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Management of hemiplegic shoulder pain following stroke

Article  in  Nursing standard: official newspaper of the Royal College of Nursing · July 2012
DOI: 10.7748/ns2012.07.26.44.35.c9191 · Source: PubMed

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 Art & science
section, email gwen.clarke@rcnpublishing.co.uk
The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Management of hemiplegic
shoulder pain following stroke
Smith M (2012) Management of hemiplegic shoulder pain following stroke.
Nursing Standard. 26, 44, 35-44. Date of acceptance: February 28 2012.
Abstract
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.
Author
Mark Smith
Consultant physiotherapist in stroke rehabilitation,
Leith Community Treatment Centre, Edinburgh.
Correspondence to: mark.smith@nhslothian.scot.nhs.uk
Keywords
Central post-stroke pain, hemiplegic shoulder, shoulder pain, stroke
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© NURSING STANDARD / RCN PUBLISHING july 4 :: vol 26 no 44 :: 2012  35
p35-44w44 35
If you would like to contribute to the Art & science
An estimated 150,000 people have a stroke
each year in the UK (Office for National Statistics
2001, Mant et al 2004). Stroke is one of the
most common causes of death and disability:
an estimated 300,000 people in the UK have
moderate to severe impairments as a result of
stroke (Adamson et al 2004).
Pain is common after stroke and is reported
by as many as 42% of patients (Kong et al 2004,
Jönsson et al 2006). In 11-14% of patients who
have had a stroke, this pain is directly attributable
to the brain damage caused by stroke and is termed
central post-stroke pain (CPSP) (Bowsher 2005,
Henry et al 2007). Pain reported by about 30% of
patients following stroke may be the result of
musculoskeletal effects of motor impairments
caused by stroke (Jönsson et al 2006), such as
hemiplegic shoulder pain (HSP) (Ratnasabapathy
et al 2003). For some, pain (for example, low back
pain) may have predated the stroke (Langhorne
et al 2000, Choi-Kwon et al 2006).
Around one quarter of patients develop HSP
following stroke; it is a significant clinical problem
associated with poor recovery of arm movement
and function and requires specific management
(Ratnasabapathy et al 2003, Lindgren et al 2007,
Dromerick et al 2008). HSP can occur in patients
with any neurological condition that causes
hemiplegia, for example traumatic brain injury,
cerebral abscess or cerebral tumour and multiple
sclerosis, but most research has focused on stroke.
Shoulder pain following stroke is often persistent
(Ratnasabapathy et al 2003), is usually moderate
to severe and can interfere with functional
activity (Lindgren et al 2007).
The literature addressing HSP following stroke
is vast. The aim of this article is to provide an
evidence-based overview of high quality published
 
