Evaluation and treatment of shoulder subluxation in hemiplegia: relationship between subluxation and pain

Ultrasound-Guided BoNT-A (Botulinum Toxin A) Injection Into the Subscapularis for Hemiplegic Shoulder Pain: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND AND PURPOSE

This study aimed to assess the efficacy of an ultrasound-guided lateral approach for BoNT-A (botulinum toxin A) injections into the subscapularis in patients with hemiplegic shoulder pain.

METHODS

This single-center trial used a randomized, double-blind, placebo-controlled design. The key inclusion criteria were a visual analogue scale score of ≥4 cm and a modified Ashworth scale score of ≥1+. The patients were randomized to receive either BoNT-A injections or a placebo. The outcomes included the visual analogue scale score, modified Ashworth scale score, pain-free passive range of motion of the hemiplegic shoulder, Fugl-Meyer assessment score for the upper extremities, and Stroke-Specific Quality-of-Life score.

RESULTS

A total of 49 hemiplegic shoulder pain patients were screened, and 36 were included. The participants receiving the BoNT-A injection reported a significant decrease in pain (visual analogue scale, -1.39 [95% CI, -2.41 to -0.36]; P=0.002) and spasticity (modified Ashworth scale score for shoulder internal rotation, -0.72 [95% CI, -1.10 to -0.35]; P=0.001; modified Ashworth scale score for shoulder abduction, -0.44 [95% CI, -0.90 to -0.01]; P=0.026) and improved pain-free passive shoulder internal rotation range of motion (14.56 [95% CI, 6.70-21.41]; P<0.001) and quality of life (Stroke-Specific Quality-of-Life upper extremity subscale, P=0.025) compared with those receiving the placebo at the end point. The shoulder abduction range of motion did not significantly improve after the BoNT-A injection at the end point (P=0.127). In addition, the patients in the BoNT-A group showed significant improvements in the visual analogue scale score and shoulder external rotation range of motion at the 12-week follow-up. No injection-related adverse events were observed during or after the interventions in either group.

CONCLUSIONS

The ultrasound-guided lateral approach for BoNT-A injections into the subscapularis is a precise and reliable method for reducing pain and spasticity and improving quality of life in stroke survivors with hemiplegic shoulder pain. Registration: URL: https://www.chictr.org.cn; Unique identifier: ChiCTR1900023513.

A New Shoulder Orthosis to Dynamically Support Glenohumeral Subluxation

OBJECTIVE

In this paper we presented a novel shoulder subluxation support that aims to reduce the stress on the passive structures around the shoulder of patients with glenohumeral subluxation and glenohumeral-related shoulder pain. The device applies a force to the upper arm without impeding the functional range of motion of the arm. Our design contains a mechanism that statically balances the arm with two elastic bands.

METHODS

A technical evaluation study was conducted to assess the performance of the orthosis. Additionally, two patients evaluated the orthosis.

RESULTS

The results of the technical validation confirm the working of the balancing mechanism. The pilot study demonstrated that the shoulder support increased the feeling of stability of the shoulder joint and, to a lesser extent, decreased shoulder pain. Furthermore, both patients reported that the orthosis did not impede their range of motion.

CONCLUSION

In this research we developed a shoulder orthosis based on two statically balanced springs that support the shoulder of patients with glenohumeral subluxation that have residual shoulder muscle force. Compared to existing shoulder supports, our design does not impede the range of motion of the arm, and continues to provide a stabilizing force to the shoulder, even if the arm is moved away from the neutral position. Tests with two participants showed promising results.

SIGNIFICANCE

The device presented in this work could have a significant impact on the shoulder function which may improve rehabilitation outcome and improve the quality of life of patients suffering from glenohumeral subluxation and shoulder pain.

Incidence, Prevalence, and Risk Factors of Hemiplegic Shoulder Pain: A Systematic Review

The current systematic review aimed to investigate the incidence, prevalence, and risk factors causing hemiplegic shoulder pain (HSP) after stroke. Two independent authors screened titles and abstracts for the eligibility of the included studies in the electronic databases PubMed and Web of Science. Studies which reported the incidence, prevalence, and risk factors of HSP following stroke were included. The included studies were assessed using the Newcastle–Ottawa Scale for evaluating the quality of nonrandomized studies in meta-analyses. Eighteen studies were included in the final synthesis. In all studies, the number of patients ranged between 58 and 608, with the mean age ranging from 58.7 to 76 years. Seven included studies were rated as “good “quality, while one study rated “fair” and 10 studies rated “poor” quality. Eight studies reported incidence rate while 11 studies reported the prevalence of HSP following a stroke. The incidence of HSP was ranging from 10 to 22% in the metanalysis of the included studies. The prevalence of HSP was ranging from 22 to 47% in the metanalysis of the included studies. The most significant predictors of HSP were age, female gender, increased tone, sensory impairment, left-sided hemiparesis, hemorrhagic stroke, hemispatial neglect, positive past medical history, and poor National Institutes of Health Stroke Scale score. The incidence and prevalence of HSP after stroke vary considerably due to various factors. Knowledge of predictors is important to minimize the risk of developing HSP following a stroke.

The Effects of Active Shoulder Exercise with a Sling Suspension System on Shoulder Subluxation, Proprioception, and Upper Extremity Function in Patients with Acute Stroke

BACKGROUND The aim of this study was to investigate the effect of active shoulder exercise with a sling suspension system on shoulder subluxation, proprioception, and upper extremity function in patients with acute stroke. MATERIAL AND METHODS Thirty-six patients with acute stroke and shoulder subluxation were randomly assigned into two groups. The study group (n=18) received active shoulder exercise with a sling suspension system, and the control group (n=18) received bilateral arm training for 40 minutes, for five days a week, for four weeks. The outcome measures before and after the intervention included measurement of shoulder subluxation distance, shoulder proprioception, the Fugl-Meyer assessment (FMA) scale, and the manual function test (MFT). RESULTS Comparison of the study group with the control group showed significant differences in all outcome scores post-intervention (p<0.05). The study group had significant improvement in shoulder subluxation distance, shoulder proprioception, the FMA score, and the MFT compared with the control group. There was a significant difference in shoulder subluxation (p=0.001), shoulder proprioception (p=0.046), the FMA score (p=0.002), and the MFT (p=0.007) between the two groups, which favored the study group. CONCLUSIONS Active shoulder exercise with a sling suspension system may be effective in reducing shoulder subluxation, improving proprioception, and upper extremity function in patients following acute stroke.

