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The Role of Botulinum Toxin Type A in the Clinical Management of Refractory Anterior Knee Pain.

Singer BJ, Silbert BI, Silbert PL, Singer KP - Toxins (Basel) (2015)

Bottom Line: Symptoms can recur in more than two thirds of cases, often resulting in activity limitation and reduced participation in employment and recreational pursuits.Evidence for long term benefit of most conservative treatments or surgical approaches is currently lacking.Initial data suggest that, compared with other interventions for anterior knee pain, Botulinum toxin type A injection, in combination with an active exercise programme, can lead to sustained relief of symptoms, reduced health care utilisation and increased activity participation.

View Article: PubMed Central - PubMed

Affiliation: Centre for Musculoskeletal Studies, School of Surgery M424, the University of Western, 35 Stirling Highway, Nedlands, WA 6009, Australia. barbara.singer@uwa.edu.au.

ABSTRACT
Anterior knee pain is a highly prevalent condition affecting largely young to middle aged adults. Symptoms can recur in more than two thirds of cases, often resulting in activity limitation and reduced participation in employment and recreational pursuits. Persistent anterior knee pain is difficult to treat and many individuals eventually consider a surgical intervention. Evidence for long term benefit of most conservative treatments or surgical approaches is currently lacking. Injection of Botulinum toxin type A to the distal region of vastus lateralis muscle causes a short term functional "denervation" which moderates the influence of vastus lateralis muscle on the knee extensor mechanism and increases the relative contribution of the vastus medialis muscle. Initial data suggest that, compared with other interventions for anterior knee pain, Botulinum toxin type A injection, in combination with an active exercise programme, can lead to sustained relief of symptoms, reduced health care utilisation and increased activity participation. The procedure is less invasive than surgical intervention, relatively easy to perform, and is time- and cost-effective. Further studies, including larger randomized placebo-controlled trials, are required to confirm the effectiveness of Botulinum toxin type A injection for anterior knee pain and to elaborate the possible mechanisms underpinning pain and symptom relief.

No MeSH data available.


Related in: MedlinePlus

Percentage of cases from an audit survey [46] who reported using non-steroidal anti-inflammatory drugs (NSAID) and/or physiotherapy prior to and following BoNT-A injection for AKP. In both groups, reliance upon NSAID and physiotherapy was markedly diminished following BoNT-A injection for AKP.
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toxins-07-03388-f006: Percentage of cases from an audit survey [46] who reported using non-steroidal anti-inflammatory drugs (NSAID) and/or physiotherapy prior to and following BoNT-A injection for AKP. In both groups, reliance upon NSAID and physiotherapy was markedly diminished following BoNT-A injection for AKP.

Mentions: Anterior knee pain is a common condition which primarily affects active people from adolescence to middle age, resulting in significant economic and social costs from pain and activity limitation. In this context, we do not regard injection of botulinum toxin as a “first line” of treatment for people presenting with AKP. However, for the majority of individuals who go on to have recurrent symptoms following initial conservative management [35,36], alternative effective non-surgical treatments are urgently needed to avoid chronicity of pain and activity limitation. Surgery is recognised as a last resort for highly selected cases with severe pain and disability associated with patella mal-tracking and instability [23]. Intramuscular injection of BoNT-A into the distal VL muscle produces reversible dose-related weakness, and can confer a “window of opportunity” to effect a lasting change in the balance of activation between VL and VM muscles, restoring more normal control of knee extension, and thereby contributing to long term symptom relief [43,44,45,46,47]. The audit data reported here [46] support the long term efficacy of intramuscular injection of BoNT-A (providing a mean of two years of symptom relief) to remediate chronic AKP which had been unresponsive to conservative management, even in relatively unselected cases who possibly had a range of contributing factors. In this case series, BoNT-A injection was associated with reduced reliance on pain relieving drugs and physiotherapy attendance (Figure 6), and in many cases, avoided the need for surgery [46]. To date, the only other conservative intervention for AKP to demonstrate long term efficacy is electrical muscle stimulation to the VM muscle [27]. Although BoNT-A injection is relatively costly, it can be argued that the point when the administration of other less evidence based interventions equals the cost of a single BoNT-A treatment is quickly reached, particularly as VL:VM imbalance is commonly demonstrated in this condition [9]. Therefore early consideration of BoNT-A injection in the clinical management of this condition could be considered to be a cost effective strategy to moderate the risk of progressive activity limitation and the development of secondary morbidities [5,6].


