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January 6, 2003


Emory Physician Uses Botox Injections to Treat Spasticity Following Stroke, Spinal Cord Injury and Brain Injury

Botulinum toxin type A, better known as Botox, has been used for more than a decade to treat patients with conditions caused by overactive muscles. Now, an Emory University physician is using Botox injections to treat spasticity, or spastic paralysis, which often occurs following a stroke, spinal cord injury or brain injury. Spasticity is usually caused by damage to the portion of the brain or spinal cord that controls voluntary movement.

"We've been using this treatment on this population of patients over the past several years here at Emory and we're seeing good results," says John Lin, M.D., assistant professor of physical and rehabilitation medicine, Emory University School of Medicine. "Botox injections are a middle-of-the-road treatment for spasticity. We first try drug therapy and rehabilitation and if they donít help, we then turn to Botox. In many cases, this treatment works so well, patients can continue the injections and avoid more complex treatments such as surgery," Dr. Lin says.

Following a stroke, spinal cord injury or brain injury, patients often develop spastic paralysis, a form of paralysis in which the part of the nervous system that controls coordinated movement of voluntary muscles becomes disabled. This leads to stiffness and lack of mobility in these muscles. Doctors can now inject Botox directly into the affected muscles to help loosen and relax them. Muscles in the upper extremity usually respond the best to the injections because they are smaller. Patients can be treated several months or many years after their disability with these injections. "This treatment is great for fine detail of muscle mobility and most any muscle can be selected for treatment," says Dr. Lin. "However, Botox injections are not recommended if one wants to treat a large group of muscles at one time."

Results are usually seen three to seven days following injections, with a peak effect at about one month. The injections tend to last three to six months and repeat injections are usually required. Most people continue to respond positively to Botox injections, although some people develop a tolerance to the drug and experience a diminished response over time. There are few side effects to taking Botox, which makes taking the drug so desirable.

Botulinum toxin is a protein that is produced by the bacterium Clostridium botulinum, once known only as the culprit of the often fatal food poisoning known as botulism. The bacterium causes muscle paralysis by blocking the release of the neurotransmitter, acetylcholine. Normally, acetylcholine plays a vital role in sending messages from the nerves to the muscles that tell the muscles to move. The area where the nerve meets the muscle is called the synapse, and a process called presynaptic release describes the secretion of acetylcholine by the nerve cell. When the synaptic transmission is blocked, the muscle to which that nerve is attached becomes paralyzed. Botox injections block the transfer of acetylcholine, and in doing so, temporarily alleviate muscle spasms caused by too much neural activity.

The use of Botox to treat spasticity following stroke, spinal cord injury and brain injury is through off-label use only, meaning the treatment has not been approved for that specific purpose by the U.S. Food and Drug Administration (FDA). However, off-label use of a medical treatment or device is acceptable provided such use is based on sound and appropriate medical evidence and judgment.

The FDA has approved the use of Botox for cervical dystonia (involuntary, abnormal movements or spasms in the neck), strabismus (crossed or misaligned eyes), blepharospasm (uncontrolled, rapid eye blinking) and for cosmetic treatment of facial wrinkles.

Most of the patients treated with Botox injections at Emory have suffered a stroke ≠ about 60 percent. Brain injuries make up about 30 percent and spinal cord injuries and other disabilities make up 10 percent of treatment. "Day after day, we see how well these injections are working for spasticity control," says Dr. Lin. "Because patients can regain mobility and use of their limbs following an injury or set-back, the injections give an aspect of independence to the patient, as well as comfort and care."

Dr. Lin knows all too well about the importance of independence. A paraplegic for 11 years following a ruptured aneurysm in his back, Dr. Lin is able to make a special connection with his patients, some of whom suffer similar paralysis as he. After his misfortune, he decided to go to medical school and become a doctor, working specifically with patients in rehabilitation medicine. "My disability helped me to figure out what I wanted to do with my life," says Dr. Lin. "I thought I might be able to make a difference and give someone that extra bit of encouragement they needed."

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