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Shoulder and Hemiplegia

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A common sequela of stroke is hemiplegic shoulder pain that can hamper functional recovery and subsequently lead to disability. Poduri et al report that hemiplegic shoulder pain can begin as early as 2 weeks poststroke but typically occurs within 2-3 months poststroke. Some of the most frequently suspected factors contributing to shoulder pain include subluxation, contractures, complex regional pain syndrome (CRPS), rotator cuff injury, and spastic muscle imbalance of the glenohumeral joint (Teasell, 1998). Hanger et al suggest that it is highly probable that the cause is multifactorial with different factors contributing at different stages of recovery (ie, flaccidity contributing to subluxation and subsequent capsular stretch, abnormal tonal and synergy patterns contributing to rotator cuff or scapular instability). Because of the difficulty in treating shoulder pain once established, initiate treatment early. For individuals who have had strokes with resultant hemiplegia, motor and functional recovery also are important steps in the treatment process. In order to understand the pathologic processes and changes that occur in the hemiplegic shoulder, the factors that contribute to normal shoulder position need to be understood. As proposed by Cailliet, normal anatomic position involves a well-approximated glenohumeral joint, proper glenoid fossa angle (forward and upward), and proper scapular alignment with the vertebral column. The joint is stabilized by musculature (ie, supraspinatus, deltoid, latissimus) and, to a smaller degree, the shoulder capsule, which supports the humerus. If any of these components are disrupted during the recovery process, then shoulder function may be compromised or a painful shoulder may result. Flaccid stage This stage of areflexia includes loss of muscle tone and volitional motor activity, variable sensory loss, and loss of muscle stretch reflexes. The shoulder capsule is thin and is composed of 2 tissue layers. Spastic stage As stroke recovery evolves, flaccidity may progress to spasticity. Following a stroke, the connections that control these reflexes can be interrupted, resulting in the release of these basic patterns and the evolution of spasticity and synergy patterns. If the neurologic deficits become severe enough, primitive tonic neck reflexes may develop. Biceps brachii spasticity further depresses the head of the humerus and flexes the elbow. As spasticity and synergy evolve, Teasell notes there is a failure of the antagonist muscles to relax when the agonist muscles contract, thus creating cocontraction. The muscles causing downward and outward rotation of the scapula, the rhomboids, overwhelm the trapezius and serratus anterior muscles. Spastic unilateral paraspinal muscles overwhelm those on the contralateral side, causing lateral flexion of the spine toward the affected side. Synergy stage If neurologic impairment of the completed stroke progresses, synergy patterns, which tend to worsen with initiated efforts, may emerge. The restrictions created by the synergy patterns create therapeutic challenges to attaining meaningful UE function. Upper extremity flexor synergy patterns include (1)



and releasing the uninhibited flexion patterns by initiating opposite movements at the "key points of control. (3) elbow flexion. When treating patients in flexion synergy. aim therapy at retraining the overwhelmed agonists.Action Research Arm Test · Evaluation of shoulder pain o Shoulder lateral rotation ROM to the point of pain (SROMP) · Evaluate for complex regional pain syndrome (CRPS) · Neurologic examination o Manual muscle testing § Assess strength and tone § Evaluate spasticity (Modified Ashworth scale) o Sensory evaluation about:blank 4/16/2012 . (2) humeral adduction/internal Page 2 of 7 shoulder/scapular depression (downward rotation and retraction)." Clinical History Common symptoms of the shoulder/UE reported by patients with hemiplegia may include the following: · Reduced mobility of the shoulder · Tenderness · Swelling/edema · Pain with movement · Decreased coordination Physical o Pain with motion o Decreased range of motion (ROM) o Decreased reflexes o External and clinical methods for measuring subluxation (Boyd. (4) forearm pronation (rarely supination).http://pt−rehabilitation. and (5) wrist/finger flexion (thumb-in-hand position). stressing the desired components of function. 1992) include the following: · Assess arm function .

