Prevention and management of shoulder pain in the hemiplegic patient

Objective The objective of this review was to summarise the best available research related to the prevention and management of shoulder pain in the hemiplegic patient. Inclusion criteria This review considered all studies that included hemiplegic patients post‐cerebral vascular accident (CVA). Interventions of interest were any treatments or programs used to manage or prevent shoulder pain secondary to hemiplegia. The primary outcomes of interest were those related to pain. This review considered any randomised controlled trials (RCT) that evaluated the effectiveness of interventions that addressed shoulder pain in hemiplegic patients. In the absence of RCT, other research designs such as non‐randomised controlled trials, time series and case series were also considered for inclusion in a narrative summary. Search strategy The search sought to find both published and unpublished studies. Databases were searched up to February 2002 and included Medline, CINAHL, Current Contents, Cochrane Library, Expanded Academic Index, Electronic Collections Online, Turning Research Into Practice (TRIP), Dissertation Abstracts and Proceedings First. The reference lists of all studies identified were searched for additional studies. Assessment of methodological quality All studies were checked for methodological quality by two reviewers and data was extracted using a data extraction tool. Results Current research evaluating the effectiveness of treatment interventions on hemiplegic shoulder pain is very limited. The studies were very diverse in their nature of research. There has been no replication of studies, with the studies found using different populations, interventions or outcome measures. Not one study could be compared with another. Meta‐analysis was unable to be performed not only because of inadequate reporting of results, but more often due to differences between the studies' participants and the range of interventions used. The diversity in interval post‐CVA also makes it difficult to make any comparisons between studies. For this reason the review is in narrative form. Conclusions With this limited evidence, no single intervention has been identified that offers a dramatic effect in terms of treating pain in the hemiplegic shoulder. There is potential for some benefits for the patient's functional and comfort status, thereby improving their quality of life and maximising their social participation. Preventive interventions demonstrated that a shoulder positioning policy had no statistically significant effect on pain. Strapping within 48 h significantly delayed the onset of pain and current research evaluating exercise is not limited to just one area of exercise, but a diverse range, making it difficult to make any comparisons. Some studies did suggest evidence of improvement, albeit limited. However, some of the exercise techniques aggravated shoulder pain. Treatment interventions demonstrated that electromyogram biofeedback cannot be evaluated as a stand‐alone therapy as it is used in conjunction with relaxation therapy. Intra‐articular Triamcinolone Acetonide injections in a small RCT have not been proven to be beneficial, and are associated with a high incidence of side‐effects. Different exercise techniques may aggravate shoulder pain more than others (e.g. Bobath technique compared to cryotherapy). The systematic review on the effectiveness of functional electrical stimulation was used for prevention and treatment and concluded that there is currently no evidence for effect.