Botulinum toxin for the treatment of chronic pain. Review of the evidence

Treatment of "plantar fasciitis"/Plantar Heel Pain Syndrome with botulinum toxin - A novel injection paradigm pilot study

Randomized controlled trials over the last two decades, although promising with favorable results, have shown varied efficacy in treatment of "plantar fasciitis" with botulinum toxin injection¹. One reason may be due to conflating the variabilities of plantar heel conditions solely as plantar fasciitis. Plantar Heel Pain Syndrome can be of one or more etiologies and symptoms which refutes the mistaken tendency to categorize all plantar heel pain singularly as either plantar fasciitis or fasciosis. Recognizing that there is likely an interplay of inflammatory, degenerative, and neuropathic etiologic conditions of this often-difficult malady to treat, a novel injection paradigm of botulinum toxin is explored in the treatment of 4 distinct presentations of Plantar Heel Pain Syndrome with encouraging results. Botulinum toxin injection into two intrinsic foot muscles; Abductor Hallucis and Quadratus Plantae at their origins with electrical stimulation is presented as novel method to treat four distinct etiologies of Plantar Heel Pain Syndrome. This method of botulinum toxin injection resulted in significant prolonged improvement of patient function and pain reduction in four variations of Plantar Heel Pain Syndrome. A precise injection paradigm facilitated with direct intrinsic muscle stimulation of the Abductor Hallucis and Quadratus Plantae at their origins may prove to be effective in reducing the disabilities of Plantar Heel Pain Syndrome and its associated pain.

Botulinum Neurotoxin A Intravesical Injections in Interstitial Cystitis/Bladder Painful Syndrome: A Systematic Review with Meta-Analysis

Botulinum neurotoxin A (BoNT/A) appears to be one of the best intravesical treatments for interstitial cystitis/bladder painful syndrome (IC/BPS). We aimed to point out what the evidence is regarding the effects of BoNT/A intravesically injected in patients with IC/BPS. We performed a systematic review of all randomized controlled trials (RCTs) assessing BoNT/A for IC/BPS by using Medline, EMBASE, CINAHL, CENTRAL and MetaRegister of Controlled Trials. Standardized mean differences (SMD) were extracted from the available trials and combined in a meta-analysis applying a random effect model, including heterogeneity of effects. Twelve trials were identified. Significant benefits from BoNT/A injections were detected in: Interstitial Cystitis Symptom Index and Problem Index (ICSI, ICPI) (small to medium effect size: SMD = -0.302; p = 0.007 and -0.430, p = 0.004, respectively); Visual Analog Scale (VAS) for pain and day-time urinary frequency (medium effect size: SMD = -0.576, p < 0.0001 and -0.546, p = 0.013, respectively). A great effect size was detected for post-void residual volume (PVR, SMD = 0.728; p =0.002) although no clinically relevant in most cases. Great heterogeneity was observed in treatments' methodologies and symptoms assessment. Overall, BoNT/A intravesical injections significantly improve some of the most relevant symptoms affecting IC/BPS patients.