The evidence for noncosmetic uses of botulinum toxin
Botulinum toxin has been studied for a variety of uses beyond the cosmetic. Here’s what you need to know about which uses are worth considering for your patient.
PRACTICE RECOMMENDATIONS
› Do not use botulinum toxin for episodic migraine, tension headache, or cluster headaches. B
› Consider off-label use of botulinum toxin for select patients with occipital and trigeminal neuralgia, gastroparesis, vaginismus, benign prostatic hypertrophy, neonatal brachial plexus palsy, post-stroke spasticity, and hemifacial spasm. B
› Consider the use of botulinum toxin as an adjunct in chronic low back pain management. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Chronic low back pain (CLBP) is defined as back pain persisting ≥ 12 weeks. More than 80% of adults have had at least 1 episode of back pain in their lifetime.
Myofascial pain syndrome (MPS) consists of myofascial trigger points (palpable, tender nodules that produce pain) with multiple pathophysiological etiologies that include dysfunctional acetylcholine activity, which releases nociceptive neurotransmitters. Studies have yielded inconsistent effects of BoNT-A on MPS.18
Spastic disorders
Cerebral palsy (CP) involves altered muscle tone, posture, and movement secondary to central motor dysfunction with spasticity. Evaluation of BoNT-A as an adjunctive therapy in CP has been extensive and conflicting. A prospective cohort study evaluating gastrocsoleus BoNT-A injections along with gait analysis in 37 children with CP showed no significant improvements.30 In 60 children with CP who received BoNT-A injections, there was improvement in muscle tone and range of motion, while gait improved in patients up to (but not after) age 7 years.19 A multicenter Dutch study of 65 children compared BoNT-A injections in addition to a comprehensive rehabilitation program vs rehabilitation alone, with no difference identified.20
Neonatal brachial plexus palsy (NBPP) is damage to the brachial plexus as a result of trauma during the perinatal period. It is typically self-resolving but can cause residual functional impairment. Surgery is recommended for serious injuries or if functional recovery is not achieved within 9 months. Off-label use of BoNT-A has been shown to be effective in relieving muscle contractures and imbalance, but data are limited and there have only been small studies performed.21 A retrospective cohort study of 59 patients with NBPP who received BoNT-A injections showed improved range of motion and function of the affected extremity. Moreover, surgical intervention was deferred, modified, or averted in patients who were under consideration for more invasive treatment.21
Post-stroke spasticity can be temporarily relieved with the use of BoNT-A injections. Several studies have examined the effect of BoNT-A coupled with rehabilitation programs vs injections alone in the treatment of post-stroke spasticity. Devier et al found that improvements in spasticity scores did not differ between groups; however, implementing rehabilitation after BoNT-A injections was associated with improved function compared to injection alone.31 A 2018 randomized, double-blind, placebo-controlled trial demonstrated improvements in both treatment groups: those who received BoNT-A plus targeted rehab regimen and those who received saline injection plus rehab.22 In this case, it appears BoNT-A acts as more of an adjunct to physical therapy in the treatment of post-stroke spasticity.5
Continue to: Hemifacial spasm
