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Botulinum toxin in painful diseases
  1. N Hyman

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    Edited by W H Jost. Published by Karger, Basel, 2003, pp 168, €128.50. ISBN 3-8055-7500-9

    It is not surprising that botulinum toxin is now an increasingly popular treatment for pain disorders including tension headache, migraine, and myofascial pain syndromes. These conditions may not be associated with muscle tension or in any event with increased EMG activity. Furthermore, many trials to date suffer from not being randomised placebo controlled studies, patient numbers are often small, and follow up is brief. It is against this background that this new book should be read with caution. The authors from various German centres offer possible explanations why botulinum toxin may work in the absence of strikingly high abnormal muscle tone. Stimulation of substance P and enkephalin and a discrete anit-inflammatory effect have been mooted. Irrespective of the theoretical difficulties, the relative sparcity of convincing control trials results in difficulties in balance within the chapters. For example, the section on tension headache includes 12 pages on classification and conventional therapy and only 4 pages directly discussing botulinum toxin therapy. The chapter on low back pain is even more unbalanced—8 pages on background and then the statement “considering the scarce data, we must refrain from recommending BTX injections in low back pain for the time being”. The chapters concerning pain relief in cervical dystonia and spasticity are well done but these conclusions are already widely known and covered in other texts. The chapter on piriformis syndrome is an excellent review of this interesting condition, irrespective of whether botulinum toxin works or not.

    For those interested in an overview of pain management with botulinum toxin my recommendation would be to read the chapter by Nurmikko in the excellent second edition of Handbook of botulinum toxin treatment.

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