eMedicine Specialties > Physical Medicine and Rehabilitation > Upper Limb Musculoskeletal Conditions

Shoulder and Hemiplegia: Follow-up

Author: Robert Gould, DO, Physiatrist, Interventional Pain Care, LLC
Coauthor(s): Susan S Barnes, DO, Assistant Professor, Department of Physical Medicine and Rehabilitation, Michigan State University
Contributor Information and Disclosures

Updated: Feb 5, 2009

Follow-up

Deterrence/Prevention

Without appropriate care, patients with hemiplegia have an increased risk of developing numerous shoulder complications, including nerve pressure palsies, nerve traction injuries, rotator cuff pathology, capsulitis, impingement syndromes, or subluxation. During the acute flaccid stage, care for the shoulder must take into account the position of the extremity in relation to gravity and body position. Techniques used in the prevention of poststroke shoulder pain and its complications must be utilized to neutralize undesirable or injurious positions.

Wheelchair armrests, lap trays, or forearm troughs are commonly used while the patient is in his or her wheelchair. Rigid armboards often are preferred to the use of slings while the patient is in the wheelchair because they allow the humeral head to approximate the glenoid fossa at a more natural angle and are less restrictive. Armrests also benefit the patient as the arm is in a nondependent position, thereby decreasing the incidence of edema. Armrests also can be used as an alternative for patients with decreased trunk control.

Even though optimal positioning is mandated, Kaplan suggested that judicious ROM exercises (through therapy) should be started within 24 hours poststroke.33

When moving patients in bed, or transferring them in and out of the wheelchair, positions of dependent arm traction should be avoided. When passive transfers are performed, the hemiplegic arm needs to be supported by holding the scapula rather than pulling on the arm. About one third of stroke patients studied by Wanklyn and colleagues required assistance during transfers and tended to be at risk for incorrect handling by their caregivers, subsequently predisposing them to the development of shoulder pain.21 Traction and excessive shoulder movement need to be avoided in order to prevent impingement or a rotator cuff tear.

When positioning the patient, it is recommended that reflex-inhibiting postures be maintained in order to avoid common hemiplegic complications, including spasticity and contractures. Carr and Kenney's literature review looked at what researchers found to be proper hemiplegic positioning.38 Consensus was found for some positions, but disagreement for other positions regarding the 9 "key points of control": head and neck, shoulder, elbow, wrist, fingers, trunk, hip, knee, and ankle/foot. Many of the authors also warned that hemiplegic patients should avoid supine-lying positions as much as possible because abnormal reflex activity is highest in this position. Since the scope of this article is specific to the shoulder, discussion of proper positioning is limited to the head and neck (which have an indirect effect on the UE) and the upper limb, as follows:

  • Head and neck - The consensus position was found to be midline or turned to the affected side, which encourages patient attention to the environment of the affected side and may be beneficial for those patients with neglect. If sidebent, turn away from the affected side.
  • Upper limb
    • Shoulder – Protracted with the arm brought forward to counteract scapular tendency for retraction
    • Arm – Varying degrees of external rotation, abduction, and flexion
    • Elbow – Extension
    • Forearm – Supination
    • Wrist – Neutral
    • Fingers – Extended
    • Thumb – Abducted

The above positions are not supported by all authors, including Cailliet. Cailliet has recommended that the head be laterally flexed and rotated toward the unaffected side, and that the hand and fingers be supported in a wrist-extended and finger-flexed position.6 Carr and Kenney have stated that "current understanding seems to suggest that attendance to posture is likely to be an important element in maximizing patients' functional gains and quality of life."38 For this reason, emphasize patient and caregiver education regarding proper positioning.

Slings often are used early poststroke in an attempt to prevent subluxation. Cailliet has contended that it continues to be the best method for supporting and protecting the hemiplegic shoulder while the patient is standing or transferring.6 However, excessive sling use should be avoided due to the increased incidence of contractures.

Kirshblum has proposed that the following considerations be used when deciding on the use of a sling63 :

  • Proper fit that promotes proper glenohumeral alignment (Poor alignment can contribute to increased flexion synergy.)
  • Protection of the flaccid extremity during transfers, standing, and ambulation (Slings can interfere with balance, however.)
  • Should not interfere with patient function
  • Should be relatively easy to don and doff
  • Should not create new problems (eg, edema in the dependent hand), contribute to synergy patterns, or cause scapulohumeral malalignment

Zorowitz and colleagues tested 4 different shoulder sling models for their efficacy in correcting subluxation in stroke patients.64 They found that the only sling that significantly corrected vertical asymmetry was the single-strap hemisling in 55% of subjects, while total asymmetry was corrected most by the Rolyan support in 45% of subjects. They contend that lateral displacement of the humeral head does not appear to be an inherent quality of subluxation, but the use of certain slings, especially the Bobath and Cavalier supports in this study, were found to contribute.