29/06/2012 13:51
 Art & science stroke series
reviews, such as those from the Cochrane Library,
supported by recent studies. Clinical guidelines
based on peer-reviewed appraisals of the evidence
pertaining to prevention and management of
HSP are discussed.
Anatomy of the shoulder complex
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.
The glenohumeral joint is a multiaxial ball and
socket joint (Figure 1). It is inherently unstable
because the socket formed by the glenoid cavity
of the scapula is too shallow to stabilise the ball,
formed by the head of the humerus, without the
influence of external forces to maintain alignment
against the effects of gravity. Stability of the
shoulder complex (humerus, clavicle, scapula and
associated attachments) is largely maintained by
muscles that work throughout the normal range of
joint motion because the only skeletal connection
of the arm to the trunk is at the sternoclavicular
joint. These muscles include the superficial
FIGURE 1
Anatomical diagram of the shoulder complex showing comparative ranges of motion of the humerus and scapula during
abduction (scapulohumeral rhythm)
Coracoid process
Acromion Acromioclavicular
joint
Subacromial bursa
Supraspinatus
tendon
Subscapularis
tendon
Glenohumeral joint
60°
120°
Humerus
joanna cameron
Scapula
36  july 4 :: vol 26 no 44 :: 2012 © NURSING STANDARD / RCN PUBLISHING
p35-44w44 36
muscles of the shoulder (trapezius, deltoid, teres
major, lattissimus dorsi, biceps and triceps), which
control the large powerful movements of the arm,
and the deep muscles (teres minor, subscapularis,
infraspinatus and supraspinatus), which maintain
the alignment of the glenohumeral joint articular
surfaces during these movements, and so prevent
soft tissue damage and pain. Ligaments, which
are non-contractile bands attaching bone to bone,
have insufficient strength to provide stability, but
contain sensory mechanoreceptors which, when
put under strain, activate surrounding muscles
to protect the joint (Sjölander et al 2002).
Full range of arm motion also depends on
sufficient spinal and thoracic flexibility, which
contribute to the normal positioning of the
shoulder girdle. There is constant re-alignment
of the glenoid cavity by rotation of the scapula
during arm movements, particularly when the arm
is lifted away from the side. This is referred to as
scapulohumeral rhythm, and is necessary for
normal pain-free movement of the arm. External
rotation of the humerus is also required during this
movement to prevent bones from impinging on one
another. This anatomical design allows maximum
Clavicle
Sternoclavicular
joint
Sternum
Subscapularis muscle
29/06/2012 13:51
 mobility and function without damage to joint reduction of movement in the shoulder joint,
structures so that the hand can be moved within wrist and hand) (Lo et al 2003). Roosink et al
a wide area around the body, but at the (2011) showed significant associations between
comparative expense of stability. HSP and impaired motor control, reduced
proprioception, abnormal sensation, spasticity
and reduced range of motion.
Effects of hemiplegia on the shoulder In some cases, HSP may result from accidental
Upper limb impairment is seen in 90% of patients damage caused by incorrect moving and
affected by stroke (Gillen 2011). Muscle paresis, handling, for example giving the patient
abnormal muscle tone and loss of proprioception underarm assistance to stand or walk, or pulling
following stroke may render the shoulder complex on the affected arm (Tyson and Chissim 2002,
unstable and therefore prone to misalignment. Pong et al 2009). HSP may also be associated
Hemiplegia interferes with movement and with rehabilitation interventions, especially when
postural control and, as a result, may increase the attempting auto-assisted, repeated exercises
potential to develop HSP and other upper limb during which the patient pulls his or her
complications caused by the effects of gravity on hemiplegic arm through a range of motion
the arm. Paralysis, particularly in association with against gravity with the unaffected hand
low muscle tone around the shoulder, may result in (Kumar et al 1990). Patients with HSP may
the glenohumeral joint being partially dislocated have problems with sleeping and low mood
under the influence of gravity, especially when (Kucukdeveci et al 1996).
unsupported. This is known as subluxation
(Figure 2). FIGURE 2
A case-control study of 107 participants who
X-ray showing subluxation of the shoulder joint
had a stroke found that subluxation was present
in 48.6% of patients, and that it was associated
with shoulder pain on admission, both at
discharge and at one month follow up (Paci
et al 2007). In addition, the loss of truncal
control and associated flexed posture commonly
seen in patients after severe stroke, especially
when sitting, further contributes to subluxation
by adversely influencing the resting angle of the
scapula (Figure 3).
If increased muscle tone or spasticity develops
subsequently in the muscles around the shoulder
complex, the resulting misalignment may cause
subacromial impingement of the bony surfaces
during movement. Spasticity occurs most Reproduced with permission of Professor Martin Dennis,
University of Edinburgh.
commonly in the large medial rotator muscles
such as pectoralis major, lattisimus dorsi and teres
major (Huang et al 2010). Subsequent attempts FIGURE 3
to move the arm actively or passively through the Posture common in patients following stroke
normal range of motion without correcting the associated with subluxation of the shoulder
abnormal alignment may result in trauma and the
onset of HSP (Vasudevan and Vasudevan 2008,
Zeferino and Aycock 2010).

