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 newstrokes of 150.5 per 100,000 population in 2017. Stroke causes upper motor neuron impairment leadingto a spectrum of muscle weakness around the shoulder joint, changes in muscle tone, and subsequentsoft tissue changes. Hemiplegic shoulder pain (HSP) is the most common pain condition in strokepatients and one of the four most common medical complications after stroke. The importance of theappropriate positioning and handling of the hemiplegic shoulder for prevention of HSP is thereforeof 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 oneof the most important identified risk factors for HSP in literature. Spasticity is one of these motorimpairments 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-choicetreatment of focal spasticity in the upper limb, as it gives the opportunity to target specifically selectedmuscles. It thereby provides the possibility of a unique patient tailored focal and reversible treatmentfor post stroke spasticity. This scoping review aims to summarize the current evidence of BTAtreatment for spastic HSP. First, the clinical manifestation and outcome measures of spastic HSP willbe 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 ofBTA. Finally, future considerations for the use of BTA for spastic HSP in clinical practice and researchsettings will be discussed