title: Treatment of refractory pain with botulinum toxins--an evidence-based review.
abstract: OBJECTIVE
  To provide updated information on the role of botulinum toxins in the treatment of refractory pain based on prospective, randomized, double-blind, placebo-controlled studies. DESIGN OF THE REVIEW: Class I and class II articles were searched online through PubMed (1966 to the end of January 2011) and OvidSP including ahead-of-print manuscripts.
  
  
  RESULTS
  Level A evidence (two or more class I studies-established efficacy): pain of cervical dystonia, chronic migraine, and chronic lateral epicondylitis. Level B evidence (one class I or two class II studies-probably effective and recommended): post-herpetic neuralgia, post-traumatic neuralgia, pain of plantar fasciitis, piriformis syndrome, and pain in total knee arthroplasty. Level C evidence (one class II study-possibly effective, may be used at discretion of clinician): allodynia of diabetic neuropathy, chronic low back pain, painful knee osteoarthritis, anterior knee pain with vastus lateralis imbalance, pelvic pain, post-operative pain in children with cerebral palsy after adductor hip release surgery, post-operative pain after mastectomy, and sphincter spasms and pain after hemorrhoidectomy. Level U evidence (efficacy not proven due to diverse class I and II results): myofascial pain syndrome and chronic daily headaches. Studies in episodic migraine and tension headaches have shown treatment failure (level A-negative).
  
  
  CONCLUSIONS
  Evidence-based data indicate that administration of botulinum toxin in several human conditions can alleviate refractory pain. The problems with some study designs and toxin dosage are critically reviewed.
authors.affiliation: Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA. bahman.jabbari@yale.edu
authors.forename: Bahman
authors.initials: B
authors.lastname: Jabbari
authors.forename: Duarte
authors.initials: D
authors.lastname: Machado
mesh_terms: D000818:Animals; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D004311:Double-Blind Method; D019317:Evidence-Based Medicine; D006801:Humans; D009465:Neuromuscular Agents / Q000627:therapeutic use*; D010148:Intractable Pain / Q000188:drug therapy*; D010149:Postoperative Pain / Q000188:drug therapy; D010919:Placebos; D011446:Prospective Studies; D016032:Randomized Controlled Trials as Topic / Q000145:classification
chemical_list: D009465:Neuromuscular Agents; D010919:Placebos; D019274:Botulinum Toxins, Type A