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Rehabilitation and Recovery following Stroke

5.3. Management of Shoulder Pain & Complex Regional Pain Syndrome (CRPS) following Stroke

6th Edition - 2019 UPDATED


Recommendations

Definition: For the purposes of these recommendations ‘early’ refers to strength of evidence for therapies applicable to patients who are less than 6 months post stroke, and ‘late’ refers to strength of evidence for therapies applicable to patients who are more than 6 months from index stroke event.

Note: Causes of shoulder pain may be due to the hemiplegia itself, injury or acquired orthopedic conditions due to compromised joint and soft tissue integrity and spasticity.

A. Prevention of Hemiplegic Shoulder Pain and Subluxation

  1. Joint protection strategies should be applied during the early or flaccid stage of recovery to prevent or minimize shoulder pain and injury. These include:
    1. Positioning and supporting the arm during rest [Evidence Level B].
    2. Protecting and supporting the arm during functional mobility; avoid pulling on the affected arm [Evidence Level C].
    3. Protecting and supporting the arm during wheelchair use; examples include using a hemi-tray, arm trough, or pillow [Evidence Level C].
    4. The use of slings should be discouraged with the exception of the flaccid stage given it may discourage arm use, inhibit arm swing, contribute to contracture formation, and decrease body image [Evidence Level C].
  2. For patients with a flaccid arm (i.e., Chedoke-McMaster Stroke Assessment Impairment Inventory <3) electrical stimulation should be considered [Evidence Levels: Early- Level B; Late- Level B].
  3. Overhead pulleys should not be used [Evidence Level A].
  4. The arm 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 [Evidence Level B].
  5. Healthcare staff, patients and family should be educated to correctly protect, position, and handle the involved arm [Evidence Level A].
    1. For example, careful positioning and supporting the arm during assisted moves such as transfers; avoid pulling on the affected arm [Evidence level C].

B. Assessment of Hemiplegic Shoulder Pain

  1. The assessment of the painful hemiplegic shoulder could include evaluation of tone, active movement, changes in length of soft tissues, alignment of joints of the shoulder girdle, trunk posture, levels of pain, orthopedic changes in the shoulder, and impact of pain on physical and emotional health [Evidence Level C].

C. 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, and typically involves increasing external rotation and abduction. [Evidence Level B].
    1. Active range of motion should be increased gradually in conjunction with restoring alignment and strengthening weak muscles in the shoulder girdle [Evidence Level B].
  2. Taping of the affected shoulder has been shown to reduce pain [Evidence Level A].
  3. If there are no contraindications, analgesics (such as ibuprofen or narcotics ) can be considered for pain relief on an individual case basis [Evidence Level C].
  4. Injections of botulinum toxin into the subscapularis and pectoralis muscles could be used to treat hemiplegic shoulder pain thought to be related to spasticity [Evidence Level B].
  5. Subacromial corticosteroid injections can 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 [Evidence level B].

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

D. Hand Edema

  1. For patients with hand edema, the following interventions may be considered:
    1. Active, active-assisted, or passive range of motion exercises [Evidence Level C].
    2. When at rest the arm should be elevated if possible [Evidence level C].
    3. Retrograde massage [Evidence Level C].
    4. Gentle grade 1-2 mobilizations for accessory movements of the hand and fingers [Evidence Level C].
  2. There is insufficient evidence for or against compression garments, e.g. compression gloves [Evidence Level C].

E. Complex Regional Pain Syndrome (CRPS) (Also known as Shoulder-Hand Syndrome or Reflex Sympathetic Dystrophy)

  1. Prevention:  Active, active-assisted, or passive range of motion exercises can be used to prevent CRPS [Evidence Level C].
  2. Diagnosis should be based on clinical findings including pain and tenderness of metacarpophalangeal and proximal interphalangeal joints and can be associated with edema over the dorsum of the fingers, trophic skin changes, hyperaesthesia, and limited range of motion [Evidence Level C].
  3. A triple phase bone scan (which demonstrates increased periarticular uptake in distal upper extremity joints) can be used to assist in diagnosis. [Evidence Level C].
  4. Management: An early course of oral corticosteroids, starting at 30 – 50 mg daily for 3 - 5 days, and then tapering doses over 1 – 2 weeks can be used to reduce swelling and pain [Evidence Level B].
Rationale +-

The incidence of shoulder pain following a stroke is high. As many as 72 percent of adult stroke patients report at least one episode of shoulder pain within the first year after stroke. Shoulder pain may inhibit patient participation in rehabilitation activities, contribute to poor functional recovery and can also mask improvement of movement and function. Hemiplegic shoulder pain may contribute to depression and sleeplessness and reduce quality of life.

