Treating Multiple Sclerosis With Botox

Overview

What is spasticity?

Spasticity is a movement disorder that can occur in conditions which affect the brain or the spinal cord, such as multiple sclerosis, stroke, cerebral palsy, spinal cord injury, or brain injury. Spasticity is caused by an imbalance between signals that inhibit or stimulate the spinal cord. This results in hyperexcitable stretch reflexes, increased muscle tone, and involuntary movements.

What are the symptoms of spasticity?

Spasticity causes muscle stiffness and tightness which interferes with voluntary movements. Spasticity can also cause muscle spasms (jerky involuntary movements) or clonus (repetitive involuntary movement).

Stiffness and spasms are often bothersome and sometimes painful, and they interfere with the ability to carry out daily activities. Spasms may also disrupt sleep and increase daytime fatigue. When spasticity is severe, contractures (fixed limitations of range of motion) may develop.

How can spasticity be treated?

Stretching, exercise, and rehabilitation are the first line of interventions for spasticity. Oral medications are often effective, but may cause side effects such as drowsiness. When spasticity affects only a few muscles, local injections of botulinum toxin can be helpful. When spasticity is diffuse and severe, intrathecal baclofen (ITB) may be a good treatment option.

What is botulinum toxin?

Botulinum toxin (BT) is a medication derived from a neurotoxin produced by bacteria (Clostridium Botulinum). In its natural form, this toxin causes botulism, a severe condition that can be fatal. The botulinum toxin medication is designed to be used safely without causing botulism. Three formulations of botulinum toxin A are approved by the FDA for the treatment of spasticity:

  • Abobotulinum toxin A (Dysport®)
  • Incobotulinum toxin A (Xeomin®)
  • Onabotulinum toxin A (Botox®)

How does botulinum toxin work?

Normally, the brain sends messages to the muscles so they can contract and move. These messages are transmitted via the nerves to the muscles by a substance called acetylcholine. BT blocks the release of acetylcholine from the nerve to the muscle, therefore the muscle relaxes.

How do I know If I am a good candidate for botulinum toxin therapy?

BT therapy is usually considered when spasticity needs to be relieved in only a few muscle groups. It can be used in addition to other treatments for spasticity. If your healthcare provider thinks that you may be a candidate for BT therapy, you will be scheduled for an evaluation. During this visit, you will also be given detailed information about the treatment, so you can make an informed decision.

Procedure Details

How is botulinum toxin (BT) given?

BT is given as an intramuscular injection (into the muscle). The injections are given during an outpatient visit, which lasts 30 to 45 minutes. Your healthcare provider will determine beforehand which muscles need to be injected.

Because BT does not travel far from the injection site, several injections are performed during one visit. To ensure that BT is injected in the right place, electrical signals are sent through the needle used for the injection, to make the muscle contract. In some cases, electrical signals from the muscle are recorded via the needle, for the same purpose.

What can I expect after the botulinum toxin injections?

There are no activity restrictions after the injections. The effect of BT is usually not felt until a few days, up to 2 weeks after the injections. We usually ask that you return for a follow-up visit or call with an update 2 to 3 weeks after the injections.

The effect of BT is expected to last between 2 and 6 months, then gradually wears off. Most often, the injections are repeated every 3 months. In many cases, physical or occupational therapy is needed after the injections to maximize the benefits of BT. In all cases, it is necessary to stretch and exercise daily at home.

Risks / Benefits

What are the advantages of botulinum toxin (BT) over other treatments for spasticity?

  • BT is usually effective in relaxing the muscles injected, and provides a stable effect for several months.
  • BT is preferred when only a few muscle groups are spastic, or when spasticity relief is needed in only a few muscle groups.
  • BT is usually very well tolerated, in part because only very small amounts of medication go into the bloodstream.

What are the disadvantages of botulinum toxin?

  • The benefits of BT are limited to the muscles injected. Therefore, it may not be a good treatment choice when many muscles are spastic.
  • The effect of the injections is always temporary, therefore the injections need to be repeated at regular intervals to maintain the therapeutic benefits.
  • There are limits to the amount of BT that can be injected during one session, and to the frequency at which BT can be injected, in part because the body can create antibodies against the medication. These antibodies are not dangerous, but may neutralize the effects of BT.
  • Even though BT therapy is approved for the treatment of spasticity, a pre-authorization is often needed before the treatment can start.

What are the side effects of botulinum toxin?

  • The main side effect is the pain that may occur with the injections. No local anesthesia is given in most cases, because the exact sites of injections are determined during the procedure.
  • The muscles injected can be sore for a few days after the injections.
  • Bleeding and bruising may also occur after BT injections. If you are on a blood thinner, the dose may need to be adjusted shortly before the injections to minimize the risk of bleeding and brusing.
  • BT causes temporary partial weakening of the muscles injected. In most cases, the benefits of spasticity relief outweigh the effects of increased weakness. BT does not cause weakness in muscles that have not been injected.
  • When BT is used for a long time, it may cause atrophy (thinning) of the muscles injected. This atrophy is reversible if the therapy is discontinued.
  • There have been reports of temporary side effects such as flu-like symptoms, palpitations, tingling sensations, or nausea. These side effects are rare, and usually go away within 1 to 2 days.
  • The FDA has reported rare cases of more severe side effects in adults treated with BT, such as difficulty swallowing or breathing.

What happens if I develop antibodies to botulinum toxin?

It is rare that people develop antibodies to BT. If this happens, you may notice that the treatment does not help any more, but no harmful effects from the antibodies have been reported. In some cases, switching from one type of BT to the other helps restore the treatment effect.

Additional Details

Does insurance cover botulinum toxin (BT) therapy?

BT therapy is approved by the FDA for the treatment of spasticity and usually covered by health insurance plans. A pre-authorization is often needed, and there may be a co-pay. Since insurance coverage varies greatly, depending on individual insurance plans, we encourage you to check with your insurance ahead of time.

The following codes can be helpful when calling your insurance:

64642/64643 chemo-denervation of extremity or extremities

  • J0585 Botox® - 100 unit vial
  • J0588 Xeomin® - 100 unit vial
  • J0586 Dysport® - 300 unit vial

In summary:

  • BT therapy can be helpful when relief of spasticity is needed in a few muscle groups.
  • The treatment is usually safe and well tolerated, but needs to be repeated every few months to maintain the therapeutic effect.
  • Daily stretching and exercise, and in some cases rehabilitation, are essential to maximize the potential benefits of treatment.

Last reviewed by a Cleveland Clinic medical professional on 01/28/2019.

References

  • National Multiple Sclerosis Society. Accessed 4/8/2019.
  • Niet MD, Bot ST, Van de warrenburg BP, Weerdesteyn V, Geurts AC. Functional effects of botulinum toxin type-A treatment and subsequent stretching of spastic calf muscles: A study in patients with hereditary spastic paraplegia. J Rehabil Med. 2014;
  • Giovannelli M, Borriello G, Castri P, Prosperini L, Pozzilli C. Early physiotherapy after injection of botulinum toxin increases the beneficial effects on spasticity in patients with multiple sclerosis. Clin Rehabil 2007; 21: 331–337.

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Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy