Shoulder in hemiplegia

Current Evidences in the understanding and

management of

Shoulder in Hemiplegia

Phinoj K. Abraham, MOTh (Neurosciences)

Occupational Therapist, Hamad Medical Corporation, Qatar

21-10-2015 1

Learning Objectives

• Discuss research 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

Anatomy & Biomechanics of Shoulder joint

3

1. Glenoheumaral

Joint

2. Sub deltoid joint

3. Acromioclavicular

Joint

4. Scapulothoracic

Joint

5. Sternoclavicular

Joint

6. 1st Costosternal

Joint

(Shoulder Pain, Rene Cailliet M.D.,

1991)

Shoulder Biomechanics

4

• Stability

• Static Stabilization

• Dynamic Stabilization

• Mobility

• 30 of freedom

• Scapulo-heumeral Rhythm

Static Stabilization

5

• Primarily by

• 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

pressure

*Degree of glenoid inclination

• 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

stroke.”

6

Robert Teasell MD et al., (2013) Hemiplegic shoulder pain p. 8; The Evidence-

Based Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com

http://www.ebrsr.com/

**Role of Muscles around 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

Role of Muscles Contd…

• ….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

Section Summary

• In a normal shoulder, the static stability

is contributed by a passive mechanism

9

Hemiplegic shoulder

> Hypotonic Shoulder

> Hypertonic Shoulder

10

Hypotonic Shoulder

1) Hemiplegic Shoulder

Subluxation (HSS)

2) Hand Edema

11

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


1. Shoulder Subluxation Contd...

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


1. Shoulder Subluxation Contd...

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

Management of shoulder subluxation

i) POSITIONING

A. Bed Positioning .

Lying on Unaffected side Lying on Affected side15

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



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


• 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)21. Marvin M Hurd, et al Shoulder sling for hemiplegia: friend or Foe? Arch phys Med Rehabil 1974; 55:519-222. Robert Teasell MD et al., Hemiplegic shoulder pain p. 21; The Evidence-Based Review of

Stroke Rehabilitation

18


Clinical Implications

• 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

ii) Strapping the Hemiplegic 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

Strapping Contd…

• Effectiveness of 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

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


iv) Electrical Stimulation in 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)”



23


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-



2) Hand Edema Contd…

• 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 controversial251. Robert Teasell MD et al., Upper extremity Interventions. P 122; The Evidence-



Treatment of Hand Edema

• 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-



Section Summary• Proper bed 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

might be effective in the management of hand

27

28

Hemiplegic shoulder

> Hypotonic Shoulder

> Hypertonic Shoulder

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

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



30


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 restrictedRobert Teasell MD et al., Hemiplegic shoulder pain p. 21; The Evidence-Based


31


Pectoralis Spasticity Disorder (PSD)

• Characterized by motion being most

limited and pain produced on abduction

32

Common associated problems1. 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

Management of hypertonic shoulder

• 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 major34

Conclusions Regarding Spastic Hemiplegic Shoulder

‘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



Major References

1. Joint Structure 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

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Health & Medicine

Shoulder in hemiplegia