Hemiplegic shoulder pain: Evidence of a neuropathic origin

Pulsed Radiofrequency Neuromodulation for Post-Stroke Shoulder Pain in Patients with Hemorrhagic Stroke

OBJECTIVE

Post-stroke shoulder pain (PSSP) is a common complication that limits the range of motion (ROM) of the shoulder, the patient's rehabilitation and in turn, affects the patients' quality of life (QoL). Several treatment modalities such as sling, positioning, strapping, functional electrical stimulation, and nerve block have been suggested in literatures, however none of the treatments had long-term effects for PSSP. In this study, the authors evaluated clinical efficacy of pulsed radiofrequency (PRF) neuromodulation on the suprascapular nerve for PSSP, and suggested it as a potential treatment with long-term effect.

METHODS

This retrospective case series was conducted at a single center, a private practice institution. From 2013 to 2021, 13 patients with PSSP underwent PRF neuromodulation of the suprascapular nerve. The primary outcome measure was the Visual analog scale (VAS) score. The secondary outcome measurements included the shoulder ROM, Disability assessment scale (DAS), modified Ashworth scale, modified Rankin scale (mRS), and EuroQol-5 dimension-3L questionnaire (EQ-5D-3L) scores. These parameters were evaluated before PRF modulation, immediately after PRF modulation, and every 3 months until the final follow-up visit.

RESULTS

Six men and seven women were enrolled, and all patients were followed-up for a minimum of 12 months. The mean VAS score was 7.07 points before PRF neuromodulation and 2.38 points immediately post-procedure. Shoulder ROM for abduction and flexion, DAS for pain, mRS, and EQ-5D-3L demonstrated marked improvement. No complications were reported.

CONCLUSION

PRF neuromodulation of the suprascapular nerve is an effective modality in patients with PSSP, and has long-term effect of pain relief, improvement of QoL.

Impact of Ultrasound-Guided Suprascapular Nerve Block in Stroke Survivors With Hemiplegic Shoulder Pain Undergoing Neurorehabilitation: A Retrospective Case Series

Background Hemiplegic shoulder pain (HSP) is one of the most common complications seen in stroke survivors. HSP is an important cause of disability in these patients and may act as a barrier to rehabilitation and functional recovery. Suprascapular nerve block (SSNB) has been shown to be an effective treatment option for managing HSP, and it may also improve overall functional and motor recovery. Methodology This is a retrospective case series. Six stroke patients with HSP received an ultrasound-guided SSNB as a part of their inpatient individualized neurorehabilitation program. They were evaluated before the intervention and at 4 and 12 weeks of follow-up. Primary outcome measures were the Shoulder Pain and Disability Index (SPADI) score, active range of motion (AROM), and the visual analog scale (VAS) score of the hemiplegic shoulder. Secondary outcome measures were the passive range of motion (PROM) and manual muscle testing (MMT) of the hemiplegic shoulder. Results Of the six patients, four (66.7%) were male, four (66.7%) had hypertension, and two (33.3%) were also suffering from diabetes mellitus. Improvement was seen in the VAS score and the pain subscale of SPADI in all six cases at 12 weeks of follow-up. VAS score improvement was between 40% and 100%, while SPADI pain subscale score improvement ranged from 21.74% to 100%. Total SPADI score improved in all cases, with improvement ranging from 7.94% to 54.55%. No Improvement was seen in four of the six cases in the SPADI disability subscale. AROM showed an improvement in three of the six cases, with the most improvement in flexion (up to 55.56%). PROM improved in all six cases for flexion and abduction and in four cases for external rotation. MMT of only two patients improved by at least two grades. Conclusions SSNB is a safe and effective treatment option for patients with HSP. Along with an improvement in pain, the addition of SSNB in neurorehabilitation may play an important role in aiding functional and motor recovery in stroke survivors with HSP.

