Intramuscular injections of botulinum toxin for the treatment of upper back myofascial pain syndrome: A systematic review of randomized controlled trials.

BACKGROUND AND OBJECTIVE: Myofascial pain syndrome (MPS) is a chronic musculoskeletal disorder characterized by the presence of trigger points. Among the treatment options, botulinum toxin injections have been investigated. The aim of this paper was to provide a synthesis of the evidence on intramuscular botulinum toxin injections for upper back MPS. DATABASES AND DATA TREATMENT: A systematic review of the literature was performed on the PubMed, Scopus and Cochrane Library, using the following formula: ("botulinum") AND ("musculoskeletal") AND ("upper back pain") OR ("myofascial pain"). RESULTS: Ten studies involving 651 patients were included. Patients in the control groups received placebo (saline solution) injections, anaesthetic injections + dry needling or anaesthetic injections. The analysis of the trials revealed modest methodological quality: one "Good quality" study, one "Fair" and the other "Poor". No major complications or serious adverse events were reported. Results provided conflicting evidence and did not demonstrate the superiority of botulinum toxin over comparators. Most of the included trials were characterized by a small sample size, weak power analysis, different clinical scores used and non-comparable follow-up periods. Even if there is no conclusive evidence, the favourable safety profile and the positive results of some secondary endpoints suggest a potentially beneficial action in pain control and quality of life. CONCLUSION: The currently available studies show conflicting results. Their overall low methodological quality does not allow for solid evidence of superiority over other comparison treatments. Further insights are needed to properly profile patients who could benefit more from this peculiar injective approach. SIGNIFICANCE: The randomized controlled trials included in this review compared using botulinum toxin to treat upper back MPS with placebo or active treatments (e.g., dry needling or anaesthetics) showing mixed results overall. Despite the lack of clear evidence of superiority, our study suggests that the use of botulinum toxin should not be discouraged. Its safety profile and encouraging results in pain control, motor recovery and disability reduction make it an interesting treatment, particularly in the subset of patients with moderate to severe chronic pain and active trigger points. To support the safety and efficacy of botulinum toxin, further high-quality studies are needed.

Extracorporeal shock wave therapy for the treatment of osteonecrosis and bone vascular diseases: a systematic review of randomized controlled trials.

OBJECTIVE: The aim of the study is to review the available literature on the use of Extracorporeal Shock Wave Therapy (ESWT) for the treatment of osteonecrosis (ON) and bone vascular disease (BVD), to understand its therapeutic potential and compare it with other therapies. MATERIALS AND METHODS: A systematic review was performed on the PubMed, Scopus, Science Direct, and Research Gate databases with the following inclusion criteria: 1) randomized controlled trials (RCTs); 2) written in English; 3) published in indexed journals within the last 25 years (1995-2020); and 4) dealing with the use of ESWT for the treatment of BVD or ON. The risk of bias was assessed by the Cochrane Risk of Bias tool for RCTs. RESULTS: Five studies involving 199 patients in total (68 female and 131 male) were included. Patients in the control groups received different treatments, like surgery, bisphosphonates in combination with prostacyclin or ESWT, and hyperbaric oxygen therapy. Looking at the quality of the available literature, none of the studies included could be considered a "good quality" study; only one was ranked as "fair" and the remaining were marked "poor" quality studies. No major complications or serious adverse events were reported in any of the included studies. Based on the available data, ESWT can produce rapid pain relief and functional improvement. CONCLUSIONS: Overall, a substandard quality of method emerged from the analysis of the literature, with most studies flawed by relevant bias. Ultimately, ESWT has the potential to be a useful conservative treatment in bone degeneration due to vascular and tissue turnover impairment.

Evidence-based treatment choices for acute lateral ankle sprain: a comprehensive systematic review.

