Management Of Hemiplegic Shoulder Pain Research Articles

Stratified management of hemiplegic shoulder pain using an integrated care pathway: an 18-year clinical cohort analysis

Purpose Hemiplegic shoulder pain (HSP) is a common but heterogeneous complication of acquired brain injury. Integrated care pathways (ICPs) can support clinical decision-making, prompting timely intervention to improve quality of care. This 18-year cohort analysis of clinical data presents outcomes from an ICP for management of HSP in an inpatient rehabilitation unit. Materials & methods Consecutive data were extracted for all eligible patients admitted between 2000–2018 (n = 333). Patients were categorised according to presentation pattern (“Floppy-subluxed” (59%), “Painful-stiff” (21%) or Mixed/not categorised(20%)) to help guide early management. Pain was assessed using the Shoulder-Q with pain ratings/10 in three domains: rest, night-time and movement. Patients with pain reduction ≥3 points in any domain were designated ‘responders'. Results Mean baseline pain scores were 4.7 (95%CI 4.5,5.0). They were higher on movement (6.1(5.8,6.3)) than at rest (4.7(4.3, 5.0)) or at night (5.7(5.2,5.9)). Pain reduced significantly in all three domains (p < 0.0001) with a 65% overall response rate and complete resolution of pain 21–41%. There was a significant relationship between category of presentation pattern and management protocol used (X2 = 31.2, p < 0.0001). Conclusion These high pain-response rates compare favourably to the literature (14–27%), suggesting that this stratified and integrated approach to HSP guides more effective management in this heterogeneous clinical presentation. Implications for Rehabilitation Two-thirds of the patients demonstrated a clinically-significant reduction in pain when managed using the integrated care pathway. These results compare favourably with pain resolution rates of well under one-third cited in the literature and suggest that the integrated care pathway leads to reduced pain and improved patient outcomes. Hemiplegic shoulder pain can result from a range of different clinical problems. The diversity of presentation and the range of required treatments are confirmed in this 18-year cohort analysis. Heterogeneity in presentation of HSP poses a challenge for both management and the evaluation of outcome. The results of this study suggest that a stratified approach helps to guide more effective management.

Efficacy of suprascapular nerve blocks for management of hemiplegic shoulder pain: a systematic review and meta-analysis.

To compare the efficacy of suprascapular nerve block (SSNB) with other treatment modalities for management of HSP in terms of relieving pain and improving range of motion of shoulder joints. An electronic search was carried out in PubMed, CENTRAL, SCOPUS and EMBASE databases using a series of relevant keywords, along with a manual search. Randomized clinical trials comparing the efficacy of SSNB with placebo injections, intra-articular injections (IAI), ultrasound and Pulsed RF were identified. The outcomes assessed were pain relief measured with visual analogue scale and improvement in the range of motion (ROM) at the end of the follow-up period. The meta-analysis was carried out for quantitative analysis of outcome data. Eight randomized clinical trials were included. The quality of the included trials was low to moderate. SSNB showed improved pain relief at the end of 1 month, compared to placebo (normal saline injections) with mean difference (MD) 1.20 95% CI [0.59,1.80], p<0.0001. When compared to Pulsed radio-frequency (RF), the pain relief at the end of 1 month and 3 months was greater for patients treated with Pulsed RF than SSNB. No significant improvement in the range of motion for flexion, external and internal rotation was observed between SSNB and inter-articular injections. SSNB is more effective in pain relief than placebo injections and ultrasound, but similar to pulsed RF. Similar effectiveness in ROM improvement was observed with SSNB and intra-articular injections.

Effect of kinesio taping on hemiplegic shoulder pain: A systematic review and meta-analysis of randomized controlled trials

Objective: The aim of this study was to evaluate the effectiveness of kinesio taping for the management of hemiplegic shoulder pain. Data sources: MEDLINE, EMBASE, Web of Science, CENTRAL, CNKI, Wan Fang databases and the grey literature research were searched from inception to July 2020. Methods: We considered randomized controlled trials in English or Chinese that used kinesio taping for the treatment of hemiplegic shoulder pain. Two reviewers independently screened the articles, scored the methodological quality using the PEDro scale, assessed risk of bias using the Cochrane’s risk of bias tool and extracted the data. The outcomes included pain, motor function of the upper limb, magnitude of shoulder subluxation and activities of daily living post-intervention. Results: A total of nine studies (n = 424) met the inclusion criteria. A meta-analysis demonstrated a significant effect of kinesio taping on pain (mean difference(MD)= −1.45, 95% confidence interval(CI): −1.98 to–0.92 cm, p < 0.0001), motor function of upper limb (MD = 4.22,95%CI: 3.49 to 4.95, p < 0.00001), magnitude of shoulder subluxation (standardized mean difference(SMD) = −0.65, 95%CI: −0.95 to −0.35, p < 0.0001) and activities of daily living (MD = 6.86, 95% CI: 3.99 to 9.73, p < 0.00001) post-intervention. Conclusion: This meta-analysis suggests a beneficial effect of kinesio taping for reducing shoulder subluxation, improving motor function of the upper limb and activities of daily living in patients with hemiplegic shoulder pain post-intervention, which could not be interpreted simply as a placebo effect. And it was associated with reduced pain for patients with chronic stroke.

