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Table of Contents
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11.8 SUMMARY.........................................................................................49
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Key Points
Strapping the hemiplegic shoulder does not appear to improve upper limb
function, but may reduce pain.
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11. Painful Hemiplegic Shoulder
Shoulder pain resulting from hemiplegia is a common clinical consequence of a focal
cerebral insult resulting from a vascular lesion (ie. hemorrhagic or ischemic stroke).
The incidence of shoulder pain varies between studies, with estimates which range from
48% to 84% (Najenson et al. 1971, Poulin de Courval et al. 1990). Shoulder pain, by
itself, can result in significant disability (Najenson et al. 1971, Poduri 1993) and although
it can occur as early as 2 weeks post stroke, an onset time of 2-3 months post stroke is
more typical (Poduri 1993). In a recent prospective study, Gamble et al. (2002)
reported that 52/152 (34%) developed shoulder pain following stroke, 28% by two
weeks and 87% by two months. By 6 months, the pain had resolved in 80% of the
patients. Lindgren et al. (2007) reported that 74 (24%) of 305 patients with first ever
stroke, who remained from an original cohort of 416 patients, experienced shoulder pain
by month 16. Approximately half of these patients developed pain between stroke onset
and 4 months.
Shoulder pain can negatively affect rehabilitation outcomes as good shoulder function is
a prerequisite for successful transfers, maintaining balance, performing activities of daily
living and for effective hand function (Risk et al. 1984). Lo et al. (2005) catalogued the
different types of shoulder dysfunction based on both clinical and arthrographic findings
and reported that 16% of patients of a cohort of 32 patients with hemiplegic shoulder
pain within one-year of stroke had shoulder-hand syndrome, 4% had rotator cuff tears
and 50% suffered from frozen shoulder. 63% of patients had a single type of shoulder
dysfunction while 34% had two types.
6
1981, Fugl-Meyer et al. 1975, Crossens-Sills and Schenkman 1985, Hakuno et al. 1984,
Risk et al. 1984) and spasticity, particularly of the subscapularis and pectoralis muscles
(Braun et al. 1981, Caldwell et al. 1969, Moskowitz 1969a, 1969b). Other suggested
causes of shoulder pain include reflex sympathetic dystrophy (Chu et al. 1981, Davis et
al. 1977, Perrigot et al. 1975), or injury to the rotator cuff musculotendinous unit
(Najenson et al. 1971, Nepomuceno et al. 1974). The role of central post stroke pain in
the etiology of shoulder pain is unclear (Walsh 2001).
7
Figure 11.1 A. Normal Shoulder. The humeral head is maintained in the glenoid fossa by the
supraspinatus muscle.
Figure 11.1 B. Shoulder Subluxation. During the initial phase of hemiplegia, the supraspinatus muscle
is flaccid. The weight of the unsupported arm can cause the humeral head to sublux downward out of the
glenoid fossa.
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11.2.2 Scapular Rotation
There appear to be other factors playing a role in subluxation of the glenohumeral joint.
Basmajian and Bazant (1959) proposed that in the normal state, subluxation of the
humeral head was prevented by upward angulation of the glenoid fossa and the upper
part of the shoulder capsule, the coracohumeral ligament and supraspinatus muscle.
After a hemiplegic stroke they hypothesized that the upward angulation of the scapula
would be lost. Calliet (1980) added that in the flaccid stage, the scapula assumed a
depressed and downward rotated position, as the paretic serratus anterior and the
upper part of the trapezius muscles no longer support the scapula. The combination of
flaccid supportive musculature (in particular, the supraspinatus muscle) and a
downward rotated scapula was presumed to predispose the head of the humerus to
undergo inferior subluxation relative to the glenoid fossa.
Table 11.2 Scapular Rotation in the Hemiplegic Shoulder
Price et al. 30 patients, 6 months post stroke received 24 patients had no shoulder subluxation, 6
2001 a standardized clinical assessment, patients suffered from shoulder
UK whereby manual palpitation of the subluxation. Among all patients, the
No Score subacrimonial space was performed to average degree of scapular downward tilt
identify those with subluxation. The Upper was 10.04 for the unaffected side and
Limb Motricity Score (ULMS) was used to 10.46 for the affected side (p=ns). There
record arm strength. The degree of was no difference in the scapular
scapular downward tilt and dynamic downward tilt of the affected shoulder of
scapular lateral rotation were assessed by subjects with and without subluxation.
9
Author, Year Method Outcome
Country
a Scapula Locator System device to
determine their association with
subluxation.
Prevost et al. (1987), using a 3-D x-ray technique, studied the movement of the scapula
and humerus in stroke patients. They studied 50 stroke patients comparing the affected
to the non-affected shoulder. They were able to demonstrate that there was a
difference between the affected and non-affected shoulders in terms of the vertical
position of the humerus (ie. degree of subluxation) in relation to the scapula. The
orientation of the glenoid fossa was also different; however, they found that with the
subluxed shoulder it was actually facing less downward. There was no significant
relationship noted between the orientation of the scapula and the severity of
subluxation. They concluded that the scapular position was not an important factor in
the occurrence of inferior subluxation in hemiplegia (Prevost et al. 1987). Culham et al.
(1995) reported that while patients with low-tone had significantly greater subluxation
compared to the high-tone group, (0.52 vs. 0.21) there was no correlation between the
amount of subluxation and the scapular abduction angle or the humeral abduction
angle. Price et al. (2001) compared patients with and without stroke (n=15) and reported
that subluxation in stroke patients was unrelated to scapular resting position. These
authors also reported that the normal scapula tilts downward to a greater degree found
in other studies.
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Table 11.3 Studies which Support or Fail to Report an Association between Shoulder Subluxation
and Pain
Studies Supporting the Role of Shoulder Studies Which Fail to Support the Role of
Subluxation in Pain Shoulder Subluxation in Pain
Individual Studies
A selection of studies examining the relationship between shoulder subluxation and pain
are presented in Table 11.4.
11
Author, Year Methods Main Outcome
Country
and the head of the humerus. He then graded indicating that patients with higher
subluxation as none (0), minimal (1) or scores on the Ritchie Index had
substantial (2). Shoulder pain was measured fewer degrees of lateral rotation of
during slow lateral rotation of the joint while the the shoulder before pain was
patients were supine. All patients’ shoulders experienced.
were abducted about 450 and their elbows were
held at 900 with their forearms pronated with
measurements beginning from neutral shoulder
rotation. Patients’ responses were graded on a
3-point scale (Ritchie Index) of: no pain,
complaint of pain and wince, complaint of pain,
wince and withdrawal. SROMP measurements
taken with patients’ shoulders laterally rotated
until they first expressed pain in the shoulder, at
which point a fluid-filled gravity goniometer, was
applied and read.
Joynt 1992 A convenience sample of 97 patients suffering 49 patients with specific shoulder
USA from pain in the upper extremity was examined. pain were compared to 18 patients
No Score The interval from stroke onset to examination with pain, not localized to the
ranged from several days to a few years. 49 shoulder. Patients complaining of
patients had specific complaints of shoulder pain. shoulder pain did not exhibit
subluxation more frequently than
patients with general pain in the
affected extremity.
Wanklyn et 108 patients were assessed clinically, 3 times Subluxation was detected clinically
al. 1996 over a 6-month period following stroke. in 31 (29%) patients at hospital
UK Subluxation was assessed clinically and graded discharge and 27 (26%) at 26
No Score in finer-breadths palpable below the acrimonion weeks. Shoulder pain was not
process. associated with subluxation at 2/3
assessment points. The authors do
not provide details of the data.