Hemiplegic shoulder pain

HSP is common in people with impaired motor
function following a severe stroke (Rajaratnam
et al 2007, Dromerick et al 2008). Multiple soft
tissue sites may be involved and associated
joanna cameron

pathology may include adhesive capsulitis,

bursitis, rotator-cuff tendon tears (Gardner
et al 2002, Huang et al 2010), and ‘shoulder-hand
syndrome’ (severe pain and considerable

© NURSING STANDARD / RCN PUBLISHING july 4 :: vol 26 no 44 :: 2012  37 

p35-44w44 37 29/06/2012 13:51

 Art & science stroke series
Hemiplegic shoulder pain and central
post-stroke pain
There is evidence that HSP is linked to CPSP,
and in some cases it may be difficult to
differentiate the two (Widar et al 2002, 2004,
Jönsson et al 2006). In CPSP, ‘phantom’ pain is
generated by the brain as a result of the stroke
(Bowsher 2005). Impaired temperature detection
by the skin and allodynia (which is when painless
stimuli become painful) in patients with CPSP
have been reported widely in the literature,
suggesting disruption of the spinothalamocortical
system – the neural pathway that transmits
information about pain. (Greenspan et al 2004).
In a study of 416 patients with a ‘first ever stroke’,
32% had moderate to severe pain at four months;
most of these patients (77%) had shoulder pain,
but about half were also diagnosed as having
CPSP (Jönsson et al 2006). In another study of
CPSP, 182 patients with stroke were prospectively
tested for sensory disturbances, specifically of
thermal perception. Those who had impaired
thermal sensation were more likely to develop
CPSP and HSP (Gamble et al 2000).
Prevalence of hemiplegic shoulder pain
following stroke
In a large population-based prospective study
of 1,761 patients with stroke, shoulder pain was
reported by 17% of participants at one week,
20% of patients at one month and 23% of
participants at six-month follow up (Ratnasabapathy
et al 2003). The authors concluded that HSP was
significantly positively correlated with the severity
of the motor deficit and the side of weakness;
left-sided hemiplegia resulted in increased incidence
of HSP. Patients with left-sided hemiplegia have an
increased tendency towards visuospatial inattention
and unilateral neglect, meaning that the left arm
is more exposed to potential trauma (Poulin de
Courval et al 1990). At one month follow up,
participants cited causes of their shoulder pain as:
the stroke (21%), physiotherapy and exercise (15%),
staff handling (12%) and other factors such as
arthritis (28%) (Ratnasabapathy et al 2003).
Lang et al (2007) assessed shoulder pain in
34 patients with stroke on a ten-point verbal rating
scale and found it correlated with upper limb activity
levels: the more active the upper limb, the worse
the shoulder pain. This is interesting as a recent
randomised controlled trial involving 68 patients
reported that participation in circuit training after
stroke did not increase the incidence of HSP (English
et al 2008). However, details of the circuit training
were not provided. It is unclear whether or not
physical activity of the upper limb influences the
development of HSP after stroke.
38  july 4 :: vol 26 no 44 :: 2012 © NURSING STANDARD / RCN PUBLISHING
p35-44w44 38
Soft tissue damage of the hemiplegic shoulder
In a sonographic study of 34 patients with acute
stroke, categorised according to severity of
hemiplegia with the Brunnstrom Recovery Scale
(Shah 1984), patients with more severe paresis
were more likely to have soft tissue lesions of
the shoulder on ultrasound than those with less
physical impairment (Pong et al 2009). These soft
tissue lesions appeared more than two weeks after
the stroke. In a subsequent study of 57 patients with
acute stroke, Huang et al (2010) observed that soft
tissue lesions in the hemiplegic shoulder were more
common in those with HSP, impaired sensation,
spasticity, subluxation and reduced range of lateral
rotation. The majority (85.3%) of the most severely
motor impaired patients were found to have soft
tissue damage. These findings should be interpreted
with caution because specific lesions visualised on
ultrasound may not be a cause of pain. However,
statistically significant differences in soft tissue
pathology were observed between initial and
follow-up ultrasound scans, suggesting that lesions
(particularly in the biceps, supraspinatus and
subscapularis tendons and the subacromial bursa)
had occurred in hospital during post-stroke care
(Huang et al 2010).
Physical tests
Previous studies have investigated the use of physical
diagnostic tests of shoulder pain following stroke,
which were originally developed in the orthopaedic
setting. Rajaratnam et al (2007) found that the
Neer Test, the Hand Behind Neck manoeuvre and
a difference in passive external rotation between the
affected and non-affected shoulder of more than
10° equated to a 98% probability of early diagnosis
of HSP following stroke. Dromerick et al (2008)
showed that simple questioning of patients
following stroke was not adequate to identify
reliably those who had abnormalities on physical
examination of the shoulder using the Neer Test,
the Speed Test, the Acromioclavicular Shear Test
and the Rowe Test. As a result, the authors
recommended that patients who report shoulder
pain following stroke should have an early specialist
physical assessment to determine the source and
nature of the pain (Dromerick et al 2008).
It is beyond the scope of this article to describe
these specialist orthopaedic tests in detail, but
interested readers will find this information
in the references cited above.