The Role of Botulinum Toxin Type A in the Clinical Management of Refractory Anterior Knee Pain.

Singer BJ, Silbert BI, Silbert PL, Singer KP - Toxins (Basel) (2015)

Percentage of cases from an audit survey [46] who reported using non-steroidal anti-inflammatory drugs (NSAID) and/or physiotherapy prior to and following BoNT-A injection for AKP. In both groups, reliance upon NSAID and physiotherapy was markedly diminished following BoNT-A injection for AKP.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4591644&req=5

toxins-07-03388-f006: Percentage of cases from an audit survey [46] who reported using non-steroidal anti-inflammatory drugs (NSAID) and/or physiotherapy prior to and following BoNT-A injection for AKP. In both groups, reliance upon NSAID and physiotherapy was markedly diminished following BoNT-A injection for AKP.
Mentions: Anterior knee pain is a common condition which primarily affects active people from adolescence to middle age, resulting in significant economic and social costs from pain and activity limitation. In this context, we do not regard injection of botulinum toxin as a “first line” of treatment for people presenting with AKP. However, for the majority of individuals who go on to have recurrent symptoms following initial conservative management [35,36], alternative effective non-surgical treatments are urgently needed to avoid chronicity of pain and activity limitation. Surgery is recognised as a last resort for highly selected cases with severe pain and disability associated with patella mal-tracking and instability [23]. Intramuscular injection of BoNT-A into the distal VL muscle produces reversible dose-related weakness, and can confer a “window of opportunity” to effect a lasting change in the balance of activation between VL and VM muscles, restoring more normal control of knee extension, and thereby contributing to long term symptom relief [43,44,45,46,47]. The audit data reported here [46] support the long term efficacy of intramuscular injection of BoNT-A (providing a mean of two years of symptom relief) to remediate chronic AKP which had been unresponsive to conservative management, even in relatively unselected cases who possibly had a range of contributing factors. In this case series, BoNT-A injection was associated with reduced reliance on pain relieving drugs and physiotherapy attendance (Figure 6), and in many cases, avoided the need for surgery [46]. To date, the only other conservative intervention for AKP to demonstrate long term efficacy is electrical muscle stimulation to the VM muscle [27]. Although BoNT-A injection is relatively costly, it can be argued that the point when the administration of other less evidence based interventions equals the cost of a single BoNT-A treatment is quickly reached, particularly as VL:VM imbalance is commonly demonstrated in this condition [9]. Therefore early consideration of BoNT-A injection in the clinical management of this condition could be considered to be a cost effective strategy to moderate the risk of progressive activity limitation and the development of secondary morbidities [5,6].

Bottom Line: Symptoms can recur in more than two thirds of cases, often resulting in activity limitation and reduced participation in employment and recreational pursuits.Evidence for long term benefit of most conservative treatments or surgical approaches is currently lacking.Initial data suggest that, compared with other interventions for anterior knee pain, Botulinum toxin type A injection, in combination with an active exercise programme, can lead to sustained relief of symptoms, reduced health care utilisation and increased activity participation.

View Article: PubMed Central - PubMed

Affiliation: Centre for Musculoskeletal Studies, School of Surgery M424, the University of Western, 35 Stirling Highway, Nedlands, WA 6009, Australia. barbara.singer@uwa.edu.au.

ABSTRACT
Anterior knee pain is a highly prevalent condition affecting largely young to middle aged adults. Symptoms can recur in more than two thirds of cases, often resulting in activity limitation and reduced participation in employment and recreational pursuits. Persistent anterior knee pain is difficult to treat and many individuals eventually consider a surgical intervention. Evidence for long term benefit of most conservative treatments or surgical approaches is currently lacking. Injection of Botulinum toxin type A to the distal region of vastus lateralis muscle causes a short term functional "denervation" which moderates the influence of vastus lateralis muscle on the knee extensor mechanism and increases the relative contribution of the vastus medialis muscle. Initial data suggest that, compared with other interventions for anterior knee pain, Botulinum toxin type A injection, in combination with an active exercise programme, can lead to sustained relief of symptoms, reduced health care utilisation and increased activity participation. The procedure is less invasive than surgical intervention, relatively easy to perform, and is time- and cost-effective. Further studies, including larger randomized placebo-controlled trials, are required to confirm the effectiveness of Botulinum toxin type A injection for anterior knee pain and to elaborate the possible mechanisms underpinning pain and symptom relief.

No MeSH data available.


Related in: MedlinePlus