Zorowitz et 20 stroke patients with shoulder pain, admitted to Shoulder pain after stroke was not
al. 1996 a rehabilitation hospital within 6 weeks of their correlated with age, vertical,
USA first stroke were studied. horizontal, or total asymmetry,
No Score shoulder flexion or abduction, or
Fugl-Meyer scores. However,
shoulder pain was strongly
correlated with degree of shoulder
external rotation
Ikai et al. 75 patients with shoulder subluxation were At rest, 10 patients reported pain.
1998 assessed for pain using a visual analogue scale During passive range of
Japan at rest and during passive range of movement. movement, 5 patients reported no
No Score The degree of pain was expressed as pain, 25 reported mild pain, 36
nonexistent (0), mild (1-3), moderate (4-7), or reported moderate pain and 9
severe (8-10) during passive movement. reported severe pain. Shoulder
pain was not related to the degree
of shoulder subluxation.
Lo et al. 2003 32 consecutive patients with shoulder pain 14 (44%) of patients had clinically
Taiwan following stroke were assessed for shoulder diagnosed shoulder subluxation.
No Score subluxation, which was diagnosed by a gap of
more than one finger breadth between the
acrimonion and the head of the humeral bone on
palpation.
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Author, Year Methods Main Outcome
Country
Aras et al. 85 consecutive stroke patients admitted to one of 27 patients had glenohumeral joint
2004 the largest rehab facilities in Turkey were studied subluxation and reported shoulder
Turkey to identify the incidence of shoulder pain and the pain, compared to 5 patients with
No Score factors associated with it. the same finding, but without pain.
Although it has not been established that shoulder subluxation is the primary
cause of hemiplegic shoulder pain it would still seem prudent to take care early
on with the hemiplegic upper extremity to avoid subluxation.
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Individual Studies
Van Ouwenaller et al. (1986) looked at various factors in 219 patients followed for one
year after a stroke and identified a much higher incidence of shoulder pain in spastic
(85%) than in flaccid (18%) hemiplegics. They identified spasticity as "the prime factor
and the one most frequently encountered in the genesis of shoulder pain in the
hemiplegic patient." They were unsure of the etiology of the subsequent shoulder pain.
Poulin de Courval et al. (1990) examined 94 hemiplegic subjects involved in a
rehabilitation program after stroke and reported that subjects with shoulder pain had
significantly more spasticity of the affected limb than those without pain. In contrast,
Bohannon et al. (1986) conducted a statistical analysis of 50 consecutive hemiplegic
patients (36 with shoulder pain) and asserted that "spasticity ... was unrelated to
shoulder pain." Joynt (1992) also supported this finding after examining 67 patients with
shoulder problems following stroke. Nevertheless, evidence for spasticity in particular
hypertonic muscle imbalance, as a cause of hemiplegic shoulder pain is growing.
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11.3.1 Spastic Muscle Imbalance
Clinically the internal rotators of the shoulder predominate after a stroke involving that
arm and external rotation is one of the last areas of shoulder function to recover.
Hence, during recovery motor units are not appropriately recruited or turned off; the
result is simultaneous co-contraction of agonist and antagonist muscles. A shortened
agonist in the synergy pattern becomes stronger and the constant tension of the agonist
can become painful. Stretching of these tightened spastic muscles causes more pain.
Shortened muscles inhibit movement, reduce range of motion, and prevent other
movements especially at the shoulder where external rotation of the humerus is
necessary for arm abduction greater than 90 degrees. Muscles that contribute to
spastic internal rotation/adduction of the shoulder include the subscapularis, pectoralis
major, teres major and latissimus dorsi muscles. However, two muscles in particular
have been implicated as most often being spastic leading to muscle imbalance. These
are the subscapularis and pectoralis major muscles.
Bohannon et al. (1986) found limitation of external rotation of the hemiplegic shoulder
was the factor which most correlated with hemiplegic shoulder pain. Zorowitz et al.
(1996) also found that limitation in shoulder external rotation correlated strongly with
pain. Hecht (1995) specifically linked this problem to the subscapularis muscle when he
noted, "The subscapularis muscle is the primary cause of shoulder pain in spastic
hemiplegia where external rotation is most limited. Although other muscles may
contribute to spasticity, pain and functional contracture, the subscapularis is the
keystone of the abnormal synergy pattern."
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Figure 11.2 The Subscapularis Muscle. The subscapularis muscle is a major internal rotator of the
shoulder. As part of the typical flexor synergy pattern in spastic hemiplegics, the subscapularis is
tonically active limiting not only external rotation but also shoulder abduction and flexion.
The subscapularis spasticity disorder is characterized by motion being most limited and
pain being reproduced on external rotation. A tight band of spastic muscle is palpated
in the posterior axillary fold. In support of this, Inaba and Piorkowski (1972) reported
external rotation was the most painful and limited movement of the hemiplegic shoulder.
16
Figure 11.3 The Pectoralis Major Muscle. The pectoralis major muscle serves to adduct, internally
rotate and forward flex the arm at the shoulder.
17
Author, Year Methods Outcome
Country
employed. The needle was inserted directly
into the glenohumeral joint space under
fluoroscopic control. Anteroposterior
radiographs were made in internal and
external rotation.
Crossen-Sills 21 male patients all received standard 67% of the patients entered the rehab
& physical therapy treatment. Shoulder pain, centre with signs of shoulder pain. An
Schenkman range of motion and subluxation were additional 10% developed initial signs of
1985 assessed on admission, three weeks post shoulder pain by 3 weeks post-admission
USA admission and at discharge. and another 5% developed signs of pain
at time of discharge. Positive correlation
noted between loss shoulder range and
increase in pain and between subluxation
and pain. There was no correlation
between subluxation and range of
motion. Suggestion that pain began in
the acute cares facility and worsened
while in rehab.
Rizk et al. Study of 30 spastic hemiplegic (18 with left 23 patients had capsular constriction
1984 hemiplegia and 12 with right hemiplegia) typical of frozen shoulder (adhesive
USA patients with painful ipsilateral shoulders capsulitis). 7 patients had normal
meeting the following criteria: maximum arthrograms. None showed rotator cuff
passive range of motion (ROM) of 600 of capsular tears. Electromyography
abduction, 900 forward flexion, 150 external revealed electrical silence in the shoulder
rotation, 450 extension; any stress at the limit musculature at rest.
of motion produced severe shoulder, with no
improvement during the previous 2 weeks,
no history of recent trauma to the affected
shoulder during the previous 2 weeks, no
history of seizures or anticonvuslant
medications; no clinical signs suggesting
shoulder-hand syndrome, no bone disease
or polyarthritis or previous shoulder pain
before stroke onset. All patients had shoulder
arthrograms performed. Electromyographic
studies were done on the deltoid, triceps,
and biceps brachii muscles on the muscles
on the involved side.
Bohannon et 50 patients whose hemiplegia was Of the 50 patients reviewed, 72% had
al. 1986 secondary to a stroke, whose unaffected shoulder pain. 20 had some pain while
USA shoulders demonstrated normal and pain- 16 had severe pain. Three zero-order
No Score free range of hemiplegia shoulder external correlations were significant: ROSER
rotation (ROSER, 900); able to adequately and shoulder pain (r=-0.061, p<0.001);
follow instructions to allow testing of all time since onset of hemiplegia and
variables pertinent to the study. Information shoulder pain (r=0.45, p<0.01); and time
was retrieved from patients’ records since onset of hemiplegia and ROSER
concerning their initial physical therapy (r=0.37, p<0.01). One-way ANOVA
evaluation. Relationships between pain and demonstrated that time since onset of
other variables were determined. hemiplegia (F=8.28, p<0.001) and the
ROSER (F=18.44, p<0.001) were
significantly different in patients with no
pain, some pain, and pronounced/severe
pain.
