The Comparison of Effects of Suprascapular Nerve Block, Intra-articular Steroid Injection, and a Combination Therapy on Hemiplegic Shoulder Pain: Pilot Study

A systematic review of the methods and drugs used for performing suprascapular nerve block injections for the non-surgical management of chronic shoulder pain

Suprascapular nerve block (SSNB) injections are growing in popularity as a treatment option for people with chronic shoulder pain. The optimal method of injection and aftercare is unknown. This review describes the current methods and drugs used for performing SSNB injections in the non-surgical management of adults with chronic shoulder pain in order to inform future research in this area. Systematic searches of CINAHL, MEDLINE (OVID), AMED, Embase databases and the Cochrane Library were undertaken from inception to June 2020. Data on the method and drugs used for injection and aftercare were extracted and summarised for areas of commonality and discrepancy. We included 53 studies in this review. In total, eight different injection methods were reported within the included studies. Indirect surface land-marked methods were the most common method reported in 21 studies. Direct surface land-marked methods were reported in 12 studies. Ultrasound-guided methods used alone were reported in 16 studies. Both fluoroscopy and computed tomography methods used alone were reported in one study each. Electromyography was used in combination with other injection methods in nine studies. Wide variation in the composition of the injectate was observed between studies. Local anaesthetic was used within injectate preparations in all studies. Local anaesthetic used alone was reported in 20 studies, combined with steroid in 29 studies and combined with various other components in 5 studies. Physiotherapy following injection was reported in 26 studies. Reported details of physiotherapy varied considerably. This review identified substantial variation in the methods and drugs used to perform SSNB injection in clinical trials. Current literature demonstrates a wide range of methods used for SSNB injection administration. Consensus research defining standardised practice for SSNB injection is now needed to guide future clinical practice and research.

Comparative Effectiveness of Injection Therapies for Hemiplegic Shoulder Pain in Stroke: A Systematic Review and Network Meta-Analysis

Hemiplegic shoulder pain (HSP) hampers post-stroke functional recovery and is not well managed with conservative treatments. This systematic review aimed to examine the various injection therapies for HSP and investigate their effectiveness at different time points. The protocol of this meta-analysis was registered on INPLASY with a registration number of INPLASY202180010. PubMed, EMBASE, and Scopus were searched from their inception to 4 August 2021 for the clinical studies investigating comparative effectiveness of different injection regimens for treating hemiplegic shoulder pain in patients with stroke. The primary outcome was the weighted mean difference (WMD) on the visual analog scale (VAS) of pain reduction in the fourth-week and between the fourth and twenty-fourth weeks. Ranking probabilities of the WMD for each treatment were obtained using simulations. Seventeen studies with 595 participants were included. The network meta-analysis showed that at the fourth-week, intra-muscular botulinum toxin (BoNT) injections and suprascapular nerve blocks (SSNB) were superior to a placebo, with WMDs of 1.55 (95% CI, 0.09 to 3.01) and 1.44 (95% CI, 0.07 to 2.80), respectively. SSNB possessed the highest probability (53.3%) and appeared to be the best treatment in the fourth-week, followed by intra-muscular BoNT injections (42.6%). Intramuscular BoNT injections were better than the placebo, with a WMD of 1.57 (95% CI, 0.30 to 2.84) between the 4th and 24th weeks. Intramuscular BoNT injections had the highest probability (79.8%) as the best treatment between the 4th and 24th weeks. SSNB was likely to rank first in relieving HSP at the fourth post-treatment week, whereas intra-muscular BoNT injections had the highest probability to achieve the best treatment effectiveness in the post-injection period between the fourth and twenty-fourth weeks. However, as some of the included studies used a non-randomized controlled design, more randomized controlled trials are needed in the future to validate and better understand the short- and long-term efficacy of different injection therapies for management of HSP.

