Tag "Botox"

Post-concussion symptoms have long been thought to be more severe and prolonged in people who have pre-existing psychological problems. This has been shown to be the case in the military personnel. A new study confirmed this observation in the first prospective study. Over 2,000 high school and college athletes in Wisconsin were asked to answer 18 questions (Brief Symptom Inventory-18, or BSI-18) and then were followed for three years. The 18 questions, which are listed below, addressed the presence of anxiety, panic attacks, depression, and somatization (excessive bodily sensations). In the ensuing three years, 127 athletes sustained a concussion. The concussion had to be diagnosed by a licensed athletic trainer according to the Department of Defence definition, which includes alteration of mental status with associated headache, nausea, vomiting, balance difficulties, dizziness, cognitive difficulties, and other. These athletes were again evaluated two and six weeks later. Eighty percent of concussed athletes were men. The mean duration of symptoms was five days. Ninety five percent of them recovered completely within a month. High somatization score on the BSI-18 questionnaire predicted prolonged duration of symptoms, while no correlation was found with the years of playing a sport, the type of sport (most played football), number of prior concussions, migraines, ADHD, or the grade point average. Another factor that delayed recovery was the initial symptom severity after the concussion. Most of the concussions were mild with less than 10% of athletes losing consciousness.

An interesting and unexplained fact, not examined in this study, is that milder concussions tend to cause more severe symptoms than severe ones.

This was a very thorough study, but it was relatively small, so it is possible that other pre-concussion factors may also delay recovery. One such factor is pre-existing migraines. I see many patients, adults and children, who suffered from migraines and after a concussion have worsening of their migraines or new daily persistent headaches. If they themselves have never suffered from migraines, often their mother or siblings have a history of migraines, suggesting genetic predisposition to migraines.

Treatment of post-concussion symptoms, include typical therapies employed in migraine sufferers, including aerobic exercise, biofeedback, magnesium supplementation, Botox injections, and a variety of medications.

Brief Symptom Inventory-18

The Somatization dimension
01. Faintness or dizziness
04. Pains in heart or chest
07. Nausea or upset stomach
10. Trouble getting your breath
13. Numbness or tingling in parts of your body
16. Feeling weak in parts of your body
The depression dimension
02. Feeling no interest in things
05. Feeling lonely
08. Feeling blue
11. Feeling of worthlessness
14. Feeling hopeless about the future
17. Thoughts of ending your life
General anxiety
03. Nervousness or shakiness inside
06. Feeling tense or keyed up
15. Feeling so restless you couldn’t sit still
09. Suddenly scared for no reason
12. Spells of terror or panic
18. Feeling fearful

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Tension headaches can be prevented, or at least made milder by strength training, according to a new Danish study just published in the journal of the International Headache Society, Cephalalgia.

Tension-type headache is the most common type of headaches and it is usually accompanied by increased muscle tenderness.

The researchers compared muscle strength in neck and shoulder muscles in 60 patients with tension-type headaches and 30 healthy controls, using rigorous strength measurement techniques. Patients were included if they had tension-type headaches on more than 8 days per month and had no more than 3 migraines a month. Compared to controls headache patients had significantly weaker muscle strength in neck extension, which helps keep the head straight. Headache patients also showed a tendency toward significantly lower muscle strength in shoulder muscles. Among the 60 headache patients, 25 had frequent headaches and 35 had chronic tension-type headaches (defined as occurring on 15 or more days each month).

The use of computers, laptops, tablets, and smart phones has increased in recent years and this may increase the time people are sitting with a forward leaning head posture, which contributes to neck muscle weakness.

Neck pain and tenderness is a common symptom in both tension-type and migraine headache sufferers.

This is not the first study to show that muscle strength and weakness were associated with tension-type headaches, but it is still not clear whether the muscle weakness is the cause or the effect of headaches. Neck and shoulder strengthening exercises have been shown to reduce neck pain in previous studies and in my experience strengthening neck muscles will often relieve not only tension-type headaches, but also migraines. So it is most likely that there is not a clear cause-and-effect relationship, but a vicious cycle of neck pain causing headaches and headaches causing worsening of neck pain and neck muscle weakness.

