Botulinum toxin for myofascial pain syndromes in adults

Myofascial pain syndrome in patients with cancer: a narrative review

PURPOSE

Myofascial pain syndrome (MPS) is a chronic musculoskeletal pain syndrome. The purpose of this review is to describe the epidemiological and treatment evidence and to address the future research agenda in patients with cancer.

METHODS

A narrative review of previous reports investigating the prevalence and treatment of MPS in the oncology field is presented. The target population is patients with cancer and cancer survivors.

RESULTS

There have been three prospective and two retrospective studies investigating the prevalence of MPS. MPS is as high as 38%-45% in patients with advanced or incurable cancer and 11.9%-44.8% in cancer survivors. A total of nine reports investigated the efficacy of the following interventions: trigger point injection (TPI), myofascial techniques and ischaemic compression. TPI has been reported to be effective in four observational studies. One randomised study reported the efficacy of myofascial techniques, but two randomised studies reported no added beneficial effects of it in breast cancer survivors. Two randomised studies investigated the efficacy of ischaemic compression, but the obtained results were contradictory.

CONCLUSIONS

MPS is highly prevalent. We should know that non-cancer pain is also common in both patients with cancer and survivors. In treating such pain, careful physical examination is essential. Then, non-pharmacological treatment should be considered as well as pharmacotherapy. As evidence regarding MPS in the oncology field is scarce, further research is warranted.

Ultrasound-Guided Lidocaine Injection as a Novel Predictor of Response to Botulinum for Patients With Myofascial Pain Syndrome: A Case Report

Botulinum injection is a well-known non-surgical intervention utilized in the management of myofascial pain syndrome (MPS). However, sparse evidence exists regarding the utility of ultrasound guidance of injectate or lidocaine as a predictive marker of patient response to botulinum toxin A (BTX-A). A 39-year-old male active duty service member demonstrated typical signs and symptoms of MPS. He reported a 10-year history of neck and back spasms that were triggered by exertion but also could occur spontaneously. Based on the characteristic regional motor-sensory defects, treatment options were discussed. With shared decision-making, the patient opted to try ultrasound-guided injection of lidocaine followed by xenomin brand BotoxA. Immediately following lidocaine injection, the patient reported complete relief of symptoms. Both injections were uncomplicated, and the patient reported great reduction in symptoms during the subsequent visit 2 months later. Relief of pain following ultrasound-guided injection of lidocaine may serve as an indicator of successful patient response to BTX-A in patients with MPS.

Mechanism and clinical use of botulinum neurotoxin in head and facial region

PURPOSE

Botulinum neurotoxin (BoNT) is a biological toxin produced by Clostridium botulinum. BoNT is a potent toxin extensively used in therapeutic interventions. This review provides an updated overview of the mechanisms of action and clinical applications of BoNT in head and facial region.

STUDY SELECTION

MEDLINE/PubMed searches were conducted using the terms "botulinum neurotoxin" and "dentistry" along with a combination of other related terms. In addition, studies were manually selected from reference lists of the selected articles.

RESULTS

The Food and Drug Administration in the United States initially approved BoNT to treat strabismus, blepharospasm, and hemifacial spasms. The use of BoNT in dermatology and cosmetics has been widely established and has created a revolution in these fields. Over the years, its applications in various medical specialties have expanded widely. Owing to its safety, efficacy, and long duration of action, it is well-accepted by patients. BoNT/A and BoNT/B are widely used in clinical practice. Several off-label uses of BoNT in the dental fraternity have yielded promising results. We have elaborated on the speculated mechanism of action, dosage, effective sites of injection, and adverse effects of each therapeutic application. The various clinical indications for BoNT include bruxism, myofascial pain, temporomandibular joint dislocation, hemifacial pain, orofacial dystonia, facial paralysis, chronic migraine, and trigeminal neuralgia.

CONCLUSIONS

BoNT is a safe treatment that can be used effectively, provided that the clinician has adequate knowledge regarding the mechanism, injection techniques, and local and systemic side effects and that it is administered cautiously and purposefully.

