Assessment approaches for hemiplegic shoulder pain in people living with stroke – A scoping review

Figures & data

Table 1. Reported of assessment approaches for Hemiplegic shoulder pain (HSP) and associated factors: Type, description and frequency as reported from the literature.

Outcome measure / Frequency (n)	Type of Measure
Visual Analogue Scale (VAS) Horizontal/Vertical (n = 74) [8–10,17–24,30,32,36,43–46,50–52,54,55,57–59,61,62,68,69,72–77,80,82,84,88,90,91,94,95–104,106,110–114,117,119,120,122,125–130,33–135,137,138]	It consists of a horizontal/vertical straight line with the endpoints defining extreme limits such as ‘no pain at all’ (0) and ‘worst possible pain’ (10 cm). The patients are asked to mark their pain level on this 10 cm line between the two endpoints. There are no specified time scale. Pain: VAS (100 points). Degree of pain: non-existent (0), mild (10–39), moderate (40–79), or severe (80–100).
Passive Range of Movement (PROM) (n = 64) [9,18,20–22,25,26,29,33–36,38,40–44,48,50–55,57,60,61,66–68,72–74,77,79–81,84,87–88,90,95,96,98–99,103–105,107–108,111,114,115,119–122,125–127,131,137,138]	Shoulder PROM is assessed clinically in the standardised starting position of supported sitting. Flexion and abduction measurements are assessed with the shoulder in neutral. External rotation range is measured with the shoulder abducted to 45°, and the elbow flexed to 90°. Patients are asked for any pain in the shoulder during movement.
Numerical Rating Scale (NRS) (n = 32) [33,34,35,40,48,53,56,59,63,64,65,66,67,69,70,71,77,81,83,86,90,92,98,105,108,109,116,118,121,123,124,132]	In an NRS, patients are asked to rate the severity of their pain between 0–10, or 0–100 that fits best to their pain intensity. Zero represents ‘no pain at all’ whereas the upper limit represents ‘the worst pain ever possible’.
Glenohumeral Subluxation (GHS) (n = 30) [8,17,22,25,28,33,34,35,40,41,47,55,60,61,67,73,74,79,82,85,86,93,94,97,103,113,115,116,127,130]	A range of methods are used. (1) Palpation – A palpable increase in the vertical distance between the acromion and the head of the humerus. (2) Anterior-posterior radiographs (x-rays) – GHS is measured on true anteroposterior radiographs by using the vertical distance between the centre of the glenoid fossa to the centre of the humeral head. The frame of reference was defined as the superior, inferior, medial, and lateral aspects of the glenoid fossa, which accounted for scapular rotation in the hemiplegic shoulder. Changes in GHS were evaluated in millimetres as measured through comparison of radiographs of the affected side and the unaffected side. (3) AP radiographs, graded on a 5-point scale (0–4). (4) Calliper method: Acromio-humeral distance (AHD), using a digital vernier calliper. The measurement is taken in centimetres (cm) from the inferior aspect of the acromion to the superior aspect of the humeral head. The patient is seated with the effected UE in a non-supported position. Ultrasound measurements of acromion-greater tuberosity distance (AGT) distance is defined as the relative distance between the lateral edge of the acromion process of the scapula and the nearest margin of the superior part of the greater tuberosity of the humerus
Fugl–Meyer Assessment (FMA) (n = 27)[21–22,33,34–35,38,41–42,53,70,72,76,79,85,97,99–101,105,106,112,114,125,132,133,136,138]	Is an impairment measure used to assess locomotor function and control of the upper and lower extremities, including balance, sensation, and joint pain in patients with stroke. A maximum 44 points passive joint motion and joint pain section, with each item rated on a three-point ordinal scale.
Active Range of Movement (AROM) (n = 11) [18,26,31,37,45,46,68,75,87,97,113]	Shoulder AROM is assessed clinically in the standardised starting position of supported sitting. Flexion and abduction measurements are assessed with the shoulder in neutral. External rotation range is measured with the shoulder abducted to 45°, and the elbow flexed to 90°. Patients are asked for any pain in the shoulder during movement.
Brief Pain Inventory (BPI) (n = 11) [33,34,35,40,41,56,70,71,91,105,107]	Is a self-administered questionnaire designed to measure pain intensity and the extent to which pain interferes in the lives of pain sufferers. Items scored on a numeric rating scale (0–10) and then a composite (averaged) score of all the items is calculated. 7 items (the original tool) ask about the impact of pain on general activity, mood, mobility, work, relationships, sleep, and enjoyment of life over the previous week.
Pain History (location, duration, frequency) (n = 9) [19,23,24,26,31,69,74,79,88]	Pain characteristics included pain intensity during rest and during movement (0, no pain; 10, maximum conceivable pain), and pain distribution, frequency, and pattern. ‘Bothersomeness’ scores, pain characteristics at rest and active movement, previous pain history.