Physical therapy can help, but the mainstay of treatment is strengthening neck exercises. Here is a YouTube video showing how to do them. The exercise takes less than a minute, but needs to be repeated many times throughout the day (10 or more). Many people have difficulty remembering to do them, so using your cell phone alarm can help. Other treatment measures include being aware of your posture when sitting in front of a computer or when using your smart phone, wearing a head set if you spend long periods of time on the phone, doing yoga or other upper body exercises, in addition to the isometrics.

Sometimes pain medications or muscle relaxants are necessary, while for very severe pain, nerve blocks and trigger point injections can help. Persistent neck pain can respond to Botox injections. When treating chronic migraines with Botox, the standard protocol includes injections of neck and shoulder/upper back muscles. Here is a video of a typical Botox treatment procedure for chronic migraines.

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A good predictor of response to Botox injections in chronic migraine patients has been found by Spanish researchers.

While Botox is a very effective treatment for chronic migraines and possibly other types of headaches and pain, it does not help everyone. Approximately 30% of patients with chronic migraine headaches do not respond to Botox. We usually try at least two sets of injections three months apart before considering the patient to be a non-responder. Considering that Botox is an expensive treatment, it would be very useful to know beforehand which patients will respond and which will not. Besides the cost, it would also save patients time, during which they could be trying other treatments.

Some studies show that having a constricting headache or pain in the eye is usually a positive predictor of response to Botox. On the other hand, exploding headache (that is when the pain is felt pushing from the inside out), is less likely to respond to Botox injections. However, these are very subjective descriptions and predictions based on them are not that reliable.

A new study by Spanish researchers just published in the journal Headache reported that the levels of CGRP (calcitonin gene-related peptide) and VIP (vasoactive intestinal peptide) in patients’ blood are good predictors of response to Botox in chronic migraine sufferers. These two chemicals, which circulate in the blood and perform various important functions in the brain have long been the subject of scientific research. Actually, we think that Botox works by blocking the release of CGRP from the peripheral nerve endings. Dr. Julio Pascual and his colleagues measured the levels of these two chemicals in chronic migraine patients before they were treated with Botox. Botox was administered according to the standard protocol every 12 weeks for at least two treatment cycles. A patient was considered a moderate responder when both: 1) moderate-severe headache episodes were reduced by between 33 and 66%; and 2) subjective benefit on a visual scale from 0 to 100 was recorded by the patient of between 33-66%. Patients were considered to be excellent responders when both items improved by more than 66%. Those without improvement of at least one-third in the two items were considered as nonresponders.

The study involved 81 patients with chronic migraine and 33 healthy controls. CGRP and VIP levels were significantly increased in the chronic migraine population vs controls. CGRP and, to a lesser degree, VIP levels were significantly increased in responders vs nonresponders. The probability of being a responder to Botox was 28 times higher in patients with a CGRP level above the threshold.

The measurement of CGRP and VIP is done only by research institutions and is not yet offered by commercial laboratories. However, considering how much money can be saved by not giving Botox to those who are unlikely to respond, these tests should become widely available once these findings are confirmed by other researchers.

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Strenuous mental activity seems to delay recovery after a head injury, according to a new study published in Pediatrics .

Doctors have always recommended rest after a head injury, but it has never been clear how much to limit activities, what kind to limit (physical, mental, or both), and for how long.

Dr. William P. Meehan III, director of the Micheli Center for Sports Injury Prevention in Waltham, Massachusetts and his colleagues studied 335 patients (62% were males), aged 8 to 23 who came to a sports concussion clinic within three weeks of their injury between 2009 and 2011. Most of the concussions were sustained while playing ice hockey, football, basketball or soccer. The researchers asked them about their symptoms and how often they were reading, doing homework or playing games at each of their appointments.

Those with minimal cognitive activity were not reading or doing homework, and spent less than 20 minutes on the Internet or playing video games each day. They could have watched TV or movies or listened to music. Those with moderate or significant cognitive activity did some reading and some homework, but less than usual. Others had not limited their cognitive activities at all since their last clinic visit.

