Objective: To present an experts’ consensus on the use of botulinum neurotoxin (BoNT) injections in the multi-pattern treatment of shoulder spasticity to increase awareness of shoulder muscle injection with BoNT, alongside the more commonly injected upper limb (UL) muscles.

Background: BoNT is a first-line treatment option for post-stroke spasticity, reducing pain and involuntary movements and helping to restore function. BoNT is frequently injected into the arm, wrist, hand and/or finger muscles, but less often into the shoulder muscles, despite clinical trials demonstrating improvements in pain and function after shoulder BoNT injection.

Method: Expert consensus was obtained after a two-part meeting held online in late 2021. Five European experts with a cumulative experience of ~100 years in post-stroke spasticity gave presentations on shoulder spasticity and treatment with BoNT injections followed by discussion. In addition, a pre-meeting survey was conducted to capture information on preferred treatment practices.

Results: When treating a patient with shoulder spasticity with BoNT, the traditional approach is to choose the target muscles based on the spastic pattern and underlying functional anatomy. However, a more reasonable and patient-centred approach was proposed by the expert consensus: to identify which activities are limited by the spastic shoulder and consider treating the muscles that are involved in hindering those activities. Two patterns of shoulder spasticity were identified: for adduction and internal rotation of the shoulder, the expert panel recommended injecting the pectoralis major and teres major muscles in most cases; for the pattern of adduction, internal rotation and extension of shoulder, the panel recommended injecting the posterior part of the deltoid, subscapularis and long head of the triceps brachii in most cases [Table 1]. It is important to consider the local guidelines and product labels, as well as discussions within the multiprofessional team when deciding to inject shoulder muscles with BoNT.

Conclusion: Choice of shoulder muscles for BoNT injection can be based on spasticity pattern, but ideally should also consider functional limitation and patient expectations in order to establish better patient-centred treatment goals. These recommendations will be of benefit for clinicians who may not be experienced in evaluating and treating spastic shoulders.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/choice-of-shoulder-muscles-for-the-multi-pattern-treatment-of-upper-limb-spasticity-with-botulinum-neurotoxin-injections/