Effect of Comprehensive Postural Instructions and Range of Motion Exercises Via Educational Videos on Motor Function and Shoulder Injury in Stroke Patients With Hemiplegia: A Preliminary Study

OBJECTIVE

The purpose of this study was to investigate the effect of comprehensive postural instructions and range of motion (ROM) exercises via educational videos for shoulder injury prevention and functional improvement of the hemiplegic shoulder after acute stroke.

METHODS

In this prospective cohort study, 48 subacute stroke patients with hemiplegia were enrolled and divided into 2 groups (23 in experimental group and 25 in control group). In the control group (n = 25), the patients performed conventional rehabilitation for 5 days per week. In the experimental group (n = 23), the patients received not only conventional rehabilitation but also additional postural instructions and regular ROM exercises via educational videos for hemiplegic shoulders for 15 minutes twice per day for 5 days per week during their hospital stay. Main outcome measures, including the presence and severity of pain, motor function, and sonography on hemiplegic shoulder, were assessed.

RESULTS

More motor recovery improvement was found in the experimental group (P < .05). In the supraspinatus tendon, a significantly increased frequency in tendinopathy or tear was observed between admission (12%) and before discharge (40%) in the control group (P < .05), but no difference was observed in the experimental group. In the subdeltoid bursa, effusion or bursitis was significantly reduced between admission (30.4%) and before discharge (8.7%) in the experimental group (P < .05).

CONCLUSION

These findings suggest that comprehensive postural instructions and ROM exercises via educational videos during inpatient rehabilitation for subacute stroke patients could improve motor recovery and limit shoulder injury in stroke patients with hemiplegia.

Design and Evaluation of Passive Shoulder Joint Tracking Module for Upper-Limb Rehabilitation Robots

As the number of people suffering from shoulder movement disabilities increases, there is a rising demand for shoulder rehabilitation. The natural motion of the shoulder joint [glenohumeral (GH) joint] includes not only three-degrees-of-freedom (DOF) rotation but also three-DOF translation of the joint center due to simultaneous motion of the shoulder girdle. If the motion of the shoulder girdle is restricted, then the arm cannot be raised above a certain posture. This paper presents a passive shoulder joint tracking device that allows three-DOF translation of the shoulder joint while compensating for gravity. The single-DOF vertical tracker with a constant-force spring compensates for the gross weight of the user's arm, the upper limb rehabilitation device, and the tracker itself while allowing vertical tracking motion. The two-DOF horizontal tracker consists of two linear guides arranged perpendicular to each other. The tracker freely follows the shoulder joint in the horizontal plane. The effect of using the passive shoulder joint tracking device was evaluated by means of experiments by combining two popular commercial upper limb rehabilitation apparatuses with the proposed tracker. Nineteen subjects (8 healthy persons and 11 patients with shoulder impairments) participated in the evaluation study. The movement of the GH joint and the interactive force between the subject and the commercial rehabilitation device were analyzed when subjects made the following shoulder movements: flexion/extension and abduction/adduction. The improved tracker allowed a greater range of motion and reduced interaction. The tracker can be combined with existing commercial rehabilitation devices for more natural shoulder movement during rehabilitation tasks.

Effects of integrating rhythmic arm swing into robot-assisted walking in patients with subacute stroke: a randomized controlled pilot study

This study aimed to identify the effects of rhythmic arm swing during robot-assisted walking training on balance, gait, motor function, and activities of daily living among patients with subacute stroke. Twenty patients with subacute stroke were recruited, and thereafter randomly allocated to either the experimental group that performed the robot-assisted walking training with rhythmic arm swing, or the control group that performed the training in arm fixation. In total, 30 training sessions were carried out. The outcome measures included the 10-m walk test, Berg balance scale, timed up-and-go test, fall index that was measured using the Tetrax system, motor function test of Fugl-Meyer assessment, and modified Barthel index. The patients of both groups showed significant improvement in all parameters after the intervention (P<0.05). The Berg balance scale, Fugl-Meyer assessment, and modified Barthel index scores at post-test appeared to be significantly higher for the experimental group than for the control group (P<0.05). These findings indicate that more favorable effects from robot-assisted walking training in patients with subacute stroke may be obtained by the use of rhythmic arm swing.

The effects of electromyography-triggered electrical stimulation on shoulder subluxation, muscle activation, pain, and function in persons with stroke: A pilot study

OBJECTIVES

The purpose of this study was to examine the effects of task-oriented electromyography-triggered stimulation for shoulder subluxation, muscle activation, pain and upper extremity function in hemiparetic stroke patients.

METHODS

Twenty participants with subacute hemiparetic stroke were recruited for this study and were randomly divided into two groups: experimental group (n = 10) and control group (n = 10). Subjects in the experimental group participated in task-oriented electromyography triggered stimulation for 30 minutes, five times a week for four weeks, whereas the control group received cyclic functional electrical stimulation for 30 minutes, five times a week for four weeks. Subjects in both groups received conventional physical therapy for four weeks (30 min/day, five times/week). Data collected included the degree of shoulder subluxation which had been confirmed by X-ray, muscle activation of the supraspinatus and posterior deltoid muscles by electromyography, pain by the Visual Analogue Scale (VAS), and hand function by the Fugl-Meyer Assessment (FMA) before and after the four week exercise period.

RESULTS

The results showed significant improvement in shoulder subluxation, muscle activation, and VAS results in the experimental group, compared with the control group(p < 0.05). FMA scores showed no significant differences between the two groups.

CONCLUSIONS

In conclusion, task-oriented electromyography-triggered stimulation improved shoulder subluxation, muscle activation, pain and upper extremity function. These results suggest that task-oriented electromyography-triggered stimulation is effective and beneficial for individuals with subacute stroke, and that further studies should be conducted on multivarious anatomical regions.

Ultrasonographic assessment of neuromuscular electrical stimulation efficacy on glenohumeral subluxation in patients with hemiplegia: a randomized-controlled study

Objectives

This study aims to investigate the short-term effects of neuromuscular electrical stimulation (NMES) on glenohumeral subluxation (GHS) in stroke patients.

Patients and methods

This prospective, randomized-controlled study included 24 unilateral hemiplegic patients (10 males, 14 females; mean age 64.1±14.8 years; range 22 to 84 years) with GHS as assessed by ultrasonography between December 2013 and September 2014. The patients were randomly divided into two groups as those in the NMES group (n=12) who were treated with NMES to supraspinatus, upper trapezius, and posterior deltoid muscles combined with conventional physiotherapy and as those in the control group (n=12) who were received conventional physiotherapy alone. Clinical (the Brunnstrom Motor Recovery Stage, Visual Analog Scale [VAS] for Pain and Shoulder Disability Questionnaire [SDQ]) and ultrasonographic (acromion-greater tuberosity distance, thicknesses of supraspinatus, upper trapezius, and posterior deltoid muscles) variables were evaluated before and after treatment in both groups.

Results

The SDQ index, acromion-greater tuberosity distance, and supraspinatus muscle thickness were improved in the NMES group, compared to the control group (for all p<0.05). The VAS-pain scores decreased in both groups. There was no statistically significant alterations in the other measurements in both groups (for all p>0.05). The percentage change (%) of the VAS-pain scores was not significantly different between two groups (p=0.03).

Conclusion

Our study results showed that GHS decreased after 20 sessions of NMES treatment. Based on these findings, ultrasonography appears to be a proper imaging tool for the evaluation of GHS in stroke patients.

Effect of kinesio tape application on hemiplegic shoulder pain and motor ability: a pilot study

The aim of our single-group pre-post design pilot study was to evaluate the short-term effect of kinesio taping (KT) application on pain and motor ability of hemiplegic shoulder pain (HSP) patients. Eleven poststroke patients with HSP hospitalized in the Department of Neurology C, Loewenstein Rehabilitation Hospital, Raanana, Israel, received a KT application in addition to their usual rehabilitation protocol. KT, consisting of one to three strips according to a predefined algorithm, was applied to the painful shoulder region. A 10 cm Visual Analog Scale of shoulder pain at rest and at arm movement, active and passive pain-free abduction range of motion, Box & Blocks, and Fugl-Meyer upper extremity motor assessment were performed before treatment and 24 h after wearing the KT. After applying the KT, there was no significant change in any variables. Short-term KT application, used in our study, produced no change in shoulder pain, range of motion, or ability of upper limb in HSP patients. Additional studies should evaluate the effect of long-term application and different types of KT applications on HSP.

The prevalence and characteristics of shoulder pain after traumatic brain injury

Objective: To determine the prevalence and characteristics of shoulder pain in people with traumatic brain injury participating in inpatient rehabilitation and to compare the clinical presentation with that of people with stroke.

Design: A prospective comparative study.

Setting: Six metropolitan rehabilitation units.

Subjects: Eighty-seven people with traumatic brain injury and 52 people with stroke took part in the study.

Main measures: Assessment of shoulder pain, range of motion, strength and function was conducted on admission and, for the subjects with traumatic brain injury, at discharge if rehabilitation exceeded two weeks.

Results: The prevalence of shoulder pain in people with traumatic brain injury was 62%, which was comparable with the 69% of subjects with stroke that experienced shoulder pain (odds ratio 0.72, 95% confidence interval 0.34 -1.5). Fracture in the shoulder complex and passive shoulder external rotation range of motion were the best predictors for shoulder pain after traumatic brain injury. This was different from the subjects with stroke for which the best predictors were passive shoulder flexion range of motion and length of acute hospital stay.

Conclusion: There is a relatively high prevalence of shoulder pain after traumatic brain injury. Trauma to the shoulder complex contributes to shoulder pain after traumatic brain injury, making clinical presentation different from people with stroke. The findings support the need for greater attention in the management of shoulder pain after traumatic brain injury.

A programme of static positional stretches does not reduce hemiplegic shoulder pain or maintain shoulder range of motion -a randomized controlled trial

Objective: To evaluate the effectiveness of a programme of static positional stretches and positioning of the stroke-affected shoulder for maintaining shoulder external rotation and decreasing hemiplegic shoulder pain.

Design: Randomized controlled trial with pretest and posttest design.

Setting: Inpatient rehabilitation unit.

Subjects: Thirty-two participants (17 treatment, 15 comparison) with a first time stroke who were admitted for rehabilitation.

Interventions: Treatment participants completed a programme of static positional stretches of the stroke-affected shoulder twice daily and positioned the stroke affected upper limb in an armrest support at all other times when seated.

Main measures: The main outcome measures were pain-free range of motion into external rotation, pain in the stroke-affected shoulder at rest and with movement, motor recovery and functional independence.

Results: All participants demonstrated a significant loss of external rotation (P=0.005) with no significant group differences. All participants demonstrated a significant improvement in motor recovery (P<0.01) and functional independence (P<0.01) with no significant group differences. There were no significant effects for pain. The comparison group recorded a decrease in mean pain reported with movement from admission to discharge, and the treatment group recorded an increase.

Conclusions: Participation in the management programme did not result in improved outcomes. The results of this study do not support the application of the programme of static positional stretches to maintain range of motion in the shoulder. The effect of increasing pain for the treatment group requires further investigation.