Real-world evidence of durable multi-dimensional improvement after 60-day peripheral nerve stimulation treatment used for shoulder pain

Aim: This real-world analysis aims to quantify improvements in multiple health domains in patients who received 60-day peripheral nerve stimulation (PNS) for shoulder pain.Materials & methods: Patients reported percent pain relief and Patient Global Impression of Change in quality of life, physical function and sleep at the end of treatment (EOT), 3 months, and 6 months.Results: Of 768 patients, 80.7% were responders in at least one domain at EOT. In a subset who were followed up, a cumulative 75% continued to respond in at least one domain through 6 months (85% [n = 140/165] at 3 months and 88% [n = 53/60] at 6 months).Conclusion: 60-day PNS used for shoulder pain produced multi-dimensional improvements across health domains at EOT and through 6 months.

Pain tolerance after stroke: The Tromsø study

BACKGROUND

Stroke lesions might alter pain processing and modulation by affecting the widely distributed network of brain regions involved. We aimed to compare pain tolerance in stroke survivors and stroke-free persons in the general population, with and without chronic pain.

METHODS

We included all participants of the sixth and seventh wave of the population-based Tromsø Study who had been tested with the cold pressor test (hand in cold water bath, 3°C, maximum time 106 s in the sixth wave and 120 s in the seventh) and who had information on previous stroke status and covariates. Data on stroke status were obtained from the Tromsø Study Cardiovascular Disease Register and the Norwegian Stroke Register. Cox regression models were fitted using stroke prior to study attendance as the independent variable, cold pressor endurance time as time variable and hand withdrawal from cold water as event. Statistical adjustments were made for age, sex, diabetes, hypertension, hyperlipidaemia, body mass index and smoking.

RESULTS

In total 21,837 participants were included, 311 of them with previous stroke. Stroke was associated with decreased cold pain tolerance time, with 28% increased hazard of hand withdrawal (hazard ratio [HR] 1.28, 95% CI 1.10-1.50). The effect was similar in participants with (HR 1.28, 95% CI 0.99-1.66) and without chronic pain (HR 1.29, 95% CI 1.04-1.59).

CONCLUSIONS

Stroke survivors, with and without chronic pain, had lower cold pressor pain tolerance, with possible clinical implications for pain in this group.

SIGNIFICANCE

We found lower pain tolerance in participants with previous stroke compared to stroke-free participants of a large, population-based study. The association was present both in those with and without chronic pain. The results may warrant increased awareness by health professionals towards pain experienced by stroke patients in response to injuries, diseases and procedures.

Bibliometric Analysis of Post-Stroke Pain Research Published from 2012 to 2021

Background and Purpose

Pain is one of the most common symptoms in patients after stroke. It is a distressing experience that affects patients' quality of life, and it is highly prevalent in clinical practice. The pathogenesis mechanisms of PSP are not so clear, and there is currently a lack of effective medical treatments, hence it is necessary to establish a sufficient understanding of this disease. Limited number of studies have applied bibliometric methods to systematically analyze studies on post-stroke pain. This study aimed to systematically analyze scientific studies conducted worldwide on post-stroke pain from 2012 to 2021 to evaluate global trends in this field using a bibliometric analysis.

Methods

Publications related to post-stroke pain from 2012 to 2021 were obtained from the Web of Science Core Collection database. Bibliometrics Biblioshiny R-package software was used to analyze the relationship of publication year with country, institution, journals, authors, and keywords and to generate variant visual maps to show annual publications, most relevant countries, authors, sources, keywords, and top-cited articles.

Results

In this study, 5484 papers met the inclusion criteria. The annual growth rate of publications was 5.13%. The USA had the highest number of publications (1381, 25.2%) and citations (36,395), and the University of Toronto had the highest number of papers (156, 2.8%). "Stroke", "management", "pain", "risk", "prevalence", "ischemic stroke", "risk factors", "disease", "diagnosis" and "therapy" are the top 10 keywords.

Conclusion

The global research interest regarding PSP has maintained growing over the past ten years. Both central post stroke pain and hemiplegic shoulder pain are the hottest research subjects. Further investigations are needed in order to reveal the mystery of the pathophysiologic mechanisms of CPSP, and high-quality well-designed trials of potential treatments of CPSP and HSP are also needed.

Research Hotspots and Frontiers in Post Stroke Pain: A Bibliometric Analysis Study

Background

Pain is a common complication after stroke with a high incidence and mortality rate. Many studies in the field of pain after stroke have been published in various journals. However, bibliometric analysis in the domain of pain after stroke is still lacking. This study aimed to deliver a visual analysis to analyze the global trends in research on the comorbidity of pain after stroke in the last 12 years.

