Rehabilitation methods for reducing shoulder subluxation in post-stroke hemiparesis: a systematic review

Cadaveric Feasibility Study on Modified Contralateral C7 Nerve Transfer for Targeted Recovery in Hemiplegic Arms

BACKGROUND

Contralateral cervical seventh (cC7) nerve to C7 transfer has been proven effective for treating spastic upper limb. However, for those whose major impairment is not in the C7 area, cC7 nerve transfer to other nerves may achieve a better outcome. The aim of this study was to explore the optimal surgical approach for transferring cC7 to 1 or 2 nerves in a cadaveric study, and to evaluate possible applications for patients with hemiplegia.

METHODS

Modified cC7 transfer to 1 (5 procedures) or 2 nonadjacent (3 procedures) nerve roots was proposed, and success rates of direct coaptation through 2 surgical approaches-the superficial surface of longus colli (sLC) and the deep surface of longus colli (dLC) approach-were compared. The length, diameter, and distance of relevant nerves were also measured in 25 cadavers.

RESULTS

Compared with the sLC approach, the distance of the dLC approach was 1.1 ± 0.3 cm shorter. The success rates for the sLC and dLC approaches were as follows: cC7 to C5 surgery, 94%, and reached 98%; cC7 to C6 surgery, 54% and 96%; cC7 to C7 surgery, 42% and 94%; cC7 to C8 surgery, 34% and 94%; cC7 to T1 surgery, 24% and 62%; cC7 to C5C7 surgery, 74% and 98%; cC7 to C6C8 surgery, 54% and 98%; and cC7 to C7T1 surgery, 42% and 88%.

CONCLUSIONS

The dLC approach greatly improved the direct coaptation rate for cC7 nerve transfer. The modified cC7 nerve transfer procedures are technically feasible for further application in clinic.

The relationship between the ratio of the supraspinatus muscle thickness measured by ultrasound imaging and glenohumeral subluxation in stroke patients: a cross-sectional study

Introduction

Glenohumeral subluxation (GHS) is a common complication in stroke patients with hemiplegia, occurring in approximately 17-81% of cases. This study aims to evaluate the relationship between shoulder muscle thickness and the degree of subluxation using ultrasound imaging.

Methods

A cross-sectional study of 61 stroke patients with hemiplegia was conducted, measuring supraspinatus muscle thickness, deltoid muscle thickness, and acromion-greater tuberosity (AGT). Logistic regression and ROC analyses were used. ROC curves, calibration plots, and decision curves were drawn on the training and validation sets.

Results

According to logistic regression analysis, the ratio of supraspinatus muscle thickness was statistically significant (OR: 0.80; 95% CI: 0.70-0.92; p < 0.01), and it was an independent factor for evaluating the presence or absence of GHS. An AUC of 0.906 (95% CI, 0.802-1.000) was found in the training set; meanwhile, the AUC in the validation set was 0.857 (95% CI, 0.669-1.000), indicating good performance. According to the training set ROC curve, the most effective statistical threshold was 93%, with a sensitivity of 84% and a specificity of 96%.

Discussion

The ratio of supraspinatus muscle thickness is a valuable criterion for evaluating GHS risk, supporting targeted rehabilitation interventions.

Effects of Sling-Suspension-Based Active Shoulder Joint Exercise on Shoulder Joint Subluxation, Pain, Muscle Strength, and Upper Limb Function in Patients with Subacute Stroke