Strapping the hemiplegic shoulder prevents development of pain during rehabilitation: a randomized controlled trial

Objective: To determine whether strapping (therapeutic or placebo) the ‘at risk’ shoulder prevented or delayed development of hemiplegic shoulder pain better than standard care.

Design: Randomized controlled trial.

Setting: Three inpatient rehabilitation hospitals, Melbourne, Australia.

Patients: Thirty-three patients ‘at risk’ of developing hemiplegic shoulder pain were randomized, one withdrew. Patients at risk were considered to be those with low or no muscle function around the shoulder (Motor Assessment Scale, upper arm score B<3).

Interventions: Standard care for control group. Therapeutic strapping or placebo strapping with lightweight adhesive tape. All strapping was maintained over four weeks.

Main outcome measures: The primary outcome was number of pain-free days measured on Ritchie Articular Index. Secondary outcome measures included range of movement, function (Motor Assessment Scale, upper arm component) and affected arm muscle tone (Modified Ashworth Scale).

Results: Only one patient in the therapeutic strapping group developed pain. One-way ANOVA revealed that mean number of pain-free days over the 28-day period was significantly different (P=0.02), with the difference between the therapeutic strapping and the control group. Patients in the therapeutic strapping group had a mean of 26.2 pain-free days, while those in the placebo group and control group had a mean of 19.1 and 15.9 pain-free days respectively. Range of movement and function improved between admission and discharge but were not significantly different between groups.

Conclusions: Therapeutic strapping limited development of hemiplegic shoulder pain during rehabilitation in at risk stroke patients. Placebo strapping has an effect, with a larger study (n=30 per group) needed to detect whether there are differences between therapeutic and placebo strapping.

The California Tri-pull Taping Method in the Treatment of Shoulder Subluxation After Stroke: A Randomized Clinical Trial

Background:

Shoulder subluxation is a frequent occurrence in individuals following a stroke. Although various methods of treatment are available, none of them address all possible consequences of the subluxation pain, limited range of motion, the subluxation, and decreased functional use of the arm.

Aims:

The purpose of this study was to evaluate the effectiveness of California tri-pull taping (CTPT) method on shoulder subluxation, pain, active shoulder flexion, and upper limb functional recovery after stroke.

Materials and Methods:

This was a randomized control study on 30 participants. All participants received conventional neurorehabilitation 5 days a week over 6 weeks. Half of the participants also received the CTPT. Pre- and post-assessment scores were taken on all participants for the amount of shoulder subluxation, pain, active shoulder flexion, and functional recovery.

Results:

The CTPT method demonstrated a significant reduction of pain in the treatment group from baseline, a significant improvement in active shoulder flexion and a significant improvement in proximal arm function as measured on the proximal subscale on the Fugl-Meyer upper extremity functional Scale but not the distal or total Fugl-Meyer subscales. Shoulder subluxation was not statistically significant.

Conclusions:

The CTPT method is an effective treatment for the hemiplegic subluxed shoulder.

To sit or stand? A preliminary, cross sectional study to investigate if there is a difference in glenohumeral subluxation in sitting or standing in people following stroke

BACKGROUND

Glenohumeral subluxation (GHS) is a common symptom following stroke. Many therapists postulate that GHS may be reduced if the base of support (BOS) is reduced and the centre of mass (COM) is raised as this requires greater postural muscle activity. However, there is little empirical evidence to support this practice.

OBJECTIVE

The aim of this preliminary study was to investigate if the amount of GHS alters from sitting to standing.

STUDY DESIGN

A cross sectional, within-subject design in a convenience sample of 15 stroke patients with GHS was utilised.

METHODS

A prospective design was used with a single blinded tester who assessed GHS using the calliper method in sitting, standing and on return to sitting. Friedman and post hoc Wilcoxon tests showed that GHS was significantly reduced in standing compared to sitting (p <0.05) but this reduction was not maintained on return to sitting (p = 0.25).

CONCLUSIONS

The results of this study are limited by its small size. However, these results indicate that reducing BOS during rehabilitation may improve GHS after stroke. Whilst the maintenance of benefit is not established, these findings suggest that reducing BOS as part of treatment may help patients with GHS. Further research is now required to replicate these results in a larger sample and to directly examine shoulder muscle activity to investigate which muscles may influence GHS in response to changing BOS. Future work could also aim to determine whether the reduction in GHS was directly attributable to a reduced BOS or the effort associated with moving from sitting to standing.

Assessment of glenohumeral subluxation in poststroke hemiplegia: comparison between ultrasound and fingerbreadth palpation methods

BACKGROUND

Glenohumeral subluxation (GHS) is a common poststroke complication. Treatment of GHS is hampered by the lack of objective, real-time clinical measurements.

OBJECTIVE

The aims of this study were: (1) to compare an ultrasound method of GHS measurement with the fingerbreadth palpation method using a receiver operating characteristic curve (ROC) and (2) to report the sensitivity and specificity of this method.

DESIGN

A prospective study was conducted.

SETTING

The study was conducted in local hospitals and day centers in the southwest of England.

PATIENTS

One hundred five patients who had one-sided weakness following a first-time stroke (51 men, 54 women; mean age=71 years, SD=11) and who gave informed consent were enrolled in the study.

MEASUREMENTS

Ultrasound measurements of acromion-greater tuberosity (AGT) distance were used for the assessment of GHS. Measurements were undertaken on both shoulders by a research physical therapist trained in shoulder ultrasound with the patient seated in a standardized position. Fingerbreadth palpation assessment of GHS was undertaken by a clinical physical therapist based at the hospital, who also visited the day centers.

