Physiotherapeutic 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 able-bodied population, the costs of long-term treatment and rehabilitation, stroke causes enormous economic damage to society. Acute disorders of cerebral circulation, in addition to neurological manifestations, have many comorbid disorders and complications. It is known that pain in the shoulder and shoulder region of stroke patients is a very common pathology that adversely affects the results of recovery and the quality of life of patients after a stroke.

The prevalence of post-stroke pain in the shoulder region, according to different authors, ranges from 16% to 80%. Such a high incidence rate is largely due to the peculiarities 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 region are: greater mobility and lack of stability of the head of the shoulder in the articular cavity of the scapula, the vulnerability of the structures of the peripheral nervous system in the shoulder and shoulder regions, and significant functional stress on the neuromuscular apparatus of the shoulder joint.

The timing of the onset of the pain syndrome, according to various researchers, ranges from 2 weeks after the onset of the stroke to 2-3 months or within one year of the stroke. According to the results of studies conducted in 2002, it was noted that 34% of patients with shoulder pain develop within the first 24 hours after a stroke, 28% in the first 2 weeks and already 87% of patients indicated pain at 2 months after a stroke . The same authors noted that earlier terms of the onset of pain syndrome indicate an unfavorable prognosis for recovery. There are data on the age factor in the development of pain in the shoulder joint. The most common shoulder pain occurs in patients between the ages of 40 and 60, when degenerative changes in the joint are observed. There is a direct relationship between the severity of stroke and the severity of the pain syndrome in the shoulder region on the side of the paresis.

Pain in the shoulder joint in stroke patients may be caused by a large range of etiological factors. These factors can be divided into two groups: the first - these are the causes associated with neurological mechanisms, the second - the local causes, caused by damage to the periarticular tissues. The neurological causes of post-stroke pain in the shoulder 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 includes sensitive agnostic disorders, ignorance syndrome, cognitive impairment, depression. Local factors of the development of the pain syndrome in the shoulder region in patients with hemiplegia represent the following range of lesions: adhesive capsulitis, rotational tear of the cuff of the shoulder with incorrect movement or position of the patient, arthritis of the shoulder joint, arthritis of the acromioclave articulation, tenosynovitis of the biceps, fake tendovaginitis, shoulder ".

Treatment for pain in the shoulder region after a stroke, in the first place, should be aimed at normalizing muscle tone (exercise therapy, Bobat-therapy, massage, botulinum toxin injections), pain reduction (use of medications depending on the etiological factors of the pain syndrome); reduction in the degree of subluxation (fixation of the shoulder joint with bandages, kinesiotherapy, electrostimulation of the muscles of the shoulder joint), treatment of inflammation of the capsule of the shoulder joint (injection of steroid drugs). In addition, it is necessary to ensure the 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 to move, which does not cause pain. It is necessary to avoid prolonged immobilization period, which further strengthens the functional insufficiency of the joint and leads to a persistent restriction of movements.

A good therapeutic effect is provided by electrostimulation of the paretic limbs. With central paralysis, electrostimulation creates centripetal afferentation, which facilitates the disinhibition of blocked centers of the brain around the ischemic site, improves nutrition and trophism of paralyzed muscles, and prevents the development of contractures. The determination of the current parameters for electrostimulation is based on electro-diagnostic data and is carried out strictly individually, since in pathological states the excitability of the neuromuscular apparatus varies widely. The chosen pulse shape must correspond to the functional capabilities of the muscle. Muscle-antagonists, being in hypertonia, do not stimulate. With the advent of active movements, electrostimulation is replaced by therapeutic physical training. With hemorrhagic stroke, electrostimulation is not used, especially in acute and early stroke. According to various studies, functional electrical stimulation (FES) reduces the degree of subluxation, but there is no convincing evidence base for reducing pain syndrome.

