Interventions for Post-Stroke Shoulder Pain: An Overview of Systematic Reviews

Figures & data

Table 1 Characteristics of Included Systematic Reviews, for Eligible Interventions

Review	Date of Search	Population No. Included Studies Mean Age % Male Time Post-Stroke (Mean)	Intervention	Comparison	Outcomes (Measurement Scale)
Appel et al (2014)^Citation26	2013, June	Adults with reduced upper limb function post-stroke 4 RCTs, 1 quasi-RCT Mean age (range): 62–79 % male: NR Post-stroke: NR	Shoulder strapping	Placebo/no strapping	Pain: pain intensity (VAS), pain-free days (RAI), upper limb function (MAS) QOL (SS-QOL)
Chau et al (2018)^Citation30	2017, August	Parallel or crossover RCTs, shoulder pain after stroke or shoulder–hand syndrome 19 RCTs conventional, 5 RCTs electro, 2 RCTs fire eedle, 1 RCT arm eedle Age: 42.8–69.5 years % male: 56.1 Time post-stroke: 17–29 days	Acupuncture Conventional Electro Fire Needle Warm Needle in addition to usual care	Usual care (including stroke rehabilitation, rehab exercises and herbal medicine)	Pain: pain intensity (“standard subjective scales” including VAS), pain-free external rotation (degrees) Function: upper limb function (FMA), physical function (Barthel index)
Koog et al (2010)^Citation32	2008, June	Shoulder pain post-stroke 1 RCT Age: 61.9 % male: 36.7 Time post-stroke: mostly ≤ 3 months	Aromatherapy (1 RCT)	Placebo or usual care (including acupressure^a)	Pain: pain intensity (VAS^Citation35)
Lim et al (2015)^Citation28	2014, August	Shoulder pain post-stroke 3 RCTs Age: NR % male: NR Time post-stroke: NR	Bee venom acupuncture	Saline injection or usual care (1 RCT: AT, medications, moxibustion, physio)	Pain: pain intensity (VAS)
Nadler et al (2017)^Citation33	2016, March	Adults with shoulder pain post-stroke 1 RCT Mean age: NR % male: NR Time post-stroke: NR	Shoulder orthoses	Usual care	Pain: pain intensity (SHSS- pain)
Qiu et al (2019)^Citation31	2018, January	Hemiplegic shoulder pain 6 RCTs Mean age range: 53–66 years % male: NR Time post-stroke: 16.5 days – 2.1 years	Electrical stimulation Surface Percutaneous	Placebo (sham) and/or usual care (including physio, hemi sling, acupuncture)	Pain: pain intensity (VAS, BPI), pain-free external rotation (degrees) Function: activities of daily living (Barthel index)
Singh et al (2010)^Citation34,Citation82	2010, January	Adults with shoulder spasticity post-stroke 4 RCTs Mean age: NR % male: NR Time post-stroke: NR	Botulinum toxin injection	Placebo^b	Pain: pain intensity (VAS or verbal rating scale), pain-free external rotation (degrees)

Notes: ^a Acupressure included as a component of standard care in both intervention and control arms. ^bTENS included as a component of standard care in both intervention and control arms in 1 trial.

Abbreviations: BPI, brief pain inventory; FMA, Fugl–Meyer Motor Assessment; MAS, Motor Assessment Scale; Physio, physiotherapy; NR, not reported; QOL, quality of life; RAI, Ritchie Articular Index; Rehab, rehabilitation; RCTs, randomized controlled trials; SHSS, Shoulder Hand Sub-Score; SS-QOL, Stroke Specific Quality of Life; VAS, visual analogue scale.

