Prevalence of Hemiplegic Shoulder Pain in Iran: A Systematic Review and Meta-analysis

authors:

avatar Aryoobarzan Rahmatian 1 , avatar Elham Bastani 2 , avatar Fariba Shokri 2 , avatar Ali Karbasfrushan ORCID 3 , 4 , *

Shahid Mostafa Khomaeini Hospital, School of Medicine, Ilam University of Medical Sciences, Ilam, Iran
Department of Internal Medicine, Shahid Mostafa Khomaeini Hospital, School of Medicine, Ilam University of Medical Sciences, Ilam, Iran
Department of Anesthesiology, Imam Khomeini Hospital, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
Department of Anesthesiology, Imam Reza Hospital, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran

how to cite: Rahmatian A, Bastani E, Shokri F, Karbasfrushan A. Prevalence of Hemiplegic Shoulder Pain in Iran: A Systematic Review and Meta-analysis. Anesth Pain Med. 2023;13(3):e136423. https://doi.org/10.5812/aapm-136423.

Abstract

Context:

Hemiplegic shoulder pain (HSP) is one of the complications of a stroke.

Objectives:

This study aimed to determine shoulder pain prevalence in cerebrovascular accident (CVA) patients.

Methods:

This meta-analysis study searched English and Persian descriptive or descriptive-analytical full-text studies on CVA patients. The search was carried out in all databases by two researchers using keywords such as stroke, pain, CVA, hemiplegic, and shoulder pain. Data analysis was done with the software CMA3.

Results:

In the initial search, 109 articles were found, and finally, the data from four articles were analyzed. The prevalence of HSP was 23% (confidence interval (CI) = 10.3% - 43.5%).

Conclusions:

Considering the HSP prevalence (28.1%) among CVA patients, it is necessary to carry out rehabilitation interventions to prevent such pain in these patients. It is also suggested that rehabilitation interventions be included in the patient education of the healthcare system.

1. Context

Global statistics show an increase in the prevalence of chronic diseases (1, 2), such as cerebrovascular accidents (CVA) (3, 4). The most common and debilitating neurological lesion in adults is CVA, known as the third cause of death after cancer and cardiovascular diseases (5, 6). Also, CVA is one of the upper motor neuron diseases, characterized by non-coordination in the normal movement pattern, and hemiplegia is considered one of the symptoms of neurovascular diseases of the brain (7-9). The length of stay and the complications of CVA are effective in managing and planning costs, resources, facilities, and the healthcare system (10). The prevalence of CVA-related complications is reported to be about 40 - 96%, and pain is one of the most common complications of CVA (19% - 74%) (11). Different types of CVA complications, including infections, deep vein thrombosis, and pain, have been reported, which can lead to death (12). Besides, CVA-related pain includes central pain, headache, spinal nerve pain, muscle pain, and hemiplegic shoulder pain (13, 14).

Hemiplegic shoulder pain (HSP) is the most common CVA-related complication that forces the patient to use other organs to compensate for the resulting disability or reduce the patient's quality of life by putting pressure on the damaged organ (5, 15). Also, HSP may become more painful due to joint immobility, muscle weakness, and soft tissue changes that occur after a stroke, negatively affecting all aspects of the patient's life (16). Several factors, such as paralysis, sensory disorders, spasticity, limited range of motion in the shoulder, and shoulder capsulitis, are involved in the development and aggravation of HSP, and effective steps can be taken to prevent HSP by identifying the above risk factors (17, 18).

Pain is an unpleasant experience that must be mitigated by taking preventive and therapeutic measures (19-21). One of these measures is to identify the prevalence of pain related to the anatomical parts of the body in different patients, and appropriate interventions can be performed accordingly (22-24). We can use oral or injectable pain medications (25) or physiotherapy (26) to reduce HSP. The subsequent disorders and disabilities are a big challenge to medical and nursing care in the hospital and at home. Families must also take care of CVA patients and undergo elevated stress levels. For this reason, it is a priority to identify the prevalence of the above disorders and disabilities and take necessary measures to improve or mitigate them (27, 28).

2. Objectives

Considering the importance of chronic diseases, the present meta-analysis study aimed to determine the HSP prevalence in CVA patients.

3. Methods

This meta-analysis study searched English and Persian descriptive or descriptive-analytical full-text studies on CVA patients. Review articles, case reports, intervention studies, and letters-to-the editors were excluded.

