A Comparison of the Short-Term Effects of a Botulinum Toxin Type A and Triamcinolone Acetate Injection on Adhesive Capsulitis of the Shoulder

Abstract

ObjectiveTo evaluate the short-term clinical effects of the intra-articular injection of botulinum toxin type A (BoNT-A) for the treatment of adhesive capsulitis.MethodsA prospective, controlled trial compared the effects of intra-articular BoNT-A (Dysport; 200 IU, n=15) with the steroid triamcinolone acetate (TA; 20 mg, n=13) in patients suffering from adhesive capsulitis of the shoulder. All patients were evaluated using a Numeric Rating Scale (NRS) of the pain intensity and a measurement of the range of motion (ROM) at baseline (before treatment) and at 2, 4, and 8 weeks post-treatment.ResultsThe NRS at 2 weeks (BoNT-A vs. TA; 5.0 vs. 5.2), 4 weeks (4.1 vs. 4.9) and 8 weeks (3.8 vs. 4.6) of both treatment groups were significantly lower than that measured at baseline (7.4 vs. 7.6). The ROM of patients' shoulders increased significantly from baseline in both treatment groups. There was no significant difference in the NRS of pain intensity or the ROM between the two groups. Reduction in the pain intensity score was maintained for 8 weeks post-injection in both groups. There were no significant adverse events in either treatment group.ConclusionThe results suggest that there are no significant short-term differences between the intra-articular injections of BoNT-A and TA. Although BoNT-A has a high cost, it may be used as a safe alternative of TA to avoid the steroid-induced side effects or as a second-line agent, for patients who have failed to respond to the current treatments.

Effect of Hypertonic Saline in Intra‐Articular Hydraulic Distension for Adhesive Capsulitis

“…Except for 15 patients lost to follow-up and 2 patients who discontinued intervention due to capsule rupture during distension, 64 patients were analyzed ( Figure 2). The inclusion criteria were symptoms lasting for at least 3 months and restriction of >30 in at least 2 shoulder ROMs of shoulder flexion, abduction, internal rotation, and external rotation compared with that of the normal side (normal range for shoulder flexion and abduction is 0 to 180 , and for internal rotation and external rotation is 0 to 90 ) [8,9]. Exclusion criteria were as follows: a complete rotator cuff tear; diagnosis of a traumatic shoulder injury; degenerative arthritis observed on radiologic studies; systemic inflammatory disease; anticoagulant medication or side effects after using lidocaine; or a suspected infectious disease.…”

Management of adhesive capsulitis

“…The authors postulate that this difference may be attributable to more effective pain relief by BoNT-A in the early stages of adhesive capsulitis. 62 In summary, several studies indicate that intra-articular injections of corticosteroid that are delivered during the first or second stage of disease provide symptom relief in the short term that is not sustained at longer-term follow-up. 56,57,[63][64][65] Both hyaluronic acid and BoNT-A injections may be safe, albeit more expensive, alternatives to corticosteroids that could find use in patients who are unable to tolerate the side effects of a corticosteroid, or as a second-line option in those whose disease does not respond to corticosteroids alone.…”

“…Botulinum toxin type A (BoNT-A) has been seen in a histological in vivo study to prevent joint fibrosis and adhesions, as well as to have inhibitory effects on pain-mediating neuropeptides and central sensitization. 62,63 It has recently been considered as another possible alternative to injected corticosteroids for adhesive capsulitis.…”

Comparative Effectiveness of Botulinum Toxin Injection for Chronic Shoulder Pain: A Meta-Analysis of Randomized Controlled Trials

“…Ten were further excluded because four lacked a control group [10,[13][14][15], five targeted myofascial pain in regions other than shoulder areas [16][17][18][19][20], and one used an enriched protocol design to assess the effect of repeated BoNT injections [14] (Figure 1). The final meta-analysis consisted of seven 2-armed [21][22][23][24][25][26][27], one 3-armed [28], and one 4-armed [29] trials. Of the four studies investigating shoulder joint pain, one targeted patients with refractory shoulder pain [27], one targeted those with subacromial bursitis or shoulder impingement syndrome [25], one targeted those with adhesive capsulitis [24], and one was shoulder osteoarthritis [23].…”

“…The final meta-analysis consisted of seven 2-armed [21][22][23][24][25][26][27], one 3-armed [28], and one 4-armed [29] trials. Of the four studies investigating shoulder joint pain, one targeted patients with refractory shoulder pain [27], one targeted those with subacromial bursitis or shoulder impingement syndrome [25], one targeted those with adhesive capsulitis [24], and one was shoulder osteoarthritis [23]. The other five studies focused on patients with myofascial pain syndrome over the shoulder region [21,22,26,28,29].…”