الفهرس 
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Abstract
Physically disabling neurological conditions such as stroke can result in secondary musculoskeletal complications that limit patients’ activities even further. Post-stroke shoulder pain (PSSP) has been reported to occur in 70% among stroke survivors (SS) and it could have negative impacts causing interference with the rehabilitation process, and decrease in the functional performance of daily activities.The cause of PSSP is uncertain, although it has been suggested that it could be related to soft-tissue lesions, impaired motor control, and altered peripheral and central nervous system activity with each one of these factors could present as separate phenomenon, coexist, or evolve to trigger each other’s development.
Therefore, the aim of this thesis was to study the prevalence of shoulder pain among SS and identify its potential causes.This study enrolled 80 SS with stroke duration >1 month (78 patients had ischemic and 2 patients with hemorrhagic stroke). Ninety age, sex and occupation matched non-stroke subjects were also included to reveal the prevalence of shoulder pain. Exclusion criteria included: history of shoulder pain prior to stroke onset, history of shoulder trauma or surgery, chronic inflammatory arthritis such as rheumatoid arthritis, other muscular disorders associated with shoulder weakness (e.g.,polymyositis, dermatomyositis, myopathies) and severe cognitive impairment that impeded communication.Screening for the presence of shoulder pain was done in SS and non-stroke subjects.All SS were subjected to history taking and clinical evaluation including assessment of shoulder muscle power, passive shoulder range of motion, spasticity assessment using Modified Ashworth scale, Fugl-Meyer for upper extremity to assess impairment of the arm function, Brunnstorm staging to assess motor recovery and assessment of level of functional activity.
Stroke survivors with PSSP were additionally subjected to the following: 1) Assessment of pain intensity: numerical rating scale, visual analogue scale, and verbal rating scale; 2) Neuropathic pain diagnostic questionnaire (DN4); 3) Laboratory investigations: serum uric acid and glycated hemoglobin (HbA1C); and 4) Electrophysiological studies (nerve conduction and electromyography); and imaging techniques (plain radiograph and magnetic resonance imaging) for the painful hemiplegic shoulder were done to reveal neuromusculoskeletal causes for PSSP.
The prevalence of shoulder pain among SS was 37.5% which was significantly higher than that among non-stroke subjects (p=.002). Shoulder muscle weakness, sensory impairment, motor impairment and hyperuricemia were significantly associated (p<0.01, p=0.001, p=0.01, and p<0.001, respectively) with the development of PSSP. However, logistic regression model revealed hyperuricemia and motor impairment (p=.019, and p=.002, respectively) as significant predictors for PSSP. Moreover, PSSP negatively affected motor recovery (p=0.002).
One or more musculoskeletal cause occurred in all patients. These were rotator cuff tear/tendinopathy (90%), impingement syndrome (90%), bursitis (66.7%), adhesive capsulitis (50%), bicipital tendinitis/tenosynovitis (23.3%), shoulder sublaxation (20%), post-stroke shoulder hand syndrome (10%) and myofascial pain syndrome (10%). Concomitant proximal neuropathies including (upper trunk brachial plexopathy, axillary neuropathy and suprascapular neuropathy) were found in 40% of PSSP patients. The DN4 questionnaire was positive in only 2 patients.
Shoulder pain is frequently seen among stroke patients. It could be a disabling problem in stroke rehabilitation. Its prevention and treatment should be included in the goals of stroke rehabilitation to prevent delay in functional recovery. The results of this study suggested PSSP is mainly musculoskeletal (nociceptive) in origin. However, thorough evaluation and nerve conduction studies of nerves supplying the proximal muscles of the shoulder and EMG of the shoulder muscles are necessary to reveal any peripheral neuropathic cause for PSSP that could be present even subclinically.