New Arthritis Pain Option – Botox It

For some years, they were finding Botox into ankle, shoulder and hip joints was giving pain relief. Now injecting Botox 25 u into a thumb Metacarpal-phalangeal and 50 – 100 units into cervical facet joints gives a similar result.

Joint Bone Spine. 2008 Oct 24. [Epub ahead of print] Intra-articular botulinum toxin A as an adjunctive therapy for refractory joint pain in patients with rheumatoid arthritis receiving biologics: A report of two cases. Singh JA, Mahowald ML abstract

• ankle (100 unit)
• first metatarsophalangeal joint (25 unit),
• “pain and function improved significantly (>/=40%) in both patients. Durable response with improvement of pain and function lasting 15-18 months was noted”

Case series have been published in past:

Novel therapeutic agentsIntra-articular botulinum toxin type A for chronic shoulder pain in the elderly . The Journal of Pain , Volume 5 , Issue 3 , Page S62J . Singh

816) Intra-articular Botulinum Toxin Type A for chronic shoulder pain in the elderly
J. Singh, M. Mahowald, D. Dykstra; Minneapolis VA Medical Center/Univ of
Minnesota, Minneapolis, MN
The purpose was to report the off-label use of botulinum toxin type A (BoNT/A) as an intra-articular (IA) treatment for refractory shoulder joint pain in frail elderly patients. We conducted a retrospective record review of 9 IA shoulder injections of 50-100 units of intra-articular BoNT/A (Allergan BOTOX) in 6 frail elderly patients (mean age 75 +/- 7.6yr). Change in pain severity was measured on a 0-10 scale and function
measured by upper extremity active flexion and abduction. Comparisons were made by using paired t tests. The time to onset of pain relief was 5.6 +/- 3d, Pain severity decreased significantly from 8.2 +/- 1.1 (0to10 scale) to 2.4 +/- 1.9 (p<.001), a 71% maximum pain reduction between 1-6 weeks after injection. Pain reduction of =50% was seen in 7/9, and =33.3% in all injected joints. Pain relief has lasted 6-11 weeks and 2 patients requested re-injection at week 12. Concomitant with the decrease in shoulder pain, there was an nexpectedl 67% improvement in degrees of active flexion from 68 +/- 28 to 113 +/- 47(p<.001) and a 42% increase in abduction from 50 +/- 19 to 71 +/- 23 (p<.01). Importantly, IABoNT/ A was safe – no patient had increased joint swelling or pain, no new muscle weakness developed and there were no systemic effects of fever or fatigue. This is the first report of intra-articular injection of botulinum toxin A for severe chronic shoulder pain, a common and disabling problem in the elderly. BoNT/A decreased pain and improved range of motion without any deleterious side effects. Durability of effects remains to be determined in a prospective randomized trial that is warranted by the findings in this pilot study.

A conference report elaborates it more here :

Intra-articular botulinum A toxin injections decrease refractory joint pain
Denise Mann; American College of Rheumatology 2004 meeting; Oct 26, 2004

• 7 frail elderly patients with refractory shoulder pain (9 joints) with 50 – 100 u Botox

• 5 patients with knee or ankle pain (3 joints each) with 25 – 50 u Botox

• included 5 rheumatoid arthritis (RA) patients, 1 psoriatic arthritis patient, and 5 osteoarthritis (OA) patients.

• 14 of 15 joints injected achieved a 30% reduction in pain and 10 of 15 joints had a 50% or greater pain reduction

They did conclude by saying they would continue their studies with 100 units in shoulders AND knees

Another study included injections into cervical facet joints:

The effects of intra-articular botulinum toxin on sacroiliac, cervical/lumbar facet and sterno-clavicular joint pain and C-2 root and lumbar disc pain: a case series of 11 patients
Authors: Dykstra, Dennis D.; Stuckey, Mark W.; Schimpff, Scott N.; Singh, Jasvinder A.; Mahowald, Maren L.
The Pain Clinic, Volume 19, Number 1, 2007 , pp. 27-32(6) abstract
article here

Cervical facet:

• 25 – 50 units Botox in 0.5 mls saline – dropped pain from 6/10 to 0-3/10 – about 1/3 the pain (but just 2 cases)

Sacroiliac:

• 50 – 100 u in 2 mls normal saline Results (before to after)

This represents about a 50% improvement

There was only one lumbar and it did not appear to work.

Comment – I find this new option exciting. Botulinum (Botox) offers great possibilities for treatment of refractory joint arthritis – shoulder, hip, knee, thumb, sacroiliac and neck facet can be reduced by 50% for up to 3 months.Most major joints seem to need 100 unit though thumb could use 25 u. This confirms my impression that arthritis is neurologically driven – ie irritated nerves are players in arthritis. Botox into neck facet joints without local could be done as an outpatient which could greatly improve availability. Thumb joints could be settled some without leeches (see blognote here ). Hips and ankles could be done without fear of steroid degenerative effects (though questioned here). Only thing is, make sure you circle 10-12 weeks on your calendar because that’s when it wears off – so you have to make plans at 10 weeks or less to redo it.

100 u botox is $400.00 Canadian and it will not be covered by insurers as this is still experimental.

Any comments?