On a More Serious Note

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The following is an article I wrote to submit to magazines – unfortunately, People turned me down.

My previous entry about botox generated a buzz on the Bookface and it wasn’t even scholarly. This one is more informative and could prove to be more helpful.

Be warned, this article is long and boring.

To Botox or not to Botox?

 Wouldn’t it be nice if there was a catch-all medication for the symptoms that occur after a brain injury or stroke? Alas, the symptoms and deficits left in the wake of such an event are so varied that such a medication would have to address thousands of symptoms. One such symptom that I continue to experience, resulting from a hemorrhage and surgery back in 2009, is spasticity, or “motor dysfunction arising from upper motor neuron lesions… significantly interfer(ing) with body image, balance and gait.”*

A common treatment for spasticity is botulinum toxin. This treatment involves vials of this toxic substance and several needles. I won’t sugarcoat it, you become a human pin cushion; I’ve had to endure as many as 15 injections in my left leg (yes, that includes my foot) and left arm.

I continue to endure this treatment because, for me, it works. However, there are some shortcomings to this treatment – that is to say, there are areas where botulinum toxin falls short; this has been my experience and the research backs me up. Before I discuss the strengths and weaknesses of botulinum toxin, I’ll tell you more about the general applications of botulinum toxin.

General Information

The consensus according to the medical literature is that botulinum toxin does work, the degree to which it helps varies depending on: 1. Where it’s injected, 2. The dose, and 3. Active vs. Passive outcomes (more on this later). Concerning the injection location, studies are divided into upper limb outcomes and lower limb outcomes. Much of the current research looks at the effect of botulinum toxin in the upper limbs (elbow, wrist, finger flexors, etc.). What little research there is for lower limb outcomes shows an improvement in gait, speed, stride length and standing posture.* Dosing is pretty straightforward – a bigger dose produces better results. With a higher dose comes the question of side effects. I’ve not experienced any of these, but it’s possible for 1. The botulinum toxin to seep onto surrounding muscle – causing them to become weaker, 2. A muscle to receive too much botulinum toxin, making it difficult to use; thereby stifling any therapeutic advantage, and 3. Building an immunity to botulinum toxin.** Moreover, a higher dose does not increase the duration of the results; there doesn’t appear to be any correlation between the amount of medicine and the length of time that spasticity symptoms subside.***

Passive vs. Active Outcomes

Improvement is not easy to define. Outcomes are often classified as “active” or “passive”. Active improvements refer to a measurable change in some activity (a timed walk, putting on a shirt, etc.). Passive improvements report changes in spasticity symptoms at rest. The former are measured by a therapist or doctor using one of various tests of function; the latter can be observed and reported by a therapist or doctor, but are more often expressed by the patients,*** or caregivers.**

As previously noted, treatment is divided into two zones: 1. Upper limb, and 2. Lower limb. This being the case, the results of botulinum toxin treatment fall into four categories: 1. Upper limb active outcomes (functional improvements, such as getting dressed faster or completing household chores more quickly), 2. Upper limb passive outcomes (relief from the spasticity symptoms, etc.), 3. Lower limb active outcomes (stride length, speed, standing posture, etc.), and 4. Lower limb passive outcomes (relief from spasticity in the lower limbs).

Upper Limb Outcomes

There is no shortage of data available that focuses on upper limb responses to botulinum toxin treatment. Although they all have different results, there are a few constants –

1. More botulinum toxin = better results

2. More botulinum toxin ≠ Longer duration of results

3. Despite the outcome of any functional measurement, patients report being more comfortable

4. Combining therapies (electronic stimulation, physical therapy, wrapping, etc.) will produce better outcomes, both in terms of active and passive.

Active outcomes are a mixed bag. A report analyzing data from several studies of botulinum toxin treatments for both upper and lower limbs found “no significant functional improvement” in five out of ten studies. Eight out of the ten reported “significant reduction” in symptoms related to spasticity; four of those eight specifically mention an increased range of movement in the fingers, wrist and/or elbow.*

A first-hand study found similar results; including, “significant reduction in spasticity at the wrist and fingers with a greater range of passive movement at the wrist and less finger curl at rest.”***

These findings suggest that botulinum toxin may not help much in terms of functional activities (i.e. getting dressed), but there’s a pretty good chance that these injections will relieve some of the passive symptoms of spasticity.

