From the Guidelines
Management of shoulder pain with neurologic origin requires a multidisciplinary approach targeting both symptoms and underlying causes, with initial treatment focusing on pain control and prevention of further injury, as recommended by the American Heart Association/American Stroke Association guidelines 1. The most recent and highest quality study, published in 2016, provides guidelines for the management of hemiplegic shoulder pain, including patient and family education, botulinum toxin injection, and neuromodulating pain medications 1. Key recommendations include:
- Patient and family education on range of motion, positioning, and shoulder care after stroke
- Botulinum toxin injection to reduce severe hypertonicity in hemiplegic shoulder muscles
- A trial of neuromodulating pain medications for patients with clinical signs and symptoms of neuropathic pain
- Positioning and use of supportive devices and slings for shoulder subluxation
- Clinical assessment, including musculoskeletal evaluation, evaluation of spasticity, identification of any subluxation, and testing for regional sensory changes The use of overhead pulley exercises is not recommended, as it can exacerbate shoulder pain and injury 1. In terms of specific interventions, suprascapular nerve blocks may be considered as an adjunctive treatment for hemiplegic shoulder pain, as they have been shown to be effective in reducing pain for up to 12 weeks after treatment 1. Additionally, corticosteroid injection into the glenohumeral joint or subacromial space may be effective in reducing shoulder pain, although the long-term effects are not well established 1. Overall, a comprehensive approach to managing shoulder pain with neurologic origin is essential, taking into account the individual patient's needs and circumstances, and incorporating a range of treatments and interventions as needed.
From the Research
Neurologic Cause of Shoulder Pain
The management approach for shoulder pain of neurologic origin is complex and requires a comprehensive understanding of the underlying causes.
- The diagnosis of shoulder pain is crucial in decision-making when treating a patient, and it is typically based on careful history taking and physical examination 2.
- Imaging studies, such as ultrasound, may be used to confirm the diagnosis and guide treatment, especially when surgery is being considered 3.
- Neurologic causes of shoulder pain may include neuropathic pain, which can be challenging to treat, and may require the use of medications such as pregabalin, gabapentin, or duloxetine 4, 5.
- The efficacy of these medications can vary depending on the individual patient and the specific cause of their pain, and combination therapy may be considered in some cases 6.
Treatment Options
- Pregabalin and gabapentin are two medications that have been shown to be effective in treating neuropathic pain, including pain related to spinal cord injury 5.
- These medications can be used alone or in combination with other treatments, such as physical therapy or steroid injections, to manage shoulder pain of neurologic origin.
- The choice of treatment will depend on the individual patient's needs and medical history, as well as the specific cause of their pain.
- It is essential to carefully evaluate the patient's response to treatment and adjust the treatment plan as needed to ensure optimal pain management.
Considerations for Treatment
- When treating shoulder pain of neurologic origin, it is essential to consider the potential side effects of medications and the risk of interactions with other medications 6.
- The use of steroid injections, such as lidocaine, should be carefully considered, as high concentrations of long-acting local anesthetics can be chondrotoxic and should not be injected into joints 3.
- A comprehensive treatment plan should include a combination of medical and non-medical interventions, such as physical therapy, to address the underlying causes of pain and promote optimal recovery.