Assessment and measurement of pain
Pain is often an overlooked symptom that is not
adequately assessed by healthcare professionals
(Appelros 2006). The Royal College of Physicians,
29/06/2012 13:51
 British Geriatrics Society and British Pain Society
(2007) have collectively released national guidelines
for the assessment of pain in older people.
These guidelines contain a section describing
observational changes associated with pain, which
could be helpful in diagnosing pain in patients
with communication problems. An algorithm
and scales suitable for pain assessment in older
people presenting with varying levels of cognitive
and communication difficulties are also provided.
These guidelines should be incorporated within
the clinical governance frameworks for the
management of older adults and, as a result, the
prospective identification of pain in older people
who have had a stroke could be improved.
There are accurate means of measuring pain
thresholds and tolerance, such as quantitative sensory
testing, but it may not be clinically or ethically
feasible to use them in patients who have had a
stroke because cognitive and communication deficits
may influence the reporting of potentially noxious
stimuli (Slyter 1998, Tu et al 2004). However, the
effective treatment of pain does require a degree of
assessment and quantification (Cox 2010).
Various rating scales have been developed and
evaluated to assess pain in patients with cognitive or
communication difficulties, for example, the Revised
Faces Pain Scale, the Verbal Descriptor Scale, the
Numeric Rating Scale, the Iowa Pain Thermometer,
the Verbal Numeric Rating Scale and the Visual
Analogue Scale (Ware et al 2006, Herr et al 2007).
Particular scales may be more suitable for some
patients than others depending on the purpose
for which they are being used and the degree of
communicative difficulty an individual may have.
Patients who have had a stroke, particularly those
with visuospatial impairments, find visual analogue
scales difficult to use and as such they may be
unreliable (Price et al 1999).
Pain measurement tools used in stroke
Several pain measurement tools have been tested
with patients who have had a stroke. Jackson et al
(2002a, 2002b) developed a tool known as a Scale
of Pain Intensity (SPIN) to evaluate and manage
HSP. This was tested in the context of developing an
integrated care pathway (Turner-Stokes and Jackson
2002, Jackson et al 2003). Significantly improved
performance in completing outcome measures
related to shoulder care was achieved by clinicians
participating in the study (Jackson et al 2002b).
This tool has been validated in an aphasia-friendly
pictorial format against both a 10cm visual analogue
scale and a numerical pain rating scale in a healthy
population (Jackson et al 2006).
The McGill Pain Questionnaire, originally
developed by Melzack in 1975, provides valuable
© NURSING STANDARD / RCN PUBLISHING july 4 :: vol 26 no 44 :: 2012  39
p35-44w44 39
information regarding the sensory, affective and
evaluative dimensions of the pain experience and
is sufficiently sensitive to discriminate between
different pain-related problems (Holyroyd
et al 1992). A truncated form of the McGill Pain
Questionnaire – the Short-Form McGill Pain
Questionnaire – was developed for use in clinical
situations when time is short or communication is
difficult (Melzack 1987). In a study of 214 patients
with stroke, Choi-Kwon et al (2006) used the
Short-Form McGill Pain Questionnaire to
determine factors that affect quality of life three
years after stroke. Pain was identified as a factor
related to poor quality of life.
Proactively identifying and quantifying pain in the
hemiplegic shoulder early following stroke should
improve patient care since it will allow clinicians
to initiate programmes of management, including
appropriate analgesics, in a timely fashion and better
evaluate their overall effects (Cox 2010).
Management of hemiplegic shoulder pain
The evidence available from Cochrane reviews
of randomised controlled trials (RCTs) is limited
because of the small number of high quality
studies relating to the prevention and management
of HSP. In a review of four RCTs of electrical
stimulation involving 170 participants, Price and
Pandyan (2008) concluded that although electrical
stimulation could reduce muscle stiffness around
the shoulder and improve range of motion, there
was insufficient evidence to recommend it for
reducing or preventing shoulder pain following
stroke. Singh and Fitzgerald (2010) reported five
RCTs of botulinum toxin in 164 patients with
HSP, and cautiously concluded that botulinum
toxin injections seemed to reduce pain severity and
improve shoulder function and range of motion
when the pain resulted from spasticity.
Ada et al (2005) reviewed four RCTs
investigating the effectiveness of supportive devices
for preventing and treating subluxation of the
shoulder after stroke in 142 participants (including
any subsequent effects on HSP). There was
insufficient evidence to conclude whether slings or
wheelchair arm supports could prevent subluxation,
reduce HSP, or increase function in the arm after
stroke. Studies investigating strapping of the
hemiplegic shoulder have suggested that the onset
of pain could be delayed but not prevented by this
technique (Figure 4) (Ancliffe 1992, Hanger et al
2000, Griffin and Bernhart 2003).
Koog et al (2010) conducted a systematic review
of interventions for HSP, including eight RCTs
from 518 studies initially identified using the
Physiotherapy Evidence-based Database (PEDro).
 
