Neurological Sciences

https://doi.org/10.1007/s10072-020-04362-0

ORIGINAL ARTICLE

Suprascapular nerve block in hemiplegic shoulder pain: comparison

of the effectiveness of placebo, local anesthetic, and corticosteroid
injections—a randomized controlled study
Rana Terlemez 1 & Selda Çiftçi 1 & Mahir Topaloglu 2 & Beril Dogu 1 & Figen Yilmaz 1 & Banu Kuran 1

Received: 28 December 2019 / Accepted: 20 March 2020

# Fondazione Società Italiana di Neurologia 2020

Abstract
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.

Keywords suprascapular nerve block . hemiplegic shoulder pain

Introduction
In the past decades, while the incidence of stroke has de-
creased in some high-income countries, it has almost doubled
in low- to middle-income countries [1]. Stroke is one of the
major causes of disability and upper limb function is generally
affected after stroke [2]. Hemiplegic shoulder pain (HSP) is
the most common pain condition in stroke patients [3, 4] and
is associated with reduced upper limb function. This may lead
to difficulties with the rehabilitation program and prolonged
hospitalization [4].
HSP may occur in 50–80% of the hemiplegic patients
which may vary widely over the time among the individuals
[5]. The etiology of HSP includes soft tissue lesions, muscle
tone changes, and altered central nervous system phenomena
[6]. The etiology is mostly multifactorial, and information on

* Rana Terlemez Figen Yilmaz

ranakaynar@hotmail.com figenyilmaz@yahoo.com

Selda Çiftçi Banu Kuran

seldavd@gmail.com banukuran@gmail.com

Mahir Topaloglu 1
Department of Physical Medicine and Rehabilitation, Saglik Bilimleri
mahirtopaloglu87@gmail.com University, Sisli Hamidiye Etfal Education and Research Hospital,
Istanbul, Turkey
Beril Dogu
2
berildogu@hotmail.com Department of Physical Medicine and Rehabilitation, Mahir
Topaloglu; MD. Koc University Hospital, Istanbul, Turkey

the presumed etiology of shoulder pain was not collected as
part of this study [7].
The aims of the treatment are providing pain relief and
increase in range of motion. Appropriate limb positioning,
slings, analgesic drugs, exercises, and physical therapy mo-
dalities are the main treatment options [6, 8]. Invasive treat-
ment options used more frequently in recent years are intra-
articular steroids, suprascapular nerve blocks (SSNB), and
botulinum toxin injections. In the rehabilitation units, all these
injections are widely used to support rehabilitation of the
hemiplegic patients. However, there is lack of evidence about
these injections for managing shoulder pain after a stroke [9].
SSNB is a safe and effective treatment option for shoulder
pain especially related to degenerative conditions [10, 11]. It is
unclear whether the results of these studies can be extrapolated
to stroke patients. This study aimed to investigate the effect of
SSNB on pain intensity in patients with HSP. In clinical prac-
tice, SSNB can be achieved using local anesthetics with or
without corticosteroids. The present study also aimed to ex-
amine whether there is an additional contribution of cortico-
steroids to local anesthetics.
Methods
Study design
A prospective, randomized, double blind, controlled trial was
conducted on 34 patients diagnosed with HSP in the physical
medicine and rehabilitation department of a university hospi-
tal. The study was conducted in accordance with the
Declaration of Helsinki Ethical Principles, and all patients
provided written informed consent prior to enrollment.
Study population
The selection criteria were patients with HSP, aged > 17 years
with a diagnosis of acute stroke within the previous 24 months.
Thirty-four patients (n = 34) with a visual analog scale (VAS)
score > 3 (0–10 scale) were enrolled. The exclusion criteria
were aphasia, cognitive impairment (Mini-Mental State
Examination score < 24), botulinum toxin treatment within
the last 6 months, fixed contractures, bony deformities, uncon-
trolled diabetes mellitus, coagulopathy, and hypersensitivity
to injection agents. All patients selected from hospitalized
patients.
A physiatrist, who was blinded to the group allocation,
performed the baseline and control assessments.
Demographic features, medical history, duration, and etiology
of stroke were obtained. VAS scores were used to assess pain
intensity. In the physical examination, passive range of motion
(PROM) of the shoulder, Brunnstrom stage of the upper ex-
tremity and spasticity according to the modified Ashworth
Neurol Sci
Scale were evaluated. All groups continued the routine
home-based exercise program, including range of motion
and stretching.
Injection procedure
Patients were randomly assigned to three groups through a
computer program. All patients were blinded to group alloca-
tion. Four patients were discontinued of the study and 30
patients completed the study. The first group (placebo group)
(n = 10) was administered an injection of 5 ml of 2% lidocaine
injected into the trapezius muscle. The second group (LA
group) (n = 10) was administered a 5 ml of 2% lidocaine in-
jection into the suprascapular notch and the third group (LA+
CS group) (n = 10) was administered 5 ml of 2% lidocaine +
1 ml of betamethasone injection into the suprascapular notch.
In the placebo group we administered LA into the trapezius
muscle to provide a similar application between the groups.
We also preferred to use LA instead of saline (in the same
volume with LA) for placebo injection to avoid increase in
pain due to saline-induced c-fiber action potentials [12, 13].
No changes were made to the medical treatment regimen for
any of the groups for 1 month.
The same, blinded physiatrist administered the injections
with guided ultrasound to all groups. The ESAOTE MyLab
20 machine with a 7-MHz linear transducer was used for the
injection procedure. Injections were administered with the pa-
tients in a sitting position and arms by the side. The transducer
was placed over the suprascapular fossa in the coronal plane
with a slight anterior tilt. This area was scanned to identify the
suprascapular notch and suprascapular artery. A 23-gauge spi-
nal needle was used for injection using the out-plane
technique.
Outcome measurements
The primary outcome was pain intensity assessed by the VAS
score (0–10 scale). The average of VAS scores during maxi-
mum PROM (flexion, abduction, and external rotation) were
calculated. For all participants, pain was assessed at baseline,
and at 1 h, 1 week, and 1 month following the injection pro-
cedure. The pain intensity score, where patients rate their cur-
rent pain intensity from 0 (“no pain”) to 10 (“worst possible
pain”) was assessed by the same blinded physiatrist who per-
formed all the clinical assessments. The PROM of the affected
shoulder (flexion, abduction, external rotation) was evaluated
at baseline and 1 h after the injection.
Statistical analysis
The SPSS Windows 15.0 software bundle was used to analyze
the data. Data are presented as mean ± SD, numbers, and per-
centage. The Fisher test was used to compare categorical
Neurol Sci