Lo et al. 2003 32 consecutive patients with shoulder pain 16 (54%) of patients had rotator cuff
18
Author, Year Methods Outcome
Country
Taiwan following stroke were assessed for shoulder tears diagnosed by arthrograpy.
No Score subluxation, which was diagnosed by a gap
of more than one finger breadth between the
acrimonion and the head of the humeral
bone on palpation.
In summary, while shoulder subluxation is not always associated with shoulder pain,
spasticity generally is. The problem of hemiplegic shoulder pain appears to be due to a
combination of spastic muscle imbalance and a frozen contracted shoulder. However,
overaggressive stretching of the shoulder through an aggressive stretching program
may simply aggravate pain (see Treatment), as it does not address the issue of spastic
muscle imbalance.
Spasticity and subsequent frozen shoulder are the most likely causes of
hemiplegic shoulder pain.
19
possible cause of hemiplegic shoulder pain. Generally, hemiplegic shoulder pain is not
commonly associated with rotator cuff disorders.
Wanklyn et al. (1996) and Roy et al. (1995, 1996) both demonstrated an association
between hemiplegic shoulder pain and poor functional outcomes. However, a cause
and effect relationship has not yet been established.
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11.6 Management of the Painful Hemiplegic Shoulder
Management of the painful hemiplegic shoulder, once the condition has developed, is
difficult and response to treatment is frequently unsatisfactory (Risk et al. 1984). The
best treatment approach has not been definitely established, in part, due to the
uncertainty of the etiology of the pain. As a result, a wide variety of treatments have
been used, with varying degrees of success (Snels et al. 2002). Ideally, measures
should be taken immediately following stroke to minimize the potential for the
development of shoulder pain. Early passive shoulder range of motion, and supporting
and protecting the involved shoulder, in the initial flaccid stage are regarded as
important steps to reduce the development of shoulder pain.
The muscles around the hemiplegic shoulder are often paralyzed, initially with flaccid
tone and later with associated spasticity. Careful positioning of the shoulder serves to
minimize subluxation and later contractures as well as possibly promote recovery, while
poor positioning may adversely affect symmetry, balance and body image.
As cited by Gilmore et al. (2004), Davies (2000) suggests that through careful and
correct positioning, the development of shoulder pain can be prevented. Bender and
Mckenna (2001) have noted that a primary goal of early stroke management is to
prevent the development of hypertonicitiy (Johnstone 1992) and to discourage
inefficient patterns (Bobath 1990). Bender and McKenna (2001) noted that the
“recommended position for the upper limb is towards abduction, external rotation and
flexion of the shoulder,” however, from Carr and Kenny (1992) review, Bender and
McKenna cite that “most popular theories failed to yield consensus for exact degrees of
the positioning.”
Individual Studies
21
Author, Year Methods Outcomes
Country
PEDro Score
a week for six days (positioning).
Ada et al. 36 stroke patients were randomized to Positioning the shoulder in maximal external
2005 an intervention or a control condition. rotation (position 1) significantly reduced the
Australia Patients in the experimental group development of contractures, compared to the
6 (RCT) received two, 30-minute sessions of control group. In position 2 (where patients sat
sustained shoulder positioning. Patients with the affected arm resting on a table with the
0
in both groups received 10 minutes of shoulder at 90 , for 30 minutes daily), did not
shoulder exercises and routine upper prevent the development of contractures.
limb care. The treatment was provided
for 4 weeks. Assessments of contracture
were taken at weeks 2 and 6 after
stroke.
DeJong et al. 19 patients with stroke onset no greater At 5 weeks, there was a loss of passive range
2006 than 12 weeks post stroke with severe of motion in both groups, although the losses
Netherlands arm paresis were randomized to receive were less pronounced in the experimental
6 RCT routine inpatient rehabilitation (n=10) or group for 3/5 measurements--shoulder external
rehabilitation + a prescribed positioning rotation (-19 vs.-18, p=0.37), shoulder flexion (-
procedure for 5 weeks, twice daily for a 23 vs. -29, p=0.29), shoulder abduction (-5.3 vs.
½ hour (n=9). The arm was positioned –23, p=0.042), elbow extension (0.6 vs. –4,
with as much shoulder abduction, p=0.84), forearm supination (-11 vs. –3,
shoulder external rotation, elbow p=0.69). There were no significant differences
extension and supination of the forearm between the groups on any of the other
as the patient could endure. Passive outcomes. No statistical tests were carried out
range of motion, Ashworth scale scores, at week 10 due to dropouts.
Pain (yes/no) Fugl-Meyer Assessment
scores and BI scores were assessed at
baseline, 5 and 10 weeks following
treatment.
Arm slings are often used in the initial stages following a stroke to support the affected
arm. However, their use is controversial and they can have disadvantages in that they
encourage flexor synergies, inhibit arm swing, contribute to contracture formation and
22
decrease body image causing the patient to further avoid using that arm. However, a
sling remains the best method of supporting the flaccid hemiplegic arm while the patient
is standing or transferring. Ada et al (2005) conducted a systematic Cochrane review
evaluating the benefit of shoulder slings and supports, and concluded that there is
insufficient evidence that these devices reduce or prevent shoulder subluxation
following a stroke. The review included only four RCTs (Ancliffe et al. 1992, Griffin et al.
2003 [unpublished data], Hanger et al. 2000 and Hurd et al. 1974). The results are
presented in Table 11.9.
Table 11.9 Results from Systematic Review (Ada et al. 2005)
Outcome Studies Included & Intervention Peto Odds ratio (95% CI) or
Weighted Mean Difference
(WMD) (95% CI)
Proportion of patients with Hurd et al. 1974 – hemisling OR 8.7 (1.1, 67.1)
pain at follow up (Favours no slings)
Number of days pain was Ancliffe et al. 1992 -strapping WMD 14 days (9.7, 17.8)
delayed with treatment Griffin et al. 2003 (Favours slings)
Pain scores on VAS Hanger et al. 2000 – strapping WMD 0.83 (-1.46, 3.12)
(10 cm scale) (No difference)
Motor Assessment sub scores Hanger et al 2000. -strapping WMD 0.8 (-1.5, 3.1)
(0-18) (No difference)
Proportion of patients with Hurd et al 1974- sling OR 1.00 (0.1, 9.3)
contractures (No difference)
Range of shoulder external Hanger et al. 2000 - strapping WMD –1.4 degrees (-10.9, 8.10)
rotation at end of follow up (No difference)
As tone returns to the shoulder muscles, the risk of shoulder subluxation decreases and
slings can then be withdrawn. Slings tend to hold the limb in a poor position, which may
accentuate the adduction and internal rotation posture and may contribute to shortening
of tonically active muscles. The best method to support the shoulder has yet to be
determined. In the absence of empirical evidence of their efficacy, many devices are
available and in common use, including a variety of slings and lapboards.
Individual Studies
23
Author, Year Methods Outcomes
Country
PEDro Score
evaluated were then applied to sling, trough, and lap tray reduced the mean
the patients’ affected arm and an subluxation to within .56 cm of normal control while the
A/P view was taken of each: roll and hook tended to under-correct the subluxation.
conventional sling; shoulder roll;
Hook-Hemi Harness; arm trough;
and plexiglass lap tray.
Williams et al. Radiographs were taken of 26 There was no significant difference in the reduction of
1988 hemiplegic patients with inferior subluxation between the two types of shoulder
Canada subluxated shoulders with two supports. However, there were significant differences in
No Score different supports-the Bobath subluxation between measurements of the unsupported
shoulder roll and the Henderson affected shoulder and the unaffected shoulder and
shoulder sling. Radiographs of between measurements of the unsupported affected
the unsupported affected shoulder and the supported affected shoulder using
shoulder were compared with both supportive devices.
radiographs of the same shoulder
with each support applied.
