shoulder pain is the second most common musculoskeletal disorder in adults over their lifetime15 ) . shoulder disorders are often accompanied by acute , sub - acute , or chronic pain , and limited range of motion ( rom)14,16 ) . limited rom of the shoulder joint affects upper extremity joint function and quality of life . effective management of shoulder pain demands a multidirectional approach including medication , physical therapy , rehabilitation , surgical procedures , and selective nerve block for local pain control7,8 ) . reduction of painful protective muscle spasms and modulation of afferent input and motor control may be facilitated by suprascapular nerve blockade ( ssnb)21 ) . if the short - term effect of peripheral nerve block using local anesthetics is not sufficient , other techniques may be used for long - term pain relief . several case studies have reported a favorable outcome for pulsed radiofrequency ( prf ) neuromodulation to the suprascapular nerve ( ssn)10,18,20 ) . in this study , we present the clinical outcomes of 11 patients with chronic shoulder pain treated using prf neuromodulation . from september 2010 to april 2011 , 18 patients who had significant chronic shoulder pain for at least 6 months who were unresponsive to medication and intra - articular injections and were not considered surgical candidates were included in this study . temporary pain relief of > 50% or improvement in rom was considered a positive response to the diagnostic nerve block . the prf procedure was performed in the operating room under fluoroscopy using a neurotherm nt1000 ( neurotherm inc . , the c - arm was oblique about 10 - 20 and angled cephalo - caudad about 10 - 20. the suprascapular notch was easily identified superior to the scapular spine , medial to the coracoids process , and lateral to the rib margins . the spine of the scapula was located , and a line was drawn along it from the tip of the acromion to the medial scapular border . the midpoint of the line was determined and a vertical line parallel to the spine of the vertebral column was drawn through it . the angle of the upper outer quadrant was bisected with a line , and an x was marked on the line 1 cm from the apex of this angle ( fig . 1 ) . a disposable 22-gauge , 15-cm radiofrequency cannula ( model s-1505 , neurotherm inc . ) with a 5-mm active tip was inserted at this point perpendicular to the skin in all planes . the author confirmed the correct needle tip relative to the suprascapular notch by fluoroscopic images . the introducer needle was withdrawn and the disposable rf electrode ( model rfde-15 , neurotherm inc . ) sensory stimulation at 50 hz was performed and reproducible paresthesias in the shoulder joint occurred at a voltage 0.3 v. motor stimulation at 2 hz was performed and contractions of the infraspinatus and supraspinatus muscles occurred at 0.4 v. after positive stimulation , prf neuromodulation was performed for a total of 240 pulses at 50 v during which the temperature at the needle tip was not permitted to exceed 42. in all patients , pain was assessed prior to the diagnostic block and once per month following the prf neuromodulation procedure by the same physician who performed the initial pain and shoulder function assessments . a visual analogue scale ( vas ) ( 0 cm - no pain ; 10 cm - worst possible pain imaginable ) and the oxford shoulder score ( oss ) test13 ) were administered following the pre - diagnostic block and once a month following prf neuromodulation . the oss is a condition - specific questionnaire with pain and function questions that assesses the impact of shoulder pain on daily life during the past four weeks . mean vas and oss values for pain and shoulder function before the diagnostic block were compared with those obtained at the last follow up after prf neuromodulation using paired t - tests . from september 2010 to april 2011 , 18 patients who had significant chronic shoulder pain for at least 6 months who were unresponsive to medication and intra - articular injections and were not considered surgical candidates were included in this study . temporary pain relief of > 50% or improvement in rom was considered a positive response to the diagnostic nerve block . the prf procedure was performed in the operating room under fluoroscopy using a neurotherm nt1000 ( neurotherm inc . , the c - arm was oblique about 10 - 20 and angled cephalo - caudad about 10 - 20. the suprascapular notch was easily identified superior to the scapular spine , medial to the coracoids process , and lateral to the rib margins . the spine of the scapula was located , and a line was drawn along it from the tip of the acromion to the medial scapular border . the midpoint of the line was determined and a vertical line parallel to the spine of the vertebral column was drawn through it . the angle of the upper outer quadrant was bisected with a line , and an x was marked on the line 1 cm from the apex of this angle ( fig . 