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Novel Use of Peripheral Nerve Stimulation in the Treatment of Pain/Shoulder Subluxation Resulting from Stroke Hemiplegia
Srinivas Chiravuri, MD; Rashad Albeiruti, MD; Ted Edward Claflin, MD; Lynda Yang, MD, PHD; Kate Wan-Chu Chang, MA, MS; University of Michigan, Ann Arbor, MI

Introduction: Pain and shoulder subluxation resulting from stroke hemiplegia can be refractory to medical pain management. Theoretically, axillary nerve stimulation can activate the deltoid and teres minor shoulder muscles, thereby reducing pain and shoulder subluxation. As opposed to the general application of peripheral nerve (PN) stimulation to address painful sensory peripheral neuropathies, we aim to demonstrate the novel utility of PN motor stimulation to ameliorate symptomatic sequalae of central nervous system conditions such as stroke. Methods: Two hemiplegic patients with pain and shoulder subluxation underwent placement of a minimally-invasive neuromodulation system (PN stimulator comprising an implanted lead, external pulse transmitter (EPT), and conductive electrode, that are controlled by a small, hand-held patient programming device) after failing maximal conventional rehabilitation methods. The following pre- and post-operative measurements were used: numeric pain scale to assess shoulder pain and finger breadth to assess shoulder subluxation. Additionally, active range of motion (AROM) for shoulder flexion/extension, abduction/adduction, and internal/external rotation, along with muscle power (MRC grade) for the aforementioned movements were recorded. Results: Both patients had significant reductions in their numerical pain scores post-operatively: 7/10 to 0/10 for the first patient and 6/10 to 0/10 for the second patient. Subluxation as measured by finger breadth decreased from 1 to 0 for both patients. Motor strength for all arm muscle groups improved from 0/5 to 4/5 for the first patient and from 3/5 to 4/5 for the second patient. For the first patient, AROM improved from 0 for all arm movements to 45 abduction/45 flexion/10 extension/10 external rotation/5 internal rotation. For the second patient, AROM improved from 0 to 90 abduction/90 flexion/10 extension/10 external rotation/5 internal rotation. Conclusions: We demonstrate that axillary nerve stimulation significantly reduced pain, shoulder subluxation, motor strength, and AROM in patient experiencing hemiplegic shoulder pain after stroke. The innovative addition of neuromodulation to conventional rehabilitation and medical treatments may be superior to conventional treatment alone for managing hemiplegic shoulder pain refractory to conservative treatments. Additionally, these results indicate that neuromodulation may represent a unique treatment opportunity not only peripheral nervous system disorders but also for selected symptomatic sequelae of central nervous system disorders.

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