Physio findings: Botox variations for shoulder pain

Survey shows Botox variations for shoulder pain

There are wide variations in British practice for treating hemiplegic shoulder pain with an intramuscular Botox injection, the results of an online survey of clinicians and physiotherapists reveals. These variations may be grounded more in personal beliefs than in the available evidence, the responses suggest. Up to 40 per cent of stroke survivors will develop hemiplegic shoulder pain, which is associated with longer inpatient rehabilitation and poorer functional outcomes.

Because of the many factors involved in the development of hemiplegic shoulder pain, the range of treatment options is vast. But, say the researchers, it’s not clear what the most effective approaches are for the various types of the condition and, in practice, it is often difficult to root out the precise cause and match that with the best treatment.

To find out whether and how practitioners in the UK are using intramuscular botulinum toxin type A to treat hemiplegic shoulder pain that arises after a stroke, the researchers surveyed 217 members of the British Society for Rehabilitation Medicine and 305 from the British Neurotoxin Network on current practice.

A total of 68 fully completed questionnaires were returned (a response rate of 13 per cent). Over half the respondents had been injecting Botox for more than 10 years and about a third used the technique at least 20 times a month.

Most respondents (nearly 87 per cent) said they would use Botox for hemiplegic shoulder pain associated with spasticity. But just over half (54 per cent) thought it worked well for this, and fewer than one in 10 said they would use it as the preferred option.

Around half said they saw no barrier to using it. One of the main obstacles was difficulty in determining the cause of the pain, which was cited by nearly a third of respondents, closely followed by difficulty isolating the muscles to inject and lack of evidence, cited by one in four respondents.

The timing, dose and volume of the injection used varied widely, as did the outcomes used to measure effectiveness, the responses showed. While the pectoralis major was the muscle of choice, cited by more than two thirds of respondents, when it came to second and third choices, a wide range of options was given.

This variation in practice, and the extent to which it deviates from guidelines and the available evidence, are not easily explained, say the researchers. But, they suggest, ‘Clinicians should perhaps consider that their individual decision-making could be based on their own beliefs rather than the available evidence.’

An understanding of those most at risk of developing hemiplegic shoulder pain linked to spasticity warrants further investigation, as early intervention might help ward to off the complications associated with the condition, the researchers say.

Holmes RJ et al. Disability and Rehabilitation 2017 A survey of the current practice of intramuscular botulinum toxin injections for hemiplegic shoulder pain in the UK.

Excess weight interferes with early stage rheumatoid arthritis remission

Carrying too much weight may affect the likelihood of achieving remission in early stage rheumatoid arthritis, suggests a study.

Previous research has suggested that weight may influence how well treatments for rheumatoid arthritis work, and a team of US and Canada-based researchers wanted to explore its potential impact in the early years after diagnosis. This is when patients should be most responsive to treatment and have the best outcomes.

The team mined data from the Canadian Early Arthritis Cohort, a multicentre observational trial of patients with early rheumatoid arthritis who had received care based on official guidance.

Out of 982 patients, around a third (32 per cent) had a healthy body mass index (BMI), 35 per cent were overweight, and 33 per cent obese. Within three years of diagnosis, just over a third (36 per cent) of all patients experienced sustained remission.

Compared with patients with a healthy BMI, those who were overweight were 25 per cent less likely to do so, while those who were obese were 47 per cent less likely to do so, despite all of them having received similar treatment.

The study is the largest of its kind to highlight the detrimental impact of excess weight on disease activity. It emphasises the need to better identify and tackle this risk in patients, particularly as rates of obesity/overweight continue to rise, say the researchers.

‘Our findings highlight the high proportion of newly diagnosed patients [with rheumatoid arthritis] who are overweight or obese and who may have disease that is harder to treat. For people with [rheumatoid arthritis] who haven’t had an adequate response to treatment, this may be another factor to consider,’ they suggest.

Schulman E et al, for CATCH Investigators. Arthritis Care & Research 2017 Overweight and obesity reduce the likelihood of achieving sustained remission in early rheumatoid arthritis: Results from the Canadian Early Arthritis Cohort Study.

Comments and conclusions

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• Around a fifth of people with cancer experience post-traumatic stress disorder (PTSD) several months after diagnosis, a study of 469 adults with the disease finds. Although overall rates decreased with time (to just over six per cent after four years), roughly a third of those with PTSD had persistent or worsening symptoms.

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