Hemiplegic shoulder pain

This article reviews the literature relevant to the possible causes, prevention, and treatment of hemiplegic shoulder pain. Shoulder pain and stiffness impede the rehabilitation of patients with hemiplegia. The cause of this complication is unknown, but it may be related to the severity of neurological deficits, preexisting or posthemiplegic soft tissue injury, subluxation, brachial plexus injury, or shoulder-hand syndrome. Shoulder pain may be preventable if risk factors can be identified and appropriate prophylaxis applied. Resolution of the condition depends on diagnosis and effective treatment at the onset of the symptoms. More clinical research is needed to clarify the cause of hemiplegic shoulder pain and to document the efficacy of prophylactic and treatment methods.

Painful shoulder in hemiplegic patients: a study of the suprascapular nerve

The etiology of painful shoulder in hemiplegic patients has not been fully explained. Since it has been shown that a suprascapular nerve lesion can be associated with "frozen shoulder," we have investigated the possibility that a similar lesion may exist in the painful contracted shoulder of hemiplegic patients. Thirty hemiplegic men with shoulder pain were examined and latencies determined for the suprascapular nerve from the supraclavicular fossa to the supra- and infraspinatus muscles on both sides. Routine EMG was also done for the same muscles. Patients' ages ranged from 45 to 85 (means 67 years) and the duration of hemiplegia from 1 month to 13 years (means 30.9 months). Mean latencies of the noninvolved side were 3.2 +/- 0.5 (SD) and 4.2 +/- 0.7 ms to the supraspinatus and the infraspinatus muscles, respectively. Three patients had latencies greater by two SD on the hemiplegic side than on the noninvolved side. Suprascapular nerve block did not relieve the shoulder pain completely in these patients. Excluding these three, mean latencies on the hemiplegic side were 3.1 +/- 0.4 ms to the supraspinatus muscle and 4.1 +/- 0.6 ms to the infraspinatus muscle. It is concluded that a lesion of the suprascapular nerve is not responsible for the painful contracted shoulder of the hemiplegic patient although such a lesion may exist incidentally.

Deep venous thrombosis in high-risk hemiplegic patients: detection by impedance plethysmography

Clinically significant thromboembolic disease originating from the paralyzed leg of hemiplegic patients can occur unexpectedly and may affect morbidity and mortality in the rehabilitation setting. Impedance plethysmography (IPG), a simple, noninvasive technique, can accurately reveal deep vein thrombosis (DVT) in the large veins of the thigh. IPG studies were performed on the lower extremities of 20 hemiplegic patients considered at high risk for DVT. Each patient had one or several of the following potential risk factors: mild swelling, vague leg discomfort, loss of sensation, poor or absent muscle power at the ankle, at least one week of complete bedrest, repeated minor trauma. None of the patients had major signs or symptoms of DVT at the time of testing (ie, severe pain and tenderness, increased temperature or redness, a palpable venous cord, or positive Homans' sign). Seven patients had an abnormal IPG in the paralyzed lower limb and DVT was confirmed in each case by venography. After appropriate anticoagulation therapy, the seven patients resumed their rehabilitation programs. It was concluded that IPG can be successfully used in the early detection of DVT in high-risk hemiplegic patients, thus leading to prompt medical management, reduced morbidity and mortality, and improved rehabilitation outcome.

Pseudohemiparesis and Tourette syndrome

Three patients with Tourette syndrome and transient recurrent hemiparetic posturing (pseudohemiparesis) are presented. The transient nature of this posturing is not consistent with a static central nervous system deficit. It is felt that the Tourette syndrome symptomatology and pseudohemiparesis share a common pathophysiology. The inclusion of pseudohemiparesis in the differential diagnosis for cerebral palsy is suggested.

Adult-onset hemiplegia: changes in gait after muscle-balancing procedures to correct the equinus deformity

Fifty-four adult patients with acquired spastic equinus and equinovarus deformity were treated with lengthening of the Achilles tendon, lateral transfer of the anterior tibial tendon, and appropriate muscle releases. All patients had preoperative dynamic electromyography and electrogoniometry performed in order to assist in planning the surgical procedures and to provide a baseline assessment of the dynamic deformities. Preoperatively, the stance and double-support phases of gait were prolonged. Throughout the stance phase, the gait of these patients was characterized by equinus deformity of the ankle, decreased flexion of the knee (hyperextension in the most severely involved patients), and increased flexion of the hip (which also varied with the severity of the equinus deformity of the ankle and hyperextension of the knee). In all patients, the operation was performed at least one year after onset of the hemiplegia. Clinical follow-up at an average of thirty months (range, twenty-four to sixty-two months) showed that the equinus deformity was corrected in all patients and that 59 per cent of them were brace-free. Two patients had a superficial infection that healed uneventfully, and two had pull-out of the tendon that required reoperation. Postoperative analyses of gait, performed at least one year after surgery for twenty-seven of the patients, showed that the stance and double-support phases of gait (which had been prolonged before surgery) approached the findings in normal control subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Thermographic evaluation of the painful shoulder in the hemiplegic patient

