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The most serious cause (or result) of shoulder pain is CRPS-I. Diagnosis is usually clinical, with metacarpophalangeal (MCP) joint (finger joint) tenderness highly predictive. However, delayed increased uptake in the wrist or proximal finger joints on bone scan may support the diagnosis. Treatment may include aggressive range of motion of the involved joint accompanied by the use of non-steroidal agents, corticosteroids, antidepressants, treating the source of the pain, TENS, sympathetic nerve blockade, local injections, spinal electrical stimulation, injectable drugs into the spine (such as intrathecal morphine or clonidine), or surgical sympathectomy. Shoulder-hand syndrome is considered to be a variant of reflex sympathetic dystrophy and is characterized by reddening of the skin over the knuckles, trophic changes in the skin (e.g., thinning or wasting away) and hair (e.g. thickening or thinning); and nonlocalized pain.

Treatment is difficult and typically consists of:

• Treating the source of pain
• Medication such as nonsteroidal anti-inflammatory (NSAIDs), tricyclic antidepressants or lidocaine
• Sympathetic nerve blockade
• Spinal stimulation
• Injectable drugs into the spine (intrathecal) such as morphine or clonidine

Shoulder Subluxation

Shoulder subluxation, a temporary partial dislocation of the should joint, is a common complication after stroke. The pathogenesis of subluxation is not well understood, but weakness of the supraspinatus muscle has been implicated as a causative factor. The treatment for ambulatory patients usually includes shoulder supports although the effectiveness of shoulder supports has not been definitively established in clinical trials. If they will be used in rehabilitation, a number of different shoulder supports should be evaluated for best fit. In addition, shoulder supports must be easy to don and doff to discourage synergistic patterns and incipient contractures, must permit the affected extremity to function as a postural support, and must not compromise circulation or hamper function.

Other treatments for shoulder subluxation include functional electrical stimulation (FES). Primary wheelchair users may require armboards, arm troughs, or lapboards to support the extremity with poor recovery. Overhead slings may prevent hand edema, but are usually substituted with foam wedges on the armboard.

Spasticity

Spasticity of the affected upper extremity is a common problem in stroke survivors and is thought to occur in up to 65% of stroke survivors. Symptoms of spasticity include:

• Increased muscle tone as velocity of movement increases
• Spasm of flexor muscles (muscles which flex the fingers and toes)
• Hyperreflexia (exaggeration of the reflexes)
• Painful muscle spasms
• Clonus (repeated involuntary jerking or shaking of a limb due to rhythmic muscle contractions)
• Slowness of movement
• Lack of coordination in movement
• Cocontraction - the simultaneous activation of opposing muscles when trying to execute a movement

Treatment of spasticity is usually more successful for symptoms such as flexor spasms and clonus and not as successful for relief of slow or uncoordinated movement.

Treatment typically includes:

• Prevention of potential sources of spasm such as pain, infection, fatigue, or abdominal complications (such as bowel, or bladder problems) by treating sources such as bedsores, in-grown toenails, pressure points from remaining in one position, pain syndromes such as reflex sympathetic dystrophy, or poorly fitting braces