Which treatment approach is better for hemiplegic shoulder pain in ...

Clinical Rehabilitation 2011; 25: 60–68
Which treatment approach is better for hemiplegic
shoulder pain in stroke patients: intra-articular steroid or
suprascapular nerve block? A randomized controlled trial
Evren Yasar, Dilek Vural, Ismail Safaz, Birol Balaban, Bilge Yilmaz, Ahmet Salim Goktepe and Ridvan Alaca Gulhane
Military Medical Academy, Department of Physical Medicine and Rehabilitation, TAF Rehabilitation Center, Ankara, Turkey
Received 10th January 2010; returned for revisions 4th June 2010; revised manuscript accepted 12th June 2010.
Objective: To determine which injection technique was effective for patients with
hemiplegic shoulder pain.
Design: Randomized prospective double-blind study.
Setting: Brain Injury Rehabilitation Unit.
Intervention: Patients with hemiplegic shoulder pain were recruited over a
12-month period and all were hospitalized in our clinic. Intra-articular steroid
injection or suprascapular nerve block was performed on all patients.
Main measures: Range of motion values at the moment that pain started (range of
motion A) and passive maximum range of motion values (range of motion B) were
recorded. Pain intensity levels (visual analogue scale) at these two range of motion
values (pain A and pain B) were also taken. Evaluations were made before the
injection, and 1 hour, one week and one month after the injection.
Results: Twenty-six patients were enrolled in the study, the mean age was
61.53 10.30 years. The mean time since injury was 8.69 15.71 months.
The aetiology was ischaemic in 16 (61%) patients. Intra-articular steroid injection
was performed in 11 (42 %) patients, and suprascapular nerve block in 15 (57%)
patients. Range of motion A and range of motion B were changed statistically in
repeated measures. There were important differences in repeated measures of
pain intensity levels at these two range of motion values (P50.05). However, no
significant differences were determined in all measurements between intra-articular
steroid injection and suprascapular nerve block groups (P40.05).
Conclusions: Our results showed that neither injection technique was superior to
the other. Both injection procedures are safe and have a similar effect in stroke
patients with hemiplegic shoulder pain.
Address for correspondence: Evren Yasar, TSK
Rehabilitasyon Merkezi 06530 Bilkent, Ankara, Turkey.
e-mail: evrenyasar@yahoo.com
Introduction
Approximately 75% of patients complain of pain
at some time in the first 12 months following
a stroke. 1,2 Although hemiplegic shoulder pain
shows a tendency to occur in the early period,
ß The Author(s), 2011.
Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav 10.1177/0269215510380827

duration of hemiplegia appears to be significantly
related to this. 3 The pathogenesis of post-stroke
shoulder pain is multifactorial, and it is often
difficult to make differential diagnosis. While
traction of capsule and soft tissue-related subluxation
of the shoulder may occur in the early
stages, limited range of motion due to spasticity
may appear in the later stages of stroke.
These biomechanical problems around the shoulder
may lead to pain. 1
The patients’ complaints increase with passive
motion, but pain may also be present at rest.
Reduced range of motion is leading sign in hemiplegic
shoulder pain, and an increase or decrease
of passive range of motion may show the changes
in pain intensity or relief.
The period of hospitalization may be prolonged
in hemiplegic patients with shoulder
pain. 4 It is an annoying complication that may
be refractory to treatment and cause poor recovery.
1 Therefore the goals of treatment are pain
reduction and improvement of range of motion.
As pain decreases, an exercise programme may
be performed to improve range of motion. 3 Thus
it is very important in rehabilitation clinics to deal
with this problem as early as possible.
Shoulder pain after stroke requires multidisciplinary
management for optimal outcomes. 5
Shoulder slings or shoulder strapping may be
used to prevent it. Simple analgesics, high-intensity
transcutaneous electrical nerve stimulation or
functional electrical stimulation can provide some
improvements in stroke patients. 5,6
In resistant cases in particular, interventional
treatments come to the fore. Although intramuscular
botulinum toxin A injection may be helpful
in the spastic stage, steroid injections and nerve
blocks are used generally in all stages of shoulder
pain after stroke. In neurologic rehabilitation
units, intra-articular steroid injections and suprascapular
nerve blocks are accepted as the treatment
approaches for shoulder pain that may contribute
to the rehabilitation of hemiplegic patients.
