Percutaneous intramuscular neuromuscular electric stimulation for the treatment of shoulder subluxation and pain in patients with chronic hemiplegia: a pilot study

Assessment approaches for hemiplegic shoulder pain in people living with stroke - A scoping review

PURPOSE

Hemiplegic shoulder pain (HSP) is reported in up to 40% of people with stroke. Causes of HSP are often multifactorial. To inform appropriate treatment, reliable/valid assessments are critical. The aim of this scoping review was to collate assessment approaches used in studies where the primary outcome was HSP, and to identify how frequently each assessment approach was used.

METHODS

A systematic search, including studies from 2000-2023 was conducted of the MEDLINE, EMBASE, CINAHL, AMED, Biomed Central, and Cochrane Library databases, with four key terms used: "assess", "stroke", "pain" and "shoulder". All primary studies published in English language fulfilling the reviews inclusion criteria were included. Six reviewers extracted the data.

RESULTS

A total of 29 assessment methods for HSP were identified from 124 studies. The common assessments were: Visual Analogue Scale (n = 75, 60%), Passive Range of Movement (n = 65, 52%), Fugl-Meyer Assessment (n = 32, 26%), glenohumeral subluxation (n = 30, 24%) and Numerical Rating Scale (n = 27, 22%).

CONCLUSION

A wide range of assessment approaches was identified for HSP, and some are used more than others. A fully comprehensive assessment that considers different aspects of pain including severity and timing, functioning, and the psychological burden, is needed in this area of practice to be able to guide appropriate treatment.

A single-center retrospective chart review of percutaneous PNS for treatment of chronic shoulder pain

Objective

The present IRB-approved retrospective chart review describes the use of a 60-day PNS treatment for shoulder pain at a single center in 60 total consecutive patients.

Background

Chronic shoulder pain affects an increasing number of patients per year and is especially prevalent in elderly populations. Percutaneous peripheral nerve stimulation (PNS) treatment targeting the nerves of the shoulder has been shown to reduce pain in prospective clinical studies and in analysis of real-world data.

Methods

Data were extracted from the electronic medical records of patients who had previously undergone percutaneous PNS treatment for chronic shoulder pain. Demographic data and treatment characteristics were summarized alongside treatment outcomes.

Results

Overall, 84 % (49/58) of patients reported substantial (≥50 %) pain relief at the end-of-treatment. The records for 2 patients did not include patient-reported percent pain relief. The average indwelling period for leads (i.e., treatment period) was 57 days. Findings on treatment effectiveness were consistent when the patient population was stratified by cause of pain, duration living with pain, and presence of pain-modifying comorbidities. Stimulation paradigms were identified and categorized by the nerve target and stimulation frequency (e.g., motor stimulation, sensory stimulation, or bimodal stimulation).

Conclusions

These results indicate percutaneous PNS is an effective treatment for patients with various shoulder pain histories, and while all stimulation paradigms were effective at reducing pain, patients who received bimodal PNS reported the greatest pain relief. Key limitations of the study included heterogeneous shoulder pain etiologies among patients and sparse availability of long-term follow-up data. These data support existing real-world and prospective clinical evidence on the efficacy of 60-day PNS treatment at treating chronic pain and provide valuable insights into its use in clinical practice.

A review of prospective studies regarding percutaneous peripheral nerve stimulation treatment in the management of chronic pain

Conventionally, peripheral nerve stimulation (PNS) for treatment of chronic pain has involved a two-stage process: a short-term (e.g., 7 days) trial and, if significant pain relief is achieved, a permanent PNS system is implanted. A percutaneous PNS treatment is now available where a coiled lead may be implanted for up to 60 days with the goal of producing sustained relief. In the present review, published prospective trials using percutaneous PNS treatment were identified and synthesized. The collected evidence indicates that percutaneous PNS treatment for up to 60 days provides durable clinically significant improvements in pain and pain interference. Similar efficacy across diverse targets and etiologies supports the broad applicability for use within the chronic pain population using this nonopioid technology.

Peripheral Nerve Stimulation for Chronic Shoulder Pain Due to Rotator Cuff Pathology

Chronic shoulder pain affects millions of patients each year. Various conditions can result in shoulder pain ranging from rotator cuff injury, subacromial impingement, post-surgical pain, bursitis, adhesive capsulitis, and osteoarthritis. Typically, rotator cuff pathology is diagnosed by physical exam maneuvers along with advanced imaging modalities. Initial treatment for rotator cuff injury typically consists of physical therapy, NSAIDs, and possible injections depending on the extent of the injury. If conservative measures fail or the injury is too substantial, surgery is typically the appropriate treatment for healthy patients. For patients who are not surgical candidates or refuse surgery, peripheral nerve stimulation (PNS) can be considered. With the use of PNS, the suprascapular and axillary nerves can be targeted to provide pain relief for a variety of chronic shoulder pain issues. We describe the use of PNS in 2 patients with significant rotator cuff pathology who were not surgical candidates.

Real-world evidence of sustained improvement following 60-day peripheral nerve stimulation treatment for pain: a cross-sectional follow-up survey

Objective: This study presents real-world data from a cross-sectional follow-up survey of patients who previously received 60-day peripheral nerve stimulation (PNS) treatment for pain. Materials & methods: A survey including validated pain and other related outcome measures was distributed to patients who previously underwent implantation of temporary PNS leads for 60-day PNS treatment. Results: Among survey respondents who were at least 3 months from the start of treatment, most reported sustained clinically significant improvements in pain and/or quality of life, with the length of follow-up at the time of survey completion ranging from 3 to 30 months. Conclusion: These real-world data support recent prospective studies indicating that 60-day percutaneous PNS provides significant and sustained relief across a wide range of pain conditions.

60-Day PNS Treatment May Improve Identification of Delayed Responders and Delayed Non-Responders to Neurostimulation for Pain Relief

Objective

Conventional neurostimulation typically involves a brief (eg, ≤10-day) trial to assess presumed effectiveness prior to permanent implantation. Low trial conversion rates and high explant rates due to inadequate pain relief highlight the need for improved patient identification strategies. The development of a 60-day percutaneous peripheral nerve stimulation (PNS) system enables evaluation of outcomes following an extended temporary treatment period of up to 60 days, that may obviate or validate the need for permanent implant. The present study provides the first real-world evidence regarding patient response throughout a 60-day PNS treatment period.

