13/04/2023

PREVENTION AND PHYSIOTHERAPY MANAGEMENT OF HEMIPLEGIC

SHOULDER PAIN (HSP)

BY

ADEAGBO, CALEB ADEWUMIPhysiotherapist

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Outline• Introduction• Definition • Epidemiology• Functional anatomy of the shoulder and

changes following a stroke• Causes• Pathophysiology• Clinical presentation and findings• Prevention and Management• Conclusion• References

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Introduction

• Hemiplegic shoulder pain (HSP) is

among the four most common, yet

preventable, medical complications

that stroke survivors may experience (Rajaratnam et al, 2007; Zhu et al, 2013; Suriya-

amarit et al, 2014).

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Introduction cont

• HSP can occur in the 2nd week after stroke

and it is independent of age and gender (Vuagnat and Chantraine, 2003; Ward, 2007; Bello and Amedzo,

2009).

• Despite the high incidence of HSP, the

literature is full of conflicting reports about

the epidemiology, risk factors, and

management (Lindgren et al, 2007; Dromerick et al, 2008).4

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Introduction cont

• HSP prolongs rehabilitation of affected

limb and hospital stay thereby affecting

ADL, decreases the QoL and it has

been implicated with withdrawal from

participation in rehabilitation process (Griffin and Bernhardt, 2006; Allen et al, 2010; Suriya-amarit et al,

2014).

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Introduction cont

• Therefore prevention and

management of HSP is obviously

important to recovery and well-being

of stroke survivors (Snels et al, 2000; Tyson and

Chissim, 2002; Suriya-amarit et al, 2014).

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Definition

• HSP is a shoulder pain that is present

at rest, during passive or active

movement on the hemiplegic side

after stroke with no direct relation to

trauma or injury (Kim et al, 2014).

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Definition cont

• HPC is also known as:

Hemiplegic Shoulder Pain Syndrome

(HSPS)

Post Stroke Shoulder Pain (PSSP)

Shoulder Pain in Hemiplegia

Shoulder Pain after Stroke

Painful Hemiplegic Shoulder (PHS)

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Epidemiology

• Reports of prevalence of HSP in the literature

vary between 5% and 84% in stroke survival

population (Walsh, 2001; Gustafsson and McKenna, 2006; Griffin

and Bernhardt, 2006). There are a number of reasons

for this variation such as different study

methods, location of the stroke and pain

reaction (Snels et al, 2002; Teasell et al, 2003; Klit et al, 2011; de

Oliveira et al, 2012). 9

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Epidemiology cont

• A prevalence study carried out in Nigeria

by Fabunmi et al, (2014) revealed that 75

(73.5%) of 102 stroke survivors had HSP,

36.3% and 37.3% patients had pain on

left and right shoulders respectively, pain

onset showed that 33.3% developed pain

within first week post stroke.10

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Functional anatomy of the shoulder and changes following a stroke

• An understanding of the normal

functional anatomy of the shoulder

and how it is affected by loss of

motor control following stroke may

inform the prevention and

management of shoulder pain (Smith,

2012). 11

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Functional anatomy of the shoulder and changes following a stroke cont

• The shoulder is formed by a complex

system of articulations:

Glenohumeral joint (GHJ)

Acromioclavicular joint (ACJ)

Sternoclavicular joint (SCJ)

Rotation of the scapula on the thoracic

wall (fig 1)12

Figure 1: the anatomical diagram of the shoulder complex (Smith, 2012).

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Functional anatomy of the shoulder and changes following a stroke cont

• Immediately following stroke there is

an initial flaccid paralysis in over

90% of individuals which is often

replaced by a predictable pattern of

spasticity (Gillen 2011; Kim, 2012, Gould and Barnes,

2013).

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Functional anatomy of the shoulder and changes following a stroke cont

• Alteration in the alignment of skeletal

components of the shoulder complex

can be described in both the flaccid

and spastic stages of paralysis after

stroke and each has been implicated

in the causation of HSP (Turner-Stokes and

Jackson, 2002).15

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Causes

• The causes of HSP are uncertain but it is

associated with upper limb weakness,

abnormal muscle tone, glenohumeral

subluxation, limited shoulder external

rotation ROM, sensory inattention, sensory

impairment, complex regional pain syndrome

(CRPS) and prior shoulder pathology (Tyson and

Chissim, 2002; Chae, 2007; Dromerick et al, 2008; Joy et al, 2012).

