Stratified management of hemiplegic shoulder pain using an integrated care pathway: an 18-year clinical cohort analysis

Abstract

Purpose

Hemiplegic shoulder pain (HSP) is a common but heterogeneous complication of acquired brain injury. Integrated care pathways (ICPs) can support clinical decision-making, prompting timely intervention to improve quality of care. This 18-year cohort analysis of clinical data presents outcomes from an ICP for management of HSP in an inpatient rehabilitation unit.

Materials & methods

Consecutive data were extracted for all eligible patients admitted between 2000–2018 (n = 333). Patients were categorised according to presentation pattern (“Floppy-subluxed” (59%), “Painful-stiff” (21%) or Mixed/not categorised(20%)) to help guide early management. Pain was assessed using the Shoulder-Q with pain ratings/10 in three domains: rest, night-time and movement. Patients with pain reduction ≥3 points in any domain were designated ‘responders'.

Results

Mean baseline pain scores were 4.7 (95%CI 4.5,5.0). They were higher on movement (6.1(5.8,6.3)) than at rest (4.7(4.3, 5.0)) or at night (5.7(5.2,5.9)). Pain reduced significantly in all three domains (p < 0.0001) with a 65% overall response rate and complete resolution of pain 21–41%. There was a significant relationship between category of presentation pattern and management protocol used (X² = 31.2, p < 0.0001).

Conclusion

These high pain-response rates compare favourably to the literature (14–27%), suggesting that this stratified and integrated approach to HSP guides more effective management in this heterogeneous clinical presentation.

Implications for Rehabilitation

• Two-thirds of the patients demonstrated a clinically-significant reduction in pain when managed using the integrated care pathway. These results compare favourably with pain resolution rates of well under one-third cited in the literature and suggest that the integrated care pathway leads to reduced pain and improved patient outcomes.

• Hemiplegic shoulder pain can result from a range of different clinical problems. The diversity of presentation and the range of required treatments are confirmed in this 18-year cohort analysis.

• Heterogeneity in presentation of HSP poses a challenge for both management and the evaluation of outcome. The results of this study suggest that a stratified approach helps to guide more effective management.

Keywords:

• Cohort study
• shoulder pain
• hemiplegia
• acquired brain injury

Acknowledgements

The authors are very grateful to all the patients and clinicians who have taken part in the integrated care pathway over the 20 years of this cohort, especially Diana Jackson who led the original development of the ICP. We would like to acknowledge in particular Heather Williams, Margaret Kaminska and Jo Clark for their help with data entry and assimilating/cleaning the dataset.

Disclosure statement

The authors have no significant conflicts of interest. The ICP was developed in our services. Development of integrated care pathways and outcome measurement are key interests of the authors and Lynne Turner-Stokes was responsible for development of the ShoulderQ.