Table 1 Comparisons of
demographics between the groups Placebo LA LA + CS p

n % n % n %

Gender Male 4 (40.0) 4 (40.0) 7 (70.0) 0.467a

Female 6 (60.0) 6 (60.0) 3 (30.0)
Age* 57.5 56.0–66.0 64.0 52.0–65.0 60.0 58.0–75.0 0.819b
Time since stroke (months)* 15.0 12.0–18.0 14.5 12.0–24.0 13.0 11.0–15.0 0.413b
Etiology Haemorrhagic 2 (20.0) 3 (30.0) 1 (10.0) 0.847a
Ischaemic 8 (80.0) 7 (70.0) 9 (90.0)
a
Fisher test, b Kruskal-wallis test, *Median values, percantil (25–75)
LA, local anesthetic; CS, corticosteroid

variables. Numerical data were compared using the
Kolmogorov-Smirnov ve Shapiro-Wilk test. Non-
parametrical data were compared with the Kruskal-Wallis test.
The repeated measures analysis of variance (ANOVA) tech-
nique was used to analyze variance in repetitive measure-
ments. A p value < 0.05 was considered statistically
significant.
In LA+CS group, significant improvements were found
between pre- and post-injection PROM of the shoulder abduc-
tion (p 0.007), flexion (p 0.012), and external rotation (p
0.004). In the LA group, significant improvements were found
on flexion (p 0.004) and external rotation (p 0.005). However,
in the placebo group, no significant differences were found in
the PROM measurements.

Results
Thirty patients with HSP were included in the study. They
were randomly divided into three groups according to treat-
ment methods. Each group had 10 patients. There was no
significant difference in the demographic features between
the groups (Table 1). The clinical features of the patients re-
vealed that the Brunnstrom stages and modified Ashworth
Scale scores were similar across the groups. No adverse events
occurred during the study.
When compared to the baseline scores, a significant de-
crease in the VAS scores was seen at all follow-up time points,
in all groups (p:0.001 for the placebo group and p < 0.001 for
the other two groups). When changes in the VAS scores were
compared between the groups, the LA+CS group demonstrat-
ed a higher VAS decrease than the placebo group at 1 month
(Table 2).
Discussion
This study investigated the effect of SSNB on pain intensity
and passive range of motion (PROM) in patients with hemi-
plegic shoulder pain (HSP) and compared the effectiveness of
injection techniques. The results showed significant pain re-
duction with all injection procedures at all follow-up time
points. However, when changes in VAS scores were compared
between the groups, the LA+CS group demonstrated a higher
VAS decrease than the placebo group at 1 month.
The SSNB is not a new method for the management of
shoulder pain, especially among non-stroke patients [14].
The suprascapular nerve provides 70% of sensory innervation
to the shoulder joint [15]. The afferent fibers of the
suprascapular nerve may become more sensitized due to un-
cured chronic shoulder pain [16]. The SSNB provides

Table 2 Comparisons of VAS a b c

scores between the groups Placebo LA LA + CS pd

Mean ± SD Mean ± SD Mean ± SD

1
Pre-injection 7.7 ± 2.1 7.6 ± 2.4 7.1 ± 1.8 0,002
2
Post-injection 5.9 ± 1.4 2.9 ± 1.4 2.8 ± 1.0
3
1 week 5.5 ± 2.4 3.7 ± 1.9 3.1 ± 1.1
4
1 month 5.5 ± 2.1 4.7 ± 2.6 3.1 ± 1.0
pd 0,001 < 0,001 < 0,001

