Title : A novel approach to the management of impaired shoulder range of motion in patients with spasticity: Intra-articular botulinum toxin to the glenohumeral joint with ultrasound guidance.
Abstract:
Botulinum toxin is a well-known treatment used for Upper Motor Neuron disorders, and most commonly for spasticity in post-stroke care. It was observed that in particular cases, limited shoulder range of motion was a limiting factor in recovery and functional use of the upper limb, and that injection of botulinum toxin to the surrounding musculature such as the pectoralis, latissimus dorsi, and less anatomically available subscapularis and teres major provided limited additional passive range of motion to the glenohumeral joint in affected patients.To our knowledge, botulinum toxin has never been injected before into the glenohumeral joint for spasticity, but has been trialed in osteoarthritis demonstrating its feasibility.Thus far, we have collected data on two patients and demonstrated a significant improvement in abduction and external rotation.
A 54yr male who had a benign 4th ventricular tumor removed in early 2023, presented with secondary left upper limb hemiparesis and spasticity. Original exam showed the left shoulder PROM of 10 degrees in external rotation, and 45 degrees in abduction. Thereafter, we injected 20 units of Botox in a diluted solution of 10cc of normal saline, mimicking the higher volumes that are used in adhesive capsulitis. At his 4 week follow-up, passive external rotation was 45 degrees, and abduction improved to 90 degrees.
An 80yr female who had a right MCA infarct in 2021 who began using Xeomin due to Botox ineffectiveness, was found to have improvement of left shoulder PROM from 30 degrees in abduction to 75 degrees 4 weeks after glenohumeral intra-articular Xeomin injections of 20 units diluted in 10cc of normal saline.
Audience Take Away:
- For upper motor neuron disorders in which spasticity limits range of motion at the shoulder, botulinum toxin is both feasible and effective in providing additional passive range at the shoulder and may improve functionality in long-term outcomes.
