The Place of Botulinum Toxin in Spastic Hemiplegic Shoulder Pain after Stroke: A Scoping Review

Abstract

Stroke is a common pathology worldwide, with an age-standardized global rate of new strokes of 150.5 per 100,000 population in 2017. Stroke causes upper motor neuron impairment leading to a spectrum of muscle weakness around the shoulder joint, changes in muscle tone, and subsequent soft tissue changes. Hemiplegic shoulder pain (HSP) is the most common pain condition in stroke patients and one of the four most common medical complications after stroke. The importance of the appropriate positioning and handling of the hemiplegic shoulder for prevention of HSP is therefore of high clinical relevance. Nevertheless, HSP remains a frequent and disabling problem after stroke, with a 1-year prevalence rate up to 39%. Furthermore, the severity of the motor impairment is one of the most important identified risk factors for HSP in literature. Spasticity is one of these motor impairments that is likely to be modifiable. After ruling out or treating other shoulder pathologies, spasticity must be assessed and treated because it could lead to a cascade of unwanted complications, including spastic HSP. In clinical practice, Botulinum toxin A (BTA) is regarded as the first-choice treatment of focal spasticity in the upper limb, as it gives the opportunity to target specifically selected muscles. It thereby provides the possibility of a unique patient tailored focal and reversible treatment for post stroke spasticity. This scoping review aims to summarize the current evidence of BTA treatment for spastic HSP. First, the clinical manifestation and outcome measures of spastic HSP will be addressed, and second the current evidence of BTA treatment of spastic HSP will be reviewed. We also go in-depth into the elements of BTA application that may optimize the therapeutic effect of BTA. Finally, future considerations for the use of BTA for spastic HSP in clinical practice and research settings will be discussed.

Botulinum toxin in the rehabilitation of painful syndromes: multiperspective literature analysis, lexical analysis and systematic review of randomized controlled trials

“…The lexical analysis again confirms the prevalence of stroke in the literature about BTX and rehabilitation, with a strong connection with the term “upper”, which includes the reference to the upper limb, an important target for spasticity after stroke and aimed at the improvement of QoL. 76 …”

“…The lexical analysis again confirms the prevalence of stroke in the literature about BTX and rehabilitation, with a strong connection with the term "upper", which includes the reference to the upper limb, an important target for spasticity after stroke and aimed at the improvement of QoL. 76 In the majority of the included RCTs, a comparison of BTX with the placebo is visible. This represents an important limitation and implies a necessary effort in the realization of large studies able to better determine the effects of BTX on pain.…”

The Complex Role of Botulinum Toxin in Enhancing Goal Achievement for Post-Stroke Patients

“…The decision to solely focus on the pectoralis major muscle for the shoulder level was based on the observation that our patients, typically, had the other muscles acting on the shoulder joint infiltrated only in a minority of cases, while the majority of patients with hypertonic upper limbs received injections in the above-mentioned pectoralis major muscles and the elbow, wrist, and finger flexors. Moreover, shoulder pain is a common issue in patients with upper limb hypertonia, and existing publications on the effects of BoNT-A on pain in stroke patients often concentrate on shoulder pain [ 56 ]; by far, the most important, most frequently injected, and most relevant for decreasing muscle pain acting on the shoulder joint is the pectoralis major muscle [ 57 , 58 , 59 ].…”