The presentation covers the epidemiology, aetiology, presentation, physical examination findings, prevention strategies, and management approaches for hemiplegic shoulder pain. It discusses how hemiplegic shoulder pain is a common complication after stroke that can negatively impact recovery and quality of life. The presentation provides an overview of the assessment and various treatment options for hemiplegic shoulder pain, including positioning, strapping, therapeutic exercises, medications, and surgery in some cases. The goal is to view hemiplegic shoulder pain as a preventable complication and utilize a range of therapeutic modalities to manage it

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PREVENTION AND MANAGEMENT OF HEMIPLEGIC
SHOULDER PAIN AMONG STROKE SURVIVOURS
AN END OF MEDICINE/NEUROLOGY POSTING
PRESENTATION
BY
AYODELE, AYOBAMI EMMANUEL
Presented at the Department of Physiotherapy
University of Abuja Teaching Hospital
Gwagwalada, Abuja
(18th April, 2017)

2. CONTENTS
• INTRODUCTION
• EPIDEMIOLOGY
• AETIOLOGY/PATHOPHYSIOLOGY
• PRESENTATION
• PHYSICAL EXAMINATION
• PREVENTION
• MANAGEMENT
• CONCLUSION
• REFERENCES
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3. INTRODUCTION
• Good shoulder function is a prerequisite for effective hand function,
as well as for performing multiple tasks involving mobility,
ambulation, and activities of daily living (ADL).
• A common sequela of stroke that can hamper functional recovery
and subsequently lead to disability is hemiplegic shoulder pain.
• 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).
• HSP can begin as early as 2 weeks post-stroke but typically occurs
within 2-3 months post-stroke (Coskun et al, 2013).
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4. HEMIPLEGIC SHOULDER PAIN
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• HSP 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)

5. HEMIPLEGIC SHOULDER PAIN
• HSP has been shown to affect stroke outcome in a negative way;
• It can cause considerable distress to the patient and caregiver
• Increased length of hospital stay
• Decreases functional recovery and quality of life
• HSP reduces participation in the rehabilitation process
• Leads to poorer recovery of arm function (Chae et al, 2007).
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6. EPIDEMIOLOGY
• 16% to 72% of stroke patients develop HSP (Hanukah et al, 1984).
• It may occur in up to 80% of stroke patients who have little or no
voluntary movement of the affected upper limb (Ancliffe, 1990).
• There is a wide reported range of the incidence of hemiplegic
shoulder pain post stroke because of different study methods,
period, activity environment, stroke foci, and pain reaction.
• It is a marker of stroke severity, and 75% of patients complain of pain
at some time in the first 12 months following a stroke (Ward, 2007).
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7. FUNCTIONAL ANATOMY OF THE SHOULDER
• The glenohumeral joint (GHJ) is inherently unstable; without the
influence of external forces to maintain alignment against the effects
of gravity.
• Stability largely maintained by muscles and ligaments which maintain
the alignment of the GHJ articular surfaces during movements, and
so prevent soft tissue damage and pain (Dromerick et al, 2008).
• Erector spinae muscle tone, along with the righting reflex, maintains
the vertebral column in an upright alignment.
• If any of these components are disrupted during the recovery
process, then shoulder function may be compromised or a painful
shoulder may result.
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8. Fig 1: Shoulder joint
Source: http://morphopedics.wikidot.com

9. AETIOLOGY
• The aetiology of HSP is probably multifactorial (Griffin, 1986)
• Several been postulated as causes of a painful hemiplegic shoulder:
• GH subluxation
• Abnormal tone (both spasticity and flaccidity)
• Impingement
• Soft tissue trauma
• Adhesive capsulitis*
• Bicipital tendinitis
• Poor handling of a hemiplegic limb may exacerbate a pre-existing
condition such as osteoarthritis
• Central post-stroke pain
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10. PRESENTATION
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• Common symptoms of HSP reported by patients include the
following:
• Pain with movement or without pain
• Tenderness
• Swelling/oedema
• Reduced mobility of the shoulder
• Decreased coordination

11. OUTCOME MEASURES
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• Verbal Rating Scales (VRS)
• Numeric Rating Scales (NRS)
• Ritchie Articular Index (for shoulder pain)
• Graded Chronic Pain Disability Score
• Shoulder lateral rotation ROM to the point of pain (SROMP)

12. PHYSIOTHERAPY
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13. PHYSICAL EXAMINATION
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• Should include both musculoskeletal and neurologic examinations.
• Atrophy
• Asymmetry
• Swelling/oedema
• Tenderness
• Pain
• Decreased range of motion (ROM)
• Decreased coordination
• Decreased reflexes
• Anatomic variation
• Palpable gap between acromion and humeral head

14. MANAGEMENT
• Mechanically based approaches:
• Strapping
• Positioning
• Electrotherapy agents (TENS, FES)
• Cryotherapy
• Soft tissue manipulation
• Therapeutic exercises
• Neurologically based approaches
• Bobath
• Brunnstrom
• Proprioceptive neuromuscular facilitation
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15. PREVENTION
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• The ideal management of hemiplegic stroke pain prevention
• For prophylaxis to be effective, it must be begin immediately after
the stroke
• Once the patient has pain, resultant anxiety and overprotection will
follow (Walsh, 2001).

