This document discusses the prevention and physiotherapy management of hemiplegic shoulder pain (HSP) in stroke patients. It defines HSP and outlines its epidemiology, causes, clinical presentation and findings. The document emphasizes that HSP is a largely preventable complication that prolongs rehabilitation and reduces quality of life. It recommends several prevention strategies including proper handling, positioning the shoulder in abduction and external rotation, use of slings or strapping, and early physiotherapy including range of motion exercises. The ideal management is to prevent HSP from occurring in the first place through diligent and careful handling of the hemiplegic upper limb.

1. PREVENTION AND PHYSIOTHERAPY
MANAGEMENT OF HEMIPLEGIC
SHOULDER PAIN (HSP)
BY
ADEAGBO, CALEB ADEWUMI
Physiotherapist
23/10/2014

2. Outline
• Introduction
• Definition
• Epidemiology
• Functional anatomy of the shoulder and
changes following a stroke
• Causes
• Pathophysiology
• Clinical presentation and findings
• Prevention and Management
• Conclusion
• References
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3. Introduction
• Hemiplegic shoulder pain (HSP) is
among the four most common, yet
preventable, medical
complications that stroke
survivors may experience
(Rajaratnam et al, 2007; Zhu et al, 2013; Suriya-amarit
et al, 2014).
23/10/2014 3

4. Introduction cont
• HSP can occur in the 2nd week after
stroke and it is independent of age and
gender (Vuagnat and Chantraine, 2003; Ward, 2007; Bello
and Amedzo, 2009).
• Despite the high incidence of HSP, the
literature is full of conflicting reports
about the epidemiology, risk factors,
and management (Lindgren et al, 2007; Dromerick et
al, 2008).
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5. Introduction cont
• HSP prolongs rehabilitation of
affected limb and hospital stay
thereby affecting ADL, decreases
the QoL and it has been implicated
with withdrawal from participation
in rehabilitation process (Griffin and
Bernhardt, 2006; Allen et al, 2010; Suriya-amarit et al, 2014).
23/10/2014 5

6. Introduction cont
• Therefore prevention and
management of HSP is obviously
important to recovery and well-being
of stroke survivors (Snels et al,
2000; Tyson and Chissim, 2002; Suriya-amarit et al,
2014).
23/10/2014 6

7. Definition
• 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).
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8. Definition cont
• HPC 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)
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9. Epidemiology
• Reports of prevalence of HSP in the
literature vary between 5% and 84% in
stroke survival population (Walsh, 2001; Gustafsson
and McKenna, 2006; Griffin and Bernhardt, 2006). There are a
number of reasons for this variation such
as different study methods, location of the
stroke and pain reaction (Snels et al, 2002; Teasell et
al, 2003; Klit et al, 2011; de Oliveira et al, 2012).
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10. Epidemiology cont
• A prevalence study carried out in
Nigeria by Fabunmi et al, (2014) revealed
that 75 (73.5%) of 102 stroke
survivors had HSP, 36.3% and 37.3%
patients had pain on left and right
shoulders respectively, pain onset
showed that 33.3% developed pain
within first week post stroke.
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11. Functional anatomy of the shoulder and
changes following a stroke
• An understanding of the normal
functional anatomy of the
shoulder and how it is affected by
loss of motor control following
stroke may inform the prevention
and management of shoulder pain
(Smith, 2012).
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12. Functional anatomy of the shoulder and
changes following a stroke cont
• The shoulder is formed by a complex
system of articulations:
Glenohumeral joint (GHJ)
Acromioclavicular joint (ACJ)
Sternoclavicular joint (SCJ)
Rotation of the scapula on the thoracic
wall (fig 1)
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13. Figure 1: the anatomical diagram of the shoulder complex
(Smith, 2012).
23/
10/
201
4
13