Virtual reality applied to home-visit rehabilitation for hemiplegic shoulder pain in a stroke patient: a case report

Objectives: Virtual reality (VR) has been shown to facilitate rehabilitation at hospitals by distracting patients’ attention from pain and by providing a virtual environment favorable for motivating the patients to continue rehabilitation. However, the application of VR in a home-visit rehabilitation remains to be validated. Here, we report a case in which home-visit rehabilitation using immersive VR was effective for post-stroke hemiplegic shoulder pain.

Case presentation: After treatment, at a general hospital, for the hypertensive hemorrhage in the right brain capsule that resulted in the residual attention deficit disorder and left hemiplegia, a 63-year-old woman was cared for with a home-visit rehabilitation in a rural area. The patient had persistent pain in her left shoulder, which increased during activities of daily living and during rehabilitation, and the pain precluded rehabilitation. A VR relaxation program was delivered to the patient to alleviate pain during rehabilitation. Her shoulder pain was successfully alleviated using VR during training for muscle stretching and passive joint mobilization.

Conclusion: The application of VR to home rehabilitation in rural areas may augment the effectiveness of home rehabilitation by alleviating pain during the procedure and sustaining the motivation for home rehabilitation.

Efficacy of platelet-rich plasma in the treatment of hemiplegic shoulder pain

OBJECTIVE

The aim of this study was to examine the effects of platelet-rich plasma (PRP) on pain and functional outcomes in patients with hemiplegic shoulder pain. We compared the effects of PRP against saline solution by designing a double blind, randomized, prospective study.

DESIGN

Forty-four patients with hemiplegia were included in this study. All patients received a total of 3 injections, 1 week apart. The first group received PRP injections while the second group received placebo injections. After 3 months of follow-up, 40 patients completed the trial. Primary outcome measure was movement-induced pain score (VAS), and secondary outcome measures were spontaneous pain score, shoulder passive range of motion (ROM), functional independence measure score, and the amount of paracetamol used. All subjects were evaluated at baseline, 1 week, 1 month, and 3 months after the completion of the last injection.

RESULTS

Both groups showed an improvement in spontaneous and movement-related pain scores and shoulder passive ROM values on 1st and 3rd month visits (p < 0.05). No significance difference was detected between groups (p > 0.05). Similarly, FIM scores improved significantly in both groups (p < 0.05) but no difference was found between groups. Paracetamol use did not differ significantly between groups.

CONCLUSION

The PRP injections were found not to be superior to placebo. Improvements in both groups can be attributed to the use of rehabilitation techniques and exercises in all patients. There is still need for further research to show whether PRP is a treatment option in the course of hemiplegic shoulder pain.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03931824.

Suprascapular nerve block in hemiplegic shoulder pain: comparison of the effectiveness of placebo, local anesthetic, and corticosteroid injections-a randomized controlled study

BACKGROUND

Shoulder pain is a common complication of hemiplegic patients that can interrupt their rehabilitation program and is associated with poorer outcomes. The usefulness of the suprascapular nerve block. (SSNB) in the stroke population has been suggested, but some concerns still remain.

OBJECTIVES

To investigate the effect of SSNB on pain intensity and passive range ofmotion (PROM) in patients with hemiplegic shoulder pain (HSP).

STUDY DESIGN

A prospective, double blind, randomized controlled trial was conductedin 34 stroke patients with HSP. They were randomly divided into three groups: Localanesthetic (LA) injection into the trapezius muscle (placebo group), LA injection into thesuprascapular notch, and LA and corticosteroid (CS) injections into the suprascapularnotch.The main outcome was visual analog scale (VAS) scores evaluated before andafter administration of the injection at 1 hour, 1 week, and 1 month.

RESULTS

There were significant decreases in the VAS scores with all three injections at all follow-up time points (p: 0.001 for the placebo group, p <0.001 for the LA group, and p <0.001 for the LA+CS group). When changes in VAS scores were compared between the groups, the LA+CS group demonstrated a higher decrease in VAS than the placebo group. Improvement in the PROM was seen only in the LA and LA+CS groups.