Background and Objectives: We investigated the effects of sling-suspension-based active shoulder joint exercise training on shoulder joint subluxation, pain, muscle strength, and upper extremity function in patients with subacute stroke. Materials and Methods: Twenty-eight patients with subacute stroke were randomly assigned to either the sling-suspension-based active shoulder joint exercise (SASE) group (n = 14) or the motorized upper extremity exercise (MUEE) group (n = 14). The SASE group actively performed shoulder joint flexion, extension, abduction, adduction, external and internal rotation, and horizontal abduction and adduction using a sling suspension system, whereas the MUEE group underwent an exercise program using a motorized upper extremity exercise machine. All participants underwent a 4-week intervention with 30 min of exercise once a day for 5 days a week. Additionally, both groups received general physical therapy and functional electrical stimulation for 30 min twice a day for 5 days a week. Shoulder joint subluxation was measured by radiographic examination before and after training, and pain was evaluated in the splenius, upper trapezius, and infraspinatus muscles using pressure parameters. In addition, a manual muscle tester was used to assess the muscle strength of the shoulder joint flexors, extensors, abductors, adductors, and external and internal rotators, and the Fugl-Mayer Assessment (FMA) and Manual Functional Test (MFT) were used to evaluate upper extremity function. Results: A significant group-time interaction was observed for pain, with F-values of F(1, 26) = 7.470, p < 0.011 for the splenius and F(1, 26) = 9.623, p < 0.005 for the upper trapezius. A significant time-group interaction was observed for the muscle strength of the shoulder, with F-values of F(1, 26) = 13.211, p < 0.001; F(1, 26) = 4.974, p = 0.035 and F(1, 26) = 9.674, p = 0.004 for flexors, abductors, and external rotators, respectively. A significant time-group interaction was observed in the FMA, with F-values of F(1, 26) = 13.243, p < 0.001. When comparing the interaction effects between time and group for MFT scores, a significant difference was observed, with F-values of F(1, 26) = 32.386, p < 0.001. Conclusions: This study confirmed that sling-suspension-based active shoulder joint exercises are effective in improving shoulder joint subluxation, pain, muscle strength, and upper extremity function in patients with subacute stroke.

Arthroscopic shoulder suspensioplasty in painful hemiplegic shoulder subluxation-a case series

Background

Inferior glenohumeral subluxation (GHS) can cause disabling pain in hemiplegics. Conservative treatments have not been proven to be effective or maintained over time. A few studies have shown the benefits of surgical treatment. The objective of our study was to evaluate the medium-term clinical and radiological results of arthroscopic glenohumeral suspensioplasty surgery by biceps tenodesis in the setting of painful GHS in hemiplegics.

Methods

We conducted a retrospective study of patients who underwent arthroscopic glenohumeral suspensioplasty. The assessment, at a minimum of 1 year, included a clinical evaluation (pectoralis major spasticity, pain, range of motion, satisfaction) and a radiographic evaluation (Dursun classification, height of subacromial space).

Results

Five patients with a mean age of 51 years (36-72 years) were included at a mean follow-up of 40 months (12-70). Satisfaction was good in 80% of patients. Pain decreased in all patients, but not significantly. Four patients (80%) would repeat the procedure if it were necessary. In all patients, a reduction in GHS over time was observed, with a reduction in subacromial height, except in 1 patient who suffered a tenodesis rupture during a fall.

Conclusion

Our results suggest that arthroscopic glenohumeral suspensioplasty by biceps tenodesis may be a therapeutic option in hemiplegic patients with painful GHS.

Rehabilitation effect of intelligent rehabilitation training system on hemiplegic limb spasms after stroke

This article aimed to explore the rehabilitation efficacy of intelligent rehabilitation training systems in hemiplegic limb spasms after stroke and provided more theoretical basis for the application of intelligent rehabilitation systems in the rehabilitation of hemiplegic limb spasms after stroke. To explore the rehabilitation efficacy of intelligent rehabilitation training system (RTS for short here) in post-stroke hemiplegic limb spasms, this study selected 99 patients with post-stroke hemiplegic limb spasms admitted to a local tertiary hospital from March 2021 to March 2023 as the research subjects. This article used blind selection to randomly divide them into three groups: control group 1, control group 2, and study group, with 33 patients in each group. Control group 1 used a conventional RTS, group 2 used the brain-computer interface RTS from reference 9, and research group used the intelligent RTS from this article. This article compared the degree of spasticity, balance ability score, motor function score, and daily living activity score of three groups of patients after 10 weeks of treatment. After 10 weeks of treatment, the number of patients in the study group with no spasms at level 0 (24) was significantly higher than the number of patients in group 1 (7) and group 2 (10), with a statistically significant difference (P < 0.05); In the comparison of Barthel index scores, after ten weeks of treatment, the total number of people in the study group with scores starting at 71-80 and 81-100 was 23. The total number of people in the score range of 71-80 and 81-100 in group 1 was 5, while in group 2, the total number of people in this score range was 8. The study group scored considerably higher than the control group and the difference was found to be statistically relevant (P < 0.05). In the Berg balance assessment scale and motor function assessment scale, after 10 weeks of treatment, the scores of the study group patients on both scales were significantly higher than those of group 1 and group 2 (P < 0.05). The intelligent RTS is beneficial for promoting the improvement of spasticity in stroke patients with hemiplegic limb spasms, as well as improving their balance ability, motor ability, and daily life activities. Its rehabilitation effect is good.

