Recent advances presentation on Post Stroke HSP Physiotherapy Management

1. RECENT ADVANCES
MANAGEMENT OF
HEMIPLEGIC SHOULDER
PAIN IN STROKE PATIENTS
Presentation by: Purva Pai
MPT 2nd year
Moderator: Dr Jeyaganesh V.

2. Introduction
• Stroke, also known as cerebrovascular accident (CVA), is the rapid demise of
brain cells owing to a shortage of oxygen caused by a blood vessel blockage
or arterial rupture to the brain.1
• Stroke is the third most common cause of mortality and the leading cause of
acquired adult impairment.2

3. • The greatest impact on patients and their families is typically caused by
long-term impairment, activity restrictions (disability), and decreased
engagement (handicap).2
• The most frequent and well-known disability brought on by a stroke is
motor impairment and complications which cause loss or restriction of
function in muscle control or movement or a restriction in mobility,
usually impacting the ability to move one side of the body's face, arm,
and leg.2

4. • It is found that 16% to 84% of patients have hemiplegic shoulder pain (HSP)
as a result of upper extremity complications.3
• It is usually discovered to happen between 4 weeks and 2 months following
a stroke, which is the optimal time for stroke patients to undergo
rehabilitation.4
• Although the exact causes of HSP poststroke are yet unknown, the key risk
factors are diminished motor function, tone alterations, soft tissue lesions,
and changed peripheral and central neuronal activity such as spasticity and
severe arm paralysis.5

5. • Another factor is shoulder subluxation where the glenohumeral joint tends to
collapse because of muscle weakness occurring around the shoulder joint and
the weight of the upper limb causing Hemiplegic shoulder pain.11
• Hemiplegic shoulder pain (HSP) can significantly interfere with upper limb
exercises, restrict motion, and have a certain impact on patients' capacity to
regain functional ability, daily living activities, and quality of life.
Additionally, it harms patient’s mental health, causing the formation and
exacerbation of negative psychological responses such as post-stroke despair
and anxiety.4

6. Interventions available till 20196
• Cryotherapy
• Joint Mobilization
• Ultrasound
• Transcutaneous electrical nerve stimulation
• Neuromuscular electrical stimulation
• Proprioceptive Neuromuscular Facilitation
• Good limb position and ROM exercises for the affected shoulder
• Bobath therapy
• Brunnstrom therapy

7. Need for Recent Studies
• Upper limb dysfunction in post-stroke patients leads to an increase in
disability and a decrease in the Quality of Life.
• Pain is the primary component due to which there will be activity
limitation.

8. • Recovery is hampered or delayed in post-stroke patients due to the
presence of hemiplegic shoulder pain hence there is a need to address
this problem early.
• Therefore in order to effectively treat hemiplegic shoulder pain, get
longer-lasting relief and improve Quality of Life it is crucial to look
for recent evidence in physiotherapy.

9. Search Strategies
• Database searched: PubMed, Google scholar, Science Direct.
• Key words: Shoulder pain, Shoulder Subluxation, Stroke, Post-stroke,
Physiotherapy management, Intervention, Exercise Therapy.
• Selection Criteria:
1) The search was limited to data published between 2020-2023 and only
English-language articles were included with full-text or abstract of the
articles.
2) Articles before 2020 were excluded.

10. Title Year
Level Of
Evidence
1) Extracorporeal shock wave therapy for shoulder
pain after stroke: A systematic review and meta-
analysis (Abstract)
2023 1a
2) Effect of Kinesiotaping on pain relief and upper
limb function in stroke survivors: A systematic
review and meta-analysis
2022 1a
3) Effects of sling exercise therapy on balance,
mobility, activities of daily living, quality of life and
shoulder pain in stroke patients: a randomized
controlled trial
2020 1b