RESULTS

The area under the ROC curve was 0.73 (95% confidence interval [95% CI]=0.63, 0.83), suggesting that the ultrasound method has good agreement compared with the fingerbreadth palpation method. A cutoff point of ≥0.2 cm AGT measurement difference between affected and unaffected shoulders generated a sensitivity of 68% (95% CI=51%, 75%), a specificity of 62% (95% CI=47%, 80%), a positive likelihood ratio of 1.79 (95% CI=1.1, 2.9), and a negative likelihood ratio of 0.55 (95% CI=0.4, 0.8).

LIMITATIONS

Clinical therapists involved in the routine care of patients conducted the fingerbreadth palpation method. It is likely that they were aware of the patients' subluxation status.

CONCLUSION

The ultrasound method can detect minor asymmetry (≤0.5 cm) and has the potential advantage over the fingerbreadth palpation method of identifying patients with minor subluxation.

Effectiveness of the California Tri-Pull Taping method for shoulder subluxation poststroke: a single-subject ABA design

OBJECTIVE

I evaluated the effectiveness of the California Tri-Pull Taping method for clients with poststroke inferior shoulder subluxation of the glenohumeral joint.

METHOD

Ten participants were followed for 9 wk using an interrupted time series quasi-experimental single-subject ABA design to examine shoulder pain, activities of daily living (ADL) function, active range of motion, tape comfort, and subluxation.

RESULTS

The California Tri-Pull Taping method decreased inferior subluxation significantly from baseline to intervention but not at postintervention. Active range of motion was significantly increased in shoulder flexion and abduction between the baseline and intervention and the intervention and postintervention phases. Functional ADL scores were significant. The taping was reported to be comfortable. No significant difference in pain was found.

CONCLUSION

This intervention is a promising adjunct to the management of the hemiplegic subluxed shoulder that warrants further research.

Current and future interventions for glenohumeral subluxation in hemiplegia secondary to stroke

Poststroke shoulder pain is a common issue and can be caused by glenohumeral subluxation. This entity hinders function and quality of life and is caused by changes in tone and loss of fi ne control of the shoulder joints' supporting structures after a stroke. Current treatments are limited in number and effectiveness and have significant problems and limitations to their use. Furthermore, prior to percutaneous implantable neuromuscular electrical stimulation, there was no evidence for any treatment to provide relief for chronic hemiplegic shoulder pain from glenohumeral subluxation. This clinical review provides a comprehensive review of the anatomy, pathogenesis, clinical features, management, and clinical efficacy of current treatment modalities.

Underlying pathology and associated factors of hemiplegic shoulder pain

The prevalence of hemiplegic shoulder pain is approximately 22%-23% in the general population of stroke survivors and approximately 54%-55% among stroke patients in rehabilitation settings. Hemiplegic shoulder pain causes a reduced quality-of-life, poor functional recovery, depression, disturbed sleep, and prolonged hospitalization. Herein, we attempted to understand, based on a literature review and experts' opinion, the pathologic processes underlying hemiplegic shoulder pain and the major associated factors contributing to its development. The systematization of underlying pathologies was proposed, which might eventually enable a more constructive clinical approach in evaluating and treating patients with hemiplegic shoulder pain.

Biceps Suspension Procedure for Treatment of Painful Inferior Glenohumeral Subluxation in Hemiparetic Patients

Introduction

This article describes our biceps suspension procedure for painful inferior subluxation of the glenohumeral joint in hemiparetic patients.

Step 1 Position Patient and Expose the Biceps Tendon

Position the patient supine and expose the long head of the biceps tendon.

Step 2 Create Tunnel

Use a curet to connect holes drilled at the superior and inferior aspects of the lesser tuberosity.

Step 3 Prepare Biceps Tendon

Incise the tendon at the musculotendinous junction to preserve as much length of the biceps tendon as possible.

Step 4 Create Suspension

Create a loop with the tendon, and suture the distal end to the proximal end.

Step 5 Postoperative Protocol

Use a sling for three months, followed by active range-of-motion exercises.

Results

In summary, all patients noted pain relief after surgery, ten (of eleven) noted decreased deformity, and nine were "very satisfied" with the outcome.

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.

Outcomes of the biceps suspension procedure for painful inferior glenohumeral subluxation in hemiplegic patients

BACKGROUND

Patients with upper motor neuron injury can develop painful inferior glenohumeral subluxation with functional impairment. If the pain is relieved by manual reduction of the subluxation, this pain is considered mechanical in nature and potentially amenable to surgical treatment to maintain this reduction. The purpose of this study was to report our outcomes with use of the biceps suspension procedure to achieve shoulder joint reduction and pain relief in hemiplegic patients.

METHODS

This retrospective case series of eleven consecutive hemiplegic patients with painful glenohumeral subluxation underwent surgical reduction with a biceps suspension procedure. Seven patients had, in addition, extra-articular tenotomies to treat coexisting muscular contractures. Pain, physical examination findings, and radiographs were evaluated before and after surgery. Patient satisfaction with the outcome of the surgery was determined as well.

RESULTS

The mean duration of the patient follow-up was 3.2 years (range, 2.0 to 5.8 years). The average patient age was 46.9 years (range, eighteen to eighty-one years). Ten of the patients were female. All patients had pain with passive shoulder motion preoperatively, but only one patient had such pain postoperatively (p < 0.001). At the time of follow-up after the surgery, the mean score for pain on a visual analog scale was 1.45 (range, 0 to 5), with all patients noting a decrease in pain. Ten patients noted that deformity was also decreased at the time of follow-up. All patients had a sulcus sign on physical examination preoperatively, but only three had such a sign postoperatively (p < 0.001). The seven patients who had undergone shoulder tenotomies had significant improvements in shoulder extension (p = 0.009), forward elevation (p = 0.030), abduction (p = 0.040), and external rotation (p = 0.043) postoperatively. Ten patients were satisfied with the outcome of the surgery. Preoperative radiographs demonstrated inferior subluxation of the humeral head at the glenohumeral joint in all patients. Postoperatively, ten patients had an improved glenohumeral joint position, and nine of these patients had complete reduction of the humeral head.