Radiographs of the unaffected
shoulder were used as a
comparison in determining the
amount of subluxation.
Brooke et al. Three different shoulder supports Harris hemi-sling improved correction of the
1991 were applied to 10 patients by subluxation with mean vertical distance of 37.8mm vs
USA their occupational and physical 38.5mm compared to the uninvolved shoulder while the
No Score therapists: Harris hemi-sling, the mean difference between Harris and Bobath sling was
Bobath sling and the arm trough 5.5(2.9) mm, in favour of the Harris sling. For
or lapboard. horizontal measurement, mean difference between
Harris and Bobath slings was 8.3(6.3) mm, in favour of
the Harris sling.
Zorowitz et An occupational therapist applied The single-strap hemisling corrected vertical
al. 1995 each shoulder support to each of displacement, while the Roylan and Bobath roll
USA 20 patients in the following order: significantly reduced vertical displacement. The
No Score (1) single-strap hemisling; (2) Bobath roll and the Cavalier support produced a
Rolyan humeral cuff sling; (3) significant lateral displacement of the humeral head of
Bobath roll; and (4) Cavalier the affected shoulder compared with the unaffected
support. shoulder. The Roylan humeral cuff sling significantly
decreased the total subluxation asymmetry.
24
11.6.3 Strapping the Hemiplegic Shoulder
Strapping the hemiplegic shoulder is used as a method to prevent or reduce the severity
of shoulder subluxation and may provide some sensory stimulation. There are three
different forms of strapping the hemiplegic shoulder, which have been described
previously:
Ancliffe 1992: 5-cm wide lightweight adhesive tape (Fixomull Stretch), “the first length of
tape was applied to the shoulder half way along the length of the clavicle, continued
across the deltoid muscle in a diagonal direction... the tape was terminated
approximately one-quarter of the way of the along the spine of the scapula. A second
length of tape was applied in the same direction as the first but 2 cm below. A small
length of tape was applied over the shoulder to secure the ends”.
Morin & Bravo 1997: “A 10 cm-wide Elastoplast adhesive bandage was applied under
tension from the forearm under the olecranon laterally to the top of the shoulder. Two
other 7.5 cm-wide bandages were applied from the olecranon under the forearm to the
forearm to the top of the shoulder, with one passing anteriorly over the clavicle and the
other posteriorly covering the spine of the scapula. No free space was left between the
bandages.”
Hanger et al. 2000: Three lengths of nonstretch Elastoplast Sports tape were used.
“The two main supporting tapes were applied first. Both were applied using a lifting
action, starting 5 cm above the elbow, and moving up the arm front and back, crossing
at the top of the shoulder. The posterior arm tape was then anchored down past the
clavicle whereas the tape from the anterior aspect of the arm came across the shoulder
and down past the spine of the scapula. They were both supported at the lower end by
a short tape to prevent them peeling off”.
Individual Studies
25
Author, Year Methods Outcomes
Country
PEDro Score
Griffin & 33 patients at risk of developing One person in the TS group developed
Bernhardt hemiplegic shoulder pain were shoulder pain compared to 5 persons in the
2006 randomized to therapeutic shoulder other 2 groups. Subjects in the TS group
Australia (TS) strapping, sham shoulder (SS) reported 26 pain-free days, compared to 19
7 (RCT) strapping or to a no strapping (control) days for SS subjects and 16 days for
group 10 days post stroke. Lightweight subjects in the control group. The difference
adhesive tape was used and strapping was statistically significant for the
continued for over 4 weeks. Primary comparison of TS and control group. There
outcome was the number of pain free were no differences between groups on any
days. Secondary outcomes included of the secondary outcomes.
range of movement, Motor Assessment
scale scores and Modified Ashworth
scores.
Strapping the hemiplegic shoulder does not appear to improve upper limb
function, but may reduce pain.
The association of spasticity, muscle imbalance and a frozen shoulder with shoulder
pain suggests that a therapeutic approach designed to improve range of motion of the
hemiplegic shoulder will improve pain.
Individual Studies
26
Author, Year Methods Outcomes
Country
PEDro Score
exercises and mock ultrasound. All patients
received ROM exercises for 4 weeks and
given a minimum of 15 treatments.
Kumar et al. 28 patients were assigned to receive a Significant difference in the incidence of
1990 rehabilitation program of range of motion by pain reported between the groups.
USA therapist (ROMT) once a day, 5 days a Shoulder pain was more common in the
5 (quasi- week; or a rehabilitation program with use of overhead pulley (63%) group than in the
randomized skate board once a day, 5 days a week; or a ROMT group (8%). ROM was
controlled rehabilitation program with use of overhead significantly reduced in those patients
trial) pulley once a day, 5 days a week while an who developed shoulder pain when
inpatient on a stroke rehabilitation unit. compared to those who did not develop
shoulder pain motion abduction, forward
flexion, internal rotation and external
rotation. Shoulder subluxation was found
in 46% of all patients with no significant
difference between treatment groups.
Patridge et al. 65 patients were randomized to receive A greater proportion of patients treated
1990 cryotherapy or Bobath therapy daily for five by the Bobath method reported no pain
UK days and then after at the therapist’s or only occasional pain on exit of the
5 (RCT) discretion for a total of four additional weeks study compared to those treated by the
and assessed by a blinded investigator. cryotherapy method.
Poduri et al. Patients with stroke experiencing shoulder A significantly greater proportion of
1993 pain after completing outpatient therapy were patients receiving the treatment drug
USA studied. One group of patients received prior to therapy experienced pain relief.
No Score either a nonsteroidal anti-inflammatory drugs Flexion, abduction and functional
(Ibuprofen 400-800g tid, and Sulindac, 150 recovery were significantly greater in
mg bid.) taken 30 to 60 minutes prior to those patients who were taking the
occupational therapy. A second group of nonsteriodal anti-inflammatory drug
patients received only occupational therapy before therapy.
consisting of range of motion, active assistive
and strengthening exercises and activities of
daily living training.
Tyson & 22 stroke patients with consequential Mean shoulder flexion for the axilla hold
Chissim weakness of the arm instructed to hold the was 115.2 degrees and 97.7 degrees for
2002 hemiplegic shoulder at: (1) an axilla hold the distal hold (p < 0.001).
UK involving shoulder support and (2) a distal
4 (RCT) hold without shoulder support. Each hold
was repeated to obtain three measurements
with order of testing randomized.
Lynch et al. 35 stroke patients with significant upper There were no between group
2005 motor impairment were randomized to a differences in changed scores between
USA control group (n=16), which received self- groups on any of the outcome measures
6 RCT range of motion exercises under the assessed (joint stability, Modified
supervision of a physiotherapist or to the Ashworth scale, Fugyl-Meyer (pain and
experimental group (n=19) of continuous self-care FIM scores).
passive motion treatments with the use of a
device (25 min sessions, 5 days/week until
discharge). All patients received
rehabilitation therapies for 3.5 hours per day.
Gustafson & 34 patients with upper extremity hemiparesis There were no significant between group
McKenna admitted within 100 days of stroke were differences reported for any of the
2006 randomized to a participated in a programme outcomes. Over time, all participants
27
Author, Year Methods Outcomes
Country
PEDro Score
Australia of two static positional stretches, each held reported decreased range of motion,
6 (RCT) for 20 minutes, once daily or to a control motor recovery and functional
condition where the affected arm was independence. The control group
supported when seated in bed. Outcome reported a decrease in pain while the
measures included: pain-free passive range treatment group reported an increase.
of motion, shoulder pain (Ritchie Articular
Index), Motor recovery (Motor Assessment
Scale) and functional independence
(modified BI) measured at hospital admission
and discharge.