Shoulder Q (n = 7) [28,39,58,79,91,116,136]	It is a questionnaire with both visual graphic rating scales, and verbal questions that is designed to assess the timing and severity of hemiplegic shoulder pain. Two items are scored with a 4-point Likert scale, four items are scored with a 3-point Likert scale, one item is scored on a 5-point Likert scale. Three items scored on a numeric rating scale (0–10) regarding severity of pain at rest, on movement, and at night. Final two items provide choice for two questions: ‘which tasks increase your pain?’ and ‘which interventions relieve your pain?’
McGill Pain Questionnaire (n = 4) [65,72,77,81]	A short form version of the McGill Pain Questionnaire contains a total of 15 descriptors (4 affective and 11 sensory) which are rated on an intensity scale: 0 = None, 1 = Mild, 2 = Moderate, 3 = Severe. In total, three pain scores are derived: The sum of the intensity rank values for sensory words chosen, The sum of the intensity rank values for the affective words chosen, The total of the descriptors. In addition, the Present Pain Intensity (PPI) index is present as in the standard McGill Pain Questionnaire, and a visual analogue scale.
Pain Present/Absent at Rest (n = 5) [27,29,47,60,85]	Shoulder pain is considered to be present if the patient localized discomfort to any aspect of the affected shoulder, either at rest or with passive or active movement.
Faces Pain Scale (FPS) (n = 4) [59,83,90,92]	FPS is a seven-item horizontal scale that defines the patients’ feelings due to pain with seven facial expressions. The first face represents ‘no pain’ and the seventh face represents ‘the worst possible pain,’ and the patients are asked to mark the face that expresses their level of pain. Face figures are scored between 0 and 6, the least score representing ‘no pain’.
Shoulder Pain and Disability Index (SPADI) (n = 4) [63,80,127,128]	Is a 13-item questionnaire that consists of 2 subscales that assess pain (5 items) and disability (8 items). The score is determined by taking an average of the 2 subscales, and scores can range from 0 to 100, with a higher score indicating greater pain and disability.
Ritchie Articular Index (RAI) (n = 3) [36,37,93]	This is a four-point scale assessing shoulder joint tenderness during passive shoulder external rotation and abduction. Patient’s response to passive movement of the shoulder joint is recorded on a 4-point single-item scale: 0 = no pain; 1 = complains of pain; 2 = complains of pain and winces; 3 = complains of pain, winces, and withdraws. The Ritchie Articular Index is performed with the subject positioned supine, their arm abducted to 30 degrees and the elbow flexed to 90 degrees. The shoulder is then externally rotated to full range or until a response is elicited.
Chedoke McMaster Stroke Assessment (CMSA) (n = 2) [89,123]	The Chedoke-McMaster Stroke Assessment is a performance-based measure that consists of two inventories: the Impairment Inventory and the Activity Inventory. The Impairment Inventory is used to determine the presence and severity of common physical impairments. It has six dimensions (recovery stage of the arm, hand, leg, foot, postural control, and shoulder pain). Each dimension is measured on a 7-point scale. The 7-point scale corresponds to seven stages of motor recovery. The 7-point scale for shoulder pain is based on pain severity
The Disabilities of the Arm, Shoulder and Hand (DASH) (n = 1) [49]	The DASH is a self-report questionnaire that measures physical function and symptoms of the upper limb. The DASH consists of 30 items that measure: (a) physical function (21 items); (b) symptom severity (5 items); and (c) social or role function (4 items). The DASH uses a 5-point Likert scale that rates the individual’s difficulties the preceding week. Lower scores indicate no difficulty, limitations or symptoms whereas higher scores indicate inability to perform tasks or extreme difficulties or symptomatology.
Shoulder Disability Questionnaire (n = 1) [75]	Is a measure of shoulder disability that consists of 22 self-reporting items to which participants respond with either yes or no. The score ranges from 0 to 22, with a higher score indicating a greater degree of disability. The measure has strong associations with quality-of-life measures and has proven levels of validity in stroke patients.
Pain Behaviours scale (n = 1) [87]	The assessor evaluates how frequently the patient displays the following pain behaviours: verbal complaints, nonverbal complaints, facial grimaces, standing posture, mobility, body language, the use of visible sup-port equipment, stationary movement, and self-reported downtime and medication. These 10 pain behaviour items are scored on a 3-point scale: 0 = None, 0.5 = Occasional, and 1 = Frequent, and the total score ranges be-tween 0 to 10.
Severity of Degree of painful shoulder (n = 1) [115]	The severity degree of the painful shoulder is defined in four grades. Severe (0), pain and functional limitation while rest with all movements limited. Moderate (1), pain that intensifies with movement and very light while resting, the movements are painful, but there is no limitation in the joint range. Light (2) without pain at rest, only occurs with rapid movements or under active mobilization and almost normal (3), where only pain appears or limitation to active movements resisted.
