Post-stroke shoulder pain in the medical rehabilitation phase (pilot study)

Introduction. Post-stoke shoulder pain (PSSP) commonly occurs within the first 2-3 months after stroke, interferes with the recovery of motor function, prolongs hospital stay, is associated with depression, and limits daily activities and proper participation in rehabilitation programs.

Aim. To identify the features of post-stroke shoulder pain before and after the rehabilitation course, taking into account the rehabilitation methods used.

Materials and methods. The study observed 37 patients (average age of 63 years, 17 men and 13 women), of which 32 patients were in the early recovery period after acute cerebrovascular event (ACVE) and 5 patients were in the late recovery period. The study evaluated the type of post-stroke pain syndrome, characteristics of pain syndrome in post-stroke arthropathy and neurological status of patients before and after rehabilitation activities.

Results. Of the 37 patients examined, 30 patients had post-stroke arthropathy (81.1%); 4 patients (10.8%) had central post-stroke pain syndrome and 3 patients (8.1%) had pain syndrome associated with a painful spasm in the spastic muscles of paretic limbs. Stroke patients with severe and pronounced arm paresis more often developed post-stroke shoulder pain. Patients had significantly limited range of motion within the shoulder joint due to pain syndrome. The shoulder’s range of motion in the shoulder joint when measured with a goniometer before rehabilitation activities averaged 1100 with the arm in fixed flexion, and 880 with the arm in passive abduction. At the time of discharge, patients who underwent traditional rehabilitation activities combined with the use of botulinum toxin type A showed better results compared to patients without botulinum therapy.

Conclusions. Early diagnosis of post-stroke shoulder pain and a thorough approach to rehabilitation activities are needed, as specific mechanisms may require personalized therapeutic interventions.

1. Feigin VL, Brainin M, Norrving B, Martins S, Sacco RL, Hacke W et al. World Stroke Organization (WSO): global stroke fact sheet 2022. Int J Stroke. 2022;17(1):18–29. https://doi.org/10.1177/17474930211065917.

2. Dutta A, Singh S, Saha S, Rath P, Sehrawat N, Kumar Singh N. Efficacy of individualized homeopathic medicines in treatment of post-stroke hemiparesis: A randomized trial. Explore. 2023;19(2):243–250. https://doi.org/10.1016/j.explore.2022.08.017.

3. Shepherd RB, Carr JH. The shoulder following stroke: preserving musculoskeletal integrity for function. Top Stroke Rehabil. 1998;4(4):35–53. https://doi.org/10.1310/U7QR-A17D-16XR-5GBT.

4. Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016;47(6):e98–e169. https://doi.org/10.1161/STR.0000000000000098.

5. Пизова НВ, Пизов НА, Мареев МС. Боль после инсульта и реабилитация (клиническое наблюдение). РМЖ. Медицинское обозрение. 2023;7(10):672–679. https://doi.org/10.32364/2587-6821-2023-7-10-10.

6. Pizova NV, Pizov NA, Mareev MS. Post-stroke pain and rehabilitation (case report). RMJ. Medical Review. 2023;7(10):672–679. (In Russ.) https://doi.org/10.32364/2587-6821-2023-7-10-10.

7. Janus-Laszuk B, Mirowska-Guzel D, Sarzynska-Dlugosz I, Czlonkowska A. Effect of medical complications on the after-stroke rehabilitation outcome. NeuroRehabilitation. 2017;40(2):223–232. https://doi.org/10.3233/ NRE-161407.

8. Wanklyn P, Forster A, Young J. Hemiplegic shoulder pain (HSP): natural history and investigation of associated features. Disabil Rehabil. 1996;18(10):497–501. https://doi.org/10.3109/09638289609166035.

9. Anwer S, Alghadir A. Incidence, prevalence, and risk factors of hemiplegic shoulder pain: a systematic review. Int J Environ Res Public Health. 2020;17(14):4962. https://doi.org/10.3390/ijerph17144962.

10. Cotellessa F, Campanella W, Puce L, May MC, Ponzano M, Picasso R et al. Clinical and Ultrasound Evaluation of Hemiplegic Shoulder Pain in Stroke Patients: A Longitudinal Observational Study Starting in the First Hours After Stroke. Medicina. 2025;61(3):484. https://doi.org/10.3390/medicina61030484.