CONCLUSIONS

The findings of this study support the use of an SSNB with or without CS, to increase the range of motion in the affected shoulder, especially during the rehabilitation period.

Comparison of the efficacy of intramuscular botulinum toxin type-A injection into the pectoralis major and the teres major muscles and suprascapular nerve block for hemiplegic shoulder pain: a prospective, double-blind, randomized, controlled trial

INTRODUCTION

This study aims to investigate the effect of botulinum toxin-A (BoNT-A) injection into pectoralis major and teres major muscles and suprascapular nerve block (SSNB) on pain, range of motion (ROM), and upper extremity function for (hemiplegic shoulder pain) HSP, and to compare the effectiveness of these two methods.

MATERIALS AND METHODS

Sixty patients with HSP were randomly assigned into 2 groups. The Group 1 (n = 30) received BoNT-A injection into the pectoralis major and teres major, and the Group 2 (n = 30) received SSSB. Patients were evaluated just before the start of the study, and 2 and 6 weeks after the start of the study with visual analog scale (VAS), Modified Ashworth Scale (MASH), the passive ROM, and the Fugl-Meyer Scale (FMS) arm section.

RESULTS

In Group 1, statistically significant improvement was found in all evaluation parameters on 2th and 6th week. Group 2 showed significant improvement in all parameters on week 2 (p < 0.05), and significant improvement was observed in MASH and pain in abduction in the 6th week (p < 0.05). When the groups were compared with each other, a statistically significant difference was observed in MASH, ROM, and FMS parameters on week 2 in favor of Group 1; in all evaluation parameters, there was a statistically significant difference in favor of Group 1 on week 6 (p < 0.05).

CONCLUSION

We concluded that BoNT-A injection into the pectoralis major and teres major muscles for HSP was equal in the short term and more effective in the middle term compared with SSNB treatment in improving pain, ROM, and function.

Efficacy of ultrasound-guided suprascapular nerve block treatment in patients with painful hemiplegic shoulder

OBJECTIVE

The aim of this study was to evaluate the efficacy of ultrasound-guided suprascapular block treatment in patients with painful hemiplegic shoulder whose pain was not reduced after conservative treatment.

DESIGN

The patients were those whose hemiplegic shoulder pain was not reduced by standard conservative treatment prior to discharge. The study group (n = 21) included patients who had undergone an ultrasound-guided suprascapular nerve block (SSNB). The control group (n = 21) were patients who had not undergone SSNB. Both groups undertook home exercise programs. All patients were evaluated at 1 week and 1 and 3 months after the discharge. Evaluations included shoulder range of motion (ROM), Visual Analog Scale (VAS) for pain, EQ-5D-3L for quality of life, the Modified Ashworth Scale (MAS), and Brunnstrom staging.

RESULTS

The shoulder ROM significantly increased in the SSNB group at 1-3 months, when compared with the baseline value. The shoulder ROM significantly decreased (p ˂ 0.05) in the control group at 1-3 months, when compared with the baseline value. The pain VAS and EQ-5D-3L scores significantly decreased (p ˂ 0.05) after treatment in the follow-ups at 1 month in the SSNB group. The control group showed no change from the baseline scores (p ˃ 0.05). The MAS scores and Brunnstrom staging did not differ between the two groups.

CONCLUSION

The ultrasound-guided SSNB is a safe and more effective treatment than conservative treatment for painful hemiplegic shoulder. Further studies are needed to compare ultrasound-guided and non-guided suprascapular blocks as treatments for hemiplegic shoulder pain.

Effects of fluoroscopy-guıded intraartıcular injectıon, suprascapular nerve block, and combınatıon therapy ın hemıplegıc shoulder paın: a prospective double-blınd, randomızed clınıcal study

OBJECTIVE

To investigate the effect and superiority of fluoroscopy-guided intraarticular shoulder injection (IAI), suprascapular nerve block (SSNB), and combination treatment in hemiplegic shoulder pain (HSP).

