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Chau Y, Roux C, Gonzalez JF, Breuil V, Bernard de Dompsure R, Fontas E, Rudel A, Sédat J. Effectiveness of Geniculate Artery Embolization for Chronic Pain after Total Knee Replacement-A Pilot Study. J Vasc Interv Radiol 2023; 34:1725-1733. [PMID: 37391071 DOI: 10.1016/j.jvir.2023.06.026] [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: 09/28/2022] [Revised: 05/19/2023] [Accepted: 06/20/2023] [Indexed: 07/02/2023] Open
Abstract
PURPOSE To evaluate the efficacy and safety of embolization of hyperemic synovial tissue for the treatment of persistent pain after total knee arthroplasty (TKA). MATERIALS AND METHODS Twelve patients with persistent pain after TKA were enrolled in this prospective, single-center pilot study. Genicular artery embolization (GAE) was performed using 75-μm spherical particles. The patients were assessed using a 100-point Visual Analog Scale (VAS) and Knee Injury and Osteoarthritis Outcome Score (KOOS) at baseline and 3 and 6 months thereafter. Adverse events were recorded at all time points. RESULTS A mean of 1.8 ± 0.8 abnormal hyperemic genicular arteries were identified and embolized, with a median volume of diluted embolic material of 4.3 mL in all 12 (100%) patients. The mean VAS score on walking improved from 73 ± 16 at baseline to 38 ± 35 at the 6-month follow-up (P < .05). The mean KOOS pain score improved from 43.6 ± 15.5 at baseline to 64.6 ± 27.1 at the 6-month follow-up (P < .05). At the 6-month follow-up, 55% and 73% of the patients attained a minimal clinically important change in pain and quality of life, respectively. Self-limited skin discoloration occurred in 5 (42%) patients. The VAS score increased by more than 20 immediately after embolization in 4 (30%) patients, who required analgesic treatment for 1 week. CONCLUSION GAE is a safe method of treating persistent pain after TKA that demonstrates potential efficacy at 12 months.
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Affiliation(s)
- Yves Chau
- Neurointerventionnal and Interventional Vascular Unit, CHU de Nice, Pasteur 2 Hospital, Nice, France.
| | - Christian Roux
- Department of Rheumatology, CHU de Nice, Pasteur 2 Hospital, Nice, France
| | | | - Véronique Breuil
- Department of Rheumatology, CHU de Nice, Pasteur 2 Hospital, Nice, France
| | | | - Eric Fontas
- Department of Clinical Research and Innovation, CHU de Nice, Pasteur 2 Hospital, Nice, France
| | - Alexandre Rudel
- Department of Osteo-Articular Radiology, CHU de Nice, Pasteur 2 Hospital, Nice, France
| | - Jacques Sédat
- Neurointerventionnal and Interventional Vascular Unit, CHU de Nice, Pasteur 2 Hospital, Nice, France
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Poenaru D, Sandulescu MI, Cinteza D. Pain Modulation in Chronic Musculoskeletal Disorders: Botulinum Toxin, a Descriptive Analysis. Biomedicines 2023; 11:1888. [PMID: 37509527 PMCID: PMC10376837 DOI: 10.3390/biomedicines11071888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/25/2023] [Accepted: 07/01/2023] [Indexed: 07/30/2023] Open
Abstract
Botulinum neurotoxin (BoNT), a product of Clostridium botulinum, reversibly inhibits the presynaptic release of the neurotransmitter acetylcholine at the neuromuscular junction. In addition, BoNT blocks the transmission of other substances involved in pain perception and, together with a soft-tissue anti-inflammatory effect, may play a role in analgesia. When first-line treatment fails, second-line therapies might include BoNT. Studies on chronic and recurrent pain using different mechanisms offer heterogenous results that must be validated and standardized. Plantar fasciitis, severe knee osteoarthritis, painful knee and hip arthroplasty, antalgic muscular contractures, and neuropathic and myofascial pain syndromes may benefit from the administration of BoNT. Research on this topic has revealed the main musculoskeletal conditions that can benefit from BoNT, stressing the effects, modalities of administration, doses, and schedule.
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Affiliation(s)
- Daniela Poenaru
- Rehabilitation Department 1, Carol Davila University of Medicine and Pharmacy, 4192910 Bucharest, Romania
| | - Miruna Ioana Sandulescu
- Doctoral School, Carol Davila University of Medicine and Pharmacy, 4192910 Bucharest, Romania
| | - Delia Cinteza
- Rehabilitation Department 1, Carol Davila University of Medicine and Pharmacy, 4192910 Bucharest, Romania
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Sconza C, Leonardi G, Carfì C, Kon E, Respizzi S, Scaturro D, Letizia Mauro G, Massazza G, Di Matteo B. Intra-Articular Injection of Botulinum Toxin for the Treatment of Knee Osteoarthritis: A Systematic Review of Randomized Controlled Trials. Int J Mol Sci 2023; 24:ijms24021486. [PMID: 36674999 PMCID: PMC9863806 DOI: 10.3390/ijms24021486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 12/18/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
The purpose of the present paper was to review the available evidence on intra-articular botulinum toxin (BTX) injection in the treatment of knee osteoarthritis and to compare it to other conservative treatment options. A systematic review of the literature was performed on the PubMed, Scopus, Cochrane Library, Web of Science, Pedro and Research Gate databases with the following inclusion criteria: (1) randomized controlled trials (RCTs), (2) written in the English language, and (3) published on indexed journals in the last 20 years (2001-2021) dealing with the use of BTX intra-articular injection for the treatment of knee OA. The risk of bias was assessed using the Cochrane Risk of Bias tool for RCTs. Nine studies involving 811 patients in total were included. Patients in the control groups received different treatments: conventional physiotherapy, hyaluronic acid injection or prolotherapy or a combination thereof in 5 studies, steroid infiltrative therapy (triamcinolone) in 1 study, placebo in 2, and local anesthetic treatment in 1 study. Looking at the quality of the available literature, two of the included studies reached "Good quality" standard, three were ranked as "Fair", and the rest were considered "Poor". No major complications or serious adverse events were reported following intra-articular BTX, which provided encouraging pain relief, improved motor function, and quality of life. Based on the available data, no clear indication emerged from the comparison of BTX with other established treatments for knee OA. The analysis of the available RCTs on BTX intra-articular injection for the treatment of knee OA revealed modest methodological quality. However, based on the data retrieved, botulinum toxin has been proven to provide good short-term outcomes, especially in patients with pain sensitization, by modulating neurotransmitter release, peripheral nociceptive transduction, and acting on the control of chronic pain from central sensitization.
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Affiliation(s)
- Cristiano Sconza
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Giulia Leonardi
- U.O.C. of Physical and Rehabilitation Medicine and Sports Medicine, Policlinico Universitario “G. Martino”, 98124 Messina, Italy
| | - Carla Carfì
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Elizaveta Kon
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
- Correspondence: ; Tel.: +39-028-224-5425; Fax: +39-028-224-4600
| | - Stefano Respizzi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Dalila Scaturro
- Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Via del Vespro, 129, 90127 Palermo, Italy
| | - Giulia Letizia Mauro
- Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Via del Vespro, 129, 90127 Palermo, Italy
| | - Giuseppe Massazza
- Division of Physical Medicine and Rehabilitation, Department of Surgical Sciences, University of Turin, 10124 Turin, Italy
| | - Berardo Di Matteo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
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4
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Sari BC, Develi T. The effect of intraarticular botulinum toxin-A injection on symptoms of temporomandibular joint disorder. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2022; 123:e316-e320. [PMID: 35523405 DOI: 10.1016/j.jormas.2022.04.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Application of arthrocentesis in temporomandibular joint disorders preferred and suggested therapeutic treatment option in recent years. This study was designed to investigate and compare the effect of intra-articular injection of botulinum toxin-A (Btx-A) on pain and mouth opening after arthrocentesis in nonreduction disc displacement. MATERIALS AND METHODS This restrospective study was conducted on 30 patients with a visual analogue scale is higher than five and limited mouth opening. Patients were divided into 2 groups as conventional arthrocentesis group (group A) and intra-articular Btx-A injection following arthrocentesis group (group B). Maximum mouth openining and temporomandibular joint pain were measured in preoperative (t0) and at postoperative 1st-week (t1), 1st-month (t2) and 6th-month (t3). RESULTS When VAS scores of group A and group B were examined, no statistical difference was observed at t0 and t1 time intervals; an increased in mouth opening values and decreased VAS score values were observed in both groups in the 1st month (t2) and 6th (t3) months, mostly in group A. CONCLUSION İntra-articular injection of Btx-A following arthrocentesis can induce mouth opening and reduce the pain and dysfunction in patients with anterior disc displacement.
