At age 35, at the height of his concert career, celebrated pianist Leon Fleisher lost the use of his right hand to dystonia, a neurological disorder. For the next 35 years, Fleisher searched unsuccessfully for a cure, trying everything from L-dopa, a drug used to treat Parkinson's disease, to a physical therapy called Rolfing.

Nothing helped.

Then, in the mid-1990s, an injection of Botox relaxed his clenched fingers, allowing him to play two-handed piano for the first time in decades. And last year, following a series of Botox injections, Fleisher embarked on his first major concert tour in nearly 40 years.

These kinds of success stories are inspiring more and more doctors to use Botox to treat serious conditions that traditional therapies don't help.

Botox was first approved by the FDA for medical use in 1989 to treat eye muscle disorders, such as spasm. This foe-turned-friend is derived from the nerve toxin that causes botulism, a rare but life-threatening illness from bacterium Clostridium botulinum. These rod-shaped spores can grow in improperly prepared or stored foods, the intestines of infants, and infected wounds.

When the paralytic agent is diluted and specially treated, it can be injected to create temporary muscle paralysis—on purpose. It currently is being tested for “off-label” applications (for conditions other than its original purpose) as a treatment for

• stroke paralysis
• facial tics
• stuttering
• back pain
• incontinence
• writer's cramp
• carpal tunnel syndrome
• tennis elbow

It is already used for

• wrinkle reduction
• eye squinting
• certain headaches
• jaw clenching
• muscle spasticity
• movement disorders
• bladder spasm
• excessive sweating

Breaking a sweat—in half

“As a safe treatment for excessive sweating, Botox is getting attention of late since the FDA has approved its use for patients as young as 18 years old,” says Dr. Adelaide Hebert, professor in the Department of Dermatology at the University of Texas Medical School at Houston. “Though there are surgical treatments for sweating, there can be complications. Botox does not carry those risks.”

Hands, feet, armpits, trunk and face are the more common sites of hyperhidrosis or profuse sweating.

“There are people who sweat so much they literally slide around in their shoes when they walk,” describes dermatologist Craig Teller, adjunct professor of dermatology at UT Medical School. One of his patients was a high-school senior whose hands sweated so much she was too embarrassed to date or get involved in after-school activities.

Hebert and Teller treat these patients by determining the pattern of sweating and following with a series of Botox injections. Just as the toxin inhibits the nerves that cause the muscles to contract, it inhibits some of the nerves in the hand, foot or armpit that stimulate the sweat glands.

Hebert says that since its FDA approval for hyperhidrosis, some insurance companies are starting to cover Botox treatment.

Headache treatment

Teller also has successfully treated patients with migraine headaches. One 23-year-old patient who had severe migraines ended up one night in the emergency room. Teller suggested Botox injections, and after three treatments over 12 months the young woman says her migraine headaches are gone.

“I have a new neurologist to make sure nothing is wrong internally,” she says. “So I don't know if I've outgrown my headaches or what, but Botox has really given me relief.”

Tension headaches caused by referred pain from muscle spasm may also respond to Botox injections.

Muscle disorders

Botulinum toxin first made medical news as a therapy in the early 1990s when physicians found it helped relax muscles in patients suffering from spastic hypertonia, severe muscle stiffness and involuntary jerking. Hypertonia, also known as spastic hypertonia occurs when the normal messaging between the spinal cord and the reflex center of the brain is interrupted through injury or disease.

This overactive muscle response usually results from stroke, spinal cord injury, brain trauma, or other neuromuscular diseases, such as multiple sclerosis or cerebral palsy. Motor response can range from clenching and severe stiffness to violent jerking, flailing, cramping or shock-like contractions in any muscle group in the body.

“Sometimes we use it just to unclench a fist or relax large leg muscles so that the patient can be bathed and properly cared for. Often, we can improve function significantly, with repeated treatments,” says Dr. Gerard Francisco, clinical associate professor in the Department of Physical Medicine and Rehabilitation at the UT Medical School, who also specializes in hypertonia. “Now and then, Botox can restore full muscle function, not often, but it does happen.”

Though the outcomes vary, Botox injections have revolutionized treatment for the residual effects of brain and spinal cord conditions. “It is a significant part of our daily practice and when used together with physical therapy, major improvements to a patient's life are possible,” Francisco says.

Bladders and botox

Bladder disorders, including incontinence – serious problems for some women – also can be successfully treated with Botox. When traditional treatments don't help for overactive bladder syndrome, for instance, Botox can be injected into various sites in the bladder wall in an outpatient procedure, explains John C. Hairston, M.D., assistant professor of surgery in the Division of Urology at the medical school.

As with all Botox procedures, however, the treatment is not permanent and may require repeated injections. And along with most other Botox applications, it hasn't gained FDA approval yet, and may not be covered by insurance.

“But I've used Botox and it works well,” says Hairston. “Now I'm trying to use it more in the neurologic population with bladder dysfunction from spinal cord injuries and multiple sclerosis.”

Anti-Aging and Cosmetic Uses

Therapeutics aside, Botox continues to serve as the premiere non-surgical antidote to time and gravity. Though the brow and forehead are still the most common sites of injection, here are some of the newer ways dermatologists are using Botox:

• Eyebrows can be slightly lifted “to change angles and arches,” Teller says. “If a woman, for instance, looks sad or heavy – or masculine – we can give her a bit of a happier, more open expression.”
• Deep creases or dimpling in the chin can be diminished.
• The corners of the mouth that start to sag from gravity and time can be lifted.
• Some creases in the neck associated either with aging or gaining weight can be eliminated.
• The chest just above the cleveage area may develop creases when women spend too much time in the sun. Botox injections can help soften those lines.

Warning: Shop the doc

No matter how many new applications there are for Botox, it is still important to choose a good doctor, Hebert warns. When four people in Florida (including the administering physician) were hospitalized last fall with severe botulism poisoning, authorities found that they had received an unapproved, raw botulism toxin. The physician was trying to cut corners by manipulating the toxin himself. Botox is the brand name for botulinum toxin type A, the approved serum, produced by Allergan Pharmaceuticals.

“The key is to go to a qualified board-certified physician who has extensive experience with Botox and not to be afraid to ask questions,” Hebert says.

Botox is not cheap and is still considered a splurge by most people. The price varies depending on the number of injections and the physician's charging policies. Average fees can run $250 to $1000.

But potential women candidates may take heart in this tidbit: male patients have a higher muscle mass and require more Botox, so they have to pay more.

UPDATED: 6-03-2005

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