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NEW Delivery Of Stroke Rehabilitation to Optimize Functional Recovery
NEW Delivery Of Stroke Rehabilitation to Optimize Functional Recovery

2. Shoulder Pain and Complex Regional Pain Syndrome (CRPS) following Stroke

Note

Shoulder pain after stroke is often multifactorial and may result from stroke-related hemiplegia, spasticity, injury or acquired musculoskeletal conditions stemming from impaired joint and soft tissue integrity. Pain may be from a combination of neuropathic, nociceptive or nociplastic causes. Accurate diagnosis of etiology is crucial for optimal management. 

Refer to Section 3 for additional information on Spasticity

For these recommendations, ‘Flaccid’ is defined as the state of low muscle tone (hypotonia) with the absence of voluntary muscle movement and diminished resistance to passive stretch.

Recommendations and/or Clinical Considerations
2.1 Prevention of Hemiplegic Shoulder Pain and Subluxation
  1. Joint protection strategies should be applied during the flaccid stage of recovery to prevent or minimize shoulder pain and injury. Strategies include: 
    1. Positioning and supporting the upper extremity when the individual is at rest [Strong recommendation; Moderate quality of evidence]. 
    2. Protecting and supporting the shoulder in neutral rotation and forearm in neutral supination/pronation using a modified lap tray designed for this purpose during wheelchair use [Strong recommendation; Moderate quality of evidence]. 
  2. Overhead pulleys should not be used [Strong recommendation; Low quality of evidence].
  3. The upper extremity should not be moved passively beyond 90 degrees of shoulder flexion or abduction, unless the scapula is upwardly rotated, and the humerus is laterally rotated [Strong recommendation; Moderate quality of evidence].
  4. Healthcare staff, individuals with stroke, family and caregivers should be educated to correctly protect, position, and move the affected upper extremity [Strong recommendation; Low quality of evidence].

Section 2.1 Clinical Considerations

  1. Healthcare staff, individuals with stroke, family, and caregivers should avoid pulling on the affected upper extremity. 
  2. The affected upper extremity should be protected and supported during functional mobility such as transfers.
  3. Shoulder slings should only be considered in the flaccid stage when no other upper extremity support is possible. After the flaccid stage, use of slings should be discouraged, given they may reduce upper extremity use, inhibit arm swing, contribute to contracture formation, and decrease body image.
2.2 Assessment of Hemiplegic Shoulder Pain
  1. The assessment of the painful hemiplegic shoulder should focus on determining the cause and include evaluation of tone, active movement, changes in length of soft tissues, alignment of joints of the shoulder girdle, trunk posture, levels of pain, musculoskeletal changes in the shoulder, and impact of pain on physical and emotional health [Strong recommendation; Low quality of evidence].

Section 2.2 Clinical Considerations

  1. The diagnosis of post-stroke CRPS should be considered when typical causes of shoulder or hand pain, such as acute trauma or bony fracture have been ruled out. Clinicians should be aware of post-stroke CRPS and its clinical presentation to facilitate early diagnosis and treatment. When available, if post-stroke CRPS is suspected, referral to physiatry or other physician with experience in stroke rehabilitation or pain should be considered.
2.3 Management of Hemiplegic Shoulder Pain
  1. Treatments for hemiplegic shoulder pain related to limitations in range of motion may include gentle stretching and mobilization techniques within pain-free range and increasing external rotation and abduction [Strong recommendation; Low quality of evidence].
  2. Taping of the affected shoulder is recommended to reduce shoulder pain in the acute phase of recovery [Strong recommendation; High quality of evidence].
  3. For patients with a flaccid upper extremity, electrical stimulation should be considered [Strong recommendation; Moderate quality of evidence]. 
  4. The use of shoulder orthoses may be considered to reduce shoulder subluxation in the flaccid stage [Strong recommendation; Moderate quality of evidence].
  5. If there are no contraindications, non-steroidal anti-inflammatory (NSAID) analgesics (oral or topical) could be considered for pain relief on an individual basis [Conditional recommendation; Low quality of evidence].
  6. Chemo-denervation botulinum toxin is recommended for the treatment of hemiplegic shoulder pain thought to be related to spasticity [Strong recommendation; High quality of evidence].
  7. Subacromial corticosteroid injections may be used in patients when pain is thought to be related to injury or inflammation of the subacromial region (rotator cuff or bursa) in the hemiplegic shoulder [Conditional recommendation; Moderate quality of evidence]. 
  8. Acupuncture should be considered, in addition to conventional rehabilitation, in the treatment of hemiplegic shoulder pain [Conditional recommendation; High quality of evidence].
  9. Extracorporeal shock wave therapy (ESWT) may be considered in the treatment of hemiplegic shoulder pain [Strong recommendation; Moderate quality of evidence].