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Affiliation(s)
- Bilal Cemsit Sari
- Department of Oral and Maxillofacial Surgery, Istanbul Medipol University Faculty of Dentistry, Istanbul, Turkey.
| | - Tuba Develi
- Department of Oral and Maxillofacial Surgery, Istanbul Medipol University Faculty of Dentistry, Istanbul, Turkey
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Oehler B, Périer C, Martin V, Fisher A, Lezmi S, Kalinichev M, McMahon SB. Evaluation of Recombinant Botulinum Neurotoxin Type A1 Efficacy in Peripheral Inflammatory Pain in Mice. Front Mol Neurosci 2022; 15:909835. [PMID: 35694440 PMCID: PMC9179158 DOI: 10.3389/fnmol.2022.909835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/02/2022] [Indexed: 11/13/2022] Open
Abstract
Well-established efficacy of botulinum neurotoxin type A (BoNT/A) in aesthetic dermatology and neuromuscular hyperactivity disorders relies on canonical interruption of acetylcholine neurotransmission at the neuromuscular junction at the site of the injection. The mechanisms and the site of activity of BoNT/A in pain, on the other hand, remain elusive. Here, we explored analgesic activity of recombinant BoNT/A1 (rBoNT/A1; IPN10260) in a mouse model of inflammatory pain to investigate the potential role of peripheral sensory afferents in this activity. After confirming analgesic efficacy of rBoNT/A1 on CFA-induced mechanical hypersensitivity in C57Bl6J mice, we used GCaMP6s to perform in vivo calcium imaging in the ipsilateral dorsal root ganglion (DRG) neurons in rBoNT/A1 vs. vehicle-treated mice at baseline and following administration of a range of mechanical and thermal stimuli. Additionally, immunohisochemical studies were performed to detect cleaved SNAP25 in the skin, DRGs and the spinal cord. Injection of CFA resulted in reduced mechanical sensitivity threshold and increased calcium fluctuations in the DRG neurons. While rBoNT/A1 reduced mechanical hypersensitivity, calcium fluctuations in the DRG of rBoNT/A1- and vehicle-treated animals were similar. Cleaved SNAP25 was largely absent in the skin and the DRG but present in the lumbar spinal cord of rBoNT/A1-treated animals. Taken together, rBoNT/A1 ameliorates mechanical hypersensitivity related to inflammation, while the signal transmission from the peripheral sensory afferents to the DRG remained unchanged. This strengthens the possibility that spinal, rather than peripheral, mechanisms play a role in the mediation of analgesic efficacy of BoNT/A in inflammatory pain.
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Affiliation(s)
- Beatrice Oehler
- Wolfson Center of Age-Related Diseases, IoPPN, Health and Life Science, King’s College London, London, United Kingdom
- Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany
- *Correspondence: Beatrice Oehler
| | | | | | - Amy Fisher
- Transpharmation Ltd., London, United Kingdom
| | | | | | - Stephen B. McMahon
- Wolfson Center of Age-Related Diseases, IoPPN, Health and Life Science, King’s College London, London, United Kingdom
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Beck AA, Paz LB, Frank MI, Engelmann AM, Krause A, Côrte FDDL. Safety and synovial inflammatory response after intra-articular injection of botulinum toxin type A in healthy horses. J Equine Vet Sci 2022; 110:103865. [PMID: 35017040 DOI: 10.1016/j.jevs.2022.103865] [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: 05/08/2021] [Revised: 12/30/2021] [Accepted: 01/04/2022] [Indexed: 11/24/2022]
Abstract
Botulinum toxin type A (BoNT-A) is a promising alternative for patients suffering from chronic joint pain. The aim of this study was to investigate whether a single injection of BoNT-A would produce adverse effects on clinical parameters and synovial parameters as well as lameness. One randomly selected radiocarpal joint was treated with 50 U of BoNT-A in eight horses, and the contralateral joint received saline solution. All horses received injections at day 0 and were re-evaluated twice daily for seven days for heart rate (HR), respiratory rate (RR), rectal temperature (RT), mucous membrane color, capillary refill time, intestinal motility, appetite, water intake, defecation, urination, and attitude. At these same time points, joint pain and circumference were assessed. Objective lameness evaluations were performed once daily for seven days and synovial fluid samples were collected at baseline, post-injection hour (PIH) 24 and PIH 168 and evaluated for synovial fluid parameters. HR and RT remained clinically unaltered, despite oscillations over time (p=0.001). The remaining clinical parameters were unaltered by treatment or time (p>0.05). Joint pain was not elicited by flexion and palpation in both limbs as well as carpal circumference was not altered (p=0.88). Lameness was observed only on saline limbs. Cellular parameters evaluated in synovial fluid samples from both carpi had significantly increased from baseline to PIH 24, decreasing at PIH 168 (p<0.05). It was concluded that the injection of 50 U BoNT-A is suggested to be a safe therapy for intra-articular use in horses and must be verified by further investigation.
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Affiliation(s)
- Antônio Alcemar Beck
- Department of Large Animal Clinics, Federal University of Santa Maria, Veterinary Teaching Hospital, Roraima Avenue, 1000 - Camobi, 97105900 Santa Maria, Rio Grande do Sul, Brazil.
| | - Letícia Bisso Paz
- Department of Large Animal Clinics, Equine Sports Medicine and Surgery, Federal University of Santa Maria, Santa Maria, Rio Grande do Sul, Brazil
| | - Maria Inês Frank
- College of Veterinary Medicine, Federal University of Santa Maria, Santa Maria, Rio Grande do Sul, Brazil
| | - Ana Martiele Engelmann
- Department of Small Animal Clinics, Veterinary Clinical Pathology Laboratory, Federal University of Santa Maria, Santa Maria, Rio Grande do Sul, Brazil
| | - Alexandre Krause
- Department of Small Animal Clinics, Veterinary Clinical Pathology Laboratory, Federal University of Santa Maria, Santa Maria, Rio Grande do Sul, Brazil
| | - Flávio Desessards De La Côrte
- Department of Large Animal Clinics, Equine Sports Medicine and Surgery, Federal University of Santa Maria, Santa Maria, Rio Grande do Sul, Brazil
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Singh JA. SToRytelliing to Improve Disease outcomes in Gout (STRIDE-GO) in African American veterans with gout: a trial study protocol. Trials 2021; 22:879. [PMID: 34863255 PMCID: PMC8645140 DOI: 10.1186/s13063-021-05847-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 11/20/2021] [Indexed: 11/28/2022] Open
Abstract
Objective Medication adherence in gout is suboptimal, and the lack of effective interventions to address it presents a huge challenge. Medication adherence and gout outcomes are worse in racial/ethnic minorities. The objective of this paper was to provide the details of the study protocol for randomized, controlled trial (RCT) in African Americans (AAs) with gout that will test the effectiveness of a culturally appropriate gout storytelling intervention. Methods The SToRytelliing to Improve Disease outcomes in Gout (STRIDE-GO) study will be a 12-month, multicenter, open-label RCT that will assess the effect of a culturally appropriate gout storytelling in at least 300 AA veterans with gout. Participants will be randomized to gout-storytelling intervention vs. a stress reduction video in a 1:1 ratio. The primary outcome is urate-lowering therapy (ULT) adherence measured with MEMSCap™, an electronic monitoring system (efficacy, 6 months; sustenance of efficacy, 12 months). Secondary outcomes include gout flares, serum urate (SU), gout-specific health-related quality of life [HRQOL], self-reported ULT adherence, patient satisfaction with treatment, and patient understanding of the intervention. AA veterans with gout who met the 1977 Preliminary American College of Rheumatology (ACR) classification criteria for gout, currently prescribed an oral ULT medication (allopurinol or febuxostat) for at least 6 months, and not using a pillbox to redistribute their medications, will be invited to an in-person study visit. After the study coordinators obtain informed consent, and ensure that participants meet the inclusion criteria, the eligible participants will be provided with their current ULT in a MEMSCap™ bottle for the 1-month run-in period and asked to return to the clinic in 1 month. ULT adherence with MEMSCap™ will be recorded at a 1-month return visit. Interested participants will complete the baseline assessments, randomized using the computerized system to either gout-storytelling intervention or a stress reduction intervention video arm and watch the respective video in-clinic. Patients will be interviewed on the phone at 2 and 4 months regarding the viewing of the videos at home at each time. Participants will be assessed in-clinic at 3, 6, 9, and 12 months; MEMSCap™ data and patient surveys will be captured at each visit. For any missed visit, assessments will be completed on the phone and MEMSCap™ data captured at the next in-clinic visit. Discussion The study will assess the efficacy of a behavioral intervention to improve ULT adherence in minority populations with gout. Trial registration ClinicalTrials.gov NCT 02741700. Registered on 14 September 2018 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05847-9.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, VA Medical Center, 510, 20th street South, FOT 805B, Birmingham, AL, 35233, USA. .,Department of Medicine at School of Medicine, University of Alabama at Birmingham, 1720 Second Ave. South, Birmingham, AL, 35294-0022, USA. .,Division of Epidemiology at School of Public Health, University of Alabama at Birmingham, 1720 Second Ave. South, Birmingham, AL, 35294-0022, USA.
