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Lam C, Francio VT, Gustafson K, Carroll M, York A, Chadwick AL. Myofascial pain - A major player in musculoskeletal pain. Best Pract Res Clin Rheumatol 2024:101944. [PMID: 38644073 DOI: 10.1016/j.berh.2024.101944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 04/03/2024] [Indexed: 04/23/2024]
Abstract
Myofascial pain is a soft tissue pain syndrome with local and referred musculoskeletal pain arising from trigger points. Myofascial pain and myofascial pain syndromes are among some of the most common acute and chronic pain conditions. Myofascial pain can exist independently of other pain generators or can coexist with or is secondary to other acute and chronic painful musculoskeletal conditions. Myofascial pain is most effectively treated with a multimodal treatment plan including injection therapy (known as trigger point injections, physical therapy, postural or ergonomic correction, and treatment of underlying musculoskeletal pain generators. The objectives of this review are to outline the prevalence of myofascial pain, describe the known pathophysiology of myofascial pain and trigger points, discuss the clinical presentation of myofascial pain, and present evidence-based best practices for pharmacologic, non-pharmacologic, and interventional treatments for myofascial pain.
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Affiliation(s)
- Christopher Lam
- Department of Anesthesiology, Pain, and Perioperative Medicine, University of Kansas School of Medicine, Kansas City, KS, USA.
| | - Vinicius Tieppo Francio
- Department of Anesthesiology, Pain, and Perioperative Medicine, University of Kansas School of Medicine, Kansas City, KS, USA.
| | - Kelsey Gustafson
- Department of Anesthesiology, Pain, and Perioperative Medicine, University of Kansas School of Medicine, Kansas City, KS, USA.
| | - Michael Carroll
- Department of Physical Medicine and Rehabilitation, University of Kansas School of Medicine, Kansas City, KS, USA.
| | - Abigail York
- Department of Anesthesiology, Pain, and Perioperative Medicine, University of Kansas School of Medicine, Kansas City, KS, USA.
| | - Andrea L Chadwick
- Department of Anesthesiology, Pain, and Perioperative Medicine, University of Kansas School of Medicine, Kansas City, KS, USA.
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Leonardi G, Alito A, Portaro S, Di Matteo B, Respizzi S, Kon E, Massazza G, Sconza C. Intramuscular injections of botulinum toxin for the treatment of upper back myofascial pain syndrome: A systematic review of randomized controlled trials. Eur J Pain 2024; 28:369-381. [PMID: 37950343 DOI: 10.1002/ejp.2198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND AND OBJECTIVE Myofascial pain syndrome (MPS) is a chronic musculoskeletal disorder characterized by the presence of trigger points. Among the treatment options, botulinum toxin injections have been investigated. The aim of this paper was to provide a synthesis of the evidence on intramuscular botulinum toxin injections for upper back MPS. DATABASES AND DATA TREATMENT A systematic review of the literature was performed on the PubMed, Scopus and Cochrane Library, using the following formula: ("botulinum") AND ("musculoskeletal") AND ("upper back pain") OR ("myofascial pain"). RESULTS Ten studies involving 651 patients were included. Patients in the control groups received placebo (saline solution) injections, anaesthetic injections + dry needling or anaesthetic injections. The analysis of the trials revealed modest methodological quality: one "Good quality" study, one "Fair" and the other "Poor". No major complications or serious adverse events were reported. Results provided conflicting evidence and did not demonstrate the superiority of botulinum toxin over comparators. Most of the included trials were characterized by a small sample size, weak power analysis, different clinical scores used and non-comparable follow-up periods. Even if there is no conclusive evidence, the favourable safety profile and the positive results of some secondary endpoints suggest a potentially beneficial action in pain control and quality of life. CONCLUSION The currently available studies show conflicting results. Their overall low methodological quality does not allow for solid evidence of superiority over other comparison treatments. Further insights are needed to properly profile patients who could benefit more from this peculiar injective approach. SIGNIFICANCE The randomized controlled trials included in this review compared using botulinum toxin to treat upper back MPS with placebo or active treatments (e.g., dry needling or anaesthetics) showing mixed results overall. Despite the lack of clear evidence of superiority, our study suggests that the use of botulinum toxin should not be discouraged. Its safety profile and encouraging results in pain control, motor recovery and disability reduction make it an interesting treatment, particularly in the subset of patients with moderate to severe chronic pain and active trigger points. To support the safety and efficacy of botulinum toxin, further high-quality studies are needed.
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Affiliation(s)
- G Leonardi
- Department of Physical and Rehabilitation Medicine, University Hospital "G. Martino", Messina, Italy
| | - A Alito
- Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, Messina, Italy
| | - S Portaro
- Department of Physical and Rehabilitation Medicine, University Hospital "G. Martino", Messina, Italy
| | - B Di Matteo
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - S Respizzi
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - E Kon
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - G Massazza
- Division of Physical Medicine and Rehabilitation, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - C Sconza
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
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Lee HJ, Lee JH, Yi KH, Kim HJ. Anatomical analysis of the motor endplate zones of the suprascapular nerve to the infraspinatus muscle and its clinical significance in managing pain disorder. J Anat 2023; 243:467-474. [PMID: 36988105 PMCID: PMC10439366 DOI: 10.1111/joa.13868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/06/2023] [Accepted: 03/14/2023] [Indexed: 03/30/2023] Open
Abstract
Myofascial pain syndrome caused by myofascial trigger points is a musculoskeletal disorder commonly encountered in clinical practice. The infraspinatus muscle is the region most frequently involved in the myofascial pain syndrome in the scapular region. The characteristics of the myofascial trigger points are that they can be found constantly in the motor endplate zone. However, localizing myofascial trigger points within the motor endplate zone and establishing an accurate injection site of the infraspinatus muscle has been challenging because the anatomical position of the motor endplate zone of the infraspinatus muscle is yet to be described. Therefore, this cadaveric study aimed to scrutinize the motor endplate zone of the infraspinatus muscle, propose potential myofascial trigger points within the muscle, and recommend therapeutic injection sites. Twenty specimens of the infraspinatus muscle for nerve staining and 10 fresh frozen cadavers for evaluation of the injection were used in this study. The number of nerve branches penetrating the infraspinatus muscle and their entry locations were analyzed and photographed. Modified Sihler's staining was performed to examine the motor endplate regions of the infraspinatus muscle. The nerve entry points were mostly observed in the center of the muscle belly. The motor endplate was distributed equally throughout the infraspinatus muscle, but the motor endplate zone was primarily identified in the B area, which is approximately 20-40% proximal to the infraspinatus muscle. The second-most common occurrence of the motor endplate zone was observed in the center of the muscle. These detailed anatomical data would be very helpful in predicting potential pain sites and establishing safe and effective injection treatment using botulinum neurotoxin, steroids, or lidocaine to alleviate the pain disorder of the infraspinatus muscle.
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Affiliation(s)
- Hyung-Jin Lee
- Catholic Institute for Applied Anatomy, Department of Anatomy, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
| | - Ji-Hyun Lee
- Department of Anatomy and Acupoint, College of Korean Medicine, Gachon University, Seongnam, 13120, South Korea
| | - Kyu-Ho Yi
- COVID-19 Division, Wonju City Public Health Center, Wonju-Si, 26417, Republic of Korea
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, Seoul, 03722, Republic of Korea
| | - Hee-Jin Kim
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, Seoul, 03722, Republic of Korea
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Lee HJ, Lee JH, Yi KH, Kim HJ. Sonoanatomy and an ultrasound scanning protocol of the intramuscular innervation pattern of the infraspinatus muscle. Reg Anesth Pain Med 2023; 48:175-179. [PMID: 36427902 DOI: 10.1136/rapm-2022-103682] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 11/15/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Botulinum neurotoxin injection is a valuable treatment method for patients with myofascial pain syndrome in the infraspinatus muscle. However, there is no botulinum neurotoxin injection guideline, and the most appropriate injection site based on topographical anatomic information for this injection to effectively treat myofascial pain syndrome in the infraspinatus muscle is unclear. The purpose of this study was to evaluate the intramuscular nerve terminal of the infraspinatus muscle and to suggest the most efficient botulinum neurotoxin injection sites. METHODS This study used 5 formalin-embalmed and 10 fresh frozen cadavers with a mean age of 78.9 years. Sihler's staining was applied to evaluate the intramuscular nerve terminal of the infraspinatus muscle. The ultrasound scanning of the infraspinatus muscle was performed based on the surface landmarks and internal structures near the scapular region. RESULTS The intramuscular nerve terminal was mostly observed in the medial third area of the infraspinatus muscle. The deltoid tubercle, inferior angle, and acromion of the scapula are useful as surface landmarks to scan the infraspinatus muscle. DISCUSSION The proposed injection sites based on the intramuscular nerve terminal and surface landmarks can be regarded as accurate locations to reach the cluster area of the intramuscular nerve terminal and each compartment of the infraspinatus muscle to manage the myofascial pain syndrome in the infraspinatus muscle.
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Affiliation(s)
- Hyung-Jin Lee
- Catholic Institute for Applied Anatomy, Department of Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji-Hyun Lee
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, Seoul, Korea
| | - Kyu-Ho Yi
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, Seoul, Korea.,COVID-19 Division, Wonju City Public Health Center, Wonju, Korea
| | - Hee-Jin Kim
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, Seoul, Korea .,Department of Materials Science & Engineering, Yonsei University College of Engineering, Seodaemun-gu, Korea
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Elsawy AGS, Ameer AH, Gazar YA, Allam AES, Chan SM, Chen SY, Hou JD, Tai YT, Lin JA, Galluccio F, Nada DW, Esmat A. Efficacy of Ultrasound-Guided Injection of Botulinum Toxin, Ozone, and Lidocaine in Piriformis Syndrome. Healthcare (Basel) 2022; 11:healthcare11010095. [PMID: 36611554 PMCID: PMC9818865 DOI: 10.3390/healthcare11010095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 12/29/2022] Open
Abstract
Background: Piriformis syndrome (PS) is a painful musculoskeletal condition characterized by a deep gluteal pain that may radiate to the posterior thigh and leg. This study was designed to compare the effectiveness of ozone and BTX to lidocaine injection in treating piriformis syndrome that was resistant to medication and/or physical therapy. Study design: Between November 2018 and August 2019, we involved eighty-four subjects diagnosed with piriformis syndrome in a double-blinded, prospective, randomized comparative study to receive an ultrasound-guided injection of lidocaine (control group), botulinum toxin A, or local ozone (28 patients each group) in the belly of the piriformis muscle. Pain condition evaluated by the visual analog score (VAS) was used as a primary outcome, and the Oswestry Disability Index (ODI) as a secondary outcome, before, at one month, two months, three months, and six months following the injection. Results: The majority (58.3%) of patients were male, while (41.7%) were female. At one month, a highly significant decrease occurred in VAS and ODI in the lidocaine and ozone groups compared to the botulinum toxin group (p < 0.001). At six months, there was a highly significant decrease in VAS and ODI in the botulinum toxin group compared to the lidocaine and ozone groups (p < 0.001). Conclusion: Botulinum toxin may assist in the medium- and long-term management of piriformis syndrome, while lidocaine injection and ozone therapy may help short-term treatment in patients not responding to conservative treatment and physiotherapy.
