Most people with an SCI will experience shoulder pain at some point, but it’s very important to prevent serious injury. Here are a few ways to reduce or avoid injury.
Shoulder pain is common in people with a spinal cord injury (SCI) as well as people who have suffered a stroke and have been left with a significant hemiplegia. The pain can negatively impact on the quality of life of these individuals and hamper independent functioning. Shoulder pain is seen both in the immediate post-injury phase and in the post-rehab/chronic phase.
In the immediate post-injury phase shoulder pain can significantly impede rehabilitation attempts and can significantly delay the patient’s discharge from hospital. This type of pain affects from 16 percent to 72 percent of patients after a cerebrovascular accident, and in an SCI up to 86 percent of persons may suffer some degree of shoulder pain at some stage.
The root cause of shoulder pain in both SCI and post stroke is multifactorial. Both the flaccid upper limb (in stroke) and spasticity in the upper limbs as seen in high spinal lesions or stroke can be a trigger for shoulder pain. The shoulder joint is a complex ball-and-socket joint supported by intact muscles and ligaments. These form a complex structure around the joint called the rotator cuff.
Inappropriate handling of the shoulder, lack of initial support or over-exertion of the joint can cause injury, inflammatory processes or even tears to the rotator cuff structures, leading to pain.
In a flaccid upper limb as seen in the hemiplegic stroke patient there may be total lack of muscle support leading to subluxation of the shoulder out of the joint causing pain, inflammation and eventually injury to the capsule of the joint. Sometimes a traction injury can result in an injury to the nerves or there may be an underlying degeneration of the joint (osteo-arthritis), exacerbating the pain.
Whatever the cause of the pain, it is important to prevent injury or to commence therapy early to prevent long-term complications setting in. Handling, positioning and transferring on a day-to-day basis can exert great stress on the vulnerable shoulder. Therefore, for prophylaxis to be effective, it must begin immediately after the stroke or SCI.
Both patient and the rehab team of caregivers should be instructed on the prevention of shoulder pain and how to avoid injuries to the shoulder. Foam supports or shoulder strapping may be used to prevent pain. (Generally, overarm slings should be avoided.) The treatment of shoulder pain after stroke or SCI should start with simple analgesics.
If shoulder pain persists, treatment should include high-intensity transcutaneous electrical nerve stimulation (TENS) or functional electrical stimulation. Physiotherapy and strapping are widely used to manage shoulder pain effectively. X-rays should be taken to rule out any reversible orthopaedic problems (rotator cuff tears, tendonitis, subluxed or even dislocation of the joint).
Botulinum toxin can often be used to relieve pain in the spastic upper limb; oral anti-inflammatory medication can also assist. In cases where simple analgesics and TENS do not help, an injection into the affected joint with a steroid may help.
Surgery should be considered only as a last resort or if there are major tears in the rotator cuff structures. It may be helpful if conservative methods have failed and the shoulder has become very painful and stiff. Recent improvements in rehabilitation techniques have, however, reduced the need for surgical intervention.
Dr Ed Baalbergen is the medical officer at the Vincent Pallotti Rehabilitation Centre (Cape Town) and is a member of the International Spinal Cord Society and the Southern African Neurological Rehabilitation Association. email: firstname.lastname@example.org