Methods

Anonymized data listings were compiled from patients who underwent implantation of temporary percutaneous leads and opted-in to provide real-world data to the device manufacturer during routine interactions with device representatives throughout the 60-day treatment.

Results

Overall, 30% (222/747) of patients were early responders (≥50% pain relief throughout treatment). Another 31% (231/747) of patients initially presented as non-responders but surpassed 50% pain relief by the end of treatment. Conversely, 32% (239/747) of patients were non-responders throughout treatment. An additional 7% (55/747) of patients initially presented as responders but fell below 50% relief by the end of the treatment period.

Conclusion

An extended, 60-day PNS treatment may help identify delayed responders, providing the opportunity for sustained relief and improving access to effective PNS treatment. Compared to a conventionally short trial of ≤10 days, a longer 60-day PNS treatment may also help reduce explant rates by identifying delayed non-responders unlikely to benefit long-term. These scenarios support the importance of an extended 60-day temporary PNS stimulation period to help inform stepwise treatment strategies that may optimize outcomes and cost-effectiveness.

Treatment of chronic axial back pain with 60-day percutaneous medial branch PNS: Primary end point results from a prospective, multicenter study

Background

The objective of this prospective, multicenter study is to characterize responses to percutaneous medial branch peripheral nerve stimulation (PNS) to determine if results from earlier, smaller single‐center studies and reports were generalizable when performed at a larger number and wider variety of centers in patients recalcitrant to nonsurgical treatments.

Materials & Methods

Participants with chronic axial low back pain (LBP) were implanted with percutaneous PNS leads targeting the lumbar medial branch nerves for up to 60 days, after which the leads were removed. Participants were followed long‐term for 12 months after the 2‐month PNS treatment. Data collection is complete for visits through end of treatment with PNS (primary end point) and 6 months after lead removal (8 months after start of treatment), with some participant follow‐up visits thereafter in progress.

Results

Clinically and statistically significant reductions in pain intensity, disability, and pain interference were reported by a majority of participants. Seventy‐three percent of participants were successes for the primary end point, reporting clinically significant (≥30%) reductions in back pain intensity after the 2‐month percutaneous PNS treatment (n = 54/74). Whereas prospective follow‐up is ongoing, among those who had already completed the long‐term follow‐up visits (n = 51), reductions in pain intensity, disability, and pain interference were sustained in a majority of participants through 14 months after the start of treatment.

Conclusion

Given the minimally invasive, nondestructive nature of percutaneous PNS and the significant benefits experienced by participants who were recalcitrant to nonsurgical treatments, percutaneous PNS may provide a promising first‐line neurostimulation treatment option for patients with chronic axial back pain.

Percutaneous Peripheral Nerve Stimulation of the Medial Branch Nerves for the Treatment of Chronic Axial Back Pain in Patients After Radiofrequency Ablation

OBJECTIVE

Lumbar radiofrequency ablation is a commonly used intervention for chronic back pain. However, the pain typically returns, and though retreatment may be successful, the procedure involves destruction of the medial branch nerves, which denervates the multifidus. Repeated procedures typically have diminishing returns, which can lead to opioid use, surgery, or implantation of permanent neuromodulation systems. The objective of this report is to demonstrate the potential use of percutaneous peripheral nerve stimulation (PNS) as a minimally invasive, nondestructive, motor-sparing alternative to repeat radiofrequency ablation and more invasive surgical procedures.

DESIGN

Prospective, multicenter trial.

METHODS

Individuals with a return of chronic axial pain after radiofrequency ablation underwent implantation of percutaneous PNS leads targeting the medial branch nerves. Stimulation was delivered for up to 60 days, after which the leads were removed. Participants were followed up to 5 months after the start of PNS. Outcomes included pain intensity, disability, and pain interference.

RESULTS

Highly clinically significant (≥50%) reductions in average pain intensity were reported by a majority of participants (67%, n = 10/15) after 2 months with PNS, and a majority experienced clinically significant improvements in functional outcomes, as measured by disability (87%, n = 13/15) and pain interference (80%, n = 12/15). Five months after PNS, 93% (n = 14/15) reported clinically meaningful improvement in one or more outcome measures, and a majority experienced clinically meaningful improvements in all three outcomes (i.e., pain intensity, disability, and pain interference).

CONCLUSIONS

Percutaneous PNS has the potential to shift the pain management paradigm by providing an effective, nondestructive, motor-sparing neuromodulation treatment.

Acute postoperative pain management with percutaneous peripheral nerve stimulation: the SPRINT neuromodulation system

INTRODUCTION

Ultrasound-guided percutaneous peripheral nerve stimulation (PNS) may be used to treat acute postoperative pain for various types of surgeries. This modality avoids several limitations of traditional local anesthetic-based peripheral nerve blocks including avoidance of motor blockade and sensory deficits.

AREAS COVERED

In this review, we discuss the use of SPRINT (SPR Therapeutics, Cleveland, OH) neuromodulation system in the setting of acute postoperative pain management.

EXPERT OPINION

PNS is a novel modality in regional anesthesia that has much promise in reducing overall opioid use after surgery. Placement of PNS is very similar to that of catheter-based regional anesthesia techniques. Ultrasound is used to guide the percutaneously placed introducer needle in proximity to the target nerve. There are several benefits of PNS over catheter-based approaches, including: 1) avoidance of motor or sensory blockade; 2) no medication bag required to be carried; and 3) electric leads may be kept in situ safely for up to 60 days. While several proof-of-concept studies have been published highlighting its use in various types of surgeries, large high-quality randomized controlled trials are still needed.

Cryoneurolysis and Percutaneous Peripheral Nerve Stimulation to Treat Acute Pain

Two regional analgesic modalities currently cleared by the U.S. Food and Drug Administration hold promise to provide postoperative analgesia free of many of the limitations of both opioids and local anesthetic-based techniques. Cryoneurolysis uses exceptionally low temperature to reversibly ablate a peripheral nerve, resulting in temporary analgesia. Where applicable, it offers a unique option given its extended duration of action measured in weeks to months after a single application. Percutaneous peripheral nerve stimulation involves inserting an insulated lead through a needle to lie adjacent to a peripheral nerve. Analgesia is produced by introducing electrical current with an external pulse generator. It is a unique regional analgesic in that it does not induce sensory, motor, or proprioception deficits and is cleared for up to 60 days of use. However, both modalities have limited validation when applied to acute pain, and randomized, controlled trials are required to define both benefits and risks.