Discussion
Inaba et al. (1972) in a “good” (PEDro = 7) study found no significant differences in the
outcomes of patients who received: ROM exercises and positioning, ROM exercises
and ultrasound or ROM exercises and mock ultrasound. Kumar et al. (1990) found that
overhead pullies caused dramatically higher levels of shoulder pain than more
restrained ROM exercises. Although there were no statistically significant differences in
change scores between the control and the experimental group, Lynch et al. (2005)
reported a trend towards improvement in the area of shoulder joint stability associated
with continuous passive motion using the OrthoLogic Danniflex600 shoulder CPM
system. A programme of positional static stretches was not only ineffective in reducing
loss of range of motion into external rotation, but was also associated with increasing
levels of pain (Gustafson & McKenna 2006). Counter to previous research, subjects in
this study continued to improve functionally, despite a loss of range of motion and
increasing pain, reported by subjects in the treatment group.
28
oulder Pain in Hemiplegia: The Role of Exercise (Kumar et al. 1990)
80
% in Pain
60
40
20
0
ROMT SB OP
Comparing the number of patients who developed pain in each group, there were dramatically
more patients in the OP group experiencing pain after rehabilitation compared to the other two
groups. Patients in the ROMT group experienced the least amount of pain after rehabilitation.
Partridge et al. (1990) found that treatments using Bobath therapy resulted in
significantly less pain than cryotherapy. The general message that emerges from these
three studies is that an active ROM exercise approach is preferable to more passive
modalities but an overly aggressive approach (i.e. overhead pullies) resulted in a very
high incidence of hemiplegic shoulder pain when compared to a gentler approach.
There is moderate (Level 1b) evidence that aggressive range of motion therapies,
using overhead pullies results in increased rates of shoulder pain.
There is moderate (Level 1b) evidence that Bobath therapy for the hemiplegic
shoulder is associated with greater pain reduction than passive cryotherapy
(application of local cold therapy).
There is moderate (Level 1b) evidence that gentle exercises to improve range of
motion are the preferred approach. There is moderate (Level 1b) evidence that
adding ultrasound therapy to range of motion exercises does not change
outcomes.
29
There is moderate (Level 1b) evidence that static positional stretches performed
daily during rehabilitation are associated with increasing pain and decreasing
range of motion.
Corticosteroid and/or local anesthetic injections are commonly used for shoulder pain, in
particular rotator cuff tendinopathies. It is not surprising that there would be interest in
this mode of treatment in hemiplegic shoulder pain.
Individual Studies
30
Discussion
One RCT (Snels et al. 2000), of “good” quality (PEDro = 8), failed to show a benefit of
corticosteriod injections. There is insufficient evidence to recommend this mode of
treatment and one trial casting doubt on its efficacy.
There is moderate (Level 1b) evidence, based on one “good” RCT that
corticosteroid injections do not improve shoulder pain or range of motion in
patients with hemiplegia.
As cited by Gresham et al. (1995), the U.S. AHCPR Post Stroke Rehabilitation
Guidelines defines FES as “bursts of electrical stimulation applied to the nerves or
muscles affected by the stroke, with the goal of strengthening muscle contraction and
improving motor control.” The supraspintus and posterior deltoid muscles are most
likely to be treated as they are important muscles in maintaining the correct alignment of
the glenohumeral joint (Paci et al. 2005). Theoretically, FES should help to compensate
or facilitate flaccid shoulder muscles, which in turn should reduce the risk of shoulder
subluxation. The ideal intensity of treatment is thought to be 6 hours daily, five days a
week for 6 weeks. FES is performed at frequencies of between 35 to 50 Hz (Paci et al.
2005).
Price & Pandyan (2001) conducted a systematic review of all forms of electrical
stimulation (ES) used in the prevention and treatment of post stroke shoulder pain. The
included studies and the results are presented in Tables 11.14(a) and 11.14(b). The
authors concluded that there was insufficient evidence from which to draw conclusions.
There was evidence that FES, in addition to conventional therapy, improves function but
is not superior for preventing pain.
Table 11.14(a) Studies included in the Systematic Review authored by Price & Pandyan (2001)
31
Table 11.14(b) Results From Studies Evaluating Any form of ES in the Treatment and Prevention
of Shoulder Pain
Ada & Foongchomcheay (2002) also conducted a meta-analysis to examine the effect
of electrical stimulation on shoulder subluxation following stroke. This review included
the results from 6 RCTs (Baker & Parker 1986, Faghri et al. 1994, Kobayashi et al.
1999, Linn et al. 1999, Wang et al. 2000). The results, presented in Table 11.15 suggest
that early treatment following stroke helps to prevent the development of hemiplegic
shoulder while later treatment helps to reduce pain, in addition to conventional therapy.
Table 11.15. Pooled Results from Ada & Foongchomcheay (2002)
32
Individual Studies
Eleven studies specifically evaluated the effects of FES on the treatment of shoulder
pain. (Table 11.16).
33
Author, Year Methods Outcomes
Country
PEDro Score
week 4. Patients in both groups received
daily occupational and physical therapy.
Treatments lasted for four weeks.
Assessments of shoulder subluxation, pain,
and motor control. were carried out at 4
and 12 weeks after stroke
Wang et al. 32 inpatient and outpatient rehabilitation The experimental subgroup of short duration
2000 patients with hemiplegia were assigned to showed significant improvements in reducing
Taiwan one of two groups based on the duration of subluxation as indicated by x-ray compared
5 (RCT) hemiplegia: the short and the long duration. with the control subgroup of short duration after
Subjects in each group were randomly the first FES treatment. The same effect was
assigned to either a control subgroup or an not shown for the experimental subgroup of
experimental subgroup. Subjects in the long duration. The second FES treatment
experimental subgroups were treated in a program only resulted in an insignificant change
type A-B-A study design, which consisted of of shoulder subluxation for both the short- and
an FES training (A), routine therapy or long-duration subgroups.
regular daily activity without FES training
(B), and another FES training (A). Each
period lasted for 6 wk. FES training
program, consisted of five sessions/week.
Yu et al. 2001 8 patients participated in six weeks of At end of treatment, there was a significant
USA percutaneous intramuscular electric improvement of shoulder subluxation, pain,
No Score stimulation (per-NMES). shoulder pain-free rotation and in FIM scores.
Further improvements were noted at the 3
month follow up in subluxation, pain, Fugl-
Meyer, shoulder pain-free external rotation and
in FIM scores.
Yu et al. 2001 10 hemiplegic stroke patients with at least 1 Pain scores were significantly lower for perc-
USA fingerbreadth of glenohumeral subluxation NMES than trans-NMES as assessed by the
6 (RCT) received 3 randomly ordered pairs of VAS and the MPQ.
neuromuscular stimulation (NMES) to the
suprasinatus and poterior deltoid muscles of
the subluxated shoulder. The stimulation
types were percutaneous-NMES (perc-
NMES) and transcutaneous-NMES (trans-
NMES). After each stimulation pain was
evaluated with the visual analog scale
(VAS) and the McGill Pain Questionnaire
(MPQ).
Renzenbrink 15 stroke survivors with chronic (> six A significant reduction in pain was found on the
& Ijerman months) hemiplegia and a therapy-resistant Brief Pain Inventory. Pain reduction was still
2004 painful shoulder with subluxation were present at six months follow-up. All domains, in
Netherlands studied. Shoulder subluxation was indicated particular bodily pain, of the SF-36 showed
No Score by at least 1/2 fingerbreadth of improvement in the short term. After six months
glenohumeral separation on palpation. of follow-up, bodily pain was still strongly and
Patients received 6 hours of Percutaneous significantly reduced, whereas social
Neuromuscular electrical stimulation (P- functioning and role physical demonstrated a
NMES) per day for a total of six weeks. nonsignificant improvement of more than 10%
compared with baseline.
