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Shoulder in hemiplegia
1) The document discusses current evidence on understanding and managing the hemiplegic shoulder. 2) It finds that proper positioning helps avoid subluxation but slings and strapping do not reduce subluxation or improve function. Gentle range of motion exercises are preferred. 3) Electrical stimulation prevents subluxation development while hand edema can be treated with passive motion or electrical stimulation.
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Shoulder in hemiplegia
- 1. Current Evidences inthe understanding and management of Shoulder in Hemiplegia Phinoj K. Abraham, MOTh (Neurosciences) Occupational Therapist, Hamad Medical Corporation, Qatar 21-10-2015 1
- 2. Learning Objectives • Discussresearch findings regarding the biomechanics of shoulder joint stability • Report evidence behind treatment techniques and management for the hemiplegic shoulder, both ‘hypotonic’ and ‘hyper tonic’ shoulder • Understand the role of the OT in the 2
- 3. Anatomy & Biomechanicsof Shoulder joint 3 1. Glenoheumaral Joint 2. Sub deltoid joint 3. Acromioclavicular Joint 4. Scapulothoracic Joint 5. Sternoclavicular Joint 6. 1st Costosternal (Shoulder Pain, Rene Cailliet M.D., 1991)
- 4. Shoulder Biomechanics 4 • Stability •Static Stabilization • Dynamic Stabilization • Mobility • 30 of freedom • Scapulo-heumeral Rhythm
- 5. Static Stabilization 5 • Primarilyby • Rotator Interval Capsule (superior capsule, superior GH ligament, and coracohumeral ligament) • Also assisted by • Degree of glenoid inclination * • Passive tension of the intact supraspinatus muscle** • Negative intra-articular
- 6. *Degree of glenoidinclination • Literature from 1987-2001 • 1987 – Prevost et. al, - 3D X-ray • 1995 – Culham et. al, - Linear and angular measures of scapular and humeral orientation • 2001 – Price & Pandyan – Sensor based scapular locator system “Severity of subluxation is not linked with a particular scapular resting position after 6 Robert Teasell MD et al., (2013) Hemiplegic shoulder pain p. 8; The Evidence- Based Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com
- 7. **Role of Musclesaround shoulder in GH stability • EMG studies showed that the muscles around shoulder joint are eclectically silent in the relaxed unloaded limb, even when the limb is tugged vigorously downward 1 71)Basmajian, Bazant & MacConaill (1959, 1969) Cross reference from ‘Joint Strcture & Function: A comprehensive Analysis – Cynthia Norkins – 5th Edn p. 253
- 8. Role of MusclesContd… • ….the ‘reinforcing passive tension (muscle tone) of supraspinatous and subscapularis muscles are actually contributing to static shoulder stability than any active muscle contraction’ 1 81) Joint Structure & Function: A comprehensive Analysis – Cynthia Norkins – 5th Edn p. 253
- 9. Section Summary • Ina normal shoulder, the static stability is contributed by a passive mechanism 9
- 10. Hemiplegic shoulder > HypotonicShoulder > Hypertonic Shoulder 10
- 11. Hypotonic Shoulder 1) HemiplegicShoulder Subluxation (HSS) 2) Hand Edema 11
- 12. 1) Shoulder Subluxation 1.1)Pathophysiology • Hypotonicity in supraspinatous muscle + Weight of the limb 1.2) Scapular Rotation • …is unrelated to hemiplegic shoulder subluxation 121) Joint Structure and function – Cynthia Norkins 4th Edn. P 249 2) Robert Teasell MD et al., Hemiplegic shoulder pain (2013) p. 21; Retrieved from The Evidence-Based Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com
- 13. 1. Shoulder SubluxationContd... 1.3) Shoulder Subluxation & Shoulder Pain • 8 large studies support, (between 1984 - 2008) 11 do not support (between 1965 - 2009) role of subluxation in pain • Not all patients with subluxation have pain! 13Robert Teasell MD et al., Hemiplegic shoulder pain (2013) p. 21; Retrieved from The Evidence-Based Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com
- 14. 1. Shoulder SubluxationContd... 1.4) Relationship between severity of shoulder subluxation and soft tissue injury • “Shoulder subluxation lateral distance, measured by physical examination, is a predictor for supraspinatus tendonitis - ≥2.25 cm 14 Shih-Wei Huang et. al, J Rehabil Med 2012; 44: 733–739
- 15. Management of shoulder subluxation i)POSITIONING A. Bed Positioning . Lying on Unaffected side Lying on Affected side 15
- 16. i) Positioning Contd… •Effectiveness of bed positioning ? “ There is consensus (Level 3) opinion that proper positioning of the hemiplegic shoulder helps to avoid subluxation. However, there is conflicting (Level 4) evidence that prolonged positioning prevents loss of active or passive range of motion, or reduces pain.”Robert Teasell MD et al., Hemiplegic shoulder pain (2013) p. 21; Retrieved from The Evidence-Based Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com 16
