Study setting {9}
The study was a 4-week randomized, double-blind controlled trial (Figure 1). The research center is the Zhujiang Hospital of Southern Medical University, which has received the ethics approval (Reference number :2022-KY-269-03). All patients in this study will be required to provide informed consent prior to data collection. Trials will be reported in accordance with CONSORT guidelines.
Eligibility criteria {10}
Inclusion criteria:
(1) Conform to the diagnostic criteria of stroke in Diagnostic Essentials of Major Cerebrovascular Diseases in China 2019, the diagnosis was confirmed by craniocerebral CT or MRI examination.
(2) First onset of stroke, age 18-80 years old, duration ≤6 months.
(3) Visual analog scale (VAS) for pain during passive abduction or external rotation of shoulder joint ≥4 points
(4) Shoulder joint drug injection was not performed in half a year
(5) The modified Ashworth Scale for external rotation or abduction of shoulder joint was rated between 0-Ⅰ+
(6) Ultrasound of shoulder joint: the patient showed no accompanying acromion-deltoid slide bursitis or biceps brachialis tendinitis
(7) There are no other bone, joint and muscle diseases or other neurological diseases that significantly affect motor function.
(8) No obvious communication and understanding obstacles, able to carry out normal communication and cooperate with the completion of the experiment.
(9) The vital signs are stable and can cooperate with the examination.
Exclusion criteria
(1) Allergy to botulinum toxin or glucocorticoid;
(2) Intra-articular glucocorticoid or botulinum toxin injection of shoulder in the last 6 months;
(3) Previous history of shoulder joint surgery, frozen shoulder, rotator cuff injury, and shoulder joint trauma;
(4) have other diseases more painful than hemiplegia shoulder pain;
(5) active malignant tumors;
(6) Coagulopathy, diabetes mellitus, gastric ulcer, infection (within the last 6 months);
(7) Currently taking oral glucocorticoids, non-steroidal anti-inflammatory drugs or immunosuppressive drugs;
(8) Pregnant and lactating women;
(9) Those who have not signed the informed consent.
Who will take informed consent? {26a}
Participants were briefed about the trial before the trial began, and if the patient consented, a written informed consent stating that the patient was willing to participate was obtained.
Additional consent provisions for collection and use of participant data and biological specimens {26b}
Not applicable. The study used primarily subjective scales to assess efficacy, and the trial did not involve collection of biospecimens for storage.
Intervention
Explanation for the choice of comparators {6b}
Local injection of botulinum toxin is an effective method for the treatment of shoulder pain. In order to reduce the time and energy spent in the hospital, we selected a single injection of botulinum toxin to verify its value in the treatment of hemiplegic shoulder pain.
Intervention description {11a}
Patients were randomly assigned to trial group (botulinum toxin) or a control group (triamcinolone acetate). Each group received an injection at baseline. The experimental group was given the injection of botulinum toxin in the shoulder joint cavity, the injection dose was 100IU, and 2ml normal saline was mixed in advance, that is, the total drug was 2ml. The control group will receive injections of triamcinolone acetate into the shoulder joint cavity, and 2ml of total drug will also be injected into the shoulder joint cavity of the control group, including 1ml of triamcinolone acetate and 1ml of normal saline.
Injections of botulinum toxin or triamcinolone acetate into the shoulder joint cavity will be operated under ultrasound guidance. The process is as follows: (1) Patient in lateral position, the affected shoulder to the top and the affected hand is placed on the healthy side of the chest; (2) The ultrasound probe is placed transversely under the scapular gonad and swept anteriorly and posteriorly to reveal the infraspinatus muscle and the articular glenoid; (3) Routinely disinfect the towel, hold the probe in one hand, hold the syringe in the other hand, use the lower part of the external scapular gonad as the entry point (Figure 2) and enter the needle inwards (Figure 3); (4) Place the needle in the shoulder joint cavity under ultrasound guidance and slowly push the drug.
Criteria for discontinuing or modifying allocated interventions {11b}
There will be no special criteria for discontinuing or modifying allocated interventions.
Strategies to improve adherence to interventions {11c}
In this study, all treatments were performed by the investigators. All treatments will be recorded and reported in the adherence instructions.
Relevant concomitant care permitted or prohibited during the trial {11d}
During the trial, injections of any analgesics or oral analgesics into the shoulder were not allowed
Provisions for post-trial care {30}
If participants are injured or suffer any discomfort as a result of this study, they are entitled to free treatment and/or compensation for injuries related to this clinical study in accordance with Chinese law.