The search was carried out in all databases by two researchers with scientific and practical mastery of CVA, pain, and orthopedic diseases. In addition to the above databases, the references of all the above articles that entered the final stage were investigated by both researchers. Keywords such as stroke, pain, CVA, hemiplegic, hemiplegic shoulder pain, and shoulder pain were used for searching. Data analysis was done with the software CMA3.

4. Results and Discussion

In the initial search, 109 articles were found, and finally, the data from four articles were analyzed (Figure 1). The lowest prevalence was 7.2% in the study of Ghayeghran et al. (29), and the highest rate was 34% in the study of Ghahremani et al. (30) (Table 1).

Flowcharts of the systematic review
Flowcharts of the systematic review
Table 1.

Demographic Data in the Studies a

Author YearNLocationMale (N)Female (N)AgePrevalence
1Hadianfard and Hadianfard (31)2008152Shiraz757761.249 (32)
2Ghahremani et al. (30)201450Hamedan282262 ± 8.1517 (34)
3Shahimoridi et al. (32)200290Rafsanjan513967 ± 11.927 (30.11)
4Ghayeghran et al. (29)2012389Rasht19819167.7 ± 13.128 (7.2)

The results showed that the prevalence of HSP was 23% (confidence interval (CI) = 10.3% - 43.5%) (Figure 2). Figure 3 shows the final plot of the studies, and Figures 4 and 5 indicate the relationships between the prevalence of HSP and the time of conducting studies and sample size.

Prevalence of shoulder pain in patients
Prevalence of shoulder pain in patients
Funnel plot of patients
Funnel plot of patients
Correlation between study publication time and pain prevalence
Correlation between study publication time and pain prevalence
Correlation between the number of patients and pain prevalence
Correlation between the number of patients and pain prevalence

A meta-analysis study was conducted on the prevalence of HSP among Iranian CVA patients. The prevalence of HSP was 23% (CI = 10.3% - 43.5%). Hatefi et al. studied 200 patients with confirmed CVA and showed that the mean scores ± SD of lifestyle and pain were 21.83 ± 3.91 and 16.22 ± 1.99 (33). Pouy et al. also showed that the mean score ± SD of the patient's lifestyle was 118.20 ± 6.00 (34). In a meta-analysis study, Holmes et al. identified 54 risk factors for shoulder pain after CVA, including reduced motor function in the upper limb, type of CVA, diabetes, gender, and previous history of shoulder pain (35). In a review of 21 articles, Kumar et al. also referred to glenohumeral subluxation, reduced function, and range of motion in the shoulder as HSP risk factors (36).

Various studies investigated the prevalence of myofascial trigger points (MTrPs) in patients with HSP. For example, Villafane et al. investigated 50 CVA patients who had HSP and found that the prevalence of MTrPs was 40% - 68% (37). Menoux et al. and Paolucci et al. also stated that the HSP prevalence was 8% - 13% and 29.56%, respectively (38, 39).

Various studies have been conducted on the HSP prevalence in different patients and study populations. For example, Luime et al. found that the HSP prevalence in 18 articles in the general population was 0.9% - 2.5% (40). Similarly, Tessaro et al. found that the HSP prevalence among Italian teenagers was 51% (41). In a study on individuals aged 58.7 to 76 years, Anwer and Alghadir found that the HSP prevalence was 10% - 12%. Other risk factors and predictors of HSP include female fertility, sensory disorders, age, hemorrhagic stroke, and medical history of previous chronic disease (42).

5. Conclusions

Considering the HSP prevalence (23%) among CVA patients, it is necessary to carry out rehabilitation interventions to prevent such pain in these patients. It is also suggested that rehabilitation interventions be included in the patient education of the healthcare system.

References

  • 1.

    Solati H, Sahebalzamani M, Adhami Moghadam F. [Effect of Family-Based Care Training by Tele-nursing on Emotional Reactions in Mothers of Children with Bone Marrow Transplantation]. J Mazandaran Univ Med Sci. 2021;30(192):156-61. Persian.

  • 2.

    Mazlominezhad A, Moghadam FA. Evaluation of quality of life and self-efficacy in adolescents with amblyopia. J Med Life. 2022;15(4):499-503. [PubMed ID: 35646181]. [PubMed Central ID: PMC9126460]. https://doi.org/10.25122/jml-2020-0035.

  • 3.