Section 2.3 Clinical Considerations

  1. Active range of motion should be increased gradually in conjunction with restoring alignment and strengthening weak muscles in the shoulder girdle.

Note: For additional information on pain management, refer to Section 9 on Central Pain.

2.4 Hand Edema

Recommendations

Note, no evidence-based recommendations are included for this section.

Section 2.4 Clinical Considerations

  1. For Individuals with stroke who experience hand edema, the following have been shown to have some benefit:
    1. Active, active-assisted, or passive range of motion exercises.
    2. Elevating the arm when at rest if possible.
    3. Retrograde massage.
    4. Gentle joint mobilization for the hand and fingers.
    5. Compression, including use of compression garments with appropriate monitoring by health professionals with expertise in use and fit.
2.5 Complex Regional Pain Syndrome (CRPS) Management
  1. Early assessment by a physiatrist or other physician with expertise in management in stroke for consideration of an early course of oral corticosteroids, on a tapering regimen, should be considered to reduce swelling and pain among patients with no contraindications [Early – Strong Recommendation; High quality of evidence].
  2. Acupuncture may be considered as an adjunct therapy to reduce pain in individuals with CRPS [Conditional recommendation; Moderate quality of evidence]. 
  3. Extracorporeal shock wave therapy (ESWT) may be considered as an adjunct therapy to reduce pain in individuals with CRPS [Strong recommendation; High quality of evidence].

Section 2.5 Clinical Considerations

  1. Clinicians should be aware of CRPS and its clinical presentation to facilitate early diagnosis and treatment. When CRPS is suspected, early assessment by a physiatrist or other physician with expertise in stroke is essential for consideration of treatment with oral corticosteroids. Diagnosis of CRPS clinical and is based on the presence of pain accompanied by other supportive sensory, vasomotor, pseudomotor/edema and motor/trophic signs and symptoms, as detailed in the revised International Association for the Study of Pain (IASP) (or Budapest) criteria. This includes hyperalgesia/allodynia, temperature asymmetry, skin color changes or asymmetry, edema, sweating changes or asymmetry, decreased range of motion, motor dysfunction, and trophic (hair, nail, skin) change. 
  2. There is currently no established protocol for corticosteroids.  A reasonable early course of corticosteroids could include starting at 30 – 50 mg daily of 3-5 days and then tapering doses over 2-3 weeks.
Rationale +-

The incidence of shoulder pain following stroke varies widely from 22% to 47%. 61 Typically developing within two weeks to two months post-stroke, shoulder pain can inhibit participation in rehabilitation activities, and contribute to poor functional recovery, longer hospital stays, reduced limb movement, depression, sleeplessness, and reduced quality of life. Shoulder pain results from muscle weakness, spasticity, and the positioning of the arm during recovery.

Individuals with stroke express that it can be difficult to perceive pain, fatigue and other sensations on the affected side following stroke. Individuals with stroke advocate for access to rehabilitation services for shoulder pain and Complex Regional Pain Syndrome across the continuum of stroke recovery. They highlight the importance of receiving education on upper extremity positioning, appropriate use of the affected arm (including how much to use arm, when to rest, and signs of fatigue) and how to safely return to ADL and leisure activities.