On average, patients took 43 days to fully recover from their concussions. Those with more minor concussions tended to get over their symptoms faster. So did those who did less with their brains while recovering.

Results showed that only those engaging in the highest levels of cognitive activity had a substantial increase in their symptom duration, while those at all lower activity levels seemed to recover at about the same pace.

According to Dr. Meehan, “This would suggest that while vigorous cognitive exertion is detrimental to recovery, milder levels of cognitive exertion do not seem to prolong recovery substantially”

In general, Meehan said, doctors recommend almost complete brain rest for three to five days after a concussion, followed by a gradual return to normal activities.

Athletes suspected of having a concussion should be seen by the most immediately available medical personnel, like an athletic trainer or team doctor, he said, with a follow-up visit to their primary care doctor.

I would also emphasize the importance of physical rest and complete avoidance of any activities that could result in another head injury before completely recovering from the first one. Complete recovery means no symptoms at all, including headaches, dizziness, mental fog, fatigue, difficulty concentrating, insomnia, anxiety, depression, and other. Taking a magnesium supplement can also help since animal studies show magnesium depletion following an injury. If rest alone does not lead to a complete recovery, cognitive behavioral therapy, medications (for anxiety, depression, and irritability), and Botox injections (for persistent headaches) are sometimes needed.

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Migraine and epilepsy drug Topamax is being recalled by its manufacturer, Ortho-McNeil Neurologics, a division of Johnson and Johnson. This recall affects only two lots of 100 mg tablets. This recall does not affect topiramate, generic copies of this brand. Since the generic form is much cheaper, most patients have switched to it from branded Topamax. This adds another problem to this beleaguered drug. It was recently reclassified by the FDA from pregnancy category C to category D, which means that it is much more dangerous for the fetus than originally thought. Topiramate is also associated with a high incidence of kidney stones (20%) and can cause other serious problems. This is why we always emphasize non-drug approaches (exercise, acupuncture, biofeedback magnesium, Botox, etc), which can be more effective and are much safer than drugs.

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Botox, which was recently approved for the treatment of chronic migraine headaches, was originally thought to relieve migraine headaches by relaxing tight muscles around the scalp.  However, several recent studies determined that besides relaxing muscles, Botox also stops the release of several neurotransmitters from the nerve endings.  These neurotransmitters are released by messages sent from the brain centers that trigger a migraine attack.  In turn the released neurotransmitters send pain messages back to the brain completing a vicious self-sustaining cycle.  A meticulous study just published in the journal Pain by Danish researcher confirmed that injections of Botox stop the release of neurotransmitters and reduce sensitivity of rat’s chewing muscles.  Not knowing the exact way how Botox works makes many doctors skeptical about its efficacy.  However, we have no idea how preventive medications, such as beta blockers, antidepressants and epilepsy drugs prevent headaches either.  These drugs, like Botox, were also discovered to help headaches by accident.  This does not and should not stop us from using them.  Botox is more effective and safer than medications taken by mouth and is an excellent option for over 3 million Americans who suffer from chronic migraines.

