Management of the Hemiplegic Shoulder Complex Christine Griffin, OTR/L, MS, BCPR1 1

School of Health and Rehabilitation Sciences, The Ohio State University Wexner Medical Center, Columbus, Ohio

Hemiplegia in the upper limb and shoulder complex is a common secondary impairment resulting from a cerebrovascular event; evidence-based intervention is required for effective treatment. Prior to addressing shoulder movement, biomechanical alignment of the pelvis and trunk must first be assessed. Extreme care must be taken when completing passive range of motion with the hemiplegic shoulder; motion should not exceed beyond 90° of shoulder flexion and abduction without scapular upward rotation and humeral head external rotation. It is recommended that the use of slings with upper limb hemiplegia be limited. A subluxation of the shoulder can be treated with surface neuromuscular electrical stimulation if the recommended protocol of 6 hours daily, 5 days a week, for 6 weeks is utilized. Taping/strapping for a subluxation has conflicting evidence for reducing the development of hemiplegic shoulder pain, and it does not improve upper limb function or range of motion. Key words: electrical stimulation, shoulder, slings, stroke, subluxation

emiplegia in the upper limb and shoulder complex is a common secondary impairment resulting from a cerebrovascular event, and evidence-based intervention is required for effective treatment. When addressing the biomechanical alignment of the hemiplegic shoulder complex, the first area to be assessed is the alignment of the trunk. The optimal alignment of anterior pelvic tilt, followed by lumbar extension and thoracic extension, provides a biomechanical foundation of all head, neck, and limb movement.1 The ability to achieve and maintain appropriate pelvic position requires a co-contraction of the abdominal muscles and lumbar extension muscles. 1 The functional influence of the position of the pelvis and trunk was reflected in Gillen et al,2 where participants who maintained anterior pelvic tilt and neutral trunk position had higher scores on the Jebsen Taylor Hand Function Test than those who were in anterior or laterally flexed trunk position. The position of the pelvis in anterior pelvic tilt has a direct biomechanical effect on the upper limb. Anterior pelvic tilt causes a biomechanical chain reaction of lumbar extension, thoracic extension, scapular adduction, and then humeral head

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external rotation. During therapy intervention, a stretch for trunk extension may be required to assist patients with achieving the optimal biomechanical alignment. A stretch for trunk extension can be achieved by asking patients to lean posterior onto a wedge with 2 towel rolls placed behind their back. One towel roll is placed in the lumbar curve, and the other is placed along the spine between the scapula to encourage thoracic extension and scapular adduction. Once the patients are able to achieve the trunk alignment passively, then trunk strengthening is required to encourage the co-contraction of trunk muscles to actively maintain the optimal trunk alignment. Assisting the patients with dynamic sitting balance activities to strengthen the trunk muscles can encourage their active achievement of optimal trunk alignment. Utilizing the treatment technique of neurotaping, such Kinesio Tape, Leukotape, or McConnel tape, for trunk extension can assist with facilitating muscle strengthening for patients to achieve optimal trunk alignment as well. Shoulder subluxation is a common association with the hemiplegia upper limb; it is a palpable gap between the acromion and humeral head and occurs within the acute hypotonic phase of

Corresponding author: Christine Griffin, School of Health and Rehabilitation Sciences, The Ohio State University Wexner Medical Center, 106 Atwell Hall, 453 West 10th Avenue, Columbus, OH 43210-1262; e-mail: [email protected]

Top Stroke Rehabil 2014;21(4):316–318 2014;21(1):316–318 © 2014 Thomas Land Publishers, Inc. www.thomasland.com www.strokejournal.com

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doi: 10.1310/tsr2104-316 10.1310/tscir2101-316

