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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
Clin Rehabil 2011 25: 60 originally published online 13 October 2010
DOI: 10.1177/0269215510380827
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Clinical Rehabilitation 2011; 25: 60–68
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.
Introduction
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Treatment for hemiplegic shoulder pain 61
duration of hemiplegia appears to be significantly hemiplegic shoulder pain. Our aim was to compare
related to this.3 The pathogenesis of post-stroke the efficacy of these two methods in patients with
shoulder pain is multifactorial, and it is often hemiplegic shoulder pain.
difficult to make differential diagnosis. While
traction of capsule and soft tissue-related sublux-
ation of the shoulder may occur in the early
stages, limited range of motion due to spasticity Methods
may appear in the later stages of stroke. Study population
These biomechanical problems around the shoul- The patients with hemiplegic shoulder pain were
der may lead to pain.1 included in this study. Subjects were recruited over
The patients’ complaints increase with passive a 12-month period and all were hospitalized in our
motion, but pain may also be present at rest. Brain Injury Rehabilitation Unit. The inclusion
Reduced range of motion is leading sign in hemi- criterion was post-stroke hemiplegic shoulder
plegic shoulder pain, and an increase or decrease pain which did not spread to the distal limb.
of passive range of motion may show the changes Those who had neglect, neuropathic pain, pressure
in pain intensity or relief. sores or any infection (urinary, respiratory, etc.) or
The period of hospitalization may be pro- language difficulties were excluded. We used the
longed in hemiplegic patients with shoulder Mini-Mental Stage Examination test, which is the
pain.4 It is an annoying complication that may instrument most widely used in screening for cog-
be refractory to treatment and cause poor recov- nitive problems in stroke patients,9 and cognitively
ery.1 Therefore the goals of treatment are pain impaired patients who had scores lower than 24
reduction and improvement of range of motion. were also excluded. A standard anteroposterior
As pain decreases, an exercise programme may radiograph of the glenohumeral joint was made
be performed to improve range of motion.3 Thus and signs of degenerative changes at the gleno-
it is very important in rehabilitation clinics to deal humeral joint were also accepted as an exclusion
with this problem as early as possible. criterion. None of the subjects had regular pain
Shoulder pain after stroke requires multidisci- medication.
plinary management for optimal outcomes.5 Subjects were assessed within first week of
Shoulder slings or shoulder strapping may be admission to the clinic. Patient demographics,
used to prevent it. Simple analgesics, high-inten- including age, gender, details of aetiology, time
sity transcutaneous electrical nerve stimulation or since stroke, affected side and Brunnstrom stage
functional electrical stimulation can provide some of upper extremity and presence of spasticity were
improvements in stroke patients.5,6
recorded. All measurements were done by a phys-
In resistant cases in particular, interventional
iatrist before and after the procedure. In addition
treatments come to the fore. Although intramus-
to injection, patients were given an exercise pro-
cular botulinum toxin A injection may be helpful
gramme including range of motion and strength-
in the spastic stage, steroid injections and nerve
ening exercises in pain range with the guidance of
blocks are used generally in all stages of shoulder
a physiotherapist. The people collecting data
pain after stroke. In neurologic rehabilitation
were masked. The subjects were allocated with
units, intra-articular steroid injections and supras-
a coin-tossing method by an investigator who
capular nerve blocks are accepted as the treatment
was blinded about the examinations and
approaches for shoulder pain that may contribute
measurements.
to the rehabilitation of hemiplegic patients.
This prospective study was approved by the hos-
However, there is lack of evidence-based data
pital’s ethics committee.
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 Injection procedures
study, we applied intra-articular steroid injection An academic physiatrist who was very experi-
or suprascapular nerve block to patients with enced in interventional pain procedures and
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62 E Yasar et al.
Table 1 Comparisons of demographics between intra-articular steroid injection and suprascapular nerve block groups
(P40.05)
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 – –
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Treatment for hemiplegic shoulder pain 63
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64 E Yasar et al.
these two range of motion values (pain A and pain steroids.14–16 Subacromial steroid injection has
B) (Table 3). However, no significant differences been found to reduce the pain related to supraspi-
were determined in measurements between intra- natus impingement, tendinitis or subacromial bur-
articular steroid injection and suprascapular nerve sitis.17 On the other hand, Lo et al. reported that
block groups (between-subject factors; P40.05). 50% of the stroke patients had adhesive capsulitis
No complication related to the injections were and 44% had shoulder subluxation in arthro-
observed in our study. A flow diagram showing graphic examinations of the patients with hemiple-
how patients progressed through the study is gic shoulder pain.18 Intra-articular corticosteroids
shown in Figure 1. have provided pain relief in non-stroke patients
with adhesive capsulitis who have predominant
pain symptoms.19 However, intra-articular injec-
Discussion tions of triamcinolone acetonide seemed to
decrease hemiplegic shoulder pain and to acceler-
ate recovery in patients with hemiplegic shoulder
In the present study, we found that both intra- pain, although there was no significant difference
articular steroid injection and suprascapular in pain, mobility or function compared with intra-
nerve block improved the limitations in all articular injections of saline.7
planes of shoulder range of motion. In addition The second injection method that we used was
to this, visual analogue scale scores for pain sever-
suprascapular nerve block. The suprascapular
ity reduced after injections in comparison with
nerve supplies some of the sensory innervation of
pre-injection evaluations. However, the efficacy
the shoulder.5 Suprascapular nerve block may pro-
of neither of these injection techniques was supe-
vide temporary cessation of nociceptive informa-
rior to the other. Both injection procedures are
tion from the shoulder to the central nervous
safe and have a similar effect in stroke patients
system.20 In a study which included 34 subjects
with hemiplegic shoulder pain. According to our
findings, the presence of actual motor stages with frozen shoulder, the efficacy of suprascapular
(Brunnstrom stages) did not affect the preference nerve block was investigated using 10 mL bupiva-
of injection method. To the best of our knowledge, caine versus placebo nerve blockade. It found a
this represents the first study to have compared the significant reduction in pain in the treatment
efficacy of intra-articular steroid injection and group versus the placebo group at one month.