However, there is lack of evidence-based data
about these injection techniques. The outcomes
of the limited literature about these injections are
still controversial. 5,7,8
In this randomized prospective double-blind
study, we applied intra-articular steroid injection
or suprascapular nerve block to patients with
hemiplegic shoulder pain. Our aim was to compare
the efficacy of these two methods in patients with
hemiplegic shoulder pain.
Methods
Treatment for hemiplegic shoulder pain 61
Study population
The patients with hemiplegic shoulder pain were
included in this study. Subjects were recruited over
a 12-month period and all were hospitalized in our
Brain Injury Rehabilitation Unit. The inclusion
criterion was post-stroke hemiplegic shoulder
pain which did not spread to the distal limb.
Those who had neglect, neuropathic pain, pressure
sores or any infection (urinary, respiratory, etc.) or
language difficulties were excluded. We used the
Mini-Mental Stage Examination test, which is the
instrument most widely used in screening for cognitive
problems in stroke patients, 9 and cognitively
impaired patients who had scores lower than 24
were also excluded. A standard anteroposterior
radiograph of the glenohumeral joint was made
and signs of degenerative changes at the glenohumeral
joint were also accepted as an exclusion
criterion. None of the subjects had regular pain
medication.
Subjects were assessed within first week of
admission to the clinic. Patient demographics,
including age, gender, details of aetiology, time
since stroke, affected side and Brunnstrom stage
of upper extremity and presence of spasticity were
recorded. All measurements were done by a physiatrist
before and after the procedure. In addition
to injection, patients were given an exercise programme
including range of motion and strengthening
exercises in pain range with the guidance of
a physiotherapist. The people collecting data
were masked. The subjects were allocated with
a coin-tossing method by an investigator who
was blinded about the examinations and
measurements.
This prospective study was approved by the hospital’s
ethics committee.
Injection procedures
An academic physiatrist who was very experienced
in interventional pain procedures and

62 E Yasar et al.
blinded about the examinations and measurements
performed all injections. He used tossing of a coin
to decide which injection method would be used.
Intra-articular steroid injections were performed
with the posterior approach: the needle was
advanced to the anteromedial region of the shoulder
below the posteroinferior border of the posterolateral
trigon of acromion. Triamsinolone
acetonide 40 mg (1 mL Kenacort A) and 6 mL of
prilocaine (Citanest 2%) were used for the injection.
Suprascapular nerve block was done using
surface anatomy. With the patient seated, the
spine of scapula was identified as the horizontal
line and a perpendicular line was drawn from the
angle of the scapula upward to bisect the spine of
the scapula. The needle was inserted at the suprascapular
notch point about 2 cm lateral and
1,5 cm superior to the intersecting point of the
horizontal and perpendicular lines. Then, 10 mL of
prilocaine (Citanest 2%) was delivered into the
suprascapular notch. All injections were done
after necessary supporting sterility measures. 10
Measurements
Patient demographics, including age, gender,
details of aetiology, time since stroke, affected
side and Brunnstrom stage of upper extremity
and presence of spasticity, were recorded. Pain
intensity was recorded with visual analogue scale,
which quantifies the perceived level of pain intensity
on a scale of 0–10 cm. 11 All range of motion
measurements were taken in the supine position
and the shoulder was stabilized to prevent hitching.
Shoulder flexion, abduction, internal and
external rotation were measured with goniometry.
7,12 Shoulder flexion and abduction were measured
in neutral rotation with the elbow extended.
Shoulder internal rotation and external rotation
were measured at 90 of abduction with the arm
with the elbow flexed to 90 and the forearm in
mid-position.
Range of motion values at the moment that pain
started (range of motion A) and passive maximum
range of motion values (range of motion B) were
recorded. Pain intensity levels at these two range
Table 1 Comparisons of demographics between intra-articular steroid injection and suprascapular nerve block groups
(P40.05)
Groups Intra-articular steroid injection Suprascapular nerve block
Gender (number ¼ n)
Male 8 9
Female 3 6
Age (years) (mean standard deviation) 63.18 12.60 60.33 8.50
Time since stroke (months) (mean standard deviation) 11.27 20.47 6.80 11.51
Aetiology (number ¼ n)
Haemorrhagic stroke 5 5
Ischaemic stroke 6 10
Affected side (number ¼ n)
Right 5 7
Left 6 8
Resting pain (VAS, cm) (mean standard deviation) 2.27 1.90 1.20 2.0
Spasticity (number ¼ n)
Present 8 8
Absent 3 7
Brunnstrom stages (upper extremity) (number ¼ n)
1 5 5
2 4 3
3 1 5
4 – –
5 1 2
6 – –
VAS, visual analogue scale.

