Botox (botulinum toxin Type A) has been available in the United States for clinical use since 1989. At that time it was approved by the FDA for treatment of eye and facial muscle spasm disorders, blepharospasm and hemifacial spasm respectively. Then in 2000 the FDA approved Myobloc (botulinum toxin Type B) for treatment of cervical dystonia, a condition of involuntary neck muscle spasm. The dystonias, as a class of muscle spasm disorders, are characterized by involuntary muscle spasms involving the muscles in the neck, face and extremities. The cause of the majority of these conditions is unknown. In some individuals, spasticity (tight muscles which cannot be relaxed, a form of dystonia) can result from stroke, traumatic brain or spinal cord injury or cerebral palsy.
Prior to the use of Botox, it was very difficult to treat muscle spasm disorders. Medications had side effects and surgery had limited benefit associated with the risk of complications. Botox opened an entirely new avenue to treat spasticity. The drug works by causing a chemical relaxation of muscles that are injected. Botox is highly selective in that it remains in the muscles that it is injected into. Patients with cervical dystonia have difficulty with their head pulling to one side of the other. They may also have their head pulling backward or forward. Not only is this condition painful, it also causes patients to have functional difficulty with activities such as driving, playing sports or even eating. In patients with limb dystonia, there is involuntary spasm of an arm, leg or both. This can cause difficulty with dressing, walking or even personal hygiene (if their hand is fisted up.) Botox (or Myobloc) can provide excellent relief of these symptoms thereby improving patients’ quality of life. For patients with severe muscle spasticity from stroke, Botox provides relief of the tight muscles allowing for greater ease in certain activities. It is important to note that Botox (or Myobloc) will not restore function of any limb affected by the stroke. What the treatment will do is provide increased comfort due to reducing pain from spasm and allow for improved ease in doing some daily activities.
Blepharospasm is characterized by involuntary blinking which can result in forced eye closure and functional blindness. Affected individuals may have difficulty driving or watching a movie because of this. Botox has been shown to be the single most effective treatment for this condition. Of all the muscle conditions treated with Botox, none respond as well as those patients affected with hemifacial spasm. This condition affects one side of the face and is characterized by spasm the facial muscles on that side. This can also result in a degree of functional blindness. While most conditions treated with Botox (or Myobloc) have a therapeutic effect for 2-3 months before requiring retreatment, patients with hemifacial spasm may not need retreatment for anywhere from 3-6 months.
For any patient considering receiving Botox or Myobloc, it is important to see a physician familiar with diagnosing and treating these uncommon movement disorders. These individuals are familiar with administration of Botox or Myobloc which will help to obtain optimum results from each treatment
Posted in Botox, Movement Disorders, Stroke and tagged blepharospasm, Botox, cervical dystonia, dystonia, Dystonias, FDA approval, hemifacial spasm, limb dystonia, movement disorder, Movement Disorders, Movement Disorders, Myobloc, Quality of Life, spasticity, Stroke by Dan Kassicieh, D.O.
Neck and back pain are some of the most common conditions for which patients seek out medical care. It is estimated that 8 out of 10 Americans will have at least one significant episode of back or neck pain in their life. For many, this can be a recurrent or persistent problem. Fortunately over 90% of the cases can be treated without surgery or other invasive procedures. The most common underlying cause for back pain is poor body conditioning. With our sedentary life styles, it is no wonder that we become deconditioned. Even persons who exercise regularly are prone to developing back or neck pain problems. Without doing specific back and neck stretching and strengthening exercises, we are setting ourselves up to have back pain. Something as simple as bending over to tie a shoe, reaching up in the cupboard or even sneezing can trigger an acute back pain episode. Neck pain is frequently caused by “sleeping wrong at night”, sleeping on a plane or just straining the neck when lifting or playing sports. All of these variations of neck and back pain have as a cause, muscle, tendon and ligament strain. Particularly in the back, individuals will have gradual tightening of the back and hip muscles and not even feel it. Then, when a “minor event” such as coughing occurs, these already tight muscles go into sudden spasm which then is felt as pain. With the acute spasm, patients can have trouble turning their head, bending over, walking and sleeping. Fortunately most of these conditions can be treated without surgery, invasive procedures or even MRI scanning.
In the vast majority of patients, a careful history and detailed physical exam is the basis for developing a treatment plan. Most patients show significant back and/or neck muscle spasm with tenderness. Some patients can have exquisite tenderness in the sacroiliac joint – where the tail bone meets the hip bone. The rest of their neurological exam is usually normal. In these individuals having a CT or MRI scan of the neck or back is not a necessary part of the initial treatment plan. A specifically designed course of hands on physical therapy combined with neuromuscular therapy in combination with self administered neck and back stretching and strengthening exercises will result in favorable outcomes the majority of the time. Sometimes anti-inflammatory medications or muscle relaxants can be of benefit. Narcotics should be avoided as they are habit-forming and do nothing to clear up the pain. In very specific cases, limited use of nerve blocks in the sacroiliac area or lower neck may be helpful. Epidural steroids, for the most part, are not particularly helpful and carry significant complication risks with them; particularly in the neck. For patients that do go on to have MRI studies, it is not uncommon to finding xray abnormalities but these do not necessarily explain the pain that that individual is experiencing. The important message is that the MRI findings must correlate exactly with the patient’s symptoms and neurological exam to have clinical significance. MRI studies of normal individuals without back pain have been done. The results have shown that approximately 38% of these MRI scans showed abnormalities and yet the patients had no symptoms. The conclusion is that just because the MRI scan shows “something”, it does not necessarily mean that that is the cause of your pain.