Likert Pain Scale (LPS) (n = 1) [59]	LPS is a five-point (0–4) scale in which zero represents ‘no pain’ and four represents ‘insufferable pain’. The patients are asked to point out the number that displays their pain level.
Croft Disability Questionnaire (n = 1) [58]	Is a 22-item questionnaire that evaluates shoulder disability. The measure consists of 22 items which can be answered “yes” or “no”, and positive responses are summed to give a score. A higher score indicates severe disability, with 22 being the highest score possible.
Constant-Murley Shoulder Score (n = 1) [100]	Is a measure of shoulder joint function that assesses pain intensity (15 points), mobility of shoulder joint measured via range of motion (20 points), activities of daily living (40 points), and muscle power (25 points). The total score adds up to be a number out of 100, where a higher score indicates greater shoulder joint function.
Musculoskeletal Tests
Neer’s Test (n = 7) [9,48,53,57,76,77,116]	In the Neer impingement test, the therapist performs the test with patient in sitting position, by limiting each patient’s scapular rotation while internally rotating the affected arm in a passive mode through elevation in the scaphoid plane. Shoulder pain during this test is suggestive of subacromial impingement or injury to the supraspinatus muscle.
Combined Upper Limb Movements: Hand Behind Neck (HBN) and Hand Behind Back (HBB) (n = 5) [9,48,70,76,77]	The performance of dorsum of hand to lumbosacral junction (hand-behind-back [HBB]) manoeuvre reflects the combination of shoulder internal rotation and extension, whereas hand-behind-neck (HBN) manoeuvre is a combination of shoulder external rotation and abduction. The therapist places patient’s affected arm passively in both positions, one at a time, while patients report the intensity of shoulder pain they experience.
Acromioclavicular Shear Test (n = 2) [53,77]	The acromioclavicular shear test is said to indicate pathology at the Acromioclavicular joint (ACJ). This manoeuvre is performed with the subject sitting; the examiner cups his/her hands anteriorly on the clavicle and posteriorly on the spine of scapula. Squeezing the heel of the hands together elicits pain in the presence of ACJ inflammation.
Rowe test (n = 2) [53,77]	The Rowe test is to show multidirectional instability in the shoulder. In this test, the patient is seated in bed with the waist flexed at a 45° angle while the examiner holds the head of the humerus by placing 1 hand over the shoulder so that the index and the middle fingers sat over the anterior aspect of the humeral head and the thumb on the posterior aspect of the humeral head. The examiner then exerts anterior and posterior force to elicit instability in either direction.
Speeds test (n = 2) [53,77]	In the Speed test, the examiner actively resists the shoulder elevated in forward flexion at the plane of the scapula in a completely extended elbow with the forearm medially rotated by the patient. Pain in the bicipital groove is said to be indicative of bicipital tendon involvement.
Palpation (n = 2) [53,116]	Physical examination of the affected shoulder begins with a structured musculoskeletal examination to identify sites of tenderness on palpation. Specific sites to be palpated include: Anteriorly, the tendon of the long head of the biceps is palpated between the lesser and greater tuberosity of the humeral head. The supraspinatus tendon is palpated anteriorly over its insertion at the greater tuberosity of the humerus, with the arm at 30° of shoulder extension. The subacromial area is examined by palpating the gap between the acromial process and head of the humerus on the superolateral aspect of shoulder. Pain in the subacromial region is usually attributed to inflammation of the subacromial bursa. The acromioclavicular joint, coracoid process, and surrounding soft tissues are also examined for any localized or diffuse tenderness. Diffuse tenderness is defined as generalized shoulder girdle tenderness without localizing features.
Apprehension Test (n = 1) [48]	The apprehension test is performed by placing the patient in supine position with their arm externally rotated, in abduction and slight extension. Reporting of shoulder pain or signs of apprehension during the test suggest the likelihood that the patient may have signs of anterior shoulder instability
Hawkins-Kennedy Test (n = 1) [57]	The clinician places one hand on top of the shoulder being tested to stabilize the girdle while elevating the humerus to 90° in the plane of the scapula. The clinician then passively internally rotates the humerus to end range of motion or until reports of pain. The test is positive if pain is reported in the superior-lateral aspect of the shoulder.