Interestingly, some patients reported and were observed to have a better walking pattern due to upper limb injections. It is believed that this unintended effect was the result of “better walking symmetry.”***

My Upper Limb Experience

When I started getting botulinum toxin injections, a small part of me hoped that the injections would completely restore my dexterity and coordination, or at least make my left arm more useful. I did get a little more use out of it, but at the time, the improvement was not enough to justify continued treatment.

I have since continued with upper limb treatment with the understanding that my arm won’t be lot more useful, but I will get some relief from spasticity. My experience with lower limb injections has been more successful from a functional standpoint.

Most of my injections go to my left leg. My doctor will often inject what is needed in my leg first, then whatever is left goes to my arm. Therefore, most of the experience I will relate will be with the leg.

Lower Limb Outcomes

Published research for lower limb botulinum toxin injections are generally positive. In an article from Neurology, researchers pooled data from multiple studies and found that injections in the hamstring and calf were effective in improving gait.**

With lower limb results, passive outcomes often lead to active outcomes. For instance,

“While correlation has been observed between muscle tone reduction and gait parameters, significant improvements have also been reported for walking speed, stride length and premature activity of soleus muscle after injection.”*

Studies that report the effects of lower limb outcomes tend to focus on issues associated with spasticity below the knee.

In the case of the thigh, studies have found some improvement in functional outcomes with hamstring injections and adductor injections.**

Most of the research regarding botulinum toxin in the lower limbs focuses on injections in the gastrocnemius (calf). One study in particular reported “Improved gait over 1 to 3 months.”** Other studies document similar results. Specifically, a study of 12 patients with spastic calf muscles showed improvement in “Velocity, stride length and stance symmetry.”***

My Lower Limb Experience

Spasticity in my left leg makes it difficult for me to walk. Without the injections, it’s difficult for me to raise my foot (ankle dorsiflexion), causing my foot to drag. In terms of function, the injections help smooth my gait by making it easier to lift my foot. Spasticity also causes the toes on my left foot to constantly curl, making them sore. I get relief from this discomfort, (note: to relieve spasticity in the toe flexors, I have to get shots in the bottom of my foot – painful, yes. Worth it? Absolutely.)

I can’t offer much information regarding injections into the hamstring. Although I have gotten them in very small doses, my doctor typically advises me to inject more into the calf muscle. The problem with the hamstring is that, if injected with too much botulinum toxin, the hamstring will be too weak for standing and walking.

I like benchmarks to measure improvement. At the end of last year I decided to time myself as I walked the perimeter of my apartment complex (roughly 1/4 mile) – my time shows an improvement when within the window of botulinum toxin’s greatest effect (10 days to two months after injection). As of this writing, my last botulinum toxin treatment was Thursday 1/03. My average time on the walks before then is 8:10. The average time for walks from the two months after the injections is 7:56. Not only do I move a bit quicker, but I feel like I’m walking much more smoothly. Both of these are due to increased dorsiflexion in my ankle – I don’t drag my foot as much.

Closing Thoughts

Like with any treatment, it’s always better to be informed and aware of what to expect. That is especially the case with a treatment like this one. Most people don’t enjoy getting one shot, let alone a dozen or more.

It is debatable how much more function you might gain, but both research and I agree that you will get some relief – worth a try while we wait for a treatment that covers every symptom of stroke/ brain injury.

*Ozcakir, S., & Koncuy, S. (2007). Botulinum Toxin in Poststroke Spasticity. Clinical Medicine & Research, 5(2), 132-138.

**Simpson, D. M., Gracies, J., & Graham, H. K. (2008). Assessment: Botulinum Neurotoxin for the treatment of spasticity (an evidence-based review): Report of the therapeutics and technology assessment subcommittee of the american academy of neurology. Neurology, 70(19), 1691-1698. Retrieved from http://www.neurology.org/content/70/19/1691.full.html

***Smith, S. J., Ellis, E., White, S., & Moore, A. P. (2000). A double-blind placebo study of botulinum toxin in upper limb spasticity after stroke or head injury. Clinical Rehabilitation, 14(5), 6-13. Retrieved from http://cre.sagepub.com/

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