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Blanshan N, Krug H. The Use of Botulinum Toxin for the Treatment of Chronic Joint Pain: Clinical and Experimental Evidence. Toxins (Basel) 2020; 12:toxins12050314. [PMID: 32397671 PMCID: PMC7291335 DOI: 10.3390/toxins12050314] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/25/2020] [Accepted: 05/05/2020] [Indexed: 12/11/2022] Open
Abstract
Chronic osteoarthritis pain is an increasing worldwide problem. Treatment for osteoarthritis pain is generally inadequate or fraught with potential toxicities. Botulinum toxins (BoNTs) are potent inhibitors of neuropeptide release. Paralytic toxicity is due to inhibition at the neuromuscular junction, and this effect has been utilized for treatments of painful dystonias. Pain relief following BoNT muscle injection has been noted to be more significant than muscle weakness and hypothesized to occur because of the inhibition of peripheral neuropeptide release and reduction of peripheral sensitization. Because of this observation, BoNT has been studied as an intra-articular (IA) analgesic for chronic joint pain. In clinical trials, BoNT appears to be effective for nociceptive joint pain. No toxicity has been reported. In preclinical models of joint pain, BoNT is similarly effective. Examination of the dorsal root ganglion (DRG) and the central nervous system has shown that catalytically active BoNT is retrogradely transported by neurons and then transcytosed to afferent synapses in the brain. This suggests that pain relief may also be due to the central effects of the drug. In summary, BoNT appears to be safe and effective for the treatment of chronic joint pain. The long-term effects of IA BoNT are still being determined.
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Affiliation(s)
- Nicole Blanshan
- Minneapolis VA Health Care System, Minneapolis, MN 55455, USA;
| | - Hollis Krug
- Minneapolis VA Health Care System, Minneapolis, MN 55455, USA;
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Correspondence: ; Tel.: +1-612-467-4190
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Matak I, Bölcskei K, Bach-Rojecky L, Helyes Z. Mechanisms of Botulinum Toxin Type A Action on Pain. Toxins (Basel) 2019; 11:E459. [PMID: 31387301 PMCID: PMC6723487 DOI: 10.3390/toxins11080459] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 07/26/2019] [Accepted: 07/29/2019] [Indexed: 12/31/2022] Open
Abstract
Already a well-established treatment for different autonomic and movement disorders, the use of botulinum toxin type A (BoNT/A) in pain conditions is now continuously expanding. Currently, the only approved use of BoNT/A in relation to pain is the treatment of chronic migraines. However, controlled clinical studies show promising results in neuropathic and other chronic pain disorders. In comparison with other conventional and non-conventional analgesic drugs, the greatest advantages of BoNT/A use are its sustained effect after a single application and its safety. Its efficacy in certain therapy-resistant pain conditions is of special importance. Novel results in recent years has led to a better understanding of its actions, although further experimental and clinical research is warranted. Here, we summarize the effects contributing to these advantageous properties of BoNT/A in pain therapy, specific actions along the nociceptive pathway, consequences of its central activities, the molecular mechanisms of actions in neurons, and general pharmacokinetic parameters.
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Affiliation(s)
- Ivica Matak
- Department of Pharmacology, University of Zagreb School of Medicine, Šalata 11, 10000 Zagreb, Croatia.
| | - Kata Bölcskei
- Department of Pharmacology and Pharmacotherapy, Medical School, University of Pécs, Szigeti út 12, 7624 Pécs, Hungary
- János Szentágothai Research Center, Center for Neuroscience, University of Pécs, Ifjúság útja 20, 7624 Pécs, Hungary
| | - Lidija Bach-Rojecky
- Department of Pharmacology, University of Zagreb Faculty of Pharmacy and Biochemistry, Domagojeva 2, 10000 Zagreb, Croatia
| | - Zsuzsanna Helyes
- Department of Pharmacology and Pharmacotherapy, Medical School, University of Pécs, Szigeti út 12, 7624 Pécs, Hungary
- János Szentágothai Research Center, Center for Neuroscience, University of Pécs, Ifjúság útja 20, 7624 Pécs, Hungary
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Efficacy of Intra-Articular Botulinum Toxin in Osteoarticular Joint Pain: A Meta-Analysis of Randomized Controlled Trials. Clin J Pain 2019; 34:383-389. [PMID: 28731959 DOI: 10.1097/ajp.0000000000000538] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This study was conducted with the aim of evaluating the efficacy of intra-articular injections of botulinum toxin type A (BT-A) into the painful joint diseases through a systematic review of the literature and a meta-analysis of controlled randomized trials. Intra-articular therapies (corticosteroids, hyaluronic acid) have limited efficacy and run a risk of toxicity in patients with joint pain. New therapeutic options are needed to treat painful osteoarticular disease. METHODS We searched via Pubmed, American College of Rheumatology, and European League Against Rheumatism congresses, and gray literature for the studies reported until June 2016 and addressing the issue of BT intra-articular injections in patients with refractory joint pain. Randomized trials were included. For the meta-analysis, we compared a numeric rating scale (NRS) from 0 to 10 before treatment and at 1 or 2 months and 6 months after in the BT-A and the control groups for each study. We also compared separately low dose and high dose of BT at 1 or 2 months' evaluation. RESULTS In a total of 269 selected articles, 8 were analyzed and 6 studies were included in the meta-analysis involving a total of 382 patients. On comparing the NRS rating for 5 trials, at 1 or 2 months irrespective of the dose of BT, 4 trials showed a positive effect of BT compared with the control on the NRS and 1 found no effect; the overall weighted mean difference [95% confidence interval (CI)] was -1.10 (-1.62, -0.58) (P<0.0001, I=63%). Among the 4 trials with a low dose of BT (100 U), comparing NRS at 1 or 2 months, 3 trials showed significant results with a positive effect of BT-A injection compared with the control on the NRS; the fourth study failed to find any effect. The overall weighted mean difference (95% CI) was -0.95 (-0.02, -1.88) (P=0.05, I=67%). In the 2 trials using a high dose of BT (200 U) comparing NRS at 1 or 2 months, there was an almost zero effect of BT, with an overall weighted mean difference (95% CI) of 0.13 (-0.55, 0.81) (P=0.71, I=0%). In the 3 trials comparing NRS at 6 months there was an overall weighted mean difference (95% CI) of -0.57 (-1.98, 0.83) (P=0.42, I=73%). CONCLUSIONS BT-A intra-articular injections have short-term benefits with a statistically significant decrease in the NRS pain score of around 1 point in patients with refractory joint pain. A decrease in the pain score was also observed at 6 months but with a nonsignificant result.