Brooke and coauthors compared the Harris hemisling, the Bobath sling, and an arm trough/lap board for their effect on subluxation as well.65 They found that the hemisling gave significantly better vertical correction compared to the Bobath sling, while the arm trough/lap board tended to overcorrect. Their results also showed that the Bobath sling horizontally distracted the glenohumeral joint significantly more than the other 2 supports. Even though improved glenohumeral asymmetry was found in some cases, there was still no sling used that consistently prevented subluxation in all cases.

Yu and colleagues also described their propensity for contributing to the deleterious effects of joint immobilization and their promotion of undesirable synergy patterns.17,18 For this reason, no consensus has been reached amongst researchers or clinicians as to which model should be used to attain a particular therapeutic goal, or if they should be used at all.

Strapping also has been studied as a means for shoulder support. Theoretically, it should support the glenohumeral joint or reduce subluxation while allowing the UE to move freely.

A study by Hanger and colleagues concluded that there was no significant benefit with the use of strapping the shoulder to preserve ROM or reduce the prevalence of subluxation over the 6-week trial, even when done concomitantly with standard physical therapy.3 However, there was a trend toward improved pain and shoulder function, but it was not found to be statistically significant. They also found that the presence of neglect or sensory loss at baseline was associated with poor outcome.

Other literature suggests that strapping has potential for reducing the incidence or the severity of hemiplegic shoulder pain, but those studies were small or uncontrolled.

Hanger and coauthors also expressed that there are different strapping techniques that may be more effective than the one they used.3

Prognosis

  • Carr and Kenney reported that about two thirds of all stroke survivors will be disabled, up to 50% will be severely disabled, and 10-15% will require institutional care.38 Motor weakness also is reported in 50-80% of survivors poststroke.
  • Brandstater reported that most spontaneous recovery of voluntary motor function occurs in the first 2-3 months following stroke; however, it can occur years later.39
  • Cailliet reported an unfavorable prognosis for complete UE motor recovery if the flaccid stage lasts longer than 2 weeks,6 while Carroll found this to be the case after only 1 week.66
  • Other unfavorable predictors in estimating functional recovery include excessive spasticity and impaired sensation and perception, with Van Buskirk and Webster reporting that sensory loss occurs in up to 80% of stroke patients.67
  • Depression also can contribute to unfavorable outcome, with Wanklyn and coauthors reporting a 22-27% incidence within the first few weeks poststroke.21

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • In the event of trauma in the patient with hemiplegia, fracture should be ruled out as a source of pain.
 


More on Shoulder and Hemiplegia

Overview: Shoulder and Hemiplegia
Differential Diagnoses & Workup: Shoulder and Hemiplegia
Treatment & Medication: Shoulder and Hemiplegia
Follow-up: Shoulder and Hemiplegia
References
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Further Reading

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Keywords

shoulder, hemiplegia, stroke, shoulder pain, shoulders, subluxation, pain in shoulder, rotator cuff injury, hemiplegic, complex regional pain syndrome, CRPS, NMES, neuromuscular electrical stimulation, shoulder pain after stroke, contractures, spastic muscle imbalance of the glenohumeral joint

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Contributor Information and Disclosures

Author

Robert Gould, DO, Physiatrist, Interventional Pain Care, LLC
Robert Gould, DO is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, International Spine Intervention Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Coauthor(s)

Susan S Barnes, DO, Assistant Professor, Department of Physical Medicine and Rehabilitation, Michigan State University
Susan S Barnes, DO is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Osteopathic Association, and American Osteopathic College of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

Medical Editor

Robert J Kaplan, MD, James E Van Zandt VA Medical Center, Staff Physician, Department of Rehabilitation Medicine
Robert J Kaplan, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service (www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Rene Cailliet, MD, Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center
Rene Cailliet, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Pain Society, Association of American Medical Colleges, International Association for the Study of Pain, and Pan American Medical Association
Disclosure: Nothing to disclose.

 
 
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