Arthroscopic Shoulder Biceps Suspensionplasty for Hemiplegic Shoulder Painful Inferior Subluxation

Inferior glenohumeral subluxation represents one of the causes of disabling pain in patients with hemiplegia after a stroke. In the case of failure of medical treatment by orthosis or electrical stimulation, surgical treatment of suspensionplasty has been described with good results. We describe here an arthroscopic technique of glenohumeral suspensionplasty by tenodesis of the biceps, proposed in the context of a painful glenohumeral subluxation in patients with hemiplegia.

Efficacy of kinesio taping on upper limb volume reduction in patients with breast cancer-related lymphedema: a systematic review of randomized controlled trials

INTRODUCTION

One of the most common disabling complications in breast cancer (BC) patients is breast cancer-related lymphedema (BCRL), a pathological condition affecting both physical and psychological function, with detrimental consequences on health-related quality of life (HR-QoL). Rehabilitation has a key role in the comprehensive management of this condition with several studies reporting positive results after performing complex decongestive therapies (CDT) in these women. Kinesio taping (KT) is a rather recent therapeutic approach to treat BCRL, however, evidence in literature regarding its effectiveness is far from being fully characterized. Therefore, this systematic review aimed at assessing the role of KT among the CDT to treat BCRL.

EVIDENCE ACQUISITION

PubMed, Scopus, and Web of Science were systematically searched from inception until May 5th, 2022 to determine randomized control trials (RCTs) reporting patients with BCRL; KT as intervention; limb volume as outcome (PROSPERO number: CRD42022349720).

EVIDENCE SYNTHESIS

Out of the documents identified, 123 were eligible for data screening, and only 7 RCTs satisfied the eligibility criteria and were included. We found that KT might have a positive effect on limb volume reduction in patients with BCRL, albeit there is little evidence for low quality of the included studies.

CONCLUSIONS

Taken together, this systematic review showed that KT did not significantly reduce the upper limb volume in BCRL women, albeit it seemed to increase the flow rate during the passive exercise. Further high-quality-studies are mandatory to improve the knowledge in order to include the KT might into a multidisciplinary rehabilitative approach for the management of BC survivors affected by lymphedema.

Parameter mapping of hemiplegic shoulder electrical stimulation for motor function: A scoping review

BACKGROUND

Electrical stimulation (ES) of the shoulder is effective in treating subluxation and shoulder pain. However, few studies have reported on ES of the hemiplegic shoulder with motor function as an outcome; thus, the method remains unclear.

OBJECTIVE

We aimed to map the existing evidence and identify the parameters for ES of the hemiplegic shoulder for motor function in stroke patients.

METHODS

A literature search was performed through PubMed and Scopus to retrieve original articles from 1975 to March 2023 using the terms "stroke", "shoulder", and "electricity". We selected studies in which ES was performed on hemiplegic shoulders after stroke, parameters were described, and upper extremity motor functional assessment was included as an outcome. The extracted data included study design, phase, sample size, electrode position, parameters, intervention period, evaluation frequency, outcomes, and results.

RESULTS

Of the 449 titles identified, 25 fulfilled the inclusion and exclusion criteria. Nineteen were randomized controlled trials. The most common electrode positions and parameters (frequency and pulse width) were over the posterior deltoid and the supraspinatus (upper trapezius) muscles, 30 Hz, and 250μs, respectively. The intervention period was 30-60 minutes per day, 5-7 days per week, for 4-5 weeks in over half of the studies.

CONCLUSION

Stimulation positions and parameters for electrical stimulation of the hemiplegic shoulder are inconsistent. Whether ES represents a significant treatment option remains unclear. Establishing universal ES methods is necessary to improve the motor function of hemiplegic shoulders.

