Shoulder Pain After Stroke: Post Stroke Shoulder Subluxation

Shoulder pain is one of the most common complaints after stroke. The intricate mechanism of the shoulder girdle makes it susceptible to malalignment following any kinds of injury, whether it is a fracture, dislocation or subluxation the pain can be quite debilitating, and the management of such chief complaints could be confusing to most clinicians. Hemiplegic shoulder on the other hand is a combination of multiple restrictions and imbalances in the shoulder girdle and the head of humorous (think of scapulohumeral rhythm and the 2:1 movement ratio of humerus in relation to scapula-see video in appendix at the bottom of the post). Whether it is due to  paralysis, paresis or spasticity, your patient needs your attention, and referring them to a PT or OT who does not understand stroke is not a wise move!  Take a few minutes and examine their shoulders, and do not send them for imaging unless you are absolutely sure that there is a fracture.

 

What To Do

Whether you see these patients in the office or on the ward, like any good physician, history and physical comes first, some patients with hemianesthesia  or hemispatial neglect bump into obstacles or fall frequently without initially feeling any pain. If falls or skeletal injuries are ruled out,   based on my experience a 30 second passive range of motion to all possible directions and angels while supporting the weight of the arm (by placing your forearm under their elbow) can drastically improve their pain. Adhesion capsulitis is a restrictive phenomenon and can lead to more pain, so educate both the patient and family members, and teach them how to range and stretch a subluxed shoulder.

prescribing splints or slings are usually problematic, because these patients are not able to put it on without assistance, also splints can potentially decrease the ROM even further and cause more complications. Pharmacotherapy also is not helpful unless clear signs of inflammation, spasticity or arthritis are observed.

Functional electrical stimulation (FES) has shown to improve outcome if used early enough. A systematic review and meta-analyis in 2015 showed that FES can decrease subluxation, though it did not affect pain scores (Vafadar, Côté, & Archambault, 2015).

Acupuncture, also has not shown any promising results (what else is new!)  another systematic review and meta-analysis, looked through 188 related published research (only 12 were RCTs) and found inconclusive results (Lee & Lim, 2016).

Conclusion

As mentioned above the best way to mange the pain for a hemiplegic shoulder is to recognize and understand the underlying cause of pain. In most cases post stroke central pain syndrome (PSCPS) is the main cause of pain, and pharmacotherapy is useless unless spasticity or inflammatory process is detected. NSAIDs or  muscle relaxants are low yield therapies and can even interfere with their ongoing rehab. Gabapentin on the other hand is a different story if suspicious of PSCPS (Hesami et al., 2015).

Know your rehab team, and do not refer patients to any PT or OT unless you are certain they can mange such conditions better than you. Master the art of range of motion and develop your magic touch.

 

 

 

Appendix

 

 

 

Reference

 

1- Hesami, O., gharagozli, K., Beladimoghadam, N., Assarzadegan, F., Mansouri, B., & Sistanizad, M. (2015). The Efficacy of Gabapentin in Patients with Central Post-stroke Pain. Iranian Journal of Pharmaceutical Research : IJPR, 14(Suppl), 95–101.
2- Lee, S.-H., & Lim, S. M. (2016). Acupuncture for Poststroke Shoulder Pain: A Systematic Review and Meta-Analysis. Evidence-Based Complementary and Alternative Medicine : eCAM, 2016. https://doi.org/10.1155/2016/3549878
3- Vafadar, A. K., Côté, J. N., & Archambault, P. S. (2015). Effectiveness of Functional Electrical Stimulation in Improving Clinical Outcomes in the Upper Arm following Stroke: A Systematic Review and Meta-Analysis. BioMed Research International, 2015. https://doi.org/10.1155/2015/729768

 

 

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