Enhanced-MRI and Ultrasound Evaluation of Painful Shoulder in Patients after Stroke: A Pilot Study

Abstract

Background: Epidemiological and radiological studies have previously been performed to identify the possible causes of hemiplegic shoulder pain (HSP). Many different etiologies have been postulated, though no clear correlations have emerged, and a multifactorial pathogenesis of HSP has been proposed. Recently, two MRI-based studies have described different shoulder findings as possible causes of pain in chronic stroke survivors. Purpose: The aim of this study was to describe the structural abnormalities of the painful shoulder in the first months after stroke by ultrasound and enhanced MRI. The secondary aims were to identify possible predisposing factors for HSP and to evaluate its impact on motor recovery. Methods: One hundred and fifty-three first-time stroke patients, admitted to the Santa Lucia Foundation for rehabilitation, were investigated for HSP. Twenty-five stroke patients with HSP and 16 stroke patients without shoulder pain were included. An ultrasound evaluation and enhanced shoulder MRI were performed for all the patients. Results: Among the shoulder abnormalities detected by both imaging studies, only capsulitis, which was detected by enhanced shoulder MRI in 88% of the HSP patients, was independently associated with pain (p < 0.001) and proven to be predictive of pain intensity as expressed by the VAS score (p < 0.003). HSP correlated with a worse global recovery (p < 0.05) as well as with male sex (p = 0.006), neglect (p = 0.02) and subluxation (p = 0.03), although none of these features were found to be independent predictors of pain. Conclusion: Adhesive capsulitis was found to be a possible cause of HSP. However, MRI, which is more expensive than other diagnostic tools, may be considered the gold standard tool for understanding the etiology of HSP.

Sonographic Evaluation of Structural Changes in Post-Stroke Hemiplegic Shoulders

“…Acute hemiplegics with subluxation (75%) were significantly more frequent than chronic hemiplegics with subluxation (15%). This agrees with previous reports that shoulder subluxation in hemiplegia is predominantly seen in the acute phase [23,26,27], which has been attributed to its self-limiting nature [27]. The subluxed hemiplegic shoulders were characterized by significantly higher raw USS score (approximately 4 abnormalities per subluxed shoulder) than the non – subluxed hemiplegic shoulders (about 2 abnormalities per non-subluxed shoulder), suggesting that presence of subluxation is associated with more soft tissue injuries.…”

“…This is in agreement with previous sonographic studies [2,9]. However, adhesive capsulitis was the dominant finding in some studies that examined hemiplegic shoulders with conventional arthrography [28], contrast enhanced MRI [26,27], and magnetic resonance arthrography [29]. This discrepancy between USS and other imaging techniques could potentially be addressed in future studies by combining all of the various sonographic methods of detecting adhesive capsulitis reported in English literature thus far [15,30–34] in order to improve detection rate.…”

“…Moreover, HSP did not correlate significantly with any sonographic variables. These observations are in line with the findings of other workers [16,21,23,26] but differ from Pong et al, [17] who found that HSP was associated with LHBT effusion and tendinosis as well as SST tendinosis in chronic hemiplegics. However, their research was a longitudinal study, in which the same set of hemiplegics were scanned on admission (acute stage) and at 6 months after discharge (chronic stage) rather than including a random selection of different stroke patients with different duration of hemiplegia.…”

“…On the other hand, the higher prevalence of RCTs (59%) in the study by Yi et al [35] could be due partly to the fact that they did not exclude diabetic stroke patients who constituted 36% of their sample size. Rotator cuff tears are more prevalent in diabetics than in the general population [26]. Hence, different inclusion/exclusion criteria may also partly account for the disparity in results.…”

Hemiplegic Shoulder Pain in Shoulder Subluxation after Stroke: Associated with Range of Motion Limitation

“…Previous studies of MR findings suggestive of adhesive capsulitis between stoke survivors with and without HSP reported that synovial capsule thickening, synovial capsule enhancement, and enhancement in the rotator cuff interval were more prominent in those with HSP [13,14]. Unlike these studies, our study conducting on shoulder subluxation found no more MR arthrography findings suggesting adhesive capsulitis in the HSP group.…”