Multiple Sclerosis: Botox Treatment

  • Medical Author:
    Danette C. Taylor, DO, MS, FACN

    Dr. Taylor has a passion for treating patients as individuals. In practice since 1994, she has a wide range of experience in treating patients with many types of movement disorders and dementias. In addition to patient care, she is actively involved in the training of residents and medical students, and has been both primary and secondary investigator in numerous research studies through the years. She is a Clinical Assistant Professor at Michigan State University's College of Osteopathic Medicine (Department of Neurology and Ophthalmology). She graduated with a BS degree from Alma College, and an MS (biomechanics) from Michigan State University. She received her medical degree from Michigan State University College of Osteopathic Medicine. Her internship and residency were completed at Botsford General Hospital. Additionally, she completed a fellowship in movement disorders with Dr. Peter LeWitt. She has been named a fellow of the American College of Neuropsychiatrists. She is board-certified in neurology by the American Osteopathic Board of Neurology and Psychiatry. She has authored several articles and lectured extensively; she continues to write questions for two national medical boards. Dr. Taylor is a member of the Medical and Scientific Advisory Council (MSAC) of the Alzheimer's Association of Michigan, and is a reviewer for the journal Clinical Neuropharmacology.

  • Medical Editor: Melissa Conrad Stöppler, MD
    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

The Effects of Multiple Sclerosis

What is Botox?

Botox is one specific brand of purified botulinum toxin, which is the toxin produced by the bacterium Clostridium botulinum. Medical uses of botulinum toxin began in 1980, when targeted weakening of eye muscles was identified as a potential treatment of strabismus, a condition in which the eyes don't line up correctly.

Although many different types of botulinum toxin have been identified, only types A and B are approved for the use in treatment of muscle problems. In addition to Botox, other approved forms of botulinum toxin A include Dysport and Xeomin. Myobloc is the approved form of botulinum toxin B.

When used for clinical purposes, the toxin is used in small amounts, leading to weakness in the muscles into which it is injected. This weakness can be beneficial in various conditions characterized by too much muscle activity, such as dystonia or spasticity. This is in distinct contrast to the disease botulism, which occurs when the non-purified bacterium is ingested and the toxin is dispersed through the body causing widespread weakness.

What is multiple sclerosis?

Multiple Sclerosis (MS) is a disease that causes demyelination of the brain and spinal cord. When this occurs, axons (the parts of the nerve cells that conduct impulses to other cells) don't work well. As more areas are affected by this loss of myelin, patients develop symptoms. The specific symptom that someone might experience is related to the area of injury in the brain or spinal cord. Patients might describe numbness, tingling, or weakness. The weakness may be mild or severe enough to cause paralysis of one side of the body. In some cases, patients may develop incontinence or even an inability to empty their bladder. As multiple sclerosis progresses, some patients are left with muscle spasticity or an involuntary painful contraction of certain muscles.

Quick GuideMultiple Sclerosis (MS) Symptoms and Treatment

Multiple Sclerosis (MS) Symptoms and Treatment

Multiple Sclerosis Treatment

Multiple Sclerosis (MS) is a disease that attacks the central nervous system (brain, spinal cord, and optic nerves) resulting in symptoms that range from mild (numbness) to severe (paralysis). Although the cause is not known, most researchers and clinicians think that somehow environmental, genetic, and/or infectious agents may, either alone or in combination, trigger an immune response in individuals that causes immune cells to begin to destroy the nerve-insulating myelin coverings. Myelin coverings protect nerves from interfering electrical impulses, irritating chemicals in their immediate environment, and promote good nerve signals. Simply stated, myelin acts like the insulation on wires that are bundled together in close proximity; if the wires start to lose their insulation, they may not function well and if they get wet, they can short out and not function at all. The disease has many symptoms that are nonspecific and makes MS a disease that is difficult to distinguish from many others. However, diagnosis is possible and once diagnosed MS can be treated (but not cured).

What is spasticity?

Spasticity is a condition in which muscles exhibit almost constant contracture or activity, leading to loss of range of motion, decreased function, and even pain. Spasticity occurs after an area of the brain or spinal cord has been injured, leading to weakness and increased tone. When an arm or leg which is affected by spasticity is moved by an examiner, there is involuntary resistance to that movement. Often, this spasticity is made worse when the speed (or velocity) of the movement increases. Spasticity is often seen after a stroke, traumatic brain or spinal cord injury, or in cases of multiple sclerosis. In some cases, spasticity can be associated with development of involuntary tremors.

How is Botox used to treat multiple sclerosis?

