Intramuscular Botulinum Toxin-A Reduces Hemiplegic Shoulder Pain: A Randomized, Double-Blind, Comparative Study Versus Intraarticular Triamcinolone Acetonide

J.-Y. Lim, J.-H. Koh, N.-J. Paik
2007 Stroke  
and Purpose-Shoulder pain is frequent after stroke and interferes with the rehabilitative process and outcome. However, treatments used for hemiplegic shoulder pain are limited and largely ineffective. This prospective, randomized, double-blind controlled study was conducted to compare the efficacies of botulinum toxin type A (BoNT-A) and triamcinolone acetonide (TA) on hemiplegic shoulder pain and their effects on arm function in patients with stroke. Methods-Twenty-nine hemiplegic stroke
more » ... iplegic stroke patients with shoulder pain (duration Յ24 months, pain on numeric rating scale Ն6/10) were randomized into 2 groups. One group received intramuscular injections of BoNT-A (BOTOX 100 U total) during one session to the infraspinatus, pectoralis and subscapularis muscles in conjunction with an intraarticular injection of normal saline to painful shoulder joint, whereas the other group received an intraarticular injection of TA (40 mg) and an intramuscular injection of normal saline to the same muscles. Outcome measures were pain (measured using a numeric rating scale), physician's global rating scale, shoulder range of motion (ROM) in 4 directions, arm function measured using Fugl-Meyer score, and spasticity measured using the modified Ashworth scale. Measurements were made at baseline and 2, 6, and 12 weeks after injection. Results-At 12 weeks after treatment mean decrease in pain was 4.2 in the BoNT-A-treated group versus 2.5 in the TA-treated group (Pϭ0.051), and improvements in overall ROM were 82.9 o versus 51.8 o in these groups (Pϭ0.059), showing a strong trend toward there being less pain and better ROM among those treated with BoNT-A than with TA. However, no significant differences were observed between the 2 groups in terms of improvement in physician global rating, Fugl-Meyer score or modified Ashworth scales. No adverse effect was observed in either group. Conclusions-Results from this study suggest that injection of BoNT-A into selected muscles of the shoulder girdle might provide more pain relief and ROM improvement than intraarticular steroid in patients with hemiplegic shoulder pain. A larger clinical trial needs to be undertaken to confirm the benefits of this approach. (Stroke. 2008;39:126-131.) Key Words: botulinum toxin a Ⅲ hemiplegia Ⅲ shoulder painstroke S houlder pain is one of the most frequent complications of hemiplegia, and occurs in 20% to 70% of stroke patients. Moreover, it can interfere with the rehabilitative process and has been associated with poorer outcomes and prolonged hospital stays. 1-9 A variety of factors may be responsible for shoulder pain after stroke, eg, joint pathology, adhesive capsulitis, subluxation of the head of the humerus, injury to rotator cuff tendons, spasticity of surrounding muscles, central poststroke pain, and complex regional pain syndrome. 10 -13 However, the etiology of hemiplegic shoulder pain (HSP) remains uncertain. With regard to treatment, nothing has yet been proven effective, although different treatment methods such as physical therapy, 12 functional electrical stimulation, 14,15 and intra-articular steroid injection 16,17 are being applied. In clinical practice, physicians frequently treat HSP using steroid injections, 17 although their effects remain controversial. 16 -18 Botulinum toxin type A (BoNT-A) has been widely used to treat spasticity and other forms of muscle overactivity, 19 -24 and recently has been used to treat chronic pain, such as, myofascial pain, low back pain, lateral epicondylitis, various types of headaches, and neuropathic pain. [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] The mechanism of pain reduction by BoNT-A may include a muscle relaxant effect 35 and the inhibition of neurotransmitter release by sensory neurons. 36 -44 Given that the suggested pain relieving mechanisms of BoNT-A cover the possible etiologies of HSP, we considered that BoNT-A might be effective for treating HSP. In this
doi:10.1161/strokeaha.107.484048 pmid:18048857 fatcat:lgatuuvc4zbtnluxeq6bdmht3i