In this study, we investigated the applicability of thermography as a technique for evaluating the painful postcerebrovascular accident (CVA) shoulder in hemiplegic patients. A thermographic series was taken of the upper extremities and upper trunk of 27 female subjects. The four groups we evaluated were nonhemiplegic subjects (n = 9), post-CVA subjects with recovered function (n = 6), hemiplegic subjects with upper extremity motor impairment (n = 6), and hemiplegic subjects with both motor impairment and ipsilateral shoulder pain (n = 6). The data revealed a normal thermographic series in 8 of the 9 nonhemiplegic subjects, but only in 1 of the 18 post-CVA subjects. The majority of the abnormal thermographic series of post-CVA subjects showed a 1 degree to 5 degree C coolness on the involved side. No consistent thermographic patterns emerged that could be related to the severity or location of pain. Further studies are needed to evaluate the efficacy of thermography as a means of determining the relationship between ipsilateral post-CVA coolness and hemiplegic shoulder pain.

Carpal tunnel syndrome in the nonparetic hands of hemiplegics. Stress-induced by ambulatory assistive devices

Three patients who had earlier sustained an acute stroke were admitted to a rehabilitation bed service. Clinically, they developed symptoms suggestive of carpal tunnel syndrome (CTS) in their nonparetic hands during a progressive ambulation training program which included ambulatory assistive devices. In each patient, the diagnosis was confirmed by electrodiagnostic evaluation. Two of the three patients were subsequently provided with forearm platform attachments for their assistive devices, and cock-up wrist splints, in an attempt to decrease compression of the median nerve. Despite these measures, both remained symptomatic and had electrodiagnostic evidence of progressive CTS. They were referred for surgical decompression of the median nerve. The third patient had resolution of symptoms when she became able to ambulate without need of an assistive device. These cases are examples of CTS secondary to excessive pressure in the nonparetic hands of hemiparetic patients, believed to occur more frequently than is clinically recognized.

Shoulder pain in hemiplegia: statistical relationship with five variables

The incidence of shoulder pain and the statistical relationship between it and five other variables (patient age, time since onset of hemiplegia, range of hemiplegic shoulder external rotation, spasticity and weakness) were investigated retrospectively. Of 50 consecutive hemiplegic patients whose records were reviewed, 36 had shoulder pain. The variables significantly (p less than 0.01) correlated with shoulder pain were: time since onset of hemiplegia (r = 0.45) and ROSER (r = -0.61). The relationship between shoulder pain and range of shoulder motion remained significant when other factors were partialled out. The relationship between shoulder pain and time since onset was not significant when the affect of range of shoulder motion was partialled out. Therefore, range of shoulder external rotation was considered the factor related most significantly to shoulder pain. This finding suggests that shoulder pain demonstrated by hemiplegia patients may be, in part, a manifestation of adhesive capsulitis.

Disappearance of parkinsonian signs after spontaneous vascular 'thalamotomy'

Disappearance of parkinsonian symptoms was observed in a 57-year-old patient with Parkinson's disease after a contralateral thalamopeduncular infarct. From analysis of stereotaxic data in parkinsonian patients, this may be explained by lesion of the ventro-oral internal nucleus or of Forel's field, both of which are involved in thalamopeduncular infarcts.

[Treatment of pediatric spastic foot deformities]

The pathophysiology of gait under the influence of cerebral-spastic leg musculature and the resulting biomechanical effects are demonstrated. The latter must be taken into account for successful treatment of functional disturbances and in the shape of the feet in children with cerebral-spastic disturbances in movement. Co-contractions in antagonistic muscle groups of the lower extremities during the second half of the stance phase, the propulsion period of the step, are the main obstacles to achieving efficient gait. The causes lie in the spastic increase of the muscle stretch reflex as well as in a defect in the reciprocal inhibition of antagonistic muscle groups. Moderate equinus gait and an increase in the normal differences in the development of force by the dorsal and plantar flexing muscles represent effective physiological compensation for these disturbances. The common secondary changes in the shape of the foot resulting from spasticity and contractures of the muscles require long-term planning of treatment, including physiotherapy, plaster casts, plastic orthoses, orthopedic shoes and, in some cases, operations, which should be delayed as long as possible during the growth phase. Premature lengthening of the Achilles tendon regularly results in iatrogenic foot deformities.