Key: VAS: Visual Analogue Scale; PROM: Passive Range of Movement; NRS: Numerical Rating Scale; GHS: Glenohumeral subluxation; AHD: Acromio-humeral distance; AGT: acromion-greater tuberosity distance; FMA: Fugl-Meyer Assessment; AROM: Active Range of Movement; BPI: Brief Pain Inventory; SPADI: Shoulder Pain and Disability Index; RAI: Ritchie Articular Index; CMSA: Chedoke McMaster Stroke Assessment; DASH: The Disabilities of the Arm, Shoulder and Hand; HBN: hand-behind-neck; HBB: hand-behind-back; ACJ: Acromioclavicular joint.

Table 2. A table illustrating the reported HSP assessment approaches in the studies and their frequency (n) within the ICF framework.

Body Structure and Function impairments	Activity limitations	Participation restrictions
Visual Analogue Scale (n = 75) Passive range of movement (n = 65) Numerical rating scale (n = 32) Glenohumeral subluxation (n = 30) Fugl-Meyer Assessment (n = 27) Active range of movement (n = 11) Brief pain inventory (12) (n = 11) Pain History (n = 9) Shoulder Q (n = 7) Pain Present /Absent (n = 5) McGill Pain Questionnaire (n = 4) Faces pain rating scale (n = 4) Shoulder pain and disability index (n = 4) Ritchie Articular Index (n = 3) Chedoke Mcmaster Stroke Assessment (n = 2) Likert pain scale (n = 1) Constant murley score (n = 1) Croft disability questionnaire (n = 1) Pain behaviour scale (n = 1) The Disability of the arm, shoulder and Hand (n = 1) Musculoskeletal tests: Neer’s test (n = 7) Hand behind neck and hand behind back test (n = 5) Rowe test (n = 2) Speeds test (n = 2) Acromioclavicular sheer test (n = 2) Palpation (n = 2) Apprehension test (n = 1) Hawkins-Kennedy test (n = 1)	Brief pain inventory (23) (n = 11) Pain behaviour scale (n = 1) Shoulder pain and disability index (n = 4) Chedoke Mcmaster Stroke Assessment (n = 2) Constant murley score (n = 1) Croft disability questionnaire (n = 1) The Disabilities of the Arm, Shoulder and Hand- pain severity (n = 1)	Brief pain inventory (23) (n = 11) Constant murley score (n = 1) Croft disability questionnaire (n = 1) The Disabilities of the Arm, Shoulder and Hand pain severity (n = 1) Shoulder Disability Questionnaire (n = 1) Severity of Degreof Painful Shoulder (n = 1)

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Data availability statement

There is no data set associated with this submission.