Percutaneous Peripheral Nerve Stimulation for the Treatment of Chronic Pain Following Amputation

Introduction

Chronic pain and reduced function are significant problems for Military Service members and Veterans following amputation. Peripheral nerve stimulation (PNS) is a promising therapy, but PNS systems have traditionally been limited by invasiveness and complications. Recently, a novel percutaneous PNS system was developed to reduce the risk of complications and enable delivery of stimulation without surgery.

Materials and Methods

Percutaneous PNS was evaluated to determine if stimulation provides relief from residual and phantom limb pain following lower-extremity amputation. PNS leads were implanted percutaneously to deliver stimulation to the femoral and/or sciatic nerves. Patients received stimulation for up to 60 days followed by withdrawal of the leads.

Results

A review of recent studies and clinical reports found that a majority of patients (18/24, 75%) reported substantial (≥50%) clinically relevant relief of chronic post-amputation pain following up to 60 days of percutaneous PNS. Reductions in pain were frequently associated with reductions in disability and pain interference.

Conclusions

Percutaneous PNS can durably reduce pain, thereby enabling improvements in quality of life, function, and rehabilitation in individuals with residual or phantom limb pain following amputation. Percutaneous PNS may have additional benefit for Military Service members and Veterans with post-surgical or post-traumatic pain.

The protocol for a multisite, double blind, randomized, placebo-controlled trial of axillary nerve stimulation for chronic shoulder pain

BACKGROUND

Shoulder impingement syndrome is one of the most common causes of shoulder pain, accounting for approximately 30% of all shoulder pain. Approximately 35% of patients with shoulder impingement syndrome are refractory to conservative treatment. For patients who fail conservative treatment, there is no established treatment to successfully treat their chronic pain. Prior randomized control trials have demonstrated efficacy for the use of a single lead intramuscular peripheral nerve stimulation of the axillary nerve at the motor points of the deltoid muscle for treatment of hemiplegic shoulder pain. This is the first controlled trial to utilize the same novel technology to treat shoulder impingement syndrome outside of the stroke population.

METHODS

This is a dual-site, placebo-controlled, double-blinded, randomized control trial. Participants will be randomized to two treatment groups. The intervention group will be treated with active peripheral nerve stimulation of the axillary nerve of the affected shoulder and the control group will be treated with sham peripheral nerve stimulation of the axillary nerve of the affected shoulder. Both groups will receive a standardized exercise therapy program directed by a licensed therapist.

DISCUSSION

This study protocol will allow the investigators to determine if this novel, non-pharmacologic treatment of shoulder pain can demonstrate the same benefit in musculoskeletal patients which has been previously demonstrated in the stroke population.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03752619. Registered on 26 November 2018.

Percutaneous Peripheral Nerve Stimulation for Chronic Low Back Pain: Prospective Case Series With 1 Year of Sustained Relief Following Short-Term Implant

INTRODUCTION

Percutaneous peripheral nerve stimulation (PNS) provides an opportunity to relieve chronic low back pain and reduce opioid analgesic consumption as an alternative to radiofrequency ablation and permanently implanted neurostimulation systems. Traditionally, the use of neurostimulation earlier in the treatment continuum has been limited by its associated risk, invasiveness, and cost.

METHODS

Percutaneous PNS leads (SPRINT MicroLead) were placed bilaterally to target the medial branches of the dorsal rami nerves under image guidance. The percutaneous leads were connected to miniature wearable stimulators (SPRINT PNS System) for the 1-month therapy period, after which the leads were removed. Pain and disability were assessed long-term up to 12 months after lead removal.

RESULTS

Substantial, clinically significant reductions in average pain intensity (≥50% reduction as measured by the Brief Pain Inventory Short Form) were experienced by a majority of subjects (67%) at end of treatment compared to baseline (average 80% reduction among responders; P < 0.05, analysis of variance; n = 9). Twelve months after the end of PNS treatment, a majority of subjects who completed the long-term follow-up visits experienced sustained, clinically significant reductions in pain and/or disability (67%, n = 6; average 63% reduction in pain intensity and 32-point reduction in disability among responders). No serious or unanticipated adverse events were reported.

CONCLUSIONS

This study challenges the long-held notion that a positive trial of PNS should be followed by a permanent implant in responders. Percutaneous PNS may serve as an effective neurostimulation therapy for patients with chronic low back pain and should be considered earlier in the treatment continuum as a motor-sparing means of avoiding opioids, denervation, and permanently implanted neurostimulation systems.

Effects of Repetitive Peripheral Magnetic Stimulation on Shoulder Subluxations Caused by Stroke: A Preliminary Study

OBJECTIVES

Shoulder subluxation is a common problem after stroke. It causes shoulder pain that affects activities of daily living. This study aimed to investigate the effect of repetitive peripheral magnetic stimulation on shoulder subluxation after stroke.

METHODS

We enrolled 12 consecutive patients who, as a result of stroke, suffered shoulder subluxations, measuring at half of a fingerbreadth or more. All subjects underwent conventional rehabilitation, as well as repetitive peripheral magnetic stimulation of their supraspinatus, posterior deltoid, and infraspinatus muscles. We assessed the following parameters: shoulder subluxation, evaluated as the acromio-humeral interval using measurements taken from X-rays; shoulder pain, evaluated using the Numerical Rating Scale; the active range of motion of shoulder abduction; and the motor impairment of the upper extremities, evaluated using the upper extremity of the Fugl-Meyer Assessment scale.

RESULTS

The acromio-humeral interval before treatment was 22.8 ± 5.7 mm (mean ± SD). It significantly decreased to 19.6 ± 7.0 mm (p = 0.004) after treatment. Shoulder pain (p = 0.039), active range of motion of shoulder abduction (p = 0.016), and total (p = 0.005), subscale A (p = 0.005), and subscale C (p = 0.008) Fugl-Meyer Assessment scores also improved significantly after treatment.

CONCLUSIONS

Repetitive peripheral magnetic stimulation effectively reduced shoulder subluxations and shoulder pain caused by stroke and improved voluntary upper-limb movements in stroke patients.