1 ) . a disposable 22-gauge , 15-cm radiofrequency cannula ( model s-1505 , neurotherm inc . ) with a 5-mm active tip was inserted at this point perpendicular to the skin in all planes . the author confirmed the correct needle tip relative to the suprascapular notch by fluoroscopic images . the introducer needle was withdrawn and the disposable rf electrode ( model rfde-15 , neurotherm inc . ) sensory stimulation at 50 hz was performed and reproducible paresthesias in the shoulder joint occurred at a voltage 0.3 v. motor stimulation at 2 hz was performed and contractions of the infraspinatus and supraspinatus muscles occurred at 0.4 v. after positive stimulation , prf neuromodulation was performed for a total of 240 pulses at 50 v during which the temperature at the needle tip was not permitted to exceed 42. in all patients , pain was assessed prior to the diagnostic block and once per month following the prf neuromodulation procedure by the same physician who performed the initial pain and shoulder function assessments . a visual analogue scale ( vas ) ( 0 cm - no pain ; 10 cm - worst possible pain imaginable ) and the oxford shoulder score ( oss ) test13 ) were administered following the pre - diagnostic block and once a month following prf neuromodulation . the oss is a condition - specific questionnaire with pain and function questions that assesses the impact of shoulder pain on daily life during the past four weeks . mean vas and oss values for pain and shoulder function before the diagnostic block were compared with those obtained at the last follow up after prf neuromodulation using paired t - tests . the study included 11 patients [ four males ( 36.4% ) and seven females ( 63.6% ) ] aged 43 to 74 years ( mean , 59 years ) . the diagnoses were rotator cuff tear in five patients ( 45.5% ) , adhesive capsulitis in four ( 36.4% ) , and rotator cuff tear with adhesive capsulitis in two patients ( 18.1% ) . the mean symptom duration was 34.6 months ( range , 6 - 72 months ) . clinical follow ups were conducted at 6 and 9 months post - prf neuromodulation ( table 1 ) . treatment outcomes following prf neuromodulation are shown in table 2 . at the 6-month follow up , all patients reported significant pain relief ( vas , 50% reduction in pain ) , and at the 9-month follow up , 10 patients ( 90.9% ) reported significant pain relief ( p<0.001 ) . at the 6- and 9-month follow ups , seven patients ( 63.6% ) reported a significant improvement in shoulder function ( oss score 40 ) . the vas and oss scores at the 6- and 9-month follow up assessments showed significant improvements in pain and function compared with the pre - diagnostic block scores ( p<0.001 ) ( table 3 ) . the mean pre - diagnostic block vas score of 6.41.49 decreased to 1.00.73 and 1.51.23 at 6 and 9 months following the prf procedure , respectively ( both p<0.001 ) . the mean pre - diagnostic block oss score was 22.78.1 and increased to 41.56.65 and 41.06.67 at the 6- and 9-month follow - up assessments , respectively ( both p<0.001 ) . the study included 11 patients [ four males ( 36.4% ) and seven females ( 63.6% ) ] aged 43 to 74 years ( mean , 59 years ) . the diagnoses were rotator cuff tear in five patients ( 45.5% ) , adhesive capsulitis in four ( 36.4% ) , and rotator cuff tear with adhesive capsulitis in two patients ( 18.1% ) . the mean symptom duration was 34.6 months ( range , 6 - 72 months ) . clinical follow ups were conducted at 6 and 9 months post - prf neuromodulation ( table 1 ) . treatment outcomes following prf neuromodulation are shown in table 2 . at the 6-month follow up , all patients reported significant pain relief ( vas , 50% reduction in pain ) , and at the 9-month follow up , 10 patients ( 90.9% ) reported significant pain relief ( p<0.001 ) . at the 6- and 9-month follow ups , seven patients ( 63.6% ) reported a significant improvement in shoulder function ( oss score 40 ) . the vas and oss scores at the 6- and 9-month follow up assessments showed significant improvements in pain and function compared with the pre - diagnostic block scores ( p<0.001 ) ( table 3 ) . the mean pre - diagnostic block vas score of 6.41.49 decreased to 1.00.73 and 1.51.23 at 6 and 9 months following the prf procedure , respectively ( both p<0.001 ) . the mean pre - diagnostic block oss score was 22.78.1 and increased to 41.56.65 and 41.06.67 at the 6- and 9-month follow - up assessments , respectively ( both p<0.001 ) . the ssn has become a target for intervention because of its extensive sensory nerve supply to the shoulder structures , including the posterior glenohumeral joint capsule , acromioclavicular joint , subacromial bursa , and coracoclavicular ligament1 ) . moreover , ssnb has a