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Botulinum Toxin in Pain Management Author: Heather Rachel
Davids, MD; Chief Editor: Consuelo T Lorenzo, MD more...
!dated: Mar "#, $"%&
'vervie(
)harmacolo*+ of otulinum To-in
se of otulinum To-in in )ainful euromuscular Disorders
otulinum To-in and M+ofascial )ain
otulinum To-in and the Muscle /!indle: Clinical 0ssues
1hen to Consider otulinum To-in
otulinum To-in se in )iriformis Muscle /+ndrome
0n2ection Methods
/ho( All
Multimedia Li3rar+
References
'vervie(
Dia*nosis and treatment of !ainful muscle s+ndromes can 3e a
difficult and frustratin* tas4 for an+clinician. T+!icall+, the
mainsta+ of thera!+ for such conditions is thera!eutic e-ercise,
anal*esics,and a tincture of time. nfortunatel+, not all !atients
res!ond to this !aradi*m, and, des!ite heroicefforts on the !art of
the treatin* clinician, some conditions are refractor+ to this
a!!roach.
Re!orts have descri3ed the !ur!orted effectiveness of usin* a
3iolo*ic neuromuscular 3loc4in*a*ent, 3otulinum to-in, in the
treatment of !ainful conditions associated (ith s4eletal muscle.
1hileincom!letel+ understood and at times controversial, use of
3otulinum to-in in the treatment ofconditions associated (ith
involuntar+ muscle contraction, such as focal d+stonia and
s!asticit+, issu!!orted 3+ !ros!ective, randomized clinical
research; ho(ever, (hile the volume of com!ara3lestudies in !ain
s+ndromes is *ro(in*, the num3er of clinical randomized trials is
limited. Moreover,
not all such re!orts have demonstrated clear efficac+ of the use
of 3otulinum to-in under allcircumstances. Therefore, in vie( of
our current understandin* of the nature of muscle5induced !ainand
the !aucit+ of !ros!ective research re*ardin* neuromuscular
3loc4ade and6or inhi3ition ofnocice!tion in such conditions,
critical and careful anal+sis of the data and o!inions !resented in
thissection is a!!ro!riate.
This article !rovides *eneral direction and !ractical details
for the clinician considerin* 3otulinumto-in for treatment of !ain.
Anatomic dra(in*s for in2ection localization and dosin* information
areintended onl+ as *eneral *uidelines; thera!+ (ith 3otulinum
to-in al(a+s must 3e individualized,accountin* for the !atient7s
needs and the clinician7s e-!ertise. 0n addition, information
!resentedshould 3e used as a convenient reference source, not as a
su3stitute for clinical trainin* in the use of3otulinum to-in.
8or e-cellent !atient education resources, see eMedicineHealth7s
!atient education articles 'T'9
0n2ectionsandChronic )ain.
)harmacolo*+ of otulinum To-in
Pharmacology
otulinum to-in is !roduced 3+ the anaero3ic 3acterium
Clostridium botulinum, a rod5sha!ed, *ram5!ositive or*anism found
in soil and (ater. otulinum to-in t+!e A a33reviated oT5A or
T95Auired for muscle contraction, from release at the nerve
terminal. ?%, $, @Thera!eutic3enefit ma+ 3e derived 3+ e-!loitin*
the !harmacolo*ic !ro!erties of carefull+ administered
re*ionala!!lication of this !urified neuroto-in.
The various 3otulinum to-ins !ossess individual !otencies, and
care is re>uired to assure !ro!er useand avoid medication
errors. Recent chan*es to the esta3lished dru* names 3+ the 8DA
(ere
http://emedicine.medscape.com/article/325574-overview#a1http://emedicine.medscape.com/article/325574-overview#a2http://emedicine.medscape.com/article/325574-overview#a3http://emedicine.medscape.com/article/325574-overview#a4http://emedicine.medscape.com/article/325574-overview#a5http://emedicine.medscape.com/article/325574-overview#a6http://emedicine.medscape.com/article/325574-overview#a7http://emedicine.medscape.com/article/325574-overview#a8http://emedicine.medscape.com/article/325574-overview#showallhttp://www.emedicinehealth.com/articles/40377-1.asphttp://www.emedicinehealth.com/articles/40377-1.asphttp://www.emedicinehealth.com/articles/40377-1.asphttp://www.emedicinehealth.com/articles/9239-1.asphttp://www.emedicinehealth.com/articles/9239-1.asphttp://emedicine.medscape.com/article/325574-overview#a1http://emedicine.medscape.com/article/325574-overview#a2http://emedicine.medscape.com/article/325574-overview#a3http://emedicine.medscape.com/article/325574-overview#a4http://emedicine.medscape.com/article/325574-overview#a5http://emedicine.medscape.com/article/325574-overview#a6http://emedicine.medscape.com/article/325574-overview#a7http://emedicine.medscape.com/article/325574-overview#a8http://emedicine.medscape.com/article/325574-overview#showallhttp://www.emedicinehealth.com/articles/40377-1.asphttp://www.emedicinehealth.com/articles/40377-1.asphttp://www.emedicinehealth.com/articles/9239-1.asp
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intended to reinforce these differences and !revent medication
errors. The !roducts and theira!!roved indications include the
follo(in*:
'na3otulinumto-inAoto-, oto- Cosmeticuals the LD" for a $"5*
/(iss51e3ster mouse. et oT5A sensitivit+ variesamon* different
s!ecies. LD" in mon4e+s has 3een determined as @# 64*. ased on
thesefindin*s from !rimate studies, human LD" is estimated at
a!!ro-imatel+ @""" for a "54* adult.T+!ical doses for lar*er muscle
*rou!s ran*e from &"5B"" total units *iven in a sin*le
treatment;ho(ever, 3ecause of inade>uate understandin* of the
com!lete dose res!onse curve in humans, arelative ceilin* dose of
@&" , *iven no sooner than %$ (ee4s a!art, is recommended.