Methods

The publications from the Web of Science (WoS) in the last 12 years (from 2010 to 2021) were collected and retrieved. CiteSpace software was used to analyze the relationship of publication year with countries, institutions, journals, authors, references, and keywords.

Results

A total of 322 publications were included in the analysis. A continuous but unstable growth in the number of articles published on pain after stroke was observed over the last 12 years. The Peoples' R China (65), Chang Gung University (10), and Topic in Stroke Rehabilitation (16) were the country, institution, and journal with the highest number of publications, respectively. Analysis of keywords showed that shoulder pain after stroke and central post-stroke pain were the research development trends and focus in this research field.

Conclusion

This study provides a visual analysis method for the trend and frontiers of pain research after stroke. In the future, large sample, randomized controlled trials are needed to identify the potential treatments and pathophysiology for pain after stroke.

Early multidisciplinary prevention program of post-stroke shoulder pain: A randomized clinical trial

OBJECTIVE

To evaluate if positioning the upper-limb promoting abduction, external rotation and flexion of the shoulder reduces the intensity of post-stroke shoulder pain at day-7 compared to usual clinical practice.

DESIGN & SETTING

Prospective single-center randomized clinical trial using a superiority design comparing two preventive strategies of post-stroke shoulder pain in a stroke unit.

SUBJECTS

Patients were included within 2 days from a first symptomatic ischemic stroke affecting shoulder motor function.

INTERVENTIONS

Intervention group included specific positioning of the shoulder in abduction, external rotation and flexion in bed, chair and during mobilization. Control group referred to usual practice i.e. positioning using a standard support scarf.

MAIN MEASURES

Primary outcome was the intensity of shoulder pain assessed by the visual analog scale (VAS) (0-100) at day-7 post-stroke. Other outcomes measured at day-7 and 2 months post-stroke were the VAS, motor function, spasticity, depression, functional independence and rates of complex regional Pain syndrome (CRPS).

RESULTS

76 patients (49 males; mean age = 68.3) were randomized. The shoulder pain at day-7 was not different between the control group (16.1, SD = 27.4) and the intervention group (10.3, SD = 21.5, p = 0.18) as well as at 2 months (p = 0.12). A lower rate of depression was observed in the intervention group at 2 months 36.7% (CI95% 19.9;56.1) vs 52.9% (CI95% 35.1;70.2). No between-group difference in other outcomes was observed at 2 months.

CONCLUSIONS

This study failed to demonstrate the benefit of a specific positioning tool in reducing the intensity of post-stroke shoulder pain which was lower than previously reported in the literature.

Dissecting neuropathic from poststroke pain: the white matter within

ABSTRACT

Poststroke pain (PSP) is a heterogeneous term encompassing both central neuropathic (ie, central poststroke pain [CPSP]) and nonneuropathic poststroke pain (CNNP) syndromes. Central poststroke pain is classically related to damage in the lateral brainstem, posterior thalamus, and parietoinsular areas, whereas the role of white matter connecting these structures is frequently ignored. In addition, the relationship between stroke topography and CNNP is not completely understood. In this study, we address these issues comparing stroke location in a CPSP group of 35 patients with 2 control groups: 27 patients with CNNP and 27 patients with stroke without pain. Brain MRI images were analyzed by 2 complementary approaches: an exploratory analysis using voxel-wise lesion symptom mapping, to detect significant voxels damaged in CPSP across the whole brain, and a hypothesis-driven, region of interest-based analysis, to replicate previously reported sites involved in CPSP. Odds ratio maps were also calculated to demonstrate the risk for CPSP in each damaged voxel. Our exploratory analysis showed that, besides known thalamic and parietoinsular areas, significant voxels carrying a high risk for CPSP were located in the white matter encompassing thalamoinsular connections (one-tailed threshold Z > 3.96, corrected P value <0.05, odds ratio = 39.7). These results show that the interruption of thalamocortical white matter connections is an important component of CPSP, which is in contrast with findings from nonneuropathic PSP and from strokes without pain. These data can aid in the selection of patients at risk to develop CPSP who could be candidates to pre-emptive or therapeutic interventions.

