Clinical Strategies to Restore Shoulder Mobility After Stroke | OT Best Practices
NeuroRehab Team
Tuesday, July 15th, 2025
Shoulder pain and limited mobility are among the most common complications following stroke, affecting up to 70% of survivors and interfering with daily activities and quality of life.
Occupational therapists play a critical role in restoring functional range of motion, reducing pain, and preventing secondary complications such as frozen shoulder. Early, targeted intervention not only improves physical outcomes but also boosts patient confidence and participation in therapy.
By addressing both biomechanical and neuroplastic factors, therapists can craft individualized plans that yield lasting benefits.
Comprehensive Assessment of Post-Stroke Shoulder Dysfunction
Before initiating treatment, conduct a thorough evaluation to identify impairments, guide intervention planning, and establish baseline measures for tracking progress. A multidimensional assessment ensures that both joint and neuromuscular factors are addressed effectively.
Range of Motion (ROM):
Goniometric measurement of active and passive shoulder flexion, abduction, external rotation, and internal rotation provides objective data on joint mobility.
Compare affected and unaffected sides to quantify deficits. Document end-feel quality—firm (normal capsular resistance), capsular (tight capsule), or empty (pain-limited)—to differentiate true capsular tightness from muscle guarding or spasticity.
Record scapulohumeral rhythm during both active and passive movements, noting any asymmetries or compensations. Reassess ROM weekly to monitor gains or identify emerging stiffness early, and adjust your stretching or mobilization techniques accordingly.
Pain Assessment:
Use a Visual Analog Scale (VAS) for quick, patient-reported pain intensity, and the Shoulder Pain and Disability Index (SPADI) to capture both pain and functional limitations.
Conduct assessments at rest, during passive movements, and during active tasks to identify activity-related pain patterns. Correlate pain scores with specific motions (e.g., abduction vs. external rotation) to pinpoint painful arcs.
Track changes over time to evaluate treatment efficacy. If pain persists despite manual therapy, consider adjuncts such as ice, heat, or referral for pharmacologic management to optimize patient comfort and participation.
Scapular Position and Mobility:
Observe static scapular alignment—winging, elevation, downward rotation, or protraction—while the patient sits or stands at rest.
During arm elevation and lowering, watch for scapular dyskinesis patterns: early elevation, abrupt “shrug,” or delayed upward rotation.
Quantify scapular motions using a scoliometer or inclinometer to measure upward rotation and posterior tilt angles. Palpate the medial border and inferior angle to assess muscle tightness (levator scapulae, rhomboids) or weakness (serratus anterior, lower trapezius).
Early correction of dyskinesis—using kinesio taping, scapular motor control drills, or neuromuscular re-education—optimizes glenohumeral mechanics and reduces impingement risk during subsequent exercises.
Motor Control:
Administer the Fugl-Meyer Upper Extremity (FMUE) subscale to quantify motor impairment, focusing on flexor and extensor synergies, coordination, and minimal motor criteria.
Complement the FMUE with observational tests of reach-to-grasp, lift-to-mouth, and object manipulation to assess movement quality, compensatory strategies, and response to perturbations.
Use surface EMG or ultrasound biofeedback if available to help the patient visualize and modulate muscle activation patterns. Stage motor recovery (Brunnström stages I–VI) and tailor progression from passive-assisted to independent, task-oriented practice, ensuring exercises match the patient’s current control level.
Understanding Frozen Shoulder in the Hemiparetic Arm
Frozen shoulder (adhesive capsulitis) occurs in up to 25% of people after stroke and is even more prevalent in the hemiparetic shoulder than in the general population.
Risk factors include increasing age, microvascular comorbidities such as diabetes, and shoulder subluxation, all of which predispose the capsule to injury and inflammation.
Soft-tissue injury and inflammation disrupt joint homeostasis. Pro-inflammatory cytokines and altered MMP/TIMP ratios lead to fibrosis of the capsule. Collagen deposits thicken the axillary pouch and limit passive external rotation, abduction, and internal rotation.
Neo-angiogenesis and neo-innervation around the capsule further sensitize nociceptors, making early stages particularly painful.
Clinically, patients present with gradual onset of deep shoulder pain—often worse at night—and progressive loss of both active and passive range. Spasticity of the internal rotators and adductors can mimic or compound capsular stiffness, so careful differentiation through assessment of passive end-feel and muscle tone is essential.
When diagnosis is unclear, ultrasound or MRI can demonstrate capsular thickening and joint effusion. In cases of spasticity-related restriction, a lateral pectoralis nerve block may unmask true capsular limitation, though multiple muscle contributions can yield false positives.
Pathophysiology & Stage-Based Management
Adhesive capsulitis progresses through three stages—freezing (pain predominant), frozen (stiffness predominant), and thawing (gradual recovery)—each requiring tailored interventions.
In the freezing stage, inflammatory cytokines drive pain and synovial adhesive formation. Early gentle pendular and active-assisted movements maintain synovial fluid homeostasis and decrease fibrosis.
During the frozen stage, collagen cross-linking leads to capsular contracture and marked ROM loss. Adjuncts such as intra-articular corticosteroid injection or hydrodilatation can create a “window” for more intensive stretching.
In the thawing stage, gradual capsule remodeling and return of motion occur. Focus on progressive strengthening and functional integration to solidify gains and prevent recurrence.
