A Systematic Review of Clinical Practice Guidelines for the Management of Shoulder Pain in Patients with Stroke


  • Weeranan Yaemrattanakul Prince of Songkla University
  • Tussaneeporn Soison Prince of Songkla University
  • Lalita Khuna Prince of Songkla University
  • Joanna Jackson University of Essex


assessment, guideline, hemiplegic shoulder pain, rehabilitation, stroke


Objectives: To assess the quality, scope, and consistency of relevant clinical practice guidelines (CPGs) recommendations for hemiplegic shoulder pain (HSP) management among stroke patients.

Study design: A systematic review of CPGs.

Setting: Publishing regions were North America, Europe, Asia, and Oceania.

Subjects: Adult (≥ 18 years) stroke patients who had HSP.

Methods: Seven databases were used to search for CPGs. A total of 267 articles were screened; 8 guidelines met the inclusion criteria. The Appraisal of Guideline for Research and Evaluation (AGREE-II) was used for evaluating the quality of the selected CPGs.

Results: The recommendations of 5 high-quality guidelines for post-stroke HSP management were synthesized and 5 scopes of consistent recommendations were found comprising assessment, prevention, medical treatment, physical therapy treatment, and management of shoulder subluxation.

Conclusions: The key recommendations proposed that the assessment should evaluate muscle tone and pain level; advice and education be provided to family members and caregivers on how to handle and position the shoulder correctly, and avoid exercises involving overhead pulleys to prevent HSP; medical treatment should consider the administration of analgesics, high doses of botulinum toxin injections, subacromial corticosteroid injections, and suprascapular nerve blocks; and that physical therapy approaches should employ active exercises, taping or strapping, and the management of shoulder subluxation via slings and electrical stimulation. Future up-to-date guidelines should consider all domains of AGREE-II in order to improve their quality.

Keywords: assessment, guideline, hemiplegic shoulder pain, rehabilitation, stroke



Download data is not yet available.


Gorelick PB. The global burden of stroke: persistent and disabling. Lancet Neurol. 2019;18:417-8.

Thomas T, Stephen B, Colin M. The global burden of cerebrovascular disease [Internet]. World Health Organization; 2006. [cited 2021 Jun 6]. p. 67. Available from: https://www.who.int/healthinfo/statistics/bod_cerebrovasculardiseasestroke.pdf.

Sall J, Eapen BC, Tran JE, Bowles AO, Bursaw A, Rodgers ME. The management of stroke rehabilitation: a synopsis of the 2019 US Department of Veterans Affairs and US Department of Defense clinical practice guideline. Ann Intern Med. 2019;171:916-24.

Lawrence M, Booth J, Mercer S, Crawford E. A systematic review of the benefits of mindfulness-based interventions following transient ischemic attack and stroke. Int J Stroke. 2013;8:465-74.

Adeoye O, Nyström KV, Yavagal DR, Luciano J, Nogueira RG, Zorowitz RD, et al. Recommendations for the establishment of stroke systems of care: a 2019 update: a policy statement from the American Stroke Association. Stroke. 2019;50:e187-210.

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:e98-169.

Lui SK, Nguyen MH. Elderly stroke rehabilitation: overcoming the complications and its associated challenges. Curr Gerontol Geriatr Res. 2018;2018:9853837. doi: 10.1155/2018/9853837.

Janus-Laszuk B, Mirowska-Guzel D, Sarzynska-Dlugosz I, Czlonkowska A. Effect of medical complications on the after-stroke rehabilitation outcome. NeuroRehabilitation. 2017;40:223-32.

Bjartmarz I, Jónsdóttir H, Hafsteinsdóttir TB. Implementation and feasibility of the stroke nursing guideline in the care of patients with stroke: a mixed methods study. BMC Nurs. 2017;16:17.

Kim M-S, Kim SH, Noh S-E, Bang HJ, Lee K-M. Robotic-assisted shoulder rehabilitation therapy effectively improved poststroke hemiplegic shoulder pain: a randomized controlled trial. Arch Phys Med Rehabil. 2019;100:1015-22.

Whitehair VC, Chae J, Hisel T, Wilson RD. The effect of electrical stimulation on impairment of the painful post-stroke shoulder. Top Stroke Rehabil. 2019;26:544-7.

Teasell R, Cotoi A, Chow J, Wiener J, Iliescu A, Hussein N, Salter K. The Stroke Rehabilitation Evidence-Based Review. 18th ed. Canadian Stroke Network. [cited 2018 Mar 18]. Available from: http://www.ebrsr.com/sites/default/files/documents/v18-SREBR-ExecutiveSummary-2.pdf.

Chau JPC, Lo SHS, Yu X, Choi KC, Lau AYL, Wu JCY, et al. Effects of acupuncture on the recovery outcomes of stroke survivors with shoulder pain: a systematic review. Front Neurol. 2018;9:30.

Pan R, Zhou M, Cai H, Guo Y, Zhan L, Li M, et al. A randomized controlled trial of a modified wheelchair arm-support to reduce shoulder pain in stroke patients. Clin Rehabil. 2018;32:37-47.

Zhou M, Li F, Lu W, Wu J, Pei S. Efficiency of neuromuscular electrical stimulation and transcutaneous nerve stimulation on hemiplegic shoulder pain: a randomized controlled trial. Arch Phys Med Rehabil. 2018;99:1730-9.