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Botox was just approved by the FDA for the treatment of chronic migraine headaches.  This is great news to the more than 3 million chronic headache sufferers in the US (people who have more than 15 days with headaches each month).  In Dr. Mauskop’s opinion Botox is one of the most effective treatments for frequent and severe headaches and it is the first treatment approved FDA for chronic migraines. Dr. Mauskop was one of the first headache specialists to begin using this treatment more than 15 years ago. He has published several scientific articles and book chapters on the use of Botox for headaches. His most recent chapter on Botox for headaches was just published a month ago in the 97th volume of the Handbook of Neurology (Elsevier).  Dr. Mauskop has trained over 200 doctors from all across the US, Canada and Europe who traveled to the New York Headache Center to learn this technique.  Initial reports of the use of Botox for headaches were met with disbelief, while strong skepticism about the efficacy of this treatment persisted for many years. The main reason for this skepticism was the fact that migraine headaches are known to originate in the brain, while Botox affects only muscles and nerves on the outside of the skull. A large amount of research led to our current understanding of how Botox works: while the brain begins the headache process, it requires feedback from nerves and muscles on the surface of the head. By blocking activation of the nerves and muscles the feedback loop remains open and the headache does not occur. After the first few treatments some patients still develop a migraine aura or just a sensation that the headache is about to start, but it does not. After repeated treatments even the auras and this sensation stops occurring. Botox seems to be effective in 70% of patients, which is a rate significantly higher than with any preventive migraine medications, such as Topamax (topiramate), Depakote (divalproex sodium), Inderal (propranolol), or Neurontin (gabapentin). These drugs are effective in less than 50% of patients who try them. The other 50% do not respond or develop unacceptable side effects. Lack of serious side effects is another big advantage of Botox over medications. Botox can cause cosmetic side effects, such as a surprised look, droopy eyelids, or one eyebrow being higher than the other. These and other side effects become less common as the doctor who performs them becomes more experienced. Occasionally, patients develop a headache from being stuck with a needle. This is also uncommon because the needle is very thin and if done correctly, the procedure usually causes very little pain. The effect of Botox begins about 5-6 days after the injections, but the improvement continues to occur for 3 months, at which point the second treatment is given. Some patient require Botox injections at 2 month intervals. Published studies have shown that the second treatment is usually more effective than the first and the third one is better than the second. After several treatments some people improve completely (a small percentage of patients stop having all of their headaches after the first treatment). Dr. Mauskop’s experience suggests that children as young as 10 who suffer from daily headaches also respond well to Botox injections. The major drawback of Botox is its cost. However, several insurance companies have been paying for this treatment and with the FDA approval most of them will have to cover this treatment for patients with chronic (more than 15 days a month) headaches.

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There are over 4 million chronic migraine sufferers in the US.  Chronic migraine is defined as a headache with migrainous features, which occurs on more than 15 days each month.  Many of these chronic migraine patients we see at the New York Headache Center have daily headaches.  By the time they come to our Center, many have seen several doctors, including neurologists and found no relief from a variety of drugs.  A new book just published by Oxford University Press may help doctors who care for headache patients to provide better care.  The book is Refractory Migraine, Mechanisms and Management.  Dr. Mauskop and Dr. Sun-Edelstein contributed a chapter to this book: Nonpharmacological Treatment for Refractory Migraine: Acupuncture, Vitamins and Minerals and Lifestyle Modifications.  An important message contained in the chapter and the one we always stress to our patients is that the best way to approach a refractory headache is not by trying one drug after another, but by combining drugs with nonpharmacological treatments, such as biofeedback, magnesium, other supplements, Botox injections, acupuncture and other therapies.

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Medication overuse headaches are usually treated by withdrawing the offending drug (usually Excedrin, Fioricet or narcotics, such as codeine, Vicodin and Percocet) or dietary caffeine.  About half of the people who stop taking these drugs improve, while the other half does not.  A recent study by Dr. Andrew Hershey and his colleagues at the University of Cincinnati suggests that by doing genomic analysis of the blood we may be able to predict who is going to improve by withdrawing overused medication and who is not. This does not mean that the latter group is going to be left to suffer. However, this test could save a major effort that is involved in getting someone off medications. Instead these patients can be maintained on their medication while other preventive treatments are tried. These treatments can include biofeedback, magnesium infusions, Botox injections, prophylactic drugs, acupuncture, CoQ10, butterbur, and other treatments.

