Physical therapy treatment for shoulder pain in patients with cerebral stroke

Stroke is one of the leading causes of morbidity and mortality worldwide. As a result of disability of the working population, costs of long-term treatment and rehabilitation, stroke causes enormous economic damage to society. Acute cerebrovascular accident, in addition to neurological manifestations, has many comorbid disorders and complications. It is known that pain in the shoulder and shoulder girdle area in patients who have suffered a stroke is a very common pathology that has a negative impact on the results of recovery and the quality of life of patients after a stroke.

The prevalence of post-stroke pain syndrome in the shoulder area, according to different authors, ranges from 16% to 80%. Such a high frequency of damage is largely explained by the features of the anatomy and biomechanics of the shoulder joint, as well as the physiology of the tendon tissue. The main conditions for the formation of pain in the shoulder area are: high mobility and insufficient stability of the humeral head in the glenoid cavity of the scapula, vulnerability of the structures of the peripheral nervous system in the shoulder girdle and shoulder, significant functional loads on the neuromuscular apparatus of the shoulder joint.

The time of occurrence of pain syndrome, according to various researchers, varies from 2 weeks after the development of a stroke to 2-3 months or within one year after a stroke. According to the results of studies conducted in 2002, it was noted that in 34% of patients, shoulder pain develops within the first day after a stroke, in 28% - within the first 2 weeks, and 87% of patients indicated the presence of pain 2 months after a stroke. The same authors noted that earlier periods of pain syndrome occurrence indicate an unfavorable prognosis for recovery. There is data on the age factor in the development of pain in the shoulder joint. Shoulder pain most often occurs in patients aged 40 to 60 years, when degenerative changes in the joint area are observed. There is a direct relationship between the severity of the stroke and the severity of pain syndrome in the shoulder area on the side of the paresis.

Shoulder pain in patients who have had a stroke can be caused by a wide range of etiologic factors. These factors can be divided into two groups: the first are the causes associated with neurological mechanisms, the second are local causes caused by damage to periarticular tissues. Neurological causes of post-stroke shoulder pain include complex regional syndrome, post-stroke pain of central origin, damage to the brachial plexus, and changes in muscle tone in the paretic limb. In addition, this group can include sensory agnostic disorders, neglect syndrome, cognitive impairment, and depression. Local factors in the development of pain syndrome in the shoulder area in patients with hemiplegia include the following range of lesions: adhesive capsulitis, rotational tears of the shoulder cuff due to incorrect movement or position of the patient, arthritis of the shoulder joint, arthritis of the acromioclavicular joint, tendovaginitis of the biceps muscle, subdeltoid tendovaginitis, "shoulder rotator cuff compression syndrome".

Treatment for pain in the shoulder area after a stroke should primarily be aimed at normalizing muscle tone (physical therapy, Bobath therapy, massage, botulinum toxin injections), reducing pain (using medications depending on the etiological factors of the pain syndrome), reducing the degree of subluxation (fixation of the shoulder joint with bandages, kinesiotaping, electrical stimulation of the shoulder muscles), treating inflammation of the shoulder joint capsule (steroid injections). In addition, it is necessary to ensure awareness, interest and active participation of the patient in the rehabilitation process.

The rehabilitation process begins with restrictions on the load on the affected joint. The patient is allowed movements that do not cause increased pain. It is necessary to avoid a long immobilization period, which further increases the functional insufficiency of the joint and leads to persistent limitation of movement.

Electrical stimulation of paretic limbs has a good therapeutic effect. In central paralysis, electrical stimulation creates centripetal afferentation, which promotes disinhibition of blocked centers of the brain around the ischemic area, improves nutrition and trophism of paralyzed muscles, and prevents the development of contractures. Determination of current parameters for electrical stimulation is based on electrodiagnostic data and is carried out strictly individually, since in pathological conditions the excitability of the neuromuscular apparatus varies within wide limits. The selected pulse shape should correspond to the functional capabilities of the muscle. Antagonist muscles that are in hypertonicity are not stimulated. With the appearance of active movements, electrical stimulation is replaced by therapeutic exercise. Electrical stimulation is not used in hemorrhagic stroke, especially in the acute and early periods of stroke. According to various studies, functional electrical stimulation (FES) reduces the degree of subluxation, but there is no convincing evidence base regarding the reduction of pain syndrome.

Transcutaneous electrical neurostimulation (TENS), unlike other methods of analgesic action (ampli-pulse, DDT, interference therapy, etc.), when using short bipolar impulses (0.1-0.5 ms) with a frequency of 2-400 Hz, is capable of exciting sensory nerve fibers without involving motor ones. Thus, excess impulses are created along cutaneous afferents, which excite intercalary inhibitory neurons at the segmental level and indirectly block pain signaling in the area of terminals of primary pain afferents and cells of the spinothalamic tract. The resulting afferent flow of nerve impulses in the central nervous system blocks pain impulses. As a result, pain stops or decreases for some time (3-12 hours). The mechanism of the analgesic effect can be explained from the position of the "gate control" theory, according to which the electrical stimulation causes activation of cutaneous low-threshold nerve fibers of type A with a subsequent facilitating effect on the neurons of the gelatinous substance. This, in turn, leads to blocking the transmission of pain afferentation along high-threshold fibers of type C.

