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

Background: 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). Aims and objectives: 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. Methods: 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). Main findings: 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. Conclusions: 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.