Percutaneous neuromuscular electrical stimulation (P-NMES) for treating shoulder pain in chronic hemiplegia. Effects on shoulder pain and quality of life

A review of prospective studies regarding percutaneous peripheral nerve stimulation treatment in the management of chronic pain

Conventionally, peripheral nerve stimulation (PNS) for treatment of chronic pain has involved a two-stage process: a short-term (e.g., 7 days) trial and, if significant pain relief is achieved, a permanent PNS system is implanted. A percutaneous PNS treatment is now available where a coiled lead may be implanted for up to 60 days with the goal of producing sustained relief. In the present review, published prospective trials using percutaneous PNS treatment were identified and synthesized. The collected evidence indicates that percutaneous PNS treatment for up to 60 days provides durable clinically significant improvements in pain and pain interference. Similar efficacy across diverse targets and etiologies supports the broad applicability for use within the chronic pain population using this nonopioid technology.

Parameter mapping of hemiplegic shoulder electrical stimulation for motor function: A scoping review

BACKGROUND

Electrical stimulation (ES) of the shoulder is effective in treating subluxation and shoulder pain. However, few studies have reported on ES of the hemiplegic shoulder with motor function as an outcome; thus, the method remains unclear.

OBJECTIVE

We aimed to map the existing evidence and identify the parameters for ES of the hemiplegic shoulder for motor function in stroke patients.

METHODS

A literature search was performed through PubMed and Scopus to retrieve original articles from 1975 to March 2023 using the terms "stroke", "shoulder", and "electricity". We selected studies in which ES was performed on hemiplegic shoulders after stroke, parameters were described, and upper extremity motor functional assessment was included as an outcome. The extracted data included study design, phase, sample size, electrode position, parameters, intervention period, evaluation frequency, outcomes, and results.

RESULTS

Of the 449 titles identified, 25 fulfilled the inclusion and exclusion criteria. Nineteen were randomized controlled trials. The most common electrode positions and parameters (frequency and pulse width) were over the posterior deltoid and the supraspinatus (upper trapezius) muscles, 30 Hz, and 250μs, respectively. The intervention period was 30-60 minutes per day, 5-7 days per week, for 4-5 weeks in over half of the studies.

CONCLUSION

Stimulation positions and parameters for electrical stimulation of the hemiplegic shoulder are inconsistent. Whether ES represents a significant treatment option remains unclear. Establishing universal ES methods is necessary to improve the motor function of hemiplegic shoulders.

Real-world evidence of sustained improvement following 60-day peripheral nerve stimulation treatment for pain: a cross-sectional follow-up survey

Objective: This study presents real-world data from a cross-sectional follow-up survey of patients who previously received 60-day peripheral nerve stimulation (PNS) treatment for pain. Materials & methods: A survey including validated pain and other related outcome measures was distributed to patients who previously underwent implantation of temporary PNS leads for 60-day PNS treatment. Results: Among survey respondents who were at least 3 months from the start of treatment, most reported sustained clinically significant improvements in pain and/or quality of life, with the length of follow-up at the time of survey completion ranging from 3 to 30 months. Conclusion: These real-world data support recent prospective studies indicating that 60-day percutaneous PNS provides significant and sustained relief across a wide range of pain conditions.

60-Day PNS Treatment May Improve Identification of Delayed Responders and Delayed Non-Responders to Neurostimulation for Pain Relief

Objective

Conventional neurostimulation typically involves a brief (eg, ≤10-day) trial to assess presumed effectiveness prior to permanent implantation. Low trial conversion rates and high explant rates due to inadequate pain relief highlight the need for improved patient identification strategies. The development of a 60-day percutaneous peripheral nerve stimulation (PNS) system enables evaluation of outcomes following an extended temporary treatment period of up to 60 days, that may obviate or validate the need for permanent implant. The present study provides the first real-world evidence regarding patient response throughout a 60-day PNS treatment period.

Methods

Anonymized data listings were compiled from patients who underwent implantation of temporary percutaneous leads and opted-in to provide real-world data to the device manufacturer during routine interactions with device representatives throughout the 60-day treatment.

Results

Overall, 30% (222/747) of patients were early responders (≥50% pain relief throughout treatment). Another 31% (231/747) of patients initially presented as non-responders but surpassed 50% pain relief by the end of treatment. Conversely, 32% (239/747) of patients were non-responders throughout treatment. An additional 7% (55/747) of patients initially presented as responders but fell below 50% relief by the end of the treatment period.

Conclusion

An extended, 60-day PNS treatment may help identify delayed responders, providing the opportunity for sustained relief and improving access to effective PNS treatment. Compared to a conventionally short trial of ≤10 days, a longer 60-day PNS treatment may also help reduce explant rates by identifying delayed non-responders unlikely to benefit long-term. These scenarios support the importance of an extended 60-day temporary PNS stimulation period to help inform stepwise treatment strategies that may optimize outcomes and cost-effectiveness.

Ultrasound-Guided BoNT-A (Botulinum Toxin A) Injection Into the Subscapularis for Hemiplegic Shoulder Pain: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND AND PURPOSE

This study aimed to assess the efficacy of an ultrasound-guided lateral approach for BoNT-A (botulinum toxin A) injections into the subscapularis in patients with hemiplegic shoulder pain.

METHODS

This single-center trial used a randomized, double-blind, placebo-controlled design. The key inclusion criteria were a visual analogue scale score of ≥4 cm and a modified Ashworth scale score of ≥1+. The patients were randomized to receive either BoNT-A injections or a placebo. The outcomes included the visual analogue scale score, modified Ashworth scale score, pain-free passive range of motion of the hemiplegic shoulder, Fugl-Meyer assessment score for the upper extremities, and Stroke-Specific Quality-of-Life score.

RESULTS

A total of 49 hemiplegic shoulder pain patients were screened, and 36 were included. The participants receiving the BoNT-A injection reported a significant decrease in pain (visual analogue scale, -1.39 [95% CI, -2.41 to -0.36]; P=0.002) and spasticity (modified Ashworth scale score for shoulder internal rotation, -0.72 [95% CI, -1.10 to -0.35]; P=0.001; modified Ashworth scale score for shoulder abduction, -0.44 [95% CI, -0.90 to -0.01]; P=0.026) and improved pain-free passive shoulder internal rotation range of motion (14.56 [95% CI, 6.70-21.41]; P<0.001) and quality of life (Stroke-Specific Quality-of-Life upper extremity subscale, P=0.025) compared with those receiving the placebo at the end point. The shoulder abduction range of motion did not significantly improve after the BoNT-A injection at the end point (P=0.127). In addition, the patients in the BoNT-A group showed significant improvements in the visual analogue scale score and shoulder external rotation range of motion at the 12-week follow-up. No injection-related adverse events were observed during or after the interventions in either group.

CONCLUSIONS

The ultrasound-guided lateral approach for BoNT-A injections into the subscapularis is a precise and reliable method for reducing pain and spasticity and improving quality of life in stroke survivors with hemiplegic shoulder pain. Registration: URL: https://www.chictr.org.cn; Unique identifier: ChiCTR1900023513.