29/06/2012 13:51
 Art & science stroke series
The authors reported pain-reducing benefits of
aromatherapy acupressure, slow-stroke massage
and neuromuscular electrical stimulation in
patients with HSP (Koog et al 2010). However,
interpretation of the findings was undertaken with
caution because of the small numbers of participants
and some methodological weaknesses.
An earlier systematic review of interventions
to prevent and manage HSP identified 126 relevant
studies, of which 11 met the stated methodological
inclusion criteria (Page and Lockwood 2003).
A series of recommendations for practice was made
based on statistically significant results reported in
the studies reviewed, but a meta-analysis of the trials
could not be conducted because of the lack of
homogeneity. Page and Lockwood (2003) found
evidence to support the use of shoulder positioning
strategies; physical exercise that did not aggravate
pain; shoulder strapping; functional electrical
stimulation; and electromyogram biofeedback
combined with relaxation to assist in the
management of HSP. In an RCT involving
38 participants, an intra-articular injection of
triamcinolone in combination with a local
anaesthetic was found to improve HSP significantly
FIGURE 4
Strapping of the hemiplegic shoulder
BOX 1
Management of patients with acute stroke
Stroke patients are prone to pain most commonly
associated with the musculoskeletal ramifications
of paralysis and immobility, particularly involving
the hemiplegic shoulder. Patients should be asked
about pain. Any pain should be assessed and treated
appropriately as soon as possible.
Given the complexity of post-stroke shoulder pain,
consideration should be given to use of algorithms
or an integrated care pathway for diagnosis and
management.
(Adapted from Section 4, Scottish Intercollegiate Guidelines
Network 2010)
40  july 4 :: vol 26 no 44 :: 2012 © NURSING STANDARD / RCN PUBLISHING
p35-44w44 40
compared with controls (Lakse et al 2009). While
these results are promising, there was a lack of detail
regarding the patients involved in the study.
Paci et al (2007) reported that subluxation at
admission accounted for 50% of shoulder pain at
one month following stroke. These results suggest
that effective early management of subluxation
could reduce the incidence of HSP. Recent imaging
studies and clinical cohort studies have shown that
subluxation is associated with soft tissue damage
and may therefore result in HSP (Huang et al
2010). Kumar et al (2010) identified 35 studies
addressing inferior subluxation and reviewed eight
that met their inclusion criteria. They reported that
loss of muscle strength after stroke was a major
risk factor for shoulder subluxation and that this
should be addressed in care and rehabilitation.
Subluxation, tissue damage and subsequent pain
may be minimised if the affected shoulder of a
patient with hemiplegia, which may be mechanically
unstable and therefore liable to subluxation, is
handled well and supported. This can, in part, be
achieved by supporting the limb proximally and
externally rotating the shoulder throughout
movements (particularly lifting the paretic arm
overhead during therapy or care procedures) and, as
a result, pain-free range of motion may be improved
(Tyson and Chissim 2002). However, another
RCT involving 32 patients with stroke did not
demonstrate a statistically significant benefit of static
positional stretches at 90° abduction for 20-minute
periods in preventing HSP (Gustafsson and
McKenna 2006). Despite a lack of robust evidence
regarding the use of shoulder supports, studies
suggest that the provision of some means of support
to maintain normal anatomical alignment and
to protect a paretic arm is desirable (Zeferino
and Aycock 2010).
Clinical guidance
Shoulder pain remains a common problem after
stroke, which suggests that it is not generally
well managed (Jönsson et al 2006). This is
reflected in UK stroke guidelines (Royal College
of Physicians Intercollegiate Stroke Working Party
2008, Scottish Intercollegiate Guidelines Network
2010, NHS Quality Improvement Scotland
2011) (Boxes 1, 2 and 3). Patients with stroke
may present with a challenging combination of
differing degrees of paralysis, sensory loss, and
cognitive and communicative impairments against
a background of the common musculoskeletal
ailments experienced by many older people,
including neck, back, hip and shoulder pain (Royal
College of Physicians, British Geriatrics Society
and British Pain Society 2007).
29/06/2012 13:51
 The use of high-visibility guidance for positioning
of patients affected by stroke, such as that developed
