Few people know that botulinum toxin type A — BoNTA, better known by its trade name Botox — can do a lot more than perk up social lives by ironing out wrinkles and drying up overactive sweat glands. The beauty toxin is increasingly being used as part of the rehabilitation therapy given to people who develop spasticity in the arms and legs following a stroke.
Results from a large study published in Archives of Physical Medicine and Rehabilitation last month show that repeated treatment with botox reduces upper limb (wrist, finger and/or arm) spasticity following stroke, and is associated with significant improvements in patients’ ability to function in their daily lives. Apart from reduction in pain, the study also reported significant reduction in both hours of care needed by the patient each week as well as the number of days that caregivers missed work to care for the patient.
Closer home, the study findings are confirmed by the families of 52 patients who were given botox injections as part of their rehabilitation therapy at Apollo Hospital’s Stroke Clinic in New Delhi over the past one year. “Botox is injected in the muscle to block overactive nerves that trigger excessive muscle contractions in patients who do not respond to physiotherapy and medicines three months after a stroke. Almost all showed improvement after the botox shots were given, and only two of the 52 patients we treated needed a second injections,” says Dr Pushpendra Renjen, consultant neurologist, Apollo Hospitals. While the US study confirmed benefits on the arms and wrists, botox has been used successfully for leg spasticity at Apollo.
One of the patients who benefited from botox therapy is a 65-year-old Delhi businessman, who suffered from a thrombotic stroke in the left side of the brain. When spasticity remained in his legs even six months after regular follow-ups, neurologists injected 100 units of botox in his legs. “Despite the very severe spasticity, just 100 units of botox helped to relieve the pain and he was walking unaided in two months,” says his son. Usually, stroke patients take at least four to six weeks to show significant improvement after being given botox shots.
Roughly one in three stroke patients develop spasticity, often affecting the hands and wrists. Spasticity occurs when muscles in some areas of the body become tight and painful, which makes it difficult for the patient to relax them, making movement difficult. Spasticity can be very disruptive because it interferes with mobility and makes routine activities such as dressing, hygiene and eating difficult.
Botox benefits patients on several fronts. It significantly reduces spasticity in the limbs; reduces pain and improves the patients’ ability to perform activities related to work as well as daily living, such as bathing, dressing, and mobility. The improvements are also associated with statistically significant decrease in the number of hours per week patients requires assistance for routine activity.
There are measurable benefits for caregivers too. The US study found that prior to treatment, the patients had required an average of 26.2 hours per week of assistance by a friend or family member, and friends or family members took an average of 2.5 days each month off from work to provide care. After treatment, the average number of hours per week of assistance provided was reduced by a third and the work time lost by the caregiver was reduced by an average of 1.5 days.
Despite the positive results, doctors are not calling botox a miracle cure for spasticity. “It does help the muscles relax but the patients still need to undergo extensive physiotherapy to keep their muscles supple and active,” says Renjen.
The cost of therapy depends on the amount of botox used. Patients need one to two 100 unit vials of botox. With each vial priced at Rs 15,000, the cost of treatment varies from Rs 20,000 to Rs 35,000. The dose is determined by the bulk of the muscle and the degree of stiffness.
At Apollo, botox has not been used to treat long-term stroke survivors who have retained some degree of spasticity despite treatment. Neurologists, however, are not dismissing the possibility just yet. “The results may not be as positive in people who have had long-term spasticity, but I’m sure there will be some benefit. It’s a risk we will have to take,” says Renjen.
Side-effects are few, with some patients reporting temporary muscle weakness or pain in the extremities. “Botox has fewer side-effects than many oral anti-spasticity medications, which are associated with sedation, dizziness and muscle weakness, all of which can impair stroke rehabilitation,” says Renjen.