Botulinum toxin A in dentistry and orofacial surgery: an evidence-based review - part 1: therapeutic applications

Objective An evidence-based review on the safety and efficacy of botulinum toxin type-A (BoNTA) in orofacial conditions, focusing on the therapeutic applications and role of BoNTA as an adjuvant treatment.Data source and selection Data was collected using PubMed (Medline), Cochrane Library of Systematic Reviews and Cochrane Central Register of Controlled Trials electronic databases. Having satisfied the search parameters, 32 studies for therapeutic applications and 26 for BoNTA as an adjunctive treatment were included. The quality of relevant studies was assessed using the Best Evidence Topics (BETs) Critical Appraisal Tool.Data extraction The highest level of evidence (LOE) behind BoNTA safety and efficacy was for wound healing and scar management in the orofacial surgery context, where BoNTA was presented as an adjunctive modality. Level-I evidence was controversial for temporomandibular disorders and bruxism. However, it showed promising results for painful temporomandibular disorders of myogenic origin refractory to conservative therapies, and to decrease muscle contraction intensity in sleeping bruxism. There was only one level-II study for persistent recurrent aphthous stomatitis. Data showed limited level-III evidence for orofacial pain conditions (temporomandibular joint recurrent dislocation and pain, burning mouth syndrome or atypical odontalgia), oral cancer complications, or as an adjuvant to maxillofacial and orthognathic surgeries. Benefits of BoNTA in prosthodontics had weak level-IV evidence. No evidence was found among the periodontology field.Conclusion There is growing evidence to support the safety and efficacy of BoNTA in the investigated orofacial pathological conditions, with high levels of satisfaction from the patient and clinician perspective. However, there are some inconsistencies and limited high-quality evidence available. Well-designed controlled clinical trials are necessary to evaluate long-term safety, efficacy and cost-effectiveness before BoNTA is widely adopted with irrefutable evidence-based clinical guidelines.

Piriformis syndrome: pain response outcomes following CT-guided injection and incremental value of botulinum toxin injection

PURPOSE

Piriformis syndrome is a common pain condition affecting the buttock and posterior hip with or without radiation to the leg, and management of the condition involves many treatments. In this study, we hypothesize that a CT-guided injection with botulinum toxin is more effective in providing pain relief than a CT-guided injection without Botox.

METHODS

Overall, 97 consecutive patients with piriformis syndrome presented for a CT-guided injection of the piriformis muscle and perineural injection of the sciatic nerve. After the injection, the patients received a visual analog scale pain log to record their pain level until the follow-up appointment. P values of less than 0.2 were considered as confounder and adjusted by inverse probability of treatment weighting (IPTW) via propensity score. The effect of botulinum toxin on 48-hour response and duration of response was tested using weighted chi-square test and weighted Kaplan-Meier analysis.

RESULTS

There was a total of 97 patients in the study, and 111 injections, as some patients had bilateral injections. Patients in the Botox group had more 48-hour response than patients in the non-botulinum toxin group (P < 0.001 with IPTW, P = 0.005 without IPTW). Median pain-free survival was 30 days for Botox group and 1 day for non-Botox group (P = 0.059 with IPTW, P = 0.10 without IPTW).

CONCLUSION

CT-guided injections with botulinum toxin for patients with piriformis syndrome are more likely to lead to a positive response and a longer duration of response than patients who receive a CT-guided injection without botulinum toxin. We hope that this study facilitates future prospective randomized blind trials for patients with suspected piriformis syndrome.

Functional Somatic Symptoms

BACKGROUND

Approximately 10% of the general population and around one third of adult patients in clinical populations suffer from functional somatic symptoms. These take many forms, are often chronic, impair everyday functioning as well as quality of life, and are cost intensive.

METHODS

The guideline group (32 medical and psychological professional societies, two patients' associations) carried out a systematic survey of the literature and ana- lyzed 3795 original articles and 3345 reviews. The aim was to formulate empirically based recommendations that were practical and user friendly.

RESULTS

Because of the variation in course and symptom severity, three stages of treatment are distinguished. In early contacts, the focus is on basic investigations, reassurance, and advice. For persistent burdensome symptoms, an extended, simultaneous and equitable diagnostic work-up of physical and psychosocial factors is recommended, together with a focus on information and self-help. In the pres- ence of severe and disabling symptoms, multimodal treatment includes further elements such as (body) psychotherapeutic and social medicine measures. Whatever the medical specialty, level of care, or clinical picture, an empathetic professional attitude, reflective communication, information, a cautious, restrained approach to diagnosis, good interdisciplinary cooperation, and above all active interventions for self-efficacy are usually more effective than passive, organ- focused treatments.

CONCLUSION

The cornerstones of diagnosis and treatment are biopsychosocial ex- planatory models, communication, self-efficacy, and interdisciplinary mangagement. This enables safe and efficient patient care from the initial presentation onwards, even in cases where the symptoms cannot yet be traced back to specific causes.