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Mendes JG, Natour J, Nunes-Tamashiro JC, Toffolo SR, Rosenfeld A, Furtado RNV. Comparison between intra-articular Botulinum toxin type A, corticosteroid, and saline in knee osteoarthritis: a randomized controlled trial. Clin Rehabil 2019; 33:1015-1026. [PMID: 30782000 DOI: 10.1177/0269215519827996] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To compare the effectiveness of intra-articular injection (IAI) with Botulinum toxin type A (BTA), triamcinolone hexacetonide (TH), and saline in primary knee osteoarthritis. DESIGN A randomized controlled trial, with blinded patients and assessor. SETTING Outpatient rheumatology service. SUBJECTS Patients with knee osteoarthritis grades II and III. INTERVENTIONS Patients received IAI with 100 IU BTA, 40 mg TH, or isotonic saline solution (SS) 0.9%. MAIN MEASURES Patients were assessed at baseline and at 4, 8, and 12 weeks with the following instruments: visual analog scale for pain during movement (VASm; primary outcome) and visual analog scale for pain at rest (VASr), Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC) questionnaire, 6-minute walk test, Timed Up and Go test, Short Form (SF)-36 questionnaire, range of motion of knee, and ultrasound (US) measurement of synovial hypertrophy. RESULTS In total, 105 patients were randomized, with 35 in each group; 96 were female (91.4%) and 9 were male (8.6%), with a mean age of 64.2 years (±6.9). At 12 weeks, the TH group showed better results only for VASm. At four weeks, the TH group showed better results than the BTA and SS groups for VASm (-68.9% (37.8) vs. -35.3% (40.3) vs. -35.9% (51.4)), WOMAC pain (-56.0% (30.7) vs. -30.8% (34.3) vs. -30.0% (39.9)), WOMAC stiffness (-53.4% (38.4) vs. -17.2% (59.3) vs. -17.3% (78.1)), WOMAC function (-48.2% (34.6) vs. 30.8% (33.6) vs. -13.6% (64.9)), WOMAC total score (-51.2% (31.0) vs. -30.9% (30.0) vs. -18.8% (54.8)), and US measurement of synovial hypertrophy (-11.6% (44.9) vs. -1.5% (47.9) vs. +28.6% (81.3)). CONCLUSION IAI with TH had a higher effectiveness than that with TBA or SS in the short-term assessment (four weeks) for pain in movement, WOMAC, and US measurement of synovial hypertrophy.
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Affiliation(s)
- Jamille Godoy Mendes
- 1 Rheumatology Division, Escola Paulista de Medicina (UNIFESP-EPM), Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jamil Natour
- 1 Rheumatology Division, Escola Paulista de Medicina (UNIFESP-EPM), Universidade Federal de São Paulo, São Paulo, Brazil
| | - José Carlos Nunes-Tamashiro
- 1 Rheumatology Division, Escola Paulista de Medicina (UNIFESP-EPM), Universidade Federal de São Paulo, São Paulo, Brazil
| | - Sandra Regina Toffolo
- 1 Rheumatology Division, Escola Paulista de Medicina (UNIFESP-EPM), Universidade Federal de São Paulo, São Paulo, Brazil
| | - André Rosenfeld
- 2 Department of Diagnostic Imaging, Escola Paulista de Medicina (UNIFESP-EPM), Universidade Federal de São Paulo, São Paulo, Brazil
| | - Rita Nely Vilar Furtado
- 1 Rheumatology Division, Escola Paulista de Medicina (UNIFESP-EPM), Universidade Federal de São Paulo, São Paulo, Brazil
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Goldman DT, Piechowiak R, Nissman D, Bagla S, Isaacson A. Current Concepts and Future Directions of Minimally Invasive Treatment for Knee Pain. Curr Rheumatol Rep 2018; 20:54. [PMID: 30033492 DOI: 10.1007/s11926-018-0765-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The purpose of this paper is to review the percutaneous interventions available for the treatment of osteoarthrosis of the knee that address pain and prolong the time to arthroplasty. RECENT FINDINGS Corticosteroid injection and viscosupplementation have been the most studied, but there is still no consensus about their value. Thermal nerve ablation, including both radiofrequency ablation and cryoneurolysis, is a promising new modality of therapy that may increase in clinical use given current data showing favorable outcomes. Of the future therapies that are currently under investigation, synovial embolization via the geniculate arteries represents an exciting new approach that may soon be available clinically. There are various percutaneous interventions available for the treatment of osteoarthrosis of the knee that address pain and prolong the time to arthroplasty.
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Affiliation(s)
| | - Rachel Piechowiak
- Vascular & Interventional Radiology, Vascular Institute of Virginia, Woodbridge, Prince William County, VA, USA
| | - Daniel Nissman
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Sandeep Bagla
- Vascular & Interventional Radiology, Vascular Institute of Virginia, Woodbridge, Prince William County, VA, USA
| | - Ari Isaacson
- Vascular and Interventional Radiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Gabriel A, Maxwell GP. Commentary on: Effect of Botulinum Toxin A on Muscle Healing and its Implications in Aesthetic and Reconstructive Surgery. Aesthet Surg J 2018; 38:562-564. [PMID: 29340596 DOI: 10.1093/asj/sjx243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Allen Gabriel
- Department of Plastic Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - G Patrick Maxwell
- Department of Plastic Surgery, Loma Linda University Medical Center, Loma Linda, CA
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Safarpour Y, Jabbari B. Botulinum toxin treatment of pain syndromes -an evidence based review. Toxicon 2018; 147:120-128. [PMID: 29409817 DOI: 10.1016/j.toxicon.2018.01.017] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 08/18/2017] [Accepted: 01/28/2018] [Indexed: 02/07/2023]
Abstract
This review evaluates the existing level of evidence for efficacy of BoNTs in different pain syndromes using the recommended efficacy criteria from the Assessment and Therapeutic Subcommittee of the American Academy of Neurology. There is a level A evidence (effective) for BoNT therapy in post-herpetic neuralgia, trigeminal neuralgia, and posttraumatic neuralgia. There is a level B evidence (probably effective) for diabetic neuropathy, plantar fasciitis, piriformis syndrome, pain associated with total knee arthroplasty, male pelvic pain syndrome, chronic low back pain, male pelvic pain, and neuropathic pain secondary to traumatic spinal cord injury. BoNTs are possibly effective (Level C -one class II study) for female pelvic pain, painful knee osteoarthritis, post-operative pain in children with cerebral palsy after adductor release surgery, anterior knee pain with vastus lateralis imbalance. There is a level B evidence (one class I study) that BoNT treatment is probably ineffective in carpal tunnel syndrome. For myofascial pain syndrome, the level of evidence is U (undetermined) due to contradicting results. More high quality (Class I) studies and studies with different types of BoNTs are needed for better understanding of the role of BoNTs in pain syndromes.
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Affiliation(s)
- Yasaman Safarpour
- Department of Medicine, Division of Nephrology, University of California, Irvine (UCI), CA, USA
| | - Bahman Jabbari
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
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Heikkilä HM, Jokinen TS, Syrjä P, Junnila J, Hielm-Björkman A, Laitinen-Vapaavuori O. Assessing adverse effects of intra-articular botulinum toxin A in healthy Beagle dogs: A placebo-controlled, blinded, randomized trial. PLoS One 2018; 13:e0191043. [PMID: 29320549 PMCID: PMC5761897 DOI: 10.1371/journal.pone.0191043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 12/27/2017] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To investigate the clinical, cytological, and histopathological adverse effects of intra-articularly injected botulinum toxin A in dogs and to study whether the toxin spreads from the joint after the injection. METHODS A longitudinal, placebo-controlled, randomized clinical trial was conducted with six healthy laboratory Beagle dogs. Stifle joints were randomized to receive either 30 IU of onabotulinum toxin A or placebo in a 1:1 ratio. Adverse effects and spread of the toxin were examined by evaluating dynamic and static weight-bearing of the injected limbs, by assessing painless range of motion and pain on palpation of joints, and by performing synovial fluid analysis, neurological examination, and electrophysiological recordings at different examination time-points in a 12-week period after the injections. The dogs were then euthanized and autopsy and histopathological examination of joint structures and adjacent muscles and nerves were performed. RESULTS Intra-articular botulinum toxin A did not cause local weakness or injection site pain. Instead, static weight-bearing and painless range of motion of stifle joints decreased in the placebo limbs. No clinically significant abnormalities associated with intra-articular botulinum toxin A were detected in the neurological examinations. Electrophysiological recordings showed low compound muscle action potentials in two dogs in the botulinum toxin A-injected limb. No significant changes were detected in the synovial fluid. Autopsy and histopathological examination of the joint and adjacent muscles and nerves did not reveal histopathological adverse effects of the toxin. CONCLUSION Intra-articular botulinum toxin A does not produce significant clinical, cytological, or histopathological adverse effects in healthy dogs. Based on the electrophysiological recordings, the toxin may spread from the joint, but its clinical impact seems to be low.