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Affiliation(s)
- Ahmed Gamal Salah Elsawy
- Anesthesia and Intensive Care Department, Faculty of Medicine, Al-Azhar University, Cairo 11884, Egypt
| | - Abdulnasir Hussin Ameer
- Clinical Neurophysiology, Department of Physiology, College of Medicine, Baghdad University, Baghdad 61224, Iraq
| | - Yasser A. Gazar
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Al-Azhar University, Cairo 11884, Egypt
| | - Abdallah El-Sayed Allam
- Department of Physical Medicine, Rheumatology and Rehabilitation, Faculty of Medicine, Tanta University, Tanta 31527, Egypt
- MoMaRC Morphological Madrid Research Center, Ultra Dissection Group, 28029 Madrid, Spain
- Interventional Clinical Neurophysiology Fellowship, Baghdad, Ministry of Health, Baghdad 61224, Iraq
| | - Shun-Ming Chan
- Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan
| | - Se-Yi Chen
- Department of Neurosurgery, Chung-Shan Medical University Hospital, Taichung 40201, Taiwan
- School of Medicine, Chung-Shan Medical University, Taichung 40201, Taiwan
| | - Jin-De Hou
- Division of Anesthesiology, Hualien Armed Forces General Hospital, Hualien 97144, Taiwan
- Department of Anesthesiology, School of Medicine, National Defense Medical Center, Taipei 11490, Taiwan
| | - Yu-Ting Tai
- Center for Regional Anesthesia and Pain Medicine, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 116, Taiwan
| | - Jui-An Lin
- Department of Anesthesiology, School of Medicine, National Defense Medical Center, Taipei 11490, Taiwan
- Center for Regional Anesthesia and Pain Medicine, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 116, Taiwan
- Center for Regional Anesthesia and Pain Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
- Department of Anesthesiology, School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- Department of Anesthesiology, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
- Correspondence:
| | - Felice Galluccio
- MoMaRC Morphological Madrid Research Center, Ultra Dissection Group, 28029 Madrid, Spain
- Center for Regional Anesthesia and Pain Medicine, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan
- Rheumatology & Rehabilitation, Fisiotech Lab Studio, 50136 Firenze, Italy
| | - Doaa Waseem Nada
- Department of Physical Medicine, Rheumatology and Rehabilitation, Faculty of Medicine, Tanta University, Tanta 31527, Egypt
| | - Ahmed Esmat
- Neurology Department, Faculty of Medicine, Al-Azhar University, Cairo 11884, Egypt
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Sayed D, Grider J, Strand N, Hagedorn JM, Falowski S, Lam CM, Tieppo Francio V, Beall DP, Tomycz ND, Davanzo JR, Aiyer R, Lee DW, Kalia H, Sheen S, Malinowski MN, Verdolin M, Vodapally S, Carayannopoulos A, Jain S, Azeem N, Tolba R, Chang Chien GC, Ghosh P, Mazzola AJ, Amirdelfan K, Chakravarthy K, Petersen E, Schatman ME, Deer T. The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain. J Pain Res 2022; 15:3729-3832. [PMID: 36510616 PMCID: PMC9739111 DOI: 10.2147/jpr.s386879] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety. Objective The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders. Methods The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented. Results After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain. Conclusion The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.
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Affiliation(s)
- Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA,Correspondence: Dawood Sayed, The University of Kansas Health System, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA, Tel +1 913-588-5521, Email
| | - Jay Grider
- University of Kentucky, Lexington, KY, USA
| | - Natalie Strand
- Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Steven Falowski
- Functional Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Christopher M Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Nestor D Tomycz
- AHN Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | - Rohit Aiyer
- Interventional Pain Management and Pain Psychiatry, Henry Ford Health System, Detroit, MI, USA
| | - David W Lee
- Physical Medicine & Rehabilitation and Pain Medicine, Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA
| | - Hemant Kalia
- Rochester Regional Health System, Rochester, NY, USA,Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Soun Sheen
- Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Mark N Malinowski
- Adena Spine Center, Adena Health System, Chillicothe, OH, USA,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Michael Verdolin
- Anesthesiology and Pain Medicine, Pain Consultants of San Diego, San Diego, CA, USA
| | - Shashank Vodapally
- Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI, USA
| | - Alexios Carayannopoulos
- Department of Physical Medicine and Rehabilitation, Rhode Island Hospital, Newport Hospital, Lifespan Physician Group, Providence, RI, USA,Comprehensive Spine Center at Rhode Island Hospital, Newport Hospital, Providence, RI, USA,Neurosurgery, Brown University, Providence, RI, USA
| | - Sameer Jain
- Interventional Pain Management, Pain Treatment Centers of America, Little Rock, AR, USA
| | - Nomen Azeem
- Department of Neurology, University of South Florida, Tampa, FL, USA,Florida Spine & Pain Specialists, Riverview, FL, USA
| | - Reda Tolba
- Pain Management, Cleveland Clinic, Abu Dhabi, United Arab Emirates,Anesthesiology, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - George C Chang Chien
- Pain Management, Ventura County Medical Center, Ventura, CA, USA,Center for Regenerative Medicine, University Southern California, Los Angeles, CA, USA
| | | | | | | | - Krishnan Chakravarthy
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA,Va San Diego Healthcare, San Diego, CA, USA
| | - Erika Petersen
- Department of Neurosurgery, University of Arkansas for Medical Science, Little Rock, AR, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA,Department of Population Health - Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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McDonald A. Primary Care-Based Interventional Procedures for Chronic Pain. Prim Care 2022; 49:425-437. [DOI: 10.1016/j.pop.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Myofascial pain and myofascial pain syndromes are among some of the most common acute and chronic pain conditions. Many interventional procedures can be performed in both an acute and chronic pain setting to address myofascial pain syndromes. Trigger point injections can be performed with or without imaging guidance such as fluoroscopy and ultrasound; however, the use of imaging in years past has been recommended to improve patient outcome and safety. Injections can be performed using no injectate (dry needling), or can involve the administration of local anesthetics, botulinum toxin, or corticosteroids.
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Butts R, Dunning J, Serafino C. Dry needling strategies for musculoskeletal conditions: Do the number of needles and needle retention time matter? A narrative literature review. J Bodyw Mov Ther 2020; 26:353-363. [PMID: 33992269 DOI: 10.1016/j.jbmt.2020.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 09/28/2020] [Accepted: 12/01/2020] [Indexed: 01/16/2023]
Abstract
Acupuncture and dry needling are both minimally invasive procedures that use thin, filiform needles without injectate for the management of a variety of neuromusculoskeletal pain conditions. While the theoretical constructs underlying the use of acupuncture and dry needling are unique, both appear to have the ability to elicit biochemical, biomechanical, endocrinological and neurovascular changes associated with reductions in pain and disability. However, optimal treatment dosage has yet to be determined, and there is a lack of consistency in the literature on the number of needles that should be inserted and the needle retention time. Therefore, the purpose of this narrative review is to further explore the importance of these two variables. While trigger point dry needling advocates single needle insertions via repetitive, quick in-and-out pistoning, most acupuncture and dry needling clinical trials have incorporated multiple needles for five to 40 min. Notably and to date, using a single needle to repeatedly prick trigger points one at a time with fast-in and fast-out pistoning maneuvers has not yet been shown to produce significant and clinically meaningful long term improvements in pain and disability in a wide array of musculoskeletal conditions. Insertion of multiple needles for typically 20-30 min durations has been shown to produce larger treatment effect sizes and longer-lasting outcomes than brief, single-needle strategies. Moreover, the number of needles and needle retention time are two variables associated with treatment dosage and must be carefully matched with specific musculoskeletal conditions and the patient's goals.
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Affiliation(s)
- Raymond Butts
- Physical Therapist, Research Physical Therapy Specialists, Columbia, SC, USA; Coordinator, American Academy of Manipulative Therapy Fellowship in Orthopaedic Manual Physical Therapy, USA.
| | - James Dunning
- Physical Therapist, Montgomery Osteopractic Physiotherapy & Acupuncture Clinic, Montgomery, AL, USA; Director, American Academy of Manipulative Therapy Fellowship in Orthopaedic Manual Physical Therapy, USA
| | - Clint Serafino
- Physical Therapist, U.S. Armed Forces Europe, Kelley Barracks, Stuttgart, Germany; Senior Instructor, American Academy of Manipulative Therapy Fellowship in Orthopaedic Manual Physical Therapy, USA
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Urits I, Charipova K, Gress K, Schaaf AL, Gupta S, Kiernan HC, Choi PE, Jung JW, Cornett E, Kaye AD, Viswanath O. Treatment and management of myofascial pain syndrome. Best Pract Res Clin Anaesthesiol 2020; 34:427-448. [PMID: 33004157 DOI: 10.1016/j.bpa.2020.08.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/03/2020] [Indexed: 12/29/2022]
Abstract
Myofascial Pain Syndrome (MPS) is a regional pain disorder that affects every age-group and is characterized by the presence of trigger points (TrPs) within muscles or fascia. MPS is typically diagnosed via physical exam, and the general agreement for diagnostic criteria includes the presence of TrPs, pain upon palpation, a referred pain pattern, and a local twitch response. The prevalence of MPS among patients presenting to medical clinics due to pain ranges anywhere from 30 to 93%. This may be due to the lack of clear criteria and guidelines in diagnosing MPS. Despite the prevalence of MPS, its pathophysiology remains incompletely understood. There are many different ways to manage and treat MPS. Some include exercise, TrP injections, medications, and other alternative therapies. More research is needed to form uniformly-accepted diagnostic criteria and treatments.