The Effects of Gender, Functional Condition, and ADL on Pressure Pain Threshold in Stroke Patients

Background

Somatosensory impairments and pain are common symptoms following stroke. However, the condition of perception and pain threshold for pressure stimuli and the factors that can influence this in individuals with stroke are still unclear. This study aimed to investigate the gender differences in pressure pain threshold (PPT) and positive somatosensory signs for pressure stimuli, and explore the effects of joint pain, motor function, and activities of daily living (ADL) on pain threshold in post-stroke patients.

Design

A cross-sectional study.

Methods

A total of 60 participants with stroke were recruited, and their pain condition, motor functions, and ADL were evaluated by the Fugl-Meyer assessment of joint pain scale, motor function scale, and Barthel index, respectively. PPTs in eight tested points at the affected and unaffected sides were assessed.

Results

Significant differences in PPTs were found between male and female patients in all measured muscles (p < 0.05). Positive somatosensory signs for pressure stimuli, including hypoalgesia and hyperalgesia, were frequently found at the affected side, particularly in the extremity muscles, but such signs were not significantly influenced by gender (p > 0.05). More equal PPTs between both sides and relatively lower PPTs at the affected side in the trunk and medial gastrocnemius muscles (p < 0.05) were observed in patients with less pain, better motor functions, and ADL.

Conclusion

Gender differences widely exist in post-stroke survivors either at the affected or unaffected side, which are multifactorial. Sensory loss and central and/or peripheral sensitization, such as hypoalgesia and hyperalgesia for pressure stimuli, caused by a brain lesion are common signs in male and female stroke patients. Moreover, patients who are in a better condition show a more symmetrical pain sensitivity between both sides in the trunk and in female lower extremities, indicating the bidirectional improvement of somatosensory abnormalities caused by a possible neural plasticity.

Central neuropathic pain in multiple sclerosis is associated with impaired innocuous thermal pathways and neuronal hyperexcitability

OBJECTIVE

About a third of patients with multiple sclerosis (MS) suffer from chronic and excruciating central neuropathic pain (CNP). The mechanism underlying CNP in MS is not clear, since previous studies are scarce and their results are inconsistent. Our aim was to determine whether CNP in MS is associated with impairment of the spinothalamic-thalamocortical pathways (STTCs) and/or increased excitability of the pain system.

DESIGN

Cross sectional study.

SETTING

General hospital.

SUBJECTS

47 MS patients with CNP, 42 MS patients without CNP, and 32 healthy controls.

METHODS

Sensory testing included the measurement of temperature, pain, and touch thresholds and the thermal grill illusion (TGI) for evaluating STTCs function, and hyperpathia and allodynia as indicators of hyperexcitability. CNP was characterized using interviews and questionnaires.

RESULTS

The CNP group had higher cold and warm thresholds (p < 0.01), as well as higher TGI perception thresholds (p < 0.05), especially in painful body regions compared to controls, whereas touch and pain thresholds values were normal. The CNP group also had a significantly greater prevalence of hyperpathia and allodynia. Regression analysis revealed that whereas presence of CNP was associated with a higher cold threshold, CNP intensity, and the number of painful body regions were associated with allodynia and hyperpathia, respectively.

CONCLUSIONS

CNP in MS is characterized by a specific impairment of STTC function; the innocuous thermal pathways, and by pain hyperexcitability. Whereas CNP presence is associated with STTC impairment, its severity and extent are associated with pain hyperexcitability. Interventions that reduce excitability level may therefore mitigate CNP severity.

Prevalence and Management Challenges in Central Post-Stroke Neuropathic Pain: A Systematic Review and Meta-analysis

Introduction

Central post-stroke pain (CPSP) is defined as the neuropathic pain that arises either acutely or in the chronic phase of a cerebrovascular event and is a result of central lesions of the somatosensory tract. The aim of this systematic review and meta-analysis was to establish the prevalence of CPSP, to describe its characteristics, and to discuss the associated management challenges.

Methods

After a systematic Medline search, we identified 69 papers eligible to be included.