    Azeem-ur-Rehman M, Saddique MA, Bilal M, Rauf K, Jabeen K, Qureshi QA. The frequency of stroke-acquired pneumonia in patients admitted to ICU with Cerebrovascular accident (CVA). Journal of Rawalpindi Medical College. 2022;26(3):491-6. https://doi.org/10.37939/jrmc.v26i3.1947.

  • 4.

    Aghamiri SH, Mansouri B, Mehrpour M, Hoseini Karani SM, Ghaffari M, Safarpour Lima B, et al. Efficacy of mechanical thrombectomy in stroke patients with large vessel involvement. Eur J Transl Myol. 2022;32(2):10456. [PubMed ID: 35736402]. [PubMed Central ID: PMC9295169]. https://doi.org/10.4081/ejtm.2022.10456.

  • 5.

    El-Sonbaty HAE, Abou Elmaaty AA, Zarad CA, El-Bahnasawy AS. Clinical and radiological assessment of hemiplegic shoulder pain in stroke patients. Egypt J Neurol Psychiatry Neurosurg. 2022;58(1):41. https://doi.org/10.1186/s41983-022-00474-w.

  • 6.

    Taghinejad H, Otaghi M, Nikan A, Beiranvand R. Investigating the effects of nurse post-discharge follow-up phone calls on the self-efficacy of patients suffering from stroke. Bali Med J. 2018;7(3):682-8. https://doi.org/10.15562/bmj.v7i3.1008.

  • 7.

    Motamedvaziri P, Bahrpeyma F, FiroozAbadi SM, Hatef B. [Effect of low frequency rTMS on stiffness of joints of the upper limbs in hemiplegic patients]. Sci J Kurdistan Univ Med Sci. 2014;19(2):103-13. Persian. https://doi.org/10.22102/19.2.103.

  • 8.

    Do JG, Choi JH, Park CH, Yoon KJ, Lee YT. Prevalence and Related Factors for Poststroke Complex Regional Pain Syndrome: A Retrospective Cross-Sectional Cohort Study. Arch Phys Med Rehabil. 2022;103(2):274-81. [PubMed ID: 34480888]. https://doi.org/10.1016/j.apmr.2021.08.003.

  • 9.

    Tahmasbi F, Madani Neishaboori A, Mardani M, Toloui A, Komlakh K, Azizi Y, et al. Efficacy of polyarginine peptides in the treatment of stroke: A systematic review and meta-analysis. Brain Behav. 2023;13(1):e2858. [PubMed ID: 36542540]. [PubMed Central ID: PMC9847609]. https://doi.org/10.1002/brb3.2858.

  • 10.

    Sharifi Razavi A, Hedayati Z, Tabrizi N. [Factors Affecting the Length of Hospital Stay in Patients with Ischemic Stroke Treated by Intravenous Thrombolysis]. J Mazandaran Univ Med Sci. 2021;30(194):42-50. Persian.

  • 11.

    Henon H. Pain after stroke: a neglected issue. J Neurol Neurosurg Psychiatry. 2006;77(5):569. [PubMed ID: 16614012]. [PubMed Central ID: PMC2117440]. https://doi.org/10.1136/jnnp.2005.085761.

  • 12.

    Feigin VL, Norrving B, Mensah GA. Global Burden of Stroke. Circ Res. 2017;120(3):439-48. [PubMed ID: 28154096]. https://doi.org/10.1161/CIRCRESAHA.116.308413.

  • 13.

    de Sire A, Moggio L, Demeco A, Fortunato F, Spano R, Aiello V, et al. Efficacy of rehabilitative techniques in reducing hemiplegic shoulder pain in stroke: Systematic review and meta-analysis. Ann Phys Rehabil Med. 2022;65(5):101602. [PubMed ID: 34757009]. https://doi.org/10.1016/j.rehab.2021.101602.

  • 14.

    Ri S. The Management of Poststroke Thalamic Pain: Update in Clinical Practice. Diagnostics (Basel). 2022;12(6):1439. [PubMed ID: 35741249]. [PubMed Central ID: PMC9222201]. https://doi.org/10.3390/diagnostics12061439.

  • 15.

    Akhlaq U, Ayaz S, Akhtar N, Khan A. Frequency and intensity of shoulder pain after stroke: A hospital based study. Pak Armed Forces Med J. 2016;66(1):71-4.

  • 16.