Cryoneurolysis and Percutaneous Peripheral Nerve Stimulation to Treat Acute Pain

Two regional analgesic modalities currently cleared by the U.S. Food and Drug Administration hold promise to provide postoperative analgesia free of many of the limitations of both opioids and local anesthetic-based techniques. Cryoneurolysis uses exceptionally low temperature to reversibly ablate a peripheral nerve, resulting in temporary analgesia. Where applicable, it offers a unique option given its extended duration of action measured in weeks to months after a single application. Percutaneous peripheral nerve stimulation involves inserting an insulated lead through a needle to lie adjacent to a peripheral nerve. Analgesia is produced by introducing electrical current with an external pulse generator. It is a unique regional analgesic in that it does not induce sensory, motor, or proprioception deficits and is cleared for up to 60 days of use. However, both modalities have limited validation when applied to acute pain, and randomized, controlled trials are required to define both benefits and risks.

Percutaneous Peripheral Nerve Stimulation for the Treatment of Chronic Pain Following Amputation

Introduction

Chronic pain and reduced function are significant problems for Military Service members and Veterans following amputation. Peripheral nerve stimulation (PNS) is a promising therapy, but PNS systems have traditionally been limited by invasiveness and complications. Recently, a novel percutaneous PNS system was developed to reduce the risk of complications and enable delivery of stimulation without surgery.

Materials and Methods

Percutaneous PNS was evaluated to determine if stimulation provides relief from residual and phantom limb pain following lower-extremity amputation. PNS leads were implanted percutaneously to deliver stimulation to the femoral and/or sciatic nerves. Patients received stimulation for up to 60 days followed by withdrawal of the leads.

Results

A review of recent studies and clinical reports found that a majority of patients (18/24, 75%) reported substantial (≥50%) clinically relevant relief of chronic post-amputation pain following up to 60 days of percutaneous PNS. Reductions in pain were frequently associated with reductions in disability and pain interference.

Conclusions

Percutaneous PNS can durably reduce pain, thereby enabling improvements in quality of life, function, and rehabilitation in individuals with residual or phantom limb pain following amputation. Percutaneous PNS may have additional benefit for Military Service members and Veterans with post-surgical or post-traumatic pain.

The protocol for a multisite, double blind, randomized, placebo-controlled trial of axillary nerve stimulation for chronic shoulder pain

BACKGROUND

Shoulder impingement syndrome is one of the most common causes of shoulder pain, accounting for approximately 30% of all shoulder pain. Approximately 35% of patients with shoulder impingement syndrome are refractory to conservative treatment. For patients who fail conservative treatment, there is no established treatment to successfully treat their chronic pain. Prior randomized control trials have demonstrated efficacy for the use of a single lead intramuscular peripheral nerve stimulation of the axillary nerve at the motor points of the deltoid muscle for treatment of hemiplegic shoulder pain. This is the first controlled trial to utilize the same novel technology to treat shoulder impingement syndrome outside of the stroke population.

METHODS

This is a dual-site, placebo-controlled, double-blinded, randomized control trial. Participants will be randomized to two treatment groups. The intervention group will be treated with active peripheral nerve stimulation of the axillary nerve of the affected shoulder and the control group will be treated with sham peripheral nerve stimulation of the axillary nerve of the affected shoulder. Both groups will receive a standardized exercise therapy program directed by a licensed therapist.

DISCUSSION

This study protocol will allow the investigators to determine if this novel, non-pharmacologic treatment of shoulder pain can demonstrate the same benefit in musculoskeletal patients which has been previously demonstrated in the stroke population.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03752619. Registered on 26 November 2018.

Percutaneous Peripheral Nerve Stimulation for Chronic Low Back Pain: Prospective Case Series With 1 Year of Sustained Relief Following Short-Term Implant

INTRODUCTION

Percutaneous peripheral nerve stimulation (PNS) provides an opportunity to relieve chronic low back pain and reduce opioid analgesic consumption as an alternative to radiofrequency ablation and permanently implanted neurostimulation systems. Traditionally, the use of neurostimulation earlier in the treatment continuum has been limited by its associated risk, invasiveness, and cost.

METHODS

Percutaneous PNS leads (SPRINT MicroLead) were placed bilaterally to target the medial branches of the dorsal rami nerves under image guidance. The percutaneous leads were connected to miniature wearable stimulators (SPRINT PNS System) for the 1-month therapy period, after which the leads were removed. Pain and disability were assessed long-term up to 12 months after lead removal.

RESULTS

Substantial, clinically significant reductions in average pain intensity (≥50% reduction as measured by the Brief Pain Inventory Short Form) were experienced by a majority of subjects (67%) at end of treatment compared to baseline (average 80% reduction among responders; P < 0.05, analysis of variance; n = 9). Twelve months after the end of PNS treatment, a majority of subjects who completed the long-term follow-up visits experienced sustained, clinically significant reductions in pain and/or disability (67%, n = 6; average 63% reduction in pain intensity and 32-point reduction in disability among responders). No serious or unanticipated adverse events were reported.

CONCLUSIONS

This study challenges the long-held notion that a positive trial of PNS should be followed by a permanent implant in responders. Percutaneous PNS may serve as an effective neurostimulation therapy for patients with chronic low back pain and should be considered earlier in the treatment continuum as a motor-sparing means of avoiding opioids, denervation, and permanently implanted neurostimulation systems.

Ultrasound-guided percutaneous peripheral nerve stimulation: neuromodulation of the suprascapular nerve and brachial plexus for postoperative analgesia following ambulatory rotator cuff repair. A proof-of-concept study

BACKGROUND AND OBJECTIVES

Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducing needle followed by the delivery of electric current. This modality has been reported to treat chronic pain as well as postoperative pain following knee and foot surgery. However, it remains unknown if this analgesic technique may be used in ambulatory patients following upper extremity surgery. The purpose of this proof-of-concept study was to investigate various lead implantation locations and evaluate the feasibility of using percutaneous brachial plexus PNS to treat surgical pain following ambulatory rotator cuff repair in the immediate postoperative period.

METHODS

Preoperatively, an electrical lead (SPR Therapeutics, Cleveland, Ohio) was percutaneously implanted to target the suprascapular nerve or brachial plexus roots or trunks using ultrasound guidance. Postoperatively, subjects received 5 min of either stimulation or sham in a randomized, double-masked fashion followed by a 5 min crossover period, and then continuous stimulation until lead removal postoperative days 14-28.

RESULTS

Leads (n=2) implanted at the suprascapular notch did not appear to provide analgesia, and subsequent leads (n=14) were inserted through the middle scalene muscle and placed to target the brachial plexus. Three subjects withdrew prior to data collection. Within the recovery room, stimulation did not decrease pain scores during the first 40 min of the remaining subjects with brachial plexus leads, regardless of which treatment subjects were randomized to initially. Seven of these 11 subjects required a single-injection interscalene nerve block for rescue analgesia prior to discharge. However, subsequent average resting and dynamic pain scores postoperative days 1-14 had a median of 1 or less on the Numeric Rating Scale, and opioid requirements averaged less than 1 tablet daily with active stimulation. Two leads dislodged during use and four fractured on withdrawal, but no infections, nerve injuries, or adverse sequelae were reported.

