Effectiveness of different doses of botulinum neurotoxin in lateral epicondylalgia: A network meta-analysis

Background: Previous studies have investigated the role of botulinum neurotoxin (BoNT) in lateral epicondy-lalgia, with controversial results. We hypothesized that BoNT would be effective and safe for the treatment of lateral epicondylalgia. Objective: To investigate the effectiveness and safety of different doses of BoNT in participants with lateral epicondylalgia.Methods: PubMed, Embase, and Cochrane Library were searched up to August 27, 2022, for randomized controlled trials (RCTs) of BoNT treatment for epicondylalgia. The Cochrane risk of bias tool was used for quality assessment. A network meta-analysis and a trial sequential analysis (TSA) were conducted on pain, grip strength and adverse events. Meta-regression was applied for high heterogeneity comparisons.Results: We included 8 RCTs consisting of 448 participants. Four studies scored low risk of bias in all catego-ries, whereas the other 4 studies had unclear risk only in the selection bias category. The network meta-anal-ysis and TSA revealed that corticosteroid (standardized mean difference [SMD]:-1.32, 95% CI:-2.13; -0.50), high-dose BoNT (SMD-1.32,-2.04;-0.61), and low-dose BoNT (SMD -0.52,-0.93;-0.10), relieved pain significantly better than placebo for up to 7 to 10 weeks. High-dose BoNT demonstrated a significantly greater reduction in pain than low-dose BoNT for up to 7 to 10 weeks (SMD-0.81, -1.39;-0.22). Finally, after low-dose BoNT, younger participants (p = 0.023) and women (p = 0.012) showed more pain decrease than older individuals and men at 2 to 6 weeks. As for grip strength and adverse events, only grip strength after low-dose BoNT versus placebo (SMD-0.49,-0.88;-0.10) and corticosteroid (SMD-1.36,-2.15; -0.57) at 2 to 6 weeks reached significance after threshold adjustment in TSA.Conclusions: Our meta-analysis confirmed the effectiveness of low-dose BoNT in the reduction of pain for lat-eral epicondylalgia. Further conclusions cannot be drawn due to insufficient available data.(c) 2022 Elsevier Masson SAS. All rights reserved.

Automated summary

This study aimed to investigate the effectiveness and safety of botulinum neurotoxin (BoNT) in patients with lateral epicondylalgia. The results showed that corticosteroid, high-dose BoNT, and low-dose BoNT had significant advantages in relieving pain compared to placebo, with high-dose BoNT being more effective than low-dose BoNT. However, due to insufficient data, further conclusions cannot be drawn.