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Causes cont• Several clinical diagnoses have been

proposed as causes of HSP, these

including rotator cuff tendonitis,

subacromial bursitis, bicipital

tendonitis, adhesive capsulitis, brachial

neuralgias, sympathetically mediated

pain, and referred pain (Lo et al, 2003, Chae et

al, 2007). 17

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Pathophysiology

• Because of the wide array of

pathologies potentially underlying the

development of HSP, the precise

aetiology is difficult to assess (Maxwell and

Nguyen, 2013). It is impossible to treat HSP

effectively without first understanding

the mechanism of the complication.

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Pathophysiology cont• Three specific types of possible

pathological processes that can cause

HSP are:

Soft tissue lesions

Impaired motor control (specifically muscle

tone changes)

Altered peripheral and central nervous

system activity19

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Clinical presentation and findings

• Common symptoms by patients with

HSP include the following:

Pain with or without movement of the

hemiplegic shoulder

Reduced mobility of the hemiplegic

shoulder

Tenderness around the hemiplegic shoulder

Swelling/oedema 20

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Clinical presentation and findings cont

• The physical examination of a patient with

HSP is extensive because there is need to

assess the involved musculoskeletal and

neurologic conditions. It should include

observation, palpation, musculoskeletal

and neurologic examination.

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HSP outcome measures

Faces Pain Scale

Verbal Rating Scales (VRS)

Numeric Rating Scales (NRS)

Visual Analogue Scale (VAS)

Physiotherapist graded (VAS)

Ritchie Articular Index (for shoulder pain)

ShoulderQ (for shoulder pain)

Graded Chronic Pain Disability Score

Shoulder lateral rotation ROM to the point of

pain (SROMP)

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Prevention and Management

• Poor handling and positioning of the

affected upper limb in stroke patients

contribute toward shoulder pain (Walsh, 2001).

The mobility of the recovering stroke

patient is dependent on the assistance of

physiotherapists, nurses, doctors, family

members and patient’s own efforts.23

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Prevention and Management cont

• The ideal management of HSP is to

prevent it from happening in the first

place. Various strategies have been

employed in the prophylaxis of HSP.

For effective prophylaxis, it must be

begin immediately after stroke (Snels et

al, 2000; Tyson and Chissim, 2002; Griffin and Bernhardt,

2006). 24

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Handling of the hemiplegic upper limb

• Good handing technique of the

hemiplegic upper extremity day and

night is recommended to prevent HSP

because it prevent trauma to soft

tissues. It is recommended that support

is provided both proximally and distally

to the upper extremity (Smith, 2012).

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Positioning hemiplegic shoulder

• Maintaining the upper limb in the

correct position is fundamental to

preventing and managing HSP. The

recommended position for the affected

upper limb is abduction, external

rotation and with the shoulder slightly

flexed (Smith, 2012).26

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Positioning hemiplegic shoulder cont

• Positioning of the hemiplegic

shoulder in different positions

Side lying on hemiplegic side (fig 2).

Side lying on unaffected side (fig 2).

Lying on back (fig 3).

Sitting in bed (fig 3).

Sitting up (fig 4).27

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Figure 2: Side lying in hemiplegic patient (Smith, 2012).

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Figure 3: Lying on back and sitting in bed in hemiplegic patient (Smith, 2012).

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Figure 4: sitting on a chair in hemiplegic patient (Smith, 2012).

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Slings and other devices

• Use of slings is controversial because

they hold the arm in a flexed

position, inhibit shoulder movement.

However, slings are considered to be

the best devices for supporting the

paretic limb (fig 5; fig 6) (Ada et al, 2005)

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Figure 5: shoulder slings (Orthocare, 2009).32

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Figure 6: functional shoulder sling (Neuro-Lux) and X-ray of the shoulder without and with the functional shoulder sling (Neuro-Lux) (Hartwig et al, 2012).