of motion values (pain A and pain B) were also
taken. Evaluations were made before the injection,
and 1 hour, one week and one month after the
injection. The investigator who did these measurements
and the patients were blinded about the
injection method that was used.
Statistical methods
SPSS programme version 10.0 for Windows was
used for stastistical analysis (SPSS Inc., Chicago,
IL, USA). Demographic variables were compared
with Mann–Whitney U-test and chi-square test.
Change over time in pain intensity and range of
motion, and the probable effect of the injection
type on this change were evaluated with General
Linear Model Repeated Measures Analysis of
Variance. A P-value 50.05 was considered to be
significant.
Table 2 The comparisons of the assessments before
injections between intra-articular steroid injection and
suprascapular nerve block (P40.05)
Examinations
before injections
Injection techniques
Intra-articular
steroid
injection
(mean SD)
Suprascapular
nerve
block
(mean SD)
ROM A (degree)
Flexion 96.36 34.79 114.33 24.26
Abduction 84.54 27.06 99.66 24.23
Internal rotation 37.27 15.38 46.66 16.22
External rotation 38.18 15.21 46.66 20.41
ROM B (degree)
Flexion 123.63 31.15 135.00 20.44
Abduction 107.72 28.84 115.00 23.82
Internal rotation 47.27 14.89 55.66 12.37
External rotation 55.00 14.14 56.33 20.04
Pain A (VAS, cm)
At flexion 6.36 2.06 5.86 2.03
At abduction 6.45 1.50 6.20 1.85
At internal rotation 5.54 1.80 5.73 1.94
At external rotation 5.81 1.83 5.80 2.00
Pain B (VAS, cm)
At flexion 8.09 0.94 7.73 1.09
At abduction 8.27 0.90 8.06 1.48
At internal rotation 7.09 1.04 7.46 1.76
At external rotation 7.54 1.12 7.80 1.37
ROM, range of motion; VAS, visual analogue scale; SD; standard
deviation.
Results
Treatment for hemiplegic shoulder pain 63
Twenty-six patients were enrolled to the study, the
mean age was 61.53 10.30 years. Seventeen
(65.4%) of them were male, 9 (34%) were
female. The mean time since injury was
8.69 15.71 months. The aetiology was ischaemic
in 16 (61%) patients. Although the hemiplegic side
was left in 14 (53%) of them, 12 (46%) had right
hemiplegia. In our study, intra-articular steroid
injection was performed in 11 (42%) patients
and suprascapular nerve block in 15 (57%).
There was no significant difference in both the
resting visual analogue scale values and the assessments
before injection between two treatment
groups (P40.05) (Tables 1 and 2).
Range of motion values at the moment that pain
started (range of motion A) and passive maximum
range of motion values (range of motion B) were
changed statistically in repeated measures
(Table 3). There were important differences in
repeated measures of pain intensity levels at
Table 3 Statistical differences in repeated measurements
of patients
Examinations Within-subject factors
f P
Range of motion A (degree)
Flexion 35.13 50.001
Abduction 34.06 50.001
Internal rotation 5.83 0.024
External rotation 40.79 50.001
Range of motion B (degree)
Flexion 8.94 0.006
Abduction 23.72 50.001
Internal rotation 8.45 0.008
External rotation 34.94 50.001
Pain A (VAS, cm)
At flexion 14.73 0.001
At abduction 36.87 50.001
At internal rotation 30.38 50.001
At external rotation 36.00 50.001
Pain B (VAS, cm)
At flexion 36.64 50.001
At abduction 63.58 50.001
At internal rotation 35.68 50.001
At external rotation 40.53 50.001
VAS, visual analogue scale.