System Implications +-

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

  • Organized stroke care, including stroke rehabilitation units with a critical mass of trained interdisciplinary staff during the rehabilitation period following stroke.
  •  Equipment for proper limb positioning (e.g. pillows, arm troughs).

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

  • 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, interdisciplinary 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.
  • Long-term rehabilitation services in nursing and continuing care facilities, and in outpatient and community programs.
  • Physicians trained in stroke care and, where needed, intra-articular shoulder injections and botulinum toxin injections.

 

  • The development and implementation of an equitable and universal pharmacare program, implemented in partnership with the provinces, designed to improve access to cost-effective medicines for all people in Canada regardless of geography, age, or ability to pay. This program should include a robust common formulary for which the public payer is the first payer.

 

Performance Measures +-
  1. 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).
  2. Length of stay during acute care hospitalization and inpatient rehabilitation for patients experiencing shoulder pain (versus patients not experiencing shoulder pain).
  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 +-

Evidence Table and Reference List

 

The use of supportive slings and supports may reduce the amount of subluxation and hemiplegic shoulder pain, although the evidence is conflicting. Ada et al. (2017) 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 (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). An earlier Cochrane review (Ada et al. 2005) included the results from 4 RCTs evaluating the use of strapping (n=3) and hemisling (n=1). All patients were in the acute phase of stroke (less than 4 weeks) with a flaccid arm with no history of shoulder pain. The number of pain-free days associated with treatment was significantly greater; (mean difference: 13.6 days, 95% CI 9.7 to 17.8, p<0.0001); however, the results from only two studies were included in the pooled result. In another systematic review that specifically evaluated the use of strapping (Appel et al. 2014), the authors concluded the efficacy of shoulder strapping to alleviate upper limb 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. A recent meta-analysis, including the results from five RCTs, reported that shoulder positioning programs were not effective in preventing or reducing the range of motion loss in the shoulders’ external rotation (Borisova & Bohannon 2009).

 

Electrical stimulation can be used for the prevention and management of shoulder subluxation. Vafadar et al (2015) included 10 trials of electrical stimulation evaluating the evidence for the effect of functional electrical stimulation 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. Lee et al. (2017) included the results of 11 trials evaluating the effectiveness of neuromuscular electrical stimulation (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. Ada and Foongchomcheay (2002) 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. (2006) randomized 176 patients to receive active or sham surface FES treatments in addition to conventional therapy, for four weeks following acute stroke. There was no significant difference between groups in measures of upper-limb 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 (Singh & Fitzgerald 2010), which included the results of 6 RCTs examined the efficacy of the use of BTX-A toxin 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 (2008) 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.

 

Intra-articular corticosteroids injections may also help to improve symptoms of shoulder pain. Rah et al. (2012) 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 significant reduction in the average shoulder pain level at day and night, at 8 weeks associated with steroid injection. In contrast, Snels et al. (2000) reported that in 37 patients with hemiplegic shoulder pain (≥ 4 on a 0 to 10 VAS) 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. Dogan et al. (2013) found that compared to traditional rehabilitation alone, the addition of intra-articular steroid, and intra-articular steroid plus hydraulic distention significantly improved range of motion immediately after treatment and at 1-month follow-up. Both steroid groups had significant improvements on VAS score at rest and during activity but the group which received steroid plus hydraulic distention were significantly more effective than only the intra-articular steroid injection and therapy.

 

For patients with hand edema, results from a systematic review (Giang et al. 2016) suggest that mobilization exercises (i.e. range of motion exercises) may be effective in reducing hand edema in patients with acute stroke. Bandaging, intermittent compression, kinesio tape, neutral functional realignment orthosis, and hand realignment orthosis were not found to be effective treatments.

 

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. (2013) 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 is not effective in CRPS and is associated with adverse events, 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 is some evidence that local anaesthetic sympathetic blockade, physiotherapy, and occupational therapy are not effective for CRPS. There is very low-quality evidence that compared with placebo, oral corticosteroids reduce pain.

 

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