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Strapping the hemiplegic shoulder

• Strapping of the hemiplegic shoulder

is used as a method for preventing or

reducing shoulder subluxation and

may provide a certain level of

sensory stimulation. (Hanger et al, 2000).

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Physiotherapy management

Electrophysical/electrotherapy agents

Electrical neuromuscular stimulation

Cryotherapy

Soft tissue manipulation (massage

using analgesic lubricant)

Therapeutic exercises:35

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Drug treatment

• Analgesic, anti-inflammatory, and

antispastic drugs have all been used

to treat HSP. Simple analgesics and

nonsteroidal anti-inflammatory drugs

should be tried first. Antispasmodic

medication may be helpful in

spasticity of cerebral origin. 36

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Conclusion• HSP should be viewed as a largely

preventable complication of stroke and

it is the responsibility of all members

rehabilitating and taking care of the

patient to ensure they handle

vulnerable upper limb with care during

positioning, transferring and assisting

in ADL. 37

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References• Ada L, Foongchomcheay A, Canning CG (2005). Supportive devices for preventing and

treating subluxation of the shoulder after stroke. Stroke 36: 1818-1819 

• Allen ZA, Shanahan EM, Crotty M (2010). Does suprascapular nerve block reduce shoulder pain following stroke: a double-blind randomized controlled trial with masked outcome assessment. BioMedCentral Neurology 10(83): 1-5

• Bello AI, Amedzo MY (2009). Relative Effectiveness of Transcutaneous Electrical Nerve Stimulation and Hot Packs in the Management of Hemiplegic Shoulder Pain. Journal of the Nigeria Society of Physiotherapy 17: 1-6

• Chae J, Mascarenhas D, Yu DT, Kirsteins A, Elovic EP, Flanagan SR, Harvey RL, Zorowitz RD, Fang Z (2007). Poststroke Shoulder Pain: Its Relationship to Motor Impairment, Activity Limitation, and Quality of Life. Archives of Physical Medicine and Rehabilitation 88: 298-301

• de Oliveira RA, de Andrade DC, Machado AG, Teixeira MJ (2012). Central post stroke pain: somatosensory abnormalities and the presence of associated myofascial pain syndrome. BioMedCentral Neurology 12: 89.

•

• Dromerick AW, Edwards DF, Kumar A (2008). Hemiplegic Shoulder Pain Syndrome: Frequency and Characteristics during Inpatient Stroke Rehabilitation Archives of Physical Medicine and Rehabilitation 89: 1589-1593.

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References cont• Fabunmi A, Awolola E, Fowodu O, Amusat S (2014). Shoulder pain among stroke

survivors: prevalence and pattern. The Journal of Pain 15(4): 37  • Gillen G (2011). Cerebrovascular accident/stroke. In Pendleton HM, Schultz-Krohn W

Pedretti’s Occupational Therapy Practice Skills for Physical Dysfunction. Seventh edition. Page 844-880 Elsevier Mosby, St Louis MO.

 • Gould R, Barnes SS (2013).Shoulder Pain in Hemiplegia. Available @

http://emedicine.medscape.com/article/328793-overview Retrieved on October 07, 2014

• Griffin A, Bernhardt J (2006). Strapping the hemiplegic shoulder prevents development of pain during rehabilitation: a randomized controlled trial Clinical Rehabilitation 20: 287-295

• Gustafsson L, McKenna K (2006). A programme of static positional stretches does not reduce hemiplegic shoulder pain or maintain shoulder range of motion - a randomized controlled trial Clinical Rehabilitation 20: 277-286

• Hanger HC, Whitewood P, Brown G, Ball MC, Harper J, Cox R, Sainsbury R (2000). A randomized controlled trial of strapping to prevent poststroke shoulder pain. Clinical Rehabilitation 14: 370-380.