by Chest Heart & Stroke Scotland (Figure 5), is
recommended (Zeferino and Aycock 2010). The
Stroke Training and Awareness Resources (STAR),
a series of web-based e-modules at core and
advancing competency levels (www.stroketraining.
org), is a useful tool designed to provide education
for a wide range of clinical staff working in stroke
management. STAR includes highly visual and
specific clinical guidance for the management of the
hemiplegic upper limb and the shoulder in patients
following stroke (NHS Education Scotland 2011).
Recommendations for the care and management
of patients with hemiplegia following stroke include:
Always
 take care when handling the hemiplegic
arm. Make sure that the scapula rotates when
the arm is moved, particularly in excess of 60°
from the dependent position when sitting or
from horizontal when lying down (Figure 6).
Move
 the arm slowly and ensure that the
arm rotates outwards when lifted to avoid
impingement.
Check
 the position of the shoulder in the hoist
sling during lifting as the joint may be pulled
forward as the patient is raised.
Check
 the position of the shoulder when
assisting the patient to move in bed to ensure
that the scapula glides forwards, particularly
when lying on the hemiplegic side.
Choose
 an appropriate chair or cushion and
bed or mattress that fits the patient and controls
resting muscle tone.
Always
 provide direct support under the paretic
arm using a pillow, cushion or foam and elevate
in the presence of hand swelling.
 a shoulder support such as a sling or cuff
Use
when the limb cannot be directly supported,
for example when standing or transferring.
Change
 the position of the arm regularly to try
and maintain normal anatomical alignment as
much as possible. Keep observing the patient
and adjust his or her position as necessary.
Ensure
 all staff are aware of the vulnerability
of the shoulder after stroke and communicate
specific management strategies during
multidisciplinary team meetings to allow
24-hour care.
Share
 clinical perspectives on the various aspects
of care to ensure the best knowledge transfer
possible among team members.
Train
 new staff in correct handling, positioning
and mobilising of the shoulder and arm and
refresh knowledge regularly.
Ensure
 appropriate timely pain relief in the form
of an analgesic if required. Look for non-verbal
cues of pain, particularly when handling the arm.
© NURSING STANDARD / RCN PUBLISHING july 4 :: vol 26 no 44 :: 2012  41
p35-44w44 41
BOX 2
National clinical guideline for stroke
Every patient with significant functional loss in his or her arm should
have the risk of developing shoulder pain reduced by:
Ensuring that everyone handles the weak arm correctly, avoiding
mechanical stress.
Employing correct anatomical positioning of the arm, using foam arm
supports if necessary.
Asking every patient with arm weakness, initially daily, about his or
her pain.
Every patient who develops shoulder pain should:
Have pain severity assessed, recorded and monitored regularly.
Have preventive measures in place.
Be offered simple analgesia.
Any patient with persistent more troublesome shoulder pain should
be considered for:
High intensity transcutaneous electrical nerve stimulation.
Shoulder strapping.
Functional electrical stimulation in the presence of subluxation.
(Adapted from Section 6.22, Royal College of Physicians Intercollegiate Stroke
Working Party 2008)
BOX 3
Pain management following acute stroke
Factors to consider when managing pain following stroke include:
Hemiplegic shoulder pain is common.
Preventive and treatment strategies should be employed.
Staff should be aware that subluxation is associated
with worse hemiplegic shoulder pain.
Staff should be aware that trauma to the shoulder can arise as a
consequence of rehabilitation so appropriate handling skills should
be taught.
Hemiplegic shoulder pain is more prevalent in left hemiplegia.
Staff should ensure that analgesia is offered to patients regularly.
(Adapted from Section 6, NHS Quality Improvement Scotland 2011)
 a protocol for pain assessment.
Use
Ensure
 patient and carer awareness and
involvement wherever possible.
Conclusion
HSP is a common complication of stroke. Its causes
are not understood fully, but it is usually associated
with weakness of the arm, particularly on the left
side; loss of sensation; abnormal muscle tone; and
loss of range of motion. Shoulder subluxation may
mean that the patient is at risk of physical trauma
during care and rehabilitation; subluxation has been
associated with soft tissue damage, which may also
contribute to HSP. 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. There is
 
