1Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan
2Department of Physical Medicine and Rehabilitation, National Taiwan University College of Medicine, Taipei, Taiwan
3Center for Regional Anesthesia and Pain Medicine, Wang-Fang Hospital, Taipei Medical University, Taipei, Taiwan
4Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
5 Department of Rehabilitation Medicine, Charles University, First Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
6Physical and Rehabilitation Medicine Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy
7 The Hong Kong Institute of Musculoskeletal Medicine, Hong Kong, China
8 Department of Family Medicine, The Chinese University of Hong Kong, Hong Kong, China
9Department of Family Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
10Center for Regional Anesthesia and Pain Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
11 Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Daegu, Korea
12Department of Anesthesiology and Pain Medicine, Seoul National University School of Medicine, Seoul, Korea
13Physical Medicine and Rehabilitation Service, Centre Hospitalier de l’Université de Montréal, Montreal, QC, Canada
14Rheumatology and Pain Medicine, Florence Fisiotech Lab Studio, Firenze, Italy
15Morphological Madrid Research Center (MoMaRC), Madrid, Spain
16Research Center for Health Science, Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
17Department of Physical Medicine and Rehabilitation, Our Lady of Lourdes Hospital, Manila, Philippines
18Physical Medicine and Rehabilitation Department, Philippine Heart Center, Quezon, Philippines
19Department of Physical Medicine and Rehabilitation, The Medical City South Luzon, Santa Rosa, Laguna, Philippines
20SMARTMD Center for Non-Surgical Pain Interventions, Makati, Philippines
21Department of Physical Medicine, Rheumatology and Rehabilitation, Faculty of Medicine, Tanta University, Tanta, Egypt
22Pain and Headache Division, Neurology Department, Faculty of Medicine, Universitas Syiah Kuala, Zainoel Abidin General Hospital, Banda Aceh, Indonesia
23 Pain Management, Ventura County Medical Center, Ventura, CA, USA
24GCC Institute Regenerative Medicine, Newport Beach, CA, USA
25Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
26Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
Shoulder pain is a common complaint over the paralytic side of stroke patients. We suggest that
ultrasound examination should be arranged for hemiplegic shoulders in the presence of pain unresponsive to
medication and physical therapy. Ultrasound-guided dual target corticosteroid injection can be introduced over
the rotator cuff interval and subdeltoid bursa in case of rotator cuff pathologies. Otherwise, suprascapular nerve
block can be performed under ultrasound guidance. Furthermore, the physician should examine whether there
is pain associated with increased spasticity, which can be managed by shock wave therapy or botulinum toxin
intra-muscular injection. Finally, if the patients have developed symptoms of complex regional pain syndrome,
ultrasound-guided cervical sympathetic ganglion block should be taken into consideration.
Shoulder pain is a common complaint over the paralytic side of stroke patients, with a prevalence ranging between 22% and 47% . Hemiplegic shoulder pain hampers motor recovery of the affected upper extremity, leading to extended hospital stay and delayed functional independence. Based on a recent bibliometric analysis investigating the hotspots of publications for post-stoke pain , the largest cluster of reference co-citation analysis was labeled as “hemiplegic shoulder pain.” Likewise, the citation most pertinent to the aforementioned cluster was the article entitled “Persistent shoulder pain in the first 6 months after stroke: results of a prospective cohort study.”  When we used the Sigma value to identify the innovative references , three of the five most novel citations were relevant to post-stroke shoulder pain, which were published in journals belonging to the categories of rehabilitation and clinical neurology. Therefore, hemiplegic shoulder pain is not only a clinically important issue but also a research focus as well.
Ultrasound has become one of the most useful tools for the evaluation of shoulder pathologies . A previous ultrasound study revealed that shoulders at the hemiplegic side were more likely to have tenosynovitis of the biceps long head tendon and subdeltoid bursitis, compared with the nonhemiplegic side . Therefore, we suggest that ultrasound examination should be arranged for hemiplegic shoulders in the presence of pain unresponsive to medication and physical therapy. Once relevant pathologies (effusion or tendinopathy) over the biceps long head, subdeltoid bursa, and rotator cuff tendons are detected, ultrasound-guided dual target injection with 40 mg triamcinolone acetonide and 3 mL 1% lidocaine can be introduced over the rotator cuff interval and subdeltoid bursa . A randomized controlled trial showed that this approach had a longer effective duration than the traditional subacromial injection for shoulder impingement syndrome . Another benefit is, for sure, the simultaneous treatment of the biceps long head tendon and subdeltoid bursa, which are the two most commonly involved structures in hemiplegic shoulders.
Nevertheless, if there are no relevant pathologies identified on shoulder ultrasonography, suprascapular nerve block can be performed under ultrasound guidance, which has also been incorporated in a recent protocol for management of stiff painful shoulders after stroke . According to a recent network meta-analysis investigating injection therapies for hemiplegic shoulder pain , suprascapular nerve block ranked first in terms of pain relief at the 4th week after intervention. The main concern of suprascapular nerve block is its short effective duration. In this sense, the physician should examine whether there is pain associated with increased spasticity. Based on another network meta-analysis investigating post-stroke spasticity management , the antispasticity effect of extracorporeal shock wave was comparable to botulinum toxin injection. Shock wave, as a noninvasive therapy, can be employed as the first line to decrease spasticity-related shoulder pain. If the treatment outcome is not optimal, intramuscular botulinum toxin injection can be applied subsequently. Furthermore, a previous meta-analysis also proved the benefits of intrabursal or intraarticular botulinum toxin injection for the treatment of chronic shoulder joint and myofascial pain, partly owing to the decreased release of substance P . Therefore, the residual botulinum toxin solution can be administered to the subdeltoid bursa or glenohumeral joint for better pain relief.
Finally, if the patients have developed symptoms of complex regional pain syndrome, ultrasound-guided cervical sympathetic ganglion block should be taken into consideration [11,12]. Before the physician introduces the injectate underneath the prevertebral fascia overlying the longus coli muscle, the power or color Doppler mode must be turned on to scrutinize nearby neurovascular structures (e.g., vagus nerve, common carotid, and vertebral arteries). The flow diagram of interventional pain management is provided in Figure 1, which is easy to follow and facilitates early relief of hemiplegic shoulder pain.
The study was made by (1) the research funding of the Community and Geriatric Medicine Research Center, National Taiwan University Hospital, BeiHu Branch, Taipei, Taiwan; (2) Ministry of Science and Technology (MOST 106-2314-B-002-180-MY3, 109-2314-B-002-114-MY3 and 109-2314-B-002-127), and (3) Taiwan Society of Ultrasound in Medicine.
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