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Affiliation(s)
- Helka M. Heikkilä
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
- * E-mail:
| | - Tarja S. Jokinen
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
| | - Pernilla Syrjä
- Department of Veterinary Biosciences, Veterinary Pathology, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
| | | | - Anna Hielm-Björkman
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
| | - Outi Laitinen-Vapaavuori
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
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Wylde V, Dennis J, Beswick AD, Bruce J, Eccleston C, Howells N, Peters TJ, Gooberman‐Hill R. Systematic review of management of chronic pain after surgery. Br J Surg 2017; 104:1293-1306. [PMID: 28681962 PMCID: PMC5599964 DOI: 10.1002/bjs.10601] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 01/24/2017] [Accepted: 04/21/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pain present for at least 3 months after a surgical procedure is considered chronic postsurgical pain (CPSP) and affects 10-50 per cent of patients. Interventions for CPSP may focus on the underlying condition that indicated surgery, the aetiology of new-onset pain or be multifactorial in recognition of the diverse causes of this pain. The aim of this systematic review was to identify RCTs of interventions for the management of CPSP, and synthesize data across treatment type to estimate their effectiveness and safety. METHODS MEDLINE, Embase, PsycINFO, CINAHL and the Cochrane Library were searched from inception to March 2016. Trials of pain interventions received by patients at 3 months or more after surgery were included. Risk of bias was assessed using the Cochrane risk-of-bias tool. RESULTS Some 66 trials with data from 3149 participants were included. Most trials included patients with chronic pain after spinal surgery (25 trials) or phantom limb pain (21 trials). Interventions were predominantly pharmacological, including antiepileptics, capsaicin, epidural steroid injections, local anaesthetic, neurotoxins, N-methyl-d-aspartate receptor antagonists and opioids. Other interventions included acupuncture, exercise, postamputation limb liner, spinal cord stimulation, further surgery, laser therapy, magnetic stimulation, mindfulness-based stress reduction, mirror therapy and sensory discrimination training. Opportunities for meta-analysis were limited by heterogeneity. For all interventions, there was insufficient evidence to draw conclusions on effectiveness. CONCLUSION There is a need for more evidence about interventions for CPSP. High-quality trials of multimodal interventions matched to pain characteristics are needed to provide robust evidence to guide management of CPSP.
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Affiliation(s)
- V. Wylde
- Musculoskeletal Research Unit, School of Clinical SciencesUniversity of BristolBristolUK
| | - J. Dennis
- Musculoskeletal Research Unit, School of Clinical SciencesUniversity of BristolBristolUK
| | - A. D. Beswick
- Musculoskeletal Research Unit, School of Clinical SciencesUniversity of BristolBristolUK
| | - J. Bruce
- Warwick Clinical Trials UnitUniversity of WarwickWarwickUK
| | - C. Eccleston
- Centre for Pain ResearchUniversity of BathBathUK
- Department of Experimental‐Clinical and Health PsychologyGhent UniversityGhentBelgium
| | - N. Howells
- Avon Orthopaedic Centre, Department of Trauma and OrthopaedicsNorth Bristol NHS TrustBristolUK
| | - T. J. Peters
- Musculoskeletal Research Unit, School of Clinical SciencesUniversity of BristolBristolUK
| | - R. Gooberman‐Hill
- Musculoskeletal Research Unit, School of Clinical SciencesUniversity of BristolBristolUK
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Singh JA, Noorbaloochi S, Knutson KL. Cytokine and neuropeptide levels are associated with pain relief in patients with chronically painful total knee arthroplasty: a pilot study. BMC Musculoskelet Disord 2017; 18:17. [PMID: 28088207 PMCID: PMC5237514 DOI: 10.1186/s12891-016-1375-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 12/21/2016] [Indexed: 12/04/2022] Open
Abstract
Background There are few studies with an assessment of the levels of cytokines or neuropeptides as correlates of pain and pain relief in patients with painful joint diseases. Our objective was to assess whether improvements from baseline to 2-months in serum cytokine, chemokine and substance P levels were associated with clinically meaningful pain relief at 2-months post-injection in patients with painful total knee arthroplasty (TKA). Methods Using data from randomized trial of 60 TKAs, we assessed the association of change in cytokine/chemokine/Substance P levels with primary study outcome, clinically important improvement in Western Ontario McMaster Osteoarthritis Index (WOMAC) pain subscale at 2-months post-injection using Student’s t-tests and Spearman’s correlation coefficient (non-parametric). Patients were categorized as pain responders (20-point reduction or more on 0-100 WOMAC pain) vs. pain non-responders. Sensitivity analysis used 0–10 daytime pain numeric rating scale (NRS) instead of WOMAC pain subscale. Results In a pilot study, compared to non-responders (n = 23) on WOMAC pain scale at 2-months, pain responders (n = 12) had significantly greater increase in serum levels of IL-7, IL-10, IL-12, eotaxin, interferon gamma and TNF-α from baseline to 2-months post-injection (p < 0.05 for all). Change in several cytokine/chemokine and substance P levels from pre-injection to 2-month follow-up correlated significantly with change in WOMAC pain with correlation coefficients ranging −0.37 to −0.51: IL-2, IL-7, IL-8, IL-9, IL-16, IL-12p, GCSF, IFN gamma, IP-10, MCP, MIP1b, TNF-α and VEGF (n = 35). Sensitivity analysis showed that substance P decreased significantly more from baseline to 2-months in the pain responders (0.54 ± 0.53; n = 10) than in the pain non-responders (0.48 ± 1.18; n = 9; p = 0.023) and that this change in serum substance P correlated significantly with change in daytime NRS pain, correlation coefficient was 0.53 (p = 0.021; n = 19). Findings should be interpreted with caution, since cytokine analyses were performed for a sub-group of the entire trial population. Conclusion Serum cytokine, chemokine and Substance P levels correlated with pain response in patients with painful TKA after an intra-articular injection in a randomized trial.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, VA Medical Center, 700 19th St S, Birmingham, AL, 35233, USA. .,Department of Medicine at School of Medicine, University of Alabama at Birmingham Faculty Office Tower, 805B, 510 20th Street S, Birmingham, AL, 35294, USA. .,Division of Epidemiology at School of Public Health, University of Alabama at Birmingham, 1720 Second Ave. South, Birmingham, AL, 35294-0022, USA. .,Department of Orthopedic Surgery, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55905, USA.
| | - Siamak Noorbaloochi
- Center for chronic disease Outcomes Research, Minneapolis Veterans Affairs Health are System Center, Minneapolis, MN, 55121, USA.,Department of Medicine, University of Minnesota, 401 East River Parkway, Minneapolis, MN, 55455, USA
| | - Keith L Knutson
- Department of Immunology, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55905, USA
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Wu T, Song HX, Dong Y, Ye Y, Li JH. Intra-articular injections of botulinum toxin a for refractory joint pain: a systematic review and meta-analysis. Clin Rehabil 2016; 31:435-443. [PMID: 27094033 DOI: 10.1177/0269215516644951] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Tao Wu
- Department of Rehabilitation Medicine, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hang Zhou, PR China
- Tao Wu and Hai-xin Song contributed equally to this work
| | - Hai-xin Song
- Department of Rehabilitation Medicine, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hang Zhou, PR China
- Tao Wu and Hai-xin Song contributed equally to this work
| | - Yan Dong
- Department of Rehabilitation Medicine, Hangzhou Hospital of Zhejiang CAPF, Hang Zhou, PR China
| | - Ye Ye
- Department of Rehabilitation Medicine, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hang Zhou, PR China
| | - Jian-hua Li
- Department of Rehabilitation Medicine, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hang Zhou, PR China
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Khenioui H, Houvenagel E, Catanzariti JF, Guyot MA, Agnani O, Donze C. Usefulness of intra-articular botulinum toxin injections. A systematic review. Joint Bone Spine 2015; 83:149-54. [PMID: 26645160 DOI: 10.1016/j.jbspin.2015.10.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2015] [Indexed: 10/22/2022]
Abstract
UNLABELLED Botulinum toxin is a proven and widely used treatment for numerous conditions characterized by excessive muscular contractions. Recent studies have assessed the analgesic effect of botulinum toxin in joint pain and started to unravel its mechanisms. LITERATURE-SEARCH-METHODOLOGY We searched the international literature via the Medline database using the term "intraarticular botulinum toxin injection" combined with any of the following terms: "knee", "ankle", "shoulder", "osteoarthritis", "adhesive capsulitis of the shoulder". RESULTS Of 16 selected articles about intraarticular botulinum toxin injections, 7 were randomized controlled trials done in patients with osteoarthritis, adhesive capsulitis of the shoulder, or chronic pain after joint replacement surgery. Proof of anti-nociceptive effects was obtained in some of these indications and the safety and tolerance profile was satisfactory. The studies are heterogeneous. The comparator was usually a glucocorticoid or a placebo; a single study used hyaluronic acid. Pain intensity was the primary outcome measure. DISCUSSION-CONCLUSION The number of randomized trials and sample sizes are too small to provide a satisfactory level of scientific evidence or statistical power. Unanswered issues include the effective dosage and the optimal dilution and injection modalities of botulinum toxin.
