Neurol Sci

DOI 10.1007/s10072-017-3057-8

ORIGINAL ARTICLE

Suprascapular nerve block for the treatment of hemiplegic

shoulder pain in patients with long-term chronic stroke:
a pilot study
Alessandro Picelli 1 & Sara Bonazza 2 & Davide Lobba 1 & Massimo Parolini 3 &
Alvise Martini 3 & Elena Chemello 1 & Marialuisa Gandolfi 1,4 & Enrico Polati 2,3 &
Nicola Smania 1,4 & Vittorio Schweiger 2,3

Received: 8 March 2017 / Accepted: 1 July 2017

# Springer-Verlag Italia S.r.l. 2017

Abstract 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 inten-
sity, spasticity, shoulder passive range of motion, and quality of
life in long-term chronic stroke patients with hemiplegic shoul-
der 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 ex-
ternal 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 sig-
nificantly improved after nerve block at 1 h (P = 0.005) and
* Alessandro Picelli
alessandro.picelli@univr.it
1
Neuromotor and Cognitive Rehabilitation Research Center,
Department of Neurosciences, Biomedicine and Movement
Sciences, University of Verona, P.le L.A. Scuro, 10,
37134 Verona, Italy
2
Anesthesia and Intensive Care Unit, Department of Surgery,
Dentistry, Pediatrics and Gynecology, University of Verona,
Verona, Italy
3
Pain Therapy Center, Department of Emergency and Intensive Care,
Hospital Trust of Verona, Verona, Italy
4
Neurorehabilitation Unit, Department of Neurosciences, Hospital
Trust of Verona, Verona, Italy
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 abduc-
tion (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.
Keywords Anesthetics . Chronic pain . Pain management .
Rehabilitation
Introduction
Stroke is the second cause of disability in Europe [1]. Damage
to the sensorimotor networks and descending tracts results in
the positive and negative signs of upper motor neuron syn-
drome [2]. Upper limb is commonly involved after stroke,
with up to 69% of patients having arm weakness on admission
to hospital [3]. Recovery of upper limb function has been
found to relate with the degree of initial paresis and its topical
distribution according to the cortico-motoneuronal represen-
tation of arm movements [4–8].
Hemiplegic shoulder pain (HSP) is the most common pain
condition in stroke patients and one of the four most common
medical complications after stroke, together with depression,
falls, and urinary tract infections [9–12]. Previous studies have
reported that HSP develops at between 2 weeks and several
months following onset involving almost a third of stroke
survivors [9, 11, 13]. The etiology of HSP is multifactorial
[9]. It can arise through several mechanisms that lead to
altered shoulder stability, including impaired motor function