14. Functional anatomy of the shoulder
and changes following a stroke cont
• Immediately following stroke
there is an initial flaccid paralysis
in over 90% of individuals which is
often replaced by a predictable
pattern of spasticity (Gillen 2011; Kim,
2012, Gould and Barnes, 2013).
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15. Functional anatomy of the shoulder
and changes following a stroke cont
• Alteration in the alignment of
skeletal components of the shoulder
complex can be described in both
the flaccid and spastic stages of
paralysis after stroke and each has
been implicated in the causation of
HSP (Turner-Stokes and Jackson, 2002).
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16. Causes
• The causes of HSP are uncertain but it is
associated with upper limb weakness,
abnormal muscle tone, glenohumeral
subluxation, limited shoulder external
rotation ROM, sensory inattention, sensory
impairment, complex regional pain
syndrome (CRPS) and prior shoulder
pathology (Tyson and Chissim, 2002; Chae, 2007;
Dromerick et al, 2008; Joy et al, 2012).
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17. Causes cont
• Several clinical diagnoses have been
proposed as causes of HSP, these
including rotator cuff tendonitis,
subacromial bursitis, bicipital
tendonitis, adhesive capsulitis,
brachial neuralgias, sympathetically
mediated pain, and referred pain (Lo et
al, 2003, Chae et al, 2007).
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18. Pathophysiology
• Because of the wide array of
pathologies potentially underlying
the development of HSP, the precise
aetiology is difficult to assess (Maxwell
and Nguyen, 2013). It is impossible to treat
HSP effectively without first
understanding the mechanism of the
complication.
23/10/2014 18

19. Pathophysiology cont
• Three specific types of possible
pathological processes that can
cause HSP are:
Soft tissue lesions
Impaired motor control (specifically
muscle tone changes)
Altered peripheral and central nervous
system activity
23/10/2014 19

20. Clinical presentation and findings
• Common symptoms by patients with
HSP include the following:
Pain with or without movement of the
hemiplegic shoulder
Reduced mobility of the hemiplegic
shoulder
Tenderness around the hemiplegic
shoulder
Swelling/oedema
23/10/2014 20

21. Clinical presentation and
findings cont
• The physical examination of a patient
with HSP is extensive because there
is need to assess the involved
musculoskeletal and neurologic
conditions. It should include
observation, palpation,
musculoskeletal and neurologic
examination.
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22. HSP outcome measures
 Faces Pain Scale
 Verbal Rating Scales (VRS)
 Numeric Rating Scales (NRS)
 Visual Analogue Scale (VAS)
 Physiotherapist graded (VAS)
 Ritchie Articular Index (for shoulder pain)
 ShoulderQ (for shoulder pain)
 Graded Chronic Pain Disability Score
 Shoulder lateral rotation ROM to the point of pain
(SROMP)
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23. Prevention and Management
• Poor handling and positioning of the
affected upper limb in stroke patients
contribute toward shoulder pain (Walsh,
2001). The mobility of the recovering
stroke patient is dependent on the
assistance of physiotherapists,
nurses, doctors, family members and
patient’s own efforts.
23/10/2014 23

24. Prevention and Management cont
• The ideal management of HSP is to
prevent it from happening in the first
place. Various strategies have been
employed in the prophylaxis of HSP.
For effective prophylaxis, it must be
begin immediately after stroke (Snels et
al, 2000; Tyson and Chissim, 2002; Griffin and Bernhardt,
2006).
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25. Handling of the hemiplegic upper limb
• Good handing technique of the
hemiplegic upper extremity day and
night is recommended to prevent
HSP because it prevent trauma to
soft tissues. It is recommended that
support is provided both proximally
and distally to the upper extremity
(Smith, 2012).
23/10/2014 25

26. Positioning hemiplegic shoulder
• Maintaining the upper limb in the
correct position is fundamental to
preventing and managing HSP. The
recommended position for the
affected upper limb is abduction,
external rotation and with the
shoulder slightly flexed (Smith, 2012).
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27. Positioning hemiplegic shoulder cont
• Positioning of the hemiplegic
shoulder in different positions
Side lying on hemiplegic side (fig 2).
Side lying on unaffected side (fig 2).
Lying on back (fig 3).
Sitting in bed (fig 3).
Sitting up (fig 4).
23/10/2014 27

28. Figure 2: Side lying in hemiplegic patient (Smith, 2012).
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29. Figure 3: Lying on back and sitting in bed in hemiplegic patient
(Smith, 2012).
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30. Figure 4: sitting on a chair in hemiplegic patient (Smith, 2012).
23/10/2014 30

31. Slings and other devices
• Use of slings is controversial
because they hold the arm in a
flexed position, inhibit shoulder
movement. However, slings are
considered to be the best devices
for supporting the paretic limb (fig
5; fig 6) (Ada et al, 2005)
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32. Figure 5: shoulder slings (Orthocare, 2009).
23/10/2014 32

