Yonsei Med J.  2016 Mar;57(2):490-495. 10.3349/ymj.2016.57.2.490.

Comparison between Steroid Injection and Stretching Exercise on the Scalene of Patients with Upper Extremity Paresthesia: Randomized Cross-Over Study

• Kim YW
• Yoon SY
• Park Y
• Chang WH
• Lee SC

• KMID: 2374058
• DOI: http://doi.org/10.3349/ymj.2016.57.2.490

Abstract

PURPOSE
To compare the therapeutic effects on upper extremity paresthesia of intra-muscular steroid injections into the scalene muscle with those of stretching exercise only.
MATERIALS AND METHODS
Twenty patients with upper extremity paresthesia who met the criteria were recruited to participate in this single-blind, crossover study. Fourteen of 20 patients were female. The average age was 45.0+/-10.5 years and duration of symptom was 12.2+/-8.7 months. Each participant completed one injection and daily exercise program for 2 weeks. After randomization, half of all patients received ultrasound-guided injection of scalene muscles before exercise, while the other was invested for the other patients.
RESULTS
After two weeks, there was a significant decrease of the visual analog scale score of treatment effect compared with baseline in both groups (6.90 to 2.85 after injection and 5.65 to 4.05 after stretching exercise, p<0.01). However, injection resulted in greater improvements than stretching exercise (p<0.01). The number of patients with successful treatment, defined as >50% reduction in post-treatment visual analog scale, was 18 of 20 (90.0%) after injection, compared to 5 of 20 (25.0%) after stretching exercise. There were no cases of unintended brachial plexus block after injection.
CONCLUSION
Ultrasound-guided steroid injection or stretching exercise of scalene muscles led to reduced upper extremity paresthesia in patients who present with localized tenderness in the scalene muscle without electrodiagnostic test abnormalities, although injection treatment resulted in more improvements. The results suggest that symptoms relief might result from injection into the muscle alone not related to blockade of the brachial plexus.

Keyword

Thoracic outlet syndrome; scalene muscle; ultrasound; injection

MeSH Terms

Adult
Brachial Plexus/*drug effects
Cross-Over Studies
*Exercise Therapy
Female
Humans
*Injections, Intramuscular
Male
Middle Aged
Neck Muscles/drug effects
Pain/drug therapy
Pain Measurement
Paresthesia/*drug therapy/rehabilitation
Single-Blind Method
Thoracic Outlet Syndrome/diagnosis/*drug therapy
Treatment Outcome

Figure

• 

  Fig. 1 Visualization of the cross-over design. AB=a participant who first received one intra-muscular injection then did stretching exercise. BA=a participant who first did stretching exercise then received one intra-muscular injection. At T1=just before an initial treatment, T2=2 weeks after an initial treatment, all participants were assessed with visual analog scale for upper extremity paresthesia. To avoid carry-over effects from the previous treatment, each treatment was separated by a one-week rest.

• 

  Fig. 2 Injection into the anterior and middle scalene muscle under ultrasound guidance. (A) Transverse image of anterior and middle scalene muscles. (B) Longitudinal image of anterior scalene muscle for in-plane approach. A color Doppler image showed branches of subclavian artery. A dash line indicated needle pathway. (C) Longitudinal image of middle scalene muscle for in-plane approach. AS, anterior scalene muscle; MS, middle scalene muscle; a dashed circle, brachial plexus; a dash arrow, needle pathway.

• 

  Fig. 3 Effect of each treatment. Visual analog scale (VAS) changed significantly after injection and exercise (p<0.01), and VAS after injection decreased more compared to that after exercise (p<0.01).

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