11. Paolucci S, Iosa M, Toni D, Barbanti P, Bovi P, Cavallini A et al. Prevalence and Time Course of Post-Stroke Pain: A Multicenter Prospective Hospital-Based Study. Pain Med. 2016;17(5):924–930. https://doi.org/10.1093/pm/pnv019.

12. Kalichman L, Ratmansky M. Underlying pathology and associated factors of hemiplegic shoulder pain. Am J Phys Med Rehabil. 2011;90(9):768–780. https://doi.org/10.1097/PHM.0b013e318214e976.

13. Adey-Wakeling Z, Liu E, Crotty M, Leyden J, Kleinig T, Anderson CS, Newbury J. Hemiplegic shoulder pain reduces quality of life after acute stroke: a prospective population-based study. Am J Phys Med Rehabil. 2016;95(10):758–763. https://doi.org/10.1097/PHM.0000000000000496.

14. Dyer S, Mordaunt DA, Adey-Wakeling Z. Interventions for post-stroke shoulder pain: an overview of systematic reviews. Int J Gen Med. 2020;13:1411–1426. https://doi.org/10.2147/IJGM.S200929.

15. Kumar P. Hemiplegic shoulder pain in people with stroke: present and the future. Pain Manag. 2019;9(2):107–110. https://doi.org/10.2217/pmt-2018-0075.

16. Fitterer JW, Picelli A, Winston P. A novel approach to new-onset hemiplegic shoulder pain with decreased range of motion using targeted diagnostic nerve blocks: the ViVe algorithm. Front Neurol. 2021;12:668370. https://doi.org/10.3389/fneur.2021.668370.

17. Neto IS 4th, Guimaraes M, Ribeiro T, Gonçalves A, Natario I, Torres M. Retrospective Cohort Study on the Incidence and Management of Hemiplegic Shoulder Pain in Stroke Inpatients. Cureus. 2024;16(12):e76030. https://doi.org/10.7759/cureus.76030.

18. Hadianfard H, Hadianfard MJ. Predictor factors of hemiplegic shoulder pain in a group of stroke patients. Iran Red Crescent Med J. 2008;10(3):215–219.

19. Yim J, Kim B. Effectiveness of Shoulder Taping in Treating Hemiplegic Shoulder Subluxation: A Randomized Controlled Study of 35 Patients. Med Sci Monit. 2024;30:e944222. https://doi.org/10.12659/MSM.944222.

20. Payton H, Soundy A. The Experience of Post-Stroke Pain and The Impact on Quality of Life: An Integrative Review. Behav Sci. 2020;10(8):128. https://doi.org/10.3390/bs10080128.

21. Vasudevan JM, Browne BJ. Hemiplegic shoulder pain: an approach to diagnosis and management. Phys Med Rehabil Clin N Am. 2014;25(2):411–437. https://doi.org/10.1016/j.pmr.2014.01.010.

22. Marotta N, Demeco A, Moggio L, Ammendolia A. The adjunct of transcranial direct current stimulation to Robot-assisted therapy in upper limb poststroke treatment. J Med Eng Technol. 2021;45(6):494–501. https://doi.org/10.1080/03091902.2021.1922527.

23. Lindgren I, Jonsson AC, Norrving B, Lindgren A. Shoulder pain after stroke: A prospective population-based study. Stroke. 2007;38(2):343–348. https://doi.org/10.1161/01.STR.0000254598.16739.4e.

24. McLean DE. Medical complications experienced by a cohort of stroke survivors during inpatient, tertiary-level stroke rehabilitation. Arch Phys Med Rehabil. 2004;85(3):466–469. https://doi.org/10.1016/S0003-9993(03)00484-2.

25. Hanger HC, Whitewood P, Brown G, Ball MC, Harper J, Cox R, Sainsbury R. A randomized controlled trial of strapping to prevent post-stroke shoulder pain. Clin Rehabil. 2000;14(4):370–380. https://doi.org/10.1191/0269215500cr339oa.

26. Gustafsson L, McKenna K. A programme of static positional stretches does not reduce hemiplegic shoulder pain or maintain shoulder range of motion-A randomized controlled trial. Clin Rehabil. 2006;20(4):277–286. https://doi.org/10.1191/0269215506cr944oa.

27. Andrews AW, Bohannon RW. Decreased shoulder range of motion on paretic side after stroke. Phys Ther. 1989;69(9):768–772. https://doi.org/10.1093/ptj/69.9.768.