Performance Measures +-

System Indicators

  1. Access to stroke rehabilitation services 7 days per week for inpatient care.
  2. Proportion of individuals within a stroke region who access an inpatient and community-based stroke rehabilitation as part of their episode of care for a stroke event.

Process Indicators

  1. Proportion of individuals with stroke 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).
  2. Length of stay during acute care hospitalization and inpatient rehabilitation for individuals with stroke experiencing shoulder pain (versus individuals with stroke not experiencing shoulder pain).

Patient-Oriented Indicators 

  1. Proportion of individuals with stroke with restricted range of motion related to shoulder pain. 
  2. Proportion of individuals with stroke who report shoulder pain at three-month and six-month follow-up. 
  3. Pain intensity rating change, from baseline to defined measurement periods.
  4. Motor score change, from baseline to defined measurement periods.
  5. Range of shoulder external rotation before and after treatment for shoulder pain.
Implementation Resources and Knowledge Transfer Tools +-

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices team or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Health Care Provider Information

Resources for Individuals with Stroke, Families and Caregivers 

Summary of the Evidence +-

Evidence Table and Reference List 2

Hemiplegic Shoulder Pain

The use of supportive slings, supports and other modalities may help to prevent and reduce the risk of subluxation and hemiplegic shoulder pain. Ada et al. 62 randomized 46 persons who were at risk of developing shoulder subluxation following a recent stroke to use a modified lap-tray while sitting and a triangular sling while standing to support the affected arm for four weeks, while those in a control group used a hemi-sling while sitting and standing. At the end of the treatment period there were no significant difference between groups in terms of shoulder subluxation (mean difference [MD] -3 mm, 95% CI -8 to 3), pain at rest (MD -0.7 out of 10, 95% CI -2.2 to 0.8), shoulder external rotation (MD -1.7 out of 10, 95% CI -3.7 to 0.3) or having less contracture of shoulder external rotation (MD -10 deg, 95% CI -22 to 2). Pan et al. 63 randomized 120 inpatients recruited from a rehabilitation hospital with upper extremity dysfunction, an average of two months post stroke, with/without shoulder pain to receive modified wheelchair arm-support used for at least 60 minutes a day, for 4 weeks, or passive rehabilitation exercises. Among patients without shoulder pain at baseline, a significantly lower percentage of those in the intervention group developed shoulder pain at the end of follow-up (1/25 vs. 6/20, p=0.034). Among all patients, at 12 weeks, there was significantly greater improvement in median pain scores, modified Barthel Index and Quality of Life Index scores in the intervention group.

Several systematic reviews have been published on the topic of hemiplegic shoulder pain. Deng et al.64 included the results of 9 RCT of 424 persons with shoulder pain following stroke to examine the potential benefit of kinesio taping in addition to conventional therapy. Kinesio taping was associated with a significant reduction in pain (MD = -1.45, 95% CI -1.98 to-0.92 cm), shoulder subluxation (SMD= -0.65, 95% CI −0.95 to −0.35), and a significant improvement in motor function (MD=4.22, 95% CI 3.49 to 4.95) and performance of ADLs (MD = 6.86, 95% CI 3.99 to 9.73). In a systematic review that evaluated the use of strapping, 65 pooling of results was possible for only a single outcome. Strapping was not associated with significant improvement in upper extremity component of the Motor Assessment Scale (MD=0.87, 95% CI -0.7 to 1.81). The results for the other outcomes (pain, subluxation, range of movement) including results from individual trials were mixed, with some studies reporting a benefit, while others did not. The authors concluded the efficacy of shoulder strapping to alleviate upper extremity dysfunction and shoulder impairments caused by stroke remains unknown, while acknowledging that shoulder strapping may delay the onset of pain in those with severe weakness or paralysis. Therapies to prevent the risk of developing a painful hemiplegic shoulder in the acute stage of stroke, were explored by Ada et al. 66 in a Cochrane review that included the results from 4 RCTs including 142 participants with a flaccid arm with no history of shoulder pain. Treatments included shoulder strapping (n=3) and hemisling (n=1) to reduce upper extremity and shoulder impairments and dysfunction, compared with no strapping or sling. The duration of treatment ranged from 5 days to 6 weeks. Shoulder strapping significantly delayed the onset of shoulder pain by a mean of 13.6 days (95% CI 9.7 to 17.8), compared with no strapping, with no difference between groups in improvement of motor function or prevention of contracture.

