Bobath axillary support for adults with hemiplegia. A biomechanical analysis

Strapping the hemiplegic shoulder prevents development of pain during rehabilitation: a randomized controlled trial

Objective: To determine whether strapping (therapeutic or placebo) the ‘at risk’ shoulder prevented or delayed development of hemiplegic shoulder pain better than standard care.

Design: Randomized controlled trial.

Setting: Three inpatient rehabilitation hospitals, Melbourne, Australia.

Patients: Thirty-three patients ‘at risk’ of developing hemiplegic shoulder pain were randomized, one withdrew. Patients at risk were considered to be those with low or no muscle function around the shoulder (Motor Assessment Scale, upper arm score B<3).

Interventions: Standard care for control group. Therapeutic strapping or placebo strapping with lightweight adhesive tape. All strapping was maintained over four weeks.

Main outcome measures: The primary outcome was number of pain-free days measured on Ritchie Articular Index. Secondary outcome measures included range of movement, function (Motor Assessment Scale, upper arm component) and affected arm muscle tone (Modified Ashworth Scale).

Results: Only one patient in the therapeutic strapping group developed pain. One-way ANOVA revealed that mean number of pain-free days over the 28-day period was significantly different (P=0.02), with the difference between the therapeutic strapping and the control group. Patients in the therapeutic strapping group had a mean of 26.2 pain-free days, while those in the placebo group and control group had a mean of 19.1 and 15.9 pain-free days respectively. Range of movement and function improved between admission and discharge but were not significantly different between groups.

Conclusions: Therapeutic strapping limited development of hemiplegic shoulder pain during rehabilitation in at risk stroke patients. Placebo strapping has an effect, with a larger study (n=30 per group) needed to detect whether there are differences between therapeutic and placebo strapping.

Therapeutic Orthosis and Electrical Stimulation for Upper Extremity Hemiplegia After Stroke: A Review of Effectiveness Based on Evidence

Upper extremity hemiplegia after stroke is common and disabling. Apart from conventional physical and occupational therapy, a number of additional approaches that use devices such as orthoses, prostheses, electrical stimulation, and robots have been introduced. The purpose of this review was to assess the clinical efficacy of such devices used for the affected upper extremities of acute, subacute, and chronic stroke patients. Assessments of their effectiveness and recommendations were based on the weight of published scientific evidence. The amount of evidence with respect to hand splints and shoulder slings is limited. Further study with a well-designed randomized controlled trial (RCT) is required to investigate accurately their short- and long-term efficacy. A number of studies suggested that the use of electrical stimulation for reducing shoulder subluxation or improving the function of wrist and finger extensors is effective during or shortly after the daily treatment period. The robotic approach to hemiplegic upper extremities appears to be a novel therapeutic strategy that may help improve hand and arm function. However, the longer term effectiveness after discontinuation as well as the motor recovery mechanism of electrical stimulation or robotic devices remains unclear. More research is needed to determine the evidence-based effectiveness of electrical stimulation or other devices for stroke survivors.

Shoulder pain after stroke: a review of the evidence base to inform the development of an integrated care pathway

BACKGROUND

Shoulder pain is a common complication of stroke. It can impede rehabilitation and has been associated with poorer outcomes and prolonged hospital stay. This systematic review was undertaken to inform the development of an evidence-based integrated care pathway (ICP) for the management of hemiplegic shoulder pain (HSP).

AIMS AND OBJECTIVES

1) To provide a background understanding of the functional anatomy of the shoulder and its changes following stroke. 2) To review the literature describing incidence and causation of HSP and the evidence for factors contributing to its development. 3) To appraise the evidence for effectiveness of different interventions for HSP.

METHODS

Data sources comprised a computer-aided search of published studies on shoulder pain in stroke or hemiplegia and references to literature used in reviews (total references = 121).

MAIN FINDINGS

Although a complex variety of physical changes are associated with HSP, these broadly divide into 'flaccid' and 'spastic' presentations. Management should vary accordingly; each presentation requiring different approaches to handling, support and intervention. (1) In the flaccid stage, the shoulder is prone to inferior subluxation and vulnerable to soft-tissue damage. The arm should be supported at all times and functional electrical stimulation may reduce subluxation and enhance return of muscle activity. (2) In the spastic stage, movement is often severely limited. Relieving spasticity and maintaining range requires expert handling; overhead exercise pulleys should never be used. Local steroid injections should be avoided unless there is clear evidence of an inflammatory lesion.

CONCLUSIONS

HSP requires co-ordinated multidisciplinary management to minimize interference with rehabilitation and optimize outcome. Further research is needed to determine effective prophylaxis and document the therapeutic effect of different modalities in the various presentations. Development of an integrated care pathway provides a reasoned approach to management of this complex condition, thus providing a sound basis for prospective evaluation of different interventions in the future.

Unpacking the black box of nursing and therapy practice for post-stroke shoulder pain: a precursor to evaluation

OBJECTIVES

To describe current nursing and therapy interventions for the prevention and treatment of post-stroke shoulder pain and to explore the extent of their reported use in England.

DESIGN

Semi-structured, the med interviews followed by a postal questionnaire.