- 17. i) Positioning Contd… Advantages •reduction of the vertical & horizontal component of shoulder subluxation; • delayed onset of shoulder pain • increased muscle tone in the flaccid shoulder muscles • increased passive range of motion (PROM) of the shoulder. Disadvantages • Immobilization of the adducted paretic arm in internal rotation • Restricted use of the paretic arm during ADL. • Lateral subluxation B. Slings and other aids (like lap boards) KNGF Clinical Practice Guidelines for physical therapy in patients with stroke, Supplement to the Dutch Journal of Physical Therapy Volume 114 / Issue 5 / 2004 P. 129 17
- 18. i) Positioning Contd… •Effectiveness of Slings and other aids ? “the commonly used hemiplegic sling has no appreciable effect on ultimate range of motion, shoulder subluxation, pain or peripheral nerve traction injury.” (1974)1 “There is limited (Level 2) evidence that shoulder slings prevent subluxation associated with hemiplegic shoulder pain, although there is also limited (Level 2) evidence that one device or method is no better than another.” (2012)2 1. Marvin M Hurd, et al Shoulder sling for hemiplegia: friend or Foe? Arch phys Med Rehabil 1974; 55:519-22 2. Robert Teasell MD et al., Hemiplegic shoulder pain p. 21; The Evidence-Based Review of Stroke Rehabilitation 18
- 19. i) Positioning Contd… ClinicalImplications • Use a sling only as a preventive measure in patients with stroke who report a painful shoulder in vertical postures. • Since wearing a sling restricts the freedom of motion of the paretic arm, it should be worn as briefly as possible. KNGF Clinical Practice Guidelines for physical therapy in patients with stroke, Supplement to the Dutch Journal of Physical Therapy Volume 114 / Issue 5 / 2004 P. 129 19
- 20. ii) Strapping theHemiplegic Shoulder • Strapping: has the theoretical advantage of reducing GHS while preserving the range of motion of the shoulder joint, • Three different forms of strapping the hemiplegic shoulder proposed by 3 authors • Ancliffe 1992: • Morin & Bravo 1997: • Hanger et al. 2000: Morin & Bravo 1997 | Hanger et al. 2000 20
- 21. Strapping Contd… • Effectivenessof Strapping ? “strapping techniques are not effective in reducing or preventing glenohumeral subluxation in the vertical direction (diastasis)” 1 There is conflicting (Level 4) evidence that strapping the hemiplegic shoulder reduces the development of pain. There is moderate (Level 1b) evidence that strapping does not improve upper limb function or range of motion. 2 1) KNGF Clinical Practice Guidelines Volume 114 / Issue 5 / 2004 P. 129 2) EBRSR Robert Teasell MD et al., Hemiplegic shoulder pain (2013) 21
- 22. iii) ROM Exercises,Passive modalities, NSAID’s “Aggressive range of motion exercises (i.e. pullies) results in a markedly increased incidence of painful shoulder; a gentle range of motion program is preferred. Adding ultrasound treatments is not helpful while NSAIDs may be helpful.” 1. Robert Teasell MD et al., Hemiplegic shoulder pain p. 21; The Evidence-Based Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com 22
- 23. iv) Electrical Stimulationin the Hemiplegic Shoulder “There is strong (Level 1a) evidence that that electrical stimulation helps to prevent the development of shoulder subluxation and reduce shoulder subluxation (Level 1a)” 1. Robert Teasell MD et al., Hemiplegic shoulder pain p. 21; The Evidence-Based Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com 23
- 24. 2) Hand Edema •Fact Sheet • Hand edema may be an isolated problem or occur as a symptom of shoulder-hand syndrome. • The etiology is unclear. • The most widely accepted explanation is of increased venous congestion related to prolonged dependency and loss of MUSCLE PUMPING FUNCTION in the paretic limb (Leibovitz et al. 2007) 241. Robert Teasell MD et al., Upper extremity Interventions. P 122; The Evidence- Based Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com
- 25. 2) Hand EdemaContd… • 83% of 85 acute stroke patients suffered from hand edema not associated with shoulder- hand syndrome. • Volumetric assessments of the hand appear to provide the best estimation; while the reliability of clinical evaluation through visual inspection is poor • Hand Edema as a Prognostic Indicator? It’s controversial 251. Robert Teasell MD et al., Upper extremity Interventions. P 122; The Evidence- Based Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com