(muscle tone changes), soft tissue lesions (rotator cuff and
biceps tendon disorders; adhesive capsulitis), and altered pe-
ripheral or central nervous system activity (complex regional
pain syndrome type 1; peripheral nerve entrapment; neglect
and sensory impairment; central post-stroke pain; central sen-
sitization) [12].
Hemiplegic shoulder pain is a major contributor to post-
stroke disability, and it is associated with reduced use of the
affected arm, interference with rehabilitation, increased length
of stay, and higher rates of depression [11]. The goals of HSP
treatment are pain reduction and improvement of range of
motion [14]. The main treatment approaches for preventing
and treating HSP are limb positioning, upper limb supports
(such as slings, orthotics, and strapping), passive movement
exercises, analgesic medications (including non-steroidal anti-
inflammatory drugs), electrical stimulation for muscle con-
traction, transcutaneous electrical nerve stimulation for pain
relief, intra-articular corticosteroids, botulinum toxin injec-
tion, perineural injection therapy, and surgery [12].
Suprascapular nerve block (SSNB) is a safe and effective
treatment option for stroke patients with HSP [9, 14–17].
However, to the best of our knowledge, its usefulness has been
mainly evaluated within 12–18 months after onset and not
during the long-term chronic phase of stroke [9, 14, 15].
This represents a lack of knowledge given that HSP has been
found to increase its incidence over time after stroke (duration
of hemiplegia is significantly related to HSP) reaching a fre-
quency of 21% over 1 year from onset [11, 12, 14]. On this
basis, there is a rationale for this study that aimed to evaluate
the effects of SSNB on subjective pain intensity, spasticity,
shoulder passive range of motion (PROM), and quality of life
in patients with HSP due to stroke in the long-term (over
2 years from onset) chronic phase of illness.
Methods
This was a single-center pilot study. Inclusion criteria were as
follows: age ≥ 18 years, first-ever unilateral stroke, Mini
Mental State Examination ≥24, hemiplegic shoulder pain
graded ≥30 mm on the Visual Analogue Scale (VAS) [18],
time since stroke onset >2 years, and time since last botulinum
toxin treatment ≥5 months. Exclusion criteria were as follows:
inclusion in other trials, change of pain medication during the
study period, aphasia, fixed contractures or bony deformities
at the affected upper limb, treatment of upper limb spasticity
with neurolytic or surgical procedures, hypersensitivity to in-
jection agents, and other conditions at the affected shoulder
(rotator cuff injury or tendinitis, frozen shoulder, thoracic out-
let syndrome, osteoarthritis, bursitis, recent trauma or bone
fracture, joint replacement). All participants were outpatients.
Written informed consent for participation in the study was
obtained from all patients. The study was carried out
Neurol Sci
according to the Declaration of Helsinki and approved by
the local Ethics Committee. Patients were not allowed to par-
ticipate in any rehabilitation program during the study period.
Treatment procedures
All participants received SSNB injection at the affected shoul-
der with 1 mL of 40 mg/mL methylprednisolone and 10 mL
0.5% bupivacaine hydrochloride [9]. Anatomic landmarks
and ultrasonography were used to determine injection site into
the supraspinous fossa. The needle was introduced parallel to
the scapula blade and the syringe contents slowly injected into
the space of the supraspinous fossa [9].
Evaluation procedures
Main outcome was the VAS evaluated before (T0) and after
SSNB at 1 h (T1—primary endpoint), 1 week (T2), and
1 month (T3). The VAS involves a 100-mm vertical line an-
chored with the extremes of subjective pain [18]. Secondary
outcomes were the modified Ashworth scale (MAS) and the
shoulder elevation, abduction, and external rotation PROM
evaluated at T0 and T1 as well as the American Chronic
Pain Association Quality of Life Scale (QOLS) evaluated at
T0 and T3. The MAS is a 6-point scale grading the resistance
to rapid passive stretch from 0 (no increase in muscle tone) to
5 (joint is rigid) [19, 20]. The QOLS is an 11-point scale
grading the impact of pain on the basic activities of daily life
ability from 0 (non-functioning/stay in bed all day/feel hope-
less and helpless about life) to 10 (normal quality of life/go to
work or volunteer each day/normal daily activities each day/
have a social life outside of work/take an active part in family
life) [21].
Statistical analysis
Statistical analysis was carried out using the Statistical
Package for Social Science for Macintosh, version 20.0
(SPSS Inc., Chicago, IL). The Wilcoxon signed-rank test on
the T1 versus T0 (VAS, MAS and PROM), T2 versus T0
(VAS), and T3 versus T0 (VAS and QOLS) comparisons
was carried out. The alpha level for significance was set at
P < 0.05. The Bonferroni correction was used for the VAS
multiple comparisons, resulting in P < 0.016 as the signifi-
cance threshold.
Results
Ten long-term chronic stroke patients (mean age 66.9 years;
mean time since stroke onset 7.2 years) with HSP were recruit-
ed from among 36 outpatients consecutively admitted to our
clinical unit. The enrolment period was from December 2015 to
Neurol Sci

Table 1 Demographic by injured tissues or sensitized after long-term unresolved pain

