The use of suprascapular nerve block injection for people with chronic shoulder pain within physiotherapy practice.

Neil Smith1                       MRes, BSc

Dr Emma Salt2                PhD, MSc, BSc

Sandwell and West Birmingham Hospitals NHS Trust / Warwick Clinical Trials Unit.

University Hospitals of Derby and Burton NHS Foundation Trust

Introduction

Chronic shoulder pain is a major cause of disability; 20% of those affected still report shoulder pain at 1 year and 14% at 3 years.9,14,16 Chronic shoulder pain is most common in people aged 65 and over, affecting 1 in 5 people,  with degenerative rotator cuff tears the most common chronic shoulder disorder in this age group.10 Local steroid injections are used in the management of chronic shoulder pain but only provide short-term benefit and regular repeat injections are not recommended.3,19

The major sensory nerve of the shoulder complex is the suprascapular nerve.2 The suprascapular nerve is a mixed motor / sensory nerve and supplies up to 70% of the sensory innervation to the shoulder complex, including the acromioclavicular joint, posterior joint capsule, rotator cuff tendons and subacromial bursa (Fig 1).2,8,17

 

Fig 1 Schematic diagram of the distal suprascapular nerve (dSSN) and its sensory branches (a, posterior view; b, superior view). The SSN has 3 sensory branches: a medial subacromial branch proximal to the suprascapular notch, a lateral subacromial branch (LSAb) at the level of the suprascapular notch, and a posterior glenohumeral branch (PGHb) distal to the spinal glenoid notch. The subacromial branches provide bipolar innovation to the subacromial bursa (in blue); the medial subacromial branch (MSAb) also innervates the coracoclavicular ligaments (conoid (*) and trapezoid (**) ligament). The PGHb provide sensory innervation to the posterior glenohumeral capsule. A, acromion; C, clavicle; Cr, coracoid process; ISp, branch to infraspinatus muscle; SSp, branch to supraspinatus muscle.  (Laumonerie P,  et al, 2019).

Suprascapular nerve block injection was first described by Wertheim and Rovenstine (1941).18 Suprascapular nerve block injections are used for people with a range of chronic shoulder disorders4,5 and interest is growing in their use as a treatment option for people with chronic shoulder pain associated with rotator cuff tears and rotator cuff arthropathy.6,11,13

Suprascapular nerve block injection can be performed land-marked or using ultrasound, computer tomography and electromyography guidance, and using local anaesthetic alone or local anaesthetic combined with steroid.1,4,5,12  The optimal method of performing suprascapular nerve block injection is unknow.

Although suprascapular nerve block injections are recommended within UK shoulder pain guidelines, 7,15 and have shown promise in small clinical trials only low-level evidence exists to support its wider use.5

Physiotherapists use of suprascapular nerve block injection

A published 2019 survey of physiotherapists use of suprascapular nerve block injection revealed that from 121 physiotherapists that considered suprascapular nerve block injections for their patients, only 8 physiotherapists actually performed the injection themselves.11

Reasons why physiotherapists did not consider suprascapular nerve block injection in their patients included uncertainty about the benefits compared to other treatments, and uncertainty about long-term effectiveness and risks.11

The reasons why so few physiotherapists performed suprascapular nerve block injection themselves from the group that did consider them in their patients included lack of support from their work place, not part of shoulder care pathways, ability to refer to other services and omission of specific training on the intervention in injection training courses.11

During the APPN Upper Limb study day in January 2020 a brief survey was conducted on physiotherapists interest in performing suprascapular nerve block injection and being involved in future research in this  area.

Although only 1 out of 120 people in the audience reported performing suprascapular nerve block injection in clinical practice, of those that completed the survey;

  • 93% (40/43) reported a desire to perform suprascapular nerve block injections
  • 67% (44/66) felt they required external additional training in order to perform them
  • 87% (46/53) reported they would be interested in being involved in future research in this area.

The future of suprascapular nerve block injection within physiotherapy practice

Suprascapular nerve block injections are recommended within UK shoulder pain guidelines, 7,15 however only low-level evidence exists to support its use.5 If suprascapular nerve bock injections are found to be effective and can be delivered safely in a timely manner by advanced practice physiotherapists this could lead to improved patient outcomes and care pathways.

A high-quality, multi-centre randomised controlled trial, delivered within physiotherapy practice, is needed to determine the effectiveness of suprascapular nerve block injection in people chronic shoulder pain.

Prior to undertaking a randomised controlled trial research is needed to define best practice in suprascapular nerve block injection and in developing a training framework for physiotherapists to perform them.

Bibliography

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Acknowledgements

Neil Smith is funded within a NHIR Pre-doctoral Clinical Academic Fellowship to undertake this research.