Recovery with or without botox…?
The question of whether botox injections help at all seem to come up quite frequently in all support groups. Most of the personal opinions online seem to be negative or neutral, but it is impossible to say anything about the average experience without a thorough research. Therefore, in this short article, I am trying to summarise what we can learn from the scientific research on botox, which might help the reader to decide whether to accept it or not.
Diagnosis and botulinum toxin as a suggested treatment
When an official diagnosis of Musician’s Focal Dystonia takes place, most neurologists immediately inform the patient that the condition is not curable. They usually add that with the help of botulinum toxin injections the symptoms might get manageable. The injections need to be repeated in every 2-3 months, otherwise, the symptoms return. Most musicians are left with the choice without any further information.
What is Botox, and where does the treatment idea coming from?
Botox, or botulinum toxin is one of the most lethal biological toxins (Oates, Wood, Jankovic et al., 1991). The process of paralysing the injected muscle is very complex, resulting in a decrease of a certain neurotransmitter, which is essential for the nervous system to communicate with the muscle. Using the scientific term, the muscle becomes ‘functionally denervated’, but only after two days, the body is already building new synaptic contacts to replace the ones which were destroyed. Which means that as the nerve endings regenerate, in most of the cases, the symptom returns. The therapy was adopted from the treatment practice of non-task-specific, more severe and extreme forms of dystonia, such as generalised dystonia (Jankovic, Schwartz & Donovan, 1990; Jankovic, & Brin, 1991). These conditions are characterised by constant and painful symptoms, which interfere with their everyday activities and have further implications on their well-being (Ben-Shlomo, Camfield & Warner, 2002). Even in these serious cases, the use of the toxin is not always helpful and has various side effects (Dressler & Benecke, 2003), such as dry mouth, dry nasal canal, visual impairments, eye irritation, sweating, swallowing difficulties, heartburn, constipation, bladder voiding difficulties, thrush, and head instability. Moreover, there is no or very little information on the long-term effect of the toxin on the body in general. However, in the case of generalised dystonias which cause constant pain and disfigurement, the use of this potentially dangerous drug seems more justified.
Botulinum toxin for MFD
In the case of MFD, the use of botulinum toxin is a questionable choice, mostly employed in the absence of alternatives. Neurologists are not always informed about MFD, but dystonia itself is more known and has been treated with botulinum toxin for decades.
The main problem is that opposing non-task specific dystonias, where the goal is simply to paralyse the over-active body part, is MFD, the sufferer needs to be capable of very fine motor movements with the body area in question after the treatment. Roughly half of the patients report any form of improvement (Altenmüller and Jabusch, 2006; Altenmüller and Jabusch, 2010), and the only patients with hand or finger problems seem to benefit from the therapy, excluding musicians who suffer from MFD in their embouchure or feet. Also, the success of the treatment is highly dependent on the precision in localising the affected muscle, and also on the injection technique used. Most dystonic patterns are accompanied by a compensatory pattern (other muscles trying to take over the affected muscle’s task and workload), which makes identifying the target muscle very challenging (Altenmüller and Jabusch, 2010). The injections given based on only visual examination reach the target muscle only in 37% of the cases (Molloy, Shill, Kaelin–Lang et al., 2002), meaning that in the remaining 63%, healthy muscles get crippled, causing further problems when playing the instrument. The employment of botulinum toxin was strongly criticised by many researchers (Tubiana, 2003), partly because of the serious side-effects, partly because it does not offer long-term rehabilitation.
From the published materials it seems that the effectiveness of botulinum toxin is not reliable, and it might lead to side effects. Even those researchers who are still experimenting with it admit, that different behavioural therapies are not only safer but also more successful in most of the cases (Altenmüller & Jabusch, 2006). The only disadvantage of behavioural therapies is that they take much longer, and this makes many musicians to choose the injections is in the hope of immediate recovery. On a personal note, since the recovery this way is not reliable and includes injecting toxin to very delicate parts of our bodies, I would advise everybody to at least experiment with other treatments before accepting the injections.
Altenmüller, E. & Jabusch, H.Ch. (2006). Focal dystonia in musicians: From phenomenology to therapy. Advances in Cognitive Psychology, 2(2-3), 207-220.
Altenmüller, E., & Jabusch, H. Ch. (2010). Focal dystonia in musicians: phenomenology, pathophysiology, triggering factors and treatment. Medical Problems of Performing Artists, 25(1), 3-9.
Dressler, D & Benecke, R. (2003). Autonomic side effects of botulinum toxin type B treatment of cervical dystonia and hyperhidrosis. European Neurology, 49, 34-38.
Jankovic, J., Schwartz, K. & Donovan, D. T. (1990). Botulinum Toxin treatment of cranial-cervical dystonia, spasmodic dystonia, other focal dystonias, and hemifacial spasm. Journal of Neurology, Neurosurgery and Psychiatry, 53,633-639.
Jankovic, J.& Brin, M.F. (1991). The therapeutic use of botulinum toxin. The New England Journal of Medicine, 324(17)., 1186-1194.
Molloy F. M., Shill H. A., Kaelin–Lang A., Karp B. I. (2002). Accuracy of muscle localization without EMG: Implications for treatment of limb dystonia. Neurology, 58, 805-807.
Oates, J.A., Wood, A., J., Jankociv, J.& Brin, M.F. (1991). The therapeutic use of botulinum toxin. The New England Journal of Medicine, 324(17)., 1186-1194.
Tubiana, R. (2003). Prolonged Neuromuscular Rehabilitation for Musician’s Focal Dystonia. Medical Problems of Performing Artists, 18(4), 166-169.