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Botulinum Toxin Treatment of Myofascial Pain: A Critical Review of the Literature

  • Myofascial Pain (RD Gerwin, Section editor)
  • Published:
Current Pain and Headache Reports Aims and scope Submit manuscript

Abstract

This is a review of literature relevant to the treatment of myofascial pain syndrome by botulinum injections. The objective is to critically review the studies to see if they are appropriately designed, conducted, and interpreted to provide guidance in the management of myofascial pain. The intent is to better understand the mixed results that these studies have provided. A search was made utilizing PubMed for literature relevant to the use of botulinum toxin in the treatment of myofascial pain. All identifiable series were reviewed, including open label, single-blinded and double-blinded studies, randomized and controlled, or not. In general, small case series of only a few patients were not included unless they made a relevant point and there were no available randomized studies or larger studies. Single case reports were not included. This is not a meta-analysis. The studies were evaluated according to their design and the selection of outcome measurements, and the interpretation of results. The studies were individually critiqued, and an overall assessment and commentary was made of the studies in the field as a whole. Problems that were common to the studies were robust placebo responders, incomplete treatment of a regional myofascial pain syndrome, inappropriate or confounding control populations or treatments, and inappropriate time periods for assessment of outcomes, or misinterpretation of the time-frame of action of botulinum toxin. The studies of the effect of botulinum toxin treatment of myofascial trigger points have had mixed results. However, few studies have been designed to avoid many of the pitfalls associated with a trial of botulinum toxin treatment of trigger points. Better-designed studies may give results that can be used to guide practice based on reliable evidence. At the present time, one must conclude that the available evidence is insufficient to guide clinical practice.

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Abbreviations

BoNT:

Botulinum neurotoxin

BoNT-A:

Botulinum neurotoxin type A (or BoNT-B: type B)

MPS:

Myofascial pain syndromes

ACh:

Acetylcholine

CGRP:

Calcitonin-gene-related-peptide

TENS:

Transcutaneous electroneural stimulation

TrPs:

Trigger points

MRI:

Magnetic resonance imaging

TMJ:

Temporomandibular joint

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. •• Ballyns JJ, Shah JP, Hammond J, Bebreab T, Gerber LH, Sikdar S. Objective sonographic measures for characterizing myofascial trigger points associated with cervical pain. J Ultrasound Med. 2011;30:1331–40. This is one of two techniques that identify the trigger point taut band by imaging techniques, providing objective confirmation of the physical examination. In this technique the taut band of the trigger point appears as a hypoechoic region distinct from its surroundings.

    PubMed  Google Scholar 

  2. Chen Q, Bensamoun S, Basford J, Thompson JM, An K-N. Identification and quantification of myofascial taut bands with magnetic resonance elastography. Arch Phys Med Rehabil. 2007;88:1658–61.

    Article  PubMed  Google Scholar 

  3. Shah JP, Phillips TM, Danoff JV, Gerber LH. An in vivo microanalytic technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol. 2005;99:1977–84.

    Article  PubMed  CAS  Google Scholar 

  4. Kuan TS, Chen JT, Chen SM, Chien SH, Hong CZ. Effect of botulinum toxin on endplate noise in myofascial trigger spots of rabbit skeletal muscle. Am J Phys Med Rehabil. 2002;81:512–20.

    Article  PubMed  Google Scholar 

  5. Aoki KR. Evidence for antinociceptive activity of botulinum toxin type A in pain management. Headache. 2003;43 Suppl 1:S9–15.

    Article  PubMed  Google Scholar 

  6. • Sim WS. Application of botulinum toxin in pain management. Korean J Pain. 2011;24:1–6. This study demonstrates the important point that the release of neurotransmitters and excitatory amino acids from sensory nerve endings is inhibited by botulinum toxin, and can therefore inhibit nociceptive nerve activation.

    Article  PubMed  CAS  Google Scholar 

  7. Lew MF, Chinnapongse R, Zhang Y, Corliss M. Rimabotulinum B effects on pain associated with cervical dystonia: results of placebo and comparator-controlled studies. Int J Neurosurg. 2010;120:2989–300.

    Google Scholar 

  8. Jancovic J, Orman J. Botulinum toxin for cranial cervical dystonia: a double-blind, placebo controlled study. Neurol. 1987;37:616–23.

    Article  Google Scholar 

  9. Freund B, Schwartz M. Temporal relationship of muscle weakness and pain reduction in subjects treated with botulinum toxin A. J Pain. 2003;4:159–66.

    Article  PubMed  CAS  Google Scholar 

  10. Welch MJ, Purkiss JR, Foster KA. Sensitivity of embryonic rat dorsal horn ganglia neurons to Clostridium botulinum neurotoxins. Toxicon. 2000;38:245–58.