The current pulses used in TENS are comparable in duration and frequency with the frequency and duration of the pulses in thick myelinated A-fibers. The flow of rhythmic ordered afferent impulses that occurs during the procedure is capable of exciting neurons of the gelatinous substance of the posterior horns of the spinal cord and blocking at their level the conduction of nocigenic (painful) information coming through thin unmyelinated fibers of the A- and C-types. A certain role is also played by the activation of the serotonin and peptidergic systems of the brain during TENS. In addition, fibrillation of the skin muscles and smooth muscles of the arterioles that occurs in response to rhythmic stimulation activates the processes of destruction of algogenic substances (bradykinin) and mediators (acetylcholine, histamine) in the pain focus. The same processes underlie the restoration of impaired tactile sensitivity in the pain zone. In the formation of the therapeutic effect of TENS, the suggestive factor is also of great importance. The location of the electrodes is determined by the nature of the pathology.

Usually, electrodes of various configurations and sizes are placed either on both sides of the painful area, or along the nerve trunk, or at acupuncture points. Segmental methods of action are also used. Most often, two types of short-pulse electroanalgesia are used. The first of them uses current pulses of up to 5-10 mA, following with a frequency of 40-400 Hz. According to foreign authors, different types of pain syndrome are affected by different TENS modes. High-frequency pulses (90-130 Hz) affect acute pain and superficial pain. In this case, the effect will not appear immediately, but will be persistent. Low-frequency pulses (2-5 Hz) are more effective in chronic pain syndrome and the effect is not persistent.

Despite the widespread use of botulinum toxin injections in the treatment of shoulder pain after stroke, there is no convincing evidence of the effectiveness of this method.

Previously, it was believed that steroid injections help relieve pain by reducing the natural duration of the pain phase. However, according to research conducted in recent years, intra-articular steroid injections do not affect pain in the shoulder joint.

Despite the small number of studies on the effect of massage on the regression of pain in the shoulder area after a stroke, researchers note its positive effect not only on the degree of pain syndrome, but also on the results of recovery and the quality of life of post-stroke patients. Mok E. and Woo C. (2004) examined 102 patients who were divided into the main and control groups. The main group received a 10-minute back massage session for 7 days. Before and after the massage sessions, the patients were assessed for the degree of pain syndrome in the shoulder area, anxiety level, heart rate and blood pressure. Patients in the main group noted an improvement in all indicators.

A significant reduction in pain syndrome was noted when using aromatherapy in combination with acupressure. In 2007, studies were conducted in Korea involving 30 patients. The patients were divided into the main and control groups. Patients in the main group received 20-minute acupuncture massage sessions twice a day for two weeks using aromatic oils (lavender, mint, rosemary oil), patients in the control group received only acupuncture massage. After a two-week course of treatment, patients in the main group noted a significant regression in the degree of pain syndrome.

Recently, studies have been conducted abroad on the effect of suprascapular nerve blockade by injection of depot-medrol (methylprednisolone) suspension with anesthetic. The suprascapular nerve provides sensitive innervation of the shoulder joint capsule. The procedure is aimed at creating anesthesia, it is carried out three times with a weekly interval. Pharmacopuncture - the introduction of a pharmacological drug into acupuncture points - has proven itself well. In addition to novocaine and lidocaine, Traumeel S is successfully used as an injected drug. 1 ampoule (2.2 ml) is used per session.

Traumeel S is a homeopathic preparation that contains herbs: arnica, belladonna, aconite, calendula, witch hazel, chamomile, yarrow, St. John's wort, comfrey, daisy, echinacea, as well as substances necessary to reduce inflammation and pain in the joint, to improve the trophism of periarticular tissues (ligaments, tendons, muscles). In addition, Traumeel S reduces swelling and hematomas in the joint area and prevents the formation of new ones; participates in the regeneration of damaged tissues; relieves pain; reduces bleeding; strengthens and tones veins; improves immunity. The introduction of the ointment into the affected joint by ultrasound phonophoresis is effective.

In addition, electrotherapy using sinusoidal modulated (SMT) and diadynamic currents (DDT), as well as electrophoresis of analgesic mixtures, non-steroidal anti-inflammatory drugs, such as fastum gel, are used to relieve pain. The Research Institute of Neurology of the Russian Academy of Medical Sciences uses methods of pain-relieving electropulse therapy as an analgesic treatment: transcutaneous stimulation analgesia, diadynamic and sinusoidal-modulated currents, as well as pulsed magnetic therapy. It should be noted that physiotherapeutic methods are ineffective in capsulitis.

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