Results

The pooled prevalence of CPSP in patients with stroke at any location was 11% (95% CI 7–18%), which can increase to more than 50% in the subgroups of patients with medullary or thalamic strokes. CPSP onset coincides with stroke occurrence in 26% of patients (95% CI 18–35%); CPSP manifests within a month since symptom onset in 31% of patients (95% CI 22–42%), and occurs between the first month and the first year in 41% of patients (95% CI 33.9–49.0%). CPSP develops more than 12 months after stroke onset in 5% of patients (95% CI 3–8%).

Conclusions

Clinicians should look for any evidence of central neuropathic pain for at least 12 months after stroke. Both pharmacological and non-pharmacological interventions can be used for the management of CPSP. Lamotrigine has the strongest evidence (Level II of evidence, derived from small randomized controlled trials) for being effective in the management of CPSP. Future research should focus on well-designed trials of pharmacological and non-pharmacological interventions aiming to relief CPSP, which is a very common but often neglected pain syndrome.

Electronic supplementary material

The online version of this article (10.1007/s12325-020-01388-w) contains supplementary material, which is available to authorized users.

Short- and medium-term effect of kinesio taping or electrical stimulation in hemiplegic shoulder pain prevention: A randomized controlled pilot trial

OBJECTIVE

To compare the short and medium-term effectiveness of combining Kinesio Tape (KT) or neuromuscular electrical stimulation (NMES) with a conventional approach to prevent shoulder pain after stroke.

METHODS

Thirty-one first-time stroke survivors (58.06% females) were recruited and randomly assigned to one group; Control (n = 10), KT (n = 11), or NMES (n = 10). Ten of all participants were lost during follow-up because of death or a second stroke. The control group underwent conventional treatment (careful shoulder handling and daily mobilizations). This approach was combined with KT or NMES over deltoid muscles in the KT and NMES groups respectively. Measurements were taken at baseline, and at weeks 1, 2, 3, 4, 12, and 24 post-stroke. Data collected included self-perceived shoulder pain (Visual Analogue Scale), disability (Barthel Index and Berg scale), and upper limb function (Action Research Arm test).

RESULTS

In all groups, shoulder pain did not appear during the first month (p < 0.001), but increased afterwards. In the between-groups analysis, all groups similarly improved disability and function, and no significant differences were observed for any measure (p > 0.05).

CONCLUSION

The combination of KT or NMES with conventional treatment is no superior to conventional treatment alone to prevent hemiplegic shoulder pain.

Botulinum Toxin for Central Neuropathic Pain

Botulinum toxin (BTX) is widely used to treat muscle spasticity by acting on motor neurons. Recently, studies of the effects of BTX on sensory nerves have been reported and several studies have been conducted to evaluate its effects on peripheral and central neuropathic pain. Central neuropathic pain includes spinal cord injury-related neuropathic pain, post-stroke shoulder pain, multiple sclerosis-related pain, and complex regional pain syndrome. This article reviews the mechanism of central neuropathic pain and assesses the effect of BTX on central neuropathic pain.

Shoulder pain after stroke - experiences, consequences in daily life and effects of interventions: a qualitative study

PURPOSE

To describe experiences of shoulder pain after stroke, how pain affects daily life and perceived effects of interventions.

METHOD

A qualitative interview study including 13 community-dwelling persons (six women; median age 65 years) with persistent shoulder pain after stroke.

RESULTS

Three categories emerged from the content analysis. In "Multiple pain characteristics" an insidious pain onset was reported. The pain existed both day and night and could be located around the shoulder girdle but also have radiation to the arm and hand. An explanation of the pain was seldom given. In "Limitations caused by the pain" it was described how the pain negatively influenced personal care, household activities and leisure, but also could lead to emotional reactions. In "Multiple pain interventions with various effects" a variety of interventions were described. Self-management interventions with gentle movements were perceived most effective. A restraint attitude to pain medication due to side effects was reported.