Adverse effects
/ince the mechanism of action of oT5A is so s!ecific, adverse
effects are uncommon and
s+stemic effects rare. 8luli4e s+ndrome has 3een re!orted, 3ut
it is *enerall+ short5lived. 'theradverse effects have 3een
re!orted, 3ut the+ are not necessaril+ a result of oT5A treatment.
The+include muscle soreness, headaches, li*ht5headedness, fever,
chills, h+!ertension, (ea4ness,diarrhea, and a3dominal !ain.
Muscular (ea4ness, the !redominant and desira3le effect of
3otulinum to-in in2ection, also ma+ 3econsidered an adverse effect
(hen (ea4ness occurs in an unintended area or is *reater
thanintended. Clinicians must understand the functional
conse>uences of unintended (ea4ness caused3+ 3otulinum to-in
in2ection. 1hile over(ea4enin* the muscles that curl the toes ma+
have fe(, ifan+, undesira3le conse>uences, s!read of to-in into
the muscles that control s(allo(in*, (hich canoccur (hen in2ectin*
muscles near the lar+n- for instance, the !ro-imal !art of
thesternocleidomastoid muscle
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3enefits in !ain reduction in muscles in2ected (ith 3otulinum
to-in. Iaria3les in the studies citedincluded the !resence or
a3sence of concurrent thera!+, dia*noses, len*th of time since
onset of!ain, dosin* and concentration, and methodolo*+ for
measurement of outcome. ?$ 0n $"%&, the /8ood and Dru*
Administration a!!roved ona3otulinumto-inA to decrease the severit+
of stiffness inan4le and toe muscles amon* adults (ith lo(er lim3
s!asticit+.?$&
Another revie( of 3otulinum to-in studies (as !erformed 3+ the
Thera!eutics and Technolo*+
Assessment /u3committee of the American Academ+ of
eurolo*+.?$Evidence of the to-in7seffectiveness (as e-amined for a
variet+ of conditions, includin* chronic tension5t+!e
headache,e!isodicmi*raine, chronic dail+ mi*raine,and chronic lo(
3ac4 !ain.
Accordin* to the su3committee7s re!ort, the evidence indicated
that 3otulinum to-in ma+ 3e useful inthe treatment of lo(er 3ac4
!ain 3ut that it is !ro3a3l+ not effective a*ainst e!isodic
mi*raine andchronic tension5t+!e headache. The re!ort also stated
that the availa3le evidence (as not stron* orconsistent enou*h to
determine 3otulinum to-in7s usefulness in the treatment of chronic
dail+headache !rimaril+, transformed mi*raineualit+ of life and
(ith a trend to(ard im!roved !ain at rest. ?$#
otulinum To-in and M+ofascial )ain
Man+ thera!ies are availa3le to !atients (ith m+ofascial !ain
s+ndrome. Much of the variation informs of treatment and
dia*noses< of this disorder !ro3a3l+ results from differences in
culture,trainin*, and reco*nition of an often undia*nosed s+ndrome
of !ain, d+sfunction, and autonomic
d+sre*ulation. The etiolo*+ of m+ofascial !ain s+ndrome
associated (ith tri**er !oints isincom!letel+ understood. /ome
clinicians 3elieve that it characteristicall+ results from either
an acutee!isode of muscle overload or from chronic and6or
re!etitive muscle overload. Active m+ofascialtri**er !oints
MTr)s
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1hatever the reason, muscle s!indle !h+siolo*+ is an im!ortant
re*ulator of muscle tone in thes!astic condition.
oT5A has 3een reco*nized to reduce !ain associated (ith various
clinical conditions, includin*craniocervical d+stonia, tension
headaches, cervico*enic headaches, and mi*raine, an effect thathas
3een o3served inde!endentl+ of the to-in7s effect on muscle
rela-ation. As stated a3ove,ho(ever, controvers+ e-ists re*ardin*
3otulinum to-in7s effectiveness in the treatment of headache.