Botulinum toxin type A applications for masticatory myofascial pain and trigeminal neuralgia: what is the evidence regarding adverse effects?

OBJECTIVES

The objective of the study was to conduct a systematic review of literature assessing botulinum toxin type A (BoNT-A) safety and adverse effects in the treatment of myofascial pain (MFP) and trigeminal neuralgia (TN).

MATERIALS AND METHODS

The search for articles by two specific researchers involved the PubMed, EMBASE, Web of Science, and Scopus databases. Specific terms were used, and no publication time and language restrictions were applied. Clinical trials that investigated the effects of BoNT-A among participants with myofascial pain in masticatory muscles or trigeminal neuralgia were considered eligible for this systematic review. Data for each study were extracted and analyzed according to a PICO-like structured reading.

RESULTS

The search strategy provided 436 citations. After analysis, 16 citations were included, seven for MFP and nine for TN. In all studies, BoNT-A was well tolerated and improved pain. The most common adverse effects were temporary regional weakness, tenderness over the injection sites, and minor discomfort during chewing. Most studies reported a spontaneous resolution of adverse effect.

CONCLUSIONS

It can be concluded that BoNT-A treatment is well tolerated, since minor adverse effects were the most frequently reported; however, it is recommended that future studies aim to assess the safety and possible adverse effects of multiples applications or high doses of this treatment.

CLINICAL RELEVANCE

BoNT-A has been increasingly diffused in dentistry, being used for the management of masticatory myofascial pain and trigeminal neuralgia. Nonetheless, there is no consensus about its efficacy and adverse effects that could occur when this treatment is applied.

Botulinum toxin for chronic pelvic pain in women with endometriosis: a cohort study of a pain-focused treatment

BACKGROUND AND OBJECTIVES

Many women with endometriosis continue to have pelvic pain despite optimal surgical and hormonal treatment; some also have palpable pelvic floor muscle spasm. We describe changes in pain, spasm, and disability after pelvic muscle onabotulinumtoxinA injection in women with endometriosis-associated pelvic pain, a specific population not addressed in prior pelvic pain studies on botulinum toxin.

METHODS

We present an open-label proof-of-concept case series of women with surgically diagnosed endometriosis. Under conscious sedation and with topical anesthetic, 100 units of onabotulinumtoxinA was injected transvaginally into pelvic floor muscle spasm areas under electromyography guidance. Changes in pain intensity, muscle spasm, disability, and pain medication use were assessed at periodic visits for up to 1 year after injection.

RESULTS

Thirteen women underwent botulinum toxin injection and were followed for at least 4 months. Before injection, 11 of the 13 women had spasm in >4/6 assessed pelvic muscles and reported moderate pain (median visual analog scale (VAS): 5/10; range: 2-7). By 4-8 weeks after injection, spasm was absent/less widespread (≤3 muscles) in all (p=0.0005). Eleven rated their postinjection pain as absent/mild (median VAS: 2; range: 0-5; p<0.0001); 7/13 reduced pain medication. Disability decreased in 6/8 women with at least moderate preinjection disability (p=0.0033). Relief lasted 5-11 months in 7 of the 11 patients followed for up to 1 year. Adverse events were mild and transient.

CONCLUSIONS

These findings suggest pelvic floor spasm may be a major contributor to endometriosis-associated pelvic pain. Botulinum toxin injection may provide meaningful relief of pain and associated disability.

TRIAL REGISTRATION NUMBER

NCT01553201.

Evidence-Based Pain Management: Building on the Foundations of Cochrane Systematic Reviews

We discuss the history and current status of evidence-based medicine for the prevention and treatment of acute and chronic pain as it has developed in the Cochrane Collaboration's Pain, Palliative and Supportive Care Review Group.To date, the Pain, Palliative and Supportive Care Review Group has published 277 reviews and a further 11 reviews of systematic reviews summarizing the evidence for interventions. The Cochrane Library has readily available high-quality summaries of evidence of pharmacological interventions especially for postsurgical pain but also for chronic musculoskeletal and neuropathic pain. The library covers all forms of intervention, not only pharmacological.The world of evidence-based medicine is changing: most historical trials have been entered into reviews, but the evidence is still not well disseminated and needs to be better translated into decision support. Evidence should be at the heart of policymaking. Much has been achieved in the past 21 years, but there are no grounds for complacency.