CONCLUSIONS

Shoulder pain after stroke can lead to a variety of pain characteristics. As the pain is complex and may affect many important areas in a person's life, multidisciplinary rehabilitation interventions are important. Implications for rehabilitation Shoulder pain after stroke can lead to a variety of pain characteristics with radiation to the arm and hand Shoulder pain often influence personal care, household activities and leisure negatively, which may lead to emotional reactions Self-management interventions with gentle movements are perceived most effective As the shoulder pain after stroke is complex, interventions by a multidisciplinary team may be needed.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Botulinum Toxin Type A for the Treatment of Neuropathic Pain in Neuro-Rehabilitation

Pain is a natural protective mechanism and has a warning function signaling imminent or actual tissue damage. Neuropathic pain (NP) results from a dysfunction and derangement in the transmission and signal processing along the nervous system and it is a recognized disease in itself. The prevalence of NP is estimated to be between 6.9% and 10% in the general population. This condition can complicate the recovery from stroke, multiple sclerosis, spinal cord lesions, and several neuropathies promoting persistent disability and poor quality of life. Subjects suffering from NP describe it as burning, itching, lancing, and numbness, but hyperalgesia and allodynia represent the most bothersome symptoms. The management of NP is a clinical challenge and several non-pharmacological and pharmacological interventions have been proposed with variable benefits. Botulinum toxin (BTX) as an adjunct to other interventions can be a useful therapeutic tool for the treatment of disabled people. Although BTX-A is predominantly used to reduce spasticity in a neuro-rehabilitation setting, it has been used in several painful conditions including disorders characterized by NP. The underlying pharmacological mechanisms that operate in reducing pain are still unclear and include blocking nociceptor transduction, the reduction of neurogenic inflammation by inhibiting neural substances and neurotransmitters, and the prevention of peripheral and central sensitization. Some neurological disorders requiring rehabilitative intervention can show neuropathic pain resistant to common analgesic treatment. This paper addresses the effect of BTX-A in treating NP that complicates frequent disorders of the central and peripheral nervous system such as spinal cord injury, post-stroke shoulder pain, and painful diabetic neuropathy, which are commonly managed in a rehabilitation setting. Furthermore, BTX-A has an effect in relief pain that may characterize less common neurological disorders including post-traumatic neuralgia, phantom limb, and complex regional pain syndrome with focal dystonia. The use of BTX-A could represent a novel therapeutic strategy in caring for neuropathic pain whenever common pharmacological tools have been ineffective. However, large and well-designed clinical trials are needed to recommend BTX-A use in the relief of neuropathic pain.

Brain computer interfaces for neurorehabilitation – its current status as a rehabilitation strategy post-stroke

The idea of using brain computer interfaces (BCI) for rehabilitation emerged relatively recently. Basically, BCI for neurorehabilitation involves the recording and decoding of local brain signals generated by the patient, as he/her tries to perform a particular task (even if imperfect), or during a mental imagery task. The main objective is to promote the recruitment of selected brain areas involved and to facilitate neural plasticity. The recorded signal can be used in several ways: (i) to objectify and strengthen motor imagery-based training, by providing the patient feedback on the imagined motor task, for example, in a virtual environment; (ii) to generate a desired motor task via functional electrical stimulation or rehabilitative robotic orthoses attached to the patient's limb – encouraging and optimizing task execution as well as "closing" the disrupted sensorimotor loop by giving the patient the appropriate sensory feedback; (iii) to understand cerebral reorganizations after lesion, in order to influence or even quantify plasticity-induced changes in brain networks. For example, applying cerebral stimulation to re-equilibrate inter-hemispheric imbalance as shown by functional recording of brain activity during movement may help recovery. Its potential usefulness for a patient population has been demonstrated on various levels and its diverseness in interface applications makes it adaptable to a large population. The position and status of these very new rehabilitation systems should now be considered with respect to our current and more or less validated traditional methods, as well as in the light of the wide range of possible brain damage. The heterogeneity in post-damage expression inevitably complicates the decoding of brain signals and thus their use in pathological conditions, asking for controlled clinical trials.

Incidence and associations of hemiplegic shoulder pain poststroke: prospective population-based study

OBJECTIVE

To provide an epidemiological perspective of the clinical profile, frequency, and determinants of poststroke hemiplegic shoulder pain.

DESIGN

A prospective population-based study of an inception cohort of participants with a 12-month follow-up period.

SETTING

General community and hospital within a geographically defined metropolitan region.