CONCLUSIONS

This proof-of-concept study demonstrates that ultrasound-guided percutaneous PNS of the brachial plexus is feasible for ambulatory shoulder surgery, and although analgesia immediately following surgery does not appear to be as potent as local anesthetic-based peripheral nerve blocks, the study suggests that this modality may provide analgesia and decrease opioid requirements in the days following rotator cuff repair. Therefore, it suggests that a subsequent, large, randomized clinical trial with an adequate control group is warranted to further investigate this therapy in the management of surgical pain in the immediate postoperative period. However, multiple technical issues remain to be resolved, such as the optimal lead location, insertion technique, and stimulating protocol, as well as preventing lead dislodgment and fracture.

TRIAL REGISTRATION NUMBER

NCT02898103.

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: Neuromodulation of the Sciatic Nerve for Postoperative Analgesia Following Ambulatory Foot Surgery, a Proof-of-Concept Study

BACKGROUND AND OBJECTIVES

Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducing needle followed by the delivery of electric current. This modality has been reported to treat chronic pain as well as postoperative pain the day following knee surgery. However, it remains unknown if this analgesic technique may be used in ambulatory subjects following foot procedures beginning within the recovery room immediately following surgery, and with only short series of patients reported to date, the only available data are derived from strictly observational studies. The purposes of this proof-of-concept study were to demonstrate the feasibility of using percutaneous sciatic nerve PNS to treat postoperative pain following ambulatory foot surgery in the immediate postoperative period and provide the first available data from a randomized controlled study design to provide evidence of analgesic effect.

METHODS

Preoperatively, an electrical lead (SPRINT; SPR Therapeutics, Inc, Cleveland, Ohio) was percutaneously inserted posterior to the sciatic nerve between the subgluteal region and bifurcation with ultrasound guidance. Following hallux valgus osteotomy, subjects received 5 minutes of either stimulation or sham in a randomized, double-masked fashion followed by a 5-minute crossover period and then continuous stimulation until lead removal on postoperative days 14 to 28.

RESULTS

During the initial 5-minute treatment period, subjects randomized to stimulation (n = 4) experienced a downward trajectory in their pain over the 5 minutes of treatment, whereas those receiving sham (n = 3) reported no such change until their subsequent 5-minute stimulation crossover. During the subsequent 30 minutes of stimulation, pain scores decreased to 52% of baseline (n = 7). Three subjects (43%) used a continuous popliteal nerve block for rescue analgesia during postoperative days 0 to 3. Overall, resting and dynamic pain scores averaged less than 1 on the numeric rating scale, and opioid use averaged less than 1 tablet daily with active stimulation. One lead dislodged, 2 fractured during use, and 1 fractured during intentional withdrawal.

CONCLUSIONS

This proof-of-concept study demonstrates that percutaneous sciatic nerve PNS is feasible for ambulatory foot surgery and suggests that this modality provides analgesia and decreases opioid requirements following hallux valgus procedures. However, lead dislodgement and fracture are concerns.

CLINICAL TRIAL REGISTRATION

This study was registered at Clinicaltrials.gov, identifier NCT02898103.

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: Neuromodulation of the Femoral Nerve for Postoperative Analgesia Following Ambulatory Anterior Cruciate Ligament Reconstruction: A Proof of Concept Study

Objectives

The purpose of this prospective proof of concept study was to investigate the feasibility of using percutaneous peripheral nerve stimulation of the femoral nerve to treat pain in the immediate postoperative period following ambulatory anterior cruciate ligament reconstruction with a patellar autograft.

Materials and Methods

Preoperatively, an electrical lead (SPRINT, SPR Therapeutics, Inc., Cleveland, OH, USA) was percutaneously implanted with ultrasound guidance anterior to the femoral nerve caudad to the inguinal crease. Within the recovery room, subjects received 5 min of either stimulation or sham in a randomized, double‐masked fashion followed by a 5‐min crossover period, and then continuous active stimulation until lead removal postoperative Day 14–28. Statistics were not applied to the data due to the small sample size of this feasibility study.

Results

During the initial 5‐min treatment period, subjects randomized to stimulation (n = 5) experienced a slight downward trajectory (decrease of 7%) in their pain over the 5 min of treatment, while those receiving sham (n = 5) reported a slight upward trajectory (increase of 4%) until their subsequent 5‐min stimulation crossover, during which time they also experienced a slight downward trajectory (decrease of 11% from baseline). A majority of subjects (80%) used a continuous adductor canal nerve block for rescue analgesia (in addition to stimulation) during postoperative Days 1–3, after which the median resting and dynamic pain scores remained equal or less than 1.5 on the numeric rating scale, respectively, and the median daily opioid consumption was less than 1.0 tablet.

Conclusions

This proof of concept study demonstrates that percutaneous femoral nerve stimulation is feasible for ambulatory knee surgery; and suggests that this modality may be effective in providing analgesia and decreasing opioid requirements following anterior cruciate ligament reconstruction. clinicaltrials.gov: NCT02898103.

A Feasibility Study of Percutaneous Peripheral Nerve Stimulation for the Treatment of Postoperative Pain Following Total Knee Arthroplasty

INTRODUCTION

The objective of the present feasibility study was to investigate the use of a new treatment modality-percutaneous peripheral nerve stimulation (PNS)-in controlling the often severe and long-lasting pain following total knee arthroplasty (TKA).

METHODS

For patients undergoing a primary, unilateral TKA, both femoral and sciatic open-coil percutaneous leads (SPR Therapeutics, Cleveland, OH) were placed up to seven days prior to surgery using ultrasound guidance. The leads were connected to external stimulators and used both at home and in the hospital for up to six weeks total.

RESULTS

In six of seven subjects (86%), the average of daily pain scores across the first two weeks was <4 on the 0-10 Numeric Rating Scale for pain. A majority of subjects (four out of seven; 57%) had ceased opioid use within the first week (median time to opioid cessation for all subjects was six days). Gross sensory/motor function was maintained during stimulation, enabling stimulation during physical therapy and activities of daily living. At 12 weeks following surgery, six of seven subjects had improved by >10% on the Six-Minute Walk Test compared to preoperative levels, and WOMAC scores improved by an average of 85% compared to before surgery. No falls, motor block, or lead infections were reported.

CONCLUSIONS

This feasibility study suggests that for TKA, ultrasound-guided percutaneous PNS is feasible in the immediate perioperative period and may provide analgesia without the undesirable systemic effects of opioids or quadriceps weakness induced by local anesthetics-based peripheral nerve blocks.

The effectiveness of 2 consecutive intra-articular polydeoxyribonucleotide injections compared with intra-articular triamcinolone for hemiplegic shoulder pain: A STROBE-complaint retrospective study

The aim of this study was to investigate the effects of intra-articular injection of polydeoxyribonucleotide (PDRN), compared with intraarticular triamcinolone (TA) injection, in subacute stroke patients with hemiplegic shoulder pain (HSP).Participants were subacute stroke patients with HSP who had undergone 2 consecutive intra-articular injections of TA or PDRN.Numeric rating scale (NRS) and passive range of motion (PROM) of hemiplegic shoulder were evaluated until 4 weeks after 2nd injection.In the results, there were significant improvements in all PROM measures 2 weeks after the second injection, compared with pre-injection results, in both groups (P < .05). In the PDRN group, however, none of the PROM measures were significantly improved at 3 and 4 weeks after the second injection, compared with pre-injection results (P ≥ .05). When comparing pre-injection results with those at 4 weeks after the second injection, all PROM and NRS measures in the TA group were more improved than in the PDRN group, but this was not statistically significant (P ≥ .05).In conclusion, considering the systemic side effects of steroids, especially among patients with diabetes or metabolic syndrome, PDRN seems to be a worthwhile treatment option for HSP, although PDRN does not seem to have an equivalent persistence effects when compared with TA.