DESIGN

We included 30 patients diagnosed with HSP. Patients were divided into three groups: IAI, SSNB, and combination treatment. Patients were assessed using a visual analogue scale (VAS) prior to the injection and at hour 1, week 2, and month 2 after the injection, with goniometry at two angles at the moment that pain started and maximum passive range of motion (ROM) of the shoulder and Modified Barthel Index prior to the injection, at week 2 and month 2 after the injection.

RESULTS

Significant decrease in the VAS and increase in shoulder passive ROMs were detected at all follow-ups in groups. In comparison, there was no significant difference in VAS scores. Change in the internal rotation at the moment that pain started was found to be higher in the patients treated with the combined method than the other methods. Change in maximum passive ROMs was similar between treatment groups.

CONCLUSION

IAI, SSNB, and the combination treatments are reliable and effective treatment modalities that provide pain relief and an increase in shoulder passive ROMs in HSP.

A retrospective case series of ultrasound-guided suprascapular nerve pulsed radiofrequency treatment for hemiplegic shoulder pain in patients with chronic stroke

Purpose

Hemiplegic shoulder pain (HSP) is the most common pain condition after stroke. Pulsed radiofrequency (PRF) treatment of the suprascapular nerve (SSN) effectively relieves shoulder pain conditions. To date, there is no study about the effects of PRF treatment for HSP. Thus, our aim was to report on a case series about its use in chronic stroke.

Patients and methods

Six chronic stroke patients with HSP (visual analog scale [VAS] score for pain ≥30 mm) underwent ultrasound-guided SSN PRF treatment. All were evaluated before treatment and at 4 and 16 weeks of follow-up. The main outcome was VAS score. Secondary outcomes were Modified Ashworth Scale, shoulder passive range of motion (PROM), Disability Assessment Scale (DAS), Fugl-Meyer Assessment, and EuroQol-5 dimension questionnaire (EuroQol-5D) scores.

Results

As compared with baseline, improvement was observed in the following parameters: VAS for pain (at 4 weeks, P=0.023; at 16 weeks, P=0.023); shoulder PROM for abduction (at 4 weeks, P=0.023; at 16 weeks, P=0.024), flexion (at 4 and 16 weeks, P=0.024), extension (at 4 and 16 weeks, P=0.02), and external rotation (4 and 16 weeks, P=0.02); DAS for hygiene (at 4 and 16 weeks, P=0.024), dressing (at 4 weeks, P=0.02; at 16 weeks, P=0.024), and pain (at 4 weeks, P=0.024; at 16 weeks, P=0.023); and EuroQol-5D (at 4 and 16 weeks, P=0.024).

Conclusion

Our observations support the use of ultrasound-guided SSN PRF treatment for HSP in chronic stroke patients.

The Influence of Suprascapular Notch Shape on the Visualization of Structures in the Suprascapular Notch Region: Studies Based on a New Four-Stage Ultrasonographic Protocol

Evaluation of the morphology of the suprascapular notch region is important from a clinical point of view because it is the most common site of suprascapular nerve compression and injury. A group of 120 patients underwent ultrasound examination of the suprascapular notch region according to our original four-stage "step-by-step" protocol. The notches were classified based on their morphology and measurements like maximal depth (MD) and superior transverse diameter (STD) as follows: type I-MD is longer than STD, type II-MD and STD are equal, type III-STD is longer than MD, and in type IV/V-notches only the bony margin was visualized without depression. Both suprascapular notches were fully visualized in 115 of 120 patients. The type III suprascapular notch was the most prevalent (64.2%), followed by type IV/V (18.7%), type I (11.1%), and type II (6.0%). Color Doppler analysis allowed the suprascapular artery to be recognized in all visualized notches. The suprascapular vein was visible in 176 notches and the suprascapular nerve in 150. Notches containing both suprascapular nerve and vein were significantly wider and shallower than average. As the suprascapular artery is the most easily recognised structure in the area, it may serve as a useful landmark of the suprascapular notch.