Percutaneous Peripheral Nerve Stimulation to Control Postoperative Pain, Decrease Opioid Use, and Accelerate Functional Recovery Following Orthopedic Trauma

Orthopedic trauma is a significant military problem, causing several of the most disabling conditions with high rates of separation from duty and erosion of military readiness. The objective of this report is to summarize the findings of case series of a non-opioid therapy-percutaneous peripheral nerve stimulation (PNS) - and describe its potential for postoperative analgesia, early opioid cessation, and improved function following orthopedic trauma. Percutaneous PNS has been evaluated for the treatment of multiple types of pain, including two case series on postoperative pain following total knee replacement (n = 10 and 8, respectively) and a case series on postamputation pain (n = 9). The orthopedic trauma induced during TKR is highly representative of multiple types of orthopedic trauma sustained by Service members and frequently produces intense, prolonged postoperative pain and extended opioid use following surgery. Collectively, the results of these three clinical studies demonstrated that percutaneous PNS can provide substantial pain relief, reduce opioid use, and improve function. These outcomes suggest that there is substantial potential for the use of percutaneous PNS following orthopedic trauma.

Peripheral nerve blocks for postoperative analgesia: From traditional unencapsulated local anesthetic to liposomes, cryoneurolysis and peripheral nerve stimulation

Peripheral nerve blocks (PNBs) using local anesthetics either via single injection or continuous perineural catheter have been the mainstay for regional anesthesia and are a vital component of postoperative multimodal opioid-sparing pain management. There are some limitations to PNBs, however, mainly its limited duration of action, but also risk of catheter-associated infection and dislodgements. Furthermore, local anesthetic-based blocks can induce sensory deficits and motor weakness, possibly increasing the risk of falling and/or decreasing the ability to participate in postoperative rehabilitation. In this review, we first discuss various local anesthetic-based PNB techniques for major surgery and then review newer modalities, including liposome bupivacaine, cryoanalgesia, and peripheral nerve stimulation; all of which may offer advantages over single and continuous local anesthetic-based PNBs.

Percutaneous peripheral nerve stimulation for acute postoperative pain

Peripheral nerve stimulation or peripheral neuromodulation is a modality utilized for decades to manage chronic pain. There have been recent studies published describing its use in managing acute surgical pain for orthopedic surgery. The postoperative acute pain associated with several types of surgeries often outlasts the analgesia duration provided by single and continuous peripheral nerve blocks. Ultrasound-guided percutaneous peripheral nerve stimulation has the potential to provide much longer analgesia for acute pain while avoiding some limitations associated with local anesthetic-based peripheral nerve blocks. We summarize the current devices used in published studies to demonstrate feasibility with a focus on acute pain control.

Ultrasound-guided percutaneous peripheral nerve stimulation: neuromodulation of the suprascapular nerve and brachial plexus for postoperative analgesia following ambulatory rotator cuff repair. A proof-of-concept study

BACKGROUND AND OBJECTIVES

Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducing needle followed by the delivery of electric current. This modality has been reported to treat chronic pain as well as postoperative pain following knee and foot surgery. However, it remains unknown if this analgesic technique may be used in ambulatory patients following upper extremity surgery. The purpose of this proof-of-concept study was to investigate various lead implantation locations and evaluate the feasibility of using percutaneous brachial plexus PNS to treat surgical pain following ambulatory rotator cuff repair in the immediate postoperative period.

METHODS

Preoperatively, an electrical lead (SPR Therapeutics, Cleveland, Ohio) was percutaneously implanted to target the suprascapular nerve or brachial plexus roots or trunks using ultrasound guidance. Postoperatively, subjects received 5 min of either stimulation or sham in a randomized, double-masked fashion followed by a 5 min crossover period, and then continuous stimulation until lead removal postoperative days 14-28.

RESULTS

Leads (n=2) implanted at the suprascapular notch did not appear to provide analgesia, and subsequent leads (n=14) were inserted through the middle scalene muscle and placed to target the brachial plexus. Three subjects withdrew prior to data collection. Within the recovery room, stimulation did not decrease pain scores during the first 40 min of the remaining subjects with brachial plexus leads, regardless of which treatment subjects were randomized to initially. Seven of these 11 subjects required a single-injection interscalene nerve block for rescue analgesia prior to discharge. However, subsequent average resting and dynamic pain scores postoperative days 1-14 had a median of 1 or less on the Numeric Rating Scale, and opioid requirements averaged less than 1 tablet daily with active stimulation. Two leads dislodged during use and four fractured on withdrawal, but no infections, nerve injuries, or adverse sequelae were reported.

CONCLUSIONS

This proof-of-concept study demonstrates that ultrasound-guided percutaneous PNS of the brachial plexus is feasible for ambulatory shoulder surgery, and although analgesia immediately following surgery does not appear to be as potent as local anesthetic-based peripheral nerve blocks, the study suggests that this modality may provide analgesia and decrease opioid requirements in the days following rotator cuff repair. Therefore, it suggests that a subsequent, large, randomized clinical trial with an adequate control group is warranted to further investigate this therapy in the management of surgical pain in the immediate postoperative period. However, multiple technical issues remain to be resolved, such as the optimal lead location, insertion technique, and stimulating protocol, as well as preventing lead dislodgment and fracture.

TRIAL REGISTRATION NUMBER

NCT02898103.

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: Neuromodulation of the Sciatic Nerve for Postoperative Analgesia Following Ambulatory Foot Surgery, a Proof-of-Concept Study

BACKGROUND AND OBJECTIVES

Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducing needle followed by the delivery of electric current. This modality has been reported to treat chronic pain as well as postoperative pain the day following knee surgery. However, it remains unknown if this analgesic technique may be used in ambulatory subjects following foot procedures beginning within the recovery room immediately following surgery, and with only short series of patients reported to date, the only available data are derived from strictly observational studies. The purposes of this proof-of-concept study were to demonstrate the feasibility of using percutaneous sciatic nerve PNS to treat postoperative pain following ambulatory foot surgery in the immediate postoperative period and provide the first available data from a randomized controlled study design to provide evidence of analgesic effect.

METHODS

Preoperatively, an electrical lead (SPRINT; SPR Therapeutics, Inc, Cleveland, Ohio) was percutaneously inserted posterior to the sciatic nerve between the subgluteal region and bifurcation with ultrasound guidance. Following hallux valgus osteotomy, subjects received 5 minutes of either stimulation or sham in a randomized, double-masked fashion followed by a 5-minute crossover period and then continuous stimulation until lead removal on postoperative days 14 to 28.