OBJECTIVE: Lateral ankle sprains are very common injuries that can be treated with different strategies. The aim of the present systematic review was to provide a comprehensive analysis on the treatment of acute lateral ankle sprains to clarify the possible differences in outcome between surgical and conservative management, different external supports, and different rehabilitation protocols. MATERIALS AND METHODS: A literature search on three different topics was carried out on PubMed, Scopus, and Web of Science databases on June 25th, 2021. The main objective of the literature search was to identify the randomized trials comparing: (1) surgery to conservative management, (2) different external supports, and (3) different rehabilitation protocols for the treatment of acute lateral ankle sprains. Two investigators extracted independently relevant data from each paper and assessed the quality of the trials using the Cochrane Risk of Bias Assessment. RESULTS: A total of 12 studies for the first topic, 8 for the second one and 4 for the last one were included in this review. 8 out of 12 RCTs demonstrated a superior outcome and better socio-economic impact of conservative treatment compared to surgical management. In the other two comparisons, due to the wide variety of braces used and the different rehabilitation protocols, inconclusive results were obtained. CONCLUSIONS: Conservative treatment should be the first choice for severe acute lateral ankle sprains, as it provides satisfactory functional outcomes without the risks and costs of surgery. It was not possible to identify the best external support, but a preference toward flexible braces emerged since they allow an earlier return to daily activities. The paucity of studies comparing different rehabilitation protocols precluded the possibility of defining the ideal one.

Oxygen-ozone therapy for the treatment of low back pain: a systematic review of randomized controlled trials.

OBJECTIVE: The aim of the study was to review the available literature on the application of oxygen-ozone therapy (OOT) in the treatment of low back pain (LBP), to understand its therapeutic potential and compare it with other available treatment options. MATERIALS AND METHODS: A systematic review was performed on the PubMed and Scopus databases, with the following inclusion criteria: (1) randomized controlled trials (RCTs), (2) published in the last 20 years, (3) dealing with OOT in patients with LBP and herniated disc, (4) comparing the results of OOT with those of other treatments. The risk of bias was assessed by the Cochrane Risk of Bias tool. RESULTS: Fifteen studies involving 2597 patients in total were included. Patients in the control groups received different treatments, from oral drugs to other injections, instrumental therapy and even surgery: corticosteroids were used in 5 studies, analgesic therapy in 2 studies; placebo, microdiscectomy, laser-therapy, TENS and postural rehabilitation, percutaneous radiofrequency intradiscal thermocoagulation and psoas compartmental block were tested in the other trials. Looking at the quality of the literature, none of the studies included reached "good quality" standard, 3 were ranked as "fair" and the rest were considered "poor". Comparison of OOT results with other approaches showed that, in the majority of studies, OOT was superior to the control treatment, and also when compared to microdiscectomy, ozone showed non inferiority in terms of clinical outcomes. CONCLUSIONS: The analysis of literature revealed overall poor methodologic quality, with most studies flawed by relevant bias. However, OOT has proven to be a safe treatment with beneficial effects in pain control and functional recovery at short to medium term follow-up.

Conservative management vs. surgical repair in degenerative rotator cuff tears: a systematic review and meta-analysis.

OBJECTIVE: To analyze the available evidence comparing the clinical and functional outcomes of physiotherapy vs. surgical repair in the management of degenerative rotator cuff tears (RCTs), and to perform a meta-analysis to clarify the possible superiority of one approach vs. the other. MATERIALS AND METHODS: A literature search was carried out on the PubMed, Scopus and Web of Science databases on May 30th, 2020, to identify all the randomized trials comparing surgery to conservative management of degenerative rotator cuff tears. The following data were extracted from each included study: patients' demographics, study design and level of evidence, follow-up times, treatment groups, evaluation scores adopted, overall clinical findings. The quality of the trials was assessed using the Cochrane Risk of Bias Assessment. RESULTS: A total of 7 studies, including 326 patients and dealing with conservative treatment vs. surgical repair for rotator cuff tears, were included in this study. Although surgery provided superior results both in terms of VAS (p=0.017) and Constant score (p<0.0001) compared to conservative management at 1 year follow-up, this superiority did not reach the "minimal clinical important difference". Otherwise, a few data are available about long-term outcomes, thus there is insufficient evidence about the role of surgery to prevent the progression of tendon wear. CONCLUSIONS: A proper rehabilitation program is able to provide similar results compared to surgery at a short term follow-up in degenerative RCTs. Further long term data are necessary to understand if tendon repair might have a protective role towards worsening of degeneration thus providing better clinical outcome than conservative management.