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It is very exciting to finally have two published studies (PREEMPT 1 and PREEMPT 2) which provide definitive proof that Botox is effective for chronic migraine headaches.  More than 15 years ago a plastic surgeon in California, Bill Binder reported that many of his patients treated with Botox for wrinkles found relief from headaches.  Everyone was very skeptical, but having many patients who failed every other treatment and having learned that Botox is very safe if used properly, I decided to try it.  To my great surprise Botox worked exceptionally well.  My most dramatic experience was in a 76-year-old woman who suffered from daily headaches for 60 years.  She had failed a long list of medications, nerve blocks, acupuncture and other treatments.  After the first Botox treatment, for the first time in 60 years she went for three months without a single headache.  Her neurologist came to my office to learn the technique I developed and has been using Botox in his practice ever since.  More than 200 doctors from around the world came to our Center to learn how to use Botox for headaches.  They were all searching for new treatments for their desperate patients.  At the same time most of the medical community had remained very skeptical and dismissive of this approach.  They could not believe that Botox could help headaches and wanted to see double-blind, placebo-controlled trials before using it in their patients.  Well, now they have it, but over the past 15 years many of their patients could have benefited from this safe and effective treatment.  Yes, we do need proof that any new treatment works, but when this treatment is safe and there are no better alternative, it is appropriate to try it before definitive proof is available.  We hope that these two studies will lead to the FDA approval of Botox for the treatment of chronic migraines before the end of 2010, which will make it easier for patients to obtain insurance reimbursement.

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There are several effective preventive medications for migraine headaches, however they are prescribed to only a small number of people who could benefit from them.  A study by Dr. Richard Lipton in the journal Cephalagia and his colleagues discovered that only 13% of migraine sufferers are taking preventive medications, but those who do have significantly less disability than those who don’t. Among possible reasons, doctors who don’t realize how disabling migraines are, patients how think that medications are dangerous or will cause side effects. Cost does not seem to be a factor because all patients in this study had insurance and most of these medications are inexpensive. Patients are often reluctant to take medications, but would rather find and remove the cause. Unfortunately, in most cases migraine is a genetic disorder and true cure is not possible. However, for most migraine sufferers it is possible to find and remove triggers which make headaches worse. If this is not sufficient, magnesium, CoQ10, other supplements, biofeedback, Botox injections, and regular exercise can provide relief without drugs. If all this still does not provide relief, medications, such as anti-depressants, epilepsy drugs, and high blood pressure drugs can be very effective and improve the quality of life.

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The fact that two out of three pregnant women stop having headaches during pregnancy is well established, however a study by Norwegian researchers published in Headache provides some additional details.  Women with headaches who are pregnant for the first time tend to have fewer headaches than non-pregnant women or women during subsequent pregnancies.  This is especially true in the third trimester.   Non-pregnant women who had never been pregnant were less likely to have headaches than women who had been.  If a woman does have headaches during pregnancy, the initial treatment should consist of non-drug therapies, such as biofeedback or meditation, magnesium and other supplements, acupuncture, and if headaches are frequent, Botox injections.

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A blinded study comparing Botox with Topamax for the prevention of migraine headaches was conducted by Drs. Jaffri and Mathew and published in the current issue of Headache.  They enrolled 60 patients and divided them into two groups – one group received real Botox and placebo tablets, while the second group received saline water injections instead of Botox, but were given tablets of Topamax.  At the end of 9 months and after 2 Botox treatments the efficacy of these two treatments was the same, but many more patients in the Topamax group developed side effects and dropped out of the study.

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Botox appears to be effective for peripheral nerve pain according to a study by French researchers.  This finding is consistent with my observation that injecting Botox into the skin of the top of the head in patients with headaches relieves pain in that area.  When I started injecting botulinum toxin (Botox) for headaches about 15 years ago the assumption was that Botox works by relieving spasm of muscles in the forehead, temples, back of the head, and neck.  However, some patients would come back and report that their headache was gone in the injected areas, but not on the top of the head.  When gave additional injections the top of the head pain also stopped.  I also see patients who get Botox injections for their headaches from dermatologists or plastic surgeons and do not obtain adequate relief.  This is usually because only the front of the head is injected, rather then all areas of pain.   There have been other reports of Botox relieving pain of diabetic as well as trigeminal neuralgia, however the French group conducted a very rigorous double-blind study which provides scientific proof of pain-relieving properties of Botox.