RESULTS

During the initial 5-minute treatment period, subjects randomized to stimulation (n = 4) experienced a downward trajectory in their pain over the 5 minutes of treatment, whereas those receiving sham (n = 3) reported no such change until their subsequent 5-minute stimulation crossover. During the subsequent 30 minutes of stimulation, pain scores decreased to 52% of baseline (n = 7). Three subjects (43%) used a continuous popliteal nerve block for rescue analgesia during postoperative days 0 to 3. Overall, resting and dynamic pain scores averaged less than 1 on the numeric rating scale, and opioid use averaged less than 1 tablet daily with active stimulation. One lead dislodged, 2 fractured during use, and 1 fractured during intentional withdrawal.

CONCLUSIONS

This proof-of-concept study demonstrates that percutaneous sciatic nerve PNS is feasible for ambulatory foot surgery and suggests that this modality provides analgesia and decreases opioid requirements following hallux valgus procedures. However, lead dislodgement and fracture are concerns.

CLINICAL TRIAL REGISTRATION

This study was registered at Clinicaltrials.gov, identifier NCT02898103.

Novel Methodologies in Regional Anesthesia for Knee Arthroplasty

Maximizing analgesia is critical following joint arthroplasty because postoperative pain is a major barrier to adequate physical therapy. Continuous peripheral nerve blocks have been the mainstay for acute pain management in this population; however, this and similar techniques are limited by their duration of action. Cryoneurolysis and peripheral nerve stimulation are two methodologies used for decades to treat chronic pain. With the advent of portable ultrasound devices and percutaneous administration equipment, both procedures may now be suitable for treatment of acute pain. This article reviews these two modalities and their application to joint arthroplasty.

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: Neuromodulation of the Femoral Nerve for Postoperative Analgesia Following Ambulatory Anterior Cruciate Ligament Reconstruction: A Proof of Concept Study

Objectives

The purpose of this prospective proof of concept study was to investigate the feasibility of using percutaneous peripheral nerve stimulation of the femoral nerve to treat pain in the immediate postoperative period following ambulatory anterior cruciate ligament reconstruction with a patellar autograft.

Materials and Methods

Preoperatively, an electrical lead (SPRINT, SPR Therapeutics, Inc., Cleveland, OH, USA) was percutaneously implanted with ultrasound guidance anterior to the femoral nerve caudad to the inguinal crease. Within the recovery room, subjects received 5 min of either stimulation or sham in a randomized, double‐masked fashion followed by a 5‐min crossover period, and then continuous active stimulation until lead removal postoperative Day 14–28. Statistics were not applied to the data due to the small sample size of this feasibility study.

Results

During the initial 5‐min treatment period, subjects randomized to stimulation (n = 5) experienced a slight downward trajectory (decrease of 7%) in their pain over the 5 min of treatment, while those receiving sham (n = 5) reported a slight upward trajectory (increase of 4%) until their subsequent 5‐min stimulation crossover, during which time they also experienced a slight downward trajectory (decrease of 11% from baseline). A majority of subjects (80%) used a continuous adductor canal nerve block for rescue analgesia (in addition to stimulation) during postoperative Days 1–3, after which the median resting and dynamic pain scores remained equal or less than 1.5 on the numeric rating scale, respectively, and the median daily opioid consumption was less than 1.0 tablet.

Conclusions

This proof of concept study demonstrates that percutaneous femoral nerve stimulation is feasible for ambulatory knee surgery; and suggests that this modality may be effective in providing analgesia and decreasing opioid requirements following anterior cruciate ligament reconstruction. clinicaltrials.gov: NCT02898103.

A Feasibility Study of Percutaneous Peripheral Nerve Stimulation for the Treatment of Postoperative Pain Following Total Knee Arthroplasty

INTRODUCTION

The objective of the present feasibility study was to investigate the use of a new treatment modality-percutaneous peripheral nerve stimulation (PNS)-in controlling the often severe and long-lasting pain following total knee arthroplasty (TKA).

METHODS

For patients undergoing a primary, unilateral TKA, both femoral and sciatic open-coil percutaneous leads (SPR Therapeutics, Cleveland, OH) were placed up to seven days prior to surgery using ultrasound guidance. The leads were connected to external stimulators and used both at home and in the hospital for up to six weeks total.

RESULTS

In six of seven subjects (86%), the average of daily pain scores across the first two weeks was <4 on the 0-10 Numeric Rating Scale for pain. A majority of subjects (four out of seven; 57%) had ceased opioid use within the first week (median time to opioid cessation for all subjects was six days). Gross sensory/motor function was maintained during stimulation, enabling stimulation during physical therapy and activities of daily living. At 12 weeks following surgery, six of seven subjects had improved by >10% on the Six-Minute Walk Test compared to preoperative levels, and WOMAC scores improved by an average of 85% compared to before surgery. No falls, motor block, or lead infections were reported.

CONCLUSIONS

This feasibility study suggests that for TKA, ultrasound-guided percutaneous PNS is feasible in the immediate perioperative period and may provide analgesia without the undesirable systemic effects of opioids or quadriceps weakness induced by local anesthetics-based peripheral nerve blocks.

The effects of electromyography-triggered electrical stimulation on shoulder subluxation, muscle activation, pain, and function in persons with stroke: A pilot study

OBJECTIVES

The purpose of this study was to examine the effects of task-oriented electromyography-triggered stimulation for shoulder subluxation, muscle activation, pain and upper extremity function in hemiparetic stroke patients.

METHODS

Twenty participants with subacute hemiparetic stroke were recruited for this study and were randomly divided into two groups: experimental group (n = 10) and control group (n = 10). Subjects in the experimental group participated in task-oriented electromyography triggered stimulation for 30 minutes, five times a week for four weeks, whereas the control group received cyclic functional electrical stimulation for 30 minutes, five times a week for four weeks. Subjects in both groups received conventional physical therapy for four weeks (30 min/day, five times/week). Data collected included the degree of shoulder subluxation which had been confirmed by X-ray, muscle activation of the supraspinatus and posterior deltoid muscles by electromyography, pain by the Visual Analogue Scale (VAS), and hand function by the Fugl-Meyer Assessment (FMA) before and after the four week exercise period.

