Evaluating the efficiency of treatment of pain in post-stroke spasticity by botulinum group a in patients with brain stroke

Journal of military pharmaco-medicine no3-2019

EVALUATING THE EFFICIENCY OF TREATMENT OF PAIN IN
POST-STROKE SPASTICITY BY BOTULINUM GROUP A IN
PATIENTS WITH BRAIN STROKE
Bui Van Nam1; Le Van Quan1
SUMMARY
Objectives: To assess the clinical characteristics and outcomes of treatment of pain in poststroke spasticity with botulinum group A. Subjects and methods: 102 patients with spasticity
after a stroke at Stroke Department, 103 Military Hospital from May 2014 to December 2017.
Results: Pain in post-stroke spasticity was 55.9%, pain level with VAS score was 2.35 ± 1.22 points.
st
rd
After botulinum injection, the pain was significantly reduced at 1 and 3 month of hospitalization,
with p < 0.05. Pain at injection was 59.6% and there was no pain after 3 days. Conclusion: The pain
level in post-stroke spasticity was moderate, common after stroke. Botulinum treatment was
effective and the unwanted effects disappeared quickly after injection.
* Keywords: Pain; Spasticity; Stroke; Botulinum group A.

INTRODUCTION
Stroke has long been considered a
major contributor to the global disease
burden due to high prevalence and
incidence. Among the sequelae of stroke,
chronic pain syndromes after cerebral
stroke are common, accounting for 50 72%. There are many types of pain after
cerebral stroke, including central pain,
shoulder pain and secondary pain due to
muscle spasticity, which is many authors’
great concerns. Muscle spasticity is very
common (43%) and leaves a lot of
serious physical and mental effects on the

patient and society [5]. Thesedays, there
are many treatments for muscle spasticity
after strokes such as rehabilitation,
systemic medications, alcohol or phenol
blockers and surgery. But these methods
are still limited. Botulinum toxin type A is

used in the treatment of muscle spasticity
in many countries around the world [6].
Being easy to use, botulinum type A is
gradually becoming the first choice in the
treatment of muscle spasticity after stroke
in many stroke and rehabilitation centers
in the country. Therefore, we conducted
the study of the treatment of post-stroke
muscle pain with botulinum A in order to:
Evaluate clinical characteristics and
assess the efficiency of treatment of pain
in post-stroke spasticity with botulinum
toxin type A.
SUBJECTS AND METHODS
1. Subjects.
102 patients with stroke had Ashworth
scores of 1 to 3, receiving inpatient
treatment at Department of Stroke,
103 Military Hospital from May 2014 to
December 2017.

1. 103 Military Hospital
Corresponding author: Bui Van Nam ()

Date received: 10/12/2018
Date accepted: 02/02/2019

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2. Research methods.
The interventional study was evaluated at 1, 3 and 6 months. With some research
indicators, the sample was divided into two groups: patients with painful spasticity and
patients with painless spasticity. Research only used simply botulinum toxin group A,
did not use background.
* Some diagnostic criteria:
- Patients with cerebral infarction stroke were diagnosed according to the World
Health Organization’s definition of stroke in 1970 [2].
- Muscle spasticity was diagnosed according to WM Lance 1980 [4].
- Muscle pain was diagnosed by Winstein's definition in 2016.
- Dosage of botulinum toxin in group A: Use the injection dosage for muscle contraction
by Huber M and Heck G (2002), which is approved and recommended for use by
Vietnam Ministry of Health.
- Pain assessment:

Diagram 1: Pain level.
To assess the pain of patients with visual scale (VAS) ranging from 0 to 10, the
patients assessed their pain level in degrees corresponding to the pain level. The pain
was calculated as either natural pain or in passive motion.
* Data analysis:
Data was analyzed by the medical statistical methods using SPSS software 20.0.
RESULTS AND DISCUSSION
1. General characteristics of the research group.

Table 1:
Characteristics

Painful spasticity (n = 57)

Painless spasticity (n = 45)

p

Age (years)

57.12 ± 9.0

55.1 ± 11.0

> 0.05

Sex (male)

56.16%

51.9%

> 0.05

38.3 ± 8.1

17.9 ± 9.4

< 0.05

Time of stroke (months)

