Hemiplegic shoulder pain

It's a frustration for me in acute care as well, and I have also had that feeling of "augh, am I ever going to be smart like that person?" I did see a short presentation on CRPS in October and can probably send you a copy of the handout if you want, lmk.

Hemiplegic shoulder pain is one of the most complex (and controversial) issues that practitioners encounter when working with stroke survivors. The literature is mixed re: cause of shoulder pain as well as recommended treatment methods. I can definitely empathize with you!

30 years ago, as a new grad, nearly half of our patients had a painful shoulder at the time of discharge. Then I was fortunate to learn how to manage the hemiplegic shoulder from some of the top experts in the field. We decreased the incidence of shoulder pain at our rehab center from 50% to about 15% by changing our handling methods.  I still use those methods today - and have shared them with  many therapists in my workshops.

Hemiplegic shoulder pain is preventable and the most important thing we can all do is handle the shoulder properly; maintaining painfree ROM with good alignment of the structures. I would be very careful of 'working through the pain' especially if you are not sure of what you are doing.

If your patient already has a painful shoulder then you must determine the source of the pain in order to know what specifically to do in treatment.

This is not easy to do - even MDs have difficulty assessing painful shoulders in stroke survivors because the typical assessment guidelines aren't feasible (for example testing for rotator cuff tear) and most won't order expensive tests (like an MRI) for a patient with a nonfunctional UE. The doctors often order an Xray, but the results are usually negative because the source of the pain is soft tissue and won't show up on an Xray.

You mentioned shoulder-hand-syndrome and adhesive capsulitis. Shoulder pain can also be caused by bursitis, tendonitis and tightness of soft tissue structures.These are just a few of the long list of potential causes of shoulder pain in hemiplegia.  Subluxation is not the source of most shoulder pain (again, controversial in the literature).

I wish I had pages and pages to help you (and hours of your time, too!).

Best of luck,

Jan

If you feel sick putting people in pain, then don't do it!  Personally, I do NOT adhere to the old adage of "no pain, no gain".

There are other professions more skilled and probably more appropriate for putting people in pain.

I absolutely agree...I do not believe in 'no pain, no gain'. Pain is counter productive.

Iif, at any time, my patient complains of pain during treatment - I stop immediately. A 'stabbing' pain is often indicative of impingement. A 'pulling' pain may be due to tightness of soft tissue structures. (Not unlike the tight feeling we have behind our knees when we haven't touched our toes in a long time).

If my patient has tightness due to soft tissue, I do slow, gentle stretches and say to my patient "You need some slow stretching to reduce the pain and get the movement necessary to be able to ______ (brush hair, etc). We'll do only what you can tolerate and try to increase the range a bit more each time."

It is very important to let your patient know that you will not move them past the point of pain, and work only within their parameters of comfort.

I absolutely agree...I do not believe in 'no pain, no gain'. Pain is counter productive.

Iif, at any time, my patient complains of pain during treatment - I stop immediately. A 'stabbing' pain is often indicative of impingement. A 'pulling' pain may be due to tightness of soft tissue structures. (Not unlike the tight feeling we have behind our knees when we haven't touched our toes in a long time).

If my patient has tightness due to soft tissue, I do slow, gentle stretches and say to my patient "You need some slow stretching to reduce the pain and get the movement necessary to be able to ______ (brush hair, etc). We'll do only what you can tolerate and try to increase the range a bit more each time."

It is very important to let your patient know that you will not move them past the point of pain, and work only within their parameters of comfort.

Thanks for all these comments, they are very helpful. I am glad to see everyone saying to avoid the pain...up until this past week I always backed off at that point and then this week I've gone a LITTLE further  than I normally would, but I still don't go very far...I agree that pain is frequently counter-productive and I guess my initial instincts to back off were more correct, especially since as Jan Davis pointed out, I'm not filled with enough experience to know the difference between "okay" pain and "bad" pain, so to speak. I did have the much more experienced PT maneuever one of my pt's shoulders today to give me her opinion....I was glad to see she was gentle and stayed within the same ranges I could get...

Cheryl - would love to see the CRPS thing. Thanks :)

Ron - thanks for your input, I agree!!

Jan - where are you located? I saw that you are associated with ICE?? Tell us more?

Thanks all for the informative comments! I have a bunch of articles coming in from various journals so I'll have to keep y'all posted on the "evidence" I read :)

Yes, I founded International Clinical Educators (ICE) in 1983 (when I moved back to the USA from Switzerland) as a way to share the clinical skills I'd learned from the experts in Europe (Bobath, Affolter, others). I am passionate  about making sure stroke survivors get the care they deserve and the hemiplegic shoulder (and prevention of shoulder pain) is one of my favorite topics.

For more info, check out my website: www.icelearningcenter.com. My Facebook page is another way to ask for help and share treatment ideas: www.facebook.com/Jan.Davis.Clinical.Educator

And, I live in Port Townsend, WA. A small town on the Olympic Peninsula, overlooking the Puget Sound - I love it here.

Waleed Al-Oboudi is a huge expert in this field.  I was fortunate enough to be trained in some of his techniques for scapular mobilization and shoulder ROM during my level II fieldwork experience.  I'm not sure if any of the info is available online, but attending a workshop would definitely be worthwhile!

The GivMohr sling and Hemi sling were also commonly used when there was subluxation.  

Waleed Al-Oboudi is a huge expert in this field.  I was fortunate enough to be trained in some of his techniques for scapular mobilization and shoulder ROM during my level II fieldwork experience.  I'm not sure if any of the info is available online, but attending a workshop would definitely be worthwhile!

The GivMohr sling and Hemi sling were also commonly used when there was subluxation.  

I think my comments are misunderstood. I was suggesting that perhaps another profession should be treating this patient's shoulder.

I've been using a lot of pain modalities with my post-CVA patients with UE pain syndromes. I've found that e-stim (tri-phasic PENS), and infra-red therapy works well. I'm fortunate to work in a transitional care facility that provides us with these types of machines.  Diathermy on a gentle heat setting also works sometimes.  I always avoid causing pain in treatments. Pain should always be your guide. Pain=BAD!