title: Botulinum toxin for shoulder pain.
abstract: BACKGROUND
  Recent evidence suggests an anti-nociceptive effect of botulinum toxin.
  
  
  OBJECTIVE
  To compare the efficacy and safety of botulinum toxin in comparison to placebo or other treatment options for shoulder pain.
  
  
  METHODS
  We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), Ovid MEDLINE, CINAHL (via EBSCOhost), Ovid SPORTDiscus, EMBASE and Science Citation Index.
  
  
  METHODS
  Randomized controlled trials (RCTs) comparing botulinum toxin with placebo or active treatment in people with shoulder pain were included.
  
  
  METHODS
  For continuous measures we calculated mean difference (MD), and for categorical measures risk ratio (RR) (with 95% confidence interval (CI)).
  
  
  RESULTS
  Six RCTs with 164 patients were included. Five RCTs in participants with post-stroke shoulder pain indicated that compared with placebo, a single intramuscular injection of botulinum toxin A significantly reduced pain at three to six months post-injection (MD -1.2 points, 95% CI -2.4 to -0.07; 0 to 10 point scale) but not at one month (MD -1.1 points, 95% CI -2.9 to 0.7). Shoulder external rotation was increased at one month (MD 9.8 degrees , 95% CI 0.2 to 19.4) but not at three to six months. Shoulder abduction, external rotation or spasticity did not differ between groups, nor did the number of adverse events (RR 1.46, 95% CI 0.6 to 24.3).One RCT in arthritis-related shoulder pain indicated that botulinum toxin reduced pain severity (MD -2.0, 95% CI -3.7 to -0.3; 10 point scale) and shoulder disability with a reduction in Shoulder Pain and Disability Index score (MD -13.4, 95% CI -24.9 to -1.9; 100 point scale) when compared with placebo. Shoulder abduction was improved (MD 13.8 degrees, 95% CI 3.2 to 44.0). Serious adverse events did not differ between groups (RR 0.35, 95% CI: 0.11, 1.12).
  
