Multimodal Treatment for Hemiplegic Shoulder Pain

Multimodal Treatment for Hemiplegic Shoulder Pain

Sponsors

Lead sponsor: MetroHealth Medical Center

Collaborator: Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
Case Western Reserve University
Shirley Ryan AbilityLab

Source MetroHealth Medical Center
Brief Summary

Hemiplegic shoulder pain (HSP) affects up to 60% of moderate to severely impaired stroke survivors. HSP is associated with poor rehabilitation outcomes, including interference with activities of daily living (ADLs) and poor quality of life (QoL). While many treatments for HSP have been proposed, most do not result in long-term relief of pain.

The investigators developed the use of intramuscular peripheral nerve stimulation (PNS) for the treatment of HSP, which involves the temporary placement of a percutaneous intramuscular electrode to stimulate the axillary nerve motor points to the deltoid muscle. A systematic review of randomized controlled trials (RCT) concluded that intramuscular PNS was the only treatment to provide long-term relief of pain for those with HSP. However, physical therapy (PT), which focuses on correcting biomechanics, is the most commonly prescribed treatment for HSP and is recommended by multiple practice guidelines. Prior to acceptance by the clinical community, the superiority of PNS to a course of PT must be demonstrated. The investigators completed a pilot RCT comparing PNS to PT and 67% vs. 25% of participants experienced successful pain relief (i.e., ≥ 2-pt or 30% reduction) from PNS and PT, respectively. Thus, the primary objective of this 2-site RCT is to confirm the findings of this preliminary pilot RCT. Combining PNS and PT, which may be how PNS is actually implemented in clinical practice, may have a synergistic therapeutic effect. Thus, the second objective of this RCT is to determine if multimodal treatment of HSP with PNS + PT is more efficacious for pain relief than PNS alone or PT alone. Mechanisms also will be explored.

Overall Status Recruiting
Start Date January 2017
Completion Date December 2021
Primary Completion Date December 2021
Phase N/A
Study Type Interventional
Primary Outcome
Measure Time Frame
Brief Pain Inventory (BPI)- Short Form (SF) question 3 (BPI-SF3) Prior 7-days
Enrollment 132
Condition
Intervention

Intervention type: Device

Intervention name: Peripheral Nerve Stimulation

Description: The stimulation system includes an external stimulator, percutaneous lead and pad. The stimulator snaps onto the pad. The pad has an embedded power source but also serves as the anode. The 1-channel stimulator outputs a biphasic current waveform with current pulse parameter ranges suitable for PNS. The percutaneous lead is inserted using an introducer (like a hypodermic needle) which is withdrawn and the lead is retained in the muscle by a barb at its tip. After a 1-week stabilization period, stimulation is initiated (6 hrs/day). The duty cycle and daily dose remain constant, but stimulus parameters may be adjusted by the research staff as deemed appropriate. The treatment period is 3 weeks after which the lead will be removed. Total time of electrode implantation is no more than 29 days.

Intervention type: Other

Intervention name: Physical Therapy

Description: Participants will receive 8 60-minute sessions of outpatient therapy over a 4 week period concurrent with PNS or sham-PNS treatment. Therapy may include: Proper Positioning and Handling, Therapeutic positioning and Strengthening Exercises, Mirror Therapy, Task-specific Therapy, Home Exercise Program, and a Mental Practice program.

Intervention type: Other

Intervention name: Sham-PT

Description: Participants randomized to sham-PT will receive 8 60-minute sessions with therapists with the goal of controlling for the effect of regular contact with a therapist and study staff in a therapeutic environment. Participants will undergo a hands-on evaluation and re-evaluation before and after treatment. Therapists will provide sham ultrasound therapy and light application of inert gel to the shoulder for 10 minutes, Pre-Gait Training or Gait training, Exercise therapy, and relaxation therapy.

Arm group label: PNS + sham-PT

Intervention type: Device

Intervention name: Sham-PNS

Description: The stimulation system includes an external stimulator, percutaneous lead and pad. The stimulator snaps onto the pad. The pad has an embedded power source.The stimulator will appear to function as normal though will not deliver electrical current to the electrode. The subjects will be prescribed 6 hours of sham-stimulation per day for 3 weeks.