Yu et al. 7 site, single-blinded, randomized clinical The main outcome measure was the Pain
2004 trial. 61 chronic stroke survivors with outcome measure Brief Pain Inventory question
USA shoulder pain and subluxation volunteered 12 (BPI 12), an 11-point numeric rating scale,
7 (RCT) to be randomized to receive intramuscular assessed at the end of treatment, and at 3 and
34
Author, Year Methods Outcomes
Country
PEDro Score
neuromuscular electric stimulation (NMES) 6 months post treatment. Post stroke shoulder
to the supraspinatus, posterior deltoid, pain was significantly less in the NMES group
middle deltoid, and trapezius for 6 hours a compared to control at 3 and 6 months
day for 6 weeks or to the control condition following treatment.
of a cuff-type sling for 6 weeks. Main
outcome measure Brief Pain Inventory
question.
Chae et al. 12 month follow up from Yu et al. 2004. 22 patients in the intervention group and 21
2005 Treatment success was defined as a patients received 12-month assessments. The
USA minimum 2-point reduction in Brief Pain electrical stimulation group exhibited a
7 (RCT) Inventory question 12 at all post treatment significantly higher success rate than controls
assessments. Secondary measures (63% vs. 21%). Repeated-measure analysis of
included pain-related quality of life (Brief variance revealed significant treatment effects
Pain Inventory question 23), subluxation, on post treatment Brief Pain Inventory
motor impairment, range of motion, questions 12 and 23. There were no other
spasticity, and activity limitation. significant between group differences.
Church et al. 176 stroke patients (≤10 days post-stroke) There was no significant difference in the ARAT
2006 were randomly assigned to receive surface scores, the primary outcome, between groups.
UK neuromuscular electrical stimulation There were no other significant differences
9 (RCT) (sNMES) or placebo with a sham stimulator between the groups with the exception of: the
for 4 weeks. Both groups received standard gross and grasp subsections of the ARAT, the
stroke unit care. One and 3-month arm section of the MI and the Frenchay Arm
assessments included Action Research Arm Test, where the control group fared better at 3
Test (ARAT), Frenchay Arm Test, Motricity months.
Index (MI), Star Cancellation Test, pain
scales, disability, global health status, and
Oxford Handicap Scale.
Discussion
Most of the RCTs reviewed reported a benefit associated with FES treatment, although
there was variability in the outcomes assessed: range of motion, muscle tone, EMG
activity, shoulder subluxation, shoulder pain and muscle function. The results suggest
that FES can reduce pain in the affected shoulder and also improve upper extremity
function. Percutaneously placed devices may improve treatment compliance. However,
the results from the largest and most methodologically rigorous trial (Church et al. 2006)
suggest that FES treatment might actually be associated with harm and may worsen
arm function, especially among those with severe paresis. The authors proposed
several mechanisms to potentially explain this finding including over-use and over
stimulation of the affected arm and the possibility that stimulation interfered with the
motor re-learning processes, influencing and impeding upper limb recovery even after
treatment ceased. These authors did not evaluate the benefit of FES with respect to
reducing shoulder subluxation or spasticity, while noting that there is evidence that FES
treatment has been shown to improve these parameters.
35
Conclusions Regarding FES in the Hemiplegic Shoulder
Given that spastic muscle imbalance has been identified as a cause of hemiplegic
shoulder pain, treatment designed to reverse that imbalance could potentially relieve
hemiplegic shoulder pain.
There is limited (Level 2) evidence that surgically resecting the subscapularis and
pectoralis muscle tendons improves pain and range of motion in stroke patients
with a painful hemiplegic shoulder. Further research is needed to confirm these
findings.
36
for spastic muscle imbalance offers the ability to redress that imbalance and relieve
hemiplegic shoulder pain.
Individual Studies
37
Author, Year Methods Outcomes
Country
PEDro Score
of high frequency and low intensity for 6 increased significantly more among patients
weeks) + 500 U of Dysport injected into 4 in the treatment group (7.9 to 38.9 vs. 6.7 to
sites of the pectoralis major muscle of 19.3, group x time interaction, p=0.041).
the paretic side under EMG guidance There were no other statistically significant
(n=16), or TENS + placebo (n=15). Pain differences between the groups.
was assessed on a 100 point VAS at 1
week, 1,3 and 6 months. Other
outcomes assessed included spasticity
(MAS) and shoulder range of motion
(flexion, abduction, and external rotation)
There is moderate (Level 1b) evidence that motor blocks of the subscapular
muscle reduces spastic shoulder pain and improves passive range of motion of
the hemiplegic shoulder.
There is conflicting (Level 4) evidence that motor blocks of the pectroralis major
muscle reduces spastic shoulder pain or improves passive range of motion of the
hemiplegic shoulder.
Aromatherapy has been shown to help reduce pain and anxiety associated with chronic
pain conditions (Buckle, 1999), The use of aromatherapy plus acupressure in the
treatment of hemiplegic shoulder pain has been investigated in a single RCT.
38
Author, Year Methods Outcomes
Country
PEDro Score
before and after treatment.
The authors speculated that the improvement in shoulder pain might result from an
enhancement of the parasympathetic response through the effects of smell and touch
that encourage relaxation. Relaxation has been shown previously to alter the perception
of pain.
Despite the high prevalence of patients suffering from painful hemiplegic shoulders, the
evidence for effective treatment is underwhelming. There is strong (Level 1a) evidence
supporting functional electrical stimulation and moderate (Level 1b) evidence supporting
an active therapy-oriented approach. There is also moderate (Level 1b) evidence that
overaggressive therapies using pullies substantially increases pain when compared to
gentler range of motion therapy approaches. There is insufficient evidence that
positioning of the shoulder, shoulder strapping, local corticosteroid injections and adding
local ultrasound therapy do not prevent subluxation, decrease pain or increase
functionality.
There have been no RCTs conducted on the use of slings, motor blocks for spastic
muscle imbalance or providing NSAID medications prior to therapy, although there is
limited (Level 2) evidence of a benefit for all three of these treatment approaches.
There is consensus (Level 3) opinion that prevention and avoidance of overaggressive
therapy is important. Those individuals caring for the stroke patient, particularly early
on, should be aware of the potential for shoulder injury. The shoulder should be
carefully positioned and supported against gravity while sitting or standing. Range of
motion exercises should not carry the shoulder beyond 90 degrees of flexion and
abduction unless there is upward rotation of the scapula and external rotation of the
humeral head (Gresham et al. 1995).
39
Table 11.19 Summary of RCTs for Management of
Hemiplegic Shoulder
Strapping
Hanger et al. 2000 7 98 -
Griffin & Bernhardt 2006 7 32 +
Active Therapies
Inaba et al. 1972 7 33 -
Patridge et al. 1990 5 65 +
Kumar et al. 1990 5 28 -
(for aggressive
pullies)
Lynch et al. 2005 6 35 -
Gustafson & McKenna 2006 6 34 -
Injection
Snels et al. 2000 8 35 -
Functional Electrical Stimulation
Baker et al. 1986 4 63 +
Faghri et al. 1994 4 26 +
Faghri & Rogers 1997 4 26 +
Linn et al. 1999 6 40 +/-
Kobayshi et al. 1999 5 17 +
Chantraine et al. 1999 4 115 +
Wang et al. 2000 5 32 +
Yu et al. 2001 6 10 +
Yu et al. 2004 & Chae et al. 2005 7 61 +
Church et al. 2006 9 106 -
Surgery for Muscle Imbalance
No RCTs - - o
Motor Block for Muscle Imbalance
Yelnik et al. 2006 (subscapularis) 7 20 +
Kong et al. 2007 (pectoralis major/biceps) 8 17 -
Marco et al. 2007 (pectoralis major) 8 31 +
Shoulder hand syndrome, also known as reflex sympathetic dystrophy (RSD) and
complex regional pain syndrome (type 1) is characterized by numerous peripheral and
central nervous system changes. Peripheral changes include vasomotor tone with
associated hand pain and swelling, exquisite tenderness or hyperaesthesia, protective
immobility, trophic skin changes and vasomotor instability of the involved upper
extremity. Central changes include a disruption of sensory cortical processing,
disinhibition of the motor cortex and disrupted body schema (Moseley et al. 2004). Iwata
et al. (2002) empirically describe 3 stages of RSD (Table 11.20).