CONCLUSIONS

Biceps suspension surgery can provide pain relief in hemiplegic patients with painful subluxation of the humeral head after upper motor neuron injury. Tenotomy of contracted muscles around the shoulder can improve passive shoulder motion in patients with spastic hemiplegia. Following surgery, there were high rates of glenohumeral reduction and patient satisfaction.

The effect of electrical stimulation in combination with Bobath techniques in the prevention of shoulder subluxation in acute stroke patients

OBJECTIVE

To examine the efficiency of electrical stimulation in combination with Bobath techniques in the prevention of inferior and anterior shoulder subluxation in acute stroke patients.

DESIGN

A prospective randomized controlled trial.

SETTING

Intensive care unit and inpatient clinics of neurology in a university hospital.

SUBJECTS

Forty-eight patients with acute stroke, divided equally into control and study groups.

INTERVENTION

Subjects in both groups were treated in accordance with the Bobath concept during the early hospitalization period. In addition to Bobath techniques, electrical stimulation was also applied to the supraspinatus muscle, mid and posterior portions of the deltoid muscle of patients in the study group.

MAIN MEASURES

Two radiological methods were used to measure the horizontal, vertical and total asymmetry and vertical distance values of the shoulder joint. Motor functions of the arm were evaluated with the Motor Assessment Scale.

RESULTS

The hospitalization period was 12.62 ± 2.24 days for the control group and 11.66 ± 1.88 days for the study group. Shoulder subluxation occurred in 9 (37.5%) subjects in the control group, whereas it was not observed in the study group. All shoulder joint displacement values were higher in the control group than in the study group (horizontal asymmetry P = 0.0001, vertical asymmetry P = 0.0001, total asymmetry P = 0.0001, vertical range P = 0.002).

CONCLUSION

Application of electrical stimulation combined with the Bobath approach proved to be efficient in preventing inferior and anterior shoulder subluxation in the acute stages of stroke.

The effectiveness of functional electrical stimulation for the treatment of shoulder subluxation and shoulder pain in hemiplegic patients: A randomized controlled trial

PURPOSE

To investigate the effect of functional electrical stimulation (FES) for the treatment of shoulder subluxation and shoulder pain in hemiplegic patients.

METHOD

A total of 50 hemiplegic patients with shoulder subluxation and shoulder pain were included in the study. The patients were randomly divided into the study and control groups. All patients were put on a rehabilitation program using conventional methods while the study group patients were additionally applied FES to supraspinatus and posterior deltoid muscles. The shoulder pain of all patients during resting, passive range of motion (PROM) and active range of motion (AROM) was measured with the visual analog scale (VAS) while the shoulder subluxation levels were evaluated with the classification developed by Van Langenberghe and by using the millimetric measurements on anteroposterior shoulder X-ray before and after the physical treatment and rehabilitation program and compared.

RESULTS

Comparison of the resting AROM vs. PROM VAS value changes showed no significant difference between the groups. There was a significant difference between the two groups for the amount of change in shoulder subluxation in favor of the study group.

CONCLUSIONS

The results of our study have shown that applying FES treatment to the supraspinatus and posterior deltoid muscles in addition to conventional treatment when treating the subluxation in hemiplegic patients is more beneficial than conventional treatment by itself.

Sonography of the shoulder in hemiplegic patients undergoing rehabilitation after a recent stroke

PURPOSE

To examine the hemiplegic shoulders for soft-tissue injury by musculoskeletal sonography and to determine the relationship between the motor functions of the upper extremity and these injuries, which play an important role in hemiplegic shoulder pain and may impede rehabilitation.

METHODS

The following characteristics of 34 acute stroke patients were recorded: age, gender, height, body weight, side of hemiplegia, type and duration of stroke, Brunnstrom stage, subluxation, and degree of spasticity of the upper extremity. On the basis of the Brunnstrom stage, the patients were divided into 2 groups. Patients with stages I, II, or III were categorized under the lower Brunnstrom stage (LBS) group (n = 21), and those with stages IV, V, or VI were allocated to the higher Brunnstrom stage (HBS) group (n = 13). Both shoulders of each patient were examined by musculoskeletal sonography with a 5-10-MHz linear transducer on 2 separate occasions (i.e., at admission and 2 weeks after rehabilitation).

RESULTS

With the exception of age, there were no significant differences in the demographic and clinical characteristics of the patients in the 2 groups. Shoulder musculoskeletal sonography revealed soft-tissue injury in 7 patients (33%) and 15 patients (71%) in the LBS group at admission and 2 weeks after rehabilitation, respectively (p < 0.05), and in 4 patients (31%) in the HBS group both at admission and 2 weeks after rehabilitation.

CONCLUSIONS

Acute stroke patients with poor upper limb motor functions are more prone to soft-tissue injury of the shoulder during rehabilitation.

Estimulação elétrica funcional na subluxação crônica do ombro após acidente vascular encefálico: relato de casos

A subluxação do ombro é comum em indivíduos que sofreram acidente vascular encefálico (AVE), podendo gerar dor, lesões do plexo braquial, capsulite adesiva e lesões nos músculos da bainha rotatória, implicando atraso da reabilitação e interferência na qualidade de vida. O objetivo deste estudo foi verificar os efeitos da estimulação elétrica funcional (EEF) na subluxação crônica do ombro em pacientes hemiplégicos que sofreram AVE. Foram avaliados três pacientes tendo tido AVE há mais de um ano com subluxação do ombro confirmada por exame de raios X. Foram analisados, antes e após o tratamento, o grau de subluxação e amplitude de movimento (ADM) do ombro, função sensório-motora pela escala de Fugl-Meyer e dor em repouso e à movimentação passiva por meio de escala visual analógica. Todos os pacientes foram submetidos a tratamento com fisioterapia convencional e EEF no membro hemiplégico por dez sessões. A análise dos resultados mostrou melhora em relação às medidas iniciais da ADM, da avaliação sensório-motora, dor e subluxação do ombro após o uso da EEF. Concluiu-se que a EEF, asociada à fisioterapia convencional, mostrou-se eficaz em produzir diminuição da subluxação, aumento da função do membro superior e agir no alívio da dor em pacientes com subluxação do ombro pós-AVE.