In Vitro Magnetic Resonance Imaging Evaluation of Fragmented, Open-Coil, Percutaneous Peripheral Nerve Stimulation Leads

OBJECTIVE

Percutaneous peripheral nerve stimulation (PNS) is an FDA-cleared pain treatment. Occasionally, fragments of the lead (MicroLead, SPR Therapeutics, LLC, Cleveland, OH, USA) may be retained following lead removal. Since the lead is metallic, there are associated magnetic resonance imaging (MRI) risks. Therefore, the objective of this investigation was to evaluate MRI-related issues (i.e., magnetic field interactions, heating, and artifacts) for various lead fragments.

METHODS

Testing was conducted using standardized techniques on lead fragments of different lengths (i.e., 50, 75, and 100% of maximum possible fragment length of 12.7 cm) to determine MRI-related problems. Magnetic field interactions (i.e., translational attraction and torque) and artifacts were tested for the longest lead fragment at 3 Tesla. MRI-related heating was evaluated at 1.5 Tesla/64 MHz and 3 Tesla/128 MHz with each lead fragment placed in a gelled-saline filled phantom. Temperatures were recorded on the lead fragments while using relatively high RF power levels. Artifacts were evaluated using T1-weighted, spin echo, and gradient echo (GRE) pulse sequences.

RESULTS

The longest lead fragment produced only minor magnetic field interactions. For the lead fragments evaluated, physiologically inconsequential MRI-related heating occurred at 1.5 Tesla/64 MHz while under certain 3 Tesla/128 MHz conditions, excessive temperature elevations may occur. Artifacts extended approximately 7 mm from the lead fragment on the GRE pulse sequence, suggesting that anatomy located at a position greater than this distance may be visualized on MRI.

CONCLUSIONS

MRI may be performed safely in patients with retained lead fragments at 1.5 Tesla using the specific conditions of this study (i.e., MR Conditional). Due to possible excessive temperature rises at 3 Tesla, performing MRI at that field strength is currently inadvisable.

The Effect of Peripheral Nerve Stimulation on Shoulder Biomechanics: A Randomized Controlled Trial in Comparison to Physical Therapy

OBJECTIVE

To establish the effects on shoulder biomechanics from a peripheral nerve stimulation (PNS) treatment compared to physical therapy (PT) in stroke survivors with chronic hemiplegic shoulder pain.

DESIGN

Single-site, pilot, randomized controlled trial for adults with chronic shoulder pain after stroke. Participants were randomized to receive a 3-week treatment of single-lead PNS or physical therapy (PT). The outcomes included isometric shoulder abduction strength, pain-free shoulder external rotation range of motion (ROM), delay in initiation and termination of shoulder abduction electromyogram (EMG) activity, and the Fugl-Meyer Motor Assessment (upper extremity section). Outcomes were measured at baseline, and at weeks 1, 4, 12, and 16.

RESULTS

Twenty-five participants were recruited, 13 to PNS and 12 to PT. There were significant improvements for both PNS and PT in maximum isometric shoulder abduction strength, pain-free external rotation ROM, and Fugl-Meyer Motor Assessment. There were no significant changes in delay of initiation or termination of deltoid EMG with either treatment.

CONCLUSIONS

Both PNS and PT are capable of improving shoulder biomechanics in those with HSP, though changes in biomechanics alone do not account for the greater pain relief associated with PNS than PT.

Ultrasound-guided percutaneous peripheral nerve stimulation for analgesia following total knee arthroplasty: a prospective feasibility study

Background

Peripheral nerve stimulation has been used for decades to treat chronic pain but has not been used for postoperative analgesia due to multiple limitations, beginning with invasive electrode placement. With the development of small-diameter/gauge leads enabling percutaneous insertion, ultrasound guidance for accurate introduction, and stimulators small enough to be adhered to the skin, neurostimulation may now be provided in a similar manner to continuous peripheral nerve blocks. Here, we report on the use of ultrasound-guided percutaneous peripheral nerve stimulation to treat postoperative pain.

Materials and methods

Subjects within 60 days of a total knee arthroplasty with pain insufficiently treated with oral analgesics had a 0.2-mm-diameter electrical lead (pre-loaded into a 20 gauge needle) introduced percutaneously using ultrasound guidance with the tip located approximately 0.5–1.0 cm from the femoral nerve (a second lead was inserted approximately 1.0–3.0 cm from the sciatic nerve for posterior knee pain). An external stimulator delivered current. Endpoints were assessed before and after lead insertion and the leads subsequently removed. Due to the small sample size for this pilot/feasibility study, no statistics were applied to the data.

Results

Leads were inserted in subjects (n = 5) 8–58 days postoperatively. Percutaneous peripheral nerve stimulation decreased pain an average of 93% at rest (from a mean of 5.0 to 0.2 on a 0–10 numeric rating scale), with 4 of 5 subjects experiencing complete resolution of pain. During passive and active knee motion pain decreased an average of 27 and 30%, respectively. Neither maximum passive nor active knee range-of-motion was consistently affected.

Conclusions

Ultrasound-guided percutaneous peripheral nerve stimulation may be a practical modality for the treatment of postoperative pain following orthopedic surgical procedures, and further investigation appears warranted.

Infection Rates of Electrical Leads Used for Percutaneous Neurostimulation of the Peripheral Nervous System

BACKGROUND

Percutaneous neurostimulation of the peripheral nervous system involves the insertion of a wire "lead" through an introducing needle to target a nerve/plexus or a motor point within a muscle. Electrical current may then be passed from an external generator through the skin via the lead for various therapeutic goals, including providing analgesia. With extended use of percutaneous leads sometimes greater than a month, infection is a concern. It was hypothesized that the infection rate of leads with a coiled design is lower than for leads with a noncoiled cylindrical design.

METHODS

The literature was retrospectively reviewed for clinical studies of percutaneous neurostimulation of the peripheral nervous system of greater than 2 days that included explicit information on adverse events. The primary endpoint was the number of infections per 1,000 indwelling days.

RESULTS

Forty-three studies were identified that met inclusion criteria involving coiled (n = 21) and noncoiled (n = 25) leads (3 studies involved both). The risk of infection with noncoiled leads was estimated to be 25 times greater than with coiled leads (95% confidence interval [CI] 2 to 407, P = 0.006). The infection rates were estimated to be 0.03 (95% CI 0.01 to 0.13) infections per 1,000 indwelling days for coiled leads and 0.83 (95% CI 0.16 to 4.33) infections per 1,000 indwelling days for noncoiled leads (P = 0.006).