Post hoc for intra-groups: Placebo 1–2,1–3,1–4; LA:1–2,1–3,1–4, 2–4; LA+CS:1–2,1–3,1–4 and for inter-
groups: a–c; 1–2, 2–4 significant decrease. d Repeated Measures Anova
LA, local anesthetic; CS, corticosteroid; SD, standard deviation

interruption of the nociceptive stimulus from the shoulder
joint to the central nervous system [17].
Previous studies reported conflicting results about SSNB in
patients with HSP. While Lee and Khunadorn found poor
efficacy of the SSNB on HSP patients, Boonsong et al. report-
ed that the SSNB was effective for HSP [18, 19]. A later study,
conducted by Adey-Wakeling et al. showed that blinded
SSNB (LA + CS) demonstrated improved pain reduction
when compared to subcutaneous LA as a control group in
chronic stroke patients [20]. In our study, we evaluated the
effect of three injection techniques. Additionally, we assessed
the PROM of the affected shoulder. Significant improvements
were seen on the PROM up to 1 h after the injection, in both
LA and LA+CS groups. These findings suggest that SSNB
might be used as adjuvant therapy before the rehabilitation
program, for patients with HSP. In contrast to the decrease in
VAS scores seen in the placebo group, there was no improve-
ment in the PROM of the shoulder. But when we examine the
decreases in VAS scores; in the LA + CS group the VAS score
decreased from 7.1 to 2.8 (a decrease of 4.3 was detected), in
the LA group the VAS score decreased from 7.6 to 2.9 (a
decrease of 4.7 was detected), beside it in the placebo group
the VAS score decreased from 7.7 to 5.9 (a decrease of 1.8 was
detected). Although more pain relief was obtained clinically in
LA and LA + CS group than placebo; there was no statistical
significant difference between the groups. The lack of effect
on PROM in the placebo group could be related to the rela-
tively less decreases seen in VAS scores.
During an SSNB, the needle passes through the trapezius
muscle. Therefore, there might be extra relief related to the
trapezius trigger point, in addition to the SSNB. There is only
one case report showing the positive effect of dry needling at
trigger points in post-stroke shoulder spasticity [21]. To pro-
vide a similar intervention between the groups we adminis-
tered the injection (5 ml of 2% lidocaine) into the trapezius
muscle instead of subcutaneous tissue in the placebo group,
unlike the other placebo-controlled study which used different
volumes of injection between the groups [20]. In our study, the
significant pain relief with the placebo may be related to this
trigger point hypothesis.
SSNB may be performed with fluoroscopy, ultrasound, or
blinded. Patients position and fluoroscopic angle in fluoro-
scopic method have not yet been optimized [22]. From a tech-
nical perspective, using ultrasound guidance during the SSNB
demonstrated higher effectiveness than other techniques [23].
Lee et al. showed a significant difference between a blinded
SSNB and an ultrasound-guided SSNB by using
electroneuromyography [24]. Similar to our study, Picelli
et al. used ultrasound guidance in a smaller group. They eval-
uated the effectiveness of SSNB by combining LA and CS in
10 chronic stroke patients with HSP. Their findings supported
the use of SSNB for treating HSP in chronic stroke patients
[25]. Aydın et al. also showed the additional benefit of the
Neurol Sci
ultrasound guided SSNB (LA + CS) to conservative treatment
on pain relief in patients with HSP, but no invasive interven-
tion was performed to the patients in their control group [26].
Our study also showed that VAS scores decreased in LA
group as well as LA + CS group. Therefore, it is reasonable
to use LA alone considering the possible side effects of corti-
costeroids, but in order to evaluate it clearly, larger studies
with longer follow-up period are needed. Likewise, a recent
study using ultrasound-guided suprascapular nerve-pulsed ra-
diofrequency in HSP, showed significant pain reduction dur-
ing a relatively longer follow-up period (16 weeks), in a small-
er group [27].
Previous studies comparing SSNB and intra-articular CS
injection, showed similar efficacies on HSP. Yasar et al. com-
pared pain intensity and the PROM of the shoulder with both
injection techniques. However, they used anatomical land-
marks instead of a scanning method [9]. Jeon et al. evaluated
the effects of an ultrasound-guided SSNB, an intra-articular
CS injection and a combination of them and found no statis-
tically significant differences between the three injection
methods [28]. A recent study which used fluoroscopy guid-
ance also showed similar results between SSNB, an intra-
articular CS injection and a combination of them [29]. On this
basis it may make sense to postpone a second injection to later,
instead of a combination therapy.
In conclusion, SSNB with or without the CS is an effective
and reliable treatment option for a post-stroke rehabilitation
program and functional recovery in patients with HSP. The
limitations of this study are the small sample size with a com-
paratively short follow-up period and we did not evaluate any
functional outcome. Further studies are required especially
with longer follow-up periods in larger groups.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval The study was conducted in accordance with the
Declaration of Helsinki Ethical Principles.
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