Botulinum Toxin Service
Botulinum toxin is a protein derived from the bacteria Clostridia botulinum. Botulinum toxin is one of the most toxic substances in nature and, in severe forms, may cause fatal botulism. However, when injected therapeutically in small doses, the toxin is a safe and effective treatment for a variety of medical disorders.
Botulinum toxin blocks the release of acetylcholine at the neuromuscular junction, where your nerves meet your muscles, thereby relieving the symptoms of dystonia, spasticity, and other motor disorders. However, evidence suggests that botulinum toxin also offers therapeutic potential for certain nonmuscular disorders, such as hyperhidrosis (excessive sweating), overactive bladder, and chronic migraine headaches.
Botulinum toxin is FDA-approved for the treatment of several movement disorders, including blepharospasm, cervical dystonia, and spasticity. Physicians at Mount Sinai’s Robert and John M. Bendheim Parkinson and Movement Disorders Center and Mount Sinai's neuromuscular division are highly skilled at performing botulinum toxin injections for these conditions.
The primary commercial formulations of botulinum toxin available in the United States for these conditions include Botox®, Dysport®, Xeomin®, and Myobloc®. These formulations differ in potency, thereby requiring different dosages.
Because of the slight risk of bleeding associated with inserting a needle into muscle, tell your doctor if you have a bleeding disorder or are receiving "blood thinning" agents (anticoagulants), such as warfarin (Coumadin) or aspirin.
What to Expect During Your Visit
Botulinum toxin injections are performed in an office setting during a visit usually lasting no more than 30 minutes. The actual injections take only a few minutes. Our physicians often use numbing medications (cream or spray) at the site of the injections to minimize discomfort.
The needles used for botulinum toxin injections are smaller in size than needles typically used to draw blood. For injection of some dystonic (overactive) muscles, we use an EMG or electrical stimulator to more precisely identify the muscles needing injection. In those cases, the EMG machine will make a noise upon insertion of the needle. This noise reflects your muscle's contraction. You may also receive small electrical stimulations through the needle. Your muscles respond to the stimulation by contracting very slightly. Your physician then injects a very small amount of botulinum toxin into your muscles. There is minimal discomfort or bleeding during the procedure.
After the procedure you may continue with your usual activities. Within one to three days, your muscles should relax, significantly relieving your symptoms. This effect usually lasts at least three months, after which time you may need to repeat the injections.
Botulinum Toxin Injections for Spasticity
Spasticity is a debilitating condition caused by injury to the brain or spinal cord in which the muscles continuously contract involuntarily. Botulinum toxin is an excellent, minimally invasive treatment option for spasticity with a low risk of side effects. The treatment is targeted, thereby avoiding potential complications associated with systemic medications or surgical interventions.
David M. Simpson, MD, Director of Mount Sinai's Clinical Neurophysiology Laboratories, has been a leader in the research and clinical use of targeted treatment for spasticity using botulinum toxin. Dr. Simpson and his colleagues provide a coordinated, multidisciplinary approach to spasticity, consulting with rehabilitation medicine, physiatry, physical and occupational therapy, and surgery department staff. Botulinum toxin injections for spasticity are performed in Mount Sinai's clinical neurophysiology area, located in the Annenberg Building, second floor (area 218).
Dr. Simpson headed a research team that performed and published the first placebo-controlled study demonstrating the safety and effectiveness of botulinum toxin (Botox®) in the treatment of post-stroke spasticity. Further studies by Dr. Simpson's group demonstrated the superiority of botulinum toxin over oral anti-spasticity medications.
Dr. Simpson has led several studies to enhance the technique of the botulinum toxin injection. He has lectured and published extensively in this area and trained physicians in these injections throughout the world.
In addition to his spasticity studies, Dr. Simpson chaired a panel chartered by the American Academy of Neurology to develop evidence-based guidelines on the use of botulinum toxin for a wide range of neurological diseases, including adult and childhood spasticity, movement disorders such as cervical dystonia and blepharospasm, pain, including migraine, and autonomic disorders, such as hyperhidrosis (excessive sweating).
Botulinum Toxin Injections for Dystonia
Dystonia encompasses a range of neurological disorders characterized by involuntary movements. Dystonia can affect your neck, eyes, voice, or limbs. Botulinum toxin is the treatment of choice for most of these conditions.
As with spasticity, botulinum toxin can be injected in select muscles affected by dystonia, thereby avoiding potential systemic side effects of medications taken by mouth or complications related to surgical procedures.
Mount Sinai doctors who perform botulinum toxin injections for dystonia, Parkinson's disease, and other neuromuscular disorders include:
- Steven Frucht, MD. Dr. Frucht, Director of Movement Disorders at the Robert and John M. Bendheim Parkinson and Movement Disorders Center, specializes in the treatment of hyperkinetic movement disorders, including task-specific dystonia affecting musicians (an area of interest given his training as a classical musician), myoclonus, and tremor. He also sees patients with blepharospasm, torticollis, hemifacial spasm, jaw dystonia, and sialorrhea. He received his undergraduate and medical degrees at Harvard.
- Winona Tse, MD. Dr. Tse sees patients with Parkinson's disease, tremor disorders, dystonia, and other movement disorders. She has published journal articles, reviews, and textbook chapters on Parkinson’s disease, essential tremor, movement disorders in HIV infection, and restless legs syndrome. Dr. Tse is a diplomate of the American Board of Psychiatry and Neurology and a diplomate of the American Board of Electrodiagnostic Medicine.
- Miodrag Velickovic, MD. Dr. Velickovic specializes in the diagnosis and treatment of dystonia, Parkinson's disease, Wilson's disease, tremor, and ataxia. Dr. Velickovic is affiliated with both the Robert and John M. Bendheim Parkinson and Movement Disorders Center and Mount Sinai’s Wilson's Disease Association International Center of Excellence. Dr. Velickovic has served as faculty during American Academy of Neurology workshops on botulinum toxin injection for cervical, laryngeal, and oromandibular dystonia, blepharospasm, and hemifacial spasm.
Botulinum Toxin Injections for Chronic Migraine Headaches
In late 2010, the Food and Drug Administration (FDA) approved Botox®, a commercial formulation of botulinum toxin, for the treatment of chronic migraine. Doctors affiliated with Mount Sinai's headache group are all very experienced in this treatment. Any preventive and acute medications you are currently taking that offer some degree of relief can be continued during your Botox treatments, although the medications often are reduced or eliminated if the Botox treatments are successful.
Mount Sinai doctors who perform botulinum toxin injections for chronic migraines include:
Mark W. Green, MD, is Director of Mount Sinai's Center for Headache and Pain Medicine. He was previously at Columbia University, where he served as Director of Headache Medicine at the College of Physicians and Surgeons and the College of Dental Medicine. Dr. Green has a long-standing interest in neuropharmacology and is a panel member of the Advisory Board of the Food and Drug Administration’s Section on Peripheral and Central Neurological Drugs.
We Can Help
To determine whether botulinum toxin injections are right for you, please call Mount Sinai's Robert and John M. Bendheim Parkinson and Movement Disorders Center at 212-241-5607 to schedule an appointment. We are conveniently located on the Upper East Side of New York City.
In this New York Times article, Mount Sinai’s David M. Simpson, MD, discusses how Botox can relax the muscles of stroke survivors. Read More