11. Title Year Level Of
Evidence
4) Post-needling soreness and trigger point dry
needling for hemiplegic shoulder pain following
stroke
2020 1b
5) Effects of Repetitive Peripheral Magnetic
Stimulation on Shoulder Subluxations Caused by
Stroke: A Preliminary Study
2020 4

12. 1) Extracorporeal shock wave therapy for
shoulder pain after stroke: A systematic review
and meta-analysis (2023)
Authors: Tingyu Zhang, Cai Zhang
Physiotherapy Department, School of Rehabilitation Science, Shanghai
University of Traditional Chinese Medicine, Shanghai, China
Journal: Clinical Rehabilitation (Sage Journals) (Impact factor: 2.88)

13. Patient Population Intervention
• Patients with Shoulder pain after stroke • Trials taken to check the effectiveness of
Extracorporeal Shock Wave Therapy (ESWT)
Comparison Outcomes
• ESWT compared with conventional
treatment
• VAS – Visual Analogue Scale
• FMA-UE – Fugl-Meyer Assessment Upper
Extremity Scale
• AROM - Active Range of Motion Assessment
• CMS - Constant-Murley Score
• MBI – Modified Barthel Index

14. Conclusion
• The ESWT has been shown to improve pain levels, motor
function, active mobility, comprehensive function of the
shoulder, and activities of daily living (ADL) better than
conventional treatment in patients with shoulder pain after
stroke

15. 2) Effect of Kinesiotaping on pain relief and
upper limb function in stroke survivors: A
systematic review and meta-analysis (2022)
Authors: Botao Tan, Gongwei Jia, Yunling Song, Wei Jiang
Department of Rehabilitation Medicine, The Second Affiliated Hospital of
Chongqing Medical University, Chongqing, China
Journal: American Journal of Translational Research (Impact factor: 4.06)

16. Patient Population Intervention
• Stroke patients with upper limb
dysfunction – Hemiplegic shoulder pain
were included
• Not limited to any race, nationality and
duration of symptoms
• Treatment with Kinesiotaping for checking its
effect on HSP and upper limb function
Comparison Outcomes
• Kinesiotaping compared with a
sham/placebo tape or with conventional
physical therapy alone
• Primary outcome measures:
 ROM of the upper limb joints
 Pain – VAS, Digital Rating scales
 Spasticity - Modified Ashworth scale (MAS)
 Shoulder subluxation
• Secondary outcome measures
 Barthel index (BI)
 Fugl-Meyer for upper extremity (FMA-UE)
assessment score

18. Possible mechanism
• Kinesiotaping provides mechanical support due to the pressure and
stretching exerted by the tape, stimulates the nervous system by giving
proprioceptive feedback, and also accelerates blood circulation, thus
reducing pain and helping to improve joint ROM and activating muscles.

19. Conclusion
• Kinesiotaping effectively relieved shoulder pain, improved
upper limb spasticity and ROM, and reduced shoulder
subluxation in stroke survivors.

20. 3) Effects of sling exercise therapy on balance, mobility,
activities of daily living, quality of life and shoulder
pain in stroke patients: a randomized controlled trial
(2020)
Authors: Jing Liu, Weibing Feng, Jun Zhou, Fujing Huang, Liping Long, Yalin Wang,
Pengcheng Liu, Xiarong Huang, Mingzhu Yang, Ke Wang, Zhilu Sun
Department of Emergency,The First Affiliated Hospital of University of South
China,NO.69 Chuanshan Road,Hengyang, Hunan,China;
Journal: European Journal of Integrative Medicine (Impact Factor: 1.31)

21. Patient Population Intervention
• Stroke patients
• Age 20-70 years
• Course of disease within 6 months
• Sling exercise therapy (SET)
• Routine physiotherapy
• Both performed in a day session for 30 minutes,
5 times per week for 4 weeks
Comparison Outcomes
• One group being given Sling exercise
therapy using a suspension device (n=25)
compared with the control group being
given Routine Physiotherapy (n=25)
• Balance - Berg Balance Scale (BBS)
• Motor Function – Fugl-Meyer Assessment
(FMA)
• ADLs – Barthel Index (BI)
• QoL – Short Form 36 (SF-36)
• Pain – Visual Analogue Scale (VAS) [For
shoulder pain that occurred after stroke]