Management of Functional Somatic Syndromes and Bodily Distress

Functional somatic syndromes (FSS), like irritable bowel syndrome or fibromyalgia and other symptoms reflecting bodily distress, are common in practically all areas of medicine worldwide. Diagnostic and therapeutic approaches to these symptoms and syndromes vary substantially across and within medical specialties from biomedicine to psychiatry. Patients may become frustrated with the lack of effective treatment, doctors may experience these disorders as difficult to treat, and this type of health problem forms an important component of the global burden of disease. This review intends to develop a unifying perspective on the understanding and management of FSS and bodily distress. Firstly, we present the clinical problem and review current concepts for classification. Secondly, we propose an integrated etiological model which encompasses a wide range of biopsychosocial vulnerability and triggering factors and considers consecutive aggravating and maintaining factors. Thirdly, we systematically scrutinize the current evidence base in terms of an umbrella review of systematic reviews from 2007 to 2017 and give recommendations for treatment for all levels of care, concentrating on developments over the last 10 years. We conclude that activating, patient-involving, and centrally acting therapies appear to be more effective than passive ones that primarily act on peripheral physiology, and we recommend stepped care approaches that translate a truly biopsychosocial approach into actual management of the patient.

Intra-articular injection of botulinum toxin type A for shoulder pain in glenohumeral osteoarthritis: a case series summary and review of the literature

INTRODUCTION

Shoulder pain is one of the most common musculoskeletal diseases, and can be due to glenohumeral osteoarthritis, rotator cuff tear, impingement, tendinitis, adhesive capsulitis, and subacromial bursitis. Several therapies have been proposed, including steroids, nonsteroidal anti-inflammatory drugs, intra-articular injections, and physical therapies. Many published studies have reported on the employment of botulinum toxin type A (BoNT-A) to reduce pain in subjects with neurological and musculoskeletal diseases by inhibiting substance P release and other inflammatory factors.

METHODS

In the present article, we briefly update current knowledge regarding intra-articular BoNT therapy, reviewing existing literature on intra-articular use of BoNT-A, including nonrandomized and randomized prospective and retrospective cohort studies and case series published from December 1989 to November 2017. We also describe a case series of six subjects treated with intra-articular injection of incobotulinumtoxin A for the treatment of pain deriving from osteoarthritis.

CONCLUSION

Intra-articular BoNT-A is effective and minimally invasive. Pain reduction with an increase in shoulder articular range of motion in our experience confirms the effectiveness of BoNT-A injection for the management of this syndrome.

Subcutaneous accessory pain system (SAPS): A novel pain pathway for myofascial trigger points

Despite the accumulating neuro-physiological evidence of myofascial pain, many clinicians are skeptical about its existence as a separate disease entity. No single theory can fully explain the four cardinal features of MPS; taut bands, local tenderness, local twitching and the characteristic pattern of referred pain. Bridging the gap between basic and clinical knowledge mandates coupling the local trigger point changes with the clinically seen distant somatically innervated referred pain. The main question addressed by the present theory is why do trigger points behave differently in comparison to the surrounding muscle tissue and are trigger points the primary problem or secondary to a primary pathology. We propose that trigger points have an extra-innervation system that connect them with other spinal structures such as the facet, the annulus and other trigger points with a role for the subcutaneous fascia as part of trigger points pathogenesis or passage for the extra-innervation. The extra-innervation system is Subcutaneous accessory pain system (SAPS). The novel SAPS system connecting trigger points to the spinal segments via dorsal rami is presented. Individuals with this accessory pathway are prone to myofascial pain, trigger point activation and segmental referred somatic pain similar to other axial spinal structures. Despite the high prevalence of myofascial pain, the mechanism is not universally agreed upon. Why do the trigger points act differently from surrounding muscle tissue and are almost constant in location in different individuals is controversial. Why does myofascial pain and its two components, trigger points and referred pain, exist or are more prevalent in some individuals than in others is unexplained. The correlation between axial spinal structures pathology and the trigger points is not explored well. The existing theories about trigger point formation and referred pain is scientifically credible for each separate component and the SAPS novel system can provide the link between the two.

Alternatives to Opioids in the Pharmacologic Management of Chronic Pain Syndromes: A Narrative Review of Randomized, Controlled, and Blinded Clinical Trials

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.

A critical overview of the current myofascial pain literature - March 2017

After two years of having contributed to this overview series of articles, we sadly say goodbye to Dr. Rob Grieve. We would like to thank Dr. Grieve for his insightful contributions and analyses of the myofascial pain literature. Dr. Grieve would have preferred to continue, but his many university and research responsibilities had to take priority. We are looking forward to reviewing his future research endeavors in this article. We are pleased that Dr. Li-Wei Chou, MD, PhD has agreed to replace Dr. Grieve and join our team. Dr. Chou is Assistant Professor at China Medical University in Taichung, Taiwan and he has an impressive publication record with many research studies and book chapters. In this edition of the overview article, we once again have included articles from around the world with a combination of basic research and clinical studies and case reports. The majority of papers deal with dry needling, but there are also several more basic research studies and manual therapy papers.