Median 31.3; the lowest 1; the highest 58

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Journal of military pharmaco-medicine no3-2019
There was no difference in age between two groups of painful and painless
spasticity after stroke: Mean age with spasticity after stroke was 55.1 ± 11.0, average
41 years old, the highest age 89; mean age in the group of patients with muscle pain
after stroke was 57.2 ± 9.0 years, the lowest was 41 years, the highest age was 82 years
(p > 0.05). Similarly to Wissel Jörg et al (2000), when the pain was studied in patients
with an average age of 41.5 years and severe muscle spasticity were present in
younger patients, there was no difference between the painful and painless spasticity
group [9]. However, the age in Wissel Jörg's study was lower than that in our study,
which was due to the choice of subjects. In our study, we selected patients right after
cerebral stroke, whereas those in Wissel Jörg’s study included both patients with
stroke and traumatic brain injury, traumatic brain injury is more common in younger
adults than those at the age of stroke. In terms of gender, males in the group of
patients with painful spasticity were 56.6% compared to 51.9% in the group of patients
with painless spasticity, the difference was not statistically significant with p > 0.05.
The gender ratio in our study was equivalent to other authors’ [4, 9] (p > 0.05).
2. Clinical characteristics of pain due to muscle spasticity.
Table 2: Clinical characteristics of patients with pain due to muscle spasticity following a
stroke at admission.
Clinical characteristics

n; ratio % (n = 102)

VAS ( X ± SD)

Pain in at least one position

57; 55.9%

2.35 ± 1.22

Adduction muscles of shoulder joint

53; 51.9%

2.98 ± 1.34

Flexor muscles of elbow joint

49; 48.0%

2.67 ± 1.51

Flexor muscles of wrist joint

35; 34.3%

1.98 ± 1.37

Flexor muscles of knee joint

45; 44.1%

2.06 ± 1.28

Flexor muscles of ankle joint

13; 12.7%

1.09 ± 1.11

In the study, we found that 55.9% of
patients had painful spasticity after stroke,
equivalent to the proportion of patients in
Wissel Jörg et al’s study [8]. In Luong
Tuan Khanh’s study, 64 patients with pain
after stroke, experienced a 46.9% of pain
due to spasticity, lower than our study. It
was explained that the time after stroke in
our study was on average 31.1 months
meanwhile it was 28.09 months in Luong
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Tuan Khanh’s study, the longer the time
of stroke is, the more increasing the
spasticity level and pain rate [1]. John W
Dunne et al (1995) had a 77.5% of stroke
rate (31/40 patients), which was higher
than our study, because the pain after
stroke was only assessed in the upper
limbs [3]. In this research, we found that
post-stroke spasticity occurred in the

flexor muscles of upper limb and the


Journal of military pharmaco-medicine no3-2019
extensor muscles of lower limb, which are
the most common after stroke. This result
was similar to Wissel Jörg’s finding (2010)
[8]. Upper limbs, adduction muscles of the
shoulder joint (51.9%) and elbow joint
(48.0%) accounted for a high rate of
muscle spasticity.
In the lower extremities, flexor muscles
of the knee joint (44.1%) were characterized
by painful muscle spasticity, which were
common muscle groups suffering from
spasticity after stroke, according to Yelnik

(2007). VAS pain score was 2.35 ± 1.22,
with typical pain at the adduction muscles
of shoulder joint (2.98 ± 1.34), flexor
muscles of elbow joint (2.67 ± 1.51),
flexor muscles of knee joint (2.06 ± 1.28);
pain was moderate (average pain score
VAS < 5 points); the results were similar
to John W Dunne et al’s findings where
the pain due to spasticity after stroke was
2.5 VAS [3]. Pain in the spasticity group is
one of the indications for the patient to
receive specialized treatment such as
medication and blocking.

Table 3: Assessment of the decreasing of pain level in VAS time before and after
injection of botulinum type A (n = 57).
VAS
Muscle groups
Pain in at least one position

At admission
(aa)

One month
p (aa-1)

Three months
p (aa-3)

Six months
p (aa-6)

( X ±SD)

( X ± SD)

( X ± SD)

( X ± SD)

2.35 ± 1.22

0.97 ± 0.11

(p < 0.05)

1.00 ± 0.31
(p < 0.05)

1.89 ± 0.7
(p > 0.05)

Pain relief 87.7% (50)

Time to start pain relief 7.5 ± 5.7 days

Shoulder adduction (n = 53)

2.98 ± 1.34

0.80 ± 0.12
(p < 0.05)

1.04 ± 0.36
(p < 0.05)

1.82 ± 0.27
(p > 0.05)

Elbow flexion (n = 49)

2.67 ± 1.51

1.11 ± 0.54

(p < 0.05)

1.25 ± 0.42
(p < 0.05)

2.31 ± 0.40
(p > 0.05)

Wrist flexion (n = 45)

1.98 ± 1.37

1.09 ± 0.25
(p < 0.05)

1.12 ± 0.31
(p < 0.05)

2.18 ± 0.11
(p > 0.05)

