Evaluating the clinical effects of a dynamic shoulder orthosis

BACKGROUND

Shoulder orthoses reduce the gravitational pull on the shoulder by providing an upward force to the arm, which can decrease shoulder pain caused by stress on the glenohumeral structures.

OBJECTIVE

In this interventional study, the clinical effects of a recently developed dynamic shoulder orthosis were assessed in 10 patients with chronic shoulder pain. The shoulder orthosis provides an upward force to the arm with 2 elastic bands. These bands are arranged to statically balance the arm, such that the supportive force is always directed toward the glenohumeral joint and shoulder movements are not impeded.

STUDY DESIGN

Clinical effect study.

METHODS

The study population was provided with a dynamic shoulder orthosis for 2 weeks. In the week before the orthosis fitting, the participants had no intervention. The primary outcome measures were the mean shoulder pain scores before and during the intervention, and the distance between the humeral head and the acromion without and with orthosis.

RESULTS

Ultrasound evaluation showed that the shoulder orthosis resulted in a reduction of the distance between the acromion and humeral head at different levels of arm support. In addition, it was demonstrated that the mean shoulder pain scores (range 0-10) decreased from 3.6 to 3 (in rest) and from 5.3 to 4.2 (during activities) after 2 weeks of orthosis use. In general, patients were satisfied with the weight, safety, ease in adjusting, and effectiveness of the orthosis.

CONCLUSIONS

The results of this study show that the orthosis has the potential to reduce shoulder complaints in patients with chronic shoulder pain.

Assistive technology on upper extremity function for stroke patients: A systematic review with meta-analysis

BACKGROUND

In stroke rehabilitation, the selection of appropriate assistive devices is of paramount importance for patients. Specifically, the choice of device can significantly influence the functional recovery of the upper limb, impacting their overall activities or functional tasks.

OBJECTIVES

This review aimed to comprehensively analyze and summarize the clinical evidence from randomized controlled trials (RCTs) regarding the therapeutic effects of commonly used assistive devices on upper extremity function in patients with stroke.

METHODS

To evaluate assistive devices for patients with stroke, we summarized qualitatively throughout synthesis of results, such as therapeutic intervention, intensity, outcome, and summary of results, and examined risk of bias, heterogeneity, mean difference, 95% confidence interval, and I-squared value. To analyze, we used RoB 2 and RevMan 5.4.

RESULTS

The qualitative synthesis included 31 RCTs. The randomization process and the reporting of results showed minimal bias, but there were issues with bias from intended interventions, and missing outcome data presented some concerns. The quantitative synthesis included 16 RCTs. There was a significant difference in the Fugl-Meyer assessment-upper extremity functioning (FMA-UE) scores between the groups, with a total mean difference (95% confidence interval) of 2.40 (0.21, 4.60), heterogeneity values were Tau2 = 0.32, chi-square = 8.22, degrees of freedom = 8 (p = 0.41), and I2 = 3% for FMA-UE and the test for the overall effect produced Z = 2.14 (p = 0.03) in patients with chronic stroke. However, there was no significant difference in all other outcome measures.

CONCLUSIONS

Upper-limb robots did not demonstrate significant superiority over conventional treatments in improving function of upper limbs, with the exception of FMA-UE scores for patients with chronic stroke. The mean difference of FMA-UE was also lower than minimally important difference. Nonetheless, the usage of upper-limb robots may contribute to enhanced function for patients with stroke, as those devices support clinicians and enable a greater number of movement repetitions within specific time frames.

Effect of using an 8-figure shoulder brace on arm swing angle and gait parameters in chronic stroke patients: a pilot randomized controlled study

BACKGROUND

The 8-figure shoulder brace during treadmill training (8-FSBTT) intervention can stabilize the shoulder joint, improve the upright of the thoracic spine, induces a change in the angle of the arm during walking, and consequently improve walking ability in stroke patients.

OBJECTIVES

Our objective is to compare the effects of a 4-week program of 8-FSBTT with those of only treadmill training (OT) on arm swing angle, and gait parameters (gait speed, cadence, and both side stride lengths) in chronic stroke patients.

