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Botulinum toxin treatment of focal dystonia

Treatment of involuntary muscle contractions causing unnatural movements and positions

Diagnosis

Dystonia is involuntary muscle contraction which causes abnormal movements and positions, but does not affect other brain functions – it does not affect intellect or sensory function. Focal dystonia is most common, when just one part of the body is affected. This includes cervical (neck) dystonia blepharospasm (spasm of the eyelids), facial hemispasmus (spasms of the face), and other more rare types of dystonia (writer’s cramp, laryngeal dystonia, oromandibular dystonia).

What is botulinum toxin?

Botulinum toxin is a natural toxic substance (also known as „sausage poison“), produced by the bacterium clostridium botulinum. In humans, the ingestion of poisoned food causes the serious disease of botulism. In medicine, however, botulinum toxin has found application in the treatment of certain nervous disorders which are characterized by increased muscular tension, involuntary movements and the twitching of certain muscle groups. Botulinum toxin is acquired for medicinal purposes in a very pure form during the industrial fostering of bacterial cultures under specific, very strictly monitored conditions. The dose used in medicine cannot cause problems in the nature of botulism, even the highest possible therapeutic dose is several times lower than the minimum dose causing general symptoms.

The effect of botulinum toxin

The time of onset and duration of effect of botulinum toxin is individual. The effect of botulinum toxin occurs usually 1-2 weeks after application and lasts for about 12 weeks, when it is necessary to repeat administration. The next application can be administered 10-12 weeks after the previous one. More frequent administration of botulinum toxin increases the risk of antibody formation and the loss of treatment efficacy. Botulinum toxin does not cure the cause of the disease, it only suppresses some of its symptoms. Even repeated and prolonged administration does not guarantee that you will recover and your problem will disappear completely. However, botulinum toxin can be administered long term, and still to good effect, for years. Botulinum toxin only loses its effect after repeated application in a minority of patients. The cause of this loss of effect may be the body’s natural defense mechanism, the formation of antibodies against the foreign protein of botulinum toxin. The risk of antibody formation is increased when too high or too frequent doses of botulinum toxin are applied.

Course of treatment

At our facility we fully examine the patient before their first application of botulinum toxin, the patient is informed of the procedure and signs an informed consent to the procedure. If the patient has already been treated at our clinic, then together with the patient we assess the effect of the treatment since the last application, its duration and any unwanted side effects. We then proceed to the application of botulinum toxin itself. In the case of blepharospasm and facial hemispasm we use an insulin needle for the application, in the case of cervical dystonia and spastic limb disability we use a special hollow application needle under EMG control for the proper evaluation of overactive muscle. The application is minimally painful, there is no need for special measures.  The procedure lasts about 10-20 minutes, before the patient can leave the clinic.

We do not administer botulinum toxin to

  • pregnant or breastfeeding mothers
  • patients with acute myocardial hypersensitivity to any component of the preparation
  • patients with some neuromuscular diseases (generalized muscle disease, hereditary sensory motor neuropathy)
  • patients with impaired neuromuscular transmission (myasthenia gravis, Lambert-Eaton myasthenic syndrome, congenital myasthenic syndromes)
  • patients with coagulopathy
  • uncooperative patients
  • when using aminoglycoside antibiotics which may enhance the effect of BTX
Side effects

In most cases these are mild and transient in nature. They are limited to the place of administration, only very rarely do they spread to more distant muscle groups. Common complications include hematoma formation and swelling. There can be a considerable weakening of strength at the injection site. If you suffer from blepharospasm, you may suffer from drooping eyelids, double or blurred vision, watery eyes, dry eyes, light sensitivity or a temporary drooping in the corner of your mouth may occur. If you suffer from cervical dystonia, the weakening of neck muscles and nodding of the head may occur. When applied to muscles in spastic disability of upper or lower limbs, the limbs may lose strength.  It must be stressed that these complications are not serious, they usually last a few days or weeks, and the beneficial therapeutic effect persists even after remission. Occasionally a transient flu-like reaction may occur within 24 hours of application with a rise in temperature, which subsides after conventional measures. In case of any side effects, tell your doctor, who will advise you on how to proceed. If BTX has not taken effect after 2-3 weeks, it is possible that the BTX dose was not strong enough for your muscles, or that the substance was not applied to all the muscles responsible for your problem. No new application can be performed earlier than 2.5-3 months after the previous one, due to the risk of antibody formation and eventual loss of efficacy during more frequent applications.

For specialists

Patients can order this treatment by telephone at our facility. We require a referral from a neurologist or general practitioner or other outpatient specialist (ophthalmologist, otolaryngologist, rehabilitation doctor). Referrals must include the medical history of the patient, subjective complaints, objective findings, clearly specified diagnosis and the reason for the application.

It is for diagnosed cervical dystonia, spasticity in patients after strokes. A special needle for BTX application under EMG control must be purchased in the hospital pharmacy and healthcare shop for 600-650 CZK.

Contact:

Phone: 485 312 728, Mrs. Michaela Chalupová, pavilon B, Neurocentre – neurology, 7. floor, EMG ambulance. E-mail : denisa.simova@nemlib.cz