• Hartwig M, Gelbrich G, Griewing B (2012). Functional orthosis in shoulder joint subluxation after ischaemic brain stroke to avoid post-hemiplegic shoulder–hand syndrome: a randomized clinical trial. Clinical Rehabilitation 26(9): 807-816

• Joy AK, Ozukum I, Nilachandra L, Khelendro T, Nandabir Y, Kunjabasi W (2012). Prevalence of Hemiplegic Shoulder Pain in Post-stroke Patients – A Hospital Based Study. Indian Journal of Physical Medicine and Rehabilitation 23(1): 15-19

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References cont• Kim CT (2012). Stroke Rehabilitation. Available @

http://www.intechopen.com/books/rehabilitation-medicine/stroke-rehabilitation Retrieved on October 07, 2014

• Kim YH, Jung SJ, Yang EJ, Paik NJ (2014). Clinical and Sonographic Risk Factors for Hemiplegic Shoulder Pain: A Longitudinal Observational Study. Journal of Rehabilitation Medicine 46: 81–87

• Klit H, Finnerup NB, Overvad K, Andersen G, Jensen TS (2011). Pain following stroke: a population-based follow-up study.  Public Library of Science (PLOS) One 6(11): 27607.

• Lindgren I, Jönsson A, Norrving B, Lindgren A (2007). Shoulder Pain after Stroke: A Prospective Population-Based Study. Stroke 38: 343-348

• Lo SF, Chen SY, Lin HC, Jim YF, Meng NH, Kao MJ (2003). Arthrographic and clinical findings in patients with hemiplegic shoulder pain. Archives of Physical Medicine and Rehabilitation 84: 1786-1791.

• Maxwell AMW, Nguyen VQC (2013). Management of Hemiplegic Shoulder Pain. Current Physical and Medical Rehabilitation Reports 1: 1–8

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References cont• Orthocare (2009). Arm Slings. Available @

http://www.orthocare.com.au/products.asp?category=342 Retrieved on October 11, 2014

• Rajaratnam BS, Venketasubramanian N, Kumar PV, Goh JC, Chan YH (2007). Predictability of Simple Clinical Tests to Identify Shoulder Pain after Stroke. Archives of Physical Medicine and Rehabilitation 88: 1016-1021.

• Smith M (2012). Management of hemiplegic shoulder pain following stroke. Nursing Standard 26(44): 35-44.

 • Snels IA, Dekker JH, van der Lee JH, Lankhorst GJ, Beckerman H, Bouter LM (2002).

Treating patients with hemiplegic shoulder pain. American Journal of Physical Medicine and Rehabilitation 81(2): 150-160

 • Snels IAK, Beckerman H, Lankhorst GJ (2000). Treatment of hemiplegic shoulder pain in

the Netherlands: results of a national survey Clinical Rehabilitation 14: 20–27 • Suriya-amarit D, Gaogasigam C, Siriphorn A, Boonyong S (2014). Effect of Interferential

Current Stimulation in Management of Hemiplegic Shoulder Pain. Archives of Physical Medicine and Rehabilitation 95: 1441-1446

 • Teasell RW, Foley NC, Bhogal SK, Speechley MR (2003). An evidence- based review of stroke

rehabilitation. Topics in Stroke Rehabilitation 10(1): 29-58.

 

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References cont• Turner-Stokes L, Jackson D (2002). Shoulder pain after stroke: a review

of the evidence base to inform the development of an integrated care pathway. Clinical Rehabilitation 16: 276–298

• Tyson SF, Chissim C (2002). The immediate effect of handling technique on range of movement in the hemiplegic shoulder Clinical Rehabilitation 16: 137–140

 • Vuagnat H, Chantraine A (2003). Shoulder pain in hemiplegia revisited:

contribution of Functional Electrical Stimulation and other therapies Journal of Rehabilitation Medicine 35: 49–56

 • Walsh K (2001). Management of shoulder pain in patients with stroke.

Postgraduate Medical Journal 77: 645–649 • Ward AB (2007). Hemiplegic shoulder pain. Journal of Neurology,

Neurosurgery and Psychiatric 78:789. • Zhu Y, Su B, Li N, Jin HZ (2013). Pain management of hemiplegic

shoulder pain post stroke in patients from Nanjing, China. Neural Regeneration Research 8(25): 2389-2398.

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Thank You for

listening