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Affiliation(s)
- Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA.
| | | | - Kyle Gress
- Georgetown University School of Medicine, Washington, DC, USA
| | - Amanda L Schaaf
- University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ, USA
| | - Soham Gupta
- University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ, USA
| | - Hayley C Kiernan
- University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ, USA
| | - Paula E Choi
- Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, USA
| | - Jai Won Jung
- Georgetown University School of Medicine, Washington, DC, USA
| | - Elyse Cornett
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | - Alan D Kaye
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | - Omar Viswanath
- University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ, USA; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, USA; Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ, USA
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Diep D, Ko J, Lan J, Koprowicz KT, Ko G. Benefits, Safety, and Adjunct Modality Prevalences of Long-Term Botulinum Toxin Injections for Cervical Dystonia and Myofascial Neck Pain: A Retrospective Cohort Study. J Pain Res 2020; 13:1297-1304. [PMID: 32581571 PMCID: PMC7276373 DOI: 10.2147/jpr.s254032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 04/29/2020] [Indexed: 12/15/2022] Open
Abstract
Introduction There is a paucity of long-term treatment benefit and safety data of botulinum toxin A (BTX-A) for cervical dystonia (CD) and myofascial neck pain syndrome (MPS). Additionally, the prevalence of adjunct modality uses during this period is unknown despite evolving practices. Objective To assess and compare treatment benefit, safety, and adjunct modality prevalences of long-term BTX-A injections between CD and MPS patients. Design Retrospective cohort study. Setting Private practice tertiary care clinics in Toronto. Patients Convenience sample of 37 (52.9%) CD and 33 (47.1%) MPS patients treated for a mean±SD duration of 7.2±4.3 and 8.3±4.7 years, respectively. Interventions BTX-A injections administered at least once yearly, for a duration longer than 1 year. Main Outcome Measures Toronto Western Spasmodic Torticollis Rating Scales (TWSTRS) for disability and pain, Patient Global Impression of Change (PGIC) score, time to peak effect, duration of total response, adverse effects, and prevalence of adjunct modalities. Results CD patients experienced improvements in TWSTRS disability (17.57±6.79 to 9.81±4.35, p<0.001) and pain (14.61±3.08 to 9.05±3.49, p<0.001) scores as well as PGIC score (52.00%±23.60% to 64.80%±23.60%, p=0.007). MPS patients experienced improvements in TWSTRS disability (15.86±7.70 to 10.07±7.01, p=0.01) and pain (15.25±4.09 to 10.85±4.49, p=0.01) scores. In both cohorts, there were no changes in time to peak effect and duration of total response. Adverse effects were minimal and self-limiting. Prevalences of adjunct modalities used by CD versus MPS patients were 28.13% versus 50.00% for anesthetic procedures, 23.08% versus 15.38% for image-guidance, 65.71% versus 56.25% for pectoralis minor injections, and 47.06% versus 53.13% for cannabis-use. Conclusion There were demonstrated and comparable treatment benefit, safety, and adjunct modality prevalences. Our study is the first to demonstrate that long-term BTX-A injections for MPS, although commonly used off-label, can be effective and safe.
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Affiliation(s)
- Dion Diep
- MD Program, University of Toronto, Toronto, ON, Canada
| | - Jasmine Ko
- Department of Kinesiology, McMaster University, Hamilton, ON, Canada
| | - John Lan
- Canadian Centre of Integrative Medicine, Toronto, ON, Canada
| | | | - Gordon Ko
- Canadian Centre of Integrative Medicine, Toronto, ON, Canada.,Division of Physical Medicine & Rehabilitation, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Abstract
Neck pain is the fourth leading cause of disability. Acute neck pain largely resolves within 2 months. History and physical examination play a key role in ruling out some of the more serious causes for neck pain. The evidence for pharmacologic interventions for acute and chronic musculoskeletal neck pain is limited. Lower back pain is the leading cause of disability and productivity loss. Consultation with a physical medicine and rehabilitation spine specialist within 48 hours for acute pain and within 10 days for all patients with lower back pain may significantly decrease rate of surgical interventions and increase patient satisfaction.
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Affiliation(s)
- Adrian Popescu
- Department of Physical Medicine and Rehabilitation, Hospital of the University of Pennsylvania, Perelman School of Medicine, 1800 Lombard Street, Philadelphia, PA 19146, USA.
| | - Haewon Lee
- Physical Medicine & Rehabilitation, Department of Orthopedic Surgery, University of California San Diego, 200 West Arbor Drive, #8894, San Diego, CA 92103, USA
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13
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Effect of Local Anesthetic Versus Botulinum Toxin-A Injections for Myofascial Pain Disorders: A Systematic Review and Meta-Analysis. Clin J Pain 2018; 35:353-367. [PMID: 30589660 DOI: 10.1097/ajp.0000000000000681] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Myofascial pain is a chronic pain disorder characterized by the presence of painful localized regions of stiff muscle and/or myofascial trigger points. Intramuscular myofascial trigger point injections are considered first-line treatments for myofascial pain. Common injectates include local anesthetics and botulinum toxin-A (BTX-A). The objective of this systematic review was to compare the effectiveness of local anesthetics and BTX-A on pain intensity in patients with myofascial pain. METHODS A comprehensive systematic search of 3 databases, EMBASE, CENTRAL, and Medline was conducted. The search was comprised of words to describe "myofascial pain" and "injections." We performed a meta-analysis comparing local anesthetic and BTX-A injections across these follow-up week periods: 0 (immediately following the injection), 1 to 2, 3 to 4, 5 to 6, 7 to 8, 9 to 10, 11 to 12, 16, 18, 24 weeks with local anesthetics and BTX-A as subgroups. We also performed subgroup analyses comparing the effectiveness of local anesthetic injections and BTX-A injections at various muscle locations and comparing the effectives of single versus multiple injection sessions. RESULTS In total, 33 studies were included. A qualitative analysis suggested that local anesthetics and BTX-A were inconsistently effective at mitigating pain across all follow-up periods. The meta-analyses revealed that local anesthetic injections were more effective than BTX-A at mitigating pain intensity. Multiple injection sessions of local anesthetics were more beneficial than a single session. CONCLUSIONS Additional studies are needed to determine sources of heterogeneity mediating the observed differences in effectiveness of local anesthetic and BTX-A injections among the studies. Additional replicative studies are also needed to delineate the relative efficacy and effectiveness of local anesthetic and BTX-A injection. The quantitative results of this study suggest that patients overall experience more pain relief with local anesthetic injections.
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14
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Kim SY, Kim YK, Yun PY, Bae JH. Treatment of non-odontogenic orofacial pain using botulinum toxin-A: a retrospective case series study. Maxillofac Plast Reconstr Surg 2018; 40:21. [PMID: 30206537 PMCID: PMC6093826 DOI: 10.1186/s40902-018-0159-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 07/12/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the clinical outcomes of treatment of non-odontogenic atypical orofacial pain using botulinum toxin-A. METHODS This study involved seven patients (seven females, mean age 65.1 years) who had non-odontogenic orofacial pain (neuropathic pain and atypical orofacial pain) and visited the Seoul National University Bundang Hospital between 2015 and 2017. All medication therapies were preceded by botulinum toxin-A injections, followed by injections in the insignificant effects of medication therapies. Five of the seven patients received intraoral injections in the gingival vestibule or mucosa, while the remaining two received extraoral injections in the masseter and temporal muscle areas. RESULTS In five of the seven patients, pain after botulinum toxin-A injection was significantly reduced. Most of the patients who underwent surgery for dental implantation or facial nerve reconstruction recovered after injections. However, the pain did not disappear in two patients who reported experiencing persistent pain without any cause. CONCLUSIONS The use of botulinum toxin-A for the treatment of non-odontogenic neuropathic orofacial pain is clinically useful. It is more effective to administer botulinum toxin-A in combination with other medications and physical therapy to improve pain.
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Affiliation(s)
- Sang-Yun Kim
- Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Young-Kyun Kim
- Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam, South Korea
- Department of Dentistry and Dental Research Institute, School of Dentistry, Seoul National University, Seoul, South Korea
| | - Pil-Young Yun
- Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Ji-Hyun Bae
- Department of Conservative Dentistry, Section of Dentistry, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam city, Gyunggi-do South Korea
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15
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Jutzeler CR, Warner FM, Cragg JJ, Haefeli J, Richards JS, Andresen SR, Finnerup NB, Mercier C, Kramer JL. Placebo response in neuropathic pain after spinal cord injury: a meta-analysis of individual participant data. J Pain Res 2018; 11:901-912. [PMID: 29750052 PMCID: PMC5933365 DOI: 10.2147/jpr.s155979] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Understanding factors associated with high placebo responses in clinical trials increases the likelihood of detecting a meaningful treatment effect. The aim of the present study was to identify subject-level factors that contribute to placebo variability in patients with neuropathic pain due to spinal cord injury (SCI). Methods Multiple regression analysis of patient data from randomized, double-blind, placebo-controlled trials (duration >4 weeks) involving individuals with SCI was performed. Patient demographics, as well as injury and pain characteristics were examined for their association with changes in pain rating from baseline to the end of the trial (i.e., placebo response). The overall effect of individual predictors was quantified with meta-analysis statistics. Results A total of 276 patients with SCI from six studies were included in the analysis. Based on the meta-analysis of subject-level predictors, larger placebo responses were associated with male subjects (β=0.635; standard error [SE]=0.262; p=0.016) and higher baseline pain (β=−0.146; SE=0.073; p=0.044). There were no significant effects for injury characteristics (i.e., severity, level, and time since injury) or pain characteristics (i.e., location and evoked). No significant publication bias was detected. Conclusion The current meta-analysis of individual patient data demonstrated the importance of sex and baseline pain intensity on changes in pain ratings in the placebo arm of SCI central neuropathic pain randomized controlled clinical trials. Overall, our findings indicate that placebo responses occur independent of injury characteristics.