40
Table 11.20 Stages and Characteristics of SHS
Stage Characteristics
I Persistent pain, described as burning, or aching and aggravated by movement
The extremity is edematous, warm and hyperesthetic
Lasting 3-6 months
2 Early dystrophic changes in the limb present
Atrophy of the muscle and skin
Vasospam with hyperhydrosis
3 Soft-tissue dystrophy
Contractures which produce “frozen shoulder”
Pain and vasomotor changes are infrequent
Shoulder hand syndrome generally presents initially with pain in the shoulder followed
by a painful, edematous hand and wrist. There is frequently decreased range of motion
at the shoulder and hand while the elbow joint is spared (Davis et al. 1977). Passive
flexion of the wrist, MCP and PIP joints is painful and limited due to edema over the
dorsum of the fingers. As time progresses, the extensor tendons become elevated and
the collateral ligaments shorten. If untreated it has long been thought that shoulder
hand syndrome eventually progresses to a dry, cold, bluish and atrophied hand.
However, experience would suggest that in most cases the pain and often the edema
subsides spontaneously after a few weeks.
Shoulder hand syndrome has been associated with lesions of the pre-motor area of the
brain. The etiology of shoulder hand syndrome is unknown; the sympathetic nervous
system has often been implicated largely because of the associated vasomotor
changes. Theoretical peripheral and central etiologies have been proposed. Peripheral
etiological theories postulate a role for trauma to the peripheral nerves. One of these
theories postulates ephaptic conduction between efferent sympathetic nerves and
afferent somatic nerves with the latter depolarization being perceived as pain.
Numerous central etiological theories have also been proposed. For instance, it has
been postulated that there is a disruption of autonomic nervous control from higher CNS
centres, which directly affects the internuncial pool of the spinal cord leading to
decreased inhibition of the sympathetic neurons of the lateral horn. Pain, either from
contractures or shoulder subluxation, may stimulate the internuncial pool of the spinal
cord resulting in an abnormal sympathetic response. A link between the abnormal
sympathetic nervous system and pain has also been postulated but never proven.
41
Geurts et al. (2000) systematically reviewed the etiology and treatments of post stroke
hand oedema and shoulder-hand syndrome. The authors identified 5 etiological studies
and 6 therapeutic studies. The authors evaluated the studies based on 11
methodological criteria and by standardized effect sizes. Based on their systematic
review of the literature, the authors concluded that the shoulder was involved in only
half the cases although all of the cases were characterized by painful swelling of the
wrist and hand, thereby suggesting a “wrist-hand syndrome” in half the cases.
Furthermore, they noted that the hand edema was not a lymphoedema and that
shoulder hand syndrome usually coincided with increased arterial blood flow.
Iwata et al. (2002) suggested that SHS might be due to paresis following stroke,
mediated by disruption of homeostasis and the balance between intracellular and
extracellular fluid. Three possible mechanisms include: i) an increase in capillary blood
pressure, caused by a decrease in peripheral venous return and lymph flow; ii) a drop in
the colloidal osmotic pressure in the early stages of stroke due to an acute phase
response; iii) enhanced permeability of capillary walls which may result from synovial
inflammation, brought about by rough management of the affected arm and hand.
42
Author, Year Methods Outcome
Country
PEDro Score
hypertensive hemorrhagic etiology as (MCP) and interphalangeal (IP) joints. 8 of
determined by CT brain scan. Patients the scan-positive RSD patients presented a
were assessed prospectively for low soft tissue blood flow pattern identical to
radionuclide and clinical features of reflex the non-RSD hemiplegic patients while the
sympathetic dystrophy (RSD). Each patient remaining 13 showed a high flow pattern.
underwent a three-phase bone scan within MCP tenderness to compression proved to
72 hours of admission. Delayed images of be the most valuable clinical sign of RSD,
both wrists and hands as well as total body with a predictive value, sensitivity, and
were obtained 2 to 4 hours after injection. specificity rates of 100%, 85.7% and 100%
respectively.
Van 219 hemiplegic patients of whom 44 had The RSD syndrome was present in only
Ouwenaller et flaccid paralysis and 175 evolved rapidly 23% of all cases but was seen more often in
al. 1986 toward a spastic state. Stroke was the spastic patients, 27% vs. 7%.
Switzerland most frequent cause (79%). Spasticity was
No score diagnosed on the basis of an increase of
the myotatic reflex. The presence of
subluxation was sought. Criteria for
diagnosing the RSD syndrome were
involvement of both the hand and shoulder
and presence of the usual characteristic
symptoms. Each shoulder was tested for
an isolated tendon lesion and for several
contributing factors.
Kondo et al. 152 stroke patients admitted to a The incidences of RSD were 15/81 (18.5%)
2001 rehabilitation unit and followed for approx. for patients receiving the protocol and 23/71
Japan 200 days were monitored for the (32.4%) among patients who did not.
No Score development of RSD, assessed clinically by
a physician. Half of the patients were
treated with a protocol to prevent RSD,
consisting of passive ROM exercises,
performed by therapists and restrictions on
passive movement by patients. The
remaining patients received standard
inpatient rehabilitation.
Gokkaya et al. A cohort of 95 stroke patients admitted for 29 patients (30.5%) developed RSD. Their
2006 inpatient rehabilitation, which usually rehabilitation stays were, on average, 10
Turkey occurred 4 to 6 weeks post stroke, were days longer compared with patients without
No Score evaluated for the presence of RSD and RSD. Patients in the lower categories of
glenohumerol joint subluxation at Brunnstrom scores tended to develop RSD
admission. more frequently. The presence of shoulder
subluxation was also more frequent among
patients with RSD (72.4% vs. 24.2%,
p<0.001).
While the incidence of RSD appears to range between 12-32%, Petchkrua et al. (2000),
suggested that the incidence of RSD is over-estimated and the results from previous
studies were obtained before patients routinely received early intensive inpatient
rehabilitation. At admission to hospital and once a week until discharge, patients
admitted to an acute rehabilitation facility were evaluated for shoulder pain, decreased
passive range of motion of the shoulder, wrist/hand pain, edema, and skin changes. If
three of these five criteria were positive, patients underwent a triple-phase bone scan
43
(TPBS). Bone scan findings consistent with CRPS type 1 were taken as confirming the
diagnosis. Of 64 subjects, 13 underwent bone scans, with only one (1.56%) positive
result. The authors noted it was possible that patients were discharged before they
developed symptoms of RSD. Patients from a more recent study (Kondo et al. 2001)
who received standard multidisciplinary rehabilitation had a much higher incidence of
RSD (34%). Gokkaya et al. (2006) were the more recent investigators to suggest that
there was a relationship between RSD and shoulder subluxation. Possible mechanisms
suggested by the authors included overstretching of periarticular tissues and
impingement on the nerve tissues and downward traction of the shoulder joint complex.