The management of hemiplegic shoulder pain in stroke subjects undergoing pulsed radiofrequency treatment of the suprascapular and axillary nerves: a pilot study.

Our trial aims to provide evidence for pain management and rehabilitation in patients with hemiplegic shoulder pain (HSP). HSP is one of the most common pains and disabilities occurring after a stroke. With accumulating evidence, the management of the suprascapular nerve (SSN) or axillary nerve (AN) might effectively relieve the pain and disability associated with HSP. However, no study has compared the effects of pulsed radiofrequency and nerve block of SSN and AN. Twenty patients with chronic stroke (over one year from onset) and HSP [visual analog scale (VAS) for pain ≥30 mm] randomly underwent ultrasound-guided SSN and AN pulsed radiofrequency or nerve block treatment. All patients were evaluated before treatment (T0) and at 4 (T1) and 16 (T2) weeks of follow-up. The primary outcome was the VAS score. Secondary outcomes were the Modified Ashworth Scale (MAS) score, passive shoulder range of motion (PROM), Disability Assessment Scale (DAS) score, and EuroQol-5 dimension questionnaire (EQ-5D). Significant improvements in the VAS score were observed in both groups at T1 and T2. However, a significant difference was not observed between the two groups (T1: P=0.43; T2: P=0.23). No statistically significant differences were observed in the MAS score between the two groups at T1 (P=0.06) and T2 (P=0.07). In the PROM of shoulder abduction and external rotation, statistically, significant differences were observed between the two groups at T1 (P=0.02*, & P=0.04*) and T2 (P=0.02*, & P=0.00*). Statistically significant differences in shoulder flexion and extension were not observed between the two groups at T1 (P=0.23, & P=0.35) and T2 (P=0.14, & P=0.14). Statistically significant differences in the DAS score were not observed between the 2 groups at T1 (P=0.51, & P=0.33, & P=0.36, & P=0.75) and T2 (P=0.12, & P=0.54, & P=0.41, & P=0.86). No statistically significant differences in the EQ-5D responses were observed between the two groups at T1 (P=0.42) and T2 (P=0.11). Pulsed radiofrequency of SSN and AN achieves similar therapeutic effects to the nerve block. Pulsed radiofrequency modulation is superior to nerve block in improving the PROM of shoulder abduction and external rotation.

Management of hemiplegic shoulder pain: A UK-wide online survey of physiotherapy and occupational therapy practice.

The purpose of this study was to explore, via an online survey, how therapists assess, diagnose and manage hemiplegic shoulder pain (HSP) in the United Kingdom. The objectives were to explore (1) how therapists assessed HSP, (2) what the aims of therapy were, (3) what interventions therapists used, (4) what outcome measures therapists used, (5) what training of HSP therapists had, and (6) what barriers therapists experienced in the management of HSP. An online survey was distributed to physiotherapists (PTs) and occupational therapists (OTs) working in stroke rehabilitation via professional bodies' interest groups. Sixty-seven responses were received: 40 (60%) were PTs and 27 (40%) were OTs. Therapists routinely screened for HSP (n = 59, 89%). When HSP was assessed, 33 (50%) spent <10 min and 34 (50%) spent >10 min on assessment. Patient-reported pain was used for assessment of HSP by 66 (99%) of respondents. Frequent interventions included positioning (n = 62, 94%), posture re-education (n = 57, 86%), and range of motion exercises (n = 55, 83%). Range of movement was used as an outcome measure by 31 (47%). Sixty (91%) respondents reported receiving training in HSP management. Time constraints (n = 41, 62%) and lack of diagnosis of HSP (n = 33, 54%) were identified as barriers to providing appropriate care to people with HSP CONCLUSION: Study findings showed varied practice in the assessment and treatment for HSP and indicate that time constraints are a considerable barrier to the management of these patients. Further research is required to establish best practice which may help improve outcomes and care for people with poststroke shoulder pain.

