A survey of the current practice of intramuscular Botulinum toxin injections for hemiplegic shoulder pain in the UK

Abstract

Current UK practice of Botulinum Toxin type A injections for hemiplegic shoulder pain associated with spasticity is highly variable. There are large gaps between current practice and available evidence with regards to muscle selection and doses used. A number of areas for further investigation have been identified to progress current understanding of this intervention. Implications for rehabilitation There are wide variations in practice for this complex intervention and clinicians should consider that their individual decision-making could be based on their own beliefs rather than available evidence. Pectoralis major is most commonly injected to treat hemiplegic shoulder pain, but further evaluation is required to address whether it is the most effective. Clinicians most often use a limitation of shoulder abduction and external rotation, flexor patterning of the upper limb, and pain on passive movement to identify when hemiplegic shoulder pain is due to spasticity over other causes. Further research is needed to identify which patients are most likely to benefit from this intervention and at what stage post-stroke its use is most optimal.

Localization of nerve entry points and the center of intramuscular nerve‐dense regions in the adult pectoralis major and pectoralis minor and its significance in blocking muscle spasticity

“…The intramuscular injection of BTX‐A to the motor endplate or to the INDR to block muscle spasticity has become increasingly popular (Tang, Li, et al, 2018 ; Tang, Zhang, et al, 2018 ; Yang et al, 2017 ). Injecting BTX‐A to block the spasticity of the pectoralis major muscle is the most commonly used method to treat hemiplegic shoulder pain (Holmes & Connell, 2019 ). For the pectoralis minor muscle, BTX‐A injection can also treat outlet syndrome (Rahman et al, 2019 ).…”

Botulinum Neurotoxin-A Injection in Adult Cervical Dystonia and Spastic Paresis: Results From the INPUT (INjection Practice, Usage and Training) Survey

“…Nevertheless, to the best of our knowledge, INPUT is the first international survey characterizing a clinical training programme in order to assess its impact and identify improvement opportunities. The few survey results published describe general or local practices or a specific aspect of management (33)(34)(35)(36)(37)(38). Respondents are probably the most motivated to undertake training and innovative approaches, and the most involved in the Ixcellence Network R programme.…”

Association of Long-Term Treatment by Botulinum Neurotoxins and Occupational Therapy with Subjective Physical Status in Patients with Post-Stroke Hemiplegia

“…Our results suggested that long-term treatment could improve subjective symptoms of sleeplessness and arm weakness caused by sequelae of stroke without recovery of motor function in upper extremity, while also decreasing pain. BoNT-A treatment for sequelae after stroke has shown short-term therapeutic effects within 12 months [12,14,15,16]. Additionally, VAS is commonly used for pain assessment [17,18].…”

“…Injections are repeated approximately every three months to maintain the efficacy of BoNT-A. The recovery of motor paralysis of the upper extremity may take more than six months post-stroke patients, indicating that doses of BoNT-A would be needed for a longer period [11,12]. These effects were verified by research of repeated BoNT-A administration for up to one and half years [9,10,11,12].…”