Post-stroke pain, fatigue, and depression: PT scope and the team

1. Case. A 60-year-old man, 4 months post-stroke. Right shoulder pain at rest 4/10, with movement 7/10. He naps twice daily and says, "I feel like I'm not myself." PHQ-9 = 11.

2. CPG section. AHA/ASA 2016 recommends routine screening for post-stroke depression (Class I), with PHQ-9 a commonly used tool (Kroenke K, Spitzer RL, Williams JBW. *J Gen Intern Med*. 2001;16:606–613). Post-stroke fatigue pooled prevalence is 50% (95% CI 43–57%) across 49 studies; using the Fatigue Severity Scale at cutoff ≥4 across 22 studies (n=3,491), estimates range 25–85% with substantial heterogeneity (I² = 94%) (Cumming TB et al., *Int J Stroke*. 2016;11:968–977). Hemiplegic shoulder pain: AHA/ASA 2016 recommends positioning, supportive devices, and avoiding traction-based handling, with selected pharmacologic and BoNT-A options where appropriate.

3. Reasoning walkthrough. PHQ-9 11 = moderate depression. PT scope: document, communicate to the primary-care or psychiatric team, screen for safety items. Do not interpret depression scores as something PT treats independently. For shoulder pain, examine subluxation, shoulder-girdle ROM, and handling at transfers; correct passive positioning, avoid axillary traction during transfers, consider taping/sling in select cases. For fatigue, structure sessions to match energy windows; aerobic exercise has modest evidence for reducing post-stroke fatigue (Wu S, Mead G, Macleod M, Chalder T. *Stroke*. 2015;46:893–898) but should be dosed conservatively at first.

4. Outcome measure. PHQ-9 (screening only, not a PT intervention measure), Fatigue Severity Scale (Krupp LB et al. *Arch Neurol*. 1989;46:1121–1123; 9 items × 1–7; ≥4 mean indicates significant fatigue), and a pain anchor (NPRS at rest and with movement).