Takaisin

Effectiveness of botulinum toxin injection in chronic lateral tendinopathy

Näytönastekatsaukset
Marja Mikkelsson
22.6.2022

Level of evidence: B

Botulinum toxin injection seems to be more effective in reducing pain for patients with lateral tendinopathy (symptoms at least for 3 months) up to 4 months compared with saline injection. Botulinum toxin injection reduces grip strength temporarily.

Botulinum toxin injection reduces pain at 2–4, 8–12, and ≥ 16 week follow-ups compared with saline injection (standardized mean differences (SMD) -0.729, -0.446, and -0.543, respectively). A short-term (2–4 or 8–12 week) reduction of grip strength is possible compared with saline.

The results were based on 4 RCTs

Table 1. Description of the included studies
Reference Study type Population Intervention and comparison Outcomes Risk of bias
«Lin YC, Wu WT, Hsu YC ym. Comparative effectivenes...»1 MA of RCTs
321 Adult patients from 6 RCTs up to 2/2017 with symptoms of epicondylitis more than 3 months, pain in palpation and resisted wrist dorsiflexion. Case studies or -series, and single arm studies without comparison group were excluded. Botulinum toxin injection 20–60 IU (Botox 20–50 IU in 3 studies, Dysport 60 IU in 3 studies) compared with placebo (saline) (4 studies) or corticosteroid injection (2 studies, (triamcinolone acetonide 40 mg) Primary outcome: Reduction of pain (VAS) measured before and 2–4 week, and 8–12 weeks, and > 16 weeks after the treatment

Secondary outcome: Grip strength
Moderate
«Creuzé A, Petit H, de Sèze M. Short-Term Effect of...»2 RCT 60 consecutive adult patients from one center with lateral epicondylar tendinopathy resistant to treatment for > 6 months. 29 patients in the Botulinum toxin A group and 28 patients in the placebo group 40 IU Botulinum toxin A from a 500 IU flask diluted in 5 ml of saline; Placebo 0.4 ml saline. Injected intramuscularly to extensor carpi radialis brevis muscle aided by EMG stimulation Pain reduction (VAS).
Secondary outcomes: Pain continuity (occasional, regular, constant), grip strength, impact of pain on quality of life (VAS), number of patients on sick leave, number of patients requesting additional therapies at day 90.
Low

RCT=randomized controlled trial; SR=systematic review; MA=meta-analysis

Table 2. Additional comments for included studies
Reference Comments
«Lin YC, Wu WT, Hsu YC ym. Comparative effectivenes...»1 4 studies were two-armed RCTs compared with botulinum toxin with saline injections, one two-armed study compared botulinum with corticosteroid injection. Possible risk of bias due randomization (allocation concealment and random sequence generation). Heterogeneity was not reported.
«Creuzé A, Petit H, de Sèze M. Short-Term Effect of...»2 Of the 60 patients, 33 were male and 27 female; mean age, 47.0 ± 7 years. The mean duration of chronic symptoms of lateral epicondylar tendinopathy was 18.7 ± 20 months, and the mean initial VAS score for pain was 56.1 ± 19 mm. The average impact on the patient's quality of life was assessed as 50.8 ± 18 mm on the VAS.

Results

Table 3. Outcome 1: PAIN (VAS)
Reference Number of studies and number of patients (I/C) Follow-up time Standardized mean difference (95% CI) *Number of patients (%) with
a > 50% reduction in
initial pain intensity (95% CI) I/C
Level of evidence: moderate
The level of evidence is downgraded due to imprecision and inconsistency.
Botulinum toxin vs placebo
«Lin YC, Wu WT, Hsu YC ym. Comparative effectivenes...»1 3 RCTs Botulinum toxin vs placebo: 122/116 2–4 weeks -0.729 (-1.286, -0.171)
«Creuzé A, Petit H, de Sèze M. Short-Term Effect of...»2 29/30 30 days *9 (31%) (15% to 51%) / 5 (16,7%) (6% to 35%)
«Lin YC, Wu WT, Hsu YC ym. Comparative effectivenes...»1 4 RCTs Botulinum toxin vs placebo: 143/135 8–12 weeks -0.446 (-0.740, -0.152)
«Creuzé A, Petit H, de Sèze M. Short-Term Effect of...»2 29/28 90 days *15 (51,7%) (33% to 71%) / 7 (25%) (10% to 44%),
«Lin YC, Wu WT, Hsu YC ym. Comparative effectivenes...»1 2 RCTs Botulinum toxin vs placebo: 92/86 16 weeks or more -0.543 (-0.978. -0.107)

I= intervention; C=comparison; CI=confidence interval

Table 4. Outcome 2: Grip strength decrease
Reference Number of studies and number of patients (I/C) Follow-up time Standardized mean difference (95% CI)
Level of evidence: moderate.
In the short-term RCT «Creuzé A, Petit H, de Sèze M. Short-Term Effect of...»2, the change of grip strength was not properly analysed.
«Lin YC, Wu WT, Hsu YC ym. Comparative effectivenes...»1

3 RCTs Botulinum toxin vs placebo: 122/116 2–4 weeks -0.334 (-0.591, -0.078)
4 RCTs Botulinum toxin vs placebo: 143/135 8–12 weeks -0.057 (-0.517, 0.403)
2 RCTs Botulinum toxin vs placebo: 92/86 16 weeks or more 0.084 (-0.211, 0.378)
Grip strength (N) (I/C, p-value)
«Creuzé A, Petit H, de Sèze M. Short-Term Effect of...»2

30/30 0 days 36.5 ± 19 / 30.2 ± 12, p=0.139
29/30 30 days 32.4 ± 19.0/30.3 ± 11.0, p=0.081
29/28 90 days 34.3 ± 16/34.2 ± 19, p=0.491

I= intervention; C=comparison; CI=confidence interval

References

  1. Lin YC, Wu WT, Hsu YC ym. Comparative effectiveness of botulinum toxin versus non-surgical treatments for treating lateral epicondylitis: a systematic review and meta-analysis. Clin Rehabil 2018;32:131-145 «PMID: 28349703»PubMed
  2. Creuzé A, Petit H, de Sèze M. Short-Term Effect of Low-Dose, Electromyography-Guided Botulinum Toxin A Injection in the Treatment of Chronic Lateral Epicondylar Tendinopathy: A Randomized, Double-Blinded Study. J Bone Joint Surg Am 2018;100:818-826 «PMID: 29762276»PubMed