with good interrater reliability and good correlation with more precise radiographic measurements. Painful shoulder subluxation improves with joint reduction.1% without subluxation reported shoulder pain. while Wanklyn et al have found no association between the severity of subluxation and the degree of pain. 78.6% with subluxation and 38. or promote undesirable synergy patterns. o Treatment of subluxation by reduction remains a controversial means of controlling shoulder pain. o A correlation between subluxation and RSD also has been studied. Sling use also may cause lateral subluxation. Dursun concluded that shoulder subluxation might be a causative factor of RSD as well as shoulder § Vibration o Reflexes o Fugl-Meyer index to test motor performance Causes · Glenohumeral subluxation Page 3 of 7 Subluxation is a common problem in patients with hemiplegia. including the following: § Painful shoulder subluxation most commonly is present when the UE is in a dependent position. o Controversy exists as to an association between shoulder subluxation and pain. However.3% of patients with RSD and 40% of patients without RSD. Yu et al demonstrated substantial reduction in subluxation. Even though sling use and other supportive devices remain controversial. as well as cases of a painful shoulder without subluxation. and possibly enhancement of motor recovery about:blank 4/16/2012 . Numerous cases of subluxation without pain have been documented. o Subluxation appears to be caused by the weight of the flaccid arm applying direct mechanical stretch to the joint capsule as well as traction to unsupportive muscles of the shoulder. Teasell suggests that other factors contributing to subluxation include improper positioning. and often occurs within 3 weeks poststroke.http://pt−rehabilitation. interfere with functional activities. with Yu et al reporting that longitudinal data suggests a correlation between early subluxation and shoulder pain. § Early prevention is warranted since chronic shoulder pain often is refractory to treatment. § Bohannon et al found that performing shoulder palpation to help diagnose subluxation can be reliably graded. Subluxation has been a commonly sited cause of shoulder pain and disability. lack of support in the upright position. sling use may not prove beneficial in preventing shoulder subluxation. § Subluxation may inhibit functional recovery by limiting shoulder ROM. Bohannon et al have found no significant correlation between the presence of subluxation and the occurrence of pain. and pulling on the hemiplegic arm when transferring the patient. Dursun et al found that subluxation was present in 74. furthermore. impair proprioception. especially during the flaccid stage. of these same patients. Yu et al report that treatment of shoulder subluxation continues to be the standard of care for several reasons.

Davis et al demonstrated that of those patients developing CRPS. · Complex regional pain syndrome (shoulder-hand syndrome. Compared to patients with flaccidity. especially external rotation and abduction. causalgia. The muscles found to predominate the synergy pattern in the shoulder include the adductors (ie. ROM. about:blank 4/16/2012 . and without significant sensory loss. o For the best prognosis. and to a greater extent. and avoiding painful stimuli are all suggested. § Kingery reports that the prognosis for resolution with preserved ROM is better in patients with some voluntary movements. o Joynt et al report that adhesive changes may reflect a later stage in the recovery process when chronic irritation or injury. ROM exercises. sympathetically maintained pain.5% of patients who have had a stroke. Nearly 35% of patients with CRPS type 1 have symptom resolution in one year. This finding suggests an association between adhesive changes and shoulder pain. rotator cuff tear. while Chalsen et al report the incidence as 61%. o Van Ouwenaller identified spasticity as a prime factor and one of the most common causes of shoulder pain in patients with hemiplegia. minor dystrophy) o The International Association for the Study of Pain has advocated using the terms complex regional pain syndromes (CRPS) type 1 (RSD) and type 2 (causalgia). Sudeck atrophy. then the use of motor point blocks have been advocated as an effective means for improving pain. although overly aggressive stretching should be avoided. pectoralis major). stroke. inflammation. latissimus dorsi). Snider reports that about 5-8% of patients have an incomplete nerve injury. Bohannon et al reports finding external rotation to correlate most with hemiplegic shoulder pain. early recognition and prompt treatment are essential for patients with CRPS. Other factors may include UE immobilization. o When Rizk et al performed shoulder arthrography in 30 patients with hemiplegic shoulder pain. RSD. If conservative treatment fails. myocardial infarction. and glenohumeral joint subluxation. Patients usually present with pain and limited passive movement of the shoulder. they found changes consistent only with capsular restriction typical of adhesive capsulitis in 77% of subjects. 65% had done so by 3 months poststroke. with less spasticity. teres major. and possibly function. which is thought to be the result of muscle imbalance. and 98% had done so by 5 months poststroke.http://pt−rehabilitation. patients with spasticity seem to experience a much higher incidence of shoulder pain. or lack of movement eventually results in adhesions. Page 4 of 7 and reduction of shoulder pain. optimal positioning of the limb. o Spasticity is defined as a velocity-sensitive disorder of motor function causing increased resistance to passive stretch of muscles and hyperactive muscle stretch reflexes. the internal rotators (ie. shoulder spasticity. Davis et al report that CRPS occurs in 12. § Treatment options are numerous. o The mainstay of treatment for spasticity begins with physical therapy and the use of ROM and stretching exercises. with physical therapy as the cornerstone. · Adhesive capsulitis o Glenohumeral capsulitis is postulated to play an important role in hemiplegic shoulder pain.