Advances in the clinical application of orthotic devices for stroke and spinal cord injury since 2013

Stroke and spinal cord injury are common neurological disorders that can cause various dysfunctions. Motor dysfunction is a common dysfunction that easily leads to complications such as joint stiffness and muscle contracture and markedly impairs the daily living activities and long-term prognosis of patients. Orthotic devices can prevent or compensate for motor dysfunctions. Using orthotic devices early can help prevent and correct deformities and treat muscle and joint problems. An orthotic device is also an effective rehabilitation tool for improving motor function and compensatory abilities. In this study, we reviewed the epidemiological characteristics of stroke and spinal cord injury, provided the therapeutic effect and recent advances in the application of conventional and new types of orthotic devices used in stroke and spinal cord injury in different joints of the upper and lower limbs, identified the shortcomings with these orthotics, and suggested directions for future research.

Effectiveness of robot-assisted arm therapy in stroke rehabilitation: An overview of systematic reviews

BACKGROUND

Robot-assisted arm therapy (RAT) has been used mainly in stroke rehabilitation in the last 20 years with rising expectations and growing evidence summarized in systematic reviews (SRs).

OBJECTIVE

The aim of this study is to provide an overview of SRs about the effectiveness, within the ICF domains, and safety of RAT in the rehabilitation of adult with stroke compared to other treatments.

METHODS

The search strategy was conducted using search strings adapted explicitly for each database. A screening base on title and abstract was realized to find all the potentially relevant studies. The methodological quality of the included SRs was assessed using AMSTAR-2. A pre-determined standardized form was used to realize the data extraction.

RESULTS

18 SRs were included in this overview. Generally, positive effects from the RAT were found for motor function and muscle strength, whereas there is no agreement for muscle tone effects. No effect was found for pain, and only a SR reported the positive impact of RAT in daily living activity.

CONCLUSION

RAT can be considered a valuable option to increase motor function and muscle strength after stroke. However, the poor quality of most of the included SRs could limit the certainty around the results.

Peripheral Nerve Stimulation in Painful Conditions of the Upper Extremity-An Overview

Our objective is to present a brief history of the evolution of peripheral nerve stimulation, the current understanding of peripheral nerve stimulation mechanisms in chronic pain, peripheral nerve stimulation applications in upper extremity chronic pain conditions, and complications of peripheral nerve stimulation. The evolution of peripheral nerve stimulation from the early ages to the current status has been facilitated by discoveries in neurobehavioral mechanisms of pain, advances in technology and percutaneous lead development, and the availability of high-quality portable ultrasound units. Peripheral nerve stimulation application in managing upper extremity pain of amputated limbs, post-stroke shoulder pain, complex regional pain syndrome (CRPS), and median, ulnar, and radial neuropathies are discussed. Finally, we describe complications of peripheral nerve stimulation. The availability of ultrasound-guided peripheral nerve stimulation techniques and superior peripheral nerve stimulation technology have opened up new and minimally invasive treatment options for chronic intractable neuropathic pain of the upper extremity. Additionally, the ability to place peripheral nerve stimulation leads percutaneously without open peripheral nerve surgery expands the pool of implanting physicians, while simultaneously decreasing the risks and complications that are associated with open surgery.

A Preliminary Study to Design and Evaluate Pneumatically Controlled Soft Robotic Actuators for a Repetitive Hand Rehabilitation Task

A stroke is an infarction in the cortical region of the brain that often leads to isolated hand paresis. This common side effect renders individuals compromised in their ability to actively flex or extend the fingers of the affected hand. While there are currently published soft robotic glove designs, this article proposed a unique design that allows users to self-actuate their therapy due to the ability to re-extend the hand using a layer of resistive flexible steel. The results showed a consistently achieved average peak of 75° or greater for each finger while the subjects’ hands were at rest during multiple trials of pneumatic assisted flexion. During passive assisted testing, human subject testing on 10 participants showed that these participants were able to accomplish 80.75% of their normal active finger flexion range with the steel-layer-lined pneumatic glove and 87.07% with the unlined pneumatic glove on average when neglecting outliers. An addition of the steel layer lowered the blocked tip force by an average of 18.13% for all five fingers. These data show strong evidence that this glove would be appropriate to advance to human subject testing on those who do have post stroke hand impairments.