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Affiliation(s)
- Hichem Khenioui
- Service de médecine physique et de réadaptation, centre hospitalier Saint-Philibert, groupe hospitalier de l'institut catholique de Lille, 115, rue du Grand-But, BP 249, 59462 Lomme cedex, France; Université Nord de France, 1, rue Lefèvre, 59000 Lille, France; Université catholique de Lille, 60, boulevard Vauban, 59800 Lille, France.
| | - Eric Houvenagel
- Université Nord de France, 1, rue Lefèvre, 59000 Lille, France; Université catholique de Lille, 60, boulevard Vauban, 59800 Lille, France; Service de rhumatologie, centre hospitalier Saint-Philibert, groupe hospitalier de l'institut catholique de Lille, 115, rue du Grand-But, BP 249, 59462 Lomme cedex, France
| | - Jean François Catanzariti
- Service de médecine physique et de réadaptation, centre hospitalier Saint-Philibert, groupe hospitalier de l'institut catholique de Lille, 115, rue du Grand-But, BP 249, 59462 Lomme cedex, France; Université Nord de France, 1, rue Lefèvre, 59000 Lille, France; Service de rhumatologie, centre hospitalier Saint-Philibert, groupe hospitalier de l'institut catholique de Lille, 115, rue du Grand-But, BP 249, 59462 Lomme cedex, France; Service de médecine physique et réadaptation, centre de SSR pédiatrique Marc-Sautelet, 10, rue du Petit-Boulevard, 59650 Villeneuve-d'Ascq, France
| | - Marc Alexandre Guyot
- Service de médecine physique et de réadaptation, centre hospitalier Saint-Philibert, groupe hospitalier de l'institut catholique de Lille, 115, rue du Grand-But, BP 249, 59462 Lomme cedex, France; Université Nord de France, 1, rue Lefèvre, 59000 Lille, France; Service de rhumatologie, centre hospitalier Saint-Philibert, groupe hospitalier de l'institut catholique de Lille, 115, rue du Grand-But, BP 249, 59462 Lomme cedex, France
| | - Olivier Agnani
- Service de médecine physique et de réadaptation, centre hospitalier Saint-Philibert, groupe hospitalier de l'institut catholique de Lille, 115, rue du Grand-But, BP 249, 59462 Lomme cedex, France; Université Nord de France, 1, rue Lefèvre, 59000 Lille, France; Service de rhumatologie, centre hospitalier Saint-Philibert, groupe hospitalier de l'institut catholique de Lille, 115, rue du Grand-But, BP 249, 59462 Lomme cedex, France
| | - Cécile Donze
- Service de médecine physique et de réadaptation, centre hospitalier Saint-Philibert, groupe hospitalier de l'institut catholique de Lille, 115, rue du Grand-But, BP 249, 59462 Lomme cedex, France; Université Nord de France, 1, rue Lefèvre, 59000 Lille, France; Service de rhumatologie, centre hospitalier Saint-Philibert, groupe hospitalier de l'institut catholique de Lille, 115, rue du Grand-But, BP 249, 59462 Lomme cedex, France
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Vilhegas S, Cassu RN, Barbero RC, Crociolli GC, Rocha TLA, Gomes DR. Botulinum toxin type A as an adjunct in postoperative pain management in dogs undergoing radical mastectomy. Vet Rec 2015; 177:391. [PMID: 26446882 DOI: 10.1136/vr.102993] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2015] [Indexed: 12/21/2022]
Abstract
The aim of this randomised placebo-controlled, observer-blinded study was to evaluate the analgesic effects of botulinum toxin type A (BoNT-A) as an adjunct for postoperative pain control in dogs. Sixteen dogs undergoing bilateral radical mastectomy for treatment of mammary tumours were enrolled. Twenty-four hours before surgery, the subjects were distributed into two groups of eight dogs each: 7 iu/kg BoNT-A (BoNT-A) or saline (Control) was administered subcutaneously in each mammary gland. Following sedation with intramuscular 0.03 mg/kg acepromazine and 0.3 mg/kg morphine, anaesthesia was induced intravenously with 4 mg/kg propofol and maintained with isoflurane/O2. Postoperative analgesia was evaluated for 72 hours after extubation using the Visual Analogue Scale (VAS) and modified Glasgow Composite Measure Pain Scale (modified-GCMPS). Rescue analgesia was provided with intramuscular morphine (0.5 mg/kg). Data were analysed using analysis of variance, Tukey's test, Mann-Whitney U test and Friedman test (P<0.05). The pain scores were significantly lower in the BoNT-A than in the Control from 8 hours to 60 hours and from 12 hours to 60 hours after extubation, based on the VAS and modified-GCMPS, respectively. Rescue analgesia was required by significantly more dogs in the Control (7/8) compared with the BoNT-A (2/8) (P=0.022). Pre-emptive BoNT-A appears to be effective as an adjuvant for postoperative pain management in dogs undergoing bilateral radical mastectomy.
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Affiliation(s)
- S Vilhegas
- Department of Veterinary Surgery and Anesthesiology, Faculty of Veterinary Medicine and Animal Science, Unoeste, 19067-175, Presidente Prudente, São Paulo, Brazil
| | - R N Cassu
- Department of Veterinary Surgery and Anesthesiology, Faculty of Veterinary Medicine and Animal Science, Unoeste, 19067-175, Presidente Prudente, São Paulo, Brazil
| | - R C Barbero
- Department of Veterinary Surgery and Anesthesiology, Faculty of Veterinary Medicine and Animal Science, Unoeste, 19067-175, Presidente Prudente, São Paulo, Brazil
| | - G C Crociolli
- Department of Veterinary Surgery and Anesthesiology, Faculty of Veterinary Medicine and Animal Science, Unoeste, 19067-175, Presidente Prudente, São Paulo, Brazil
| | - T L A Rocha
- Department of Veterinary Surgery and Anesthesiology, Faculty of Veterinary Medicine and Animal Science, Unoeste, 19067-175, Presidente Prudente, São Paulo, Brazil
| | - D R Gomes
- Department of Veterinary Surgery and Anesthesiology, Faculty of Veterinary Medicine and Animal Science, Unoeste, 19067-175, Presidente Prudente, São Paulo, Brazil
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Kostrzewa RM, Kostrzewa RA, Kostrzewa JP. Botulinum neurotoxin: Progress in negating its neurotoxicity; and in extending its therapeutic utility via molecular engineering. MiniReview. Peptides 2015; 72:80-7. [PMID: 26192475 DOI: 10.1016/j.peptides.2015.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 07/01/2015] [Accepted: 07/01/2015] [Indexed: 12/12/2022]
Abstract
While the poisonous effects of botulinum neurotoxin (BoNT) have been recognized since antiquity, the overall actions and mechanisms of effects of BoNT have been elucidated primarily over the past several decades. The general utility of BoNT is described in the paper, but the focus is mainly on the approaches towards negating the toxic effects of BoNT, and on the projection of an engineered BoNT molecule serving as a Trojan Horse to deliver a therapeutic load for treatment of a host of medical disorders. The BoNT molecule is configured with a binding domain, a zinc-dependent protease with specificity primarily for vesicular proteins, and a translocation domain for delivery of the metalloprotease into the cytoplasm. The anti-toxin approaches for BoNT include the use of vaccines, antibodies, block of BoNT binding or translocation, inhibition of metalloprotease activity, impeded translocation of the protease/catalytic domain, and inhibition of the downstream Src signaling pathway. Projections of BoNT as a therapeutic include its targeting to non-cholinergic nerves, also targeting to non-neuronal cells for treatment of hypersecretory disorders (e.g., cystic fibrosis), and treatment of hormonal disorders (e.g., acromegaly). Still in the exploratory phase, there is the expectation of major advances in BoNT neuroprotective strategies and burgeoning utility of engineered BoNTs as therapeutics.
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Affiliation(s)
- Richard M Kostrzewa
- Department of Biomedical Sciences, Quillen College of Medicine, East Tennessee State University, P.O. Box 70577, Johnson City, TN 37614, USA.
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Botulinum Toxin Type A for the Treatment of Neuropathic Pain in Neuro-Rehabilitation. Toxins (Basel) 2015; 7:2454-80. [PMID: 26134256 PMCID: PMC4516923 DOI: 10.3390/toxins7072454] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 05/22/2015] [Accepted: 06/23/2015] [Indexed: 02/06/2023] Open
Abstract
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.