and clinical features Age (years)
of patients Mean (SD)
Sex
Male/female
Time from stroke onset (years)
Mean (SD)
DN4 (score)
Mean (SD)
SD standard deviation, DN4 Douleur
Neuropathique en 4 Questions
May 2016. No adverse events occurred during the study. There
were no dropouts. Table 1 presents patients’ features.
The Wilcoxon test showed significant improvements on
the VAS after SSNB at T1 (P = 0.005; Z = −2.814) and T2
(P = 0.011; Z = −2.436) but not at T3 (P = 0.041; Z = −2.041).
Furthermore, significant improvements were found at T1 on
the MAS (P = 0.014; Z = −2.449) and the PROM of shoulder
abduction (P = 0.026; Z = −2.226), flexion (P = 0.007;
Z = −2.680), and external rotation (P = 0.017; Z = −2.388).
At last, a significant improvement was found at T3 on the
QOLS (P = 0.046; Z = −2.000). Table 2 reports data about
outcomes at all time points.
Discussion
The suprascapular nerve (stemming from the ventral rami of
spinal nerves C4–C5–C6 and emerging from the upper trunk
of the brachial plexus) provides 70% of sensory innervation to
the shoulder joint [22]. In patients with chronic shoulder pain,
the afferent fibers of suprascapular nerve may become entrapped
[23, 24]. Suprascapular nerve block is a widely used approach in
66.9 (8.3)
the management of acute and chronic shoulder pain conditions
[24–27]. It provides temporary cessation of nociceptive infor-
5/5
mation from the affected shoulder to the central nervous system
[14]. From a technical point of view, the application of ultra-
7.2 (3.1)
sound guidance demonstrated consistently better effectiveness
than other injection procedures [24]. For injection, the patient is
4.9 (2.6)
in sitting position with the ultrasound probe placed horizontal to
the scapular spine and the supraspinous fossa (the suprascapular
notch is found by slowly locating the probe laterally, and the
pulsating suprascapular artery is a good indicator for the location
of suprascapular nerve) [15].
As to stroke patients with HSP, only few previous studies
mainly focused on the first 12–18 months after onset had
investigated the effectiveness of SSNB [9, 14, 15, 17, 28].
Their first two studies in the literature about SSNB in stroke
patients with HSP were contradictory, given that Lee and
Khunadorn reported poor efficacy of SSNB on HSP relief
while Boonsong and colleagues claimed that SSNB was a safe
and effective treatment for HSP [17, 28]. A later, properly
sized, randomized controlled trial by Adey-Wakeling and col-
leagues supported and enlarged Boonsong’s findings by a
consistent demonstration on a sample of 64 stroke patients
(onset <1 year) that SSNB would be superior to placebo in-
jection for reducing HSP intensity [9]. As to the comparison
with other treatment approaches for HSP in stroke patients,
similar efficacies of SSNB and intra-articular steroid injection
have been found by previous literature [14, 15]. However,
considering some issues about side effects related to steroid
injection (e.g., detrimental effects on articular cartilage and
changes of glucose metabolism), SSNB should be considered
a more convenient method to treat HSP in patients with stroke
[14, 15, 24]. Our findings about the significant reduction of
subjective pain intensity (main outcome) up to 1 week after

Table 2 Outcomes at all time points

Parameter Before SSNB 1 h after SSNB 1 week after SSNB 1 month after SSNB

VAS (0–100 mm) 7.8 (1.3) 3.2 (2.9) 4.1 (3.7) 5.8 (2.8)
Mean (SD)
MAS shoulder adductors (0–5) 1.5 (1.0; 2.0) 1.0 (1.0; 1.8)
Median (IQR)
Shoulder elevation PROM (degrees) 95.5 (24.8) 115.0 (33.2)
Mean (SD)
Shoulder abduction PROM (degrees) 97.0 (30.2) 108.5 (28.7)
Mean (SD)
Shoulder external rotation PROM (degrees) 57.0 (18.4) 80.5 (17.7)
Mean (SD)
American Chronic Pain Association Quality Of Life Scale (0–10) 5.5 (4.8; 6.3) 6.0 (5.0; 6.5)
Median (IQR)

SSNB suprascapular nerve block, VAS Visual Analogue Scale, SD standard deviation, MAS Modified Ashworth Scale, IQR interquartile range, PROM
passive range of motion

SSNB further support its use as an effective intervention for
treating HSP in patients with stroke and expand its application
to the long-term chronic phase of illness (over 2 years
from onset).
As to our secondary outcomes, we observed that SSNB
might effectively reduce spasticity and increase shoulder
PROM up to 1 h after treatment in long-term chronic stroke
patients with HSP. This would be keeping with a main concern
about the use of SSNB for patients with shoulder pain, which
is the short duration of action of local anesthetics [24]. On
these bases, given that the mechanism of short-term effects
are attributable to blocking sensory fibers and reducing noci-
ceptive input to the central nervous system [3], SSNB might
be proposed as an adjuvant treatment to be performed before
physiotherapy in order to facilitate shoulder mobilization and
neuromotor technique application in chronic stroke patients
with HSP. Interestingly, our patients also showed a significant
improvement of quality of life up to 1 month from SSNB. This
finding, together with the lack of decline of SSNB effect on
HSP intensity by 1 week, might suggest also a potential
reduction in central sensitization secondary to a diminished
nociceptive stimulus, which would be in line with the pro-
posed both nociceptive and neuropathic nature of HSP [3, 4].
This pilot study has several limitations. First, the sample
size was small. We estimated that a total of 27 patients would
provide 90% power to detect a difference of 13 mm on the
VAS (minimal clinically important difference) at the primary
endpoint [29]. Second, there was no control group treated with
placebo or other (pharmacological and physical) treatments
for shoulder pain. Third, no medium- and long-term follow-
up was planned for all secondary outcomes. Fourth, even if the
goals of HSP treatment are pain reduction and improvement of
PROM [14], we did not evaluate any functional outcome.
Future larger controlled trials should take into account all the
issues described so far in order to further validate our findings
by overcoming our limitations and obtaining some more
information about the effects of HSP treatment on upper
limb function.
Compliance with ethical standards
Competing interests The authors declare that they have no conflict
of interest.
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