MRI findings in the painful poststroke shoulder

BACKGROUND AND PURPOSE

We describe the structural abnormalities in the painful shoulder of stroke survivors and their relationships to clinical characteristics. Method- Eighty-nine chronic stroke survivors with poststroke shoulder pain underwent T1- and T2-weighted multiplanar, multisequence MRI of the painful paretic shoulder. All scans were reviewed by one radiologist for the following abnormalities: rotator cuff, biceps and deltoid tears, tendinopathies and atrophy, subacromial bursa fluid, labral ligamentous complex abnormalities, and acromioclavicular capsular hypertrophy. Clinical variables included subject demographics, stroke characteristics, and the Brief Pain Inventory Questions 12. The relationship between MRI findings and clinical characteristics was assessed through logistic regression.

RESULTS

Thirty-five percent of subjects exhibited a tear of at least one rotator cuff, biceps or deltoid muscle. Fifty-three percent of subjects exhibited tendinopathy of at least one rotator cuff, bicep or deltoid muscle. The prevalence of rotator cuff tears increased with age. However, rotator cuff tears and rotator cuff and deltoid tendinopathies were not related to severity of poststroke shoulder pain. In approximately 20% of cases, rotator cuff and deltoid muscles exhibited evidence of atrophy. Atrophy was associated with reduced motor strength and reduced severity of shoulder pain.

CONCLUSIONS

Rotator cuff tears and rotator cuff and deltoid tendinopathies are highly prevalent in poststroke shoulder pain. However, their relationship to shoulder pain is uncertain. Atrophy is less common but is associated with less severe shoulder pain.

Predictability of Simple Clinical Tests to Identify Shoulder Pain After Stroke

OBJECTIVE

To identify simple diagnostic musculoskeletal tests that can be performed early after stroke to predict patients' likelihood of reporting early signs of hemiplegic shoulder pain.

DESIGN

Case control.

SETTING

Multicenter acute care hospitals.

PARTICIPANTS

A total of 152 adults after a first episode of stroke, of whom 135 met the inclusion criteria. Thirty patients were assigned to the experimental group because they reported moderate intensity of hemiplegic shoulder pain at rest. The remaining 105 patients made up the control group.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Therapists measured the performance of combined upper-limb movement including the hand-behind-neck (HBN) maneuver, passive pain-free ranges of shoulder motion, 3 musculoskeletal tests, and the strength of deltoid muscles during each patient's hospital stay. The numeric rating scale (NRS) identified those who reported moderate or greater intensities of hemiplegic shoulder pain during rest and during assessment.

RESULTS

In our study, 22.2% (95% confidence interval, 15.5-30.2) of the patients reported hemiplegic shoulder pain, on average 1 week after the onset of stroke. Positive Neer test (NRS score >or=5) during the HBN maneuver and a difference of more than 10 degrees of passive range of external rotation between shoulders had a 98% probability of predicting the presence of hemiplegic shoulder pain (receiver operating characteristic, .994; sensitivity, 96.7%; specificity, 99.0%; positive predictive value, 96.7%; negative predictive value, 99.0%; P<.001).

CONCLUSIONS

Three diagnostic clinical tests that can be performed during a bedside evaluation increase the likelihood of determining those who complain of hemiplegic shoulder pain after an acute episode of stroke.

Shoulder subluxation after stroke: relationships with pain and motor recovery

BACKGROUND AND PURPOSE

Glenohumeral subluxation (GHS) is a frequent complication in patients with post-stroke hemiplegia, but its role in functional recovery is still unclear. The aim of the present investigation was to understand the relationship of GHS with shoulder pain and arm motor recovery.

METHOD

A case-control study design was used. A sample of 107 hemiplegic adults with recent stroke (less than 30 days from onset) was differentiated into two groups according to the presence of GHS. Motor recovery was assessed using the upper extremity part of the Fugl-Meyer Assessment Scale and the presence of shoulder pain was recorded at admission (T1), at discharge (T2) and at follow-up, 30-40 days after discharge (T3).

RESULTS

GHS was present in 52 patients (48.6%) and correlated significantly to shoulder pain at TI, at T2 and at T3 (p < 0.001). Moreover, GHS at admission accounted for nearly 50% of shoulder pain at T3 (adjusted R2 = 0.458; p < 0.001). The presence of GHS was independently associated with the upper extremity score of the Fugl-Meyer Assessment Scale at follow-up (adjusted R2 = 0.766; p < 0.001).

CONCLUSIONS

GHS is a factor associated with shoulder pain development and with arm motor recovery and should be treated in the acute stage of hemiplegia.

Complex regional pain syndrome in stroke patients

The objective of this study was to investigate the incidence, and the factors influencing the development, of complex regional pain syndrome-I in the upper extremity in hemiplegic patients within the first 28 weeks following a stroke. We followed up 82 stroke patients. All patients were evaluated at weeks 2, 6, 14 and 28 after suffering a stroke. Outcomes were assessed using passive range of motion of shoulder, presence of subluxation, Ashworth score, Motricity index arm score, Brunnstrom stages and depression score. The incidence of complex regional pain syndrome-I was 48.8% in the first 28 weeks. Significant correlation was found between complex regional pain syndrome-I and the presence of subluxation, Ashworth score, Motricity index arm score, Brunnstrom stage and depression score (r=0.259, P=0.019; r=0.271, P=0.014; r=-0.393, P<0.001; r=-0.385, P<0.001; r=0.293, P=0.008, respectively). In this study, there was a relationship between complex regional pain syndrome-I and subluxation, loss of range of motion, spasticity of shoulder muscles and muscle strength. In order to prevent the development of complex regional pain syndrome-I, exercises directed at increasing the range of motion for the glenohumeral joint, strengthening shoulder muscles and reduction of spasticity will establish the integrity of the shoulder joint.