    Kumar P. Hemiplegic shoulder pain in people with stroke: present and the future. Pain Manag. 2019;9(2):107-10. [PubMed ID: 30681020]. https://doi.org/10.2217/pmt-2018-0075.

  • 17.

    Zeng H, Chen J, Guo Y, Tan S. Prevalence and Risk Factors for Spasticity After Stroke: A Systematic Review and Meta-Analysis. Front Neurol. 2020;11:616097. [PubMed ID: 33551975]. [PubMed Central ID: PMC7855612]. https://doi.org/10.3389/fneur.2020.616097.

  • 18.

    Hao N, Zhang M, Li Y, Guo Y. Risk factors for shoulder pain after stroke: A clinical study. Pak J Med Sci. 2022;38(1):145-9. [PubMed ID: 35035416]. [PubMed Central ID: PMC8713217]. https://doi.org/10.12669/pjms.38.1.4594.

  • 19.

    Vasigh A, Tarjoman A, Borji M. Relationship Between Spiritual Health and Pain Self-Efficacy in patients with Chronic Pain: A Cross-Sectional Study in West of Iran. J Relig Health. 2020;59(2):1115-25. [PubMed ID: 31087227]. https://doi.org/10.1007/s10943-019-00833-7.

  • 20.

    Vasigh A, Tarjoman A, Borji M. The effect of spiritual-religious interventions on patients’ pain status: systematic review. Anaesthesia, Pain & Intensive Care. 2018;22(4):499-505.

  • 21.

    Hatefi M, Parvizi R, Borji M, Tarjoman A. Effect of Self-Management Program on Pain and Disability Index in Elderly Men with Osteoarthritis. Anesth Pain Med. 2019;9(4):e92672. [PubMed ID: 31750095]. [PubMed Central ID: PMC6820295]. https://doi.org/10.5812/aapm.92672.

  • 22.

    Parish M, Asghari Jafarabadi M, Ghaffarzadeh E, Abedini N. Studying the effects of chemical shivering in diabetic and non-diabetic patients after orthopedic surgery. Eurasian Chem Commun. 2022;4(7):620-4. https://doi.org/10.22034/ecc.2022.333627.1369.

  • 23.

    Hatefi M, KomLakh K. Investigation of the effect of Duloxetine on pain status of patients with spinal cord injuries: A systematic review of drug therapy. Eurasian Chem Commun. 2022;4(3):256-62. https://doi.org/10.22034/ecc.2022.324516.1298.

  • 24.

    Khalighi E, Soufinia A, Solaimanizadeh L, Borji M, Tarjoman A, Soltany B, et al. Knowledge, Attitudes and Barriers Pain Management by Nurses in Iran: Systematic Review. Anaesthesia, Pain & Intensive Care. 2019;23(4):360-9. https://doi.org/10.35975/apic.v23i4.1063.

  • 25.

    Jang MH, Lee CH, Shin YI, Kim SY, Huh SC. Effect of Intra-articular Hyaluronic Acid Injection on Hemiplegic Shoulder Pain After Stroke. Ann Rehabil Med. 2016;40(5):835-44. [PubMed ID: 27847713]. [PubMed Central ID: PMC5108710]. https://doi.org/10.5535/arm.2016.40.5.835.

  • 26.

    Klotz T, Borges HC, Monteiro VC, Chamlian TR, Masiero D. Physiotherapy treatment in hemiplegic shoulder pain in stroke patients-Literature Review. Acta Fisiatrica. 2006;13(1):12-6. https://doi.org/10.11606/issn.2317-0190.v13i1a102563.

  • 27.

    Garnett A, Ploeg J, Markle-Reid M, Strachan PH. Factors impacting the access and use of formal health and social services by caregivers of stroke survivors: an interpretive description study. BMC Health Serv Res. 2022;22(1):433. [PubMed ID: 35365130]. [PubMed Central ID: PMC8975449]. https://doi.org/10.1186/s12913-022-07804-x.

  • 28.

    Garnett A, Ploeg J, Markle-Reid M, Strachan PH. Formal Health and Social Services That Directly and Indirectly Benefit Stroke Caregivers: A Scoping Review of Access and Use. Can J Nurs Res. 2022;54(2):211-33. [PubMed ID: 35130749]. [PubMed Central ID: PMC9109593]. https://doi.org/10.1177/08445621211019261.

  • 29.