  
  CONCLUSIONS
  The results should be interpreted with caution due to few studies with small sample sizes and high risk of bias. Botulinum toxin A injections seem to reduce pain severity and improve shoulder function and range of motion when compared with placebo in patients with shoulder pain due to spastic hemiplegia or arthritis. It is unclear if the benefit of pain relief in post-stroke shoulder pain at three to six months but not at one month is due to limitations of the evidence, which includes small sample sizes with imprecise estimates, or a delayed onset of action. More studies with safety data are needed.
authors.affiliation: Department of Medicine, Birmingham VA Medical Center, Faculty Office Tower 805B, 510 20th Street South, Birmingham, USA, AL 35294.
authors.forename: Jasvinder A
authors.initials: JA
authors.lastname: Singh
authors.forename: Patrick M
authors.initials: PM
authors.lastname: Fitzgerald
mesh_terms: D018712:Analgesics, Non-Narcotic / Q000627:therapeutic use*; D001905:Botulinum Toxins / Q000627:therapeutic use*; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D016059:Range of Motion, Articular; D020069:Shoulder Pain / Q000188:drug therapy*
chemical_list: D018712:Analgesics, Non-Narcotic; D001905:Botulinum Toxins
references.citation: Cochrane Database Syst Rev. 2005 Apr 18;(2):CD005319
references.pmid: 15846753
references.citation: J Neurol Neurosurg Psychiatry. 2008 May;79(5):581-3
references.pmid: 18408090
references.citation: Toxicon. 2009 Oct;54(5):658-67
references.pmid: 19351542
references.citation: Neurology. 1990 Feb;40(2):277-80
references.pmid: 2300249
references.citation: J Bone Joint Surg Am. 2005 Mar;87(3):503-7
references.pmid: 15741614
references.citation: BMJ. 2004 Jun 19;328(7454):1490
references.pmid: 15205295
references.citation: BMJ. 1990 Mar 31;300(6728):848-9
references.pmid: 2140063
references.citation: J Rehabil Med. 2002 Mar;34(2):51-61
references.pmid: 12019580
references.citation: Spine (Phila Pa 1976). 1998 Mar 1;23(5):607-14
references.pmid: 9530793
references.citation: Clin Orthop Relat Res. 2002 Aug;(401):125-31
references.pmid: 12151889
references.citation: Occup Environ Med. 1997 May;54(5):316-21
references.pmid: 9196453
references.citation: Clin Rehabil. 2007 Jan;21(1):28-35
references.pmid: 17213238
references.citation: Ann Intern Med. 2008 Feb 19;148(4):295-309
references.pmid: 18283207
references.citation: Stroke. 2004 Apr;35(4):918-23
references.pmid: 14976324
references.citation: Arthritis Rheum. 1980 Feb;23(2):137-45
references.pmid: 7362664
references.citation: Stroke. 1999 Aug;30(8):1538-41
references.pmid: 10436097
references.citation: BMC Health Serv Res. 2004 Dec 22;4(1):38
references.pmid: 15615589
references.citation: Biochem Pharmacol. 2000 Jun 1;59(11):1403-6
references.pmid: 10751549
references.citation: Eur J Pain. 2006 May;10(4):287-333
references.pmid: 16095934
references.citation: Neurorehabil Neural Repair. 2007 Nov-Dec;21(6):561-7
references.pmid: 17369520
references.citation: Clin Orthop Relat Res. 1988 Jun;(231):234-8
references.pmid: 3370878
references.citation: Clin J Pain. 2002 Nov-Dec;18(6 Suppl):S119-24
references.pmid: 12569958
references.citation: Anesthesiology. 2005 Aug;103(2):377-83
references.pmid: 16052120
references.citation: Curr Rheumatol Rep. 2000 Dec;2(6):454-8
references.pmid: 11123097
references.citation: Baillieres Clin Rheumatol. 1989 Dec;3(3):437-51
references.pmid: 2696600
references.citation: Ann Intern Med. 2005 Dec 6;143(11):793-7
references.pmid: 16330790
references.citation: Arthritis Rheum. 1971 Nov-Dec;14(6):706-20
references.pmid: 5135791
references.citation: J Neurol Neurosurg Psychiatry. 2007 Aug;78(8):845-8
references.pmid: 17088333
references.citation: Clin Rheumatol. 2002 Feb;21 Suppl 1:S5-8
references.pmid: 11954900
references.citation: Neurology. 2006 Jul 25;67(2):241-5
references.pmid: 16864815
references.citation: BMC Musculoskelet Disord. 2005 Feb 03;6:4
references.pmid: 15691370
references.citation: Trials. 2008 Oct 23;9:59
references.pmid: 18947418
references.citation: Arch Phys Med Rehabil. 2001 Jul;82(7):986-92
references.pmid: 11441390
references.citation: Pain Pract. 2004 Mar;4 Suppl 1:S27-37
references.pmid: 17129273
references.citation: Pain. 2000 Dec 1;88(3):287-294
references.pmid: 11068116
references.citation: Pain. 2000 Mar;85(1-2):101-5
references.pmid: 10692608
references.citation: J Rehabil Med. 2007 Jul;39(6):440-7
references.pmid: 17624477
references.citation: Pain. 2004 Jan;107(1-2):125-33
references.pmid: 14715398
references.citation: Cochrane Database Syst Rev. 2009 Jul 08;(3):CD006355
references.pmid: 19588386
references.citation: Cochrane Database Syst Rev. 2006 Oct 18;(4):CD006189
references.pmid: 17054278
references.citation: BMJ. 1996 Sep 7;313(7057):601-2
references.pmid: 8806252
references.citation: Cochrane Database Syst Rev. 2003;(2):CD004258
references.pmid: 12804509
references.citation: Clin J Pain. 2002 Nov-Dec;18(6 Suppl):S147-54
references.pmid: 12569962
references.citation: Cochrane Database Syst Rev. 2003;(1):CD004016
references.pmid: 12535501
references.citation: Arch Phys Med Rehabil. 1992 May;73(5):409-13
references.pmid: 1580765
references.citation: Clin J Pain. 2002 Nov-Dec;18(6 Suppl):S142-6
references.pmid: 12569961
references.citation: Vital Health Stat 1. 1973 Feb;(10a):1-46
references.pmid: 4347506
references.citation: Neurology. 2007 Mar 20;68(12):963; author reply 963-4
references.pmid: 17372141
references.citation: Stroke. 2008 Jan;39(1):126-31
references.pmid: 18048857
references.citation: Acta Radiol Diagn (Stockh). 1977 Jul;18(4):481-91
references.pmid: 920239
references.citation: Scand J Rehabil Med Suppl. 1995;32:107-12
references.pmid: 7784832
references.citation: J Pain Symptom Manage. 2000 Jul;20(1):44-9
references.pmid: 10946168
references.citation: Pain. 2006 Nov;125(1-2):82-8
references.pmid: 16750294
references.citation: Clin J Pain. 2006 Jan;22(1):90-6
references.pmid: 16340597
references.citation: Clin Rehabil. 2002 May;16(3):276-98
references.pmid: 12017515
references.citation: Toxicon. 2009 Oct;54(5):614-23
references.pmid: 19073203
references.citation: J Neurol. 2001 Apr;248 Suppl 1:34-8
references.pmid: 11357239
references.citation: Ann Rheum Dis. 2003 May;62(5):385-7
references.pmid: 12695146
references.citation: Ann Neurol. 2008 Sep;64(3):274-83
references.pmid: 18546285
references.citation: Transl Res. 2009 May;153(5):205-16
references.pmid: 19375681
references.citation: Arthritis Rheum. 1991 Jun;34(6):766-9
references.pmid: 2053923
references.citation: Cochrane Database Syst Rev. 2008 Jan 23;(1):CD007005
references.pmid: 18254123
references.citation: Arq Neuropsiquiatr. 2008 Jun;66(2A):213-5
references.pmid: 18545785