Outcomes {12}
All assessments (VAS, upper limb Fugl-Meyer scores, passive range of motion (ROM) improvement, spasticity (MAS) improvement) and regarding painkillers use will be applied at the baseline, 1 week and 4 week follow-up visits. fNIRS assessments include dorsolateral prefrontal area (DLPFC), primary motor area (M1), primary sensory area (S1) oxyhaemoglobin versus total haemoglobin levels, which will be checked at baseline, 1 week and 4 week follow up. Other measures include demographics, history taking, and ultrasound of the shoulder joint in the study will be recorded at screening only. Adverse events were documented as described in the results.
VAS score
Shoulder pain was assessed using a 100mm VAS (1 point per 1mm). Shoulder pain was measured under passive abduction and passive external rotation. The standard question used was: "How would you rate the pain level in your shoulder joint during this movement?"
fNIRS assessments
This experiment used a portable near-infrared functional brain imager (NirSmart, Danyang Huichuang Medical Equipment Co., Ltd., China) to record the cortical activation state. Our equipment consisted of 13 light sources and 15 detectors, making up a total of 35 channels, with an average distance between light sources and detectors of 2.7 cm. Reference was made to the international 10-20 system for localization33, with the Cz point and Fpz point marked as standard localization points.
Subjects carry a special backpack to carry the fNIRS mainframe which transmits the data to the computer via wireless mode. Based on previous studies, the present study selected bilateral DLPFC, M1, and S1, which have been shown to be associated with sensory function, for testing. In this study, we examined bilateral PFC and S1 brain regions associated with sensory functions, and their channels corresponded to cortical distributions in CH17, CH20, CH22, CH26, CH27, CH31, CH36, CH43, CH48, CH49. During the fNIRS test, the room temperature was kept at a comfortable constant and the room was kept quiet. The patient is guided by audio to remain quietly in a seated position (Figure 4) and is informed that self-activity and communication are prohibited during the test. Measurements will be taken in the resting state and in the shoulder joint external rotation and abduction state, three times in each state and averaged.
Data analysis for this experiment focused on oxyhaemoglobin (HbO) concentration as a marker of cortical activation, as it is the most sensitive and reliable indicator of changes related to regional brain oxygenation movements. NirSpark software was used to analyse the fNIRS data. Oxygenated hemoglobin concentrations for each region are superimposed and averaged to produce results for that region. By analysing the trend of each parameter, it is possible to see the variation of each channel in the task state versus the resting state.
Upper limb Fugl-Meyer scores
The Fugl-Meyer motor function assessment with the upper limb containing 33 items for assessment. This test only requires the assessment of the patient's upper limb motor function. 1. presence or absence of reflex activity 2. flexor synergism 3. extensor synergism 4. activity with synergism 5. activity out of synergism 6. hyperreflexia 7. wrist stability 8. elbow extension with 30° of shoulder flexion 9. fingers 10. synergism and speed (finger finger-nose test 5 times in a row) 10 items, each with different sub-items, each with a score of 0-2.
Shoulder ROM
1. Passive anterior flexion (0° to 170°)
Position: sitting or supine (humerus in neutral position).
Goniometer placement: The axis is located at the lateral crest of the humerus, the fixed arm is parallel to the trunk and the movable arm is parallel to the humerus.
2. Passive abduction (0° to 180°)
Position: seated or prone (humerus in externally rotated position).
Goniometer placement: the axis is located posterior to the acromion, the fixed arm is parallel to the trunk and the movable arm is parallel to the humerus.
3. Passive external rotation (0° to 90°)
Position: sitting or supine (90° elbow flexion, 90° shoulder abduction, forearm rotation posterior).
Protractor placement: axis at the eminence, fixed and mobile arms parallel to the forearm. Note: The fixed arm remains in its original position parallel to the ground when the shoulder is externally rotated, while the mobile arm follows the forearm.
Spasticity (MAS)
A scale for grading muscle tone and assessing spasticity based on passive joint movement resistance. The speed of movement is the completion of a joint movement in 1s. There are 5 levels: Grade 0, no muscle tone; Grade 1, a slight increase in muscle tone, passive flexion and extension of the affected part with minimal resistance or sudden catch and release at the end of the joint range of movement; Grade 1+, a mild increase in muscle tone with sudden catch in the second 50% of the joint range of movement and then minimal resistance in the second 50% of the joint range of movement; Grade 2, a more pronounced increase in muscle tone with a more pronounced; Grade 3, severe increase in muscle tone, with difficulty in passive movement; Grade 4, tonicity, with stiffness and immobility of the affected part during passive flexion and extension.