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Affiliation(s)
- Catherine R Jutzeler
- Faculty of Medicine, ICORD, University of British Columbia, Vancouver, BC, Canada.,Faculty of Education, School of Kinesiology, University of BC, Vancouver, BC, Canada.,Faculty of Medicine, Spinal Cord Injury Center, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
| | - Freda M Warner
- Faculty of Medicine, ICORD, University of British Columbia, Vancouver, BC, Canada.,Faculty of Education, School of Kinesiology, University of BC, Vancouver, BC, Canada
| | - Jacquelyn J Cragg
- Faculty of Medicine, ICORD, University of British Columbia, Vancouver, BC, Canada.,Faculty of Medicine, Spinal Cord Injury Center, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
| | - Jenny Haefeli
- Weill Institute for Neurosciences, Department of Neurological Surgery, Brain and Spinal Injury Center, University of California, San Francisco, CA, USA
| | - J Scott Richards
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sven R Andresen
- Spinal Cord Injury Centre of Western Denmark, Department of Neurology, Regional Hospital of Viborg, Viborg, Denmark
| | - Nanna B Finnerup
- Danish Pain Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Catherine Mercier
- Center for Interdisciplinary Research in Rehabilitation and Social Integration, Québec, QC, Canada
| | - John Lk Kramer
- Faculty of Medicine, ICORD, University of British Columbia, Vancouver, BC, Canada.,Faculty of Education, School of Kinesiology, University of BC, Vancouver, BC, Canada
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16
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Bayet K, Chikhani L, Ejeil AL. Therapeutic uses and efficacy of botulinum toxin in orofacial medicine. JOURNAL OF ORAL MEDICINE AND ORAL SURGERY 2018. [DOI: 10.1051/mbcb/2017030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction: Botulinum toxin, primarily known for its use in cosmetic surgery, is also used for therapeutic purposes in many medical fields. It works as a muscle relaxant and inhibits glandular secretions. In the orofacial sphere, the use of this toxin is proposed in particular for disabling myofascial pain and aberrant salivary disorders. Methodology: A critical analysis of the literature, based on PUBMED data, concerning the orofacial indications of botulinum toxin was carried out. Results: The literature is abundant regarding the therapeutic interest of this toxin for several oral pathologies, but scientific merits vary markedly from one indication to another. Discussion: The musculorelaxant and antisecretory action of this toxin appears to be demonstrated in the case of bruxism, limitation of the mouth opening and in hypersialorrhea. On the other hand, its medical benefit is still not supported by scientific evidence for masseter hypertrophy, tonicity of the levator labii superioris muscles, sialocele fistulae and Frey's syndrome. Conclusion: Additional high-level studies, unbiased, randomized controlled trials, are required to eliminate the uncertainties that persist about the clinical impact of botulinum toxin and to justify the development of recommendations for good practice valid and credible.
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17
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Abboud W, Hassin-Baer S, Joachim M, Givol N, Yahalom R. Localized myofascial pain responds better than referring myofascial pain to botulinum toxin injections. Int J Oral Maxillofac Surg 2017; 46:1417-1423. [DOI: 10.1016/j.ijom.2017.04.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 12/20/2016] [Accepted: 04/21/2017] [Indexed: 10/19/2022]
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18
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Nicol AL, Hurley RW, Benzon HT. Alternatives to Opioids in the Pharmacologic Management of Chronic Pain Syndromes: A Narrative Review of Randomized, Controlled, and Blinded Clinical Trials. Anesth Analg 2017; 125:1682-1703. [PMID: 29049114 DOI: 10.1213/ane.0000000000002426] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Chronic pain exerts a tremendous burden on individuals and societies. If one views chronic pain as a single disease entity, then it is the most common and costly medical condition. At present, medical professionals who treat patients in chronic pain are recommended to provide comprehensive and multidisciplinary treatments, which may include pharmacotherapy. Many providers use nonopioid medications to treat chronic pain; however, for some patients, opioid analgesics are the exclusive treatment of chronic pain. However, there is currently an epidemic of opioid use in the United States, and recent guidelines from the Centers for Disease Control (CDC) have recommended that the use of opioids for nonmalignant chronic pain be used only in certain circumstances. The goal of this review was to report the current body of evidence-based medicine gained from prospective, randomized-controlled, blinded studies on the use of nonopioid analgesics for the most common noncancer chronic pain conditions. A total of 9566 studies were obtained during literature searches, and 271 of these met inclusion for this review. Overall, while many nonopioid analgesics have been found to be effective in reducing pain for many chronic pain conditions, it is evident that the number of high-quality studies is lacking, and the effect sizes noted in many studies are not considered to be clinically significant despite statistical significance. More research is needed to determine effective and mechanism-based treatments for the chronic pain syndromes discussed in this review. Utilization of rigorous and homogeneous research methodology would likely allow for better consistency and reproducibility, which is of utmost importance in guiding evidence-based care.
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Affiliation(s)
- Andrea L Nicol
- From the *Department of Anesthesiology, University of Kansas School of Medicine, Kansas City, Kansas; †Department of Anesthesiology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina; and ‡Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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19
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Cartagena-Sevilla J, García-Fernández MR, Vicente-Villena JP. Analgesic Effect of Botulinum Toxin A in Myofascial Pain Syndrome Patients Previously Treated with Local Infiltration of Anesthetic and Steroids. J Pain Palliat Care Pharmacother 2016; 30:269-275. [DOI: 10.1080/15360288.2016.1231742] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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20
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Khalifeh M, Mehta K, Varguise N, Suarez-Durall P, Enciso R. Botulinum toxin type A for the treatment of head and neck chronic myofascial pain syndrome: A systematic review and meta-analysis. J Am Dent Assoc 2016; 147:959-973.e1. [PMID: 27737756 DOI: 10.1016/j.adaj.2016.08.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 08/22/2016] [Accepted: 08/23/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND The authors conducted a systematic review to study the efficacy of botulinum toxin type A (BoTN-A) in the treatment of myofascial pain syndrome. TYPES OF STUDIES REVIEWED The authors identified randomized, double-masked, placebo-controlled studies on June 1, 2016, from PubMed, Web of Science, and the Cochrane Library. Three of the authors assessed the studies for risk of bias. Outcomes included pain reduction on a visual analog scale, the number of responders, and the posttreatment pain threshold to applied pressure using algometry. RESULTS The initial search strategy yielded 253 unduplicated references, which the authors reduced to 13 relevant studies. The authors included 11 studies in the meta-analyses as the investigators of those studies had reported similar outcomes. Pooled results showed a nonsignificant improvement in the posttreatment intensity of pain in the BoTN-A group compared with the placebo group at 4 to 6 weeks (standardized difference in means [SDM], -0.110; 95% confidence interval [CI], -0.344 to 0.124; P = .356) and a significant improvement at 2 to 6 months (SDM, -0.360; 95% CI, -0.623 to -0.096; P = .008). The number of study participants who responded to treatment was not statistically significantly different between the groups (risk ratio, 1.346; 95% CI, 0.922-1.964; P = .123) nor was the increase of pain threshold to pressure (algometry) at 2 months (SDM, 0.131; 95% CI, -0.178 to 0.440; P = .405). The study investigators reported no major adverse events. CONCLUSIONS AND PRACTICAL IMPLICATIONS Pain was reduced significantly in the group that received BoTN-A compared with the placebo group at 2 to 6 months but not at 4 to 6 weeks (with moderate quality of the evidence). Additional studies with larger numbers of participants are needed to confirm these results.
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21
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Intramuscular botulinum toxin injection additional to arthrocentesis in the management of temporomandibular joint pain. Oral Surg Oral Med Oral Pathol Oral Radiol 2016; 122:e99-e106. [DOI: 10.1016/j.oooo.2016.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 05/10/2016] [Accepted: 05/15/2016] [Indexed: 11/20/2022]
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22
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Langevin P, Peloso PMJ, Lowcock J, Nolan M, Weber J, Gross A, Roberts J, Goldsmith CH, Graham N, Burnie SJ, Haines T. WITHDRAWN: Botulinum toxin for subacute/chronic neck pain. Cochrane Database Syst Rev 2015; 2015:CD008626. [PMID: 25994306 PMCID: PMC10637244 DOI: 10.1002/14651858.cd008626.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Withdrawn due to non‐compliance with The Cochrane Collaboration’s Commercial Sponsorship Policy The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Pierre Langevin
- Département de réadaptation, Faculté de Médecine, Université LavalCliniques Physio Interactive3520 rue de l'HêtrièreSt‐Augustin‐de‐DesmauresQCCanadaG3A 2V4
| | - Paul Michael J Peloso
- MRL ‐ MerckDepartment of Clinical DevelopmentRY34‐B272126 E. Lincoln AveRahwayNJUSA07065
| | | | - May Nolan
- University of British ColumbiaSchool of Physiotherapy, Faculty of Medicine212‐2177 Westbrook MallVancouverBCCanadaV6T 1Z3
| | - Jeff Weber
- Family Physiotherapy Inc.G04, 7408 ‐ 139th AvenueEdmontonABCanadaT5C 3H7
| | - Anita Gross
- McMaster UniversitySchool of Rehabilitation Science & Department of Clinical Epidemiology and Biostatistics1400 Main Street WestHamiltonONCanadaL8S 1C7
| | - John Roberts
- University of Calgary Sport Medicine CentrePhysiotherapy Department302 838 4th Ave NWCalgaryABCanadaT2N 0M8
| | - Charles H Goldsmith
- Simon Fraser UniversityFaculty of Health SciencesBlossom Hall, Room 95108888 University DriveBurnabyBCCanadaV5A 1S6
| | - Nadine Graham
- McMaster UniversitySchool of Rehabilitation Science1200 Main Street WestHamiltonONCanada
| | - Stephen J Burnie
- Canadian Memorial Chiropractic CollegeDepartment of Clinical Education6100 Leslie StreetTorontoONCanadaM2H 3J1
| | - Ted Haines
- McMaster UniversityDepartment of Clinical Epidemiology and Biostatistics1200 Main Street WestHSC 3H54HamiltonONCanadaL8N 3Z5
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Dommerholt J, Gerwin RD. A critical evaluation of Quintner et al: missing the point. J Bodyw Mov Ther 2015; 19:193-204. [PMID: 25892372 DOI: 10.1016/j.jbmt.2015.01.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 01/29/2014] [Accepted: 01/30/2014] [Indexed: 02/03/2023]
Abstract
The objective of this article is to critically analyze a recent publication by Quinter, Bove and Cohen, published in Rheumatology, about myofascial pain syndrome and trigger points (Quintner et al., 2014). The authors concluded that the leading trigger point hypothesis is flawed in reasoning and in science. They claimed to have refuted the trigger point hypothesis. The current paper demonstrates that the Quintner et al. paper is a biased review of the literature replete with unsupported opinions and accusations. In summary, Quintner et al. have not presented any convincing evidence to believe that the Integrated TrP Hypothesis should be laid to rest.
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Affiliation(s)
- Jan Dommerholt
- Bethesda Physiocare, Bethesda, MD, USA; PhysioFitness, Rockville, MD, USA; Myopain Seminars, Bethesda, MD, USA.
| | - Robert D Gerwin
- Myopain Seminars, Bethesda, MD, USA; Johns Hopkins University, Baltimore, MD, USA; Pain & Rehabilitation Medicine, Bethesda, MD, USA.