Selective posterior rhizotomy in the dorsal root entry zone for treatment of hyperspasticity and pain in the hemiplegic upper limb

The authors report a series of 16 hemiplegic patients suffering from harmful spasticity in the upper limb and treated with selective posterior rhizotomy (SPR) in the dorsal root entry zone (DREZ). This severe spasticity was associated with irreducible abnormal postures in flexion in 11 cases and painful manifestations in 12. The method was introduced in 1972 on the basis of anatomical studies of the DREZ in humans, in which a topographical segregation of the root afferents, according to their anatomicofunctional destinations, has been shown. It consists of a DREZ microsurgical lesion 1 to 2 mm in depth and directed at a 45 degree angle, performed ventrolaterally in the posterolateral sulcus of the spinal cord and into the internal part of the Lissauer's tract. The procedure is carried out in each rootlet of the posterior roots considered to be responsible for the harmful spasticity. SPR interrupts selectively the (lateral) nociceptive and (central) myotactic afferent fibers connecting the motor neurons, while sparing most of the (medial) lemniscal fibers and the inhibitory circuitry of Lissauer's tract and the dorsal horn. The results were evaluated after a 1- to 12-year follow-up. There were no deaths and no general complications; in 1 case a loss of motility in the leg ipsilateral to the procedure occurred. The excess of spasticity was slightly diminished (2 cases), markedly reduced (9 cases), or totally abolished (5 cases), making possible an improvement in voluntary movements in 8 patients and at least a good passive mobilization in 7 further cases. In 1 case only, a marked tendency for spasticity to return was observed. Of the 12 patients with painful manifestations, 9 were completely relieved and 3 improved. These beneficial effects on both spasticity and pain led to a gain in functional status in 93% of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Transient erythroblastopenia of childhood presenting with papilledema

A 4-year-old boy with transient erythroblastopenia of childhood (TEC) presented with papilledema and transient hemiparesis. Upon spontaneous hematologic recovery, the papilledema resolved. It is concluded that TEC, like other forms of anemia, may present with papilledema and even focal neurologic deficit, from which spontaneous recovery may be anticipated.

Biceps tenodesis for painful inferior subluxation of the shoulder in adult acquired hemiplegia

Painless inferior subluxation of the shoulder is a common finding following stroke and is a manifestation of the adynamic nature of the disorder. The weight of the limb is not counterbalanced by shoulder musculature. This is a preliminary report of a simple tenodesis procedure performed in six patients with uniformly successful reduction of the subluxation. The tenodesis is performed through a short deltopectoral approach. The tendon of the long head of the biceps is looped over the coracoid process of the scapula and secured with a barbed staple, thus reducing the subluxation. The indications were painful inferior subluxation of a flail shoulder and failure of multiple orthotic attempts to relieve discomfort. Follow-up evaluation ranged from ten to 42 months with no instances of pain or recurrent subluxation in five cases. The one failure was in a patient whose pain was thought to be thalamic in origin. The subluxation was reduced, but the pain persisted.

Ataxic hemiparesis syndrome: clinical and CT study of 20 new cases and review of the literature

20 new cases of ataxic hemiparesis syndrome (AHS) are reported and the findings compared with those of published cases. AHS may be due to lesions either of the brainstem or of supratentorial structures, where motor fibers run together with the cerebro-cerebellar pathways. Specific syndromes related to the lesion site cannot be identified from the clinical signs. Ischemic infarct is the most frequent cause of the syndrome, but hemorrhagic, neoplastic and demyelinating lesions have also been reported.

[A study of constructional activity in patients with cerebrovascular disorders]

Three experiments were conducted to examine the differences of constructional disabilities between left and right hemiplegic patients with cerebrovascular disorders. In Exp. I, 32 left and 30 right hemiplegics were given the Block Design Test. In Exp. II, the Visual Cognition Test, consisted of 10 subtests to measure the abilities which were presumed to be essential for the process of block design construction, was performed. In Exp. III, the patients with constructional disabilities were given various aids to facilitate the constructional activities. The main results were as follows: Constructional disabilities were more frequent and severe in left than right hemiplegic patients. There were qualitative differences in construction between the two groups. The factors underlying constructional disabilities were responsible to visuoperceptual disorder and programming disorder of behavior for both groups. However, visuoperceptional disorder in left hemiplegics and programming disorder in right hemiplegics manifested relatively closer relation to constructional disabilities than others.