The effectiveness of 2 consecutive intra-articular polydeoxyribonucleotide injections compared with intra-articular triamcinolone for hemiplegic shoulder pain: A STROBE-complaint retrospective study

The aim of this study was to investigate the effects of intra-articular injection of polydeoxyribonucleotide (PDRN), compared with intraarticular triamcinolone (TA) injection, in subacute stroke patients with hemiplegic shoulder pain (HSP).Participants were subacute stroke patients with HSP who had undergone 2 consecutive intra-articular injections of TA or PDRN.Numeric rating scale (NRS) and passive range of motion (PROM) of hemiplegic shoulder were evaluated until 4 weeks after 2nd injection.In the results, there were significant improvements in all PROM measures 2 weeks after the second injection, compared with pre-injection results, in both groups (P < .05). In the PDRN group, however, none of the PROM measures were significantly improved at 3 and 4 weeks after the second injection, compared with pre-injection results (P ≥ .05). When comparing pre-injection results with those at 4 weeks after the second injection, all PROM and NRS measures in the TA group were more improved than in the PDRN group, but this was not statistically significant (P ≥ .05).In conclusion, considering the systemic side effects of steroids, especially among patients with diabetes or metabolic syndrome, PDRN seems to be a worthwhile treatment option for HSP, although PDRN does not seem to have an equivalent persistence effects when compared with TA.

Suprascapular nerve block for the treatment of hemiplegic shoulder pain in patients with long-term chronic stroke: a pilot study

Hemiplegic shoulder pain is the most common pain condition after stroke. Suprascapular nerve block is an effective treatment for shoulder pain. The aim of this pilot study was to evaluate the effects of suprascapular nerve block on pain intensity, spasticity, shoulder passive range of motion, and quality of life in long-term chronic stroke patients with hemiplegic shoulder pain. Ten chronic stroke patients (over 2 years from onset) with hemiplegic shoulder pain graded ≥30 mm on the Visual Analogue Scale underwent suprascapular nerve block injection with 1 mL of 40 mg/mL methylprednisolone and 10 mL 0.5% bupivacaine hydrochloride. Main outcome was the Visual Analogue Scale evaluated before and after nerve block at 1 h, 1 week, and 1 month. Secondary outcomes were the modified Ashworth scale and the shoulder elevation, abduction, and external rotation passive range of motion evaluated before the nerve block and after 1 h as well as the American Chronic Pain Association Quality of Life Scale evaluated before and after nerve block at 1 month. The Visual Analogue Scale significantly improved after nerve block at 1 h (P = 0.005) and 1 week (P = 0.011). Significant improvements were found at 1 h after nerve block in the modified Ashworth scale (P = 0.014) and the passive range of motion of shoulder abduction (P = 0.026), flexion (P = 0.007), and external rotation (P = 0.017). The American Chronic Pain Association Quality of Life Scale significantly improved at 1 month after nerve block (P = 0.046). Our findings support the use of suprascapular nerve block for treating hemiplegic shoulder pain in long-term chronic stroke patients.

The application of sonography in shoulder pain evaluation and injection treatment after stroke: a systematic review

[Purpose] This review article is designed to expose the application of sonography in shoulder pain after stroke. [Methods] A range of databases was searched to identify articles that address sonography examination, with or without ultrasound guided corticosteroid injection for hemiplegic shoulder pain (HSP). The electronic databases of PubMed, CENTRAL, CINAHL, Cochrane Library, Medline were searched. [Results] According to the articles identified in our databases research, sonographic technique has potential to provide objective measurements in patients with HSP. The main sonography finding of HSP included subacromial subdeltoid (SASD) bursal effusion, tendinosis of the supraspinatus and subscapularis tendon, long head of biceps tendon sheath effusion, and shoulder subluxation. Our analysis also revealed significantly decreased pain score (VAS) and increased passive external rotation degree in the steroid injection group than control group. [Conclusion] The sonography examination is useful for HSP assessment and ultrasound guided technique is recommended for HSP injection treatment.