The incidence of RSD post stroke ranges form 12-34% and may be influenced by
the timing as well as the type of assessment.
Several approaches to diagnose RSD have been used. Routine radiographs of the
involved upper extremity may demonstrate a patchy, periarticular demineralization
(Sudek's atrophy) as early as 3-6 months after the onset of clinical signs. The most
sensitive diagnostic test is the technetium diphosphonate bone scan which
demonstrates increased periarticular uptake (mostly at the shoulder and wrist) in the
affected upper extremity. Bone scan abnormalities appear earlier than the x-ray
changes. Tepperman et al. (1984) found 25% of hemiplegic patients demonstrated
evidence of reflex sympathetic dystrophy in the involved upper extremity although only
two-thirds went on to develop the clinical syndrome. Temporary resolution of symptoms
with sympathetic blockade is considered diagnostic despite potential difficulties with the
technique in terms of diagnostic validity. Thermography, in controlled studies, has failed
to consistently diagnose reflex sympathetic dystrophy and is not considered a valid test.
However, Kozin et al. (1981) suggested that that clinical measurements such as grip
strength, tenderness and ring size were more accurate diagnostic indicator of RSD.
Iwata et al. (2002) have suggested that a ratio of the circumference of the middle finger
(affected:unaffected) greater than 1.06 at four weeks post stroke was predictive of RSD
Shoulder hand syndrome is a painful clinical entity, which is not understood from
a pathophysiological basis. The diagnosis is made clinically. Most cases appear
to improve with time.
44
physiotherapy with a focus on range of motion exercises. A one to two week course of
high dose corticosteroids and/or sympathetic blocks either in the form of stellate
ganglion blocks or guanethedine local venous blocks may be tried in persistent
disabling cases. Constraint-induced movement therapy and sensory discrimination
training have also been proposed as possible treatments for SHS (Acerra et al. 2007). A
surgical sympathectomy may be considered if stellate ganglion sympathetic blocks are
consistently effective but symptoms recur. However, there is no evidence that surgical
sympathectomy alter outcomes. There is no definitive therapeutic intervention for reflex
sympathetic dystrophy, as reflected by the large number of suggested treatments.
Shoulder hand syndrome, which presents for greater than 6 months without appropriate
treatment, has a poor prognosis (Lieberman 1986).
Prevention Splints
• Extremely early ROM exercises • Resting splint of hand and wrist
• Avoid shoulder subluxation (controversial)
Exercise Medication
• Prevention and treatment of upper • Analgesics
extremity contractures • NSAIDs
• Active exercise if possible • High dose oral corticosteroids (10 day
• Frequent passive ROM course and then taper)
Modalities Injections
• Interferential deep heat • Stellate ganglion sympathetic block
• Heat/cold modalities especially contrast • Guanethedine bier block
baths
• Hand desensitization program Surgical
• Transcutaneous electrical nerve stimulation • Sympathectomy
Three studies evaluated drug therapies for the treatment of SHS associated with stroke.
The results are presented in table 11.23.
45
Author, Year Methods Outcome
Country
PEDro Score
1994 stroke of the middle cerebral artery and shoulder-hand syndrome in the placebo
Germany exhibited definite shoulder-hand syndrome group after 4 weeks at which time all patients
5 (RCT) were studied. Patients were randomized switched over the corticosteroid protocol.
to orally receive either 8 mg Patients receiving the corticosteroid
methylprednisolone or a placebo over 4 treatment demonstrated significant
weeks. All patients received daily physical improvement in shoulder-hand syndrome
therapy. For patients in the placebo group, that was maintained at 6 months. 31 of the
if no improvement was noted in shoulder- 36 patients became almost symptom free
hand syndrome then they were given 4 within 10 days of treatment with low dose
weeks of corticosteroid treatment as per oral corticosteroids.
the experimental group.
th
Hamamci et A controlled trial of 41 hemiplegic patients By the end of the 4 week patients receiving
al.1996 with grades 1-2 of SHS. All patients calcitonin had significantly lower median pain
Turkey received conventional physical therapy as scores compared to the controls (1 vs. 5).
No Score part of inpatient rehabilitation. 25 patients Patients receiving calcitonin treatments also
received 1 x 100 IU salmon calcitonin daily reported less tenderness and improved
for 4 weeks and 16 patients received a range of motion. There was no difference in
saline injection as a placebo. Pain was hand edema between groups.
measured on a 7-point visual analogue
scale at the beginning and end of
treatment
Discussion
The study by Braus et al. (1994) was the only RCT examining a treatment for shoulder-
hand syndrome. Oral corticosteroids improved SHS for at least 4 weeks. Despite a
limited number of trials, a review by Geurts et al. (2000) concluded that oral
corticosteroids were the most effective treatment for SHS. While a single controlled trial
found that calcitonin treatment effectively treated pain associated with SHS, it is not
widely used clinically.
There is limited (Level 2) evidence that calcitonin improves pain associated with
SHS following stroke.
46
11.7.6 Graded Motor Imagery as a Treatment for CRPS1
In the first phase of the treatment hand laterality recognition, avoidance of activation of
the primary motor cortex was achieved by only initiating activation in the pre-motor
cortices. In the second stage, patients were asked to imagine their own hand placed in
the same position as a picture selected from 28 pictures chosen at random. In the final
stage, pictures of the unaffected hand were placed into a cardboard mirror box. Patients
were asked to adopt the posture in the picture (n=20) times with both hands, but to
discontinue if they experienced pain.
Moseley et al. (2004) reported that treatment with MIP was more effective than ongoing
medical management of CRPS1. Patients experienced significant reductions in pain and
swelling associated with treatment, which persisted for at least 6 weeks. The authors
also noted that 6 weeks after completing the MIP program, approximately 50% of
patients no longer fulfilled the diagnostic criteria for CRPS1.
There is moderate (Level 1b) evidence that a modified imagery program can
reduce pain associated with shoulder-hand syndrome.
47
A motor imagery program appears to improve shoulder-hand syndrome.
48
11.8 Summary
1. Shoulder subluxation occurs early following a stroke.
5. There is moderate (Level 1b) evidence that prolonged positioning does not
negatively influence shoulder range of motion or pain.
8. There is moderate (Level 1b) evidence that the use of overhead pullies results
in surprisingly high levels of hemiplegic shoulder pain and should be avoided.
9. There is moderate (Level 1b) evidence that a gentle range of motion program
by a therapist results in less hemiplegic shoulder pain.
10. There is moderate (Level 1b) evidence that corticosteroid injections do not
improve shoulder pain or range of motion in hemiplegic patients. There is
limited (Level 2) evidence that oral non-steroidal anti-inflammatories can
reduce pain during therapy sessions. There is limited (Level 2) evidence that
botulinum toxin can reduce pain in the hemiplegic shoulder.
12. There is moderate (Level 1b) evidence that motor blocks of the subscapular
muscle reduces spastic shoulder pain and improves passive range of motion
of the hemiplegic shoulder.
49
13. There is conflicting (Level 4) evidence that motor blocks of the pectroralis
major muscle reduces spastic shoulder pain or improves passive range of
motion of the hemiplegic shoulder.
14. There is moderate (Level 1b) evidence that aromatherapy combing with
acupressure can reduce pain associated with painful hemiplegic shoulder.
15. Shoulder hand syndrome is a poorly understood clinical entity. Most cases
improve with time.
16. There is moderate (Level 1b) evidence that oral corticosteroids improves
shoulder hand syndrome for at least the first 4 weeks.
17. There is moderate (Level 1b) evidence that a modified imagery program can
reduce pain associated with shoulder-hand syndrome. There is limited (Level
2) evidence that calcitonin improves pain associated with SHS following
stroke.
50
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