long history of reducing pain and improving rom in patients with shoulder pain including rotator cuff lesions and frozen shoulder2,4,17,21,23 ) . several studies have reported that ssnb provides significant and sustained pain relief and improvement in disability scores and rom in degenerative disease and conditions that are inflammatory in origin21 ) . however , the effects of ssnb are short term , and although pain relief may be prolonged by steroids , long - lasting pain reduction exceeding 12 weeks has not been reported6,21,23 ) . our results indicate that prf neuromodulation of the suprascapular nerve improved pain and function in patients with intractable chronic shoulder pain . of the 11 patients who underwent the procedure , these findings have important clinical implications because chronic shoulder pain is debilitating and difficult to treat . at present , the evidence is not sufficient to support or refute the efficacy of traditional shoulder pain treatments9 ) . medical treatments such as simple analgesia , non - steroidal anti - inflammatory drugs , and physical therapy , rehabilitation , intra - articular steroid injection , and surgery have limitations21 ) . rf treatment of ssn may be an alternative method of providing prolonged relief for chronic shoulder pain12 ) . conventional rf treatment destroys nerve tissue , thus preventing the propagation of pain signals and providing sustained pain relief19 ) . unlike conventional rf treatment , prf neuromodulation makes rapid changes in strong electric fields and can lead to alteration of pain signal and pain relief . moreover , temperatures do not exceed 42 during the procedure , and the target nerves and surrounding tissue are not damaged . thus , the risk of neural damage and neuritis is reduced in the prf neuromodulation procedure compared with conventional rf treatment5,11,19 ) . shah and racz20 ) described the case of a patient with severe post - traumatic pain who received repeated prf neuromodulation on the suprascapular nerve . gurbet et al.10 ) found that prf neuromodulation on the ssn of eight patients with chronic shoulder pain caused by rotator cuff tear had a beneficial effect for up to 3 months . in the present study , patients with adhesive capsulitis and/or rotator cuff tear reported a significant reduction in pain ( vas score ) and improvement in shoulder function increasing the life of quality ( oss score)13 ) lasting more than 9 months following prf neuromodulation . the results of our study suggest that prf neuromodulation of the ssn may improve chronic shoulder pain of various origins for a relatively long period . first , although the vas and oss are proven tools for the quantification of pain , they are subjective outcome measures because they may vary according to individual interpretations . our study has some limitations . first , although the vas and oss are proven tools for the quantification of pain , they are subjective outcome measures because they may vary according to individual interpretations . prf neuromodulation of the ssn markedly improved chronic shoulder pain and shoulder function for up to 9 months . prf neuromodulation technique is easily performed and is a safe treatment modality for relatively long - term pain relief from various types of chronic shoulder pain disorders .
objectivethe aim of this study was to evaluate effect of pulsed radiofrequency ( prf ) neuromodulation of suprascpaular nerve ( ssn ) in patients with chronic shoulder pain due to adhesive capsulitis and/or rotator cuff tear.methodsthe study included 11 patients suffering from chronic shoulder pain for at least 6 months who were diagnosed with adhesive capsulitis ( n=4 ) , rotator cuff tear ( n=5 ) , or adhesive capsulitis+rotator cuff tear ( n=2 ) using shoulder magnetic resonance imaging or extremity ultrasonography . 
 after a favorable response to a diagnostic suprascapular nerve block twice a week ( pain improvement > 50% ) , prf neuromodulation was performed . shoulder pain and quality of life 
 were assessed using a visual analogue scale ( vas ) and the oxford shoulder score ( oss ) before the diagnostic block and every month after prf neuromodulation over a 9-month period.resultsthe mean vas score of 11 patients before prf was 6.41.49 , and the scores at 6-month and 9 month follow - up were 1.00.73 and 1.51.23 , respectively . a significant pain reduction ( p<0.001 ) 
 was observed . 
 the mean oss score of 11 patients before prf was 22.78.1 , and the scores at 6-month and 9 month follow - up were 41.56.65 and 41.06.67 , respectively . 
 a significant oss improvement ( p<0.001 ) was observed.conclusionprf neuromodulation of the suprascapular nerve is an effective treatment for chronic shoulder pain , and the effect was sustained over a relatively long period in patients with medically intractable shoulder pain .