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24
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Cohen SP. Epidemiology, diagnosis, and treatment of neck pain. Mayo Clin Proc 2015; 90:284-99. [PMID: 25659245 DOI: 10.1016/j.mayocp.2014.09.008] [Citation(s) in RCA: 296] [Impact Index Per Article: 32.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 09/07/2014] [Accepted: 09/10/2014] [Indexed: 01/22/2023]
Abstract
Neck pain is the fourth leading cause of disability, with an annual prevalence rate exceeding 30%. Most episodes of acute neck pain will resolve with or without treatment, but nearly 50% of individuals will continue to experience some degree of pain or frequent occurrences. History and physical examination can provide important clues as to whether the pain is neuropathic or mechanical and can also be used to identify "red flags" that may signify serious pathology, such as myelopathy, atlantoaxial subluxation, and metastases. Magnetic resonance imaging is characterized by a high prevalence of abnormal findings in asymptomatic individuals but should be considered for cases involving focal neurologic symptoms, pain refractory to conventional treatment, and when referring a patient for interventional treatment. Few clinical trials have evaluated treatments for neck pain. Exercise treatment appears to be beneficial in patients with neck pain. There is some evidence to support muscle relaxants in acute neck pain associated with muscle spasm, conflicting evidence for epidural corticosteroid injections for radiculopathy, and weak positive evidence for cervical facet joint radiofrequency denervation. In patients with radiculopathy or myelopathy, surgery appears to be more effective than nonsurgical therapy in the short term but not in the long term for most people.
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Affiliation(s)
- Steven P Cohen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD; Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD; Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, MD; Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD.
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25
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Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology (Oxford) 2014; 54:392-9. [PMID: 25477053 DOI: 10.1093/rheumatology/keu471] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The theory of myofascial pain syndrome (MPS) caused by trigger points (TrPs) seeks to explain the phenomena of muscle pain and tenderness in the absence of evidence for local nociception. Although it lacks external validity, many practitioners have uncritically accepted the diagnosis of MPS and its system of treatment. Furthermore, rheumatologists have implicated TrPs in the pathogenesis of chronic widespread pain (FM syndrome). We have critically examined the evidence for the existence of myofascial TrPs as putative pathological entities and for the vicious cycles that are said to maintain them. We find that both are inventions that have no scientific basis, whether from experimental approaches that interrogate the suspect tissue or empirical approaches that assess the outcome of treatments predicated on presumed pathology. Therefore, the theory of MPS caused by TrPs has been refuted. This is not to deny the existence of the clinical phenomena themselves, for which scientifically sound and logically plausible explanations based on known neurophysiological phenomena can be advanced.
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Affiliation(s)
- John L Quintner
- Rheumatology and Pain Medicine, Mount Claremont, Perth, Western Australia, University of New England, College of Osteopathic Medicine, Biddeford, Maine, USA and Pain Medicine and Rheumatology, St Vincent's Clinical School, University of New South Wales Australia, Sydney, New South Wales, Australia
| | - Geoffrey M Bove
- Rheumatology and Pain Medicine, Mount Claremont, Perth, Western Australia, University of New England, College of Osteopathic Medicine, Biddeford, Maine, USA and Pain Medicine and Rheumatology, St Vincent's Clinical School, University of New South Wales Australia, Sydney, New South Wales, Australia
| | - Milton L Cohen
- Rheumatology and Pain Medicine, Mount Claremont, Perth, Western Australia, University of New England, College of Osteopathic Medicine, Biddeford, Maine, USA and Pain Medicine and Rheumatology, St Vincent's Clinical School, University of New South Wales Australia, Sydney, New South Wales, Australia
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26
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Zhou JY, Wang D. An update on botulinum toxin A injections of trigger points for myofascial pain. Curr Pain Headache Rep 2014; 18:386. [PMID: 24338700 DOI: 10.1007/s11916-013-0386-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Myofascial pain syndrome (MPS) is a common chronic pain condition that is characterized by distinct "trigger points." Despite current treatments with physical therapy, analgesics, anti-depressants and trigger-point injections, myofascial pain remains a challenging chronic pain condition in clinical practice. Botulinum toxin A (BTX-A) can cause prolonged muscle relaxation through inhibition of acetylcholine release. It may offer some advantages over the current treatments for MPS by providing a longer sustained period of pain relief. Despite numerous clinical trials, the efficacy of BTX-A in alleviating MPS is not well-established due to mixed results from recent clinical trials. Active trigger points are associated with referred pain and greatly impact many aspects of activities of daily living, mood, and health status. This review is designed to analyze the clinical trials regarding the efficacy of BTX-A injection of active trigger points as a treatment for MPS. The literature referenced was obtained via a computer search with Google Scholar, Pubmed, Medline and EMbase. Our search terms included "Botulinum toxin," "myofascial pain," "trigger points," "myofascial trigger points," "chronic pain." Additional references were retrieved from the reference list of the reports found via this search. Studies were considered eligible for inclusion if they were double-blinded, randomized, controlled trials evaluating the efficacy of BTX-A injections into trigger points for pain reduction, and if the trigger point selection in the trial included referred pain and/or local twitch response. Open-label studies, case reports, and other non-randomized studies were excluded. Eight trials were found according to the above criteria and are summarized in Table 1. There are well-designed clinical trials to support the efficacy of trigger-point injections with BTX-A for MPS. However, further clinical trials with considerations of minimizing placebo effect, repeated dosing, adequate coverage of trigger points, and using ultrasound confirmation and guidance are required to provide conclusive evidence for BTX-A in the treatment of myofascial pain.
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Affiliation(s)
- Jon Y Zhou
- Department of Anesthesiology, Thomas Jefferson University Hospital, 111. S 11th Street, Suite 8290 Gibbon, Philadelphia, PA, USA,
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Soares A, Andriolo RB, Atallah AN, da Silva EMK. Botulinum toxin for myofascial pain syndromes in adults. Cochrane Database Syst Rev 2014; 2014:CD007533. [PMID: 25062018 PMCID: PMC7202127 DOI: 10.1002/14651858.cd007533.pub3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND This is an updated version of the original Cochrane review published in Issue 4, 2012. Myofascial pain syndrome (MPS) is a regional muscular pain syndrome characterised by the presence of trigger points, which are painful points in one or more muscles. The pain can be felt at the site where the trigger point is located or it can be felt away from that place when the muscle is pressed (referred pain). Botulinum toxin is a protein produced by the bacterium Clostridium botulinum and is a potent neurotoxin that eventually inhibits muscle contractions. It is capable of selectively weakening painful muscles and interrupting the pain cycle. OBJECTIVES To assess the effectiveness and safety of botulinum toxin A (BTXA) in the treatment of myofascial pain syndrome (MPS), excluding MPS in neck and head muscles. SEARCH METHODS This is an updated version of the original Cochrane review published in Issue 4, 2012. The search strategy for the update was the same as in the original review and we searched CENTRAL in The Cochrane Library (2013, Issue 11 of 12), MEDLINE (Ovid) (2012 to 29 November 2013) and EMBASE (Ovid) (2012 to 27 November 2013). The search strategy was composed of terms for myofascial pain and botulinum toxin. For the original review, we also searched the Cochrane Pain, Palliative and Supportive Care (PaPaS) Review Group Specialised Register until December 2011, PubMed (from 1966 to 2011) and LILACS (from 1982 to 2011). There was no language restriction. SELECTION CRITERIA We included randomised controlled trials (RCTs) involving botulinum toxin for treating participants with MPS. We excluded studies with MPS of the neck and head from this review as they have already been assessed in existing systematic reviews. We considered a diagnosis of MPS to be based on the identification of trigger points in the taut band through palpation of sensitive nodules, local twitch response and specific patterns of referred pain associated with each trigger point. DATA COLLECTION AND ANALYSIS Two review authors independently screened identified studies, extracted data, assessed trial quality and analysed results using the Cochrane PaPaS Review Group criteria. MAIN RESULTS Four studies with a total of 233 participants, comparing BTXA with placebo, met the inclusion criteria. In one study with 145 participants, significant improvement rates of pain intensity scores and duration of daily pain were demonstrated when comparing BTXA with placebo. The three other studies showed that there was no statistically significant difference between BTXA and placebo in pain intensity. AUTHORS' CONCLUSIONS Since the first publication of this review, no new studies were found. There is inconclusive evidence to support the use of botulinum toxin in the treatment of MPS based on data from four studies with a total of 233 participants, which we considered were of sufficient quality to be included in this review. Meta-analyses were not possible due to the heterogeneity between studies. We suggest that in future studies the same methodology to assess pain, a standardised dose of treatment, follow-up of at least four months (to observe the maximum and minimum curve of the drug effect) and appropriate data presentation should be used. More high-quality RCTs of botulinum toxin for treating MPS need to be conducted before firm conclusions on its effectiveness and safety can be drawn.
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Affiliation(s)
- Adriana Soares
- Department of Medicine, Universidade Federal de São Paulo, Rua Grão Pará, 570 apt.1101 Bairro Santa Efigênia, Belo Horizonte, Minais Gerais, Brazil, 30150-341
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Abstract
Myofascial pain syndrome (MPS) is a regional pain disorder caused by taut bands of muscle fibers in skeletal muscles called myofascial trigger points. MPS is a common disorder, often diagnosed and treated by physiatrists. Treatment strategies for MPS include exercises, patient education, and trigger point injection. Pharmacologic interventions are also common, and a variety of analgesics, antiinflammatories, antidepressants, and other medications are used in clinical practice. This review explores the various treatment options for MPS, including those therapies that target myofascial trigger points and common secondary symptoms.
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Affiliation(s)
- Joanne Borg-Stein
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, 300 First Avenue, Boston, MA 02129, USA.
| | - Mary Alexis Iaccarino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, 300 First Avenue, Boston, MA 02129, USA
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Gupta VK. CSD, BBB and MMP-9 elevations: animal experiments versus clinical phenomena in migraine. Expert Rev Neurother 2014; 9:1595-614. [DOI: 10.1586/ern.09.103] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Desai MJ, Shkolnikova T, Nava A, Inwald D. A critical appraisal of the evidence for botulinum toxin type A in the treatment for cervico-thoracic myofascial pain syndrome. Pain Pract 2013; 14:185-95. [PMID: 23692187 DOI: 10.1111/papr.12074] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 04/12/2013] [Indexed: 11/28/2022]
Abstract
Myofascial pain syndrome (MPS) is a musculoskeletal condition characterized by regional pain and muscle tenderness associated with the presence of myofascial trigger points (MTrPs). The last decade has seen an exponential increase in the use of botulinum toxin (BTX) to treat MPS. To understand the medical evidence substantiating the role of therapeutic BTX injections and to provide useful information for the medical practitioner, we applied the principles of evidence-based medicine to the treatment for cervico-thoracic MPS. A search was conducted through MEDLINE (PubMed, OVID, MDConsult), EMBASE, SCOPUS and the Cochrane database for the period 1966 to 2012 using the following keywords: myofascial pain, muscle pain, botulinum toxin, trigger points, and injections. A total of 7 trials satisfied our inclusion criteria and were evaluated in this review. Although the majority of studies found negative results, our analysis identified Gobel et al.'s as the highest quality study among these prospectively randomized investigations. This was due to appropriate identification of diagnostic criteria, excellent study design and objective endpoints. The 6 other identified studies had significant failings due to deficiencies in 1 or more major criteria. We conclude that higher quality, rigorously standardized studies are needed to more appropriately investigate this promising treatment modality.