Participant timeline {13}
The participant timeline is presented in Table 1.
Table 1. Schedule of data collection
VAS: visual analogue scale;
# Functional near infrared imaging examination includes: the primary motor area (M1), dorsolateral prefrontal area (DLPFC), and primary sensory area (S1).
Sample size {14}
This study was a randomised controlled trial with botulinum toxin injections in the experimental group and glucocorticoid (tretinoin acetate) injections in the control group. The main regression indicator observed was the VAS pain score.
In this study, the sample size was calculated with reference to similar relevant literature and pre-experimental results. The sample size was calculated using two independent sample mean validity tests using G-Power version 3.1.2 software. It was assumed that the means of the two groups were equal at baseline, that there was a 1-point difference in VAS pain score between the two groups at the first post-treatment assessment, and that the standard deviation of the two groups was 1.4, which should be consistent at each subsequent assessment, measured as an effect size (i.e. Cohen d, 0.71). Based on these magnitudes, Alpha = 0.05 two-tailed was set. To achieve 80% efficacy, 32 patients per group were counted as study subjects. To compensate for potential loss to follow-up, approximately 20% of patients were added, with a final inclusion target of 78 patients (39 in each group).
Recruitment {15}
Participants will be recruited through: (1) advocacy by participating clinical teams for presenting patients with hemiplegic shoulder pain; (2) mobilizing the surrounding community hospitals to publicize; (3) Posting recruitment advertisements in hospitals and surrounding communities; (4) use social media to post and disseminate e-recruitment advertisements.
Assignment of interventions: allocation
Sequence generation {16a}
This study, subjects were divided into experimental and control groups in a 1:1 ratio using a completely randomized method. Random numbers were generated using SPSS software, a random allocation table was prepared and the drugs were blindly packed according to the random allocation table. Each subject was allocated a group of drugs with the subject number displayed on the drug label. The subject number corresponded to the corresponding random number, drug label and drug name.
Concealment mechanism {16b}
Allocation concealment will be ensured, the randomisation code will not be generated until the patient has completed all baseline measurements. The drugs were packaged and sealed uniformly by a person unrelated to the trial. Each of the random numbers assignment are to be written on a piece of paper and enclosed in a sealed envelope.
Implementation {16c}
Trial assistants will generate and maintain the allocation sequence but will not be involved in the overall treatment process. The principal investigator will group participants according to their No. Participants will not be allowed to change their group assignment after allocation.
Assignment of interventions: Blinding
Who will be blinded {17a}
This trial was a double-blind design, with subjects and investigators (including outcome measures and statisticians etc.) not aware of the grouping. The physician who injected the drug was unblinded in this trial as the test drug used in this trial was a colourless, clear liquid with a different appearance to the cloudy glucocorticoid liquid used in the control group. This physician is not involved in the rest of the trial and must be out of the view of the subject and investigator when preparing the drug and injecting it.
Procedure for unblinding if needed {17b}
There is an emergency unblinding contingency letter, which is numbered to match the subject number and contains instructions for the study drug grouping. If a serious adverse event occurs requiring emergency unblinding, the investigator will open the blinded envelope with the appropriate subject number to determine the drug grouping of the subject.
Data collection and management
Plans for assessment and collection of outcomes {18a}
Data collection will be conducted by questionnaire and automatically stored in a mobile database. The database will be collaboratively managed by the research team. Subsequent data analysis will be performed by the statistical analyst, ensuring that both the allocation and the intervention protocol remain blinded.
Plans to promote participant retention and complete follow-up {18b}
To improve patient retention, we planned a short-term follow-up (4 weeks) to maximize the completeness of data collection and minimize the risk of dropout.
Data management {19}
Data collection: Two testers will assess each subject on each of the scales in strict accordance with the requirements of the test. The "Basic Profile Questionnaire" and the results of each scale for each subject should include the number, date of assessment and name of each subject.
Data recording: The original medical record and the CRF results should be recorded truthfully and carefully as required and the contents should not be changed once completed. If a correction is required due to a genuine error, the original record should not be altered, but only by means of an additional narrative, signed and dated by the responsible study physician.