Electrical stimulation can be used for the prevention and management of shoulder subluxation. A systematic review 67 examined the use of a variety of techniques including transcutaneous electrical nerve stimulation (TENS), percutaneous nerve stimulation, functional electrical stimulation (FES), and electric acupuncture for the treatment of hemiplegic shoulder. The results from 6 RCTs were included. Compared with electrical stimulation +/- sham treatment, other active treatments and conventional treatment, overall electrical stimulation was associated with a significant reduction in pain following treatment (SMD= -1.89, 95% CI -3.05 to -0.74), significant improvement in pain-free external rotation (WMD=18.9 degrees, 95% CI 7.00-30.8) and improvement in ADL, assessed using the Barthel Index (WMD=8.96, 95% CI 5.26-12.66).  Lee et al. 68 included the results of 11 trials evaluating the effectiveness of NMES for the management of shoulder subluxation in both the acute and chronic stages of stroke. NMES was effective in reducing subluxation in the acute stage of stroke (SMD= -1.1, 95% CI -1.53 to -0.68, p<0.001) but not in the chronic stage (SMD= -1.25, 95% CI -1.61 to 0.11, p=0.07) but did not significantly reduce pain in either the acute or chronic stages. Vafadar et al.20 included 10 trials evaluating the evidence for the effect of FES on shoulder subluxation, pain and upper extremity motor function when added to conventional therapy. Pooling data from 6 trials showed that electrical stimulation was more effective than the conventional therapy alone in improving shoulder subluxation, when applied within the first 6 months of stroke (SMD= −0.70, 95% CI −0.98 to −0.42). Only data from two trials were available for the effect of electrical stimulation when applied 6 months after stroke. Ada & Foongchomcheay 66 included participants with subluxation or shoulder muscle paralysis in both the acute and chronic stages of stroke, from seven RCTs. The results suggested that early treatment, starting with electrical stimulation for 2 hours per day increasing to between 4 and 6 hours per day, in addition to conventional therapy helps to prevent the development of hemiplegic shoulder while later treatment helps to reduce pain. In one of the largest RCTs, Church et al. 69 randomized 176 patients to receive active or sham surface NMES treatments in addition to conventional therapy, for four weeks following acute stroke. There was no significant difference between groups in measures of upper extremity function, or the prevalence of pain post intervention, at 3 months.

Treatment with botulinum toxin type a (BTX-A) may help to improve hemiplegic shoulder pain. A Cochrane review, 70 which included the results of 6 RCTs examined the efficacy of the use of BTX-A in the treatment of shoulder pain. Treatment with BTX-A was associated with reductions in pain at 3 and 6 months, but not at 1 month following injection.  De Boer et al. 71 randomized 22 patients, an average of 6 months following stroke with significant shoulder pain to receive a single injection of 100 U Botox or placebo to the subscapularis muscle in addition to some form of physical therapy. While pain scores improved in both groups over time, there was no significant difference at 12 weeks following treatment, nor was there significant improvement between groups in degree of humeral external rotation.  In a more recent RCT, Tan et al. 72 randomized 36 patients with spastic hemiparesis due to a stroke occurring ≥2 months previously to receive either ultrasound-guided BTX-A (100 U) or 2.0-mL saline (placebo). At the end of 4 weeks the mean pain score had improved in both groups, but the change from baseline was significantly greater in the BTX-A group (7.1 to 2.8 vs. 7.3 to 4.2, mean change= −1.39, 95% CI −2.41 to −0.36), while at week 24, there was no longer a significant difference between groups. At 4 weeks, there was significantly greater improvement in the BTX-A group in mean Fugl Meyer Assessment (FMA) change scores from baseline.