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Affiliation(s)
- Mehul J Desai
- The George Washington University Spine & Pain Center, Washington, District of Columbia, U.S.A
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Seo HG, Bang MS, Chung SG, Jung SH, Lee SU. Effect of Electrical Stimulation on Botulinum Toxin A Therapy in Patients With Chronic Myofascial Pain Syndrome: A 16-Week Randomized Double-Blinded Study. Arch Phys Med Rehabil 2013; 94:412-8. [PMID: 23123438 DOI: 10.1016/j.apmr.2012.09.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 09/07/2012] [Indexed: 11/27/2022]
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Climent JM, Kuan TS, Fenollosa P, Martin-del-Rosario F. Botulinum toxin for the treatment of myofascial pain syndromes involving the neck and back: a review from a clinical perspective. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2013; 2013:381459. [PMID: 23533477 PMCID: PMC3590763 DOI: 10.1155/2013/381459] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 01/21/2013] [Indexed: 12/20/2022]
Abstract
Introduction. Botulinum toxin inhibits acetylcholine (ACh) release and probably blocks some nociceptive neurotransmitters. It has been suggested that the development of myofascial trigger points (MTrP) is related to an excess release of ACh to increase the number of sensitized nociceptors. Although the use of botulinum toxin to treat myofascial pain syndrome (MPS) has been investigated in many clinical trials, the results are contradictory. The objective of this paper is to identify sources of variability that could explain these differences in the results. Material and Methods. We performed a content analysis of the clinical trials and systematic reviews of MPS. Results and Discussion. Sources of differences in studies were found in the diagnostic and selection criteria, the muscles injected, the injection technique, the number of trigger points injected, the dosage of botulinum toxin used, treatments for control group, outcome measures, and duration of followup. The contradictory results regarding the efficacy of botulinum toxin A in MPS associated with neck and back pain do not allow this treatment to be recommended or rejected. There is evidence that botulinum toxin could be useful in specific myofascial regions such as piriformis syndrome. It could also be useful in patients with refractory MPS that has not responded to other myofascial injection therapies.
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Affiliation(s)
- José M. Climent
- Physical and Rehabilitation Medicine Department, Alicante University General Hospital, C/Pintor Baeza s/n, 03010 Alicante, Spain
| | - Ta-Shen Kuan
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | | | - Francisco Martin-del-Rosario
- Physical and Rehabilitation Medicine Department, Gran Canaria Insular Hospital, Avenida Marítima del Sur, 35006 Las Palmas de Gran Canaria, Spain
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Machado E, Santos LZD, Custódio LG, Cunali PA. Botulinum toxin for treating muscular temporomandibular disorders: a systematic review. Dental Press J Orthod 2012. [DOI: 10.1590/s2176-94512012000600029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE: This study, through a systematic literature review, aims to analyze the effectiveness of Botulinum Toxin as a treatment for masticatory myofascial pain and muscles temporomandibular disorders (TMD). METHODS: Survey in research bases: MEDLINE, Cochrane, EMBASE, Pubmed, Lilacs and BBO, between the years of 1966 and April 2011, with focus in randomized or quasi-randomized controlled clinical trials, blind or double-blind. RESULTS: After applying the inclusion criteria, 4 articles comprised the final sample: 3 were double-blind randomized controlled clinical trials and 1 was single-blind randomized controlled clinical trial. CONCLUSIONS: According to the literature, there is lack of evidence about the real effectiveness of botulinum toxin in the treatment of masticatory myofascial pain and muscular TMD. Thus, further randomized controlled clinical trials, with representative samples and longer follow-up time, to assess the real effectiveness of the technique are needed.
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Sidebottom AJ, Patel AA, Amin J. Botulinum injection for the management of myofascial pain in the masticatory muscles. A prospective outcome study. Br J Oral Maxillofac Surg 2012; 51:199-205. [PMID: 22871559 DOI: 10.1016/j.bjoms.2012.07.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Accepted: 07/05/2012] [Indexed: 12/14/2022]
Abstract
We prospectively analysed the outcome after botulinum injection in patients who did not recover after conservative measures to manage masticatory myofascial pain, and who were not willing to take low dose tricyclic antidepressants as a muscle relaxant. We prospectively 62 patients were assessed with visual analogue scores (VAS) for pain on the affected side before, and 6 weeks after botulinum injection(s) (50 units Dysport in up to 3 sites), and measured mouth opening in mm. Of those treated 49 (79%) showed at least some improvement (pain reduced by more than 25%). Patients reported more than a 90% reduction in the VAS for 25 (30%) of the 84 sides of the face treated. Only 22 of the 62 patients had more than one course of treatment to the same side. Interincisal distance improved by a mean/median of 0.9 mm (p<0.03) after treatment. Side effects included 3 cases of temporary weakness of a facial muscle. Ranking the VAS pain scores using the Wilcoxon test before and after injection showed a significant reduction in pain (median change -29.5, interquartile range -53 to -16, p<0.0001). The treatment significantly improved patients' pain scores and the overall mean/median reduction in pain was 57%. Botulinum injection does not guarantee complete resolution of myofascial pain, but it usually has some beneficial effect in improving the symptoms, and should be considered as an alternate treatment for masticatory myofascial pain if conservative methods have failed.
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Affiliation(s)
- Andrew J Sidebottom
- Maxillofacial Unit, Nottingham University Hospitals NHS Trust, Queens Medical Centre, Derby Road, Nottingham NG7 2UH, United Kingdom.
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Botulinum Toxin Treatment of Myofascial Pain: A Critical Review of the Literature. Curr Pain Headache Rep 2012; 16:413-22. [DOI: 10.1007/s11916-012-0287-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
BACKGROUND Myofascial pain syndrome (MPS) is a regional muscular pain syndrome characterised by the presence of trigger points, which are painful points in one or more muscles. The pain can be felt at the site where the trigger point is located or it can be felt away from that place when the muscle is pressed (referred pain). Botulinum toxin is a protein produced by the bacterium Clostridium botulinum and is a potent neurotoxin that eventually inhibits muscle contractions. It is capable of selectively weakening painful muscles and interrupting the pain cycle. OBJECTIVES To assess the effectiveness and safety of botulinum toxin in treating MPS, excluding MPS in neck and head muscles. SEARCH METHODS The search strategy was composed of terms for myofascial pain and botulinum toxin. We searched the Cochrane Pain, Palliative and Supportive Care (PaPaS) Review Group's Specialised Register until December 2011, CENTRAL (Cochrane Database of Systematic Reviews 2011, Issue 4), PUBMED (from 1966 to 2011), EMBASE (from 1980 to 2011) and LILACS (from 1982 to 2011). There was no language restriction. SELECTION CRITERIA We included randomised controlled trials (RCTs) involving botulinum toxin for treating participants with MPS. We excluded studies with MPS of the neck and head from this review, as they have already been assessed in existing systematic reviews. We considered a diagnosis of MPS to be based on the identification of trigger points in the taut band through palpation of sensitive nodules, local twitch response and specific patterns of referred pain associated with each trigger point. DATA COLLECTION AND ANALYSIS Two review authors independently screened identified studies, extracted data, assessed trial quality and analysed results using the Cochrane PaPaS Review Group criteria. MAIN RESULTS Four studies with a total of 233 participants, comparing botulinum toxin A (BTXA) with placebo, met the inclusion criteria. In one study with 145 participants, a significant improvement rate of pain intensity scores, as shown by the mean difference (MD) of -0.23 (95% confidence interval (CI) -0.26 to -0.20; P value < 0.00001) and duration of daily pain (MD -1.11; 95% CI -1.37 to -0.85; P value < 0.00001), was demonstrated when comparing BTXA with placebo. The three other studies showed that there was no statistically significant difference between BTXA and placebo in pain intensity. AUTHORS' CONCLUSIONS There is inconclusive evidence to support the use of botulinum toxin in the treatment of MPS based on data from four studies with a total of 233 participants, which we considered adequate to be included in this review. Meta-analyses were not possible due to the heterogeneity between studies. We suggest that in future studies the same methodology to assess pain, a standardised dose of treatment, follow-up of at least four months (to observe the maximum/minimum curve of the drug effect) and appropriate data presentation should be used. More high-quality RCTs of botulinum toxin for treating MPS need to be conducted before firm conclusions on its effectiveness and safety can be drawn.
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Affiliation(s)
- Adriana Soares
- Department of Medicine, Universidade Federal de São Paulo, Belo Horizonte, Brazil.
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Rosales RL, Kanovsky P, Fernandez HH. What’s the “catch” in upper-limb post-stroke spasticity: Expanding the role of botulinum toxin applications. Parkinsonism Relat Disord 2011; 17 Suppl 1:S3-10. [PMID: 21999894 DOI: 10.1016/j.parkreldis.2011.06.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Annaswamy TM, De Luigi AJ, O'Neill BJ, Keole N, Berbrayer D. Emerging Concepts in the Treatment of Myofascial Pain: A Review of Medications, Modalities, and Needle-based Interventions. PM R 2011; 3:940-61. [DOI: 10.1016/j.pmrj.2011.06.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 06/14/2011] [Accepted: 06/19/2011] [Indexed: 10/16/2022]
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Jabbari B, Machado D. Treatment of refractory pain with botulinum toxins--an evidence-based review. PAIN MEDICINE 2011; 12:1594-606. [PMID: 21958302 DOI: 10.1111/j.1526-4637.2011.01245.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To provide updated information on the role of botulinum toxins in the treatment of refractory pain based on prospective, randomized, double-blind, placebo-controlled studies. DESIGN OF THE REVIEW: Class I and class II articles were searched online through PubMed (1966 to the end of January 2011) and OvidSP including ahead-of-print manuscripts. RESULTS Level A evidence (two or more class I studies-established efficacy): pain of cervical dystonia, chronic migraine, and chronic lateral epicondylitis. Level B evidence (one class I or two class II studies-probably effective and recommended): post-herpetic neuralgia, post-traumatic neuralgia, pain of plantar fasciitis, piriformis syndrome, and pain in total knee arthroplasty. Level C evidence (one class II study-possibly effective, may be used at discretion of clinician): allodynia of diabetic neuropathy, chronic low back pain, painful knee osteoarthritis, anterior knee pain with vastus lateralis imbalance, pelvic pain, post-operative pain in children with cerebral palsy after adductor hip release surgery, post-operative pain after mastectomy, and sphincter spasms and pain after hemorrhoidectomy. Level U evidence (efficacy not proven due to diverse class I and II results): myofascial pain syndrome and chronic daily headaches. Studies in episodic migraine and tension headaches have shown treatment failure (level A-negative). CONCLUSION Evidence-based data indicate that administration of botulinum toxin in several human conditions can alleviate refractory pain. The problems with some study designs and toxin dosage are critically reviewed.