    Ghayeghran AR, Bakhshayesh Eghbali B, Hosseini Nejad M, Azari P, Kazem Nejad E. [Survey of Various Post Stroke Pain Syndromes and the Related Risk Factors]. J Guilan Univ Med Sci. 2012;21(82):1-7. Persian.

  • 30.

    Ghahremani F, Dadgoo M, Noorizadeh S, Mazdeh M, Pourahmadi MR. [The relationship between shoulder pain with shoulder neuromusculoskeletal disorders in post stroke hemiparsis]. J Mod Rehabil. 2014;8(4):30-6. Persian.

  • 31.

    Hadianfard H, Hadianfard MJ. Predictor factors of hemiplegic shoulder pain in a group of stroke patients. Iran Red Crescent Med J. 2008;10(3):218-22.

  • 32.

    Shahimoridi D, Asgharnia H, Sheikhfathollahi M. [The frequency of sensorimotor dysfunctions During the first 3 months after stroke hospitalized patients in AliIbn Abitaleb Hospital in Rafsanjan City]. J Rafsanjan Univ Med Sci. 2002;1(4):241-51. Persian.

  • 33.

    Hatefi M, Tarjoman A, Borji M. The Relationship Between Lifestyle with Chronic Pain and Pain Acceptance in Elderly with Stroke. Arch Neurosci. 2018;6(1):e83717. https://doi.org/10.5812/ans.83717.

  • 34.

    Pouy S, Otaghi M, Borji M, Tarjoman A, Sanei P. Lifestyle of the Elderly with Stroke: A Cross Sectional Study. Arch Neurosci. 2018;5(4):e68049. https://doi.org/10.5812/ans.68049.

  • 35.

    Holmes RJ, McManus KJ, Koulouglioti C, Hale B. Risk Factors for Poststroke Shoulder Pain: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis. 2020;29(6):104787. [PubMed ID: 32229074]. https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104787.

  • 36.

    Kumar P, Fernando C, Mendoza D, Shah R. Risk and associated factors for hemiplegic shoulder pain in people with stroke: a systematic literature review. Phys Ther Rev. 2022;27(3):191-204. https://doi.org/10.1080/10833196.2021.2019369.

  • 37.

    Villafane JH, Lopez-Royo MP, Herrero P, Valdes K, Cantero-Tellez R, Pedersini P, et al. Prevalence of Myofascial Trigger Points in Poststroke Patients With Painful Shoulders: A Cross-Sectional Study. PM R. 2019;11(10):1077-82. [PubMed ID: 30734521]. https://doi.org/10.1002/pmrj.12123.

  • 38.

    Menoux D, Jousse M, Quintaine V, Tlili L, Yelnik AP. Decrease in post-stroke spasticity and shoulder pain prevalence over the last 15 years. Ann Phys Rehabil Med. 2019;62(6):403-8. [PubMed ID: 29604351]. https://doi.org/10.1016/j.rehab.2018.03.003.

  • 39.

    Paolucci S, Iosa M, Toni D, Barbanti P, Bovi P, Cavallini A, et al. Prevalence and Time Course of Post-Stroke Pain: A Multicenter Prospective Hospital-Based Study. Pain Med. 2016;17(5):924-30. [PubMed ID: 26814255]. https://doi.org/10.1093/pm/pnv019.

  • 40.

    Luime JJ, Koes BW, Hendriksen IJ, Burdorf A, Verhagen AP, Miedema HS, et al. Prevalence and incidence of shoulder pain in the general population; a systematic review. Scand J Rheumatol. 2004;33(2):73-81. [PubMed ID: 15163107]. https://doi.org/10.1080/03009740310004667.

  • 41.

    Tessaro M, Granzotto G, Poser A, Plebani G, Rossi A. Shoulder Pain in Competitive Teenage Swimmers and It's Prevention: A Retrospective Epidemiological Cross Sectional Study of Prevalence. Int J Sports Phys Ther. 2017;12(5):798-811. [PubMed ID: 29181257]. [PubMed Central ID: PMC5685406].

  • 42.

    Anwer S, Alghadir A. Incidence, Prevalence, and Risk Factors of Hemiplegic Shoulder Pain: A Systematic Review. Int J Environ Res Public Health. 2020;17(14):4962. [PubMed ID: 32660109]. [PubMed Central ID: PMC7400080]. https://doi.org/10.3390/ijerph17144962.