Table 2 Effectiveness of HSP Interventions on Outcome of Pain

Review	Intervention	Number of Studies (Participants)	Outcome (Measure)	Summary of Effect (95% CI)
Appel et al (2014)^Citation26	Shoulder strapping	2 (219)^Citation25,Citation38	Pain intensity (VAS)	Pooled MD -2.76 (−9.08 to 3.56) I^2 = 56%, P = 0.39^a
		2 (30)^Citation36,Citation37	Pain-free days (RAI)^g	MD 10.3 (2.27 to 18.33, N = 22)^Citation37 MD 15.5 (9.22 to 21.78, N = 8, quasi RCT)^Citation36
Chau et al (2018)^Citation30	Conventional acupuncture	19 (1462) ^e	Pain intensity (VAS)	Range SMD −2.41 (−2.93, −1.89) to 0.15 (−0.21, 0.50)^f. High-heterogeneity, see Figure 2
	Electroacupuncture	4 (289) ^e	Pain intensity (VAS)	Range SMD −1.46 (−1.95 to −097) to −0.49 (−0.91 to −0.06)^f. High heterogeneity, see Figure 2
	Fire needle acupuncture	2 (169)^e	Pain intensity (VAS)	SMD −3.43 (−4.11 to −2.75); −1.58 (−2.06 to −1.09). High heterogeneity, see Figure 2
	Warm needle acupuncture	1 (40)^e	Pain intensity (VAS)	SMD −2.75 (−3.64, −1.86)
Koog et al (2010)^Citation32	Aromatherapy	1 (30)^Citation35	Pain intensity (VAS, 3 day mean)	SMD −1.94 (−2.79 to −1.09)
Lim et al (2015)^Citation28	Bee venom acupuncture	3 (126)^Citation72^–^Citation74	Pain intensity (VAS)	MD 1.01 (0.65, 1.37), P < 0.01, I^2 = 0%^d
Nadler et al (2017)^Citation33	Shoulder orthosis	1 (41)^Citation75	Pain reduction (SHS-pain)	SMD (−1.65 −2.37, −0.94)^b
Qui et al (2019)^Citation31	Electrical stimulation (surface and percutaneous)^c	4 (193)^Citation76^–^Citation79	Pain intensity (VAS)	SMD −1.89 (−3.05, −0.74), I^2 = 90%
	Surface stimulation	2 (107)^Citation76,Citation77	Pain intensity (VAS)	SMD −2.89 (−3.44, −2.34), I^2 = 0%
		3 (139)^Citation76,Citation80,Citation81	Pain-free external rotation (degrees)^c	MD 7.88 (4.86, 10.89) MD 8.20 (0.87, 15.53) MD (25.83, 19.29, 32.37)
	Percutaneous stimulation	2 (86)^Citation78,Citation79	Pain intensity (VAS)	SMD −0.96 (−1.41, −0.51), I^2 = 0%
		1 (25)^Citation79	Pain-free external rotation	MD 37.1 (25.10, 49.10)
Singh et al (2010)^Citation34,Citation82	Botulinum toxin injection	4 (86)^Citation83^–^Citation86	Pain intensity (VAS/VRS) at 4–6 weeks	MD −1.12 (−2.89, 0.66), P = 0.22, I^2 = 076%
		3 (66)^Citation83^–^Citation85	Pain intensity (VAS/VRS) at 12–24 weeks	MD −1.22 (−2.37, −0.07), P = 0.04, I^2 = 0%
		3 (70)^Citation83,Citation85,Citation86	Pain-free external rotation (degrees) at 4–6 weeks	SMD 0.41 (−0.06, 0.89), P = 0.09, I^2 = 0%
		2 (50)^Citation84,Citation85	Pain-free external rotation (degrees) at 12–24 weeks	SMD 0.55 (−0.01, 1.12), P = 0.06), I^2 = 0%

Notes: ^a Pooled by overview authors following retrieval of individual group data from primary report of one included RCT.²⁵ b SMD based on study endpoint data. ^c Significant heterogeneity for overall pooling of intervention studies (4 trials, I² = 93%, P = 0.000) not explained by subgroup analysis of stimulation delivery method (surface stimulation 3 trials I² = 92%, P = 0.000), thus results not presented as pooled values. ^d Pooled by overview authors using a generic inverse variance method (GIV) meta-analysis. ^e Source studies are cited in Chau et al.³⁰ f SMD determined by overview authors from individual study effects. ^g Review authors did not pool outcomes due to high heterogeneity.

Abbreviations: RAI, Ritchie Articular Index; SHS, Shoulder Hand Score; VAS, visual analogue scale; VRS, verbal rating scale.

Figure 1 Study selection flowchart.¹⁸

Note: Adapted from Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. © 2009 Moher et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License.¹⁸

Figure 2 Forest plot of acupuncture trial effects on shoulder pain.

Note: Data from Chau et al 2018.³⁰

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