METHODS

Participants were randomized to either the 8-FSBTT (n = 11) or OT (n = 11) group. Patients in both groups underwent standard physiotherapy for 30 min per session. In addition, 8-FSBTT and OT interventions were performed 10 min, 5 times per week for 4 weeks. Arm swing angle, gait speed, cadence, and both side stride lengths were measured after 4 weeks of training.

RESULTS

After 4 weeks of training, the 8-FSBTT group showed significant improvement in all outcome measures compared with baseline (p < 0.05). Furthermore, Arm swing angle, gait speed, cadence, and both side stride lengths showed greater improvement in the 8-FSBTT group compared to the OT group (p < 0.05).

CONCLUSIONS

This study demonstrated that 8-FSBTT training, combined with standard physiotherapy, improved Arm swing angle, gait speed, cadence, and both side stride lengths in the chronic stroke patients.

A predictive model based on random forest for shoulder-hand syndrome

Objectives

The shoulder-hand syndrome (SHS) severely impedes the function recovery process of patients after stroke. It is incapable to identify the factors at high risk for its occurrence, and there is no effective treatment. This study intends to apply the random forest (RF) algorithm in ensemble learning to establish a predictive model for the occurrence of SHS after stroke, aiming to identify high-risk SHS in the first-stroke onset population and discuss possible therapeutic methods.

Methods

We retrospectively studied all the first-onset stroke patients with one-side hemiplegia, then 36 patients that met the criteria were included. The patients’ data concerning a wide spectrum of demographic, clinical, and laboratory data were analyzed. RF algorithms were built to predict the SHS occurrence, and the model’s reliability was measured with a confusion matrix and the area under the receiver operating curves (ROC).

Results

A binary classification model was trained based on 25 handpicked features. The area under the ROC curve of the prediction model was 0.8 and the out-of-bag accuracy rate was 72.73%. The confusion matrix indicated a sensitivity of 0.8 and a specificity of 0.5, respectively. And the feature importance scored the weights (top 3 from large to small) in the classification were D-dimer, C-reactive protein, and hemoglobin.

Conclusion

A reliable predictive model can be established based on post-stroke patients’ demographic, clinical, and laboratory data. Combining the results of RF and traditional statistical methods, our model found that D-dimer, CRP, and hemoglobin affected the occurrence of the SHS after stroke in a relatively small sample of data with tightly controlled inclusion criteria.

EMG biofeedback combined with rehabilitation training may be the best physical therapy for improving upper limb motor function and relieving pain in patients with the post-stroke shoulder-hand syndrome: A Bayesian network meta-analysis

Background

Post-stroke shoulder-hand syndrome (SHS), although not a life-threatening condition, may be the most distressing and disabling problem for stroke survivors. Thus, it is essential to identify effective treatment strategies. Physical therapy is used as a first-line option for treating SHS; however, it is unclear which treatment option is preferred, which creates confusion in guiding clinical practice. Our study aims to guide clinical treatment by identifying the most effective physical therapy interventions for improving clinical symptoms in patients with post-stroke SHS using Bayesian network meta-analysis.

Methods

We conducted a systematic and comprehensive search of data from randomized controlled trials using physical therapy in patients with SHS from database inception to 1 July 2022. Fugl-Meyer Upper Extremity Motor Function Scale (FMA-UE) and pain visual analog score (VAS) were used as primary and secondary outcome indicators. R (version 4.1.3) and STATA (version 16.0) software were used to analyze the data.

Results

A total of 45 RCTs with 3,379 subjects were included, and the intervention efficacy of 7 physical factor therapies (PFT) combined with rehabilitation training (RT) was explored. Compared with the control group, all the PFT + RT included were of statistical benefit in improving limb motor function and pain relief. Also, our study indicated that EMG biofeedback combined with RT (BFT + RT) [the surface under the cumulative ranking curve (SUCRA) = 96.8%] might be the best choice for patients with post-stroke SHS.

Conclusion

EMG biofeedback combined with rehabilitation training may be the best physical therapy for improving upper limb motor function and relieving pain in patients with post-stroke SHS according to our Bayesian network meta-analysis results. However, the above conclusions need further analysis and validation by more high-quality RCTs.

