Clinical effectiveness of ultrasound guided subacromial-subdeltoid bursa injection of botulinum toxin type A in hemiplegic shoulder pain: A retrospective cohort study

Medicine (Baltimore). 2019 Nov;98(45):e17933. doi: 10.1097/MD.0000000000017933.


Hemiplegic shoulder pain (HSP), which occurs in most patients with hemiplegia, causes considerable distress and worsens outcomes in rehabilitation. Although they have received the treatments such as anti-inflammatory drugs or physical therapy, many of the individuals remain suffering from shoulder pain 6 months after acute stroke event. In this retrospective study, we evaluated the effectiveness of ultrasound guided subacromial-subdeltoid (SASD) bursa injections with botulinum toxin type A (BoNT/A) compared to steroids for refractory HSP.The data were collected retrospectively by reviewing the patient's medical records and pain questionnaires in our rehabilitation center. In total, 38 patients who received ultrasound guided SASD bursa injection (BoNT/A group, n = 18; corticosteroid group, n = 20) were included. The pain visual analog scale (VAS) score at rest and during arm passive abduction, Fugl-Meyer score of upper limbs (F-M score) were evaluated before, 2, 4, 8, and 12 weeks after injection.Both 2 groups obtained a significant improvement of VAS score at rest or during arms passive abduction compared to baseline score (within group compare, P < .05). There were no significant differences of pain score improvement between two groups at week 2, 4, 8, and 12 after injection either at rest or during passive arm abduction (between 2 groups compare, P > .05). There were also no differences in results of the post treatment F-M score between 2 groups (between 2 groups compare, P > .05). Similarly, during the follow-up period no collateral effects were reported after BoNT/A injection.SASD bursa BoNT/A injection can substantially reduce the pain as corticosteroid in patients with HSP. BoNT/A injection could be a useful strategy for replacing steroids as a treatment for refractory HSP especially in the patients who cannot tolerate the steroids injection.

Publication types

  • Observational Study

MeSH terms

  • Aged
  • Anti-Inflammatory Agents / administration & dosage
  • Betamethasone / administration & dosage
  • Betamethasone / analogs & derivatives
  • Botulinum Toxins, Type A / administration & dosage*
  • Bursa, Synovial / drug effects
  • Case-Control Studies
  • Female
  • Hemiplegia / complications
  • Humans
  • Injections, Intra-Articular
  • Male
  • Middle Aged
  • Neuromuscular Agents / administration & dosage*
  • Retrospective Studies
  • Shoulder Pain / drug therapy*
  • Shoulder Pain / etiology
  • Stroke / complications
  • Treatment Outcome
  • Ultrasonography, Interventional / methods


  • Anti-Inflammatory Agents
  • Neuromuscular Agents
  • betamethasone-17,21-dipropionate
  • Betamethasone
  • Botulinum Toxins, Type A