Stroke Survivors, Pain, and the OTP

Patients who have survived a stroke often experience pain that must be addressed to improve functional performance.

The American Stoke Association says 84% of stroke survivors develop shoulder pain due to motor weakness and shoulder subluxation. Skilled professionals such as occupational therapy practitioners can address pain using treatment interventions such as manual therapy, therapeutic exercises, physical modalities, and patient/caregiver education.

Treatment for post-stroke pain is determined by the root cause to maximize outcomes. OTPs may use one or more interventions based on the survivor’s cause of pain, client factors, and rehab goals.

Recommended course: Functional Gains in Stroke Recovery using Therapeutic Exercise

Range of Motion Exercises

A frozen shoulder can result from extended shoulder joint immobilization. Shoulder immobilization can be caused by common post-stroke conditions such as arm paralysis or significant arm weakness, also known as hemiplegia or hemiparesis.

Passive and active range of motion exercises provide movement to the affected arm joints to decrease the chances of a frozen shoulder, contracted joints, and affected arm neglect. Initially, an OTP may passively range the survivor’s arm when significant weakness is present in the arm, or the arm has increased muscle tone, also known as spasticity.

However, with guidance and education, stroke survivors and their caregivers can learn to complete passive ROM exercises safely and independently to maintain the range achieved in therapy sessions. As the patient progresses, the patient may be able to actively engage in range of motion exercises with the affected arm.

Reducing pain via shoulder subluxation

Shoulder subluxations cause the long bone of the arm to partially dislocate from the shoulder socket due to the pull of gravity. This ultimately causes stress on the shoulder joint and the muscle ligaments of the arm.

Research has found that shoulder orthotics effectively prevent and reduce subluxations and pain for patients with hemiplegic shoulders. A total shoulder sling provides support to the shoulder-arm joint. Shoulder subluxation can occur if the arm and shoulder joint are not adequately supported when a stroke survivor is sitting, standing, or being assisted with surface transfers, such as transitioning from the bed to the wheelchair. Inadequate support can also worsen subluxations that already exist. A survivor can wear the same orthotic daily, but it must be removed during showers and when in bed.

The use of arm supports such as slings is encouraged for safe positioning. However, the ninth item of the American Occupational Therapy’s Choosing Wisely initiative provides additional evidence-based guidance. The recommendation cautions against using a sling for an extended period to prevent use limitations.

Recommended course: Stroke Rehabilitation Maximizing Outcomes: Interventions

Kinesiology taping

In addition to positioning equipment and orthotics, kinesiology taping can be used as an effective technique to address pain. A research study found immediate improvement in shoulder pain after the first day and significant improvement in pain after four weeks.

Kinesiology tape is strategically applied to the muscles surrounding the arm and the shoulder. The breathable tape helps to position the arm in the shoulder joint to lessen the harmful effects of gravity on the affected arm. Once the tape is applied, the survivor wears it continuously. However, it requires changing every three to five days due to elasticity loss.

Transcutaneous electrical nerve stimulation

Transcutaneous Electrical Nerve Stimulation (TENS) uses electrical stimulation to address pain signals, allowing increased participation in therapeutic exercises by the patient. It also enables the OTP to use manual therapy techniques to range the painful arm with decreased discomfort for the patient.

A TENS unit can support functional performance with its use while the patient participates in self-care activities or other active rehabilitation activities.

Modified Constraint-Induced Therapy

Modified constraint-induced movement therapy (mCIMT) involves constraining the less affected or unaffected arm with a sling or a mitt to prevent movement of that arm. Restraint of the lesser affected or unaffected arm causes the mCMIT participant to rely on the affected arm to perform desired tasks.

This technique uses the brain’s neuroplasticity to build new pathways to control the affected arm’s movements. Although evidence supports the effectiveness of mCIMT alone, more recent research shows that combining robotic therapy with mCIMT provides better patient outcomes.

Positioning techniques

Inadequate or harmful arm positioning when in bed, in a wheelchair, or when standing can place stress on the shoulder joint. This constant stress contributes to pain in the shoulder joint. Positioning techniques are effective for patients with limited movement and strength in the affected arm. Proper positioning reduces the risk of contractures, shoulder subluxation, and pain.

After thoroughly assessing the stroke survivor’s unique needs, occupational therapists can make recommendations to support the upper limb when the patient is engaged in functional activities.

• Forearm troughs or wheelchair trays may be recommended when the survivor is seated in a wheelchair. A forearm trough supports the affected arm in a position to keep it from accidentally being sat on by the patient and prevents the arm from getting caught in the wheels of the wheelchair. The position helps prevent subluxation or further subluxation and keeps the rest of the arm out of harm's way.
• For survivors who can walk, a platform on the walker handle can prevent the affected arm from hanging at the side while walking. This positioning will also help prevent shoulder subluxations or subluxations from worsening.
• Pillows can be used for arm positioning when the survivor is in bed for arms with a low or high tone.

Patient and caregiver education

A 5-year longitudinal study found stroke patients can continue to experience pain five years post-stroke. The study also found patients who still had frequent pain had decreased quality of life compared to those with less frequent pain. It suggested that interventions for pain be included in follow-up care for stroke patients since most of the factors causing the pain were treatable.

Patients and caregivers who understand the importance of engaging in a rehabilitative home exercise program and adhering to preventative measures increase the success of the patient’s program. It also gives patients and caregivers some control to mitigate pain themselves.

Pain management teams for post-stroke patients

Occupational therapy practitioners are essential to interprofessional pain management teams for patients requiring a pain plan focusing on function. To increase functional performance, OTPs can address the acute and chronic pain associated with post-stroke circumstances.