Electrical interferential current stimulation versus electrical acupuncture in management of hemiplegic shoulder pain and disability following ischemic stroke-a randomized clinical trial

BackgroundHemiplegic Shoulder Pain (HSP) is among common complications occurring after stroke leading to disability. This study was conducted to compare the effects of electrical Interferential Current stimulation (IFC) and Electrical Acupuncture (EAC) on pain intensity, range of motion, and functional ability in patients with HSP and also comparing the two modalities regarding improvement of above indices.MethodsIn this randomized clinical trial, 46 patients with HSP caused by ischemic stroke were recruited and assigned into 2 groups. Conventional exercise trainings were applied for both groups. Group A received additional IFC with medium frequency of 4000 HZ, and Group B received additional EAC two times a week for a total of 10 sessions. Pain severity, daily function, and shoulder Range of Motion (ROM) were evaluated using Visual Analogue Scale (VAS), Shoulder Pain and Disability Index (SPADI), and goniometry, respectively before and 5 weeks after the treatment.ResultsBoth groups showed relative improvement in pain severity, SPADI score, and its subscales, and also active and passive shoulder ROM after the treatment. However, IFC group compared to EAC group had higher mean changes of active ROM in abduction (28.00 ± 3.81 vs. 12.25 ± 2.39) and functional subscale of SPADI (11.45 ± 1.88 vs. 5.80 ± 1.66) after the treatment. On the contrary, EAC group showed higher percentage of VAS changes (46.14 ± 6.88 vs. 34.28 ± 5.52), indicating better pain improvement compared to IFC group. Other parameters did not show significant difference between two groups.ConclusionBoth IFC and EAC caused short term improvement in functional state, increased motion, and decreased pain in patients with HSP. Although pain control was more evident in acupuncture group, IFC resulted in better effects on function and active ROM of abduction, and seems to have higher efficacy.Trial registrationThis clinical trial was registered in the Iranian Registry of Clinical Trials at 2016-07-16 with a registry number of IRCT201602153217N10.

Effect of Interferential Current Stimulation in Management of Hemiplegic Shoulder Pain

ObjectiveTo study the immediate effects of interferential current stimulation (IFC) on shoulder pain and pain-free passive range of motion (PROM) of the shoulder in people with hemiplegic shoulder pain (HSP). DesignDouble-blind, placebo-controlled clinical trial. SettingInstitutional physical therapy clinic, neurologic rehabilitation center. ParticipantsA population-based sample of people with HSP (N=30) was recruited. InterventionParticipants were divided into 2 groups—an IFC group and a placebo group—by using a match-paired method (age, sex, and Brunnstrom motor recovery stage). In the IFC group, participants received IFC for 20 minutes with an amplitude-modulated frequency at 100Hz in vector mode. The current intensity was increased until the participants felt a strong tingling sensation. Main Outcome MeasuresPain intensity and pain-free PROM of the shoulder until the onset of pain were measured at baseline and immediately after treatment. ResultsParticipants reported a greater reduction in pain during the most painful movement after treatment with IFC than with placebo (P<.05). The IFC group showed a greater improvement in posttreatment pain-free PROM than the placebo group in shoulder flexion (P<.01), abduction (P<.01), internal rotation (P<.01), and external rotation (P<.01). ConclusionsThis study provides evidence that IFC is effective for the relief of pain during movement and also increases the pain-free PROM of the shoulder in people with HSP.

Management of hemiplegic shoulder pain following stroke

Shoulder pain is a common problem following stroke. Patients may present with varying degrees of paralysis (hemiplegia), which commonly affects the arm. As a consequence, the stability of the shoulder may be compromised with subsequent risk of damage to soft tissue structures. Patients with more severe paralysis of the arm are increasingly likely to develop shoulder pain. The underlying causes of shoulder pain, and the sources of this pain, have been the subject of debate and research for many years. There is recent evidence to suggest that damage to soft tissues can occur during post-stroke care in hospital. An evidence-based, multidisciplinary approach should be used to prevent damage to the shoulder and enable management of any complications that arise.

Management of hemiplegic shoulder pain following stroke

Management of hemiplegic shoulder pain following stroke

Poster 203: Assessment of shoulder pain after stroke: sensitivity of the shoulderQ.

Objective: To assess the sensitivity of the ShoulderQ, a structured instrument to assess shoulder pain in patients with cognitive and communicative deficits after stroke. Design: Before-after study. Setting: A regional rehabilitation service for young adults (16–65y) with severe complex disabilities after stroke. Participants: 30 consecutive adults with cognitive and communicative deficits after stroke, who presented with hemiplegic shoulder pain. Intervention: An integrated care pathway providing a holistic approach to management of hemiplegic shoulder pain, including pain relief, support, and physical management. Main Outcome Measure: The ShoulderQ is a structured questionnaire designed to assess the timing and severity of shoulder pain in order to target pain relief effectively. The ShoulderQ includes both verbal and visual analog type questions, simply presented to optimize accessibility for patients with language or visuospatial deficits after stroke. Results: Changes on visual analog scale (VAS) were associated with verbal reports of improvement ( r=.629, P<.001). Patients were divided retrospectively into responders (n=15) and nonresponders (n=15) on the basis of their overall clinical response. The ShoulderQ VASs recorded significant changes in pain at night (mean change ± SD, 2.2±3.4; confidence interval [CI], .31–4.1; P<.02) and during physiotherapy (mean change, 3.6±3.0; CI, 2.0–5.3; P<.001) in the responder group. The nonresponder group showed no significant change on any parameter. Conclusions: These results suggest that the ShoulderQ is sensitive enough to record changes in symptoms, despite the difficulties that this group of patients may have in reporting their symptoms. Set alongside previously reported test-retest reliability, the results confirm the utility of the ShoulderQ as a simple and practical tool for evaluation of shoulder pain in patients with severe complex disabilities.