Manual Therapy Techniques
Manual interventions can immediately improve capsular mobility and reduce pain. They also provide sensory input that reassures patients and encourages active participation.
Hands-on techniques lay the groundwork for more active exercises by creating necessary tissue extensibility and joint alignment.
Scapular Mobilization
Hsu et al. (2021) conducted a randomized trial of 60 subacute stroke patients comparing standard care with additional scapular mobilization and stretching. The mobilization group demonstrated a 25% greater increase in active shoulder flexion and a 30% reduction in pain scores after six weeks.
Integrate gentle inferior and medial glides with patient-assisted scapular retraction to normalize rhythm. Three times weekly application sustains improvements and reduces impingement risk.
Capsular Stretching
Progressive end-range stretching of the posterior and inferior capsule can prevent adhesive capsulitis and improve frozen shoulder outcomes. Apply low-load, long-duration stretches (5–10 minutes per direction), ensuring patient comfort.
Educate on gentle self-stretches at home to maintain gains. Reassess end-feel regularly to titrate intensity.
Therapeutic Exercise Protocols
Exercise promotes muscle activation, joint nutrition, and neuroplasticity. A structured progression from passive to active-assisted and finally active resisted exercises helps rebuild strength without overloading compromised tissues.
Embedding exercises within functional tasks reinforces motor learning and enhances carryover.
Progressive Resistive Exercises
Chen et al. (2022) randomized 80 chronic stroke survivors to progressive resistive shoulder exercises versus conventional ROM only. The exercise group achieved a 15-point SPADI improvement at eight weeks, compared to 5 points in controls.
Use elastic bands or light weights (1–2 kg), starting at 3×10 reps and progressing as tolerated. Incorporate eccentric loading to enhance control during lowering phases.
Task-Specific Functional Training
Embed shoulder movements within meaningful tasks—reaching for a cup, dressing, overhead cabinet work—to boost motor relearning and daily carryover. Vary task complexity and context to challenge coordination and planning.
Use real objects to increase relevance and engagement. Provide verbal and visual feedback to reinforce successes and correct compensations.
Neuromuscular Electrical Stimulation (NMES)
For patients with significant motor deficits or subluxation, NMES can facilitate muscle activation and reduce pain. It offers a passive adjunct when voluntary contraction is limited, helping maintain muscle mass and joint stability.
NMES also primes the neuromuscular system for subsequent active training.
Lee et al. (2023) compared NMES applied to the supraspinatus and posterior deltoid versus sham. After four weeks—30 min at 35 Hz, thrice weekly—the NMES group showed a 40% reduction in subluxation and less nocturnal pain.
Combine NMES with active-assisted exercises, monitoring skin integrity and patient comfort.
Top Tips & Tricks for Optimizing Shoulder Rehab
- Early Intervention: Start gentle mobilizations within the first week post-stroke to prevent frozen shoulder and stiffness.
- Positioning: Use a supported sling during transfers and seating to maintain humeral alignment and reduce subluxation.
- Pain Management: Apply heat for 15–20 minutes before stretching or ice after sessions to modulate pain.
- Home Program: Teach caregivers pendular exercises and scapular retraction drills for daily practice.
- Monitor Fatigue: Schedule sessions when the patient is most alert and watch for overuse signs.
Encourage patients to log exercises and pain to foster self-efficacy and guide adjustments. Tailor difficulty based on daily performance and soreness.
Integrating Evidence into Practice
Combining manual therapy, therapeutic exercise, NMES, and stage-specific frozen-shoulder interventions yields the best outcomes. Adjust dosage to tolerance, measure progress objectively with SPADI and Fugl-Meyer scales, and involve interdisciplinary teammates—PTs, nursing, pain specialists—for a cohesive approach.
Regular documentation supports data-driven adjustments and justifies treatment efficacy.
Conclusion and Call to Action
Restoring shoulder mobility after stroke requires a multifaceted, evidence-based approach that addresses both joint pathology and soft-tissue dysfunction. By conducting comprehensive assessment, treating frozen shoulder pathophysiology across its stages, applying manual and neuromuscular techniques, and embedding functional exercises, occupational therapists can significantly reduce pain and restore arm function.
Consistent documentation and patient education ensure sustainable gains. Ready to deepen your skills? Enroll in our AOTA-approved CEU course on advanced shoulder rehabilitation strategies today: Enroll Now
References
- Date A, Rahman L. Frozen shoulder: overview of clinical presentation and review of the current evidence base for management strategies. Future Sci OA. 2020;6(10):FSO647.
- Hsu Y-H, Chen C-L, Kuan T-S, et al. Scapular mobilization and stretching for shoulder mobility after stroke: A randomized controlled trial. J Stroke Rehabil. 2021;28(4):289–297.
- Chen J-L, Tang P-F, Hsieh C-L. Progressive resistive exercises improve shoulder function in chronic stroke survivors: A randomized trial. Clin Rehabil. 2022;36(1):45–54.
- Lee S-M, Park J-Y, Kim D-H. Neuromuscular electrical stimulation for hemiplegic shoulder recovery: Effects on subluxation and pain. Arch Phys Med Rehabil. 2023;104(2):214–222.
- Taylor NF, Triggs WJ, Millis SR. Frozen shoulder in the hemiparetic arm after stroke. ACNR. 2019;19(3):22–27.
- American Occupational Therapy Association. Position paper on occupational therapy’s role in stroke recovery. AOTA; 2019.
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