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Section 5.4.3

Management of Shoulder Pain

Therapeutic Goal: Maintain Pain Free Shoulder and Arm

5.4.3.1 Assessment and Prevention of Shoulder Pain

  1. The presence of pain and any exacerbating factors should be identified early and treated appropriately [Evidence Level C].
  2. Joint protection strategies include:
    1. Positioning and supporting the limb to minimize pain [Evidence Level B].
    2. Protection and support for the limb to minimize pain during functional mobility tasks using slings, pocket, or by therapist and during wheelchair use by using hemi tray or arm troughs)[Evidence Level C].
    3. Teaching patient to respect the pain. [Evidence Level C].
  3. Overhead pulleys should not be used [Evidence Level A].
  4. The shoulder should not be passively moved beyond 90 degrees of flexion and abduction unless the scapula is upwardly rotated and the humerus is laterally rotated [Evidence Level A].
  5. Educate staff and caregivers about correct handling of the hemiplegic arm [Evidence Level A].

5.4.3.2 Management of Shoulder Pain

  1. Treat Shoulder pain and limitations in range of motion through gentle stretching and mobilization techniques focusing especially on external rotation and abduction [Evidence Level B].
  2. Reduce hand edema by:
    1. Active self-range of motion exercises in conjunction with elevation [Evidence Level C] to gain full range of movement of the fingers, thumb and wrist.
    2. Retrograde massage [Evidence Level C].
    3. Gentle grade 1-2 mobilizations for accessory movements of the hand and fingers [Evidence Level C].
    4. Cold water immersion (Level B) or contrast baths [Evidence Level C].
  3. Consider using FES to increase pain free range of motion of lateral rotation of the shoulder [Evidence Level A].
  4. Consider use of acetaminophen or other analgesics for pain relief [Evidence Level C].
  5. Consider the use of botulinum toxin injections into subscapularis and pectoralis muscles for individual with hemiplegic shoulder pain [Evidence Level C].

5.4.3.3. Assessment and Management of Complex regional pain syndrome

(Also known as shoulder-hand syndrome, Reflex sympathetic Dystrophy, Sudecks atrophy)

  1. A bone scan may be used to assist diagnosis of this condition [Evidence Level C].
  2. Oral corticosteroids in tapering doses may be used to reduce swelling and pain due to this condition [Evidence Level B].
    Rationale

    The incidence of shoulder pain following a stroke is high, with as many as 72 percent of adult stroke patients reporting at least one episode of shoulder pain within the first year after stroke. Shoulder pain can delay rehabilitation and recovery of function; the pain may mask improvement of movement and function or may inhibit patient participation in rehabilitation activities such as therapy or activities of daily living.11Hemiplegic shoulder pain may contribute to poor functional recovery of the arm and hand, depression and sleeplessness. 34 Preventing shoulder pain may affect quality of life.

    System Implications

    To achieve timely and appropriate assessment and management of shoulder pain the organization requires:

    • Organized stroke care, including stroke units with a critical mass of trained staff and an interprofessional team during the rehabilitation period following stroke.
    • Initial assessment of active or passive upper extremity range of motion of shoulder, based on Chedoke-McMaster Stroke Assessment score and assessment of external rotation performed by clinicians experienced in stroke rehabilitation.
    • Timely access to specialized, interprofessional stroke rehabilitation services for the management of shoulder pain.
    • Timely access to appropriate rehabilitation therapy intensity/ treatment modalities for management or reduction of shoulder pain in stroke survivors.
    • Equipment for proper positioning of limb (pillows, troughs).
    • Long-term rehabilitation services widely available in nursing and continuing care facilities, and in outpatient and community programs.
    Performance Measures
    1. Length of stay during acute care hospitalization and inpatient rehabilitation for patients experiencing shoulder pain (as compared with patients not experiencing shoulder pain).
    2. Proportion of stroke patients who experience shoulder pain in acute care hospital, inpatient rehabilitation and following discharge into the community (NRS tool has a self report question about pain on admission/discharge)
    3. Proportion of stroke patients who report shoulder pain at three-month and six-month follow-up.
    4. Pain intensity rating change, from baseline to defined measurement periods.
    5. Motor score change, from baseline to defined measurement periods.
    6. Range of shoulder external rotation before and after treatment for shoulder pain.
    7. Proportion of patients with restricted range of motion related to shoulder pain.

    Measurement notes

    • Performance measure 4: Standardized rating scales should be used for assessment of pain levels and motor scores.
    • Some data will require survey or chart audit. The quality of documentation related to shoulder pain by healthcare professionals will affect the quality and ability to report some of these performance measures.
    • Audit tools at a local level may be helpful in collecting shoulder pain data on patients who experience shoulder pain.
    Summary of the Evidence

    The use of supportive slings and supports has been evaluated in the context of improving shoulder alignment among patients with existing shoulder subluxation. 419-421 The use of these devices has been demonstrated to reduce the amount of subluxation upon radiographic evaluation; however, neither the presence, nor resolution of pain was assessed in these studies. In a small controlled trial, the proportion of patients who wore a hemisling reported a lower incidence of pain compared with patients who did not.422 There have been two RCTS examining the use of strapping to prevent the development of shoulder pain, with conflicting results. 423, 424 The use of overhead pulleys was found to result in an increase in the development of shoulder pain compared with the control condition (passive range of motion exercises) in the single RCT examining this intervention. 425

    Ada &Foongchomcheay conducted a meta-analysis to examine the effect of electrical stimulation on shoulder subluxation following stroke.426 This review included the results from six RCTs. 427-431The authors suggested that there was evidence that early treatment following stroke, in addition to conventional therapy, helps to prevent the development of hemiplegic shoulder while later treatment helps to reduce pain. More recently, Church reported that 176 patients randomized to receive surface FES treatments for four weeks following acute stroke, in addition to conventional therapy, had similar outcomes in terms of pain and function compared to patients who received sham treatment.432Koyuncu and colleagues also reported no differences in shoulder pain of all patients during resting, passive range of motion or active range of motion following 20 sessions of surface FES in addition to inpatient rehabilitation, compared with patients who did not receive FES treatments.433

    Three different treatment approaches to aid in the reduction of hand edema following stroke have been studied, including passive motion exercises, neuromuscular stimulation and intermittent pneumatic compression. The results from two small uncontrolled trials suggest that neither passive motion exercises nor neuromuscular stimulation are effective means to reduce hand edema.434,435 Based on the results from a single RCT there is evidence that two hours of intermittent pneumatic compression for one month was no more effective than standard physical therapy as a means to decrease edema.436

    There is no definitive therapeutic intervention for complex regional pain syndrome (CRPS). Although a wide variety of preventative measures and treatments have been used including exercise, heat, contrast baths, hand desensitization programs, splints, medications, and surgical options, there is little evidence that many of the commonly-used treatments are effective. Although physiotherapy is regarded as the cornerstone of integrated treatment, no controlled trials have been conducted to evaluate its effect in preventing the development of CRPS. A single trial using historical controls evaluated the benefit of an exercise program to reduce the incidence of CRPS following stroke. 437There is some evidence that oral corticosteroids are more effective than either NSAIDS or placebo in improving symptoms of CRPS.438, 439

    For further information and references, please consult the Evidence Based Review of Stroke Rehabilitation http://www.ebrsr.com/uploads/Module_11_hemiplegic_shoulder_formatted.pdf