Arm group label: sham-PNS + PT

Eligibility

Criteria:

Inclusion Criteria:

- shoulder pain localized to the glenohumeral joint, subacromial area or deltoid insertion associated with: a) rest; b) passive abduction or external rotation range of motion (ROM); c) active abduction ROM; or, d) manual palpation;

- shoulder pain onset or worsening after the most recent stroke;

- weakness of shoulder abductors (≤4/5 on Medical Research Council (MRC) scale if isolated movement is present);

- ≥ 21-yrs old; < 90-yrs old;

- time of stroke ≥ 3-mo;

- duration of HSP ≥3-mo;

- HSP with moderate to severe pain (BPI SF-3 ≥ 4);

- cognitive and communication ability to fulfill study requirements (cognitive ability based upon a score of ≥24 on the Mini Mental Status Exam (MMSE));

- availability of reliable adult who can assist with study procedures if necessary;

- willing and able to report shoulder pain and other conditions and complete study visits throughout the 4 month study period.

Exclusion Criteria:

- joint or overlying skin infection or history of recurrent skin infections;

- insensate skin;

- need to take > 1 opioid and > 1 nonopioid analgesic medication for HSP;

- regular intake of pain medications for another chronic pain;

- botox injection or subacromial steroid injections to the shoulder within the past 12 weeks;

- receiving occupational therapy (OT) or PT for HSP;

- bleeding disorder or international normalized ratio (INR) > 3.0;

- sensitivity to skin surface electrodes and/or medical-grade adhesives, gels, tapes;

- medical instability;

- pregnancy;

- uncontrolled seizures (>1/mo for 6-mo);

- history of cardiac arrhythmia with hemodynamic instability;

- history of lidocaine allergy;

- history of Parkinson's disease, spinal cord injury (SCI), traumatic brain injury (TBI), multiple sclerosis (MS), or ipsilateral upper extremity (UE) lower motor neuron lesion;

- history of complex regional pain syndrome, myofacial pain syndrome, other pain conditions (investigator discretion);

- cardiac pacemaker or other implanted electronic device;

- history of valvular heart disease (artificial valves, requiring antibiotics for procedures, etc.);

- severely impaired communication.

Gender: All

Minimum age: 21 Years

Maximum age: 89 Years

Healthy volunteers: No

Overall Official
Last Name Role Affiliation
Richard D Wilson, MD Principal Investigator MetroHealth Medical Center
Overall Contact

Last name: Kristine Hansen, PT

Phone: 216-778-5347

Email: [email protected]

Location
facility status contact contact_backup investigator
Shirley Ryan Abilitylab | Chicago, Illinois, 60611, United States Recruiting Sneha Solanki 312-238-3647 [email protected] Richard L Harvey, MD Principal Investigator
Carolinas Rehabilitation | Charlotte, North Carolina, 28203, United States Recruiting Juliana Turner, RN - CCRP 704-355-1409 [email protected] Vu Nguyen, MD Principal Investigator
MetroHealth Medical Center | Cleveland, Ohio, 44109, United States Recruiting Kristine Hansen, PT 216-778-5347 [email protected] Richard D Wilson, MD Principal Investigator
Location Countries

United States

Verification Date

August 2019

Responsible Party

Responsible party type: Principal Investigator

Investigator affiliation: MetroHealth Medical Center

Investigator full name: Richard Wilson, MD

Investigator title: Assistant Professor, Physical Medicine and Rehabilitation

Keywords
Has Expanded Access No
Condition Browse
Number Of Arms 3
Arm Group

Arm group label: PNS + PT

Arm group type: Experimental

Description: The PNS+PT Group will receive peripheral nerve stimulation treatment (which will produce muscle contraction) for three weeks (6 hours daily) with an Intramuscular Electrical Stimulator following a one week electrode stabilization period, and also receive eight 60-minute sessions of outpatient physical therapy focused on shoulder pain over the same four week period.

Arm group label: PNS + sham-PT

Arm group type: Active Comparator

Description: The PNS + sham-PT Group will receive peripheral nerve stimulation treatment (which will produce muscle contraction) for three weeks (6 hours daily) with an Intramuscular Electrical Stimulator following a one week electrode stabilization period, and also receive eight 60-minute sessions of sham outpatient physical therapy not focused on shoulder pain over the same four week period.

Arm group label: sham-PNS + PT

Arm group type: Active Comparator

Description: The sham-PNS + PT Group will receive sham peripheral nerve stimulation treatment (which will not produce muscle contraction) for three weeks (6 hours daily) with an Intramuscular Electrical Stimulator following a one week electrode stabilization period, and also receive eight 60-minute sessions of outpatient physical therapy focused on shoulder pain over the same four week period.

Patient Data Yes
Study Design Info

Allocation: Randomized

Intervention model: Parallel Assignment

Primary purpose: Treatment

Masking: Triple (Participant, Care Provider, Outcomes Assessor)

Source: ClinicalTrials.gov