24. Possible mechanism
• As a training program, the SET focuses on strengthening the trunk and limb
muscles, as well as on stimulating the proprioceptors, thus promoting
coordination of the neuromuscular system.
• Sling suspension training could induce active contraction of shoulder muscle,
thus, it could effectively reduce shoulder subluxation, and improve
proprioception and upper limb function in acute stroke.

25. • In this study, through some progressive approaches like relaxation training,
manipulative therapy, and stability training, they activated the soft tissue
around the hemiplegic shoulder joint, corrected the abnormal scapula posture,
and balanced the muscle strength and muscle tension around the shoulder
joint.
• This significantly relieved the patient’s pain and improved upper extremity
motor function. Therefore by activating the proprioception of nerve and
muscle, and improving the stability of the shoulder joint, the SET was more
effective to relieve shoulder pain and improve the upper limb movement
function of stroke patients than the conventional treatment.

26. Conclusion
• The sling exercise therapy has been shown to be a safe and effective
method to improve balance, mobility, activities of daily living, quality
of life, and shoulder pain in stroke patients.
• It could be an important therapeutic strategy to promote
comprehensive functional recovery post-stroke.

27. 4) Post-needling soreness and trigger point dry
needling for hemiplegic shoulder pain following
stroke (2020)
Authors: Ana Mendigutía-Gómez, María T Quintana-García, Miriam Martín-Sevilla,
Diego de Lorenzo-Barrientos, Jorge Rodríguez-Jiménez, César Fernández-de-las-
Peñas and José L Arias-Buría
Department of Physical Therapy, Occupational Therapy, Physical Medicine and
Rehabilitation, Universidad Rey Juan Carlos, Alcorcón, Spain
Journal: Acupuncture in Medicine (Sage Journals) (Impact factor: 2.26)

28. Patient Population Intervention
• Stroke patients
• Aged 30-60 years
• Hypertonic upper extremity with
hemiplegic shoulder pain
• Active Trigger Points (TrPs) in
shoulder muscles with referred pain
• TrPs Dry Needling (single session)
• Neurorehabilitation program with modulatory
interventions
• 45 minutes each session
Comparison Outcomes
• Rehabilitation program alone
compared with Rehabilitation
combined with TrPs Dry Needling
• Primary outcome - intensity of post-needling induced
pain assessed with an 11-point numerical pain rating
scale (NPRS; 0=no pain; 10=maximum pain)
assessed at 1min, 24 h and 72 h after DN
• Secondary outcome - intensity of shoulder pain and
the presence of active TrPs assessed before, and 3
and 7 days after the intervention

31. Possible mechanism
• The mechanisms underlying the observed changes in shoulder pain after the
application of DN are unclear, but some hypotheses are proposed.
• It seems that DN exerts several mechanical effects on the TrP and the central
nervous system, which may potentially initiate a cascade of
neurophysiological mechanisms leading to anti-nociceptive effects.
• In fact, TrP-DN may reduce peripheral and central sensitization by removing
the source of peripheral nociception (i.e. the TrP), by modulating spinal
dorsal horn activity, and by activating central inhibitory pain pathways.