Poststroke Shoulder Pain: Its Relationship to Motor Impairment, Activity Limitation, and Quality of Life

OBJECTIVE

To assess the relationship between poststroke shoulder pain, upper-limb motor impairment, activity limitation, and pain-related quality of life (QOL).

DESIGN

Cross-sectional, secondary analysis of baseline data from a multisite clinical trial.

SETTING

Outpatient rehabilitation clinics of 7 academic medical centers.

PARTICIPANTS

Volunteer sample of 61 chronic stroke survivors with poststroke shoulder pain and glenohumeral subluxation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

We measured poststroke shoulder pain with the Brief Pain Inventory question 12 (BPI 12), a self-reported 11-point numeric rating scale (NRS) that assesses "worst pain" in the last 7 days. Motor impairment was measured with the Fugl-Meyer Assessment (FMA). Activity limitation was measured with the Arm Motor Ability Test (AMAT) and the FIM instrument. Pain-related QOL was measured with BPI question 23, a self-reported 11-point NRS that assesses pain interference with general activity, mood, walking ability, normal work, interpersonal relationships, sleep, and enjoyment of life.

RESULTS

Stepwise regression analyses indicated that poststroke shoulder pain is associated with the BPI 23, but not with the FMA, FIM, or AMAT scores.

CONCLUSIONS

Poststroke shoulder pain is associated with reduced QOL, but not with motor impairment or activity limitation.

The BION devices: injectable interfaces with peripheral nerves and muscles

Object

The purpose of this study was to describe a novel technology for implantable neuromuscular stimulation to treat complications of paralysis and disuse atrophy, including shoulder subluxation, hand contractures, drop foot, and osteoarthritis. The authors review the results so far of several pilot clinical studies of these muscle stimulation devices.

Methods

Miniature wireless stimulators received power and individually addressed command signals from an external radiofrequency transmission coil. One or more implants were injected through a 12-gauge hypodermic insertion tool into muscles or adjacent to motor nerves, where they provided the means to activate the muscles in any desired pattern of intensity and frequency. Randomized controlled studies in small numbers of patients are underway to identify efficacy, acceptability, best methods of practice, and any design changes that may be required to improve the technology.

Fifty patients have been enrolled in five studies; 35 patients have undergone implantation of a total of 79 BION1 devices. Comparisons with surface stimulation in patients who have suffered a stroke with shoulder subluxation and hand contractures show similar improvements in objective measures of efficacy but higher comfort levels for stimulation by implants.

Conclusions

Injected microstimulators represent a promising new class of technology for the rehabilitation of patients with upper motor neuropathies. As the technology evolves, practitioners may be able to use it to facilitate functional reanimation of paralyzed limbs.

Comparative Effectiveness of the GivMohr Sling in Subjects With Flaccid Upper Limbs on Subluxation Through Radiologic Analysis

OBJECTIVE

To test the effectiveness of the GivMohr sling in reducing subluxation while providing joint compression through a flaccid limb, using the criterion standard of radiography for measuring subluxation.

DESIGN

Anteroposterior 0 degree radiographs were taken of each subject: 1 of the unaffected shoulder and 3 of the affected shoulder; 1 without a sling, 1 with the GivMohr sling, and 1 with the Rolyan humeral cuff sling.

SETTING

Two large rehabilitation centers.

PARTICIPANTS

Twenty-five adult volunteers with a flaccid upper limb (UL) secondary to cerebrovascular accident or other pathology.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Vertical and horizontal subluxation were measured in millimeters on each of the 4 radiographs for each subject.

RESULTS

A 1-way analysis of variance revealed a significant main effect for vertical but not horizontal subluxation. Post hoc tests showed that the GivMohr sling measures were similar to measures for the uninvolved shoulder, but significantly different from measures for the Rolyan and the involved shoulder.

CONCLUSIONS

These results show that a properly fitted GivMohr sling reduces subluxation without overcorrecting. This new sling provides an alternative treatment option for persons with flaccid ULs that may prevent secondary complications and improve outcomes.

Shoulder pain in hemiplegia

Shoulder pain is a common complication in poststroke hemiplegia that reduces functional recovery. Many types of shoulder pathology have been suggested as causes of shoulder pain in hemiplegia,including shoulder subluxation, capsulitis, tendinitis, rotator cuff injury, bursitis, impingement syndrome, spasticity, complex regional pain syndrome, brachial plexus injury, and proximal mononeuropathies. More than one type of pathology may exist in a given patient. Shoulder pain improves in many cases with prompt diagnosis and appropriate management. Although the relationship between subluxation and pain is controversial, upper limb support to reduce subluxation is the standard of care and may prevent the development of pain and secondary complications. Further work is needed to elucidate the natural history of shoulder pain in hemiplegia, including the identification of physiologic common denominators that can lead to improved strategies to treat and prevent shoulder pain.

Neuro-Orthopedic Management of Shoulder Deformity and Dysfunction in Brain-Injured Patients

Shoulder problems are common in patients with traumatic brain injury. Very little has been written about the evaluation and neuro-orthopedic management of these problems. This is largely because there have not been surgical treatments available other than release of contracted, nonfunctional shoulders. Shoulder problems can be classified and evaluated using several different strategies: bony versus soft tissue restrictions; static versus dynamic deformities; traumatic injuries versus impairments secondary to weakness and spasticity; or problems of active function versus problems of passive function. Regardless of the classification system employed a systematic approach to evaluation and treatment is essential. Shoulder impairments can be corrected leading to significant improvement in functional outcomes. In this paper we report on the novel evaluation and surgical management options developed in our program for the most common shoulder problems encountered in patients with traumatic brain injury.