A Combination of Long-Duration Electrical Stimulation with External Shoulder Support during Routine Daily Activities in Patients with Post-Hemiplegic Shoulder Subluxation: A Randomized Controlled Study

The study objective was to determine the effect of long-duration neuromuscular electric stimulation (NMES) on shoulder subluxation and upper-extremity function during the acute post-stroke stage. Twenty-eight subjects (mean age ± standard deviation -70.0 ± 14.0 years) were randomly assigned to an experimental or to a control group receiving NMES to the supraspinatus and posterior deltoid muscles or sham treatment for 6 weeks. All the subjects continued standard rehabilitation and external shoulder support (EST). Assessments were conducted pre- and post-intervention and at a 2 week follow-up session by an assessor blind to group allocation. Outcome measures included the degree of shoulder subluxation, Fugl-Meyer assessment-upper extremity (FMA-UE) test, FMA-hand and finger subscales, Functional Independence Measure (FIM), and shoulder pain (using the Numeric Pain Rate Scale). Shoulder subluxation was significantly lower, while the FMA-UE and FMA-hand and finger subscales were significantly improved in the experimental group post-intervention and at follow-up compared to the control group. FIM at follow-up improved more in the experimental group. No change was observed in pain level in both groups. Supplementing NMES to standard rehabilitation and EST is beneficial in reducing shoulder subluxation and improving upper-extremity function. Further research is necessary to determine effect of longer treatment duration and longer follow-up periods.

Effect of Electroacupuncture on Shoulder Subluxation in Poststroke Patients with Hemiplegic Shoulder Pain: A Sham-Controlled Study Using Multidimensional Musculoskeletal Ultrasound Assessment

OBJECTIVE

This study aimed to use multidimensional musculoskeletal ultrasound imaging technique to investigate the effect of electroacupuncture (EA) on shoulder subluxation in poststroke patients with hemiplegic shoulder pain.

METHODS

In this prospective single-blind, randomized, sham-controlled study, thirty-four patients with shoulder subluxation and hemiplegic shoulder pain were recruited and randomly assigned into the EA group or the sham EA (SEA) group. In the EA group, EA was applied to the Jian yu (LI15), Bi nao (LI14), Jian zhen (SI9), and Jian liao (TE14) acupoints. In the SEA group, the EA was applied 15 mm away from the Lou gu (SP7), Di ji (SP8), Jiao xin (KI8), and Zhu bin (KI9) acupoints. Both groups underwent treatment 30 minutes/day, five days a week, for two weeks using dense waves with a frequency of 2/100 Hz. A Visual Analogue Scale (VAS) was used to evaluate the effectiveness of treatment in reducing shoulder pain. Musculoskeletal ultrasound was used to evaluate the changes of measures of shoulder subluxation in multidimensions (i.e., the acromiohumeral distance, AHD; acromion-greater tuberosity, AGT; and acromion-lesser tuberosity, ALT). Both the within- and between-groups treatment effects were assessed.

RESULTS

The pain intensity measured by VAS and shoulder subluxation measured by musculoskeletal ultrasound (i.e., AHD, AGT, and ALT) showed significant (p < 0.05) within-group difference in both groups. The between-group difference appeared in the pain intensity (p < 0.05), while it disappeared in the three measures of shoulder subluxation (p > 0.05).

CONCLUSIONS

Using VAS for measuring pain intensity and multidimensional musculoskeletal ultrasound imaging technique for measuring shoulder subluxation, this study finds that the hemiplegic shoulder pain can be improved significantly by the EA while the shoulder subluxation cannot be. Our findings further reveal the analgesic mechanism of EA on hemiplegic shoulder pain following stroke.

A newly designed shoulder orthosis for patients with glenohumeral subluxation: a clinical evaluation study

BACKGROUND

Shoulder complaints from glenohumeral subluxation are a common problem and limit patients during daily activities.

OBJECTIVE

To assess the clinical pros and cons and usability of a newly developed shoulder orthosis (Roessingh Omo Support [ROS]) in patients with chronic shoulder complaints.