Intra-articular corticosteroids injections may also help to improve symptoms of shoulder pain. Rah et al. 73 randomized 58 patients with chronic shoulder pain (at least 3/10 on a Visual Analog Scale [VAS]) to receive a single subacromial injection of 40 mg triamcinolone acetonide or lidocaine (control condition), in addition to a standardized exercise program. There was significantly greater reduction in the average shoulder pain level, both and night, at 8 weeks associated with steroid injection. In contrast, Snels et al. 74 reported that in 37 patients with hemiplegic shoulder pain (≥ 4, VAS 0 to 10) randomized to receive three injections (1-2 weeks apart) of 40 mg triamcinolone acetonide or placebo, active treatment was not associated with improvements in pain scores three weeks later. 

Acupuncture can be beneficial for patients with hemiplegic shoulder pain, improving both pain levels and functional outcomes, although it is generally considered a complementary therapy. Typically, it is combined with other rehabilitation strategies. For example, a systematic review by Zhan et al. 75 included the results of 40 RCTs of persons with hemiplegic shoulder pain following stroke. Trials compared many different types of acupuncture + rehabilitation therapies vs. therapy only, provided for 5 to 60 sessions, over 7 days to 4 months. Acupuncture + therapy was associated with a significantly greater reduction in pain scores (MD= −1.32, 95% CI −1.58 to −1.07), significantly greater improvement in motor function, assessed using the FMA (MD=6.81, 95% CI 4.95 to 8.67), and ADL performance (MD=11.17, 95% CI 9.44 to 2.91).

Extracorporeal shock wave therapy (ESWT) has been suggested as a non-invasive and alternative treatment for shoulder pain. Zhang & Zhang 76 reported that ESWT was associated with a significant reduction in pain scores (MD= − 1.19, 95% CI − 1.43 to − 0.95) and improvement in motor function (MD = 6.25, 95% CI 4.64 to 7.87) in a systematic review including 18 RCT of 1,248 participants with shoulder pain following stroke, or with shoulder hand syndrome. Trials compared ESWT +/- cointerventions vs. conventional rehabilitation +/- other modalities. The duration of the intervention ranged from 14 to 30 days.

Topical non-steroidal anti-inflammatory ointments may also be helpful for relief of shoulder pain. 77

Hand Edema

For patients with hand edema, results from a systematic review suggest that mobilization exercises (i.e. range of motion exercises) may be effective in reducing hand edema in patients with acute stroke. 78 Bandaging, intermittent compression, kinesio tape, neutral functional realignment orthosis, and hand realignment orthosis were not found to be effective treatments.

Complex Regional Pain Syndrome (CRPS)

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. A Cochrane overview of reviews conducted by O’Connell et al. 79 evaluated 19 studies that used a variety of interventions to treat pain and/or disability associated with CRPS. The authors found moderate quality evidence that intravenous regional blockade with guanethidine was not effective in treating CRPS and is associated with adverse events, and low-quality evidence for biphosphates, calcitonin or daily IV of ketamine for the treatment of pain compared to a placebo. Both motor imagery and mirror therapy may be effective for the treatment of pain compared to a control condition. There was low-quality evidence that local anaesthetic sympathetic blockade, physiotherapy, and occupational therapy are not effective for CRPS. Acupuncture has been shown to reduce pain, improve motor performance and improve performance of ADLs when added to conventional therapy.80, 81

Sex & Gender Considerations

The research on sex and gender differences related to the frequencies of shoulder pain and CRPS is limited. No studies were reviewed that addressed incidence, prevalence or response to treatment of these conditions. 

Stroke Resources
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