RESULTS

The results showed significant improvement in shoulder subluxation, muscle activation, and VAS results in the experimental group, compared with the control group(p < 0.05). FMA scores showed no significant differences between the two groups.

CONCLUSIONS

In conclusion, task-oriented electromyography-triggered stimulation improved shoulder subluxation, muscle activation, pain and upper extremity function. These results suggest that task-oriented electromyography-triggered stimulation is effective and beneficial for individuals with subacute stroke, and that further studies should be conducted on multivarious anatomical regions.

Percutaneous Peripheral Nerve Stimulation for the Treatment of Chronic Low Back Pain: Two Clinical Case Reports of Sustained Pain Relief

As the leading cause of disability among U.S. adults, chronic low back pain (LBP) is one of the most prevalent and challenging musculoskeletal conditions. Neuromodulation provides an opportunity to reduce or eliminate the use of opioids to treat chronic LBP, but the cost and invasiveness of existing methods have limited its broad adoption, especially earlier in the treatment continuum. The present case report details the results of a novel method of short-term percutaneous peripheral nerve stimulation (PNS) in 2 subjects with chronic LBP. At the end of the 1-month therapy, stimulation was discontinued and the leads were withdrawn. PNS produced clinically significant improvements in pain (62% average reduction in Brief Pain Inventory Question #5, average pain), and functional outcomes (73% reduction in disability, Oswestry Disability Index; 83% reduction in pain interference, Brief Pain Inventory). Both subjects reduced nonopioid analgesic use by 83%, on average, and the one subject taking opioids ceased using all opioids. The only adverse event was minor skin irritation caused by a topical dressing. The clinically significant improvements were sustained at least 4 months after start of therapy (79% average reduction in pain; both reported minimal disability; 100% reduction in opioids; 74% reduction nonopioids). The results reveal the utility of this novel, short-term approach and its potential as a minimally invasive neuromodulation therapy for use earlier in the treatment continuum to produce sustained pain relief and reduce or eliminate the need for analgesic medications, including opioids, as well as more expensive and invasive surgical or therapeutic alternatives.

Ultrasound-guided percutaneous peripheral nerve stimulation for analgesia following total knee arthroplasty: a prospective feasibility study

Background

Peripheral nerve stimulation has been used for decades to treat chronic pain but has not been used for postoperative analgesia due to multiple limitations, beginning with invasive electrode placement. With the development of small-diameter/gauge leads enabling percutaneous insertion, ultrasound guidance for accurate introduction, and stimulators small enough to be adhered to the skin, neurostimulation may now be provided in a similar manner to continuous peripheral nerve blocks. Here, we report on the use of ultrasound-guided percutaneous peripheral nerve stimulation to treat postoperative pain.

Materials and methods

Subjects within 60 days of a total knee arthroplasty with pain insufficiently treated with oral analgesics had a 0.2-mm-diameter electrical lead (pre-loaded into a 20 gauge needle) introduced percutaneously using ultrasound guidance with the tip located approximately 0.5–1.0 cm from the femoral nerve (a second lead was inserted approximately 1.0–3.0 cm from the sciatic nerve for posterior knee pain). An external stimulator delivered current. Endpoints were assessed before and after lead insertion and the leads subsequently removed. Due to the small sample size for this pilot/feasibility study, no statistics were applied to the data.

Results

Leads were inserted in subjects (n = 5) 8–58 days postoperatively. Percutaneous peripheral nerve stimulation decreased pain an average of 93% at rest (from a mean of 5.0 to 0.2 on a 0–10 numeric rating scale), with 4 of 5 subjects experiencing complete resolution of pain. During passive and active knee motion pain decreased an average of 27 and 30%, respectively. Neither maximum passive nor active knee range-of-motion was consistently affected.

Conclusions

Ultrasound-guided percutaneous peripheral nerve stimulation may be a practical modality for the treatment of postoperative pain following orthopedic surgical procedures, and further investigation appears warranted.

Neurostimulation for Postsurgical Analgesia: A Novel System Enabling Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation

While neurostimulation—stimulation of the nervous system using electrical current—has been used to treat chronic pain, its use treating postsurgical pain has been limited. Here, we report on the clinical application of a novel investigational lead to provide analgesia following total knee arthroplasty. In 5 subjects, leads were inserted percutaneously using ultrasound guidance within 0.5 to 3.0 cm of the femoral and/or sciatic nerve(s). With the delivery of current, pain decreased an average of 63% at rest, with 4 of 5 subjects having relief of > 50%. During passive and active knee flexion, pain decreased an average of 14% and 50%, with 0/3 and 1/2 subjects attaining > 50% relief, respectively. Ultrasound‐guided percutaneous peripheral nerve stimulation may be a practical modality for the treatment of postsurgical pain.

Infection Rates of Electrical Leads Used for Percutaneous Neurostimulation of the Peripheral Nervous System

BACKGROUND

Percutaneous neurostimulation of the peripheral nervous system involves the insertion of a wire "lead" through an introducing needle to target a nerve/plexus or a motor point within a muscle. Electrical current may then be passed from an external generator through the skin via the lead for various therapeutic goals, including providing analgesia. With extended use of percutaneous leads sometimes greater than a month, infection is a concern. It was hypothesized that the infection rate of leads with a coiled design is lower than for leads with a noncoiled cylindrical design.

METHODS

The literature was retrospectively reviewed for clinical studies of percutaneous neurostimulation of the peripheral nervous system of greater than 2 days that included explicit information on adverse events. The primary endpoint was the number of infections per 1,000 indwelling days.

RESULTS

Forty-three studies were identified that met inclusion criteria involving coiled (n = 21) and noncoiled (n = 25) leads (3 studies involved both). The risk of infection with noncoiled leads was estimated to be 25 times greater than with coiled leads (95% confidence interval [CI] 2 to 407, P = 0.006). The infection rates were estimated to be 0.03 (95% CI 0.01 to 0.13) infections per 1,000 indwelling days for coiled leads and 0.83 (95% CI 0.16 to 4.33) infections per 1,000 indwelling days for noncoiled leads (P = 0.006).

CONCLUSIONS

Percutaneous leads used for neurostimulation of the peripheral nervous system have a much lower risk of infection with a coiled design compared with noncoiled leads: approximately 1 infection for every 30,000 vs. 1,200 indwelling days, respectively.