visuospatial cueing. poor positioning of the hemiplegic patient. Because diminished ROM of shoulder spasticity and adhesive capsulitis present similarly. · Subacromial bursitis o Some patients with hemiplegia complain of lateral shoulder pain that radiates down the arm when moved. or improper transfer technique. · Brachial plexus traction neuropathies/injury o Wanklyn et al reported a 27% increased incidence of shoulder pain in dependent patients after discharge. tingling ("pins and needles"). neglect. o Kumar et al showed that 62% of their patients using an overhead pulley system for therapy and performing ROM exercises experienced shoulder pain irrespective of other pathology. dull. or neglect more commonly experience recurrent injuries of the shoulder. o Through the use of shoulder arthrography. shooting. Other treatment alternatives include sympathetic blockade. thus demonstrating that overaggressive stretching or ROM should be avoided during the rehabilitation process. guanethidine block. or a combination. o The patient also relates experiencing hyperpathia (an exaggerated pain reaction to mild external cutaneous stimulation). · Thalamic syndrome (central poststroke pain. compared to only 16% on the unaffected Page 5 of 7 o A study by Wanklyn et al also found an association between reduced ROM (specifically external rotation) and hemiplegic shoulder pain. including one by Joynt et al. have revealed no incidence of rotator cuff tear with about:blank 4/16/2012 . o Joynt et al demonstrated that injecting 10 mL of 1% lidocaine into the subjective pain sites related to at least moderate pain relief at the subacromial injection site and improved ROM in 50% of the patients. sharp. and other sensory deficits tend to be predisposed to traumatic injuries to the affected extremity. Dejerine-Roussy syndrome) Patients describe the pain as burning. which may reflect improper handling at home by caregivers. visual field deficits. · Soft tissue injury/trauma o Soft tissue trauma often is a result of uncontrolled ROM exercises. as well as psychological evaluation and treatment. o Treatment options suggested by Lorish et al include caloric stimulation. spasticity. Najenson et al demonstrated an incidence of rotator cuff tear in patients who were poststroke and were experiencing shoulder pain to be as high as 40% on the affected side. o Patients with poor cognition. possibly contributing to capsulitis. gnawing. · Neglect Snels et al have found that on numerous occasions. Kaplan suggests that plexus injury should be considered in a patient who has atypical return of distal function. o Other studies. computer-assisted training. This pain often is refractory to treatment. or achy. and compensatory strategies. it is often difficult to distinguish between pain in the limited hemiplegic shoulder based on capsulitis.http://pt−rehabilitation. analgesia dolorosa. patients with sensory deficits. prism glasses. stabbing. with an incidence as high as 66%.