CONCLUSIONS

Percutaneous leads used for neurostimulation of the peripheral nervous system have a much lower risk of infection with a coiled design compared with noncoiled leads: approximately 1 infection for every 30,000 vs. 1,200 indwelling days, respectively.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Fully implantable peripheral nerve stimulation for the treatment of hemiplegic shoulder pain: a case report

This case report describes the first participant treated with a fully implantable, single-lead peripheral nerve stimulation system for refractory hemiplegic shoulder pain. During the 6-wk trial stage, a temporary lead was placed percutaneously near the terminal branches of the axillary nerve to the deltoid. The primary outcome measure was the Brief Pain Inventory-Short Form Question 3, a 0-10 pain numeric rating scale. The participant experienced 75% pain reduction and proceeded to the implantation stage, where he received a single-lead, implantable pulse generator. After 3 wks, the participant became pain-free. However, 7 wks after implantation, the system was turned off because of an unrelated acute medical illness. Hemiplegic shoulder pain reemerged with a Brief Pain Inventory-Short Form Question 3 score of 9. After 11 wks of recovery, peripheral nerve stimulation was reinitiated and the participant became pain-free through the 9-mo follow-up. At 12 mos, Brief Pain Inventory-Short Form Question 3 score was 1. This case report demonstrates the feasibility of a single-lead, fully implantable peripheral nerve stimulation system for refractory hemiplegic shoulder pain.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation

BACKGROUND AND PURPOSE

The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA).

METHOD

Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale.

RESULTS

The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation.

DISCUSSION AND CONCLUSION

The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke.

Peripheral nerve stimulation compared with usual care for pain relief of hemiplegic shoulder pain: a randomized controlled trial

OBJECTIVE

This study sought to establish the efficacy of single-lead, 3-wk peripheral nerve stimulation (PNS) therapy for pain reduction in stroke survivors with chronic hemiplegic shoulder pain.

DESIGN

This study is a single-site, pilot, randomized controlled trial of adults with chronic shoulder pain after stroke. Participants were randomized to receive a 3-wk treatment of single-lead PNS or usual care. The primary outcome was the worst pain in the last week (Brief Pain Inventory, Short Form, question 3) measured at baseline and weeks 1, 4, 12, and 16. The secondary outcomes included pain interference (Brief Pain Inventory, Short Form, question 9), pain measured by the ShoulderQ Visual Graphic Rating Scales, and health-related quality-of-life (Short-Form 36 version 2).

RESULTS

Twenty-five participants were recruited, 13 to PNS and 12 to usual care. There was a significantly greater reduction in pain for the PNS group compared with the controls, with significant differences at 6 and 12 wks after treatment. Both PNS and usual care were associated with significant improvements in pain interference and physical health-related quality-of-life.

CONCLUSIONS

Short-term PNS is a safe and efficacious treatment of shoulder pain. Pain reduction is greater compared with usual care and is maintained for at least 12 wks after treatment.

Percutaneous peripheral nerve stimulation for chronic pain in subacromial impingement syndrome: a case series

OBJECTIVE

The objective of this study was to determine the effect of peripheral nerve stimulation (PNS) on pain reduction for those with refractory subacromial impingement syndrome (SIS) and to evaluate the association with reduced disability, impairment, and safety. Our hypotheses are that PNS will be associated with a reduction in pain, impairment and disability, and improvement in quality of life while demonstrating safety.

MATERIAL AND METHODS

Adults with shoulder pain of at least six months duration were recruited for a three-week treatment of percutaneous PNS applied through a percutaneous electrode to the axillary motor points of the deltoid muscle. Subjects were followed for 12 weeks after treatment. The primary outcome was the worst pain in the last week, and secondary outcomes included pain interference, the Disabilities of the Arm, Shoulder, and Hand questionnaire, shoulder abduction range of motion, and safety. Analysis was with a linear mixed model.

RESULTS

Ten subjects were recruited. Longitudinal analysis demonstrated significant reduction in pain relative to baseline (F(1, 66) = 12.9, p < 0.01). After correcting for multiple comparisons, there were significant reductions at explantation and all follow-up time points when compared with baseline. There were also significant improvements in pain interference (F(1,65) = 15.0, p < 0.01), the Disabilities of the Arm, Shoulder, and Hand questionnaire (F(1,35) = 7.0, p = 0.01), and shoulder abduction range of motion (F(1,35) = 6.3, p = 0.02).

CONCLUSION

Intramuscular PNS for chronic shoulder pain due to SIS is a safe treatment associated with pain reduction, lower pain interference with activities of daily living, reduced disability, and improved shoulder abduction. Pain reduction is maintained for at least 12 weeks after treatment.

Changes in the electrical properties of the electrode-skin-underlying tissue composite during a week-long programme of neuromuscular electrical stimulation

Particular neuromuscular electrical stimulation (NMES) applications require the use of the same electrodes over a long duration (>1 day) without having access to them. Under such circumstance the quality of the electrode-skin contact cannot be assessed. We used the NMES signal itself to assess the quality of the electrode-skin contact and the electrical properties of the underlying tissues over a week. A 14% decrease in the skin's stratum corneum resistance (from 20 to 17 kΩ) and a 15% decrease in the resistance of the electrodes and underlying tissues (from 550 to 460 Ω) were observed in the 14 healthy subjects investigated. A follow-on investigation of the effect of exercise-induced sweating on the electrical properties of the electrode-skin-underlying tissue composite during NMES indicated a correlation between the decrease in the resistance values observed over the course of the week and the accumulation of sweat at the electrode-skin interface. The value of the capacitance representing the dielectric properties of the skin's stratum corneum increased after exercise-induced sweating but did not change significantly over the course of the week. We conclude that valuable information about the electrode-skin-underlying tissue composite can be gathered using the NMES signal itself, and suggest that this is a practical, safe and relatively simple method for monitoring these electrical properties during long-term stimulation.

Eletroestimulação neuromuscular, exercícios contrarresistência, força muscular, dor e função motora em pacientes com osteoartrite primária de joelho

INTRODUÇÃO: A osteoartrite (OA) do joelho é um processo degenerativo e os sintomas são dor mecânica e períodos de dor inflamatória, rigidez articular e fraqueza muscular. Ela não tem cura. O objetivo do tratamento é aliviar os sinais e sintomas e, quando possível, retardar sua evolução. O fortalecimento muscular é indicado como tratamento da OA. OBJETIVO: Comparar a eficácia da eletroestimulação neuromuscular (EENM) e de exercícios contrarresistência (ECR) no ganho de força extensora de joelho, na diminuição da dor e na recuperação da função motora em pacientes com OA primária do joelho. MATERIAIS E MÉTODOS: Participaram da pesquisa 23 pacientes com diagnóstico de OA primária do joelho, segundo os critérios clínicos e radiológicos do American College of Rheumatology. Eles foram alocados aleatoriamente para um grupo de ECR (n = 9), um grupo de EENM (n = 8) e um grupo controle (n = 6), e foram submetidos aos procedimentos característicos de seu grupo três vezes por semana até completar 24 sessões. Foram avaliadas de forma cega a força extensora de joelho, a dor e a função motora. Foi utilizado o teste MANOVA 3 x 2 com medidas repetidas para P < 0,05. RESULTADOS: Foi encontrada diferença significativa (P < 0.05) somente nas comparações intragrupos para força extensora de joelho no grupo EENM e para dor nos grupos EENM e ECR. CONCLUSÃO: O fortalecimento da musculatura extensora de joelho pode auxiliar na diminuição da dor de pacientes com OA. A EENM, quando aplicada de acordo com o protocolo utilizado neste estudo, pode ser uma terapia interessante para o tratamento da OA do joelho.

