The integrated care pathway comprises clinical and service management guidelines for management of hemiplegic shoulder pain.
Hemiplegic shoulder pain can result from a number of different clinical problems, including tone, structural mal-alignment etc.
This heterogeneity poses a challenge for clinical management requiring a range of different approaches, according to individual presentation:
- At one end of the spectrum is the low-toned, flaccid, subluxed shoulder,
- and at the other the high-toned, spastic shoulder –
- although many patients will have a mixed pattern of high and low tone muscles in the affected upper limb.
Visual examples of different presentations of the spectrum (PDF).
Early management of the hemiplegic shoulder with appropriate handing and positioning can prevent secondary soft-tissue damage. The key founding principles of the integrated care pathway are:
- Handling
- Support
- Pain relief
A key feature of the integrated care pathway is the initial stratification of the presentation into 'Floppy Subluxed' and 'Painful stiff' shoulder which trigger different immediate management plans and initial handling /support protocols (within 48 hours), pending more detailed multimodal assessment with a personalised management plan (within 10 days).
The bespoke programme comprises:
- Personalised handling and support
- Physical management (including spasticity management, electrical stimulation etc.)
- Medical investigation to identify any soft tissue pathology (such as impingement, tendinitis, bursitis, capsulitis) etc., which are managed in their own right
Fortnightly reviews include serial of evaluation of pain using adapted tools to support pain reporting by patients with cognitive communication difficulties until the symptoms resolve of plateau.
Time-scale of hemiplegic shoulder pain management in the form of flowchart (PDF).
The integrated care pathway is not intended to be a rigid protocol. Instead it provides a framework to assist with clinical reasoning and decision-making, to support interventions that are targeted towards the root cause(s) of the symptoms and presentation.
Using the tools and resources
The integrated care pathway tools and resources are to free download and use.
Clinicians are welcome to adapt them for their own settings and patient groups. We ask only that they cite the integrated care pathway source paper in any resulting publications.
Original integrated care pathway documentation
Documentation (PDF)
Training
Guidelines for application (PDF)
Training slides (PDF)
Publications
Underpinning systematic review of the evidence base for the integrated care pathway
Turner-Stokes L, Jackson D. Shoulder pain after stroke: a review of the evidence base to inform the development of an integrated care pathway. Clinical Rehabilitation. 2002;16(3):276-298. doi:10.1191/0269215502cr491oa
Integrated care pathway source paper
D. Jackson, L. Turner-Stokes, A. Khatoon, H. Stern, L. Knight & A. O'Connell (2002). Development of an integrated care pathway for the management of hemiplegic shoulder pain, Disability and Rehabilitation, 24:7, 390-398, DOI: 10.1080/09638280110101569
Application to improve the quality of care
Jackson D, Turner-Stokes L, Williams H, Das-Gupta R. Use of an integrated care pathway: a third-round audit of the management of shoulder pain in neurological conditions. J Rehabil Med. 2003 Nov;35(6):265-70. doi: 10.1080/16501970310012446
Management of Shoulder spasticity using Botulinum toxin
Ashford S, Turner-Stokes L. Management of shoulder and proximal upper limb spasticity using botulinum toxin and concurrent therapy interventions: a preliminary analysis of goals and outcomes. Disabil Rehabil. 2009;31(3):220-6. doi: 10.1080/09638280801906388
Evaluation of outcome
Michele Walsh, Stephen Ashford, Hilary Rose, Ejessie Alfonso, Aideen Steed & Lynne Turner-Stokes (2022) Stratified management of hemiplegic shoulder pain using an integrated care pathway: an 18-year clinical cohort analysis, Disability and Rehabilitation, 44:20, 5909-5918, DOI: 10.1080/09638288.2021.1951851
Many patients with stroke or other acquired brain injury have cognitive / communicative or visuo-spatial difficulties that limit their ability to report their symptoms accurately. The ICP introduces a number of adapted tools to support pain assessment in this group of patients
A questionnaire is only as accurate as the patient’s ability to understand the questions and select the appropriate responses.
AbilityQ
The AbilityQ is a pre-screening tool, designed to be used in conjunction with the ShoulderQ.