[Botulinum toxin type A in headache treatment : Established and experimental indications]

In recent years botulinum toxin type A has been used increasingly more in the treatment of specific headache disorders. Especially regarding chronic migraine with and without combined medication overuse, convincing randomized studies have proven the efficacy of this treatment option and have led to approval for this indication. Regarding other headache entities, such as episodic migraine, tension-type headache, trigeminal autonomic cephalalgia (TAC), neuralgic, neuropathic and myofascial pain, currently available scientific data on the efficacy of botulinum toxin type A are scarce and often ambiguous. The exact underlying mechanisms of the influence of botulinum toxin type A on the pathophysiology of headache are not completely clear but an influence on the release of calcitonin gene-related peptide (CGRP) seems to play a crucial role. This article summarizes the most important studies as well as experiences of treatment with botulinum toxin type A regarding different headache entities.

Applications of botulinum toxin in dentistry: A comprehensive review

The horizons of treatment options in dentistry are broadening rapidly. In this scenario, applications of unconventional treatment options like use of botulinum toxin (BT) are gaining momentum. The use of BT has been popularly accepted in esthetic procedures like management of facial wrinkles; however, it has been documented to be successful in a variety of conditions. Of particular interest to this paper are applications of BT in the maxillofacial region, concerned to dentistry. BT offers a transient, reversible, relatively safe treatment option to many conditions of interest to a dental practitioner. Dental surgeons by their virtue of being extensively aware of the anatomy of faciomaxillary region are a potential pool of operators who can use BT in their armamentarium with minor skill enhancement and thus widen the perspective of alternative, minimally invasive options to refractory conditions or invasive protocols.

Injections for chronic pain

Although interventional procedures should be used cautiously in the setting of chronic pain, there is a role for a variety of injections to facilitate a patient's overall rehabilitation program. There are many resources available, including a prior issue of Physical Medicine and Rehabilitation Clinics of North America, which discuss the more conventional spinal injections. The focus of this article is on lesser-known injection options for treating chronic pain. The authors separately discuss trigger point injections, regenerative injections (prolotherapy), and injections using botulin toxins.

Botulinum Toxin Type A for the Treatment of Neuropathic Pain in Neuro-Rehabilitation

Pain is a natural protective mechanism and has a warning function signaling imminent or actual tissue damage. Neuropathic pain (NP) results from a dysfunction and derangement in the transmission and signal processing along the nervous system and it is a recognized disease in itself. The prevalence of NP is estimated to be between 6.9% and 10% in the general population. This condition can complicate the recovery from stroke, multiple sclerosis, spinal cord lesions, and several neuropathies promoting persistent disability and poor quality of life. Subjects suffering from NP describe it as burning, itching, lancing, and numbness, but hyperalgesia and allodynia represent the most bothersome symptoms. The management of NP is a clinical challenge and several non-pharmacological and pharmacological interventions have been proposed with variable benefits. Botulinum toxin (BTX) as an adjunct to other interventions can be a useful therapeutic tool for the treatment of disabled people. Although BTX-A is predominantly used to reduce spasticity in a neuro-rehabilitation setting, it has been used in several painful conditions including disorders characterized by NP. The underlying pharmacological mechanisms that operate in reducing pain are still unclear and include blocking nociceptor transduction, the reduction of neurogenic inflammation by inhibiting neural substances and neurotransmitters, and the prevention of peripheral and central sensitization. Some neurological disorders requiring rehabilitative intervention can show neuropathic pain resistant to common analgesic treatment. This paper addresses the effect of BTX-A in treating NP that complicates frequent disorders of the central and peripheral nervous system such as spinal cord injury, post-stroke shoulder pain, and painful diabetic neuropathy, which are commonly managed in a rehabilitation setting. Furthermore, BTX-A has an effect in relief pain that may characterize less common neurological disorders including post-traumatic neuralgia, phantom limb, and complex regional pain syndrome with focal dystonia. The use of BTX-A could represent a novel therapeutic strategy in caring for neuropathic pain whenever common pharmacological tools have been ineffective. However, large and well-designed clinical trials are needed to recommend BTX-A use in the relief of neuropathic pain.