Hypesthetic-ataxic-hemiparesis in thalamic hemorrhage

Acute onset hypesthetic-ataxic-hemiparesis is described in two hypertensive patients. Computed tomography (CT) showed an area of increased attenuation consistent with blood in contralateral thalamus. The pathophysiologic implications of the cerebellar and pyramidal system in thalamic hemorrhage is discussed.

Carotid body tumour: 30 years experience

Thirty-two patients with 37 carotid body tumours, seen in the Vascular Unit at the Royal Victoria Infirmary, Newcastle upon Tyne between 1956 and 1985 are reviewed. Twenty-six of the tumours were treated by surgical excision. There were no peri- or postoperative deaths, but one patient developed a permanent hemiplegia following surgery (3.8 per cent); cranial nerve palsy occurred in five patients (19.2 per cent). There were no malignant tumours although in one patient, histology of the resected specimen showed the presence of local lymph node invasion (3.8 per cent). In the 7 patients who did not undergo surgery, 3 have been lost to follow-up; the remainder have not shown any significant increase in the size of the tumour. One patient was treated by radiotherapy. It is concluded that surgical excision is the treatment of choice, though observation may be preferred for the older patient with a symptomless, slow-growing tumour. To help reduce the risk of hemiplegia (the most serious complication of surgery) a meticulous surgical technique is necessary and heparin, intraluminal shunting and facilities for arterial repair and grafting must be at hand.

Painful shoulder in hemiplegia

Shoulder pain is probably the most frequent complication of hemiplegia. In this study 219 hemiplegia patients were regularly followed up after their cerebrovascular accident (CVA) for one year (166 men, 53 women, with a mean age of 47 years). Criteria and parameters for evaluation of these shoulders were established at the outset. Distinction was made between flaccid and spastic hemiplegia. Other influencing factors were subluxation reflex sympathetic dystrophy syndrome (RSD), isolated tendon lesion cuff rotator tear or association of some of these. Roentgen examinations were done for each patient. In our series of patients, 72% had shoulder pain at least once during the course of their recovery. This problem occurred more often in patients having spasticity (85%) than in those with flaccidity (18%). An evolution towards spasticity was noted in 80% of the patients in this series, whereas 20% remained hypotonic. Among the other possible causes of shoulder pain, anteroinferior subluxation was incontrovertibly the most frequently cited. The RSD syndrome was present in only 23% of all cases but was seen more often in spastic patients, that is 27% compared to 7% among flaccid patients. Whatever the cause, the subluxation with flaccid paralysis should be corrected and spasticity should be combatted as early and as vigorously as possible.

[Neurorehabilitation of the hemiplegic. Short-term clinical study]

The hemiplegic patients, hospitalized for focal vascular encephalopathy, have been examined and subjected to a neurorehabilitation, in order that we could estimate the possible correlations between their response to the therapy, the presence of the deficits of superior cortical functions and the anatomic lesions which gave rise to the motor deficit. The presence of aphasia, apraxia and disorder of body image give an unfavorable influence on the response to the rehabilitative therapy, similarly as what we have observed in the patients who presented symptoms of a spread neuropsychologic compromission, correlable at CT scan with a positive result of ischemic-atrophia. The younger patients, probably better adduced reasons for the treatment and with less incidence of plurifocal lesions, show a better clinical progress.

[Synovitic and enthesitic changes in the hand during reflex dystrophy]

Synovial reactions do not only affect articular but also tenosynovial compartments as proven by low kV radiography in 3 views. Erosions develop in both compartments and also enthesitically at the insertions of fibrous structures. There are also localized osseous changes, which resemble localized areas of hyperparathyroidism. In cases with unilateral trauma of a lesser degree scintigraphic examination of the soft tissues and bones of the contralateral side may confirm the results. The response of the soft tissues and bones is more severe distally.

Hypoglycemia masquerading as cerebrovascular disease (hypoglycemic hemiplegia)

Hypoglycemia produced hemiplegia with right-sided predilection in 16 patients initially suspected of having suffered a stroke. Fifteen patients had no demonstrable brain disease, and the hemiplegia cleared rapidly once the hypoglycemia was corrected. Invasive investigations such as carotid arteriography are not required in most patients. The features of hypoglycemia hemiplegia suggest that a selective neuronal vulnerability and not underlying focal brain disease is responsible in most cases.

Interhemispheric commissurotomy for congenital hemiplegics with intractable epilepsy

Five patients with congenital hemiplegia and intractable epilepsy had interhemispheric commissurotomy (the split-brain operation). After intervals of 2 to 12 years, the response has been excellent in four cases. One patient had moderate benefit. There were no late complications. Commissurotomy seems to be substantially better than hemispherectomy for this syndrome.