Absent median somatosensory evoked potential is a predictor of type I complex regional pain syndrome after stroke

PURPOSE

The objective was to determine whether the abnormal finding of somatosensory evoked potentials (SEPs) associated with the development of type I complex regional pain syndrome (CRPS) after stroke.

METHODS

This was a retrospective study conducted from January, 2003, to December, 2007. Seventy patients were confirmed as CRPS type I, and one hundred and eighty-two patients were assigned to the control group. The initial clinical data were reviewed including age, gender, main type of stroke, lateralization and location of the lesion, presence of glenohumeral subluxation, and the development of CRPS. Somatosensory evoked potentials tests (SEP) in median nerve (N20) and posterior tibial nerve (P37) were performed.

RESULTS

CRPS groups revealed significantly higher incidence of the absent and abnormal hemiplegic median SEP, hemorrhagic stroke, and glenohumeral subluxation (GHS). Binary logistic regression analysis indicated that GHS (exp.(B)=4.083, p<0.01) with the absent median SEP (exp.(B)=3.246, p<0.01) were significant independent predictors of CRPS onset.

CONCLUSIONS

In conclusion, GHS and the absent median SEP at sub-acute phase of stroke were primary predictors of the onset of post-stoke CRPS. Implications for Rehabilitation Recent investigations have suggested that autonomic, motor and somatosensory abnormalities of CRPS are impairments involving the central nervous system (CNS) as well as the peripheral neurogenic inflammatory process. However, the understanding of the pathophysiology of CRPS is still far from complete. The absence of SEP at the sub-acute stage of stroke correlated with the onset of post-stroke CRPS type I. The SEP evaluation at the sub-acute period after stroke might be generally used for predicting the concomitant development of post-stroke CRPS type I as well as functional recovery after stroke.

A meta-analysis evaluating the effectiveness of two different upper limb hemiparesis interventions on improving health-related quality of life following stroke

PURPOSE

The aim of this article is to quantitatively assess the efficacy of different upper limb interventions on health-related quality of life (QOL) in stroke patients.

METHOD

Two botulinum type A injection (BTX-A) studies and 4 constraint-induced movement therapy (CIMT) studies were separately combined in a meta-analysis using a fixed effects model. QOL mean scores were extracted and transformed into weighted mean differences.

RESULTS

Combined, the BTX-A studies showed no significant improvements in overall health-related QOL. Similarly, a meta-analysis of 4 CIMT studies revealed nonsignificant findings for the domains of activities of daily living, communication, and hand function. A separate meta-analysis of 3 CIMT studies showed a significant increase in strength scores (P = .007); however, sensitivity analysis for this domain due to significant heterogeneity led to a newP value of .078, showing a nonsignificant increase in strength. Further results for memory, mobility, mood, participation, and overall recovery were all nonsignificant.

CONCLUSION

This report did not show these types of upper limb interventions to be effective in improving health-related QOL in the poststroke population.

Eletroestimulação e core training sobre dor e arco de movimento na lombalgia

INTRODUÇÃO: Eletrotermofototerapia e cinesioterapia são opções para o tratamento de lombalgias. Exercícios voltados para a musculatura paravertebral visam ao aumento de força e arco de movimento (ADM). A eletroestimulação neuromuscular (EENM) incrementa a função muscular. OBJETIVOS: Apurar a influência da EENM associada a um programa de core training (CT) sobre a lombalgia inespecífica crônica, com as variáveis de dor e ADM da coluna vertebral. MATERIAIS E MÉTODOS: Foi realizado ensaio clínico controlado randomizado duplo cego, com 27 pacientes atendidos na Clínica-Escola FIT-UGF, com diagnóstico médico relacionado a lombalgias. Foram formados dois grupos aleatoriamente: controle ativo (CORE; n = 13) e experimental (CORE + EENM; n = 14). O questionário de McGill e a fotogrametria foram aplicados antes da primeira e após a última sessão de tratamentos para medir dor e ADM, respectivamente. RESULTADOS: Os grupos eram homogêneos quanto à dor inicial (p = 0,99); a dor final do grupo CORE + EENM foi significativamente menor que a do grupo CORE (p = 0,03); a dor final do grupo CORE não apresentou diferença significativa em relação à inicial (p = 0,93); a dor final do grupo CORE + EENM foi significativamente menor que a inicial (p = 0,00). O ADM não apresentou diferença significativa intragrupos e intergrupos (p = 0,10). CONCLUSÃO: A aplicação de EENM em região lombar após CT foi eficaz, causando diminuição significativa da lombalgia inespecífica. Entretanto, não ocorreu diferença significativa do ADM entre os grupos.

Current and future interventions for glenohumeral subluxation in hemiplegia secondary to stroke

Poststroke shoulder pain is a common issue and can be caused by glenohumeral subluxation. This entity hinders function and quality of life and is caused by changes in tone and loss of fi ne control of the shoulder joints' supporting structures after a stroke. Current treatments are limited in number and effectiveness and have significant problems and limitations to their use. Furthermore, prior to percutaneous implantable neuromuscular electrical stimulation, there was no evidence for any treatment to provide relief for chronic hemiplegic shoulder pain from glenohumeral subluxation. This clinical review provides a comprehensive review of the anatomy, pathogenesis, clinical features, management, and clinical efficacy of current treatment modalities.

Peripheral nerve stimulation in treatment of intractable postherpetic neuralgia

Objective.  This case report presents an application of peripheral nerve stimulation to a patient with intractable postherpetic neuralgia that conventional treatment failed to ameliorate. Methods.  The patient underwent an uneventful peripheral nerve stimulator trial with placement of two temporal eight-electrode percutaneous leads (Octrode leads, Advanced Neuromodulation Systems, Plano, TX, USA) into the right subscapular and right paraspinal area of the upper thoracic region. Results.  Upon experiencing excellent pain relief over the next two weeks, the patient underwent implantation of permanent leads two weeks later and reported sustained pain relief. Conclusion. Peripheral nerve stimulation offers an alternative treatment option for intractable pain associated with postherpetic neuralgia, especially for elderly patients where treatment options are limited due to existing comorbidities. Further studies are warranted.

Single-lead percutaneous peripheral nerve stimulation for the treatment of hemiplegic shoulder pain: a case series

OBJECTIVE

Previous studies demonstrated the efficacy of Intramuscular Nerve (IMN) therapy with a 4-lead percutaneous, peripheral nerve stimulation (PNS) system in reducing hemiplegic shoulder pain (HSP). This case series investigates the feasibility of a less complex, single-lead approach in reducing HSP.