Percutaneous neuromuscular electrical stimulation (P-NMES) for treating shoulder pain in chronic hemiplegia. Effects on shoulder pain and quality of life

Objective: To evaluate the effect of percutaneous neuromuscular electrical stimulation (P-NMES) of the shoulder muscles on shoulder pain intensity and health-related quality of life in chronic hemiplegia.

Design: Prospective, open label design.

Setting: The outpatient services of a large teaching rehabilitation hospital in the Netherlands.

Subjects: Fifteen stroke survivors with chronic (> six months) hemiplegia and a therapy-resistant painful shoulder with subluxation. All patients suffered from clinically relevant shoulder pain, as assessed by a score of at least 4 out of 10 on a numerical rating scale. Shoulder subluxation was indicated by at least 1/2 fingerbreadth of glenohumeral separation on palpation.

Intervention: Six hours of P-NMES per day for a total of six weeks.

Main outcome measures: Shoulder pain (Brief Pain Inventory), shoulder subluxation (clinical and radiographic), shoulder pain-free external rotation (hand-held goniometer), motor impairment (Fugl-Meyer Motor test) and quality of life (SF-36) were assessed before treatment, after six weeks of intramuscular stimulation, at three months and six months follow-up.

Results: A significant reduction in pain was found on the Brief Pain Inventory. Pain reduction was still present at six months follow-up. All domains, in particular bodily pain, of the SF-36 showed improvement in the short term. After six months of follow-up, bodily pain was still strongly and significantly reduced, whereas social functioning and role physical demonstrated a nonsignificant improvement of more than 10% compared with baseline.

Conclusion: This pilot suggests that P-NMES potentially reduces shoulder pain in chronic hemiplegia. To establish the clinical value of P-NMES in treating hemiplegic shoulder pain a randomized controlled trial is needed.

[The principles of pharmacotherapy of poststroke shoulder pain]

AIM

To analyze the results of examination and treatment of patients with poststroke shoulder pain.

MATERIAL AND METHODS

The study included 213 patients who have had a stroke, including 16.4% patients with poststroke shoulder pain in early recovery period and 35.9% patients with poststroke shoulder pain in late recovery period. Therapeutic efficacy of amitriptyline, lidocaine (intravenously), pregabalin, tizanidine and non-steroid anti-inflammatory drugs was assessed.

RESULTS AND CONCLUSION

Dysfunction of nervous system plays the main role in this pain syndrome. The efficacy of the drugs in the early/late recovery period was estimated as follows: nonsteroidal anti-inflammatory drugs - 33%/12%, amitriptyline - 24%/42%, gabapentin - 10%/13%, lidocaine - 95%/100%, tizanidine - 29%/33%. Seventy-six percent of patients were free of pain after treatment using a regimen suggested by the authors.

Fully implantable peripheral nerve stimulation for the treatment of hemiplegic shoulder pain: a case report

This case report describes the first participant treated with a fully implantable, single-lead peripheral nerve stimulation system for refractory hemiplegic shoulder pain. During the 6-wk trial stage, a temporary lead was placed percutaneously near the terminal branches of the axillary nerve to the deltoid. The primary outcome measure was the Brief Pain Inventory-Short Form Question 3, a 0-10 pain numeric rating scale. The participant experienced 75% pain reduction and proceeded to the implantation stage, where he received a single-lead, implantable pulse generator. After 3 wks, the participant became pain-free. However, 7 wks after implantation, the system was turned off because of an unrelated acute medical illness. Hemiplegic shoulder pain reemerged with a Brief Pain Inventory-Short Form Question 3 score of 9. After 11 wks of recovery, peripheral nerve stimulation was reinitiated and the participant became pain-free through the 9-mo follow-up. At 12 mos, Brief Pain Inventory-Short Form Question 3 score was 1. This case report demonstrates the feasibility of a single-lead, fully implantable peripheral nerve stimulation system for refractory hemiplegic shoulder pain.

Recovery Patterns of Shoulder Subluxation After Stroke: A Six-Month Follow-Up Study

PURPOSE

Poststroke shoulder subluxation is a common complication that is thought to be irreversible without intervention. This study explores the natural recovery patterns of shoulder subluxation 6 months after stroke onset.

METHOD

Ten first-stroke survivors were evaluated in a free-standing rehabilitation hospital within 6 weeks of stroke onset and were reevaluated 6 months thereafter. Shoulder subluxation was measured in terms of glenohumeral asymmetries between affected and unaffected shoulders using anteroposterior radiographs before and after fitting of an appropriate support. Main outcome measures included shoulder subluxation asymmetries, range of motion, pain, and motor function as measured by the Fugl-Meyer Motor Function Assessment.

RESULTS

Decreases in vertical asymmetry 6 months after initial evaluation were correlated with significant motor recovery (r =.7382, p =.018) and were associated with increases in the range of motion of shoulder abduction (r =.7167, p =.020). However, changes in vertical asymmetries were not correlated with changes in shoulder flexion (r =.3744, p =.286) or external rotation (r =.2155, p =.578) range of motion or with changes in shoulder pain (r = -.5189, p =.124). Six-month vertical asymmetries were correlated only with 6-month shoulder abduction range of motion (r =.6408, p =.046).

CONCLUSION

Reductions in shoulder subluxation may occur spontaneously only when significant motor recovery of the affected upper limb occurs.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation

BACKGROUND AND PURPOSE

The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA).

METHOD

Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale.

RESULTS

The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation.

DISCUSSION AND CONCLUSION

The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke.

Therapeutic Orthosis and Electrical Stimulation for Upper Extremity Hemiplegia After Stroke: A Review of Effectiveness Based on Evidence

Upper extremity hemiplegia after stroke is common and disabling. Apart from conventional physical and occupational therapy, a number of additional approaches that use devices such as orthoses, prostheses, electrical stimulation, and robots have been introduced. The purpose of this review was to assess the clinical efficacy of such devices used for the affected upper extremities of acute, subacute, and chronic stroke patients. Assessments of their effectiveness and recommendations were based on the weight of published scientific evidence. The amount of evidence with respect to hand splints and shoulder slings is limited. Further study with a well-designed randomized controlled trial (RCT) is required to investigate accurately their short- and long-term efficacy. A number of studies suggested that the use of electrical stimulation for reducing shoulder subluxation or improving the function of wrist and finger extensors is effective during or shortly after the daily treatment period. The robotic approach to hemiplegic upper extremities appears to be a novel therapeutic strategy that may help improve hand and arm function. However, the longer term effectiveness after discontinuation as well as the motor recovery mechanism of electrical stimulation or robotic devices remains unclear. More research is needed to determine the evidence-based effectiveness of electrical stimulation or other devices for stroke survivors.