32. Conclusion
• The results showed that application of a single session of DN of the active
TrPs reproducing the shoulder pain symptoms was effective at reducing
the intensity of shoulder pain at a 1 week follow-up time point
• This trial found that 50% of stroke patients receiving DN experienced
post-needling-induced pain, a side effect that almost disappeared 72h after
the intervention without any additional therapeutic action.
• In addition, the inclusion of TrP-DN into a rehabilitation session was
effective at decreasing shoulder pain in the patients

33. 5) Effects of Repetitive Peripheral Magnetic
Stimulation on Shoulder Subluxations Caused by
Stroke: A Preliminary Study (2020)
Authors: Kenta Fujimura, Hitoshi Kagaya, Chiharu Endou, Akihito
Ishihara, Kozue Nishigaya, Kana Muroguchi, Hiroki Tanikawa, Masayuki
Yamada, Yoshikiyo Kanada, Eiichi Saitoh
Faculty of Rehabilitation, School of Health Sciences, Fujita Health
University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, Japan
Journal: Neuromodulation Journal (Elsevier) (Impact factor: 4.02)

34. Patient Population Intervention
• 12 hemiplegic patients
• Shoulder subluxation post stroke
measuring half at least
fingerbreadth with more than 30
days since onset
• Conventional Rehabilitation for 180min/day, 7 days a
week
• Repetitive peripheral magnetic stimulation (RPMS) to
Supraspinatus, Infraspinatus and Posterior Deltoid
Muscles for 17min/day, 5 days a week, for 4 weeks
Comparison Outcomes
• None • Primary Outcome – Acromio-humeral interval with
Xray using a scale
• Shoulder Pain – Numerical Rating scale
• Active range of motion of shoulder abduction
• Spasticity – Modified Ashworth Scale
• Fugl Meyer Assessment Scale (FMA-UE)

36. Possible mechanism
• rPMS activates without stimulating the skin nociceptors by using time-
varying electromagnetic fields to induce eddy currents in the adjacent volume
without passing the skin.
• It does not excite the Aδ-fibers and C-fibers of the skin. Therefore, in
addition to providing stronger stimulation while limiting pain, rPMS can
stimulate peripheral nerves and muscles located relatively deep in the body

37. Conclusion
• Repetitive peripheral magnetic stimulation effectively reduced
shoulder subluxations and subluxation-related shoulder pain caused by
stroke and improved voluntary upper-limb movements in stroke
patients.

38. Clinical Implications
Intervention – Kinesiotaping
 Clinic Condition – HSP post-stroke (Acute, Subacute, Chronic
 1 month to 1-year approx.)
 Duration – 12-72 hours, 3-5 days per week for an average of 4
weeks
 Applied over – Deltoid (anterior, middle, and posterior fibers),
Supraspinatus, Biceps, Triceps, Pectoralis Major, Teres Minor.

39. Intervention – Sling Exercise Therapy using Suspension
 Clinic Condition – Stroke patients (course of the disease within 6
months)
 Duration – 30 minutes per session, 5 times per week for 4 weeks
 Exercises Performed
1) The patient’s chest and abdomen suspended by a wide elastic band
and positioning in the prone position with the fulcrum of bilateral
elbows and knees, then swaying the torso in all directions,
therapists can assist.
2) Target elbow and wrist suspended, according to the patient's ability
to do passive/active open and close chain movement,
supplementing by shoulder loosening technology

40. Intervention – TrPs Dry Needling combined with rehabilitation
 Clinic Condition – Stroke patient with HSP presenting with active
TrPs in Shoulder muscles
 Duration – 45 mins single session including unilateral arm training
focusing on decreased muscle tone, passive positioning of the
shoulder girdle, and repetitive task training exercises along with TrPs
Dry Needling on active TrPs
 Technique – The needle is inserted into the skin over the TrP area
and advanced into the muscle using the “fast-in and fast-out”
technique until a first local twitch response is obtained, the needle
moved up and down (3–5mm vertical motions, no rotations) for 60
seconds until no more local twitch responses are elicited.