PARTICIPANTS

Six nurses, five occupational therapists (OTs) and six physiotherapists (PTs) were interviewed. Twelve nurses, 12 OTs and 12 PTs were sent the pilot questionnaire and the main questionnaire was posted to 332 nurses, 332 OTs and 332 PTs.

SETTING

NHS Trusts in England which provide acute stroke care/rehabilitation.

PROCEDURE

Two researchers independently condensed the transcripts of the interviews into a list of interventions which were then transformed into a pilot postal questionnaire. Following the pilot small changes were made. Participants sent the main questionnaire were given three weeks to return it before being posted a reminder. After a further two weeks a researcher gave a telephone reminder.

RESULTS

One hundred and seventy-five different types of interventions were identified. The main questionnaire (57.8% response rate) found that all of the interventions were used by at least one respondent and that only 22.9% of the interventions were used to the same extent by nurses, OTs and PTs. The data also suggest variation in reported use within professions.

CONCLUSIONS

This study has found a large number of interventions for post-stroke shoulder pain which are reported to be used. This might reflect different causes of shoulder pain or variation between clinicians. Answers to these questions are expected to guide future evaluative research.

Short-term effects of dynamic lycra splints on upper limb in hemiplegic patients

OBJECTIVE

To assess acceptability, effects on swelling, resting posture, spasticity, and active (AROM) and passive range of motion (PROM) of individually tailored upper limb Lycra garments, designed as dynamic splints to exert directional pull on certain limb segments, when worn for 3 hours by hemiplegic patients.

DESIGN

Crossover trial.

SETTING

Outpatient and inpatient rehabilitation center.

PATIENTS

Convenience sample of 16 patients with hemiparesis and upper limb spasticity caused by a stroke more than 3 weeks before the study.

INTERVENTIONS

Assessments performed at the start and end of a 3-hour period during a standard rehabilitation day when the patients were and were not wearing the garment.

MAIN OUTCOME MEASURES

(1) Comfort assessed by questionnaire; (2) circumference of each limb segment; (3) resting posture at elbow and wrist; (4) spasticity at shoulder, elbow, and wrist using the Tardieu scale; and (5) AROM and PROM at shoulder, elbow, and wrist measured using a goniometer; (6) elbow proprioception using McCloskey's method; (7) visual neglect syndrome using the line bisection test. Differences between changes occurring with and without the garment were compared using Wilcoxon's signed rank test for ordinal variables (spasticity grading) and Student's t test for continuous variables (all other data).

RESULTS

During 3 hours, garments worn on the arm by patients with hemiplegia (1) were comfortable, (2) improved wrist posture and reduced wrist and finger flexor spasticity, (3) reduced swelling in patients with swollen limbs (digit circumference decreased by 4%; p<.01), (4) improved PROM at shoulder (mean increase in range, 4.1 degrees +/- 13.0 degrees per shoulder movement; p<.01); and (5) impaired ability to flex fingers (range of voluntary flexion of digit III reduced from 107.3 degrees +/-79.6 degrees to 91.4 degrees +/-74.1 degrees; p<.05).

CONCLUSION

Lycra garments, designed to produce continuous stretch of spastic muscles when worn for several hours each day, have rapid splinting and antispastic effects on wrist and fingers in patients with hemiplegia. These garments may help severely affected patients with major spasticity or painful swollen limbs.

Shoulder supports revisited: a Canadian follow-up survey

This paper investigates the use of shoulder supports with stroke patients in Canada and compares the results of two survey questionnaires carried out in 1984 and 1994. It describes which shoulder supports therapists are using with stroke patients and which goals they hope to achieve with specific supports. The Lapboard, Cuff Type Sling, and Arm Trough Support were the most frequently used supports at both time periods. The most frequent goal chosen for each of these three most frequently chosen supports was the same at both time periods but were chosen significantly less frequently in 1994. There was a significant decrease in the use of the Bobath Axial Roll over the ten-year period. This follow up questionnaire documents the limited changes which have occurred in the last ten years in the management of the shoulder following stroke, raises some questions about this area of practice, and outlines some solutions including the need to base occupational therapy practice on more evidence.

Biomechanical analysis of four supports for the subluxed hemiparetic shoulder

External support systems, such as slings and lapboards, may reduce shoulder subluxation in individuals with hemiplegia. However there is controversy among occupational therapists concerning the most appropriate method to support the affected arm. The purpose of the present paper is to report the biomechanical analysis of four support systems; two shoulder support systems, a Bobath axillary roll, and a laptray. Two dimensional static biomechanical analyses determine the mechanical characteristics of each of these four support systems. The results of the analyses demonstrate the magnitude of the shoulder loading and the effectiveness of the various components of each of the systems. The effect of changing some of the characteristics of the slings is demonstrated. Slings with straps over the unaffected shoulder provide continuous support for the flaccid extremity. The Bobath axillary roll may introduce an unwanted lateral force. Lapboards must be maintained at an appropriate distance from the subluxed shoulder to be effective. This theoretical analysis of supports systems will provide therapists information to help them understand effective supports for subluxation.