Comparative Effectiveness of Injection Therapies for Hemiplegic Shoulder Pain in Stroke: A Systematic Review and Network Meta-Analysis.

Levent Özçakar,Po-Cheng Hsu,Ke-Vin Chang,Yi-Hsiang Chiu,Wei-Ting Wu

doi:10.3390/ph14080788

Abstract

Hemiplegic shoulder pain (HSP) hampers post-stroke functional recovery and is not well managed with conservative treatments. This systematic review aimed to examine the various injection therapies for HSP and investigate their effectiveness at different time points. The protocol of this meta-analysis was registered on INPLASY with a registration number of INPLASY202180010. PubMed, EMBASE, and Scopus were searched from their inception to 4 August 2021 for the clinical studies investigating comparative effectiveness of different injection regimens for treating hemiplegic shoulder pain in patients with stroke. The primary outcome was the weighted mean difference (WMD) on the visual analog scale (VAS) of pain reduction in the fourth-week and between the fourth and twenty-fourth weeks. Ranking probabilities of the WMD for each treatment were obtained using simulations. Seventeen studies with 595 participants were included. The network meta-analysis showed that at the fourth-week, intra-muscular botulinum toxin (BoNT) injections and suprascapular nerve blocks (SSNB) were superior to a placebo, with WMDs of 1.55 (95% CI, 0.09 to 3.01) and 1.44 (95% CI, 0.07 to 2.80), respectively. SSNB possessed the highest probability (53.3%) and appeared to be the best treatment in the fourth-week, followed by intra-muscular BoNT injections (42.6%). Intramuscular BoNT injections were better than the placebo, with a WMD of 1.57 (95% CI, 0.30 to 2.84) between the 4th and 24th weeks. Intramuscular BoNT injections had the highest probability (79.8%) as the best treatment between the 4th and 24th weeks. SSNB was likely to rank first in relieving HSP at the fourth post-treatment week, whereas intra-muscular BoNT injections had the highest probability to achieve the best treatment effectiveness in the post-injection period between the fourth and twenty-fourth weeks. However, as some of the included studies used a non-randomized controlled design, more randomized controlled trials are needed in the future to validate and better understand the short- and long-term efficacy of different injection therapies for management of HSP.

Highlights

We identified 5769 citations in the literature search from the electronic databases, PubMed, EMBASE, and Scopus
Our meta-analysis revealed that the doses and target muscles for intra-muscular botulinum toxin (BoNT)
The current systematic review and meta-analysis found that suprascapular nerve blocks (SSNB) was likely to rank first in relieving Hemiplegic shoulder pain (HSP) at the fourth post-treatment week the probability of being the best treatment was approximately 50%

Summary

Introduction

Hemiplegic shoulder pain (HSP) is one of the most debilitating complications after stroke [1]. Its reported incidence varies from 30% to 72% at one-year follow-up across different studies [2,3,4]. HSP is mostly graded as ranging from moderate to severe intensity [4] and rarely resolves spontaneously [3]. Stroke patients with poor upper extremity function have an increased risk of HSP [5]. Various theories have been proposed for the development of HSP, including deficiency in pain adaption [6], central sensitization to normal or subthreshold sensory stimuli [7], and impaired neuromuscular control of the Pharmaceuticals 2021, 14, 788.

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