Abstract
Chronic musculoskeletal pain is a common cause of chronic pain, which is associated with a total cost of $635 billion per year in the U.S. Emerging evidence suggests an anti-nociceptive action of botulinum toxin, independent of its muscle paralyzing action. This review provides a summary of data from both non-randomized and randomized clinical studies of botulinum toxin in back pain and various osteoarticular conditions, including osteoarthritis, tennis elbow, low back pain and hand pain. Three randomized controlled trials (RCTs) of small sizes provide evidence of short-term efficacy of a single intra-articular injection of 100 units of botulinum toxin A (BoNT/A) for the relief of pain and the improvement of both function and quality of life in patients with chronic joint pain due to arthritis. Three RCTs studied intramuscular BoNT/A for tennis elbow with one showing a significant improvement in pain relief compared with placebo, another one showing no difference from placebo, and the third finding that pain and function improvement with BoNT/A injection were similar to those obtained with surgical release. One RCT of intramuscular BoNT/A for low back pain found improvement in pain and function compared to placebo. Single RCTs using local injections of BoNT in patients with either temporomandibular joint (TMJ) pain or plantar fasciitis found superior efficacy compared to placebo. One RCT of intramuscular BoNT/B in patients with hand pain and carpal tunnel syndrome found improvement in pain in both BoNT/B and placebo groups, but no significant difference between groups. Most evidence is based on small studies, but the use of BoNT is supported by a single, and sometimes up to three, RCTs for several chronic musculoskeletal pain conditions. This indicates that botulinum toxin may be a promising potential new treatment for chronic refractory musculoskeletal pain. Well-designed large clinical trials are needed.
Highlights
Pain is a major public health problem
A single intra-articular injection of botulinum toxin was associated with a clinically and statistically significant decrease in pain severity and improvement in function compared to baseline: lower extremity and shoulder pain decreased from 7 to 2.7 and 8.2 to 2.4, respectively; shoulder flexion improved from 68 to 113 degrees and shoulder abduction improved from 50 to 74 degrees, respectively
Summary and study limitations: OA knee and shoulder pain In summary, three randomized controlled trials (RCTs) and three non-randomized studies indicate that a single intra-articular injection of botulinum toxin is associated with a clinically meaningful reduction of pain and an improvement of function in patients with refractory joint pain due to osteoarthritis or other underlying arthritic-conditions
Summary
Pain is a major public health problem. Pain was recognized as a major challenge by the Institute of Medicine (IOM) in their recent report[1]. Common side effects include: peptic ulcer disease with its complications (bleeding and perforation), renal failure and liver toxicity in patients using NSAIDs; sedation, confusion, constipation and falls in those taking narcotics; and liver toxicity in patients taking acetaminophen Both intra-articular therapies (including the use of corticosteroids and hyaluronic acid) as well as topical preparations such as capsaicin and lidocaine have limited efficacy in patients with osteoarthritis (OA) and/or joint pain[37,38,39,40,41]. Joint injury or inflammation is associated with decrease in the excitation threshold of these nociceptors This leads to enhanced responses to both innocuous and noxious mechanical, chemical and thermal stimuli. Recent reviews have summarized the injectable treatments for osteoarthritis[64], injectable treatments for knee osteoarthritis[65] or use of neurotoxin for the treatment of painful disorders[66], In this review, I provide a review of evidence regarding botulinum toxin for the treatment of musculoskeletal pain conditions
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