64 E Yasar et al.
these two range of motion values (pain A and pain
B) (Table 3). However, no significant differences
were determined in measurements between intraarticular
steroid injection and suprascapular nerve
block groups (between-subject factors; P40.05).
No complication related to the injections were
observed in our study. A flow diagram showing
how patients progressed through the study is
shown in Figure 1.
Discussion
In the present study, we found that both intraarticular
steroid injection and suprascapular
nerve block improved the limitations in all
planes of shoulder range of motion. In addition
to this, visual analogue scale scores for pain severity
reduced after injections in comparison with
pre-injection evaluations. However, the efficacy
of neither of these injection techniques was superior
to the other. Both injection procedures are
safe and have a similar effect in stroke patients
with hemiplegic shoulder pain. According to our
findings, the presence of actual motor stages
(Brunnstrom stages) did not affect the preference
of injection method. To the best of our knowledge,
this represents the first study to have compared the
efficacy of intra-articular steroid injection and
suprascapular nerve block techniques on pain
and range of motion for hemiplegic shoulder
pain in stroke patients.
The literature is poor about the efficacy of intraarticular
steroid injection in hemiplegic shoulder
pain. Our study showed that intra-articular steroid
injection may provide pain relief and improve
range of motion of hemiplegic shoulder in stroke
patients. This information encourages the practice
of intra-articular steroid injection, which has poor
evidence in the literature although it has been
widely used in physiatry clinics.
Although the anti-inflammatory effects of steroids
are the leading source of the pain relief,
they may also reduce non-inflammatory or degenerative
sources of pain such as tendinosis. 13 This
efficacy of steroids are poorly defined. Nociceptive
receptors that are under the control of some neurotransmitters
or mechanoreceptors that are irritated
by traction forces may be affected by
steroids. 14–16 Subacromial steroid injection has
been found to reduce the pain related to supraspinatus
impingement, tendinitis or subacromial bursitis.
17 On the other hand, Lo et al. reported that
50% of the stroke patients had adhesive capsulitis
and 44% had shoulder subluxation in arthrographic
examinations of the patients with hemiplegic
shoulder pain. 18 Intra-articular corticosteroids
have provided pain relief in non-stroke patients
with adhesive capsulitis who have predominant
pain symptoms. 19 However, intra-articular injections
of triamcinolone acetonide seemed to
decrease hemiplegic shoulder pain and to accelerate
recovery in patients with hemiplegic shoulder
pain, although there was no significant difference
in pain, mobility or function compared with intraarticular
injections of saline. 7
The second injection method that we used was
suprascapular nerve block. The suprascapular
nerve supplies some of the sensory innervation of
the shoulder. 5 Suprascapular nerve block may provide
temporary cessation of nociceptive information
from the shoulder to the central nervous
system. 20 In a study which included 34 subjects
with frozen shoulder, the efficacy of suprascapular
nerve block was investigated using 10 mL bupivacaine
versus placebo nerve blockade. It found a
significant reduction in pain in the treatment
group versus the placebo group at one month.
But shoulder function was not improved notably.
21 In a prospective, randomized, comparison
crossover investigation, suprascapular nerve
block decreased the severity and frequency of the
perceived pain and increased compliance with the
rehabilitation programme in patients with rotator
cuff tendinitis. 20
Suprascapular nerve block has been used with
some success in relieving resistant shoulder pain in
some other rheumatologic problems. 21,22
However, there are only two studies in the literature
about suprascapular nerve block in patients
with hemiplegic shoulder pain. Lee and
Khunadorn reported that its efficacy on pain
relief was poor in patients with hemiplegia, 8 and
Boonsong et al. claimed that suprascapular nerve
block was a safe and effective treatment for hemiplegic
shoulder pain. 23 Our study has also shown
good results following suprascapular nerve block
in hemiplegic shoulder pain.

