Botulinum toxin for subacute/chronic neck pain.

BACKGROUND: Neck disorders are common, disabling and costly. Botulinum toxin (BoNT) intramuscular injections are often used with the intention of treating neck pain. OBJECTIVES: To systematically evaluate the literature on the treatment effectiveness of BoNT for neck pain, disability, global perceived effect and quality of life in adults with neck pain with or without associated cervicogenic headache, but excluding cervical radiculopathy and whiplash associated disorder. SEARCH STRATEGY: We searched CENTRAL, MEDLINE, AMED, Index to Chiropractic Literature, CINAHL, LILACS, and EMBASE from their origin to 20 September 2010. SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials in which BoNT injections were used to treat subacute or chronic neck pain. DATA COLLECTION AND ANALYSIS: A minimum of two review authors independently selected articles, abstracted data, and assessed risk of bias, using the Cochrane Back Review Group criteria. In the absence of clinical heterogeneity, we calculated standardized mean differences (SMD) and relative risks, and performed meta-analyses using a random-effects model. The quality of the evidence and the strength of recommendations were assigned an overall grade for each outcome. MAIN RESULTS: We included nine trials (503 participants). Only BoNT type A (BoNT-A) was used in these studies.High quality evidence suggests there was little or no difference in pain between BoNT-A and saline injections at four weeks (five trials; 252 participants; SMD pooled -0.07 (95% confidence intervals (CI) -0.36 to 0.21)) and six months for chronic neck pain. Very low quality evidence indicated little or no difference in pain between BoNT-A combined with physiotherapeutic exercise and analgesics and saline injection with physiotherapeutic exercise and analgesics for patients with chronic neck pain at four weeks (two trials; 95 participants; SMD pooled 0.09 (95% CI -0.55 to 0.73)) and six months (one trial; 24 participants; SMD -0.56 (95% CI -1.39 to 0.27)). Very low quality evidence from one trial (32 participants) showed little or no difference between BoNT-A and placebo at four weeks (SMD 0.16 (95% CI -0.53 to 0.86)) and six months (SMD 0.00 (95% CI -0.69 to 0.69)) for chronic cervicogenic headache. Very low quality evidence from one trial (31 participants), showed a difference in global perceived effect favouring BoNT-A in chronic neck pain at four weeks (SMD -1.12 (95% CI: -1.89 to -0.36)). AUTHORS' CONCLUSIONS: Current evidence fails to confirm either a clinically important or a statistically significant benefit of BoNT-A injection for chronic neck pain associated with or without associated cervicogenic headache. Likewise, there was no benefit seen for disability and quality of life at four week and six months.

Pharmacological Interventions Including Medical Injections for Neck Pain: An Overview as Part of the ICON Project.

OBJECTIVES: To conduct an overview (review-of-reviews) on pharmacological interventions for neck pain. SEARCH STRATEGY: Computerized databases and grey literature were searched from 2006 to 2012. SELECTION CRITERIA: Systematic reviews of randomized controlled trials (RCT) in adults with acute to chronic neck pain reporting effects of pharmacological interventions including injections on pain, function/disability, global perceived effect, quality of life and patient satisfaction. DATA COLLECTION & ANALYSIS: Two independent authors selected articles, assessed risk of bias and extracted data The GRADE tool was used to evaluate the body of evidence and an external panel provided critical review. MAIN RESULTS: We found 26 reviews reporting on 47 RCTs. Most pharmacological interventions had low to very low quality methodologic evidence with three exceptions. For chronic neck pain, there was evidence of: a small immediate benefit for eperison hydrochloride (moderate GRADE, 1 trial, 157 participants);no short-term pain relieving benefit for botulinum toxin-A compared to saline (strong GRADE; 5 trial meta-analysis, 258 participants) nor for subacute/chronic whiplash (moderate GRADE; 4 trial meta-analysis, 183 participants) including reduced pain, disability or global perceived effect; andno long-term benefit for medial branch block of facet joints with steroids (moderate GRADE; 1 trial, 120 participants) over placebo to reduce pain or disability; REVIEWERS' CONCLUSIONS: While in general there is a lack of evidence for most pharmacological interventions, current evidence is against botulinum toxin-A for chronic neck pain or subacute/chronic whiplash; against medial branch block with steroids for chronic facet joint pain; but in favour of the muscle relaxant eperison hydrochloride for chronic neck pain.

Botulinum toxin intramuscular injections for neck pain: a systematic review and metaanalysis.

OBJECTIVE: To assess the effect of intramuscular botulinum toxin type A (BoNT-A) injections on pain, function/disability, global perceived effect, and quality of life (QOL) in adults with neck pain (NP). METHODS: We searched Central, Medline, and Embase databases up to June 2010. A minimum of 2 authors independently selected articles, abstracted data, and assessed risk of bias and clinical applicability. We estimated standard mean differences (SMD) with 95% CI, relative risks (RR), and performed metaanalyses (SMD(p)) using a random-effects model for nonheterogeneous data. The approach of the Grading of Recommendations Assessment, Development, and Evaluation working group summarizes the quality of evidence. RESULTS: We selected 14 trials. High-quality evidence suggested BoNT-A was no better than saline at 4 weeks [4 trials/183 participants; SMD(p) -0.21 (95% CI -0.50 to 0.07)] and 6 months for chronic NP. Moderate-quality evidence showed a similar effect for subacute/chronic whiplash-associated disorder (WAD) on pain [4 trials/122 participants; SMD(p) -0.21 (95% CI -0.57 to 0.15)], disability, and QOL. Very low-quality evidence indicated BoNT-A combined with exercise and analgesics was not significant for chronic NP reduction at 4 weeks [3 trials/114 participants; SMD(p) -0.08 (95% CI -0.45 to 0.29)] but was at 6 months [2 trials/43 participants; SMD(p) -0.66 (95% CI -1.29 to -0.04)]. CONCLUSION: Current evidence does not confirm a clinically or statistically significant benefit of BoNT-A used alone on chronic NP in the short term or on subacute/chronic WAD pain, disability, and QOL. Larger trials, subgroups, and predictors of responses defined a priori (to facilitate selection of patients most likely to benefit) and factorial designs to explore BoNT as an adjunct treatment to physiotherapeutic exercise and analgesics are needed.