The Benefit of Botulinum Toxin A in the Management of Central Post Stroke Pain: A Case Report

Abstract

Purpose: Spasticity and pain are common complications of stroke. Pain following stroke is multi factorial and can be due to musculoskeletal problems, painful spasticity or central post stroke pain. Botulinum Toxin A is the first line pharmacotherapy in spasticity management and increasing evidence has shown benefits in neuropathic pain.Results: This case report demonstrates the benefit of Botulinum Toxin A in the management of central post-stroke pain with elbow flexor spasticity. The clinical characteristics of the pain were neuropathic and the severity was greater than expected given the degree of spasticity. The pain responded to Botulinum Toxin treatment within a few days, independently of the improvement in spasticity and the effect was continued over six cycles of treatment. Conclusion:Management of central post stroke pain is challenging due systemic side effects of oral medications. Botulinum Toxin A has increasingly being shown to benefits in neuropathic pain either through blockade of nociceptive substances or acting on central transmission of pain. Although the treatment in our case was given for spasticity management, the patient had unexpected and significant improvement in pain prior to improvement in range of movement. Given the increasing evidence in use of Botulinum Toxin A in neuropathic pain, we feel this may be a possible future treatment option for central post-stroke pain

Botulinum Toxin for the Treatment of Neuropathic Pain

“…After the second day, the pain was reduced, and the spasticity was improved one week after administration. The patients repeat BoNT every three months to control pain [ 63 ]. Barbosa et al also published a case report in which an analgesic effect was obtained using BoNT-A in patients with central poststroke pain.…”

Botulinum Neurotoxin for the Treatment of Neuropathic Pain

“…One major limitation is the use of different toxin serotypes and preparations which hampers the comparison of studies' results. Most studies specified the use of the common BoNT/A brand (Botox®) ( 27 , 29 , 32 , 34 , 36 , 40 , 43 , 44 , 52 , 55 , 67 – 71 , 74 , 77 , 84 , 89 , 90 , 93 , 101 ) or other BoNT/A compounds (e.g., HengLi®, Meditoxin®, Disport®) ( 33 , 38 , 39 , 41 , 50 , 62 , 72 , 94 , 96 ), but, in many cases, no specification of the BoNT/A serotype was provided ( 27 , 31 , 35 , 37 , 42 , 47 , 51 , 53 , 54 , 60 , 61 , 66 , 75 , 78 , 83 , 85 , 86 , 94 , 102 – 104 ). Furthermore, two studies were performed with botulinum toxin type B ( 73 , 87 ) and two with incobotulinum toxin type A ( 76 , 88 ).…”

“…The efficacy of BoNT/A in central PSP control has been investigated (Table 3) (66)(67)(68)(69). A prospective RCT performed on 37 patients failed to demonstrate any BoNT/A efficacy on PSP (68).…”

OnabotulinumtoxinA Reduces Temporal Pain Processing at Spinal Level in Patients with Lower Limb Spasticity

“…Regarding the relationship between OnabotulinumtoxinA injection, pain and spasticity, we are aware that the reduction of the spasticity can influence the anti-nociceptive effect of the OnabotulinumtoxinA on the NWR. However, recent evidences suggest that central post-stroke pain relief and spasticity improvement after OnabotulinumtoxinA injection were independent from each other, and with a different and typical temporal profile [35,36].…”