All results from clinical trials are verified in detail and documented as early as possible to ensure that the data is authentic and reliable.
The various equipment, instruments and drugs used in clinical research should have strict quality and safety standards and be guaranteed to be used under normal conditions.
Confidentiality {27}
To ensure privacy, each patient will be assigned an ID number to hold personal information and contact details.
Plans for collection, laboratory evaluation and storage of biological specimens for genetic or molecular analysis in this trial/future use {33}
No biological specimens will be collected in the present study.
Statistical methods
Statistical methods for primary and secondary outcomes {20a}
All statistical inferences were performed by two-sided test, the test level of statistical significance was set as 0.05, and the confidence interval of parameters was 95%. The count data describe the number of cases and percentage, and the measurement data describe the mean, standard deviation, minimum, maximum, median, 25th and 75th quantiles. The counting data give the frequency distribution and the corresponding percentage. Qualitative data give the number of cases of positive rate, positive number and denominator.
Shapiro-Wilk test was used to verify the normality of the variables. For normally distributed variables, continuous variables are represented by "mean ± standard deviation"; For data that is not normally distributed, it is represented by "median, interquartile".
In the analysis of baseline data, the independent sample t test was used to compare the normal distribution between the measurement data groups. The t 'test was used to compare the non-normal distribution measurement data groups. Mann-Whitney U test was used to compare ordered categorical variables between groups.
Repeated measure ANOVA was used to study the independent effects, main effects, and interactions of time and grouping. p<0.05 was considered statistically significant. Intentionality and protocol sets will be used to analyze primary and secondary outcomes. The results of intentionality treatment analysis were compared with those of protocol set analysis to determine whether the results were consistent. Missing data are processed as carried forward from the last observation. Adverse events will be listed and analyzed using Chi-square tests or Fisher precision tests. Analyze test results using IBM SPSS24.0 software.
Interim analyses {21b}
One interim analysis was to be performed when 39 patients had been enrolled. The investigators performed the analyses according to methods described in the statistical plan to ensure the robustness and validity of the analyses. All results will be discussed with the PI.
Methods for additional analyses (e.g. subgroup analyses) {20b}
Sub-group analyses are not foreseen.
Methods in analysis to handle protocol non-adherence and any statistical methods to handle missing data {20c}
Missing data will be addressed using multiple inference methods. Analyses were performed in the imputed data sets, and the results were summarized to ensure that the data were unbiased and the inferences were reliable.
Plans to give access to the full protocol, participant level-data and statistical code {31c}
The study protocol and data analysis will be obtained from the corresponding author according to the protocol.
Oversight and monitoring
Composition of the coordinating centre and trial steering committee {5d}
The ethics committee of Zhujiang Hospital Affiliated to Southern Medical University will supervise the researchers and all levels of the study to ensure that the study follows ethical principles and protects the health of patients.
Composition of the data monitoring committee, its role and reporting structure {21a}
A data monitoring committee was not required because of the short duration of our trial and the known low risks. But researchers will regularly analyze the data and make adjustments.
Adverse event reporting and harms {22}
Adverse events for patients will be recorded at each follow-up visit. Adverse events are defined as all negative events of consequence that occur during the trial, regardless of their relationship to the study content, and need to be recorded when they occur. Details of the relevant event will also be recorded and a determination made as to whether it is an adverse event.
We will report and manage adverse events associated with drug injections in detail, mainly induced muscle atrophy. Participants were encouraged to keep a daily training diary to monitor their physical condition. This is a quick way to identify and mitigate any potential hazards.
Frequency and plans for auditing trial conduct {23}
Our study will have scheduled audits every 4 weeks. The audit included data on participants' personal information, written informed consent, and primary and secondary assessment scales. In addition, we will carefully review good practice for treatment safety, reporting of adverse events, and completeness and accuracy of data collection. Routine audits reinforced methodological rigor and ethical compliance.
Plans for communicating important protocol amendments to relevant parties (e.g. trial participants, ethical committees) {25}
Any measures that may affect the study protocol, patient interests, or patient safety need to be modified. This includes aspects such as study objectives, study design, demographics, sample size, etc. All proposed changes need to be submitted to the Ethics Committee of Zhujiang Hospital Affiliated to Southern Medical University for approval. The revised protocol can proceed only after the necessary ethical approval has been obtained.
Dissemination plans {31a}
The findings of the study will be released to participants, medical professionals, the general public, and other relevant groups through publications.