Botox can be used to treat many symptoms associated with multiple sclerosis. Patients who have spasticity affecting their arms or legs may be good candidates for botulinum toxin injections to relieve painful spasms and improve mobility to help with bathing or dressing. Botox may be especially beneficial in situations in which patients have a difficult time tolerating oral anti-spasticity medications due to side effects. Botox has also been used to treat overactive bladder symptoms associated with multiple sclerosis. Some patients with multiple sclerosis develop problems with their vocal cords, called dysphonia. Very small amounts of Botox injected into the vocal cords are used to treat this condition. It is important to recognize that Botox is used to decrease spasticity and cannot improve muscle strength.

Who is a good candidate for Botox injections?

Patients who have limited areas of spasticity, such as one arm or one leg, are often very good candidates for botulinum toxin treatments. Patients who have been poorly tolerant of oral medications due to sleepiness, dry mouth, or even cognitive problems may also benefit from the use of botulinum toxin injections to treat their spasticity.

Patients who have certain underlying neuromuscular diseases, such as myasthenia gravis, or who are being treated with medications that block the neuromuscular junction, should not be given botulinum toxin injections, as widespread or prolonged weakness may occur.

How many Botox injections are needed? How do Botox injections work?

The exact number of injections needed to treat a patient's condition is highly individualized. One patient may respond to as few as two or three injections, while another patient may require many more.

Botox works by blocking the release of acetylcholine from nerve endings. Acetylcholine is a neurotransmitter required by muscles for muscular contraction. By eliminating the ability of a muscle to contract, it relaxes, thereby decreasing spasticity and tone. The blockade of acetylcholine does not occur immediately. Most patients do not begin to see the effect of a botulinum toxin injection for a few days, and it may take a few weeks for the maximum benefit to become apparent. Additionally, the benefit of botulinum toxin injections is not permanent; after a few months (typically three), the effect of the injections is no longer seen, and the injections need to be repeated.

What are the potential risks and side effects of Botox injections?

Botox injections have been determined to be safe and effective when given by experienced injectors. However, there is a risk of weakness in the area which has been injected. If this occurs, the weakness may interfere with function of that area. As with any injection, there is a potential for pain, bleeding, or infection at the injection site. With a large injection of the toxin, there is a possibility that there may be widespread dispersion of the toxin leading to problems with breathing or swallowing.

How much do Botox injections cost? Does insurance cover Botox injections?

The exact cost of Botox injections is dependent on many factors, including the amount of toxin used, the number of sites injected, and whether electromyography (EMG) or ultrasound guidance is used to determine placement of the toxin. The U.S. Food and Drug Administration (FDA) has approved Botox for the treatment of upper limb spasticity caused by multiple sclerosis and other conditions, and insurance companies will often cover the majority of the costs associated with this procedure. In some cases insurance companies may also cover the cost of “off-label” uses of Botox, but this is dependent on the company and the patient's policy. Most companies will be able to identify if this is a covered benefit before the injections take place.

How can I expect to feel after getting Botox injections?

Immediately after receiving botulinum toxin injections, you may not feel any specific change, other than some slight soreness at the injection sites. After a few days, there will be evidence of some decrease in the spasticity of the targeted area. This may be associated with decreased pain and even improved function. Rarely, some patients experience a flu-like reaction or generalized achiness and fatigue which may last for a few days. If this type of reaction occurs, discuss your symptoms with your physician.

Medically reviewed by Joseph Carcione, DO; American board of Psychiatry and Neurology

REFERENCES:

Goldman, M. D., et al. "Multiple sclerosis: treating symptoms, and other general medical issues." Cleveland Clinic Journal of Medicine 73.2 (2006): 177-186.

Graham, L. A. "Management of spasticity revisited." Age Ageing 42.4 (2013): 435-441.

Jankovic, J. "Botulinum toxin in clinical practice." Journal of Neurology, Neurosurgery, and Psychiatry 75.7 (2004): 951-957.

Last Editorial Review: 3/11/2016

Reviewed on 3/11/2016
References
Medically reviewed by Joseph Carcione, DO; American board of Psychiatry and Neurology

REFERENCES:

Goldman, M. D., et al. "Multiple sclerosis: treating symptoms, and other general medical issues." Cleveland Clinic Journal of Medicine 73.2 (2006): 177-186.

Graham, L. A. "Management of spasticity revisited." Age Ageing 42.4 (2013): 435-441.

Jankovic, J. "Botulinum toxin in clinical practice." Journal of Neurology, Neurosurgery, and Psychiatry 75.7 (2004): 951-957.

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