Lien vers les tableaux de données probantes et la liste des références (en Anglais)
The use of supportive slings and supports may reduce the amount of subluxation and hemiplegic shoulder pain, although the evidence is conflicting. Ada et al. (2017) randomized 46 persons who were at risk of developing shoulder subluxation following a recent stroke to use a modified lap-tray while sitting and a triangular sling while standing to support the affected arm for four weeks, while those in a control group used a hemi-sling while sitting and standing. At the end of the treatment period there were no significant difference between groups in terms of shoulder subluxation (MD -3 mm, 95% CI -8 to 3), pain at rest (MD -0.7 out of 10, 95% CI -2.2 to 0.8), shoulder external rotation (MD -1.7 out of 10, 95% CI -3.7 to 0.3) or having less contracture of shoulder external rotation (MD -10 deg, 95% CI -22 to 2). An earlier Cochrane review (Ada et al. 2005) included the results from 4 RCTs evaluating the use of strapping (n=3) and hemisling (n=1). All patients were in the acute phase of stroke (less than 4 weeks) with a flaccid arm with no history of shoulder pain. The number of pain-free days associated with treatment was significantly greater; (mean difference: 13.6 days, 95% CI 9.7 to 17.8, p<0.0001); however, the results from only two studies were included in the pooled result. In another systematic review that specifically evaluated the use of strapping (Appel et al. 2014), the authors concluded the efficacy of shoulder strapping to alleviate upper limb dysfunction and shoulder impairments caused by stroke remains unknown, while acknowledging that shoulder strapping may delay the onset of pain in those with severe weakness or paralysis. A recent meta-analysis, including the results from five RCTs, reported that shoulder positioning programs were not effective in preventing or reducing the range of motion loss in the shoulders’ external rotation (Borisova & Bohannon 2009).
Electrical stimulation can be used for the prevention and management of shoulder subluxation. Vafadar et al (2015) included 10 trials of electrical stimulation evaluating the evidence for the effect of functional electrical stimulation on shoulder subluxation, pain and upper extremity motor function when added to conventional therapy. Pooling data from 6 trials showed that electrical stimulation was more effective than the conventional therapy alone in improving shoulder subluxation, when applied within the first 6 months of stroke (SMD= −0.70, 95% CI −0.98 to −0.42). Only data from two trials were available for the effect of electrical stimulation when applied 6 months after stroke. Lee et al. (2017) included the results of 11 trials evaluating the effectiveness of neuromuscular electrical stimulation (NMES) for the management of shoulder subluxation in both the acute and chronic stages of stroke. NMES was effective in reducing subluxation in the acute stage of stroke (SMD=-1.1, 95% CI -1.53 to -0.68, p<0.001) but not in the chronic stage (SMD=-1.25, 95% CI -1.61 to 0.11, p=0.07), but did not significantly reduce pain in either the acute or chronic stages. Ada and Foongchomcheay (2002) included participants with subluxation or shoulder muscle paralysis in both the acute and chronic stages of stroke, from seven RCTs. The results suggested that early treatment, starting with electrical stimulation for 2 hours per day increasing to between 4 and 6 hours per day, in addition to conventional therapy helps to prevent the development of hemiplegic shoulder while later treatment helps to reduce pain. In one of the largest RCTs, Church et al. (2006) randomized 176 patients to receive active or sham surface FES treatments in addition to conventional therapy, for four weeks following acute stroke. There was no significant difference between groups in measures of upper-limb function, or the prevalence of pain post intervention, at 3 months.
Treatment with botulinum toxin type a (BTX-A) may help to improve hemiplegic shoulder pain. A Cochrane review (Singh & Fitzgerald 2010), which included the results of 6 RCTs examined the efficacy of the use of BTX-A toxin in the treatment of shoulder pain. Treatment with BTX-A was associated with reductions in pain at 3 and 6 months, but not at 1 month following injection. De Boer et al (2008) randomized 22 patients, an average of 6 months following stroke with significant shoulder pain to receive a single injection of 100 U Botox or placebo to the subscapularis muscle in addition to some form of physical therapy. While pain scores improved in both groups over time, there was no significant difference at 12 weeks following treatment, nor was there significant improvement between groups in degree of humeral external rotation.
Intra-articular corticosteroids injections may also help to improve symptoms of shoulder pain. Rah et al. (2012) randomized 58 patients with chronic shoulder pain (at least 3/10 on a Visual Analog Scale (VAS) to receive a single subacromial injection of 40 mg triamcinolone acetonide or lidocaine (control condition), in addition to a standardized exercise program. There was significant reduction in the average shoulder pain level at day and night, at 8 weeks associated with steroid injection. In contrast, Snels et al. (2000) reported that in 37 patients with hemiplegic shoulder pain (≥ 4 on a 0 to 10 VAS) randomized to receive three injections (1-2 weeks apart) of 40 mg triamcinolone acetonide or placebo, active treatment was not associated with improvements in pain scores three weeks later. Dogan et al. (2013) found that compared to traditional rehabilitation alone, the addition of intra-articular steroid, and intra-articular steroid plus hydraulic distention significantly improved range of motion immediately after treatment and at 1-month follow-up. Both steroid groups had significant improvements on VAS score at rest and during activity but the group which received steroid plus hydraulic distention were significantly more effective than only the intra-articular steroid injection and therapy.
For patients with hand edema, results from a systematic review (Giang et al. 2016) suggest that mobilization exercises (i.e. range of motion exercises) may be effective in reducing hand edema in patients with acute stroke. Bandaging, intermittent compression, kinesio tape, neutral functional realignment orthosis, and hand realignment orthosis were not found to be effective treatments.
There is no definitive therapeutic intervention for complex regional pain syndrome (CRPS). Although a wide variety of preventative measures and treatments have been used including exercise, heat, contrast baths, hand desensitization programs, splints, medications, and surgical options, there is little evidence that many of the commonly-used treatments are effective. A Cochrane overview of reviews conducted by O’Connell et al. (2013) evaluated 19 studies that used a variety of interventions to treat pain and/or disability associated with CRPS. The authors found moderate quality evidence that intravenous regional blockade with guanethidine is not effective in CRPS and is associated with adverse events, low quality evidence for biphosphates, calcitonin or daily IV of ketamine for the treatment of pain compared to a placebo. Both motor imagery and mirror therapy may be effective for the treatment of pain compared to a control condition. There is some evidence that local anaesthetic sympathetic blockade, physiotherapy, and occupational therapy are not effective for CRPS. There is very low-quality evidence that compared with placebo, oral corticosteroids reduce pain.