- 26. Treatment of HandEdema • 3 treatment approaches have been studied1 • passive motion exercises, • neuromuscular stimulation and • intermittent pneumatic compression • Effectiveness of these interventions “ Continuous passive motion and electrical stimulation might be effective treatments for hand edema, while intermittent pneumatic compression is not.” 26 1. Robert Teasell MD et al., Upper extremity Interventions. P 122; The Evidence- Based Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com
- 27. Section Summary • Properbed position may helps to avoid subluxation • Shoulder slings can be used a s a preventive measure and it should be worn as briefly as possible. • Strapping will not help to prevent / reduce shoulder subluxation • Gentle ROM exercises helps to prevent secondary complications • FES may help to prevent / reduce shoulder subluxation • Passive ROM exercises and electrical stimulation 27
- 28. 28 Hemiplegic shoulder > HypotonicShoulder > Hypertonic Shoulder
- 29. Hypertonic Shoulder • Causes: Multifactorial • Spasticity & spastic muscle imbalance (Neural elements induced) • Tightness / Contracture (Non Neural Elements or biomechanical elements induced) • Associated Reactions / Position induced • Consequences of high tone: • Impaired skin care (axilla and hand) • Impaired ADLs (dressing) • Impaired range of motion • Shoulder pain 29
- 30. Spastic Muscle Imbalance •Imbalance between agonist and antagonist • Agonist in synergy pattern become strong and tight • Stretching of these muscle cause pain • Flexor synergy is common in hemiplegic U/E with predominating spasticity in shoulder internal rotators • Among these spastic muscle imbalance is most common in subscapularis and pectoralis major 1. Robert Teasell MD et al., Hemiplegic shoulder pain p. 21; The Evidence-Based Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com 30
- 31. Subscapularis Spasticity Disorder(SSD) • Normally, subscapularis are inhibited in shoulder abduction and allow the heumerus to externally rotate • In flexor synergy pattern, the subscapularis is tonically active limiting external rotation, shoulder abduction and flexion 1 This leads to shoulder impingement • In SSD, shoulder Ext. Rotation will be most painful and restricted Robert Teasell MD et al., Hemiplegic shoulder pain p. 21; The Evidence-Based Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com 31
- 32. Pectoralis Spasticity Disorder(PSD) • Characterized by motion being most limited and pain produced on abduction 32
- 33. Common associated problems 1.Rotator cuff disorders • shoulder pain is not commonly associated with rotator cuff disorders. • Partial tears of the rotator cuff musculature are common and it is always difficult determining whether they were present premorbidly even in previously asymptomatic patients. • Najenson et al. (1971) 2. Frozen (or) contracted shoulder (Adhesive capsulitis) • Majorly affected the capsule of shoulder joint 3. Shoulder hand syndrome / RSD (CRPS) 4. Myofacial syndrome / trigger points 33
- 34. Management of hypertonicshoulder • Positioning • Promote position that is opposite to flexor pattern • Position for extended periods of time (up to 1 hour or more) • Use pillow, air splint, casting etc… • ROM exercises • As mentioned in the previous section. • Medical Management • Botilinium toxin – effects are un cleare 1 • Deinnervation of the subscapularis improve ROM than pectoralis major 34
- 35. Conclusions Regarding Spastic HemiplegicShoulder ‘There is an association between spasticity and the development of hemiplegic shoulder pain’ ‘Spasticity and subsequent frozen shoulder are the most likely causes of hemiplegic shoulder pain’ 35Robert Teasell MD et al., Hemiplegic shoulder pain p. 21; The Evidence-Based Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com
- 36. Major References 1. JointStructure and function (2005), 4th edn. By Pamela K Levangie and Cynthia C. Norkins. FA Davis Publication 2. Shoulder Pain, Rene Calliate MD, (1980) FA Davis publication 3. Robert Teasell MD et al., Hemiplegic shoulder pain p. 21; The Evidence-Based Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com 4. KNGF Clinical Practice Guidelines for physical therapy in patients with stroke,Supplement to the Dutch Journal of Physical Therapy Volume 114 / Issue 5 / 2004 P. 129 5. Relationship between Severity of Shoulder Subluxation and Soft-Tissue Injury IN Hemiplegic Stroke Patients Shih-Wei Huang et. al, J Rehabil Med 2012; 44: 733– 739 36
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Editor's Notes
- #7 Role of sling in the reduction of scapular downward rotation