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Shoulder Pain in Hemiplegia

Hemiplegic Shoulder Pain

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 is hemiplegic shoulder pain, which can hamper functional recovery and subsequently lead to disability. Poduri reports that hemiplegic shoulder pain can begin as early as 2 weeks poststroke but typically occurs within 2-3 months poststroke.
 A study by Adey-Wakeling et al found the frequency of poststroke hemiplegic shoulder pain to be 29% over a 12-month follow-up period, with the median pain score being most severe at 4 months.

Most studies have speculated about the etiology of shoulder pain in hemiplegia but have failed to establish a cause-and-effect relationship. Some of the most frequently suspected factors contributing to shoulder pain include subluxation, contractures, complex regional pain syndrome (CRPS), rotator cuff injury, and spastic muscle imbalance of the glenohumeral joint.

However, identifying the exact mechanism(s) of shoulder pain can be inherently difficult, with many of the current treatment regimens varying according to assumptions made about its cause. Hanger and colleagues suggested it to be highly probable that the cause is multifactorial, with different factors contributing at different stages of recovery (ie, flaccidity contributing to subluxation and subsequent capsular stretch, abnormal tonal and synergy patterns contributing to rotator cuff or scapular instability).
Because of the difficulty in treating shoulder pain once established, early initiation of treatment is valuable.

For individuals who have had strokes with resultant hemiplegia, motor and functional recovery are important steps in the treatment process. Chae and coauthors indicated that the amount of motor recovery is related to the degree of initial severity and the amount of time before voluntary movements are initiated.

Numerous neurofacilitative treatments have been developed in hopes of improving the quality and decreasing the amount of time to recovery. Unfortunately, Chae et al found that the length of stay at most acute inpatient rehabilitation facilities is shortening; they also determined that the primary means of restoring maximal function involves the use of compensatory strategies, rather than the employment of motor control restoration.

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