title: Comparative effectiveness of botulinum toxin versus non-surgical treatments for treating lateral epicondylitis: a systematic review and meta-analysis.
abstract: OBJECTIVE
  To explore the effectiveness of botulinum toxin compared with non-surgical treatments in patients with lateral epicondylitis.
  
  
  METHODS
  Data sources including PubMed, Scopus, Embase and Airity Library from the earliest record to February 2017 were searched. Study design, patients' characteristics, dosage/brand of botulinum toxin, injection techniques, and measurements of pain and hand grip strength were retrieved. The standardized mean differences (SMDs) in pain relief and grip strength reduction were calculated at the following time points: 2-4, 8-12, and 16 weeks or more after injection.
  
  
  RESULTS
  Six randomized controlled trials (321 participants) comparing botulinum toxin with placebo or corticosteroid injections were included. Compared with placebo, botulinum toxin injection significantly reduced pain at all three time points (SMD, -0.729, 95% confidence interval [CI], -1.286 to -0.171; SMD, -0.446, 95% CI, -0.740 to -0.152; SMD, -0.543, 95% CI, -0.978 to -0.107, respectively). Botulinum toxin was less effective than corticosteroid at 2-4 weeks (SMD, 1.153; 95% CI, 0.568-1.737) and both treatments appeared similar in efficacy after 8 weeks. Different injection sites and dosage/brand did not affect effectiveness. Botulinum toxin decreased grip strength 2-4 weeks after injection, and high equivalent dose could extend its paralytic effects to 8-12 weeks.
  
  
  CONCLUSIONS
  When treating lateral epicondylitis, botulinum toxin was superior to placebo and could last for 16 weeks. Corticosteroid and botulinum toxin injections were largely equivalent, except the corticosteroid injections were better at pain relief in the early stages and were associated with less weakness in grip in the first 12 weeks.
authors.affiliation: 1 Department of Physical Medicine and Rehabilitation, College of Medicine, National Cheng Kung University, Tainan, Taiwan.|2 Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
authors.forename: Yu-Ching
authors.initials: YC
authors.lastname: Lin
authors.affiliation: 3 Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan.|4 Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch, Taipei, UK.
authors.forename: Wei-Ting
authors.initials: WT
authors.lastname: Wu
authors.affiliation: 5 Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan.
authors.forename: Yu-Chun
authors.initials: YC
authors.lastname: Hsu
authors.affiliation: 3 Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan.|4 Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch, Taipei, UK.|6 Department of Physical Medicine and Rehabilitation, National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: Der-Sheng
authors.initials: DS
authors.lastname: Han
authors.affiliation: 3 Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan.|4 Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch, Taipei, UK.|6 Department of Physical Medicine and Rehabilitation, National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: Ke-Vin
authors.initials: KV
authors.lastname: Chang
mesh_terms: D019274:Botulinum Toxins, Type A / Q000008:administration & dosage*; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D005260:Female; D018737:Hand Strength; D006801:Humans; D015552:Injections, Intralesional; D008297:Male; D010147:Pain Measurement; D016032:Randomized Controlled Trials as Topic; D016059:Range of Motion, Articular / Q000187:drug effects* / Q000502:physiology; D012720:Severity of Illness Index; D013624:Taiwan; D013716:Tennis Elbow / Q000175:diagnosis / Q000188:drug therapy* / Q000534:rehabilitation; D016896:Treatment Outcome
chemical_list: D019274:Botulinum Toxins, Type A
keywords: Pain; botulinum toxin; elbow; lateral epicondylitis; rehabilitation