Botox for Neck Pain
Most people will associate botox injections with the expressionless faces of numbed, washed-out celebrities desperate to reclaim their wrinkle-free youth. But botox has also been used for a number of years in the attempt to help patients cope with the neck pain that can occur in injuries such as whiplash. How effective is this treatment, and how does it work, if at all?
Indications for Botox Use
The premise behind botox’s use for whiplash associated disorder is based on the occurrence of rapid extension and then flexion of the neck musculature during the accident which can lead to aberrant muscle spasms in the cervical spine. Using systemic drugs such as oral steroids, muscle relaxants, or NSAIDs immediately after the car accident, fall, or other trauma have potential side-effects which can limit their utilization. Other therapeutic interventions involving physical manipulation, and neck exercises can be beneficial for a limited period after injury, but physical therapies such as ultrasonography, heat, ice, and acupuncture are not associated with an improved prognosis in whiplash associated disorder. They can, of course, help with many other disorders that cause neck pain, such as arthritis or muscle strain, whilst remaining inappropriate for acute whiplash related neck pain. In using botulinum toxin-A to reduce muscle spasms, patients may suffer less neck pain after whiplash and have improved scores on the QTD-WAD.
The QTD-WAD What?
The Quebec Task Force (QTF) on Whiplash Associated Disorders (WAD) uses a five level classification system to categorize the level of disability and pain experienced by patients after such an injury and it is this scale that is often used during research, such as that into botox.
- WAD 0 - no neck complaints or physical signs
- WAD I - neck complaints but no physical signs
- WAD II - neck complaints and musculoskeletal signs, such as decreased range of motion and muscle tenderness
- WAD III - neck complaints and neurological signs
- WAD IV - neck complaints and fracture or dislocation
The most common symptoms of whiplash, after a car collision, are neck pain (80-100%) and headache (54-66%) (Norris, 1983, Stovner, 1996). Patients may also experience neck stiffness, dizziness, visual and auditory symptoms, paraesthesia, pain or numbness in the arms or shoulders, and muscle weakness or loss of fine motor control in the hands. These symptoms often mirror those present in patients with disc bulging or herniation and, indeed, these can be consequences of the accident itself. In the majority of cases people who suffer WAD recover quickly, with 47% returning to normal activities within four weeks, and just 2% prevented from enjoying their normal routine a year after the accident (Spitzer, 1995).
How Might Botox Help?
Although there remains some debate over the actual existence of WAD, with some claiming that symptoms may be a result of psychosomatic suggestion and expectation connected to litigation in many cases, there is evidence that nearly nine out of ten whiplash sufferers have some degree of muscle spasm (Wiley, 1986, Radanov, 2000). Blocking the sensory nerves that innervate (stimulate) the zygapopyseal joints was found in one study to reduce symptoms in half of those with chronic whiplash pain which suggests that the soft tissues are involved in the pathology of neck pain rather than simply the joints (Lord, 1996). The use of surface electromyography has also discovered that many patients have a decreased ability to relax the trapezius muscle after suffering a whiplash injury (Nederhand, 2000).
The question now becomes one of cause and effect; is the cervical muscular dysfunction present and causing excess loading of the zygapophysal joints, or is the muscle dysfunction an attempt to splint an injured cervical spine? If a way was found to forcibly relax the trapezius muscle then, so some thinking goes, the patient would have a substantial amount of their pain reduced, enhancing the recovery of the soft tissues. Could this, however, actually lead to more damage to the cervical spine? In the absence of diagnostic imaging data indicating structural problems with the cervical spine after whiplash, perhaps botox provides a way to relax the muscles and allow healing of the soft tissues to begin. If joint injury, fracture, disc bulging, or disc herniation are present then botox may be contraindicated with other treatments warranted instead. A fuller understanding of the mechanism at work in WAD and the biological effects of botox may lead to this treatment becoming either completely discredited, or part of mainstream therapeutic intervention.
How Does Botox Work?
The mechanism behind the effects of botox is still to be fully established, but it appears to be connected to the toxin blocking the release of acetylcholine at the synapses. However, the neurotoxin only exerts its effects on the motonerve endings and not the sensory nerve fibers. This means that any analgesic effect, rather than simply being a result of blocked pain signals, is due to muscle paralysis, the improvement in blood flow, and decompression of fibers which were previously compressed by stiff and inflamed muscles. Studies into the use of botox have used injections totalling between 100-250 units of BTX-A, with injections distributed across five or so specific sites including the trapezius, the splenius capitus, rectus capitus, and semispinalis capitus. These are often the most tender points in the cervical musculature in whiplash sufferers.
A study by Freund in 2000 found that at two week and four week follow-ups there were significant improvements in subjective pain and function, and objective range of motion in the neck. A 2003 study by Juan reported that 77.4% of the 31 participants with WAD III showed improvement in range of motion at eight weeks after botox injections of 50-75 units. Unfortunately these trials, and many of the other studies into botox, are small in scope and relatively short making it hard to establish a clear benefit from botox for whiplash. A Cochrane review in 2007 determined that botox treatment for neck pain was not supported by sufficient evidence, although this review did not differentiate acute whiplash cases from chronic cervical musculoskeletal pain.
Is Botox Treatment Safe?
The biological effects of botox are not permanent, making it an attractive alternative to surgery. The inhibiting effects on neuromuscular signalling (through acetylcholine release) last between three and six months, with signalling then returning to normal. Some patients find the injection of botox a painful experience and those who are hypersensitive to any of the ingredients, or have an infection present should not have the treatment. Anyone with a concurrent motor neuropathic disease or dysfunction should discuss the treatment fully with their doctor as they may not be a suitable candidate for botox. Aminoglycoside medications can also interfere with the treatment, and some patients may actually form antibodies to the BTX-A making it less effective if repeated. It is important to remember that botox is a toxin and it can have serious adverse effects if used incorrectly. Botox injections require the correct dilution to be used, and the material to be prepared in a safe and controlled fashion prior to injection. Only licensed medical professionals are allowed to conduct botox injections, and patients should ensure their physician’s credentials prior to undergoing any treatment.
Botox treatment has not been approved for whiplash associated disorder by the FDA, but is considered safe for those with cervical dystonia to help correct abnormal head position that can cause neck pain. Botox use in other musculoskeletal conditions show similar benefits to those found in whiplash, but have not been officially approved in most cases. Conditions include myofascial pain syndrome and chronic low back pain. Use of botox in other conditions, such as TMJ disorder, migraine, and tension headaches is not, as yet, substantiated by scientific evidence, although research continues. Trials continue into botox treatment of whiplash associated disorder, in the meantime patients may consider talking to their physician about the therapy and possibly enrolling in one of these studies themselves. The Cochrane review (2007) suggested that the most effective treatment currently known for whiplash was the administration of methylprednisone through injection within eight hours of the trauma occurring. In the absence of access to such treatment, botox may provide an alternative method of coping with the neck pain that can result from whiplash.
Last Updated: 11/20/2010