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Botox can relieve pain of occipital neuralgia, according to a pilot study by neurologists in Ohio, published in Headache.  Occipital neuralgia is a painful condition that manifests itself by pain in the back of the head, usually on one side.  Pain can be burning, but also sharp,or throbbing in character.  It is often the result of a spasm of occipital and suboccipital muscles, so it is not surprising that Botox would relieve this pain by relaxing these muscles.  In addition to relaxing muscles Botox also reduces activation of the sensory nerve that send pain messages to the brain.  Other treatments for occipital neuralgia include isometric neck exercise, acupuncture, medications, and occipital nerve block with corticosteroids and lidocaine.

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Two large trials of Botox provide unequivocal proof of its efficacy in the treatment of chronic migraine headaches.  The results of these two double-blind, placebo-controlled studies (I participated in one of the two trials) of onabotulinumtoxinA (Botox) in chronic migraines were presented at the International Headache Congress in Philadelphia last week.  Botox was proven to reduce the number of days with headaches, improve multiple headache symptoms, and improve the quality of life.  The treatment was extremely well tolerated with very few side effects overall and no serious side effects.   Having used Botox for the treatment of various headache types for over 15 years in several thousand patients it is very gratifying to finally have well-designed trials which confirm my and my colleagues’ experience.   The manufacturer is submitting the results of these trials to the FDA and we expect to have approval of Botox for the treatment of chronic migraines by the end of 2010.  FDA approval will force insurance companies to pay for this highly effective treatment and will make it affordable for people who desperately need it.

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In my post 2 years ago I wrote about surgery for migraines and the many reasons why Botox injections is a better option than surgery to permanently cut nerves and muscles.  I also wrote that there were no controlled studies to show that surgery actually works.  Now we do have one study.  The study was blinded, which means that some patients had nerves and muscles cut, while others had only a skin incision.  The results were much better in patients who had real surgery.  The plastic surgeons who performed the study tried their best to produce a blinded study, but they admit that blinding is far from perfect since patients who had real surgery can see their muscles shrink or not move.  But even if we accept that blinding was achieved and surgery indeed provides relief of headaches, all of my other arguments stand.  These include surgical risks (bleeding, infection, scarring, and persistent nerve pain) and high cost.  Yes, Botox is expensive too, but migraine usually is not a life-long illness and migraine attacks often stop for long periods of time or permanently with or even without treatment.  I have seen many patients whom I treated with Botox every 3 months and whose headaches stop after a year or two.  Two years of Botox treatments is significantly cheaper than surgery and it does not carry all of the surgical risks.

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Botulinum toxin injections relieve tension headaches, according to a study just published in the European Journal of Neurology .  Most of the previous studies had been conducted in patients with migraines or chronic migraines (more than 15 days of headaches a month).  There is much less evidence that Botox also helps tension headaches.  Our experience at the NYHC treating patients with tension headaches with Botox injections has been also very positive.  In this European study doctors used Dysport – a version of botulinum toxin type A that is not available in the US.  However, Dysport is very similar to Botox.  On the other hand, Myobloc, which is botulinum toxin type B,  is a very different version of botulinum toxin and in several aspects is inferior to Botox.

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Botox has been shown to relieve migraine headaches in another two studies published in Headache.  One study compared the efficacy of Botox and an epilepsy drug, Depakote and found them to be equally effective.  However, Depakote caused more side effects, which resulted in more patients taking Depakote dropping out of the study.  The second study was done in patients who had difficulty complying with daily preventive medications.  Half of them were injected with Botox and the other half with saline water.  Neither the doctor nor the patient knew who received which treatment (double-blind study).  The impact of migraines on patients’ lives was significantly improved by Botox.  These two studies by leading headache specialists provides additional proof that Botox is effective for the relief of migraine headaches.

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Botox relieves migraine headaches and other painful conditions, such as sciatica, neuralgias and neck pain.  A recent study of 43 patients with arthritis of the shoulder suggests that Botox may relieve arthritis pain as well.  This was a double-blind study where half of the patients were given Botox and the other half saline injections.  Neither the doctor nor the patient knew what was being injected.  The results clearly favored Botox and the difference was statistically significant.  This adds another possible indication to a long list of conditions that Botox might relieve.  The safety of Botox in this study was as remarkble as in all previous studies, which now number in hundreds.  

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