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Affiliation(s)
- Bahman Jabbari
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA.
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Langevin P, Peloso PMJ, Lowcock J, Nolan M, Weber J, Gross A, Roberts J, Goldsmith CH, Graham N, Burnie SJ, Haines T. Botulinum toxin for subacute/chronic neck pain. Cochrane Database Syst Rev 2011:CD008626. [PMID: 21735434 DOI: 10.1002/14651858.cd008626.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Neck disorders are common, disabling and costly. Botulinum toxin (BoNT) intramuscular injections are often used with the intention of treating neck pain. OBJECTIVES To systematically evaluate the literature on the treatment effectiveness of BoNT for neck pain, disability, global perceived effect and quality of life in adults with neck pain with or without associated cervicogenic headache, but excluding cervical radiculopathy and whiplash associated disorder. SEARCH STRATEGY We searched CENTRAL, MEDLINE, AMED, Index to Chiropractic Literature, CINAHL, LILACS, and EMBASE from their origin to 20 September 2010. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials in which BoNT injections were used to treat subacute or chronic neck pain. DATA COLLECTION AND ANALYSIS A minimum of two review authors independently selected articles, abstracted data, and assessed risk of bias, using the Cochrane Back Review Group criteria. In the absence of clinical heterogeneity, we calculated standardized mean differences (SMD) and relative risks, and performed meta-analyses using a random-effects model. The quality of the evidence and the strength of recommendations were assigned an overall grade for each outcome. MAIN RESULTS We included nine trials (503 participants). Only BoNT type A (BoNT-A) was used in these studies.High quality evidence suggests there was little or no difference in pain between BoNT-A and saline injections at four weeks (five trials; 252 participants; SMD pooled -0.07 (95% confidence intervals (CI) -0.36 to 0.21)) and six months for chronic neck pain. Very low quality evidence indicated little or no difference in pain between BoNT-A combined with physiotherapeutic exercise and analgesics and saline injection with physiotherapeutic exercise and analgesics for patients with chronic neck pain at four weeks (two trials; 95 participants; SMD pooled 0.09 (95% CI -0.55 to 0.73)) and six months (one trial; 24 participants; SMD -0.56 (95% CI -1.39 to 0.27)). Very low quality evidence from one trial (32 participants) showed little or no difference between BoNT-A and placebo at four weeks (SMD 0.16 (95% CI -0.53 to 0.86)) and six months (SMD 0.00 (95% CI -0.69 to 0.69)) for chronic cervicogenic headache. Very low quality evidence from one trial (31 participants), showed a difference in global perceived effect favouring BoNT-A in chronic neck pain at four weeks (SMD -1.12 (95% CI: -1.89 to -0.36)). AUTHORS' CONCLUSIONS Current evidence fails to confirm either a clinically important or a statistically significant benefit of BoNT-A injection for chronic neck pain associated with or without associated cervicogenic headache. Likewise, there was no benefit seen for disability and quality of life at four week and six months.
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Affiliation(s)
- Pierre Langevin
- Cliniques Physio Interactive, Département de réadaptation, Faculté de Médecine, Université Laval, 1100 boul Chaudière, CP 75217, Quebec City, PQ, Canada, G1Y 3C7
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Benecke R, Heinze A, Reichel G, Hefter H, Göbel H. Botulinum type A toxin complex for the relief of upper back myofascial pain syndrome: how do fixed-location injections compare with trigger point-focused injections? PAIN MEDICINE 2011; 12:1607-14. [PMID: 21692970 DOI: 10.1111/j.1526-4637.2011.01163.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE This was a prospective, randomized, double-blind, placebo-controlled, 12-week, multicenter study to evaluate the efficacy and tolerability of fixed location injections of botulinum type A toxin (BoNT-A, Dysport) in predetermined injection sites in patients with myofascial pain syndrome of the upper back. DESIGN Patients with moderate-to-severe myofascial pain syndrome affecting cervical and/or shoulder muscles (10 trigger points, disease duration 6-24 months) and moderate-to-severe pain intensity were randomized to BoNT-A (N = 81) or saline (N = 72). INTERVENTION Patients received treatment into 10 predetermined fixed injection sites in the head, neck, and shoulder (40 units of BoNT-A per site or saline, a total of 400 units of BoNT-A). OUTCOME MEASURES The primary efficacy outcome was the proportion of patients with mild or no pain at week 5 (responders). Secondary outcomes included changes in pain intensity and the number of pain-free days per week. RESULTS At week 5, 49% (37/76) of BoNT-A patients and 38% (27/72) of placebo patients had responded to treatment (P = 0.1873). Duration of daily pain was reduced in the BoNT-A group compared with the placebo group from week 5, with statistically significant differences at weeks 9 and 10 (P = 0.04 for both). Treatment was well tolerated. CONCLUSION Fixed-location treatment with BoNT-A of patients with upper back myofascial pain syndrome did not lead to a significant improvement of the main target parameter in week 5 after treatment. Only in week 8 were significant differences found. Several secondary parameters, such as physicians' global assessment and patients' global assessment, significantly favored BoNT-A over placebo at weeks 8 and 12.
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Affiliation(s)
- Reiner Benecke
- University of Rostock, Department of Neurology, Rostock, Germany
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Sharan D, Jacob BN, Ajeesh PS, Bookout JB, Barathur RR. The effect of cetylated fatty esters and physical therapy on myofascial pain syndrome of the neck. J Bodyw Mov Ther 2011; 15:363-74. [PMID: 21665114 DOI: 10.1016/j.jbmt.2010.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Revised: 12/09/2009] [Accepted: 02/07/2010] [Indexed: 10/18/2022]
Abstract
Participants with Myofascial Pain Syndrome (MPS) of the neck were randomly assigned into 2 groups of the double-blinded study: topical cetylated fatty ester complex (CFEC) cream application plus physical therapy (CF-PT; n=37), and placebo cream application plus physical therapy (PL-PT; n=35). There were 3 visits during 4 weeks of treatment. Physical Therapy (PT), given twice/week, included Ischaemic Compression, Deep Pressure Trigger Point Massage and Myofascial Releases. Topical cream [CFEC cream (5.6%) and 1.5% menthol] or placebo cream [1.5% menthol, in a cream base] was applied twice/day. CF-PT provided the fastest and most effective study treatment modality. The addition of CFEC cream to PT resulted in statistically significant improvements, compared to PL-PT, for reduction of pain, neck disability and life quality indicators. Our results indicate that cetylated derivatives of fatty acids can effectively reduce pain and symptoms associated with neck MPS, when combined with physical therapy.
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Affiliation(s)
- Deepak Sharan
- RECOUP Neuromusculoskeletal Rehabilitation Centre, 312, 80 Feet Road, Further Extension of Anjanapura Layout, 10th Block, Bangalore 560062, Karnataka, India.
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Ernberg M, Hedenberg-Magnusson B, List T, Svensson P. Efficacy of botulinum toxin type A for treatment of persistent myofascial TMD pain: a randomized, controlled, double-blind multicenter study. Pain 2011; 152:1988-1996. [PMID: 21514731 DOI: 10.1016/j.pain.2011.03.036] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2010] [Revised: 03/22/2011] [Accepted: 03/28/2011] [Indexed: 11/30/2022]
Abstract
Evidence of an effect by botulinum toxins is still lacking for most pain conditions. In the present randomized, placebo-controlled, crossover multicenter study, the efficacy of botulinum toxin type A (BTX-A) was investigated in patients with persistent myofascial temporomandibular disorders (TMD). Twenty-one patients with myofascial TMD without adequate pain relief after conventional treatment participated. A total of 50 U of BTX-A or isotonic saline (control) was randomly injected into 3 standardized sites of the painful masseter muscles. Follow-up was performed after 1 and 3 months, followed by a 1-month washout period, after which crossover occurred. Pain intensity at rest was the primary outcome measure, while physical and emotional function, global improvement, side effects, and clinical measures were additional outcome measures. There was no main difference between drugs (ANOVA; P=.163), but there was a significant time effect (P<.001), so BTX-A reduced mean (SD) percent change of pain intensity by 30 (33%) after 1 month and by 23 (30%) after 3 months compared to 11 (40%) and 4 (33%) for saline. The number of patients who received a 30% pain reduction was not significantly larger for BTX-A than after saline at any follow-up visit. The number needed to treat was 11 after 1 month and 7 after 3 months. There were no significant changes after treatment in any other outcome measures, with the exception of pain on palpation, which decreased 3 months after saline injection (P<.05). These results do not indicate a clinical relevant effect of BTX-A in patients with persistent myofascial TMD pain.
