Therapeutic use of botulinum toxin in pain treatment

Raj Kumar, Raj Kumar

Abstract

Botulinum toxin is one of the most potent molecule known to mankind. A neurotoxin, with high affinity for cholinergic synapse, is effectively capable of inhibiting the release of acetylcholine. On the other hand, botulinum toxin is therapeutically used for several musculoskeletal disorders. Although most of the therapeutic effect of botulinum toxin is due to temporary skeletal muscle relaxation (mainly due to inhibition of the acetylcholine release), other effects on the nervous system are also investigated. One of the therapeutically investigated areas of the botulinum neurotoxin (BoNT) is the treatment of pain. At present, it is used for several chronic pain diseases, such as myofascial syndrome, headaches, arthritis, and neuropathic pain. Although the effect of botulinum toxin in pain is mainly due to its effect on cholinergic transmission in the somatic and autonomic nervous systems, research suggests that botulinum toxin can also provide benefits related to effects on cholinergic control of cholinergic nociceptive and antinociceptive systems. Furthermore, evidence suggests that botulinum toxin can also affect central nervous system (CNS). In summary, botulinum toxin holds great potential for pain treatments. It may be also useful for the pain treatments where other methods are ineffective with no side effect(s). Further studies will establish the exact analgesic mechanisms, efficacy, and complication of botulinum toxin in chronic pain disorders, and to some extent acute pain disorders.

Keywords: Axonal transport; Botulinum Toxin; Central Nervous System; Neurotransmitters; Nociception; Sensory Neurons.

Conflict of interest statement

The author declares that there are no competing interests associated with the manuscript.

© 2018 The Author(s).

Figures

Figure 1. The endplate hypothesis of formation…
Figure 1. The endplate hypothesis of formation of MTrPs
One of the reasons for the pain associated with a muscle tension or spasm is due to compression of the muscles for the pain. Formation of MTrP starts with a muscle lesion that leads to an excessive release of Ach into the synapse, which leads to depolarization. Depolarization is followed by a Ca2+ release from SR, which leads to the sliding of the myosin and actin filaments that form a local contracture. This local contracture compresses blood vessels that run along the muscle cells, which sensitizes nociceptors and generate pain. BoNT can be effective in hyperactive state of the muscle by abolishing the release of Ach in the neuromuscular junction that starts and maintain MTrPs (Mense [117]).Abbreviations: Ach, Acetylcholine.
Figure 2. Possible effects of BoNT on…
Figure 2. Possible effects of BoNT on PNS and CNS
Effect of BoNT on PNS could be termed as direct effect on sensory neurons (nociceptors) either by disruption of expression of various receptors on neuronal membrane in presynaptic region or by inhibition of release of various neurotransmitters. The effect on CNS, on the other hand, is primarily due to the indirect effect either by deactivation/inhibition of signaling molecule or effect on purigenic transmission (due to ATP or nucleotides).
Figure 3. Schematics of peripheral and central…
Figure 3. Schematics of peripheral and central sensitization and possible mechanisms of antinociceptive activity of BoNT.
(A) Schematics of peripheral and central sensitization. Normal sensitization process occurs with the help of several neurotransmitters (SP, CGRP, and glutamate), ion channels, and receptors. Peripheral sensitization leads to central sensitization. (B) Possible mechanisms of antinociceptive activity of BoNT. BoNT not only inhibits release of peripheral and central neurotransmitters, but also affects the pain receptors (taken from Oh and Chung [131]).
Figure 4. A possible mechanism for BoNT…
Figure 4. A possible mechanism for BoNT effectiveness on pain
(A) Process showing the transfer of sensory receptor from synaptic vesicle through regular fusion process. Exocytosis process at the synapse is not only involved in neurotransmitter release, but also populates presynaptic regions with several pain receptors. (B) Impairment of fusion process by BoNT toxin which ultimately stops the transfer of receptors to the membrane. Inhibition of fusion vesicles reduces number of pain receptors at the synapse.

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