    Article  PubMed  CAS  Google Scholar 

  11. Durham PL, Cady R, Cady R. Regulation of calcitonin gene-related peptide secretion form trigeminal nerve cells by botulinum toxin type A. Implications for migraine therapy. Headache. 2004;44:35–43.

    Article  PubMed  Google Scholar 

  12. Cui M, Khanijou S, Rubino J. Aoki KR Subcutaneous administration of botulinum toxin A reduces formalin-induced pain. Pain. 2004;107:125–33. human model of trigeminal sensitization. Pain. 2006;122:15–25.

    Article  PubMed  CAS  Google Scholar 

  13. • Gazerani P, Pedersen NS, Staahl C, Drewes AM, Arendt-Nielsen L. Subcutaneous botulinum toxin type A reduces capsaicin-induced trigeminal pain and vasomotor reactions in human skin. Pain. 2009;141:60–9. This is an important study that shows that botulinum toxin has an action at sensory nerve receptors, not just at the neuromuscular junction.

    Article  PubMed  CAS  Google Scholar 

  14. Tugnoli V, Capone JG, Eleopra R, Quatrale R, Sensi M, Gastaldo E, et al. Botulinum toxin type A reduces capsaicin-evoked pain and neurogenic vasodilitation in human skin. Pain. 2007;130:76–83.

    Article  PubMed  CAS  Google Scholar 

  15. Voller B, Sucha T, Gustorff B, Schmetterer L, Lehr S, Eichler HG, et al. A randomized, double-blind, placebo controlled study on analgesic effects of botulinum toxin A. Neurol. 2003;61:940–4.

    Article  CAS  Google Scholar 

  16. Ferrante FM, Bean L, Rothrock R, King L. Evidence against trigger point injection techniques for the treatment of cervicothoracic myofascial pain with botulinum toxin type A. Anesthesiol. 2005;103:377–83.

    Article  CAS  Google Scholar 

  17. Graboski CL, Gray DS, Burnham RS. Botulinum toxin A vs bupivicaine trigger point injections for the treatment of myofascial pain syndrome: a randomized double blind crossover study. Pain. 2005;118:170–5.

    Article  PubMed  CAS  Google Scholar 

  18. Kamanli A, Kaya A, Ardicoglu O, Ozgocmen S, Zengin FO, Bayik Y. Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome. Rheumat Int. 2005;25:604–11.

    Article  CAS  Google Scholar 

  19. •• Lucas KR. The impact of latent trigger points on regional muscle function. Curr Pain Headache Rep. 2008;12:344–9. This is the first study to establish the importance of latent trigger points in the orderly recruitment of muscles in a volitional activity. As such, it demonstrated the ability of latent trigger points to produce a dysfunction, showing that latent trigger points were not inert.

    Article  PubMed  Google Scholar 

  20. Ojala T, Arokoski JPA, Partanen J. The effect of small doses of botulinum toxin A on neck-shoulder myofascial pain syndrome: a double-blind, randomized, and controlled crossover trial. Clin J Pain. 2006;22:90–6.

    Article  PubMed  Google Scholar 

  21. Benecke R, Heinze A, Reichel G, Hefter H, Göbel H. Dysport myofascial pain study group. Botulinum type A toxin complex for the relief of upper back myfascial pain syndrome: how do fixed-location injections compare with trigger point-focused injections. Pain Med. 2011;12:1607–14.

    Article  PubMed  Google Scholar 

  22. Gül I, Onal SA. Comparison of non-invasive and invasive techniques in the treatment of patients with myofascial pain syndrome. Aqri. 2009;21:104–12. Turkish.

    Google Scholar 

  23. De Andrés J, Adsuara VM, Palmisani S, Villanueva V, López-Alarcón. A double-blind, controlled, randomized trial to evaluate the efficacy of botulinum toxin for the treatment of lumbar myofascial pain in humans. Reg Anesth Pain Med. 2010;35:255–60.

    Article  PubMed  Google Scholar 

  24. Foster L, Clapp L, Erickson M, Jabbari B. Botulinum toxin A and chronic low back pain. Neurol. 2001;56:1290–3.

    Article  CAS  Google Scholar 

  25. Jabbari B, Ney J, Sichani A, Monacci W, Foster L, Difazio M. Treatment of refractory, chronic low back pain with botulinum neurotoxin A: an open-label, pilot study. Pain Med. 2006;7:260–4.

    Article  PubMed  Google Scholar 

  26. Göbel H, Heinze A, Reichel G, Hefter H, Benecke R. Efficacy and safety of a single botulinum type A toxin complex treatment (Dysport) for the relief of upper back myofascial pain syndrome: results from a randomized double-blind placebo-controlled multicenter study. Pain. 2006;125:82–8.

    Article  PubMed  Google Scholar 

  27. Wheeler AH, Goolkasian P, Gretz SS. A randomized, double-blind, prospective pilot study of botulinum toxin injection for refractory, unilateral, cervicothoracic, paraspinal, myofascial pain syndrome. Spine. 1998;23:1662–66.