suprascapular nerve block techniques on pain But shoulder function was not improved nota-
and range of motion for hemiplegic shoulder bly.21 In a prospective, randomized, comparison
pain in stroke patients. crossover investigation, suprascapular nerve
The literature is poor about the efficacy of intra- block decreased the severity and frequency of the
articular steroid injection in hemiplegic shoulder perceived pain and increased compliance with the
pain. Our study showed that intra-articular steroid rehabilitation programme in patients with rotator
injection may provide pain relief and improve cuff tendinitis.20
range of motion of hemiplegic shoulder in stroke Suprascapular nerve block has been used with
patients. This information encourages the practice some success in relieving resistant shoulder pain in
of intra-articular steroid injection, which has poor some other rheumatologic problems.21,22
evidence in the literature although it has been However, there are only two studies in the litera-
widely used in physiatry clinics. ture about suprascapular nerve block in patients
Although the anti-inflammatory effects of ste- with hemiplegic shoulder pain. Lee and
roids are the leading source of the pain relief, Khunadorn reported that its efficacy on pain
they may also reduce non-inflammatory or degen- relief was poor in patients with hemiplegia,8 and
erative sources of pain such as tendinosis.13 This Boonsong et al. claimed that suprascapular nerve
efficacy of steroids are poorly defined. Nociceptive block was a safe and effective treatment for hemi-
receptors that are under the control of some neu- plegic shoulder pain.23 Our study has also shown
rotransmitters or mechanoreceptors that are irri- good results following suprascapular nerve block
tated by traction forces may be affected by in hemiplegic shoulder pain.
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Treatment for hemiplegic shoulder pain 65
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)
Figure 1 Flow diagram showing how patients progressed through the study. IASI, intra-articular steroid injection; SSNB,
and suprascapular nerve block.
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66 E Yasar et al.
A few investigations comparing the effective- Although our data suggest that both intra-
ness of intra-articular steroid injection and articular steroid injection and suprascapular
suprascapular nerve block have been published. nerve block reduce hemiplegic shoulder pain in
Taskaynatan et al. compared the effects of supras- patients with stroke, there are some limitations
capular nerve block with those of steroid injection that prevent the formulation of more definitive
in patients with non-specific shoulder pain, and conclusions. Small patient group, lack of placebo
found a significant difference in all follow-up group and long-term follow-up are the leading
parameters in both groups. However, there was limitations for this study. If there had been
no difference in efficacy between the two meth- long-term follow-up of the patients, it would
ods.24 It was reported that combined suprascapu- have contributed to our outcomes. The use of
lar nerve block and glenohumeral intra-articular neither ultrasonography nor magnetic resonance
steroid injection may be more effective than imaging in diagnosis of hemiplegic shoulder pain
either injection alone in addition to physical ther- and not using any guide for interventions such as
apy in patients with adhesive capsulitis.25 ultrasonography, fluoroscopy or neurostimula-
However, these two studies were done in non- tors may be seen as a limitation. If the physician
stroke patients. has any concern about the side-effects of steroids,
In a retrospective study which investigated the suprascapular nerve block should be considered
efficacy of suprascapular nerve block in treating to be the preferred treatment for hemiplegic
rotator cuff tendonitis, 88% of the patients had shoulder pain because it is as effective as steroid
significant pain relief, and the authors claimed injection with rare side-effects. However, our
that suprascapular nerve block may be a safer study did not aim to investigate side-effects and
alternative than injections involving steroid expo- risks and it was too small to draw any firm
sure.26 It was reported that rotator cuff tear might conclusion.
be seen in about a third of patients with hemiple- Our aim is to find a convenient injection method
gia.18,27 It is necessary to avoid repeated steroid which can be used easily to break the vicious cycle
injections, particularly because of their atrophic of hemiplegic shoulder pain. The gradual reduc-
effects.5 Efficacy over the longer term is not tion of the pain levels indicated to us that this
clear. Some authors recommended the use of ste- vicious cycle was broken. Nevertheless, neither
roid injections only in the presence of active injection technique was better than the other.
inflammation.28 At the time of follow-up in the At the same time, there was an increasing improve-
hospital or after hospitalization, there were no ment in the patients who went on to join the exer-
complications related to steroid injection in our cise programme.
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 Clinical message
group, we did not determine any adverse effect
related to the injection. Both intra-articular steroid injection and
Suprascapular nerve block is a simple, safe and suprascapular nerve block can be used
inexpensive technique to relieve pain originating safely and provide similar pain relief and
from the hemiplegic shoulder.5 The similar effica- improvement in all planes of shoulder
cies of intra-articular steroid injection and supras- range of motion limitations in stroke
capular nerve block that have been found in our patients with hemiplegic shoulder pain.
study and some controversial issues about side-
effects related to steroid injection lead us to
think that suprascapular nerve block may be a
more convenient method in hemiplegic shoulder Acknowledgements
pain of stroke patients for whom a specific aetio- This study was performed in TAF
logic diagnosis has not been made. Rehabilitation Center with no financial support.
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Treatment for hemiplegic shoulder pain 67
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68 E Yasar et al.
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