33. Figure 6: functional shoulder sling (Neuro-Lux) and X-ray
of the shoulder without and with the functional shoulder
sling (Neuro-Lux) (Hartwig et al, 2012).
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34. Strapping the hemiplegic
shoulder
• Strapping of the hemiplegic
shoulder is used as a method for
preventing or reducing shoulder
subluxation and may provide a
certain level of sensory
stimulation. (Hanger et al, 2000).
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35. Physiotherapy management
Electrophysical/electrotherapy agents
Electrical neuromuscular stimulation
Cryotherapy
Soft tissue manipulation (massage using
analgesic lubricant)
Therapeutic exercises:
23/10/2014 35

36. Drug treatment
• Analgesic, anti-inflammatory, and
antispastic drugs have all been used
to treat HSP. Simple analgesics and
nonsteroidal anti-inflammatory
drugs should be tried first.
Antispasmodic medication may be
helpful in spasticity of cerebral
origin.
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37. Conclusion
• HSP should be viewed as a largely
preventable complication of stroke
and it is the responsibility of all
members rehabilitating and taking
care of the patient to ensure they
handle vulnerable upper limb with
care during positioning,
transferring and assisting in ADL.
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38. References
• Ada L, Foongchomcheay A, Canning CG (2005). Supportive devices for preventing
and treating subluxation of the shoulder after stroke. Stroke 36: 1818-1819
• Allen ZA, Shanahan EM, Crotty M (2010). Does suprascapular nerve block reduce
shoulder pain following stroke: a double-blind randomized controlled trial with
masked outcome assessment. BioMedCentral Neurology 10(83): 1-5
• Bello AI, Amedzo MY (2009). Relative Effectiveness of Transcutaneous Electrical
Nerve Stimulation and Hot Packs in the Management of Hemiplegic Shoulder Pain.
Journal of the Nigeria Society of Physiotherapy 17: 1-6
• Chae J, Mascarenhas D, Yu DT, Kirsteins A, Elovic EP, Flanagan SR, Harvey RL,
Zorowitz RD, Fang Z (2007). Poststroke Shoulder Pain: Its Relationship to Motor
Impairment, Activity Limitation, and Quality of Life. Archives of Physical Medicine
and Rehabilitation 88: 298-301
• de Oliveira RA, de Andrade DC, Machado AG, Teixeira MJ (2012). Central post stroke
pain: somatosensory abnormalities and the presence of associated myofascial pain
syndrome. BioMedCentral Neurology 12: 89.
•
• Dromerick AW, Edwards DF, Kumar A (2008). Hemiplegic Shoulder Pain Syndrome:
Frequency and Characteristics during Inpatient Stroke Rehabilitation Archives of
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39. References cont
• Fabunmi A, Awolola E, Fowodu O, Amusat S (2014). Shoulder pain among stroke
survivors: prevalence and pattern. The Journal of Pain 15(4): 37
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http://emedicine.medscape.com/article/328793-overview Retrieved on October 07, 2014
• Griffin A, Bernhardt J (2006). Strapping the hemiplegic shoulder prevents development
of pain during rehabilitation: a randomized controlled trial Clinical Rehabilitation 20:
287-295
• Gustafsson L, McKenna K (2006). A programme of static positional stretches does not
reduce hemiplegic shoulder pain or maintain shoulder range of motion - a randomized
controlled trial Clinical Rehabilitation 20: 277-286
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randomized controlled trial of strapping to prevent poststroke shoulder pain. Clinical
Rehabilitation 14: 370-380.
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subluxation after ischaemic brain stroke to avoid post-hemiplegic shoulder–hand
syndrome: a randomized clinical trial. Clinical Rehabilitation 26(9): 807-816
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40. References cont
• Kim CT (2012). Stroke Rehabilitation. Available @
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Factors for Hemiplegic Shoulder Pain: A Longitudinal Observational Study.
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41. References cont
• Orthocare (2009). Arm Slings. Available @
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(2007). Predictability of Simple Clinical Tests to Identify Shoulder Pain
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LM (2002). Treating patients with hemiplegic shoulder pain. American
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Rehabilitation 14: 20–27
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Interferential Current Stimulation in Management of Hemiplegic Shoulder Pain.
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42. References cont
• Turner-Stokes L, Jackson D (2002). Shoulder pain after stroke: a review
of the evidence base to inform the development of an integrated care
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on range of movement in the hemiplegic shoulder Clinical Rehabilitation
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