Inclusion
Post-stroke hemiplegic
shoulder pain which did not
spread to the distal limb
Exclusion
Those who had neglect,
neuropathic pain, pressure
sore or any infection (urinary,
respiratory etc.), language
difficulties, cognitive deficits
and degenerative changes at
the glenohumeral joint were
excluded
IASI group
N=11
Approximately 120 patients who were
hospitalized over a 12-month period in
our Brain Injury Rehabilitation Unit were
examined according to inclusion and
exclusion criteria
26 patients
were included
Measurements
Asessesment of visual analogue scale at rest
Goniometric range of motion values(shoulder flexion,
abduction, internal and external rotation) measurement
at the moment that pain started (ROM-A) and passive
maximum range of motion values (ROM-B)
Pain intensity levels at these two range of motion
values (pain-A and pain-B)
Patients allocated with
coin tossing method by an
investigator who was
blinded about
examinations and
measurements
Evaluations were repeated at 1 hour, 1
week and 1 month after the injection. The
investigator who did these measurements and the
patients were blinded about the injection method
that was used
Treatment for hemiplegic shoulder pain 65
SSNB group
N=15
Figure 1 Flow diagram showing how patients progressed through the study. IASI, intra-articular steroid injection; SSNB,
and suprascapular nerve block.

66 E Yasar et al.
A few investigations comparing the effectiveness
of intra-articular steroid injection and
suprascapular nerve block have been published.
Taskaynatan et al. compared the effects of suprascapular
nerve block with those of steroid injection
in patients with non-specific shoulder pain, and
found a significant difference in all follow-up
parameters in both groups. However, there was
no difference in efficacy between the two methods.
24 It was reported that combined suprascapular
nerve block and glenohumeral intra-articular
steroid injection may be more effective than
either injection alone in addition to physical therapy
in patients with adhesive capsulitis. 25
However, these two studies were done in nonstroke
patients.
In a retrospective study which investigated the
efficacy of suprascapular nerve block in treating
rotator cuff tendonitis, 88% of the patients had
significant pain relief, and the authors claimed
that suprascapular nerve block may be a safer
alternative than injections involving steroid exposure.
26 It was reported that rotator cuff tear might
be seen in about a third of patients with hemiplegia.
18,27 It is necessary to avoid repeated steroid
injections, particularly because of their atrophic
effects. 5 Efficacy over the longer term is not
clear. Some authors recommended the use of steroid
injections only in the presence of active
inflammation. 28 At the time of follow-up in the
hospital or after hospitalization, there were no
complications related to steroid injection in our
study group. On the other hand, transient vagal
symptoms and local tenderness at the injection
site were reported side-effects of suprascapular
nerve block. 29 In our suprascapular nerve block
group, we did not determine any adverse effect
related to the injection.
Suprascapular nerve block is a simple, safe and
inexpensive technique to relieve pain originating
from the hemiplegic shoulder. 5 The similar efficacies
of intra-articular steroid injection and suprascapular
nerve block that have been found in our
study and some controversial issues about sideeffects
related to steroid injection lead us to
think that suprascapular nerve block may be a
more convenient method in hemiplegic shoulder
pain of stroke patients for whom a specific aetiologic
diagnosis has not been made.
Although our data suggest that both intraarticular
steroid injection and suprascapular
nerve block reduce hemiplegic shoulder pain in
patients with stroke, there are some limitations
that prevent the formulation of more definitive
conclusions. Small patient group, lack of placebo
group and long-term follow-up are the leading
limitations for this study. If there had been
long-term follow-up of the patients, it would
have contributed to our outcomes. The use of
neither ultrasonography nor magnetic resonance
imaging in diagnosis of hemiplegic shoulder pain
and not using any guide for interventions such as
ultrasonography, fluoroscopy or neurostimulators
may be seen as a limitation. If the physician
has any concern about the side-effects of steroids,
suprascapular nerve block should be considered
to be the preferred treatment for hemiplegic
shoulder pain because it is as effective as steroid
injection with rare side-effects. However, our
study did not aim to investigate side-effects and
risks and it was too small to draw any firm
conclusion.
Our aim is to find a convenient injection method
which can be used easily to break the vicious cycle
of hemiplegic shoulder pain. The gradual reduction
of the pain levels indicated to us that this
vicious cycle was broken. Nevertheless, neither
injection technique was better than the other.
At the same time, there was an increasing improvement
in the patients who went on to join the exercise
programme.
Clinical message
Both intra-articular steroid injection and
suprascapular nerve block can be used
safely and provide similar pain relief and
improvement in all planes of shoulder
range of motion limitations in stroke
patients with hemiplegic shoulder pain.
Acknowledgements
This study was performed in TAF
Rehabilitation Center with no financial support.

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