16. HANDLING
• Poor handling and positioning of the affected upper limb in stroke
patients contribute toward shoulder pain (Anderson, 1985).
• The mobility of the recovering stroke patient is dependent on the
assistance of nurses, therapists, doctors, and family members.
• Handling, positioning, and transferring on a day-to-day basis can
exert great stress on the vulnerable shoulder.
• Patients who need help with transfers were more likely to develop
hemiplegic shoulder pain (Wanklyn et al, 1996)
• Braus et al (1994) investigated the efficacy of an information and
education programme in the prevention of HSP; reduced the
frequency of shoulder pain from 27% to 8%.
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17. Fig 2: Positioning for hemiplegic patients
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Source: pintrest.com

18. STRAPPING
• Physiotherapists have employed various forms of strapping designed
for shoulder pain or subluxation following stroke.
• Not all such devices have been successful
• Ancliffe (1990) demonstrated that strapping the hemiplegic shoulder
delayed the onset of shoulder pain.
• In patients with subluxation and shoulder pain, use of a brace has
been reported to be successful: patients become asymptomatic
within seven days (Krempen, 1977).
• External support can be discontinued when muscle tone around the
GHJ is sufficient to prevent subluxation.
• An exercise programme should always accompany the use of a sling.
• However, slings may hold the limb in a poor position that is likely to
cause soft tissue contracture and have an adverse effect on
symmetry, balance, and body image (Walsh, 2001).
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19. THERAPEUTIC EXERCISES
• Passive abduction of the hemiplegic arm can result in rotator cuff
injury: this in turn causes shoulder pain (Walsh, 2001).
• If impingement during range of motion exercises is determined to be
the cause of hemiplegic shoulder pain, the amplitude of passive
movement should be kept within the pain-free range.
• Caldwell et al (1969) reported that pain subsided in 43% of patients
with hemiplegic shoulder pain when the amplitude of passive range
of motion was reduced.
• Wanklyn et al (1996) reported an increase in the prevalence of
shoulder pain in the first weeks after discharge in patients who did
not continue to exercise properly.
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20. DRUG TREATMENT
• Analgesic, anti-inflammatory, and antispastic drugs have all been
used to treat hemiplegic shoulder pain.
• Antispasmodic medication may be helpful in spasticity of cerebral
origin.
• Antispasmodic agents may supplement inhibition and relaxation
techniques in physiotherapy.
• These agents have a modest effect on post-stroke hypertonicity but
their cognitive side effects may limit their usefulness (Walsh, 2001).
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21. SURGERY
• Surgery may be of use if conservative methods have failed and the
shoulder has become very painful and stiff.
• Recent improvements in rehabilitation techniques have reduced the
need for surgical intervention.
• Indications for surgery in various series have included range of
motion limitation to the point of functional impairment, pain of such
intensity that it interferes with skin hygiene or prevents participation
in rehabilitation.
• Surgery is usually delayed until at least six months after the stroke to
allow as much spontaneous functional improvement as possible.
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22. CONCLUSION
• HSP is a common complication of stroke.
• Its causes are multifactorial.
• The hemiplegic shoulder in patients with stroke continues to present
a clinical challenge to delivering effective prevention and treatment
of pain and soft tissue damage
• HSP should be viewed as a largely preventable complication of stroke
• A wide range of therapeutic modalities can be harnessed to manage
this complication among stroke survivors
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23. REFERENCES
• Ancliffe J (1990). Shoulder pain in hemiplegia: incidence and influence on movement
and recovery of function. Proceedings 3rd International Physiotherapy Congress.
Hong Kong, pp 187–192.
• Anderson L (1985) Shoulder pain in hemiplegia. Am J Occup Ther 39:11–19.
• Braus DF, Krauss JK, Strobel J (1994) The shoulder-hand syndrome after stroke: a
prospective clinical trial. Ann Neurol 36:728–733
• Caldwell CB, Wilson DJ, Braum RM (1969) Evaluation of treatment of upper extremity
in the hemiplegic stroke patient. Clin Orthop 63:69–93.
• Coskun Benlidayi I, Basaran S. Hemiplegic shoulder pain: a common clinical
consequence of stroke. Pract Neurol. 2013 Aug 12.
• Chae J, Mascarenhas D, Yu DT, et al. Poststroke shoulder pain: its relationship to
motor impairment activity limitation and quality of life. Arch Phys Med Rehabil.
2007;88:298–301
• 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, 8, 1589-1593.
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24. REFERENCES
• Griffin JW (1986). Hemiplegic shoulder pain. Phys Ther 12:1884–1893.
• Hanukah A, Sashimi H, Ohkawa T, et al. (1984) Arthrographic findings in hemiplegic
shoulders. Arch Phys Med Rehabil 65:706–711
• 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
• Krempen JF, Silver RA, Hadley J, et al. (1977) The use of the Varney brace for
subluxating shoulders in stroke and upper motor neuron injuries. Clin Orthop
122:204–206.
• Walsh K (2001). Management of shoulder pain in patients with stroke. Postgraduate
medical journal, 77(912), pp.645-649.
• Wanklyn P, Forster A, Young J (1996). Hemiplegic shoulder pain (HSP): natural history
and investigation of associated features. Disabil Rehabil. 18(10):497-501
• Ward AB (2007). Hemiplegic shoulder pain. Journal of Neurology, Neurosurgery &
Psychiatry, 78(8), pp.789-789.
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25. THANK YOU
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