Pain

Treatment for shoulder subluxation focusses on protection of the shoulder and prevention of developing associated pain or injury. 

Positioning: Careful positioning of the affected arm is important, allowing the weight of the arm to be supported either through use of armrests on wheelchairs, pillows or cushions under the arm.  In addition to this, it is important that anyone handling or assisting the movement of the arm such as family members or carers have been shown by a healthcare professional how to support the arm effectively so that they don't cause strain or damage. Some people feel they want to ‘protect’ the arm by keeping it close to their body or across their lap-this can be detrimental long term, as it can cause shortening of muscles and affect function and use.

Orthotics and taping: Orthotic slings can also be used to support the weight of the arm where they have been prescribed by a healthcare professional.  Shoulder taping can sometimes be used by a trained therapist if appropriate, to try and stabilise the joint. Use of both taping and shoulder slings should be monitored by a healthcare professional and they are not done routinely, as can at times cause muscles to ‘switch off’ and become less active. 

Neuromuscular electrical stimulation (NMES): Electrical stimulation machines may also be used to stimulate the activity of the muscles surrounding the shoulder and help to reduce the subluxation.  This would need to be prescribed by a therapist and worn regularly.  Your therapist should show you, your relative or carer how to safely apply the device so that it can be put on daily. This is usually considered after several assessment sessions by a therapist who is trained in NMES, to see if there is benefit and carryover.

Movement: Physiotherapists or Occupational Therapists can advise on gentle exercises to either stretch or strengthen the shoulder so that movement can be improved in a safe way and stiffness from lack of movement does not occur. They can also advise on the safest way to move your arm during routine day to day activities such as getting washed and dressed. 

There is no formal diagnosis method for neuropathic pain so providing an accurate description of your symptoms to your GP, consultant or therapist is very important. Diagnosis will likely be based on:

• No other identifiable cause of the pain such as muscle tightness or infection.
• Pain occurring at the same time or following a stroke.
• The type of pain described being like those in the paragraph above. 

Medication: Because neuropathic pain is a nerve pain, ordinary pain killers such as paracetamol and ibuprofen are often not effective. Medications which are aimed at changing the chemicals in your brain may often be more effective but might take a little while before you see the benefit so regular use (as prescribed) is important, not just when you feel the pain. The medications prescribed will often be started at low doses and gradually increased as required to gain the maximum relief.

Medications often prescribed for neuropathic pain include:

• Pregabalin or Gabapentin
• Amitriptyline - Often used for mood disorders but when used in low doses can be effective for neuropathic pain. 

If these pain relief measures are unsuccessful then you may be considered for a referral to a pain clinic; contact your GP for advice about this. Pain clinics can provide advice and different treatments to help you to manage your pain and the associated distress it causes.

Some pain clinics offer pain management programmes which may run for a set period and focus on physical management, exercises and group therapy. They also focus on managing the emotional aspects through psychological support, relaxation and education. 

Injections: If oral analgesia is ineffective, there may be access to a specialist clinic in your area, where Botulinum Toxin could be considered or other injectables such as nerve blocks or steroid injections. This requires a referral from either your therapist, GP or other healthcare professional.

Unfortunately, not all areas have a specialist clinic, so enquire locally.

Medical professionals guide diagnosis and treatment, but many people explore complementary approaches. These are things you might want to consider when trying to manage the emotional and physiological strain of experiencing pain after stroke.

Cognitive‑behavioural strategies: Cognitive behavioural therapy works with your current thought patterns, especially any beliefs you may have that might be worsening the pain unintentionally. This would help you to recognise cycles such as overly worrying about pain (catastrophising) fears of moving or thinking the worst about sensations. These thoughts can be changed so that they are more balanced and realistic. The level of treat in your brain becomes reduced and this helps because pain is stronger when the brain is operating from a survival state. These steps help you to teach the body that it is safe and calm the nervous system.  

Solution‑focused hypnotherapy: This is an example of another therapy that combines a talking component with relaxation (also known as hypnosis). This approach to therapy is forward thinking, rather than focused on the past. In relation to pain this part would involve you being guided visualise small steps to managing pain. The idea is this therapy supports people from operating from the survival part of the brain (primitive brain) where pain is amplified, to the part of the brain where they can feel more calm, positive and rational. Then the relaxation part of this therapy encourages your brain to be in a relaxed state where your nervous system is calmer. This therapy can make your experience of pain more manageable and help people feel more resourced and less overwhelmed as they navigate recovery. This therapy also has a ripple effect in terms of how it supports people across different areas of life, so even if they were coming to the therapy to manage pain, they could see benefits such as confidence, feeling better emotionally and managing better physically.

Relaxation practices: This forms part of the solution focused approach but relaxation alone can be beneficial for pain after stroke. This may include slow breathing or muscle relaxation which can help to calm the nervous system.

Music or art therapy: These therapies also support relaxation, mood regulation, and distraction from persistent pain sensations.

Social and emotional support: Alternatives for gaining emotional support in more of a group-based setting could include talking with peers, attending support groups, or counsellors can reduce isolation and stress, which often influence pain perception.