28. Ratnasabapathy Y, Broad J, Baskett J, Pledger M, Marshall J, Bonita R. Shoulder pain in people with a stroke: A population-based study. Clin Rehabil. 2003;17(3):304–311. https://doi.org/10.1191/0269215503cr612oa.

29. Ikai T, Tei K, Yoshida K, Miyano S, Yonemoto K. Evaluation and treatment of shoulder subluxation in hemiplegia: Relationship between subluxation and pain. Am J Phys Med Rehabil. 1998;77(5):421–426. https://doi.org/10.1097/00002060-199809000-00012.

30. Vuagnat H, Chantraine A. Shoulder pain in hemiplegia revisited: Contribution of functional electrical stimulation and other therapies. J Rehabil Med. 2003;35(2):49–54. https://doi.org/10.1080/16501970306111.

31. Meskers CG, Koppe PA, Konijnenbelt MH, Veeger DH, Janssen TW. Kinematic alterations in the ipsilateral shoulder of patients with hemiplegia due to stroke. Am J Phys Med Rehabil. 2005;84(2):97–105. https://doi.org/10.1097/01.PHM.0000150792.26793.E9.

32. Roosink M, Renzenbrink GJ, Buitenweg JR, Van Dongen RT, Geurts AC, IJzerman MJ. Persistent shoulder pain in the first 6 months after stroke: Results of a prospective cohort study. Arch Phys Med Rehabil. 2011;92(7):1139–1145. https://doi.org/10.1016/j.apmr.2011.02.016.

33. Khatooni M, Dehghankar L, Samiei Siboni F, Bahrami M, Shafaei M, Panahi R, Amerzadeh M. Association of post-stroke hemiplegic shoulder pain with sleep quality, mood, and quality of life. Health Qual Life Outcomes. 2025;23(1):32. https://doi.org/10.1186/s12955-025-02367-x.

34. Shirokov VA, Baluyeva TV, Gusev VV. The effectiveness of local injection therapy into trigger zones with lornoxicam in the treatment of post-stroke periarthropathy. Мanage Pain. 2014;(4):46–48. (In Russ.) Available at: https://elibrary.ru/trjllr.

35. Murie-Fernandez M, Carmona Iragui M, Gnanakumar V, Meyer M, Foley N, Teasell R. Painful hemiplegic shoulder in stroke patients: Causes and management. Neurologia. 2012;27(4):234–244. https://doi.org/10.1016/j.nrl.2011.02.010.

36. Широков ВА. Боль в плече: патогенез, диагностика, лечение. Екатеринбург: МЕДпресс-информ; 2012. 240 с.

37. de Sire A, Moggio L, Demeco A, Fortunato F, Spanò R, Aiello V et al. Efficacy of rehabilitative techniques in reducing hemiplegic shoulder pain in stroke: Systematic review and meta-analysis. Ann Phys Rehabil Med. 2022;65(5):101602. https://doi.org/10.1016/j.rehab.2021.101602.

38. Huang YC, Chen PC, Tso HH, Yang YC, Ho TL, Leong CP. Effects of kinesio taping on hemiplegic hand in patients with upper limb post-stroke spasticity: a randomized controlled pilot study. Eur J Phys Rehabil Med. 2019;55(5):551–557. https://doi.org/10.23736/S1973-9087.19.05684-3.

39. Yang L, Yang J, He C. The effect of kinesiology taping on the hemiplegic shoulder pain: a randomized controlled trial. J Healthc Eng. 2018:2018:8346432. https://doi.org/10.1155/2018/8346432.

40. Xie HM, Guo TT, Sun X, Ge HX, Chen XD, Zhao KJ, Zhang LN. Effectiveness of Botulinum Toxin A in Treatment of Hemiplegic Shoulder Pain: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil. 2021;102(9):1775–1787. https://doi.org/10.1016/j.apmr.2020.12.010.

41. Picelli A, Baricich A, Cisari C, Paolucci S, Smania N, Sandrini G. The Italian real-life post-stroke spasticity survey: unmet needs in the management of spasticity with botulinum toxin type A. Funct Neurol. 2017;32(2):89–96. https://doi.org/10.11138/fneur/2017.32.2.089.

42. Wissel J, Ganapathy V, Ward AB, Borg J, Ertzgaard P, Herrmann C et al. Onabotulinumtoxin A improves pain in patients with post-stroke spasticity: findings from a randomized, double-blind, placebo-controlled trial. J Pain Symptom Manage. 2016;52(1):17–26. https://doi.org/10.1016/j.jpainsymman.2016.01.007.