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Abstract
Background. The ShoulderQ is a structured questionnaire designed to assess timing and severity of hemiplegic shoulder
pain (HSP), in order to target pain relief effectively. It includes both verbal and visual graphic rating scale questions, simply
presented for patients with language/visuo-spatial deficits following stroke.
Objective. To assess the sensitivity of the ShoulderQ to clinical improvement in shoulder pain following multi-disciplinary
intervention.
Design and setting. Retrospective analysis of serial questionnaires collected in the course of clinical treatment in an in-patient
neurological rehabilitation unit.
Subjects and interventions. Thirty consecutive adults with cognitive and communicative deficits, presenting with hemiplegic
shoulder pain following acquired brain injury. Multi-disciplinary treatment was delivered through an integrated care
pathway, and ShoulderQs recorded fortnightly, including at baseline and end of treatment.
Results. Changes on visual graphic rating scale (VGRS) were associated with verbal reports of improvement (rho 0.665,
p 5 0.001). Patients were divided retrospectively on the basis of their overall clinical response into responders (n 18) and
non-responders (n 12). Responders showed significant change in both VGRS and verbal scores, whereas the nonresponder group did not. A change in summed VGRS score of 3 showed 77% sensitivity and 91.3% specificity for
identifying the responders, with a positive predictive value of 93.3%. Summed VGRS scores of 2 had a negative predictive
value of 73.3%.
Conclusion. In this preliminary evaluation of clinical data, the ShoulderQ appears to provide a sensitive measure of shoulder
pain which is responsive to change in pain experience for those able to complete the questionnaire, despite the difficulties
that many of this group of patients may have in reporting their symptoms. Set alongside previously reported test-retest
reliability, the results support the utility of the ShoulderQ as a simple and practical tool for evaluation of shoulder pain in
patients with severe complex disabilities.
Keywords: Rehabilitation, integrated care pathway, hemiplegic shoulder pain, pain assessment
Introduction
Hemiplegic shoulder pain is a common complication
of stroke which may interfere with rehabilitation and
delay discharge from hospital. Following a systematic
review [1], an evidence-based integrated care pathway (ICP) has been developed [2]. This ICP offers a
holistic multi-disciplinary approach to management
of hemiplegic shoulder pain, including suitably
targeted analgesia, support for the paralysed arm,
and physical treatment as appropriate to the underlying presentation [1]. Regular accurate assessment
of shoulder pain is integral to the effective application
of the care pathway and decisions regarding pain
interventions.
Correspondence: Professor Lynne Turner-Stokes, Regional Rehabilitation Unit, Northwick Park Hospital, Watford Road, Harrow, Middlesex., HA1 3UJ, UK.
Tel: 020 8869 2800. Fax: 020 8869 2803. E-mail: lynne.turner-stokes@dial.pipex.com
ISSN 0963-8288 print/ISSN 1464-5165 online 2006 Taylor & Francis
DOI: 10.1080/09638280500287692
390
2.
3.
Methods
The study was conducted in a regional rehabilitation service for young adults (16 65 years) with
severe complex neurological disability (i.e., physical
cognitive and/or communicative deficits), mainly
following acquired brain injury of any cause
(including stroke, trauma, hypoxia etc). Of 39
consecutive adults who presented with hemiplegic
shoulder pain and were enrolled in the ICP over a
two-year period, 30 were demonstrated, through
screening with the AbilityQ, to be able to respond
to questionnaires with acceptable accuracy [6] and
were included in this analysis. Twenty-three
patients were able to complete both verbal and
VGRS scores correctly, and the remaining seven
were able to complete either VGRS (n 4) or
verbal (n 3) scores.
The ShoulderQ takes about 5 10 minutes to
complete for most patients. It includes verbal assessments of overall severity of pain (graded 0 4) and
pain in comparison to the previous week (the same,
better or worse on a 5-point scale). Three visual
graphic rating scales, with numbered tick-marks
(1 10) at 1 cm intervals, provide separate assessment
391
Figure 1. Serial VGRS scores in one of the six patients who made an initial response, but whose pain relapsed when they left the support of
their wheelchair and started to walk.
.
.
392
Timing of pain
Responders (n 18)
At night (VGRS)
On movement (VGRS)
At rest (VGRS)
Summed VGRS score
Verbal score
Non-responders (n 12)
At night (VGRS)
On movement (VGRS)
At rest (VGRS)
Summed VGRS score
Verbal score
Confidence Intervals*
Significance*
4.0
5.8
2.5
11.7
2.2
(0.8)
(0.6)
(0.6)
(1.5)
(0.2)
2.2
3.2
0.4
5.0
1.0
(0.7)
(0.8)
(0.6)
(1.7)
(0.3)
0.6,
1.5,
70.9,
1.4,
0.4,
3.7
5.0
1.7
8.6
1.6
0.009
0.001
0.533
0.009
0.002
2.3
3.9
2.7
9.7
1.8
(0.7)
(0.9)
(0.4)
(1.4)
(0.2)
70.5
71.7
0.4
0.7
70.2
(0.9)
(0.7)
(0.6)
(1.6)
(0.3)
72.7,
73.4,
70.9,
72.8,
70.9,
1.7
0.1
1.8
4.3
0.4
0.623
0.040
0.526
0.654
0.389
Set alongside previously reported test-retest reliability [3], the results provide support for the utility of
the ShoulderQ as a simple and practical tool for
evaluation of shoulder pain in patients with complex
disabilities, who are demonstrated by pre-screening
with the AbilityQ to be able to complete the
questionnaire accurately. So far as the authors are
aware, there is currently no other validated tool for
assessing hemiplegic shoulder pain in this group of
patients. The instrument is now worthy of more
detailed evaluation.
Clinical points
. The ShoulderQ is designed to assess hemiplegic shoulder pain in patients with cognitive
and communicative deficits;
. Serially recorded ShoulderQs appear to detect
fluctuations in pain experience appropriately
in those able to complete the questionnaire;
. Both verbal and visual analogue scales were
sensitive to change and differentiated between
the responder and non-responder groups;
. Changes in individual VGRS scores for pain
at night, at rest and on movement provided
more specific information on which clinical
management decisions, such as analgesic
prescribing, could be based.
Acknowledgements
The authors gratefully acknowledges the hard work
of the RRU staff in collecting the data presented in
this study, and the cooperation of the patients to
whom it belongs. Special thanks are due to Lisa
Knight, Lisa Beatty, Anne OConnell, Hilary Stern,
Rana Das Gupta, Ajoy Nair and Jan Gavronski for
their roles in coordinating the ICP data collection.
References
1. Turner-Stokes L, Jackson D. Shoulder pain after stroke: A
review of the evidence base to inform the development of an
integrated care pathway. Clin Rehab 2002;16(3):276 298.
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