trains the patient in those components of the task. Sensory stimulation. As muscle tone returns to the hemiplegic limb. Brennan relates that exercises that promote normal muscle tone and diminish excessive spasticity through the use of reflex-inhibiting postures are performed and allow the patient to feel normal movements while preventing the use of compensatory motions. this practical method emphasizes motor relearning by practicing taskspecific motor activities while sitting. causing glenohumeral joint reduction and proprioceptive stimulation to the shoulder. Volpe believes that "focused sensorimotor exercise appears to produce better motor outcome. Cailliet suggests initiating trunk motions with sideto-side rolling. Motor relearning program Developed by Carr and Shephard. standing. attempt to maintain the patient in reflex-inhibiting positions. Biofeedback about:blank 4/16/2012 . Functional utilization uses techniques such as tonic stretches and voice commands to elicit muscle contractions. Brunnstrom encouraged reflex tensing in order to develop flexor and extensor synergies during early recovery. Neurodevelopmental technique Developed by the Bobaths for the treatment of cerebral palsy. as well as NMES. then optimal therapies can be tailored for individual patient needs through treatments performed by robotic devices. if motor recovery does in fact depend on motor relearning. spasticity may progressively increase. determine which components the patient cannot perform or has difficulty performing. Teasell reports that hemiplegic shoulder pain is not commonly associated with a rotator cuff disorder. Therapists analyze each task. the patient begins gentle weight-bearing exercises through the impaired arm with the elbow and wrist extended. Before active rehabilitation exercises of the extremities are started. Overall.http://pt−rehabilitation. Sensorimotor integration So theoretically. Brennan has maintained that ultimately. and ensures carryover of this training during daily Treatment Physical Therapy · Therapy during the flaccid stage Page 6 of 7 hemiplegic shoulder pain." Functional utilization of evolving synergies Assuming normal stages of recovery following stroke. Arm support and preservation of joint ROM is performed through early passive motion. · Therapy during the spastic stage A major goal of early stroke management is the prevention of muscle spasticity that could interfere with the patient's potential for regaining function. treatment focuses on eliminating unnecessary muscle activity. subsequently expediting skilled motor activities. More conventional rehabilitation methods involve reeducating weak muscles by strengthening and stretching. As the patient progresses from the supine to the prone position. Upon regaining the seated position. the neurodevelopmental technique (NDT) is probably the most widely accepted method used in the development of motor control in patients with hemiplegia. can be used to initiate sensory-motor reeducation. Development of motor control The recruitment patterns of individual motor units in these affected muscles are slow and inconsistent. or walking.

· Start seated and standing stimulation exercises to help decrease subluxation and modify synergy patterns. Brennan asserts that it is based on the principles of normal human development (ie. In an attempt to relax spastic antagonist muscle groups. possessed some early volitional arm movement) prior to treatment benefited from the use of early additional therapies that involved repetitive movements and functional tasks. control is gained proximally prior to distally. proprioceptive neuromuscular facilitation (PNF) involves repeated muscle activation of the limbs by quick stretching. Active repetition Parry and coworkers found that stroke patients who were less severely impaired ( Proprioceptive neuromuscular facilitation Page 7 of 7 Developed by Kabat. However. and Voss. about:blank 4/16/2012 . Knott. Brandstater revealed PNF to be more effective when muscle weakness is not due to upper motor neuron lesions. patients with severe arm impairment showed very little improvement in function irrespective of receiving additional therapies. · Use modalities (eg. Lorish and coauthors have considered it to be an optimal method of stretching in patients with hemiplegia. reflexive movements precede volitional movements. rhythmic stabilization can be used. · Use of electric stimulation can enhance muscle relaxation. vibration) to diminish spasticity. the timing of normal movements is distal to proximal). mass movements precede individual movements. · Patient should visualize (ie. However. ice. transcutaneous electrical nerve stimulation [TENS]. · Use prone exercises to stimulate righting reflexes that tend to imitate primitive motor function. developments occur cephalically to caudally. traction. This data supports previous clinical trials that suggest there is no current physical therapy approach that results in sustained improvements of upper limb function in patients who are severely impaired.http://pt−rehabilitation. · Apply sensory stimulation simultaneously to movements. · Avoid vigorous traction on the arm when stretching connective tissue around the spastic joint. which involves alternating voluntary contractions of agonist and antagonist muscles. approximation. mirror) specific movements. spiral and diagonal patterns) to assist with motor relearning and increasing sensory input. · Position the UE to decrease scapular depression and retraction. · Use the functional arm to simultaneously train the paretic arm to improve ROM and proprioceptive stimulation. and maximal manual resistance in functional directions (ie.