It tests the patient’s ability to respond to verbal and visual questions accurately when presented in the same format in the format of the ShoulderQ, and to identify the level of support that a patient may need in order to do so.
ShoulderQ
The ShoulderQ comprises a combination of verbal and visual questions to facilitate the recording of pain in three scenarios:
- At rest
- On Movement
- At night
Its purpose is to identify the severity of pain in each scenario in order to guide the timing of analgesic medication.
The visual component of the ShoulderQ may either be applied in the form of three numbered graphic rating scales or the SPIN.
Download AbilityQ and ShoulderQ
AbilityQ and ShoulderQ (PDF)
Publications
Turner-Stokes L, Rusconi S. Screening for ability to complete a questionnaire: a preliminary evaluation of the AbilityQ and ShoulderQ for assessing shoulder pain in stroke patients. Clinical Rehabilitation. 2003;17(2):150-157. Doi:10.1191/0269215503cr595oa
Turner-Stokes L, Rusconi S. Screening for ability to complete a questionnaire: a preliminary evaluation of the AbilityQ and ShoulderQ for assessing shoulder pain in stroke patients. Clinical Rehabilitation. 2003;17(2):150-157. Doi:10.1191/0269215503cr595oa
Turner-Stokes L, Jackson D. Assessment of shoulder pain in hemiplegia: sensitivity of the ShoulderQ. Disabil Rehabil. 2006 Mar 30;28(6):389-95. Doi:10.1080/09638280500287692
Find out more about the AbilityQ and Shoulder Q tool.
The Scale of Pain Intensity (SPIN) is a six-point ordinal scale (range 0-5) for measuring pain intensity.
It consists of a sequence of red circles, and is designed to avoid the use of numbers, words or faces and to promote clarity for patients with visual and language impairments.
The Numbered Graphic Rating Scale (NGRS) is a 10cm vertical scale with interval labels 1 to 10, anchored at each end with the same descriptors as the SPIN.
Download SPIN
SPIN booklet (PDF)
SPIN Scrreen (PDF)
Publications
Diana Jackson, Sandra Horn, Paula Kersten and Lynne Turner-Stokes, Development of a pictorial scale of pain intensity for patients with communication impairments: initial validation in a general population (PDF, 262kb), Clin Med 2006;6:580–5
Lynne Turner-Stokes, Rebecca Disler, Asa Shaw and Heather Williams, Development of a pictorial scale of pain intensity for patients with communication impairments: initial validation in a general population, Screening for pain in patients with cognitive and communication difficulties: evaluation of the SPIN-screen (PDF, 382kb), Clin Med 2008;8:393–8
Find out more about the Scale of Pain Intensity (SPIN) tool
Literature review
A review of the literature has been completed from end of the development of the integrated care pathway in 2000 to 2021. The quality of the research is being assimilated using the typology that was developed for the national service framework for long term conditions.
Refined protocol
The integrated care pathway protocol is being updated with reference to the update literature.
It continues to be founded on careful positioning and handling with clear guidelines with an emphasis on education.
The broad stratification for management shoulder is retained (ie weak and low tone shoulder or the stiff and painful) as are the more defined components of the presentation to guide further treatment:
- Bony (eg trauma, heterotropic ossification)
- Capsular (eg adhesive capsulitis)
- Soft tissue (eg impingement, tendonitis)
- Muscular (eg spasticity, weakness)
- Sensory (eg central pain, chronic pain)
The protocol provides clearer guidance on the indications and place for specific interventions according to individual presentation including:
- Botulinum toxin injection for spasticity in the shoulder muscles
- Neuromuscular and Muscular Electrical Stimulation (NMES), both for sensory stimulation and for muscle strengthening
- Carefully targeted injection of steroid, guided by ultrasound and/or MRI
- Hydrodistension for adhesive capsulitis
- Supra-scapular nerve block for chronic or intractable pain
Evaluation of outcome
The integrated care pathway has been evaluated in an 18-year cohort study. This showed a significant reduction in pain in 65% of the population. This compares favourably to results seen in the literature of 27% or less.