The efficacy of botulinum toxin in treating musculoskeletal back pain and dysfunction

Title: The efficacy of botulinum toxin in treating musculoskeletal back pain and dysfunction. Clinical Bottom Line: At this point there is still limited research on the efficacy of botulinum toxin (BTX) for back pain. Our research found 2 articles examining generalized low back pain which provided convincing evidence for the efficacy of botulinum toxin type A (BTX-A) in reducing pain and disability. In other subgroups of low back pain, the evidence in support of BTX effectiveness was less substantial. There were 2 articles that provided little evidence for the efficacy of BTX-A for myofascial pain syndrome, and there were 4 articles that provided moderate evidence for either BTX-A or BTX-B in treating piriformis syndrome. Of these, two articles show compounding effects of combining BTX injections with physical therapy intervention. Lastly, two articles were examined that showed little evidence for the efficacy of BTX-A in treating patients with chronic neck pain. Overall it appeared that there is potential for BTX to be beneficial to patients with chronic back pain in decreasing pain, especially for those who do not respond to more conservative approaches. We would like to see more long term follow up studies to determine if the decreases in pain and disability are continued after the effects of BTX have elapsed. Additionally, we would like to see more studies that examine if physical therapy, in conjunction with BTX injections, prolongs or enhances the treatment effect. Clinical Scenario: A patient with chronic LBP due to several MVAs approached us in the clinic and asked about the effectiveness of botulinum toxin to relieve his back pain. The patient has had extensive imagining done, and he has had disk herniation and nerve root impingement ruled out. This patient has been through several attempts at physical therapy, cortisone injections into multiple facet joints, and trigger point injections with lidocaine into the paraspinal musculature, all without relief. The patient’s physiatrist has now recommended that he undergo a botulinum toxin injection to relieve tight back musculature and decrease pain. Our clinically answerable question: Population: The population that we are focusing on is patients with musculoskeletal pain attributed to: low back pain, piriformis syndrome, myofascial pain or chronic neck pain. Intervention: We wish to determine the efficacy of botulinum toxin for musculoskeletal pain in the back. Comparison: Our comparison group is a control group who will receive saline injections or steroid injections. Outcome: We wish to measure outcomes by decreased score on the Visual Analogue Scale (VAS) and/or increased scores on functional outcome measures