METHODS

Eight participants received one percutaneous intramuscular lead in the hemiparetic deltoid muscle and were then treated 6 hours/day for 3 weeks. The primary outcome measure was the Brief Pain Inventory (Short-Form) Question 3 (BPI3), which queries worst pain in the last week on a 0 to 10 numeric rating scale. Secondary outcomes included pain interference (BPI9) and Medical Outcomes Study Short-Form 36 (SF-36v2). Primary and secondary outcomes were assessed at the end of treatment (EOT) and 1 and 4 weeks after the EOT.

RESULTS

All participants tolerated the treatment well with 96% compliance. All leads remained infection-free and were removed intact at the EOT. On average, participants exhibited 70% reduction in BPI3 at the EOT and 61% reduction at 4 weeks after the EOT. All participants satisfied the success criterion of at least a 2-point reduction in BPI3 at the EOT. Longitudinal analysis revealed significant treatment effect for BPI3 (F = 14.0, P < 0.001), BPI9 (F = 5.9, P < 0.01), and the bodily pain domain of SF-36v2 (F = 12.8, P < 0.001).

CONCLUSION

This case series demonstrates the feasibility of a single-lead, 3-week IMN therapy for the treatment of chronic HSP. Additional studies are needed to further demonstrate safety, efficacy, and long-term benefit, define optimal prescriptive parameters and dose, and expand clinical indications.

A randomized controlled trial of electrostimulation effects on effussion, swelling and pain recovery after anterior cruciate ligament reconstruction: a pilot study

OBJECTIVE

To evaluate rehabilitation results of electrostimulation especially on joint effusion, swelling and pain recovery after anterior cruciate ligament reconstruction.

DESIGN

A randomized controlled trial; the assessor was not blinded to the group allocation.

SETTING

Orthopaedics-traumatology and physical medicine-rehabilitation departments.

SUBJECTS

Twenty-nine consecutive patients underwent anterior cruciate ligament reconstruction.

INTERVENTIONS

Both groups began the voluntary exercise protocol one day post-surgery. The intervention group (n = 15) also received 30 sessions electrostimulation treatment protocol started four days after the operation.

MAIN MEASURES

Numerical bulge-dancing patella signs for effusion assessment; differences in circumferences of the mid-centre of the patella between operated and non-operated knees for swelling assessment. A self-report of average daily resting pain assessed by visual analogue scale; Intenational Knee Documentation Committee scoring system and Tegner Activity Scale for subjective response assessment.

RESULTS

Twenty-six subjects including 13 patients from the intervention group completed the study. Significantly less effusion and swelling were determined in the intervention group after seven days (1.8 ± 1.3 versus 2.4 ± 1.7 for effusion and 1.7 ± 1.2 versus 3.4 ± 1.5 for swelling) to 12 weeks (0.2 ± 0.7 versus 0.6 ± 0.8 for effusion and 0.2 ± 0.8 versus 0.8 ± 0.9 for swelling) postoperative (P < 0.05). Patients treated with electrostimulation had significantly lower pain scores from seven days up to 12 weeks after the operation (P < 0.05).

CONCLUSION

Electrostimulation along with exercise therapy appears superior to exercise alone regarding knee effusion, swelling and pain recovery after anterior cruciate ligament reconstruction. Still, there is need for further clinical studies using a radiologic method to demonstrate this effect of electrostimulation.

Single-lead percutaneous peripheral nerve stimulation for the treatment of hemiplegic shoulder pain: a case report

Previous studies demonstrated the efficacy of 6 weeks of a 4-lead percutaneous, peripheral nerve stimulation system in reducing hemiplegic shoulder pain. This case report describes the first stroke survivor treated for 3 weeks with a less complex, single-lead approach. The participant was a 59-year-old male who developed hemiplegic shoulder pain shortly after his stroke 7.5 years prior to study enrollment and was treated with multiple modalities without sustained pain relief. After study enrollment, a single intramuscular lead was placed percutaneously into the deltoid muscle. He was treated 6 hours per day for 3 weeks and the lead was removed. The primary outcome measure was the Brief Pain Inventory (Short-Form) Question 3 (BPI-3), which queries the worst pain in the last week on a 0 to 10 numeric rating scale. At baseline, BPI 3 was an 8. At the end of treatment and at 1 and 4 weeks after treatment was completed, BPI 3 scores were 3, 2, and 2, respectively. Substantial improvements in quality of life measures were also observed. The participant remained infection-free and the lead was removed fully intact. After completing the study protocol, the participant was followed clinically for 13 months posttreatment with complete resolution of hemiplegic shoulder pain. This case report demonstrates the feasibility of a single-lead peripheral nerve stimulation for the treatment of chronic hemiplegic shoulder pain. Additional studies are needed to further demonstrate safety and efficacy, determine optimal dose, define optimal prescriptive parameters, expand clinical indications, and demonstrate long-term effect.

Somatosensory symptoms and signs and conditioned pain modulation in chronic post-stroke shoulder pain

Persistent shoulder pain is a common complication after stroke. Its etiology and underlying mechanisms are not well understood and treatment is generally unsatisfactory. The objective of this study was to assess the role of central sensitization and disinhibition in chronic stroke patients with chronic PSSP (n = 19), pain-free stroke patients (n = 29), and healthy controls (n = 23). Positive and negative somatosensory symptoms and signs were assessed using clinical examination and electrical and mechanical quantitative sensory testing (QST). Conditioned pain modulation (CPM) was assessed by comparing QST thresholds before and after applying a cold pressor test. Sensory abnormalities were more frequently observed and more severe in patients with PSSP, including positive signs such as allodynia at the affected side and generalized hyperalgesia at the unaffected side. CPM was similar in stroke patients and healthy controls. This study showed that chronic PSSP was associated with several positive and negative somatosensory signs, implicating a role for central sensitization and possibly for disinhibition. Since the causal relationship remains unclear, and may be related to either neuroplasticity induced by ongoing nociception as well as to the neuropathic brain lesion, prospective studies are warranted.

PERSPECTIVE

The assessment of somatosensory symptoms and signs and endogenous pain modulation demonstrated a role for central sensitization and possibly for disinhibition in chronic PSSP. Prevention and treatment of PSSP could benefit from a more detailed analysis of both peripheral and central pain mechanisms.

The effectiveness of functional electrical stimulation for the treatment of shoulder subluxation and shoulder pain in hemiplegic patients: A randomized controlled trial

PURPOSE

To investigate the effect of functional electrical stimulation (FES) for the treatment of shoulder subluxation and shoulder pain in hemiplegic patients.

METHOD

A total of 50 hemiplegic patients with shoulder subluxation and shoulder pain were included in the study. The patients were randomly divided into the study and control groups. All patients were put on a rehabilitation program using conventional methods while the study group patients were additionally applied FES to supraspinatus and posterior deltoid muscles. The shoulder pain of all patients during resting, passive range of motion (PROM) and active range of motion (AROM) was measured with the visual analog scale (VAS) while the shoulder subluxation levels were evaluated with the classification developed by Van Langenberghe and by using the millimetric measurements on anteroposterior shoulder X-ray before and after the physical treatment and rehabilitation program and compared.

RESULTS

Comparison of the resting AROM vs. PROM VAS value changes showed no significant difference between the groups. There was a significant difference between the two groups for the amount of change in shoulder subluxation in favor of the study group.