41. Intervention – Repetitive Peripheral Magnetic Stimulation
 Clinic Condition – Stroke patients with shoulder subluxation
 Duration – rPMS for 17mins/day, 5 days per week for 4 weeks.
One stimulation was 30 Hz for 2 sec. Off time was set at 3 sec.
100 cycles of stimulation for each muscle (6,000 pulses).
Conventional Rehabilitation – 180 mins/day, 7 days per week
 rPMS applied over Supraspinatus, Posterior deltoid and
Infraspinatus
 Conventional Rehabilitation including neuromuscular
facilitation, joint mobilization, and muscle stretching for shoulder
joints

42. Future Recommendations
1. According to the SR and MA, comparing Kinesiotaping with
sham/placebo tape or with conventional physical therapy alone, the
sample size is small which can cause publication bias. Therefore
studies with larger sample sizes are recommended for better
generalizability and higher-quality evidence for clinical practice.

43. 2. According to the RCT for TrPs Dry Needling for HSP, the follow-up
taken was only for changes that lasted for a week. Since stroke
survivors are chronic patients it is recommended to take longer follow-
ups to see how long the effects last and also take a larger sample size.
Also only a single session of Dry Needling was done for the
intervention. Future studies can look for effects with an increased
number of treatment sessions.

44. References
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2016;94(9):634-634A. doi:10.2471/BLT.16.181636
2) Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: a systematic review. Lancet Neurol. 2009;8:741-54.
3) Alanbay E, Aras B, Kesikburun S, Kizilirmak S, Yasar E, Tan AK. Effectiveness of Suprascapular Nerve Pulsed
Radiofrequency Treatment for Hemiplegic Shoulder Pain: A Randomized-Controlled Trial. Pain Physician.
2020;23(3):245-252.
4) Wei YH, Du DC, Jiang K. Therapeutic efficacy of acupuncture combined with neuromuscular joint facilitation in
treatment of hemiplegic shoulder pain. World J Clin Cases. 2019 Dec 6;7(23):3964-3970. doi:
10.12998/wjcc.v7.i23.3964. PMID: 31832398; PMCID: PMC6906577.
5) Kim MS, Kim SH, Noh SE, Bang HJ, Lee KM. Robotic-Assisted Shoulder Rehabilitation Therapy Effectively
Improved Poststroke Hemiplegic Shoulder Pain: A Randomized Controlled Trial. Arch Phys Med Rehabil.
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6) Walsh K. Management of shoulder pain in patients with stroke. Postgrad Med J. 2001;77(912):645-649.
doi:10.1136/pmj.77.912.645

45. 7) Zhang T, Zhang C. Extracorporeal shock wave therapy for shoulder pain after stroke: A systematic review and meta-analysis
[published online ahead of print, 2023 Jan 22]. Clin Rehabil. 2023;2692155231152134. doi:10.1177/02692155231152134
8) Tan B, Jia G, Song Y, Jiang W. Effect of kinesiotaping on pain relief and upper limb function in stroke survivors: a
systematic review and meta-analysis. Am J Transl Res. 2022 May 15;14(5):3372-3380. PMID: 35702074; PMCID:
PMC9185082.
9) Liu J, Feng W, Zhou J, Huang F, Long L, Wang Y, Liu P, Huang X, Yang M, Wang K, Sun Z, Effects of Sling Exercise
Therapy on balance, mobility, activities of daily living, quality of life and shoulder pain in stroke patients: a randomized
controlled trial, European Journal of Integrative Medicine (2020), doi: https://doi.org/10.1016/j.eujim.2020.101077
10) Mendigutía-Gómez A, Quintana-García MT, Martín-Sevilla M, et al. Post-needling soreness and trigger point dry needling
for hemiplegic shoulder pain following stroke. Acupunct Med. 2020;38(3):150-157. doi:10.1177/0964528419882941
11) Fujimura K, Kagaya H, Endou C, et al. Effects of Repetitive Peripheral Magnetic Stimulation on Shoulder Subluxations
Caused by Stroke: A Preliminary Study. Neuromodulation. 2020;23(6):847-851. doi:10.1111/ner.13064

46. THANK YOU