    Article  PubMed  CAS  Google Scholar 

  28. Miller D, Richardson D, Eisa M, Bajwa RJ, Jabbari B. Botulinum neurotoxin-A for treatment of refractory neck pain: a randomized, double-blind study. Pain Med. 2009;10:1012–17.

    Article  PubMed  Google Scholar 

  29. Kurtoglu C, Gur OH, Kurkcu M, Sertdemir Y, Guler-Uysal F, Uysal H. Effect of botulinum toxin-A in myofascial pain patients with or without functional disc displacement. J Oral Maxillofac Surg. 2008;66:1644–51.

    Article  PubMed  Google Scholar 

  30. Emberg M, Hedenberg-Mangusson B, List T, Svensson P. Efficacy of botulinum toxin type A for treatment of persistent myofascial TMD pain: a randomized, controlled, double-blind multicenter study. Pain. 2011;152:1988–96.

    Article  Google Scholar 

  31. von Lindern J, Niederhagan B, Bergé S, Appel T. Type A botulinum toxin in the treatment of chronic facial pain associated with masticatory hyperactivity. J Oral Maxillofac Surg. 2003;61:774–8.

    Article  Google Scholar 

  32. • Soares A, Andriolo RB, Atallah AN, da Silva EM. Botulinum toxin for myofascial pain syndromes in adults. Cochrane Database Syst Rev. 2012;4:CD007533. Cochrane reviews are always held in high regard. This review found only 4 studies that met its criteria, and bases its conclusions on a narrow sample. However, the conclusion that there is not enough data to make an informed decision in favor of the effects of botulinum in the treatment of myofascial trigger points is valid.

    PubMed  Google Scholar 

  33. Simons DG, Travell JG, Simons LS. Myofascial Pain and Dysfunction: the trigger point manual. Baltimore: Williams & Wilkins; 1999. p. 31–5.

    Google Scholar 

  34. Zhang T, Adatia A, Zarin W, Moitri W, Vijenthira A, Chu R, et al. The efficacy of botulinum toxin type A in managing chronic musculoskeletal pain”: a systematic review and meta analysis. Inflammopharmacol. 2011;19:21–34.

    Article  CAS  Google Scholar 

  35. Jabbari B, Machado D. Treatment of refractory pain with botulinum toxins– an evidence-based review. Pain Med. 2011;12:1594–606.

    Article  PubMed  Google Scholar 

  36. Harden RN, Cottrill J, Gagnon CM, Smitherman TA, Weinland SR, Tann B, et al. Botulinum toxin a in the treatment of chronic tension-type headache with cervical myofascial trigger points: a randomized, double-blind, placebo-controlled pilot study. Headache. 2009;49:732–43.

    Article  PubMed  Google Scholar 

  37. Venancio RA, Alencar Jr FG, Zamperini C. Botulinum toxin, lidocaine, and dry needling injections in patients with myofascial pain and headaches. Cranio. 2009;27:46–53.

    Google Scholar 

  38. Langevin P, Peloso PM, Lowcock J, Nolan M, Weber J, Gross A, et al. Botulinum toxin for subacute/chronic neck pain. Cochrane Database Syst Review. 2011;6:CD008626.

    Google Scholar 

  39. Braker C, Yariv S, Adler R, Badarny S, Eisenberg E. The analgesic effect of botulinum-toxin A on postwhiplash neck pain. Clin J Pain. 2008;24:5–10.

    Article  PubMed  Google Scholar 

  40. Carroll A, Barnes M, Comiskey C. A prospective randomized controlled study of the role of botulinum toxin in whiplash-associated disorder. Clin Rehabil. 2008;22:513–19.

    Article  PubMed  Google Scholar 

  41. Safarpour D, Jabbari B. Botulinum toxin A (Botox) for treatment of proximal myofascial pain in complex regional pain syndrome: two cases. Pain Med. 2010;11:1415–18.

    Article  PubMed  Google Scholar 

  42. Taylor M, Silva S, Cottrell C. Botulinum toxin type-A (Botox) in the treatment of occipital neuralgia: a pilot study. Headache. 2008;48:1476–81.

    Article  PubMed  Google Scholar 

  43. Qerama E, Fuglsang-Frederiksen A, Kasch H, Bach FW, Jensen TS. A double-blind, controlled study of botulinum toxin A in chronic myofascial pain. Neurol. 2006;67:241–5.

    Article  CAS  Google Scholar 

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  1. Johns Hopkins University, 7830 Old Georgetown Road, Bethesda, MD, 20814, USA

    Robert Gerwin

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Gerwin, R. Botulinum Toxin Treatment of Myofascial Pain: A Critical Review of the Literature. Curr Pain Headache Rep 16, 413–422 (2012). https://doi.org/10.1007/s11916-012-0287-6

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