain can be as that or less of a small mosquito bite.
- When and how long does the Botulinum toxin injections work?
It normally takes several days for the effects of the botulinum neurotoxin to become apparent. The benefit peaks in approximately four weeks and lasts three to four months. In some cases the benefits can last between 6 to 12 months.
- What are the adverse effects of Botulinum toxin?
Temporary side effects for both types A and B may include muscle weakness, mild pain at the injection site, and dry mouth. Patients should feel free to ask their physician about additional side effects that may be specific to the body area that is to be injected--for example, temporary difficulty swallowing may occur in patients injected for laryngeal or cervical dystonias, but is highly unlikely for someone getting injected for writer's cramp. If a patient experiences side effects, adjusting the dosage or site of injection for future treatments may help avoid these effects.
- In case of any adverse effects, can it be reversed?
As Botulinum toxin effects are temporary, most of the side effects usually resolve within days to weeks.
- What is the success rate of treatment?
The success of a botulinum neurotoxin injection depends upon: a. The dose used b. The specific sites in the muscles where the product is injected c. The experience of the physician giving the injection d. Clear communication between physician and patient, so that both parties understand and agree on the specific symptoms that are being treated and what can be expected as a result of an injection. e. Because of the multiple factors that determine the success of a botulinum neurotoxin injection, a person might require being injected on two or three separate occasions before the optimal benefit is achieved. All of the factors listed above must be aligned for the best result, and this may take some time to perfect.
- How much would it cost for the Botulinum injections?
The cost varies based upon the amount of medication being planned to use. It may cost as little as 2000 to 3000 rupees in case of where minimal amounts are required (e.g Hemifacial spasm) and increases with the amount of medication being used.
- How long can one use Botulinum injections?
Based on over a decade of clinical experience, patients who respond well to botulinum neurotoxin may continue treatment over the course of many years without side effects from long-term use.