Nadler M, Pauls M, Cluckie G, Moynihan B, Pereira AC. Shoulder pain after recent stroke (SPARS): hemiplegic shoulder pain incidence within 72 hours post-stroke and 8-10 week follow-up. Physiotherapy. 2020;107:142-9.

Lindgren I, Brogårdh C, Gard G. Pain management strategies among persons with long-term shoulder pain after stroke–a qualitative study. Clin Rehabil. 2019;33:357-64.

Lindgren I, Gard G, Brogårdh C. Shoulder pain after stroke–experiences, consequences in daily life and effects of interventions: a qualitative study. Disabil Rehabil. 2018;40:1176-82.

Teasell R, Salbach NM, Foley N, Mountain A, Cameron JI, Jong Ad, et al. Canadian stroke best practice recommendations: rehabilitation, recovery, and community participation following stroke. part one: rehabilitation and recovery following stroke; update 2019. Int J Stroke. 2020;15:763-88.

Qiu H, Li J, Zhou T, Wang H, Li J. Electrical stimulation in the treatment of hemiplegic shoulder pain: a meta-analysis of randomized controlled trials. Am J Phys Med Rehabil. 2019;98:280-6.

Lee SC, Kim AR, Chang WH, Kim JS, Kim DY. Hemiplegic shoulder pain in shoulder subluxation after stroke: associated with range of motion limitation. Brain Neurorehabil. 2018;11:9. [cited 2021 Jun 12]. Available from: https://doi.org/10.12786/bn.2018.11.e6.

Ghozy S, Dung NM, Morra ME, Morsy S, Elsayed GG, Tran L, et al. Efficacy of kinesio taping in treatment of shoulder pain and disability: a systematic review and meta-analysis of randomised controlled trials. Physiotherapy. 2020;107:176-88.

Intercollegiate Stroke Working Party. National clinical guideline for stroke. 5th ed. 2016. p. 178. [cited 2021 Apr 1]. Available from:https://www.strokeaudit.org/SupportFiles/Documents/Guidelines/2016-National-Clinical-Guideline-for-Stroke-5t-(1).aspx.

Royal Dutch Society for Physical Therapy. KNGF clinical practice guideline for physical therapy in patients with stroke. Amersfoort: 2014. p. 72. [cited 2021 Apr 2]. Available from: https://www.dsnr.nl/wp-content/uploads/2012/03/stroke_practice_guidelines_2014.pdf.

Lim SM, Lee S-H. Effectiveness of bee venom acupuncture in alleviating post-stroke shoulder pain: a systematic review and meta-analysis. J Integr Med. 2015;13:241-7.

Hebert D, Lindsay MP, McIntyre A, Kirton A, Rumney PG, Bagg S, et al. Canadian stroke best practice recommendations: stroke rehabilitation practice guidelines, update 2015. Int J Stroke. 2016; 11:459-84.

O’Sullivan SB, Siegelman RP. National physical therapy examination review and study guide. 22nd ed. Illinois: TherapyEd; 2019. p. 943.

Johnston A, Kelly SE, Hsieh S-C, Skidmore B, Wells GA. Systematic reviews of clinical practice guidelines: a methodological guide. J Clin Epidemiol. 2019;108:64-76.

Jolliffe L, Lannin NA, Cadilhac DA, Hoffmann T. Systematic review of clinical practice guidelines to identify recommendations for rehabilitation after stroke and other acquired brain injuries. BMJ Open. 2018;8:e018791.

del-Rosal-Jurado A, Romero-Galisteo R, Trinidad-Fernández M, González-Sánchez M, Cuesta-Vargas A, Ruiz-Muñoz M. Therapeutic physical exercise post-treatment in breast cancer: a systematic review of clinical practice guidelines. J Clin Med. 2020;9. doi: 10.3390/jcm9041239.

Defense USDoVAaUSDo. VA/DOD clinical practice guideline for the management of stroke rehabilitation. 2019. p. 170. [cited 2021 Apr 1]. Available from: https://www.healthquality.va.gov/guidelines/Rehab/stroke/VADoDStrokeRehabCPGFinal8292019.pdf.

Iruthayarajah J, Wiener J, Iliescu A, Saikaley M, Cotoi A. Evidence-based review of stroke rehabilitation. Hemiplegic shoulder pain and complex regional pain syndrome. 2018. Chapter 11. [cited 2021 Mar 30]. Available from: http://www.ebrsr.com/sites/default/files/Ch.%2011%20Hemiplegic%20shoulder%20pain_v20.pdf.

Institute of Neurology, Department of Medical Services. Clinical practice guidelines for ischemic stroke. Bangkok: Thanapress Company Limited; 2019. p. 84. [cited 2021 Mar 30]. Available from: http://www.rbpho.moph.go.th/upload-file/doc/files/ 16062020-011313-8291.pdf.

Matsakunpan P, Saringkarinkun T, Riewthong K, Thimayom P, Wichianphaisan P. Clinical practice guidelines for stroke rehabilitation. 3rd ed. Bangkok: Thana press; 2016. p. 138.

Stroke Foundation. Clinical guidelines for stroke management 2017. Australia: 2017. [cited 2021 Mar 30]. Available from: https://informme.org.au/en/Guidelines/Clinical-Guidelines-for-Stroke-Management.

Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, Deruyter F, Eng JJ, Fisher B, Harvey RL, Lang CE, MacKay-Lyons M, Ottenbacher KJ, Pugh S, Reeves MJ, Richards LG, Stiers W, Zorowitz RD; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016;47:e98–e169. doi: 10.1161/STR.0000000000000098.






Review Article