PARTICIPANTS

Multiple ascertainment techniques were used to identify 318 confirmed stroke events in 301 individuals. Among adults with stroke, data on shoulder pain were available for 198 (83% of the survivors) at baseline and for 156 and 148 at 4 and 12 months, respectively.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Subjective reports of onset, severity, and aggravating factors for pain and 3 passive range-of-motion measures were collected at baseline and at 4- and 12-month follow-up.

RESULTS

A total of 10% of the participants reported shoulder pain at baseline, whereas 21% reported pain at each follow-up assessment. Overall, 29% of all assessed participants reported shoulder pain during 12-month follow-up, with the median pain score (visual analog scale score=40) highest at 4 months and more often associated with movement at later time points. Objective passive range-of-motion tests elicited higher frequencies of pain than did self-report and predicted later subjective shoulder pain (crude relative risk of 3.22 [95% confidence interval, 1.01-10.27]).

CONCLUSIONS

The frequency of poststroke shoulder pain is almost 30%. Peak onset and severity of hemiplegic shoulder pain in this study was at 4 months, outside of rehabilitation admission time frames. Systematic use of objective assessment tools may aid in early identification and management of stroke survivors at risk of this common complication of stroke.

Pain management of hemiplegic shoulder pain post stroke in patients from Nanjing, China

We selected 106 hemiplegic patients with shoulder pain hospitalized after stroke from three hospitals in Nanjing, China between February 2007 and January 2012. All patients had complete clinical data sets and accounted for 45.5% of the inpatients because of stroke. Results showed that the number of patients with hemiplegic shoulder pain post stroke increased yearly, attacking mainly males 50-69 years of age. Of 106 patients, there were 60 cases (56.6%) of adhesive capsulitis, 19 (17.9%) of shoulder subluxation, 14 (13.2%) of complex regional pain syndrome, and 13 (12.6%) of central pain. The main symptoms were shoulder pain (100%), limit of shoulder mobility (98.1%), and adhesion of the scapula (56.6%). MRI of the shoulder showed tendon and ligament lesions (57.1%) and rotator cuff tear (38.1%). 53.8% of central pain was related to the thalamus, in addition to the basal ganglia, brain stem, and cerebellopontine angle. Shoulder pain, upper limb motor function, and function independence were significantly improved after comprehensive rehabilitation. In particular, electroacupuncture based on basic physical therapy exhibited efficacy on shoulder tion and complex regional pain syndrome. Multiple linear regression results showed a negative relationship of efficacy of pain management with the attack period of shoulder pain, involvement of the posterior limb of the internal capsule, and duration between onset and rehabilitation treatment, but a positive correlation with pain-related education, pain regression period, and pain diagnosis.

Suprascapular Nerve Block for Shoulder Pain in the First Year After Stroke

Background and Purpose—

Shoulder pain is a common complication after stroke that can impede participation in rehabilitation and has been associated with poorer outcomes. Evidence-based treatments for hemiplegic shoulder pain are limited. Suprascapular nerve block (SSNB) is a safe and effective treatment of shoulder pain associated with arthritic shoulder conditions, but its usefulness in a stroke population is unclear.

Methods—

We undertook a randomized controlled trial assessing the effectiveness of SSNB in a population of 64 stroke patients (onset < 1 year) with hemiplegic shoulder pain. The primary outcome was pain measured on a visual analogue scale (VAS). Secondary outcomes were disability (Modified Rankin Scale, Croft Disability Index) and quality of life (EuroQol Health Questionnaire). All participants were assessed before randomization, and at 1, 4, and 12 weeks postintervention. Both groups continued with routine therapy.

Results—

Although both intervention and control groups demonstrated reduction in pain score, participants who received SSNB consistently demonstrated superior, statistically significant pain reduction compared with placebo. Mean VAS reduction in the SSNB group was >18 mm greater than participants receiving placebo injection. The number needed to treat with SSNB to reduce 1 stroke survivor’s pain by 50% at 4 weeks is 4. No significant differences in function or quality of life were observed. No adverse events were reported.

Conclusions—

Suprascapular nerve block is a safe and effective treatment for patients with hemiplegic shoulder pain.

Clinical Trial Registration—

URL: http://www.anzctr.org.au . Unique identifier: ACTRN12609000621213.