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Beswick AD, Wylde V, Gooberman-Hill R. Interventions for the prediction and management of chronic postsurgical pain after total knee replacement: systematic review of randomised controlled trials. BMJ Open 2015; 5:e007387. [PMID: 25967998 PMCID: PMC4431062 DOI: 10.1136/bmjopen-2014-007387] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES Total knee replacement can be a successful operation for pain relief. However, 10-34% of patients experience chronic postsurgical pain. Our aim was to synthesise evidence on the effectiveness of applying predictive models to guide preventive treatment, and for interventions in the management of chronic pain after total knee replacement. SETTING We conducted a systematic review of randomised controlled trials using appropriate search strategies in the Cochrane Library, MEDLINE and EMBASE from inception to October 2014. No language restrictions were applied. PARTICIPANTS Adult patients receiving total knee replacement. INTERVENTIONS Predictive models to guide treatment for prevention of chronic pain. Interventions for management of chronic pain. PRIMARY AND SECONDARY OUTCOME MEASURES Reporting of specific outcomes was not an eligibility criterion but we sought outcomes relating to pain severity. RESULTS No studies evaluated the effectiveness of predictive models in guiding treatment and improving outcomes after total knee replacement. One study evaluated an intervention for the management of chronic pain. The trial evaluated the use of a botulinum toxin A injection with antinociceptive and anticholinergic activity in 49 patients with chronic postsurgical pain after knee replacement. A single injection provided meaningful pain relief for about 40 days and the authors acknowledged the need for a large trial with repeated injections. No trials of multidisciplinary interventions or individualised treatments were identified. CONCLUSIONS Our systematic review highlights a lack of evidence about the effectiveness of prediction and management strategies for chronic postsurgical pain after total knee replacement. As a large number of people are affected by chronic pain after total knee replacement, development of an evidence base about care for these patients should be a research priority.
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Affiliation(s)
- Andrew D Beswick
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Vikki Wylde
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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Gabriel A, Champaneria MC, Maxwell GP. The efficacy of botulinum toxin A in post-mastectomy breast reconstruction: a pilot study. Aesthet Surg J 2015; 35:402-9. [PMID: 25825421 DOI: 10.1093/asj/sjv040] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Botulinum toxin A has been successfully used in a variety of areas to temporarily obliterate muscle mobility for either functional or aesthetic gain. Tissue expander-based breast reconstruction has been plagued with pain and discomfort. OBJECTIVE The purpose of this pilot study was to evaluate the role of a neurotoxin (Botulinum toxin A) in expander-based breast reconstruction. METHODS Thirty patients underwent mastectomies with immediate expander or acellular dermal matrix reconstruction. The neurotoxin group (n = 15) received 40 units of neurotoxin (Botulinum toxin A, Allergan, Inc, Irvine, CA) into each pectoralis major muscle through 4 serial injections and the placebo group (n = 15) received 4 serial injections of 0.9% NaCl. All patients were followed over 1 year, and patient demographics, VAS (visual analog score), laterality, office visits, amount of expansion and number of times to full expansion, and amount of narcotics required were recorded. Statistical significance was considered as p < .05. RESULTS There were no significant differences between the two groups in terms of age, laterality, expander size, or complications (p = .46-.66). There was a significant difference between the two groups in the VAS score, demonstrating decreased pain in the neurotoxin group (p < .05). In addition, there was a significant increase in the volume of expansion per visit in the neurotoxin group as compared to the placebo group (p < .05). There was no significant difference in narcotic use in the first 3 days after surgery; however, there was a significant decrease in use of narcotics from 7 to 45 days in the neurotoxin group (p < .05). There were no complications associated with the use of the neurotoxin. CONCLUSIONS The infiltration of the pectoralis major muscle with neurotoxin in immediate, expander-based reconstruction may be beneficial in reducing pain and expediting expansions.
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Affiliation(s)
- Allen Gabriel
- Drs Gabriel and Maxwell are Associate Clinical Professors in the Department of Plastic Surgery at the Loma Linda University Medical Center, Loma Linda, CA. Dr Champaneria is a plastic surgeon in private practice in Vancouver, WA
| | - Manish C Champaneria
- Drs Gabriel and Maxwell are Associate Clinical Professors in the Department of Plastic Surgery at the Loma Linda University Medical Center, Loma Linda, CA. Dr Champaneria is a plastic surgeon in private practice in Vancouver, WA
| | - G Patrick Maxwell
- Drs Gabriel and Maxwell are Associate Clinical Professors in the Department of Plastic Surgery at the Loma Linda University Medical Center, Loma Linda, CA. Dr Champaneria is a plastic surgeon in private practice in Vancouver, WA
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Huleatt JB, Campbell KJ, Laprade RF. Nonoperative treatment approach to knee osteoarthritis in the master athlete. Sports Health 2014; 6:56-62. [PMID: 24427443 PMCID: PMC3874223 DOI: 10.1177/1941738113501460] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Context: Middle-age and elderly participants in athletic activities frequently encounter the chronic disabling process of osteoarthritis. Knowledge of the treatment of knee osteoarthritis is needed to keep the master athlete active. Objective: This article reviews the current scientific evidence regarding recommendations for the maturing athlete, specifically discussing the strengths and weaknesses of dietary and lifestyle modifications, physical therapy, bracing, supplements, pharmacotherapies, and biologics in the management of knee osteoarthritis. Level of Evidence: Level 4. Conclusion: These treatment modalities can help keep the aging athlete active, which in itself plays an important role in reducing the symptoms of knee osteoarthritis.
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Singh JA. Efficacy of Long-term Effect and Repeat Intraarticular Botulinum toxin in Patients with Painful Total Joint Arthroplasty: A Retrospective Study. ACTA ACUST UNITED AC 2014; 4. [PMID: 24319672 PMCID: PMC3850174 DOI: 10.9734/bjmmr/2014/4897] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective Based on recent success of intra-articular (IA) Botulinum neurotoxin type A (BoNT/A; OnabotulinumtoxinA) in patients with osteoarthritis, we examined if repeat IA-BoNT/A is an effective antinociceptive in patients with refractory arthroplasty pain. Methods 11 patients with refractory chronic arthroplasty joint pain without any evidence of infection or prosthesis loosening were referred by orthopedic surgeons. After discussion of off-label use, each patient underwent IA injection of BoNT/A, repeated based on return of pain on numeric rating scale (NRS) and functional limitation on composite validated scales, Western Ontario McMaster Osteoarthritis index (WOMAC) or Shoulder Pain and Disability (SPADI). Results 11 patients (10 men, 1 woman) with 14 painful arthroplasty joints (3 bilateral; 12 knee and 2 shoulder) underwent ≥1 IA-BoNT/A injections (8 joints injected once, one joint injected twice only, five joints injected thrice) with doses ranging 100–300 units. Mean age was 68 years (standard deviation, 12) and follow-up ranged 1–28 months. Clinically meaningful reduction of 2-units in pain severity and really meaningful reduction in pain severity (50% reduction) were reported by 6/11 patients (6/13 joints) and 3/11 patients (3/13 joints), respectively, 1 month after the first IA-BoNT/A (100-units each). Significant improvements were noted in composite functional scales (WOMAC/SPADI). Pain relief was sustained at 3–4 month follow-up and was reproducible in those who received repeat injections. No significant adverse events were seen in any patients. Conclusions A single intra-articular injection of BoNT/A improved pain and function in patients with chronic, refractory painful knee or shoulder arthroplasty, which sustained with repeat injections. Patients who were refractory to the first injection, did not respond to subsequent injections of higher dose of IA-BoNT/A.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service and Center for Surgical Medical Acute Care Research and Transitions (C-SMART), Birmingham VA Medical Center, Birmingham, AL; USA ; Department of Medicine, University of Alabama, and Division of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL; USA. ; Department of Orthopedic Surgery, Mayo Clinic School of Medicine, Rochester, MN, USA
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Perret D, Chang EY, Pang W, Shinada S, Panush RS. Reflecting on pain management for patients with osteoarthritis and other rheumatic disorders: there's more to pain management than managing pain. Pain Manag 2013; 3:295-301. [PMID: 24654815 PMCID: PMC4363121 DOI: 10.2217/pmt.13.30] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
SUMMARY Medical progress is measured by advances in science and technology. The pace of discovery will surely accelerate. We are increasingly challenged not only to assimilate new information, but also to reconcile our learning with our art. We present the common clinical problem of managing pain in osteoarthritis as a paradigm for this dilemma in contemporary patient care. We do not yet have the understanding and interventions to do this optimally for all with osteoarthritis, leaving us with uncertainties as we struggle to care for these patients. In a world of growing complexity and sophistication we must not overlook the person who is our patient. It is easy to be seduced by electronic and informational advances, to be entranced by machinery, and to forget the unique individuality and needs of each patient. Osler taught that "the practice of medicine is an art, based on science". This doesn't change.
