Neurology ยท Medical Literature
Combining Pulsed Radiofrequency With Transcranial Magnetic Stimulation to Manage Hemiplegic Shoulder Pain and Somatosensory Nerve Transmissions.
Abstract
Hemiplegic shoulder pain (HSP) is a major cause of disability that is still challenging to manage in clinical practices. Both pulsed radiofrequency (PRF) and repetitive transcranial magnetic stimulation (rTMS) could reduce poststroke HSP to certain extents. However, it remains unknown whether combined PRF and rTMS treatment could increase analgesic efficacy for poststroke HSP. To evaluate the therapeutic efficacy of combined PRF and transcranial magnetic stimulation in treating HSP. This was a randomized, assessor-blinded pilot study. The rehabilitation department of a single hospital. In this pilot study, a 3-arm study design was utilized to compare the treatment efficacy of combined PRF and rTMS treatment with a single PRF or rTMS strategy. Patients were randomly assigned to receive PRF, rTMS, or combined treatment. Outcomes assessments included pain intensity, motor activity, and neurophysiological activities. Our data indicated that rTMS acted more efficiently to reduce pain than PRF treatment. Combined treatment had a larger long-term efficacy than rTMS treatment alone. Both combined and single treatment improved motor recovery and neural transmissions, such as suprascapular nerve amplitude and somatosensory N20. As we designed a pilot study, the sample size was small in each treatment arm. Our findings thus need to be validated in future large studies. These novel findings provide a safe and effective treatment strategy for poststroke HSP by combining PRF with rTMS treatment. Chinese Clinical Trial Registry: ChiCTR2500100181.
Clinical relevance
Hemiplegic shoulder pain (HSP) is a prevalent and debilitating complication of stroke that remains difficult to manage with existing unimodal interventions, significantly impeding neurorehabilitation and functional recovery. This pilot RCT addresses a critical clinical gap by evaluating whether combining pulsed radiofrequency (PRF) with repetitive transcranial magnetic stimulation (rTMS) yields superior analgesia and neurophysiological benefit over either modality alone in poststroke HSP patients. Given the limited evidence base for interventional pain strategies in this population, these findings are timely and relevant for neurologists and rehabilitation physicians managing stroke sequelae.
Key findings
1. rTMS monotherapy demonstrated greater short-term pain reduction compared to PRF monotherapy alone, suggesting differential analgesic mechanisms between the two modalities in poststroke HSP. 2. Combined PRF plus rTMS treatment produced superior long-term analgesic efficacy compared to rTMS treatment alone, indicating an additive or synergistic effect when the modalities are used together. 3. Both combined and single-modality treatments resulted in measurable improvements in motor recovery, supporting the functional rehabilitation benefit of each intervention beyond pain relief alone. 4. All treatment arms demonstrated improvements in neurophysiological parameters, specifically suprascapular nerve amplitude and somatosensory N20 cortical evoked potential, reflecting enhanced peripheral and central somatosensory nerve transmission. 5. The study was designed as a 3-arm randomized, assessor-blinded pilot trial; however, sample size was small in each treatment arm, limiting statistical power and precluding definitive effect size, confidence interval, p-value, and NNT/NNH reporting from the available abstract. 6. No significant safety concerns were reported with the combined PRF and rTMS protocol, supporting its tolerability in the poststroke population.
Practice implications
Clinicians managing poststroke HSP refractory to conventional analgesia should consider sequential or combined use of PRF and rTMS as a safe, multimodal interventional strategy, particularly for patients in whom sustained long-term pain control is the primary goal. Patient selection should prioritize those with confirmed poststroke HSP with neurophysiological evidence of somatosensory dysfunction (e.g., abnormal N20 latency or suprascapular nerve amplitude), as these may serve as objective biomarkers of treatment response and targets for monitoring. These findings should be regarded as hypothesis-generating given the pilot design and small cohort size; adoption into routine practice should await validation in adequately powered, multicenter RCTs with standardized PRF and rTMS parameters (frequency, pulse duration, coil placement, and number of sessions).