With careful management and patient cooperation to do the exercises most patients have significant relief with subsequent clearing of their pain within 4-6 weeks. It is then important that patients continue to do their neck and back exercises on a regular basis, as part of their daily exercise routine. With doing this back surgery or neck surgery can almost always be avoided. The most important step in getting better is to seek out care from a knowledgeable, medical physician such as a neurologist or physiatrist who specializes in the non-surgical treatment of neck and back conditions. More information on back disorders can be found at my website or at Spine Universe.
Posted in Back Pain and tagged back exercises, Back Pain, Back Pain, back surgery, epidural steroids, neck pain, neck surgery, neurologist, Physical Therapy by Dan Kassicieh, D.O.
High cholesterol and triglyceride levels are at epidemic proportions in the United States. It is estimated that there are 30 million affected individuals with this condition but only about 10% are treated with medications. This is an unfortunate fact considering that vascular disease (heart disease, stroke) combined is the leading cause of death in the United States. Multiple clinical studies have shown the dramatic beneficial effects of the main class of cholesterol lowering drugs, the statins. The summary of these studies is that they provide a 25-35% secondary risk reduction in ischemic vascular events. The class of statins include: Zocor, Lipitor, Pravachol, Crestor and Mevacor. While highly effective in lowering total cholesterol as well as “bad cholesterol” and raising “good cholesterol” (LDL and HDL, respectively, these medications require lab monitoring for liver and muscle problems. Fortunately the incidence of severe side effects is low. More commonly, patients treated with these drugs can have muscle and joint pains. With proper treatment and monitoring, patient’s experience an over all improvement in health and marked reduction in their risk for having a stroke or heart attack. For every 1 million patients treated with one of these agents, 10,000 stroke and heart attacks are prevented, annually. The economic and personal benefits of this are staggering.
There are other non-medication ways that individuals can lower their cholesterol. The American Heart Association lists the benefits of taking fish oil supplements in cholesterol reduction. Other nutritional aids can include flax seed and limiting sugar intake. Of course regular, daily exercise, stop smoking and a healthy, low-fat diet are all important in controlling cholesterol levels and blood pressure.
In summary, one cannot “feel” elevated cholesterol levels. It is an insidious disease that causes a slow death by gradually blocking off arteries that carry blood to the vital organs of the body. If you are overweight, have diabetes, smoke or have a family history of these or high cholesterol, you should see you health care professional for further evaluation.
Posted in Stroke and tagged American Heart Association, bad cholesterol, cholesterol, Crestor, fish oil, good cholesterol, heart attack, heart disease, High Cholesterol, Lipitor, Mevacor, Pravachol, statins, Stroke, Zocor by Dan Kassicieh, D.O.
Botox is a potent neurotoxin that causes muscle paralysis by blocking the release of the neurotransmitter, acetylcholine, from the nerves that control muscles. When given under controlled clinical applications, this medication can have a dramatically beneficial effect in relieving muscle spasm due to certain conditions such as cervical dystonia, blepharospasm, hemifacial spasm and limb dystonia. Over the past several years the media has reported that Botox can relieve migraines. These claims are based on random reports of individuals who may have gotten some benefit. The manufacturer of Botox, Allergan, has conducted several nationwide studies on the use of Botox for headaches, none of which have shown a statistically significant difference over placebo. Sandra Leong writes in Natural Headache Remedies a summary about the use of Botox in the treatment of various headache disorders. She notes that one theory on how Botox works for migraine is by relieving the muscle tension. It should be noted however that physiologic studies have not shown an overall increase in muscle spasm around the head in patients suffering from acute headache attacks. It is also important to note that the placebo effect in headache studies is as high has 35%.
In a summary of the studies done by Allergan for headaches, Medical News Today lists the previous and ongoing studies that the company is conducting to analyze the potential benefits of Botox in the treatment of migraine and other headache disorders. Personally, having participated in several of these Botox trials, I would agree with the study results that there was no distinct clinical benefit from Botox over placebo. It is important to note however that these were randomized, double blind placebo studies where neither I or the patient knew if they were getting Botox or placebo saline injections. I base my conclusions on reading the final study reports. At the Florida Headache & Movement Disorder Center, we carefully screen patients with head and neck pain for the possibility of benefiting from Botox therapy. Only very few patients actually meet my criteria for using Botox for migraine treatment. Even with this careful selection of patients, our results are about 50% success rate, slightly higher that the placebo effect rate. The patients that benefit the most from Botox treatment most commonly have a high degree of muscle spasm in their neck and head, associated with but separate from their actual headaches. There have been reports by other respected headache specialists, in non-controlled trials, that Botox may effective for some patients with migraine.
In conclusion, Botox has not been shown to have a major therapeutic advantage in the treatment of otherwise intractable migraine and headache disorders. The “media hype” is without scientific basis to back up the claims cited in many reports. If you have recurrent headaches, your best bet it to be evaluated and treated by a board certified headache specialist.
Posted in Botox, Migraines / Headache and tagged acetylcholine, Allergan, blepharospasm, Botox, cervical dystonia, Florida Headache & Movement Disorder Center, headache, headaches, hemifacial spasm, limb dystonia, migraine, migraine treatment, movement disorder, neck pain by Dan Kassicieh, D.O.