STUDY DESIGN

Retrospective cross-sectional study.

METHODS

All patients older than 18 years who received the ROS were invited. Medical information was collected from medical records. Two questionnaires were sent to the patient: The "Shoulder Rating Questionnaire" (SRQ, max 100 points) for evaluation before and during use and a custom orthosis usability questionnaire.

RESULTS

In total, 28 patients (34 orthoses) participated in the study. Neuralgic amyotrophy was the most common diagnosis (64.3%). The SRQ showed a significant positive change of 8.9 points (from 35.0 [SD 12.6] to 43.9 [SD 14.3]). The most described goal was pain reduction (76.5%). 47.1% of the patients achieved their goal(s), and 71.4% were still using the orthosis. The mean satisfaction rate was 7.1 (SD 1.4).

CONCLUSION

The use of the ROS shows a significant functional improvement (SRQ), a decrease of pain, and a high degree of satisfaction, although the individual experiences of the patients are highly variable. Some modifications to the design to improve comfort may be needed.

Impact of shoulder subluxation on peripheral nerve conduction and function of hemiplegic upper extremity in stroke patients: A retrospective, matched-pair study

Purpose: To investigate the impact of shoulder subluxation (SS) on peripheral nerve conduction and function of the hemiplegic upper extremity (HUE) in poststroke patients.Methods: Thirty post-stroke patients were selected (SS group: 15 patients, non-SS group: 15 patients, respectively). Evaluation of nerve conduction in upper limbs: the compound muscle action potential (CMAP) amplitude and latency of suprascapular, axillary, musculocutaneous, radial, median, and ulnar nerves; the motor and sensory conduction velocity and the sensory nerve action potential (SNAP) amplitude of median, ulnar, and radial nerves. The Brunnstrom stage scale was used to evaluate the HUE motor function.Results: Compared with the healthy side, the CMAP and SNAP amplitudes of tested nerves on the HUE in both groups were lower, and the CMAP latency of the suprascapular, axillary and musculocutaneous nerves on the HUE in the SS group was longer (P < 0.05). Compared with the HUE in non-SS group, the CMAP amplitude of tested nerves (except ulnar) was decreased more (P < 0.05), the motor conduction velocity of the median nerve was lower (P < 0.05), and the Brunnstrom stage of the HUE was lower in SS group (P < 0.05).Conclusions: Stroke may lead to extensive abnormal nerve conduction on the HUE, and SS may aggravate the abnormality, which may disturb the recovery of upper limb function.

Effectiveness of interventions to improve hand motor function in individuals with moderate to severe stroke: a systematic review protocol

INTRODUCTION

The human hand is extremely involved in our daily lives. However, the rehabilitation of hand function after stroke can be rather difficult due to the complexity of hand structure and function, as well as neural basis that supports hand function. Specifically, in individuals with moderate to severe impairment following a stroke, previous evidence for effective treatments that recover hand function in this population is limited, and thus has never been reviewed. With the progress of rehabilitation science and tool development, results from more and more clinical trials are now available, thereby justifying conducting a systematic review.

METHODS AND ANALYSIS

This systematic review protocol is consistent with the methodology recommended by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols and the Cochrane handbook for systematic reviews of interventions. Electronic searches will be carried out in the PubMed, CINAHL, Physiotherapy Evidence Database and Cochrane Library databases, along with manual searches in the reference lists from included studies and published systematic reviews. The date range parameters used in searching all databases is between January 1999 and January 2019. Randomised controlled trials (RCTs) published in English, with the primary outcome focusing on hand motor function, will be included. Two reviewers will screen all retrieved titles, abstracts and full texts, perform the evaluation of the risk bias and extract all data independently. The risk of bias of the included RCTs will be evaluated by the Cochrane Collaboration's tool. A qualitative synthesis will be provided in text and table, to summarise the main results of the selected publications. A meta-analysis will be considered if there is sufficient homogeneity across outcomes. The quality of the included publications will be evaluated by the Grading of Recommendations Assessment, Development and Evaluation system from the Cochrane Handbook for Systematic Reviews of Interventions.

ETHICS AND DISSEMINATION

No ethical approval is needed, and the results of this review will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

CRD42019128285.