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Affiliation(s)
- Malin Ernberg
- Unit of Clinical Oral Physiology, Department of Dental Medicine, Karolinska Institutet, Box 4064, SE 141 04 Huddinge, Sweden Department of Stomatognathic Physiology, Eastman Institute, Dalagatan 11, SE 113 24 Stockholm, Sweden Department of Stomatognathic Physiology, Faculty of Dentistry, Malmö University, SE 212 22 Malmö, Sweden Department of Clinical Oral Physiology, School of Dentistry, Aarhus University, DK 8000 Aarhus, Denmark Center for Functionally Integrative Neuroscience (CFIN), MindLab, Aarhus University Hospital, Aarhus, Denmark
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Müller-Schwefe GHH, Überall MA. Dysport® for the treatment of myofascial back pain: Results from an open-label, Phase II, randomized, multicenter, dose-ranging study. Scand J Pain 2011; 2:25-33. [PMID: 29913724 DOI: 10.1016/j.sjpain.2010.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Accepted: 11/08/2010] [Indexed: 01/12/2023]
Abstract
Background and purpose Botulinum toxin type A (BoNT-A) has antinociceptive and muscle-relaxant properties. The objectives of this study were to investigate the efficacy and safety of a single BoNT-A (Dysport®) treatment in myofascial back pain. Methods In this randomized, open-label, multicenter study, adults with myofascial lower back pain received Dysport® injections at four trigger points (60,80 or 120 units per injection point). Patients were followed for 12 weeks. The a priori primary endpoint was a pooled evaluation, at Week 6, of seven measures of efficacy, including pain intensity (patient diary), modified Pain Disability Index (PDI) score, use of interfering concomitant analgesics, and patient-rated global efficacy. Optional assessments of pressure thresholds and tissue compliance were conducted. Safety was also assessed. Results A total of 202 patients were randomized to treatment and 189 patients received a low (n = 57), medium (n = 57), or high (n = 75) total dose of Dysport® at 34 centers in Germany between October 2002 and October 2003. All treated patients were included in the safety population; 8 patients were excluded from the intention-to-treat population. Patients had moderate to severe pain at baseline. At baseline, 120 patients were receiving concomitant analgesic therapy; 6.7%, 74.2% and 19.2% were considered to cause mild, moderate and severe interference with pain measurements, respectively. There was no difference between doses for the a priori combined primary endpoint. Patient-reported pain intensity scores at rest and on movement decreased significantly after treatment for all groups combined (p < 0.0001 at all visits). At Week 6, reductions in pain intensity at rest were 29%, 19% and 26% for the low-, medium- and high-dose groups, respectively; reductions in pain intensity on movement were 27%, 18% and 26%, respectively. Overall, patients who reported pain intensity reductions at Week 6 were evident within 3 weeks of treatment and were maintained for the 12 weeks of the study. In the total population, significant decreases in mean PDI sum scores from baseline were observed from Week 3 and were maintained through to the end of treatment (Week 12); no differences between the dose groups were observed. Pressure thresholds and tissue compliance also increased during the study. Adverse events were generally as expected for BoNT-A; the majority were mild or moderate in severity. Conclusions Dysport® treatment was associated with reductions in myofascial back pain and was well tolerated. Nodose-response relationship was observed; treatment with Dysport® using a four-trigger-point injection protocol at 60 units per trigger point was associated with a clinically relevant and statistically significant improvement in pain and pain-related disability; there was no additional benefit from the higher doses. Implications Our findings are limited by the lack of a control group and further research is warranted to confirm the value of Dysport® for the treatment of myofascial back pain and confirm the optimum dosing in this indication.
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Affiliation(s)
- Gerhard H H Müller-Schwefe
- Facharzt für Anasthesiologie und fur Allgemeinmedizin, Spezielle Schmerztherapie, Leitender Arzt Schmerzzentrum Göppingen, Schillerplatz 8/1, D-73033 Göppingen, Germany
| | - Michael A Überall
- Institut für Neurowissenschaften, Algesiologie und Pädiatrie (IFNAP), Deutsche Gesellschaft für Schmerztherapie (DGS), O. Meany - Medical Data & Project Management GmbH, Theodorstraße 1, D-90489 Nürnberg, Germany
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The role of botulinum toxin in management of pain: an evidence-based review. Curr Opin Anaesthesiol 2010; 23:602-10. [PMID: 20585245 DOI: 10.1097/aco.0b013e32833c3405] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW In the present review we discuss the role of botulinum neurotoxins (BoNTs) in the management of different pain conditions, with evidence-based data on the toxins' efficacy on pain and its mechanisms. RECENT FINDINGS Experimental in-vitro studies have reported promising results of a novel recombinant chimera of BoNT A and E that inhibits the calcitonin gene-related peptide exocytosis from brainstem sensory neurons. Animal studies in neuropathic pain rat models have reported an analgesic effect of BoNT A given after the neuropathic procedure and a bilateral antinociceptive effect to the unilateral noxious stimuli. There is a growing body of evidence that BoNTs are effective in myofascial pain syndrome, neuropathic pain, and joint pain. The pre-existing evidence that BoNTs are ineffective in migraine or other headache disorders has not yet been challenged. In other pain syndromes, studies published in the last review year have not contributed significantly in either demonstrating or invalidating the research that has so far proved inconclusive. SUMMARY The role of BoNTs in management of pain is not yet well established. Larger studies in neuropathic pain, joint pain, and myofascial pain syndrome are needed to fully ascertain the role for BoNT therapy in those areas.
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Ruyssen-Witrand A, Tubach F, Ravaud P. Systematic review reveals heterogeneity in definition of a clinically relevant difference in pain. J Clin Epidemiol 2010; 64:463-70. [PMID: 21109400 DOI: 10.1016/j.jclinepi.2010.06.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Revised: 01/31/2010] [Accepted: 06/04/2010] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To describe the pain decrease considered as clinically relevant when designing a trial and reporting its results. METHODS A systematic review of the literature in MEDLINE was conducted to select randomized controlled trials (RCTs) with pain as a primary outcome. Data extracted included the definition (terms and values) of a clinically relevant difference in pain, the type of pain studied (acute or chronic), the level of application (group or individual) of the clinically relevant difference, and the reference justifying the choice of value for clinically relevant difference. STUDY DESIGN AND SETTING Seventy-four trials were included, and only 16 articles justified the choice of a value for clinically relevant difference with a reference citation. The values chosen for the clinically relevant relative decrease in pain varied from 4 to 40 mm or from 15% to 55% at the group level and from 20 to 50 mm at the individual level. In seven articles, the authors confused the application of the reference value at the individual or group level. CONCLUSION Our review revealed a great heterogeneity in definition, format, and values of what is considered a clinically relevant difference in pain in RCTs of analgesics, and standardizations are advisable.
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The efficacy of botulinum toxin type A in managing chronic musculoskeletal pain: a systematic review and meta analysis. Inflammopharmacology 2010; 19:21-34. [PMID: 21076878 DOI: 10.1007/s10787-010-0069-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Accepted: 10/19/2010] [Indexed: 01/09/2023]
Abstract
BACKGROUND Botulinum toxin type A (BoNTA) is a neurotoxin that acts by inhibiting the release of neurotransmitters acetylcholine at neuromuscular junctions, thus reducing muscular contractions. Recent evidence suggests that BoNTA can reduce nociceptive activities of sensory neurons in animal models by inhibiting release of certain neuropeptides. Despite the therapeutic benefit of BoNTA in alleviating painful muscle spasms, its efficacy in other musculoskeletal pain conditions is less clear. OBJECTIVE We aim to examine the efficacy of BoNTA in reducing chronic musculoskeletal pain. METHODS Studies for inclusion in our report were identified using MEDLINE, EMBASE, PUBMED, Cochrane Central Register of Controlled Trials, CINAHL, and reference lists of relevant articles. Studies were considered eligible for inclusion if they were randomized controlled trials (RCTs), evaluating the efficacy of BoNTA injections in pain reduction. All studies were assessed and data were abstracted independently by paired reviewers. The outcome measures were baseline and final pain scores as assessed by the patients. The internal validity of trials was assessed with the Jadad scale. Disagreements were resolved through discussions. MAIN RESULTS Twenty-one studies were included in the systematic review and 15 of them were included in the final meta-analysis. There was a total of 706 patients in the meta-analysis, represented from trials of plantar fasciitis (n = 1), tennis elbow (n = 2), shoulder pain (n = 1), whiplash (n = 3), and myofascial pain (n = 8). Overall, there was a small to moderate pain reduction among BoNTA patients when compared to control (SMD = -0.27, 95% CI: -0.44 to -0.11). When the results were analyzed in subgroups, only tennis elbow (SMD = -0.44, 95% CI: -0.86 to -0.01) and plantar fasciitis (SMD = -1.04, 95% CI: -1.68 to -0.40) demonstrated significant pain relief. Although not in the meta-analysis, one back pain study also demonstrated positive results for BoNTA. Lastly, BoNTA was effective when used at ≥ 25 units per anatomical site or after a period ≥ 5 weeks. CONCLUSION In our meta-analysis, BoNTA had a small to moderate analgesic effect in chronic musculoskeletal pain conditions. It was particularly effective in plantar fasciitis, tennis elbow, and back pain, but not in whiplash or shoulder pain patients. However, more evidence is required before definitive conclusions can be drawn. On the other hand, there is convincing evidence that BoNTA lacks strong analgesic effects in patients with myofascial pain syndrome. A general dose-dependent and temporal response with BoNTA injections was also observed.
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Abstract
BACKGROUND Recent evidence suggests an anti-nociceptive effect of botulinum toxin. OBJECTIVES To compare the efficacy and safety of botulinum toxin in comparison to placebo or other treatment options for shoulder pain. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), Ovid MEDLINE, CINAHL (via EBSCOhost), Ovid SPORTDiscus, EMBASE and Science Citation Index. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing botulinum toxin with placebo or active treatment in people with shoulder pain were included. DATA COLLECTION AND ANALYSIS For continuous measures we calculated mean difference (MD), and for categorical measures risk ratio (RR) (with 95% confidence interval (CI)). MAIN RESULTS Six RCTs with 164 patients were included. Five RCTs in participants with post-stroke shoulder pain indicated that compared with placebo, a single intramuscular injection of botulinum toxin A significantly reduced pain at three to six months post-injection (MD -1.2 points, 95% CI -2.4 to -0.07; 0 to 10 point scale) but not at one month (MD -1.1 points, 95% CI -2.9 to 0.7). Shoulder external rotation was increased at one month (MD 9.8 degrees , 95% CI 0.2 to 19.4) but not at three to six months. Shoulder abduction, external rotation or spasticity did not differ between groups, nor did the number of adverse events (RR 1.46, 95% CI 0.6 to 24.3).One RCT in arthritis-related shoulder pain indicated that botulinum toxin reduced pain severity (MD -2.0, 95% CI -3.7 to -0.3; 10 point scale) and shoulder disability with a reduction in Shoulder Pain and Disability Index score (MD -13.4, 95% CI -24.9 to -1.9; 100 point scale) when compared with placebo. Shoulder abduction was improved (MD 13.8 degrees, 95% CI 3.2 to 44.0). Serious adverse events did not differ between groups (RR 0.35, 95% CI: 0.11, 1.12). AUTHORS' CONCLUSIONS The results should be interpreted with caution due to few studies with small sample sizes and high risk of bias. Botulinum toxin A injections seem to reduce pain severity and improve shoulder function and range of motion when compared with placebo in patients with shoulder pain due to spastic hemiplegia or arthritis. It is unclear if the benefit of pain relief in post-stroke shoulder pain at three to six months but not at one month is due to limitations of the evidence, which includes small sample sizes with imprecise estimates, or a delayed onset of action. More studies with safety data are needed.
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Affiliation(s)
- Jasvinder A Singh
- Department of Medicine, Birmingham VA Medical Center, Faculty Office Tower 805B, 510 20th Street South, Birmingham, USA, AL 35294
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Effect of Botulinum Toxin on Pressure Pain Threshold and EMG Power Spectrum of Masseter Muscle During Sustained Fatiguing Contraction. Am J Phys Med Rehabil 2010; 89:736-43. [DOI: 10.1097/phm.0b013e3181ec9463] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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