Botulinum Toxin

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Category: Medical Options

Injury Type: Acute

What is it?

Botulinum toxin is a neurotoxin protein which is produced by the bacterium Clostridium Botulinum. It is one the most poisonous naturally occurring substances in the world and is considered to be the most toxic protein. Although this is a highly toxic substance, it is used to treat muscle spasms and for cosmetic reasons. It is commonly referred to as Botox and Dysport in the cosmetic industry.

How does it work?

Botulinum toxin is used to treat a variety of neurological disorders which are caused by pathological increases in muscle tone. When injected in minute quantities into the overactive muscles, Botulinum toxin type A decreases muscle activity by blocking the release of acetylcholine (a neurotransmitter) from the nerve which normally signals the muscle to contract. This ensures that the muscle is unable to contract for a period of up to six months.

Is it effective?

A recent systematic review and meta-analysis analyzed the effect of intramuscular Botulinum toxin injections in adults with sub-acute and chronic WAD. This review found moderate evidence that Botulinum toxin injections were no more effective than saline injections in terms of pain, disability and quality of life.

A high quality study undertaken in The Netherlands investigated the effectiveness of Botulinum toxin compared to saline solution injections for patients suffering from chronic whiplash. The findings indicated that there was no difference between Botulinum toxin and saline solution for pain, range of movement and number of pain tablets taken. This was the case for both short term and long term outcomes.

Some studies have shown that Botulinum toxin might be successful in treating chronic neck pain after whiplash. However, these studies were limited by small sample sizes and lack of long-term follow up. A recent systematic review and meta-analysis concur with the above findings. This review did find a small analgaesic effect associated with Botox A, however the authors recommend collecting more evidence before definitive conclusions can be drawn.

Are there any disadvantages?

There can be potential side effects as a result of Botulinum toxin injections. This could be in the form of paralysis of the wrong muscle group leading to loss of muscle function and allergic reaction. It has also been noted that bruising at the site of injection can occur if inappropriately administered.

Where do you get it?

Botulinum toxin for whiplash patients can only be administered by registered health professional, most likely a medical specialist (i.e. Neurologist). As this is an emerging area of intervention, it may not be widely available.

Recommendations

Based on current evidence, Botulinum toxin cannot be recommended as routine treatment for patients with acute or chronic whiplash who are suffering from neck pain and other associated symptoms. While it may be useful in some instances, more research is required to establish this practice as one which produces consistent and sustainable positive outcomes.

Key References

  • Braker, C, Yariv, S, Adler, R, Badarney, S & Eisenburg, E 2008, 'The analgesic effect of botulinum-toxin A on post whiplash neck pain', The Clinical Journal of Pain, vol. 24, pp. 5-10.
  • Carroll, A, Barnes, M & Comiskey, C 2008, 'A prospective randomised controlled study of the role of botulinum toxin in whiplash-associated disorder', Clinical Rehabilitation, vol. 22, no. 6, pp. 513-519.
  • Freund, B & Schwartz, M 2000, 'Treatment of Whiplash Associated with Neck Pain with Botulinum Toxin-A: A Pilot Study', The Journal of Rheumatology, vol. 27, no. 2, pp. 481-484.
  • Freund, B & Schwartz, M 2002, 'Use of Botulinum Toxin in Chronic Whiplash-Associated Disorder', The Clinical Journal of Pain, vol. 18, pp. S163-S168.
  • Freund, B & Schwartz, M 2004, 'Whiplash Associated Disorders: A Review of Recent Advances in Treatment', Journal of Whiplash & Related Disorders, vol. 3, no. 1, pp. 49-58.
  • Freund, B & Schwartz, M 2006, 'The Role of Botulinum Toxin in Whiplash Injuries', Current Pain and Headache Reports, vol.10, no.5, pp. 355-359.
  • Hurwitz, E, Carragee, E, Van der Velde, G, Carroll, L Nordin, M, Guzman, J, Peloso, P, Holm, L, Coˆte, P, Hogg-Johnson, S, Cassidy, D, & Haldeman, S 2008, 'Treatment of neck pain: noninvasive interventions, results of the bone and joint decade 2000–2010 task force on neck pain and its associated disorders', European Spine Journal, vol. 17, no 1, pp. 123-152.
  • Juan, FJ 2003, 'Treatment of neck pain after whiplash injuries with Botulinum toxin-A injections', Journal of Musculoskeletal Research, vol.7, no. 3&4, pp.221-226.
  • Langevin, P, Lowcock, J, Weber, J, Nolan, M, Gross, A, R, Peloso, P, M, Roberts, J, Graham, N, Goldsmith, C, Burnie, S, J & Haines, T 2010, 'Botulinum toxin intramuscular injections for neck pain: a systematic review and meta-analysis', The Journal of Rheumatology, published online, Dec 2010
  • Padberg, M, de Bruijn, SFTM & Tavy, DLJ 2007, 'Neck pain in chronic whiplash syndrome treated with Botulinum toxin. A double blind, placebo-controlled clinical trial', Journal of Neurology, vol. 254, pp. 290-295.
  • Pelso, P, Gross, A, Haines, T, Trinh, K, Goldsmith, CH, Burnie, S, Cervical Overview Group 2007, 'Medicinal and injection therapies for mechanical neck disorders', Cochrane Database of Systematic Reviews, Issue 3, Art.No.: CD000319. DOI:10.1002/14651858. CD000319.pub4.
  • Suijlekom, HV, Mekhail, N, Patel, N, Zundert, JV, Kleef, MV & Patijn, J 2010, 'Whiplash- associated disorders', Pain Practice, vol. 10, no. 2, pp. 131–136.
  • Zhang, T, Adatia, A, Zarin, W, Moitri, M, Vijenthria, A, Chu, R, Thabane, L & Kean, W 2011, 'The efficacy of botulinum toxin type A in managing chronic musculoskeletal pain: a systematic review and meta-analysis', Inflammopharmacology, vol. 19, pp. 21-34.
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