29/06/2012 13:51
 Art & science stroke series

FIGURE 5
Guidance on positioning of patients affected by stroke

POSITIONING FOR PEOPLE

AFFECTED BY STROKE
The careful positioning and
placement of pillows can be
used to achieve safe and
comfortable postures.
Affected stroke side is in blue.
Pictures do not depict bed
rails. These positioning
suggestions apply after 72
hours of having a stroke.

LYING ON AFFECTED SIDE LYING ON UNAFFECTED SIDE

• One or two pillows for head • One or two pillows for head
• Affected shoulder positioned comfortably • Affected shoulder forward with arm
• Place unaffected leg forward on one or supported on pillow
two pillows • Place affected leg backwards on one
• Place pillows in front and behind or two pillows
• Place a pillow behind.

SITTING UP
• Sitting well back in the centre of chair
or wheelchair
• Place arms well forward onto two
pillows on table
• Feet flat on floor or footrests
• Knees directly above feet

SITTING IN BED
LYING ON BACK (if desired) • Sitting in bed is desirable for
• Place three pillows supporting both short periods only
shoulders and head • Sitting upright well supported by
• Place affected arm on pillow. pillows
• Optional pillow beneath affected hip • Place both arms on pillows
• Ensure feet in neutral position • Legs supported for comfort
CHSS takes no responsibility for the consequences of error, loss or damage suffered by users of information published on this chart.

CHEST HEART & STROKE SCOTLAND

Rosebery House, 9 Haymarket Terrace, Edinburgh EH12 5EZ
Tel: 0131 225 6963 Fax: 0131 220 6313
Advice Line: 0845 077 6000
Website: www.chss.org.uk

F16 Chest Heart & Stroke Scotland and CHSS are operating names of The Chest Heart & Stroke Association Scotland, a registered Charity No. SCO18761 Jan 2012

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p35-44w44 42 29/06/2012 13:51

 FIGURE 6 a lack of robust evidence despite 30 years of research
Correct handling technique for assisting a patient in this area. This is reflected in national guidelines,
with a hemiplegic shoulder which emphasise the need for further research.
Given the dearth of high quality and specific
guidance, healthcare professionals must continue
to care for patients to the best of their ability,
highlighting the problems associated with
hemiplegic shoulder pain within stroke
units and specialist multidisciplinary teams,
sharing knowledge and expertise, and applying
evidence-based practice whenever possible NS

Acknowledgement
Nursing Standard thanks Anne Rowat, lecturer,
School of Nursing, Midwifery and Social Care,
Edinburgh Napier University, and chair of the
research action group, Scottish Stroke Nurses
Forum, for co-ordinating and developing this series.

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