Shoulder pain after stroke: a review of the evidence base to inform the development of an integrated care pathway.

Shoulder pain is a common complication of stroke. It can impede rehabilitation and has been associated with poorer outcomes and prolonged hospital stay. This systematic review was undertaken to inform the development of an evidence-based integrated care pathway (ICP) for the management of hemiplegic shoulder pain (HSP). 1) To provide a background understanding of the functional anatomy of the shoulder and its changes following stroke. 2) To review the literature describing incidence and causation of HSP and the evidence for factors contributing to its development. 3) To appraise the evidence for effectiveness of different interventions for HSP. Data sources comprised a computer-aided search of published studies on shoulder pain in stroke or hemiplegia and references to literature used in reviews (total references = 121). Although a complex variety of physical changes are associated with HSP, these broadly divide into 'flaccid' and 'spastic' presentations. Management should vary accordingly; each presentation requiring different approaches to handling, support and intervention. (1) In the flaccid stage, the shoulder is prone to inferior subluxation and vulnerable to soft-tissue damage. The arm should be supported at all times and functional electrical stimulation may reduce subluxation and enhance return of muscle activity. (2) In the spastic stage, movement is often severely limited. Relieving spasticity and maintaining range requires expert handling; overhead exercise pulleys should never be used. Local steroid injections should be avoided unless there is clear evidence of an inflammatory lesion. HSP requires co-ordinated multidisciplinary management to minimize interference with rehabilitation and optimize outcome. Further research is needed to determine effective prophylaxis and document the therapeutic effect of different modalities in the various presentations. Development of an integrated care pathway provides a reasoned approach to management of this complex condition, thus providing a sound basis for prospective evaluation of different interventions in the future.

Development of an integrated care pathway for the management of hemiplegic shoulder pain

Purpose: To improve clinical management of patients with hemiplegic shoulder pain through development of an evidence-based multidisciplinary integrated care pathway (ICP), and to use this to audit quality of care against predefined standards. Methods: The ICP was developed by a team of medical, paramedical and nursing staff. The evidence base was established through a systematic literature review supplemented by clinical consensus to ensure best practice where scientific evidence was lacking. Following development, performance was assessed against standards in a cohort of stroke patients with hemiplegia (n=32) consecutively admitted to a regional unit providing in-patient rehabilitation for young patients with complex disabilities. Results: Performance showed improvements in assessment and documentation of pain and in initial care, including analgesia and application of positioning/handling protocols. However, review and response to continuing or changing symptoms were poorly documented. Changes to the ICP were introduced to improve this. Conclusions: Principal benefits have been to raise awareness of shoulder pain, to educate staff and prompt management in line with recommended best practice, but strong leadership is essential to ensure continuity in clinical practice. Future research is needed to establish whether improved quality of care offsets the substantial investment of staff time in ICP development.

Hemiplegic shoulder pain: a study of two methods of physiotherapy treatment

A study was undertaken to examine the effectiveness of two methods of physiotherapy treatment for hemiplegic shoulder pain. Sixty-five patients were randomly allocated to receive either cryotherapy or the Bobath approach. Patients were assessed before and after a four-week period of treatment. The differences between the scores of the two groups on exit were not found to reach statistically significant levels for severity of pain at rest, on movement, or for reported distress; however the proportion of patients who reported no pain after the four weeks' treatment was greater in those who received the Bobath approach. The differences in reported frequency of occurrence of pain reached a significant level (p &lt; .05), those in the Bobath group reporting less frequent pain. It is suggested that reasons forthe lack of expected differences in outcome between the two groups may be in part due to the diversity of underlying pathology, and to further trauma which occurred in the study period. The difference between before and after ratings for all pain variables was significant; for reported severity and frequency p &lt; .05, and for reported distress p &lt; .001. These findings suggest that physiotherapy may have a role to play in the treatment and management of hemiplegic shoulder pain, but further investigations are needed. It may be appropriate to set up and monitor programmes of careful handling to see if shoulder pain can be avoided, and it is also suggested that those with severe pain at rest and on movement may be considered as a separate group for study.