Transcutaneous electroneurostimulation (TENS), in contrast to other methods of analgesic effect (pulse amplitude, DDT, interference therapy, etc.) when using short bipolar pulses with a frequency of 2-400 Hz (0.1-0.5 ms ), is capable of exciting sensitive nerve fibers without involving motor cells. Thus, excessive impulse is created over the skin afferents, which excites intercalary inhibitory neurons at the segmental level and indirectly blocks pain signaling in the zone of the terminals of the primary pain afferents and cells of the spinotalamic tract. The resulting afferent flow of nerve impulses in the CNS blocks painful impulses. As a result, for some time (3-12 hours), pain stops or decreases. The mechanism of anesthetic action can be explained from the position of the theory of "gate control", according to which the electrostimulating effect causes the activation of cutaneous low-threshold nerve fibers of type A with the subsequent facilitating effect on neurons of gelatinous substance. This, in turn, leads to blocking the transmission of painful afferentation to high-threshold fibers of type C.

Current pulses used in TENS are commensurable in duration and frequency with the frequency and duration of pulse repetition in thick myelinated A-fibers. The flow of rhythmic ordered afferent impulses, arising during the procedure, is able to excite the neurons of the gelatinous substance of the horn of the spinal cord and block at their level the carrying of nosigenic (painful) information coming through the thin non-myelinated A- and C-type fibers. A definite role is played by the activation of serotonin and peptidergic systems of the brain in CHENS. In addition, the fibrillation of the muscles of the skin and smooth muscles of the arterioles, which arises in response to rhythmic stimulation, activates the processes of destruction of algogenic substances (bradykinin) and mediators (acetylcholine, histamine) in the painful focus. These same processes underpin the restoration of impaired tactile sensitivity in the area of pain. In the formation of the therapeutic effect of Chans, an important suggestive factor is also the suggestive factor. The location of the electrodes is determined by the nature of the pathology.

Typically, electrodes of different configurations and sizes are located either on either side of the pain site, either along the nerve trunk or at the acupuncture points. Apply and segmental technique of exposure. Two types of short-pulse electroanalgesia are most often used. In the first of these, pulses of a current of up to 5-10 mA are applied, with the following frequency of 40-400 Hz. According to foreign authors, various types of pain syndrome are affected by various TENS regimes. High-frequency pulses (90-130Hz) affect acute pain and surface pain. In this case, the effect will not appear immediately, but will have a persistent character. 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 a stroke, there is no convincing evidence of the effectiveness of this method.

Earlier it was believed that injections of steroid drugs can reduce pain syndrome, reducing the natural duration of the pain phase. But according to studies conducted in recent years, intra-articular injections of steroid drugs do not affect pain in the shoulder region.

Despite the small number of studies on the effect of massage on the regress of pain in the shoulder area after a stroke, the researchers note its positive effect not only on the degree of pain syndrome, but also on the results of restoration and 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 session of back massage within 7 days. Before and after the massage sessions, the patients assessed the degree of pain syndrome in the shoulder region, the level of anxiety, the heart rate and the level of blood pressure were assessed. Patients of the main group noted improvement in all indicators.

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

Recently, studies have been carried out abroad on the effect of blockade of the suprapathic nerve by injection with a suspension of depot-medrol (methylprednisolone) with an anesthetic. The suprathiopathic nerve carries a sensitive innervation of the capsule of the shoulder joint. The procedure is aimed at creating an anesthesia, spend it three times a week at a time. Pharmacopuncture - the introduction of a pharmacological drug into acupuncture points - proved to be very useful. In addition to novocaine and lidocaine, Traumeel S is successfully used as the injectable drug. 1 ampoule (2.2 ml) is used for 1 session.

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

In addition, electrotherapy using sinusoidal modulated (CMT) and diadynamic currents (DDT), as well as electrophoresis of analgesic mixtures, non-steroidal anti-inflammatory drugs, for example, gel fustus, is used to stop the pain syndrome. In the Scientific Research Institute of Neurology of the Russian Academy of Medical Sciences, analgesic electropulse therapy is used as an analgesic therapy: percutaneous stimulation analgesia, diadynamic and sinusoidal modulated currents, and pulse magnetotherapy. It should be noted that with capsulitis physiotherapy methods are ineffective.

[1], [2], [3]