Botulinum toxin assessment, intervention and aftercare for paediatric and adult niche indications including pain: international consensus statement

Abstract

Evidence is emerging for the use of botulinum neurotoxin type-A (BoNT-A) for niche indications including pain independent of spasticity. Pain indications such as chronic nociceptive back pain, piriformis syndrome, chronic myofascial pain, pelvic pain, complex regional pain syndrome, facial pain and neuropathic pain are outlined in this paper. Of these, class I evidence is available for the treatment of chronic nociceptive low back pain, piriformis syndrome, myofascial pain, facial pain, neuropathic pain and plantar fasciitis. Peri-operative use of BoNT-A is emerging, with indications including planning for surgery and facilitating surgery, as well as healing and improving analgesia post-operatively. Evidence is limited, although there are some reports that clinicians are successfully using BoNT-A peri-operatively. There is class I evidence showing pre-operative use of BoNT-A has a beneficial effect on outcomes following adductor-release surgery. The use of BoNT for treatment of tremor, other than neck tremor in the setting of cervical dystonia, including evidence for upper limb tremor, cranial tremor and non-dystonic neck tremor is reviewed. The evidence is variable at this stage, and further study is required to develop definitive recommendations for the clinical utility of BoNT-A for these indications.

Effectiveness of botulinum toxin type A for pain control in children with spastic cerebral palsy

“…For this, it was necessary to initially identify the presence of pain in patients with spastic cerebral palsy before the administration of botulinum toxin type A [18][19][20] , and also one week and one month after this application 21 , all using the FLACC scale, which is an interval scale that measures pain in patients between 2 and 7 years old, quantifying it in behaviors with values ? ?from 0 (painless behaviors) to 10 (behaviors most likely related to pain); there are five categories included in the scale:…”

Dystonia, Spasticity and Botulinum Toxin Therapy: Rationale, Evidences and Clinical Context

“…These findings underscore the BoNT effects far beyond simply blocking muscle spasms in dystonia. For instance, the head posture may be related to muscle spindle changes among other factors(4) and the associated pain relief having perhaps an independent mechanism (29) . The role of BoNT-A in pain pathophysiology is beginning to be understood, however, larger studies in neuropathic pain, joint pain, and myofascial pain syndrome are needed to fully ascertain robustness of BoNT therapy in those areas(40-41).…”

“…applying TVR [28]), it is believed that the BoNT does have sensory modulatory effects, apart from pure muscle relaxation (see a recent review on the subject by Kanovsky and Rosales [26]). In addition, BoNT-A may reduce pain comorbidity that occur in dystonia (see a recent review by Rawicki and cohorts [29]). The fact that BoNT injections are able to improve an individual's occupational function and quality of life elevates the rationale for its applications.…”

Novak et al. reply

“…In response to Thomason and Graham's remarks about our potential conflict of interest, we confirm again that we did not have any conflict of interest in extracting data from secondary sources for this systematic review. In relation to the five primary sources referred to, [12][13][14][15][16] these publications included disclosure statements printed in the public domain, and we quote: 'The Cerebral Palsy Institute also gratefully acknowledges the unrestricted educational grant received from Allergan to support the project [International Consensus Statements for Botulinum Toxin]. It should be noted that no authors were provided with any funds to participate in the project .…”