Botulinum toxin type A for refractory post-stroke shoulder pain

Abstract

-Botulinum toxin type A (BTX-A) has been used to treat several neurological conditions such as sialorrhea, hyperhydrosis, dystonia, hemifacial spasm, spasticity and pain. Although spasticity has been successfully treated with BTX-A, few are the authors studying the use of BTX-A to treat shoulder pain secondary to stroke. In order to study if BTX-A is effective to treat post-stroke shoulder pain, we followed up during 4 months 16 patients with sustained shoulder pain. Patients received BTX-A according to previous discussion with the rehabilitation group to determine the muscles and dose to be injected and were evaluated by the join range of motion and analogic pain scale. There was decrease of pain during shoulder motion, mainly during the movements of extension and rotation. We conclude that BTX-A is a safe and efficacious therapy.

Spasticity after stroke: Physiology, assessment and treatment

“…Moreover, Simpson et al [115] showed that BoNT-A is safer and more effective than Tizanidine, reporting a higher reduction of muscle tone in the upper limbs and lower incidence of side-effects. Aside from acting on the tonus and increasing the efficiency of physiotherapy techniques, this injection can also have an analgesic effect [116]. Only Botox (onabotulinumtoxin A) is approved by the United States' Food and Drug Administration (FDA) for the treatment of upper limb spasticity in adults at the elbow (biceps), wrist (flexor carpi ulnaris and radialis) and fingers (flexor digitorum profundus and flexor digitorum sublimis [118] and no study on its efficiency for the lower limbs has been done yet.…”

Botulinum toxin A injection in the management of shoulder muscle overactivity: A scoping review

“…None of the 15 studies provided adequate data to determine whether the symptom being assessed was likely to respond to BTX-A. For example, only seven studies explicitly excluded ABI patients with fixed joint position or contracture (Bakheit et al, 2004;Lam et al, 2012;Marciniak et al, 2012;Pedreira et al, 2008;Rousseaux et al, 2002;Slawek et al, 2005;Yelnik et al, 2007), despite 'rigid affected joints [being] unlikely to respond to BTX-A injection' (Lam et al, 2012, p.478).…”

“…Most studies (n = 10) used a visual analogue or a numerical rating scale (Ashford & Turner-Stokes, 2009;Bakheit et al, 2004;Bhakta et al, 1996;Choi et al, 2016;de Boer et al, 2008;Kong et al, 2007;Lim et al, 2008;Marco et al, 2007;Pedreira et al, 2008;Yelnik et al, 2007), with the remainder using subscales of other published tests (Lam et al, 2012;Marciniak et al, 2012). Beyond identifying the measure used, six studies reported that the pain was suggestive of spasticity-associated pain (Choi et al, 2016;Kong et al, 2007;Lim et al, 2008;Marciniak et al, 2012;Marco et al, 2007;Pedreira et al, 2008). Shoulder internal rotators or adductors were targeted in these six studies, with or without injection of other UL muscles, with pectoralis major the most frequently injected muscle (5/6) (Kong et al, 2007;Lim et al, 2008;Marciniak et al, 2012;Marco et al, 2007;Pedreira et al, 2008).…”

“…Beyond identifying the measure used, six studies reported that the pain was suggestive of spasticity-associated pain (Choi et al, 2016;Kong et al, 2007;Lim et al, 2008;Marciniak et al, 2012;Marco et al, 2007;Pedreira et al, 2008). Shoulder internal rotators or adductors were targeted in these six studies, with or without injection of other UL muscles, with pectoralis major the most frequently injected muscle (5/6) (Kong et al, 2007;Lim et al, 2008;Marciniak et al, 2012;Marco et al, 2007;Pedreira et al, 2008).…”

Localization of the Centers of Intramuscular Nerve Dense Regions of the Rotator Cuff Muscles: A Guide for Botulinum Toxin A Injection for Spasticity Accompanied by Shoulder Pain

“…Individuals suffering from rotator cuff muscles spasticity usually present with shoulder pain (Van Ouwenaller et al, 1986;Yelnik et al, 2007) and limited shoulder joint movement affecting patient's daily life (Chae et al, 2007). Currently, treatment methods of rotator cuff muscles spasticity include intra-articular injection of drugs, such as triamcinolone (Snels et al, 2000), percutaneous electric stimulation therapy (Renzenbrink & Ijzerman, 2004), suprascapular nerve block (Wassef, 1992;Shanahan et al, 2003;Picelli et al, 2017), subscapular nerve block (Hecht, 1992) and intramuscular injection of botulinum toxin A (BTX-A ) (Pedreira et al, 2008). BTX-A injection is becoming increasingly popular by blocking the release of acetylcholine from the presynaptic membrane at the motor endplate (Friedman et al, 2000;Kinnett, 2004;Park & Chung, 2018).…”