Knee extension (n = 27)

2.06 ± 1.28

0.89 ± 0.37
(p < 0.05)

1.09 ± 0.48
(p < 0.05)

1.89 ± 0.33
(p > 0.05)

Ankle flexion (n = 13)

1.90 ± 1.11

1.05 ± 0.21
(p < 0.05)

1.19 ± 0.31
(p < 0.05)

1.79 ± 0.22
(p > 0.05)

Our findings showed that the decreasing
of pain level occupied 87.7% of patients
(50/57). The mean duration of pain relief
ranged from 7.5 ± 5.7 days. Our study
was similar to John W Dunne’s finding
with a 90.3% of reduction in pain (28/31
patients) [3]; according to Wissel Jörg
(2000), the decreasing pain levels

achieved in 90% of patients and a clear
reduction in pain was found in 6.8 ±
5.2 days [9]. Seven patients in our study
showed a reduction of pain after

botulinum A and 3 patients had a poststroke duration of over 43 months, and
four patients had a muscle spasticity with
a 3-point Ashworth score. The placement
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Journal of military pharmaco-medicine no3-2019
with no decreasing pain were seen in the
muscles of the shoulder and the knee,
where many mass muscles participate in
a movement.
To improve the level of pain associated
with spasticity, muscle spasticity groups
were injected with botulinum A at 1 and
3 months, there was a statistically
signigficant reduction in pain (p < 0.05).
At 6 months, pain level was significantly
lower than at admission but the difference
was not statistically significant (p > 0.05),
it was the time when botulinum was about
to expire. Our research results were
similar to Luong Tuan Khanh’s [1], John
W Dunne’s [3]. Yelnik et al carried a
randomized, double-blind, placebo-controlled
study of patients with shoulder pain due
to spasticity after stroke who received
botulinum A injections into the muscles
spasticity, showed that pain reduced more
than the control group, which had statistically
significant with p < 0.05 [7].

The cause of pain in muscle contraction
is not fully understood. There are now
many theories that explain spasticity and
pain. One of the theories is that the longterm and abnormal contraction of the
muscle acts on the artery wall, excessive
oxygen consumption gradually leads to
coercive muscle spasticity in the absence
of oxygen, resulting in the release of
inflammatory and painful mediators such
as bradykinin, prostaglandins (PGE2),
potassium in blood in the muscle and
tendon site; pain can be a long-term muscle
spasm that causes joint deformities,
arthritis pain. Pain is also a stimulant to
increase the degree of contraction of the
muscles, which is a pathological twist that
promote each other in the course of the
disease. Injection of botulinum toxin A
cuts neuromuscular transmission to
soften the muscles, cuting off the adverse
cycle and alleviates pain. The results
have been well documented and proven
in the treatment of postmenopausal
stroke and skull brain injury [8].

Table 4: Side effects (n = 102).
Painful spasticity

Painless spasticity

(n = 57); n; %

(n = 45); n; %

Bleeding at the injection site

11; 19.3%

09; 20.0%

> 0.05

Pain at the injection site

34; 59.6 %

30; 66.7%

> 0.05

Swine flu syndrome

03; 5.3%

02; 4.4%

> 0.05

Dry mouth

02; 3.5 %

02; 4.4%

> 0.05

Side effects

p

In our study, side effects of botulinum type A in patients with post-stroke spasticity
included pain at the injection site with 59.6%, bleeding at the injection site with 19.3%;
there was no difference between the two groups about adverse effects (p > 0.05).
These unwanted effects usually disappear after 3 days of injection. The rate of adverse
effects in the study was similar to that in other researches, according to John W Dunne,
the rate of patients with pain after injection with botulinum A was 61.3% [3].
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CONCLUSION
Through a study of 102 patients with
muscle spasticity after stroke in Stroke
Department, 103 Military Hospital, we drew
the following conclusions:
- The incidence of pain due to
spasticity in patients with post-stroke
muscle spasticity was 55.9%; mean
intensity of pain with pain score VAS was

2.35 ± 1.22; severe spasticity was present
in the adduction muscles of the shoulder
joint with 51.9%, and flexor muscles of
knee joint with 48.0%.
- After injecting botulinum in group A:
pain due to muscle spasticity at 1 month,
3 months decreased significantly compared
to the time of hospitalization (p < 0.05);
at 6-month post-injection, the pain level
increased at 1 and 3 months (VAS:
1.89 ± 0.7), but still lower than at admission.
- Side effects of injection of botulinum
A in pain treatment: pain at the injection
site with 59.6%, bleeding at the injection
site with 19.3%, the side effects disappeared
after 3 days.
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