Hemiplegic shoulder pain after stroke: causes, positioning and treatment

The shoulder is the most mobile joint in the body and relies on muscles, rather than bony shape, to stay stable. When stroke weakens those muscles, the weight of the arm can pull the joint out of its normal position. At the same time, increased tone can pull the arm inward, and reduced sensation means the person may not notice the strain.

Pain after stroke is not always a joint problem. Tight muscles, rotator cuff injury, a stiff capsule, nerve irritation or a complex regional pain syndrome picture can each be present. For this reason NICE recommends assessing people with shoulder pain after stroke to identify its cause and using the result to decide how to manage it.

NICE advises that people at risk of shoulder pain, for example those with upper limb weakness and spasticity, and their families and carers, get information on avoiding pain or trauma to the shoulder. Practical points that teams teach include supporting the arm on a pillow or lap tray when sitting, never pulling on the weak arm when helping someone stand or turn, and checking the arm is not left hanging or trapped under the body in bed.

Patients who begin fitness training later are also warned that shoulder pain is a common problem and told to seek advice from their GP or therapist if it appears, rather than exercising through it.

A therapist or doctor will usually ask when the pain began, what makes it worse, whether it disturbs sleep and whether it limits dressing or exercises. They examine the range of movement, tone, joint position and tenderness, and may arrange imaging if an injury is suspected. Because many people cannot describe their pain clearly, for example after aphasia, observation of facial expression and behaviour during movement helps.

NICE guidance on neurological rehabilitation also asks teams to ask about pain at every holistic rehabilitation needs assessment and to support people with adequate pain relief so they can take part in therapy.

For managing shoulder pain after stroke, NICE says to encourage or help the person to adapt position to ease pain, and to consider one or more of the following.

• Taping of the shoulder, applied by a trained therapist to support position and reduce strain.

• Neuromuscular electrical stimulation, using small electrical pulses to activate the weak shoulder muscles.

• Intra-articular corticosteroid injection, placed inside the joint by a clinician.

• Nerve block with a local anaesthetic, sometimes used to allow therapy to continue.

Positioning is the unglamorous but important part of treatment. In a chair the arm should be supported so the shoulder is not dragged downwards. In bed, lying on the affected side for long periods is usually avoided, and a pillow supporting the arm in front of the body can reduce pain at night. Wheelchair arm supports and lap trays may be provided by occupational therapists.

Carers are usually shown safe transfer techniques. People who need hoisting should have a sling and technique that keep the shoulder supported. Splints and arm supports are sometimes used within the 24-hour postural management strategies described in neurological rehabilitation guidance for people who cannot sit or move independently.

If spasticity is pulling the arm into a painful position, treatment of the tone, through stretching, splinting, medicines, or botulinum toxin from a specialist team, may relieve the shoulder. NICE recommends giving people and families information about spasticity, what it is and what makes it better or worse.

Pain with burning, electric or allodynic features may be neuropathic, and NICE directs clinicians to its neuropathic pain guideline in those cases. Referral to a pain specialist can be considered when the cause is hard to identify, or when a biopsychosocial approach is needed.

People are told they can self-refer, usually with support from the GP or a named contact in the stroke rehabilitation service, if they need more help later. A sudden change, such as a hot, swollen, red arm, new numbness, or severe pain after a fall, should be assessed promptly. For sudden new weakness, facial droop, speech problems or severe headache, call 999.