Peripheral Nerve Stimulation Compared with Usual Care for Pain Relief of Hemiplegic Shoulder Pain

Abstract

Objective This study seeks to establish the efficacy of single-lead, 3-week peripheral nerve stimulation (PNS) therapy for pain reduction 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 usual care (UC). 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. 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 (SF-36v2). Results Twenty-five participants were recruited, 13 to PNS and 12 to UC. There was a significantly greater reduction in pain for the PNS group compared to controls, with significant differences at 6 and 12 weeks after treatment. Both PNS and UC 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 for shoulder pain. Pain reduction is greater than compared to UC and is maintained for at least 12 weeks after treatment.

Fully Implantable Peripheral Nerve Stimulation for the Treatment of Hemiplegic Shoulder Pain

“…27 The theory also predicts that once the non-noxious afferent input is removed pain recurs, which is consistent with clinical experience with TENS. 29 Thus, the presence of a long “carry-over” effect in prior studies, 9–14 and to a lesser degree in the present study, also makes the Gate Theory an unlikely explanation for the observed results.…”

“…28 Improved biomechanics is unlikely as the RCT that only enrolled participants with glenohumeral subluxation failed to show evidence of improved motor function or reduction of subluxation. 10,13 Two more recent trials enrolled stroke patients with and without glenohumeral subluxation; 9,14 however, participants in both groups experienced significant pain reduction, which further suggests that improved biomechanics of the glenohumeral joint is not the mechanism of action.…”

“…9–14 Stroke survivors who are treated within 18-mo of their stroke experience sustain pain relief after completion of treatment. However, those who are greater than 18-months post-stroke experience significant relief initially, but pain returns within 3-mo.…”

An Etiological Paradigm Shift for Chronic Hemiplegic Shoulder Pain

“…9 A review of baseline demographics (Table 1) indicates that the randomization procedure performed as expected to create well-balanced cohorts, even with the small sample sizes in this study. 1 There is no indication of lack of balance, and this is supported by the acknowledgement in the letter that glenohumeral subluxation occurs in similar proportions in both of the cohorts. Thus, the results should be considered valid and not due to chance.…”

“…We appreciate the interest in the recently published manuscript, “Peripheral Nerve Stimulation Compared with Usual Care for Pain Relief of Hemiplegic Shoulder Pain.” 1 This study provides evidence that peripheral nerve stimulation (PNS) is an efficacious treatment for hemiplegic shoulder pain (HSP) and reduces pain to a greater extent and with longer durability than usual care. It has been correctly pointed out that there was no attempt by the study authors to provide a diagnosis for the occurrence of HSP based on the nociceptive and biomechanical models.…”