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Affiliation(s)
- Danielle Perret
- Department of Anesthesiology & Perioperative Care, Division of Pain Medicine, The University of California, Irvine, CA, USA
- Department of Physical Medicine & Rehabilitation, The University of California, Irvine, CA, USA
| | - Eric Y Chang
- Department of Anesthesiology & Perioperative Care, Division of Pain Medicine, The University of California, Irvine, CA, USA
- Department of Physical Medicine & Rehabilitation, The University of California, Irvine, CA, USA
- Reeve-Irvine Research Center, Irvine, CA, USA
| | - Winnie Pang
- Department of Medicine, Division of Rheumatology, Keck School of Medicine, The University of Southern California & Los Angeles County Medical Center, Los Angeles, CA 90033, USA
| | - Shuntaro Shinada
- Department of Medicine, Division of Rheumatology, Keck School of Medicine, The University of Southern California & Los Angeles County Medical Center, Los Angeles, CA 90033, USA
| | - Richard S Panush
- Department of Medicine, Division of Rheumatology, Keck School of Medicine, The University of Southern California & Los Angeles County Medical Center, Los Angeles, CA 90033, USA
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Abstract
Chronic musculoskeletal pain is a common cause of chronic pain, which is associated with a total cost of $635 billion per year in the U.S. Emerging evidence suggests an anti-nociceptive action of botulinum toxin, independent of its muscle paralyzing action. This review provides a summary of data from both non-randomized and randomized clinical studies of botulinum toxin in back pain and various osteoarticular conditions, including osteoarthritis, tennis elbow, low back pain and hand pain. Three randomized controlled trials (RCTs) of small sizes provide evidence of short-term efficacy of a single intra-articular injection of 100 units of botulinum toxin A (BoNT/A) for the relief of pain and the improvement of both function and quality of life in patients with chronic joint pain due to arthritis. Three RCTs studied intramuscular BoNT/A for tennis elbow with one showing a significant improvement in pain relief compared with placebo, another one showing no difference from placebo, and the third finding that pain and function improvement with BoNT/A injection were similar to those obtained with surgical release. One RCT of intramuscular BoNT/A for low back pain found improvement in pain and function compared to placebo. Single RCTs using local injections of BoNT in patients with either temporomandibular joint (TMJ) pain or plantar fasciitis found superior efficacy compared to placebo. One RCT of intramuscular BoNT/B in patients with hand pain and carpal tunnel syndrome found improvement in pain in both BoNT/B and placebo groups, but no significant difference between groups. Most evidence is based on small studies, but the use of BoNT is supported by a single, and sometimes up to three, RCTs for several chronic musculoskeletal pain conditions. This indicates that botulinum toxin may be a promising potential new treatment for chronic refractory musculoskeletal pain. Well-designed large clinical trials are needed.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service and Center for Surgical Medical Acute Care Research and Transitions (C-SMART), Birmingham Veterans Affairs Medical Center, Birmingham AL, 35294, USA ; Department of Medicine at School of Medicine, and Division of Epidemiology at School of Public Health, University of Alabama, Birmingham AL, 35294, USA ; Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester MN, 55123, USA
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Mittal S, Machado DG, Jabbari B. OnabotulinumtoxinA for treatment of focal cancer pain after surgery and/or radiation. PAIN MEDICINE 2012; 13:1029-33. [PMID: 22776097 DOI: 10.1111/j.1526-4637.2012.01437.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To report the relief from refractory focal post-radiation and/or postsurgical cancer pain after local treatment with onabotulinumtoxinA. SETTING AND DESIGN We studied the effect of onabotulinumtoxinA in seven cancer patients who suffered from severe focal pain (visual analog scale >5) at the site of local surgery or radiotherapy or both. OnabotulinumtoxinA (20-100 units) was injected into the focal pain areas (skin or muscle or both). Five of seven patients were followed beyond 1 year (1.5-5 years) with repeat treatment. RESULTS All seven patients reported a significant improvement in pain (mean drop in visual analog scale score of 5.1). They described their response on the patient global assessment as satisfactory (two patients) or very satisfactory (five patients). Six of seven patients found the pain relief associated with significant improvement in quality of life. One patient developed weakness of jaw muscles after bilateral masseter injection that was not observed during second injection (reduced dose). Improvements with treatment persisted with repeat injections during long-term follow-up (five patients). CONCLUSION Local treatment with onabotulinumtoxinA can significantly reduce pain and improve quality of life in cancer patients suffering from pain in the area of surgery and radiation and was well tolerated in cancer patients.
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Affiliation(s)
- Shivam Mittal
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA.
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Cheng OT, Souzdalnitski D, Vrooman B, Cheng J. Evidence-based knee injections for the management of arthritis. PAIN MEDICINE 2012; 13:740-53. [PMID: 22621287 DOI: 10.1111/j.1526-4637.2012.01394.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Arthritis of the knee affects 46 million Americans. We aimed to determine the level of evidence of intraarticular knee injections in the management of arthritic knee pain. METHODS We systematically searched PUBMED/MEDLINE and the Cochrane databases for articles published on knee injections and evaluated their level of evidence and recommendations according to established criteria. RESULTS The evidence supports the use of intraarticular corticosteroid injections for rheumatoid arthritis (1A+ Level), osteoarthritis (1A+ Level), and juvenile idiopathic arthritis (2C+ Level). Pain relief and functional improvement are significant for months up to 1 year after the injection. Triamcinolone hexacetonide offers an advantage over triamcinolone acetonide and should be the intraarticular steroid of choice (2B+ Level). Intraarticular injection of hyaluronate may provide longer pain relief than steroid injection in osteoarthritis (2B+ Level). It can also be effective for rheumatoid arthritis knee pain (1A+ Level). However, it is only recommended for patients with significant surgical risk factors and for patients with mild radiographic disease in whom conservative treatment has failed (2B± Level). Botulinum toxin type A injection is effective in reducing arthritic knee pain (2B+ Level), and so is tropisetron (2B+ Level) and tanezumab (2B+ Level). The new agents, such as rAAV2-TNFR:Fc, SB-210396/CE 9.1, and various radioisotopes have provided various degrees of success, but their long-term safety and efficacy remains to be determined. CONCLUSIONS We conclude that strong evidence supports the use of intraarticular knee injection as a valuable intervention in the continuum of management of arthritis between conservative treatment and knee surgeries.
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Affiliation(s)
- Olivia T Cheng
- Department of Pain Management, Cleveland Clinic, Cleveland, OH, USA.
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Singh JA. Stem cells and other innovative intra-articular therapies for osteoarthritis: what does the future hold? BMC Med 2012; 10:44. [PMID: 22551396 PMCID: PMC3364907 DOI: 10.1186/1741-7015-10-44] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 05/02/2012] [Indexed: 12/13/2022] Open
Abstract
Osteoarthritis (OA), the most common type of arthritis in the world, is associated with suffering due to pain, productivity loss, decreased mobility and quality of life. Systemic therapies available for OA are mostly symptom modifying and have potential gastrointestinal, renal, hepatic, and cardiac side effects. BMC Musculoskeletal Disorders recently published a study showing evidence of reparative effects demonstrated by homing of intra-articularly injected autologous bone marrow stem cells in damaged cartilage in an animal model of OA, along with clinical and radiographic benefit. This finding adds to the growing literature showing the potential benefit of intra-articular (IA) bone marrow stem cells. Other emerging potential IA therapies include IL-1 receptor antagonists, conditioned autologous serum, botulinum toxin, and bone morphogenetic protein-7. For each of these therapies, trial data in humans have been published, but more studies are needed to establish that they are safe and effective. Several additional promising new OA treatments are on the horizon, but challenges remain to finding safe and effective local and systemic therapies for OA.Please see related article: http://www.biomedcentral.com/1471-2474/12/259.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, Birmingham VA Medical Center and Department of Medicine, University of Alabama, Faculty Office Tower 805B, 510 20th Street S, Birmingham, AL 35294, USA.
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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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