Neuromuscular Electrical Stimulation for Motor Restoration in Hemiparesis

This article assesses the clinical efficacy of established neuromuscular electrical stimulation (NMES) technologies for motor restoration in hemiparesis and provides an overview of evolving technologies. Transcutaneous NMES facilitates motor recovery. However, its impact on physical disability remains uncertain. Transcutaneous NMES also decreases shoulder subluxation, but its effect on shoulder pain remains uncertain. Clinically deployable upper extremity neuroprosthesis systems will not be available until sometime in the distant future. However, there is stronger evidence for the clinical utility of lower extremity neuroprosthesis systems. Evolving technology utilizes semi-implanted or fully implanted systems with more sophisticated control paradigms. Initial experiences with these systems are reviewed and directions for future research are discussed in this article.

Current and future interventions for glenohumeral subluxation in hemiplegia secondary to stroke

Poststroke shoulder pain is a common issue and can be caused by glenohumeral subluxation. This entity hinders function and quality of life and is caused by changes in tone and loss of fi ne control of the shoulder joints' supporting structures after a stroke. Current treatments are limited in number and effectiveness and have significant problems and limitations to their use. Furthermore, prior to percutaneous implantable neuromuscular electrical stimulation, there was no evidence for any treatment to provide relief for chronic hemiplegic shoulder pain from glenohumeral subluxation. This clinical review provides a comprehensive review of the anatomy, pathogenesis, clinical features, management, and clinical efficacy of current treatment modalities.

Single-lead percutaneous peripheral nerve stimulation for the treatment of shoulder pain from subacromial impingement syndrome

This case report demonstrates the feasibility of a single-lead peripheral nerve stimulation system for the treatment of pain secondary to chronic subacromial impingement syndrome. The participant was a 57-year-old man who experienced persistent pain from subacromial impingement syndrome for 20 months despite having undergone conservative therapy of steroid injection and physical therapy. After study enrollment, a single intramuscular lead was placed percutaneously into the deltoid muscle of the affected shoulder. He was treated 6 hours per day for 3 weeks and the lead was removed. The primary outcome measure was the Brief Pain Inventory (Short-form) Question 3 (BPI 3), which queries the worst pain in the last week on a 0-10 numerical rating scale. At baseline, BPI 3 was an 8. At the end of treatment and at 4 and 12 weeks after treatment, BPI 3 scores were 2, 0, and 0, respectively. Substantial improvements in shoulder impairment, quality of life, and shoulder disability measures were also observed. Additional studies are needed to further demonstrate safety and efficacy, determine optimal dose, define optimal prescriptive parameters, expand clinical indications, and demonstrate long-term effect.

Single-lead percutaneous peripheral nerve stimulation for the treatment of hemiplegic shoulder pain: a case series

OBJECTIVE

Previous studies demonstrated the efficacy of Intramuscular Nerve (IMN) therapy with a 4-lead percutaneous, peripheral nerve stimulation (PNS) system in reducing hemiplegic shoulder pain (HSP). This case series investigates the feasibility of a less complex, single-lead approach in reducing HSP.

METHODS

Eight participants received one percutaneous intramuscular lead in the hemiparetic deltoid muscle and were then treated 6 hours/day for 3 weeks. The primary outcome measure was the Brief Pain Inventory (Short-Form) Question 3 (BPI3), which queries worst pain in the last week on a 0 to 10 numeric rating scale. Secondary outcomes included pain interference (BPI9) and Medical Outcomes Study Short-Form 36 (SF-36v2). Primary and secondary outcomes were assessed at the end of treatment (EOT) and 1 and 4 weeks after the EOT.

RESULTS

All participants tolerated the treatment well with 96% compliance. All leads remained infection-free and were removed intact at the EOT. On average, participants exhibited 70% reduction in BPI3 at the EOT and 61% reduction at 4 weeks after the EOT. All participants satisfied the success criterion of at least a 2-point reduction in BPI3 at the EOT. Longitudinal analysis revealed significant treatment effect for BPI3 (F = 14.0, P < 0.001), BPI9 (F = 5.9, P < 0.01), and the bodily pain domain of SF-36v2 (F = 12.8, P < 0.001).

CONCLUSION

This case series demonstrates the feasibility of a single-lead, 3-week IMN therapy for the treatment of chronic HSP. Additional studies are needed to further demonstrate safety, efficacy, and long-term benefit, define optimal prescriptive parameters and dose, and expand clinical indications.

Single-lead percutaneous peripheral nerve stimulation for the treatment of hemiplegic shoulder pain: a case report

Previous studies demonstrated the efficacy of 6 weeks of a 4-lead percutaneous, peripheral nerve stimulation system in reducing hemiplegic shoulder pain. This case report describes the first stroke survivor treated for 3 weeks with a less complex, single-lead approach. The participant was a 59-year-old male who developed hemiplegic shoulder pain shortly after his stroke 7.5 years prior to study enrollment and was treated with multiple modalities without sustained pain relief. After study enrollment, a single intramuscular lead was placed percutaneously into the deltoid muscle. He was treated 6 hours per day for 3 weeks and the lead was removed. The primary outcome measure was the Brief Pain Inventory (Short-Form) Question 3 (BPI-3), which queries the worst pain in the last week on a 0 to 10 numeric rating scale. At baseline, BPI 3 was an 8. At the end of treatment and at 1 and 4 weeks after treatment was completed, BPI 3 scores were 3, 2, and 2, respectively. Substantial improvements in quality of life measures were also observed. The participant remained infection-free and the lead was removed fully intact. After completing the study protocol, the participant was followed clinically for 13 months posttreatment with complete resolution of hemiplegic shoulder pain. This case report demonstrates the feasibility of a single-lead peripheral nerve stimulation for the treatment of chronic hemiplegic shoulder pain. Additional studies are needed to further demonstrate safety and efficacy, determine optimal dose, define optimal prescriptive parameters, expand clinical indications, and demonstrate long-term effect.