CONCLUSIONS

The results of our study have shown that applying FES treatment to the supraspinatus and posterior deltoid muscles in addition to conventional treatment when treating the subluxation in hemiplegic patients is more beneficial than conventional treatment by itself.

Peripheral subcutaneous stimulation for the treatment of intractable postherpetic neuralgia: two case reports and literature review

Postherpetic neuralgia (PHN) is a common cause of chronic pain in the elderly. Antidepressants, anticonvulsants, and opioids may reduce discomfort in many patients, while others have pain intractable to all forms of therapy. We present a novel treatment approach for intractable PHN utilizing percutaneous peripheral nerve stimulation. Two cases are described in which an 80-year-old man and a 67-year-old woman with intractable PHN, lasting 2 and 10 years, respectively, were effectively treated with implantation of two octapolar leads in the lateral thoracic region. These cases suggest that peripheral nerve stimulation may offer an alternative treatment option for intractable pain associated with PHN especially in the elderly where treatment options are limited because of existing comorbidities.

Neuromuscular electrical stimulation for motor restoration in hemiplegia

Clinical applications of neuromuscular electrical stimulation (NMES) in stroke rehabilitation provide both therapeutic and functional benefits. Therapeutic applications include upper and lower limb motor relearning and reduction of poststroke shoulder pain. There is growing evidence that NMES, especially those approaches that incorporate task-specific strategies, is effective in facilitating upper and lower limb motor relearning. There is also strong evidence that NMES reduces poststroke shoulder subluxation and pain. Functional applications include upper and lower limb neuroprostheses. Lower limb neuroprostheses in the form of peroneal nerve stimulators is effective in enhancing the gait speed of stroke survivors with foot-drop. The development of hand neuroprostheses is in its infancy and must await additional fundamental and technical advances before reaching clinical viability. The limitations of available systems and future developments are discussed.

Intramuscular botulinum toxin-A reduces hemiplegic shoulder pain: a randomized, double-blind, comparative study versus intraarticular triamcinolone acetonide

BACKGROUND AND PURPOSE

Shoulder pain is frequent after stroke and interferes with the rehabilitative process and outcome. However, treatments used for hemiplegic shoulder pain are limited and largely ineffective. This prospective, randomized, double-blind controlled study was conducted to compare the efficacies of botulinum toxin type A (BoNT-A) and triamcinolone acetonide (TA) on hemiplegic shoulder pain and their effects on arm function in patients with stroke.

METHODS

Twenty-nine hemiplegic stroke patients with shoulder pain (duration <or=24 months, pain on numeric rating scale >or=6/10) were randomized into 2 groups. One group received intramuscular injections of BoNT-A (BOTOX 100 U total) during one session to the infraspinatus, pectoralis and subscapularis muscles in conjunction with an intraarticular injection of normal saline to painful shoulder joint, whereas the other group received an intraarticular injection of TA (40 mg) and an intramuscular injection of normal saline to the same muscles. Outcome measures were pain (measured using a numeric rating scale), physician's global rating scale, shoulder range of motion (ROM) in 4 directions, arm function measured using Fugl-Meyer score, and spasticity measured using the modified Ashworth scale. Measurements were made at baseline and 2, 6, and 12 weeks after injection.

RESULTS

At 12 weeks after treatment mean decrease in pain was 4.2 in the BoNT-A-treated group versus 2.5 in the TA-treated group (P=0.051), and improvements in overall ROM were 82.9 degrees versus 51.8 degrees in these groups (P=0.059), showing a strong trend toward there being less pain and better ROM among those treated with BoNT-A than with TA. However, no significant differences were observed between the 2 groups in terms of improvement in physician global rating, Fugl-Meyer score or modified Ashworth scales. No adverse effect was observed in either group.

CONCLUSIONS

Results from this study suggest that injection of BoNT-A into selected muscles of the shoulder girdle might provide more pain relief and ROM improvement than intraarticular steroid in patients with hemiplegic shoulder pain. A larger clinical trial needs to be undertaken to confirm the benefits of this approach.

Effects of aromatherapy acupressure on hemiplegic shoulder pain and motor power in stroke patients: a pilot study

OBJECTIVES

The aim of this study was to determine if aromatherapy acupressure, compared to acupressure alone, was effective in reducing hemiplegic shoulder pain and improving motor power in stroke patients.

DESIGN

This work was a randomized, controlled trial.

SUBJECTS

Thirty (30) stroke patients with hemiplegic shoulder pain participated in this study.

INTERVENTION

Subjects were randomly assigned to either an aromatherapy acupressure group (N = 15) or an acupressure group ( N = 15), with aromatherapy acupressure using lavender, rosemary, and peppermint given only to the former group. Each acupressure session lasted 20 minutes and was performed twice-daily for 2 weeks.

OUTCOMES MEASURES

Shoulder pain and motor power were the outcome measures used in this study.

RESULTS

The pain scores were markedly reduced in both groups at post-treatment, compared to pretreatment (both aroma acupressure and acupressure group, p < 0.001). A nonparametric statistical analysis revealed that the pain score differed significantly between the 2 groups at post-treatment ( p < 0.01). The motor power significantly improved at post-treatment, compared to pretreatment, in both groups ( p < 0.005). However, there was no intergroup difference between two groups.

CONCLUSIONS

These results suggest that aromatherapy acupressure exerts positive effects on hemiplegic shoulder pain, compared to acupressure alone, in stroke patients.

Intramuscular Electrical Stimulation for Shoulder Pain in Hemiplegia: Does Time From Stroke Onset Predict Treatment Success?

Background. A randomized clinical has shown the effectiveness of intramuscular electrical stimulation for the treatment of poststroke shoulder pain. Objective. Identify predictors of treatment success and assess the impact of the strongest predictor on outcomes. Method. This is a secondary analysis of a multisite randomized clinical trial of intramuscular electrical stimulation for poststroke shoulder pain. The study included 61 chronic stroke survivors with shoulder pain randomized to a 6-week course of intramuscular electrical stimulation (n = 32) versus a hemisling (n = 29). The primary outcome measure was Brief Pain Inventory Question 12. Treatment success was defined as ≥ 2-point reduction in this measure at end of treatment and at 3, 6, and 12 months posttreatment. Forward stepwise regression was used to identify factors predictive of treatment success among participants assigned to the electrical stimulation group. The factor most predictive of treatment success was used as an explanatory variable, and the clinical trials data were reanalyzed. Results. Time from stroke onset was most predictive of treatment success. Subjects were divided according to the median value of stroke onset: early (<77 weeks) versus late (> 77 weeks). Electrical stimulation was effective in reducing poststroke shoulder pain for the early group (94% vs 7%, P < .001) but not for the late group (31% vs 33%). Repeated-measure analysis of variance revealed significant treatment ( P < .001), time from stroke onset ( P = .032), and treatment by time from stroke onset interaction ( P < .001) effects. Conclusions. Stroke survivors who are treated early after stroke onset may experience greater benefit from intramuscular electrical stimulation for poststroke shoulder pain. However, the relative importance of time from stroke onset versus duration of pain is not known.