Management of Hemiplegic Shoulder Complex

hemiplegia. Two primary theories of the cause of a subluxation have been proposed: (1) a subluxation occurs due to prolonged downward pull by gravity on the arm against which hypotonic muscles offer little resistance,3 and (2) the combination of flaccid supportive musculature (in particular, the supraspinatus muscle) and a downward rotated scapula is presumed to predispose the head of the humerus to undergo inferior subluxation relative to the glenoid fossa.4,5 Both theories result in overstretching of the glenohumeral capsule (especially its superior aspect) and hypotonic supraspinatus and deltoid muscles.4,6 Prevost et al,7 Culham et al,8 and Price et al9 negate the theory of the subluxation resulting from a downward rotating scapula through the use of scapular angle measurements of hemiplegic shoulders with and without subluxations. These researchers state that “scapular position was not an important factor”7(p786) and was unrelated in the occurrence of inferior subluxation in hemiplegia.9 Both theories agree that a subluxation is a result of weak rotator cuff muscles, most especially the supraspinatus. A subluxation can be measured clinically by utilizing clinician finger widths with appropriate interrater reliability7,10 and can be measured with calipers for research purposes.11 Extreme care must be taken when completing passive range of motion (PROM) with the hemiplegic shoulder. Kumar et al12 confirmed that with the use of pulleys and aggressive PROM of the shoulder, subacromial trauma occurred within the hemiplegic shoulder resulting in pain. Through the use of autopsy studies and a prevention protocol, Braus, Krauss, and Strobel13 determined that subacromial trauma was associated with complex regional pain syndrome (CRPS) in the hemiplegic shoulder. Mobilization of the scapula prior to PROM of the glenohumeral joint is critical to preventing subacromial trauma, secondary orthopedic complications, and CRPS of the upper limb. PROM exercises should not exceed beyond 90° of shoulder flexion and abduction without scapular upward rotation and humeral head external rotation.14 The use of slings with hemiplegia and its effectiveness have been debated in literature for many years. Hurd15 assessed the use of the full arm sling and concluded that there was no difference found in shoulder ROM, pain, or subluxation for patients with

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or without slings. Zorowitz16 assessed the use of the single-strap hemisling, Bobath roll, Cavalier support, and Roylan humeral cuff sling and determined that there was “no absolute evidence that supports prevent or reduce long term shoulder subluxation… or that a support will prevent complications of the shoulder subluxation.”(p771) The GivMohr Sling has been proven to reduce a subluxation when worn,17 but no comment was made on long-term effects, functional outcomes, range of motion, or pain. A Cochrane Database Systematic Review18 concluded, “There is insufficient evidence that to conclude whether slings and wheelchair attachments prevent subluxation, decrease pain, increase function or adversely increase contracture in the shoulder after stroke.” (p1818) It is recommended that the use of slings with upper limb hemiplegia be limited, especially slings that maintain the shoulder in internal rotation. This is because limited shoulder external rotation is correlated strongly with pain in the hemiplegic shoulder.19,20 Common treatment techniques for a shoulder subluxation are neuromuscular electrical stimulation (NMES) and taping/strapping. NMES is effective in reducing and preventing a shoulder subluxation21,22 when the posterior deltoid and supraspinatus muscles are stimulated and the appropriate treatment protocol of applying NMES 6 hours daily, 5 days a week, for 6 weeks is utilized.23 Taping/strapping has conflicting evidence for reducing the development of hemiplegic shoulder pain, and it does not improve upper limb function or range of motion.24-27 Active movement is required to build stability of the scapula on the thoracic wall with emphasis on scapular upward rotation.28 If a patient is unable to perform shoulder active movement against gravity, it is highly recommended that gravity-eliminated active assistive range of motion be completed to establish shoulder stability and muscle strength. For the hemiplegic shoulder, treatments that should be considered include trunk alignment, trunk control, positioning of the scapula, causes of a subluxation, pain prevention, NMES, and active movement of the shoulder. Acknowledgments The authors declare no conflicts of interest.

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Management of the hemiplegic shoulder complex.

Hemiplegia in the upper limb and shoulder complex is a common secondary impairment resulting from a cerebrovascular event; evidence-based intervention...
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