Systematic review registration

www.crd.york.ac.uk/prospero/, identifier: CRD42022348743.

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.

Interventions for Post-Stroke Shoulder Pain: An Overview of Systematic Reviews

Background

Shoulder pain following stroke leads to poorer quality of life and daily functioning. Whilst many treatment approaches exist, there is currently no systematic overview of the evidence base for these. This review addressed the question “What is the evidence for interventions for treating hemiplegic shoulder pain?”

Methods

An overview of systematic reviews was performed according to PROSPERO protocol (CRD42020140521). Five electronic databases including Cochrane, MEDLINE, Embase and EmCare were searched to June 2019. Included systematic reviews were those of comparative trials of interventions for hemiplegic shoulder pain in adults, reporting pain outcomes using a validated pain scale. Review quality was assessed with AMSTAR2 and those considered at high risk of bias for four or more items were excluded. The most recent, comprehensive review for each intervention category was included. Outcomes of function and quality of life were also extracted.

Results

Seven systematic reviews of 11 interventions were included, with varied quality. Reviews showed significant benefits in terms of pain reduction for many interventions including acupuncture (conventional 19 trials, electroacupuncture 5 trials, fire needle 2 trials, warm needle 1 trial and bee venom 3 trials), orthoses (1 trial), botulinum toxin injection (4 trials), electrical stimulation (6 trials) and aromatherapy (1 trial). However, the majority of trials were small, leading to imprecise estimates of effect. Findings were often inconsistent across outcome measures or follow-up times. Outcomes from trials of acupuncture were heterogenous with likely publication bias.

Conclusion

A number of systematic reviews indicate significant reductions in pain, with a wide range of treatments appearing promising. However, significant limitations mean the clinical importance of these findings are uncertain. Due to complex etiology, practitioners and health systems must consider the range of potential interventions and tailor their approach to individual presentation, guided by their local circumstances, expert opinion and the growing literature base.

A New Shoulder Orthosis to Dynamically Support Glenohumeral Subluxation

OBJECTIVE

In this paper we presented a novel shoulder subluxation support that aims to reduce the stress on the passive structures around the shoulder of patients with glenohumeral subluxation and glenohumeral-related shoulder pain. The device applies a force to the upper arm without impeding the functional range of motion of the arm. Our design contains a mechanism that statically balances the arm with two elastic bands.

METHODS

A technical evaluation study was conducted to assess the performance of the orthosis. Additionally, two patients evaluated the orthosis.

RESULTS

The results of the technical validation confirm the working of the balancing mechanism. The pilot study demonstrated that the shoulder support increased the feeling of stability of the shoulder joint and, to a lesser extent, decreased shoulder pain. Furthermore, both patients reported that the orthosis did not impede their range of motion.

CONCLUSION

In this research we developed a shoulder orthosis based on two statically balanced springs that support the shoulder of patients with glenohumeral subluxation that have residual shoulder muscle force. Compared to existing shoulder supports, our design does not impede the range of motion of the arm, and continues to provide a stabilizing force to the shoulder, even if the arm is moved away from the neutral position. Tests with two participants showed promising results.

SIGNIFICANCE

The device presented in this work could have a significant impact on the shoulder function which may improve rehabilitation outcome and improve the quality of life of patients suffering from glenohumeral subluxation and shoulder pain.

Predictors of the effect of an arm sling on gait efficiency in stroke patients with shoulder subluxation: a pre-post design clinical trial

BACKGROUND

The predictors affecting the gait efficiency were not known for the arm sling, including general and stroke-related characteristics.

PURPOSE

This study investigated the predictors of gait efficiency when walking with and without an arm sling in individuals with hemiplegia with shoulder subluxation.

METHODS

A total of 57 individuals with shoulder subluxation were recruited. Individuals assigned odd numbers walked with the arm sling first and those with even numbers walked without the arm sling first in a pre-post design. Outcome measures were the energy cost, energy consumption, and heart rate during a 6-min walk test and a 10-m walk test. Gait efficiency is defined as energy consumption divided by the distance walked, with lower energy costs reflecting higher gait efficiency. Age, MMSE scores adjusted for education, and significant variables (p < .01) in the univariate analyses were entered into multiple regression analyses, to identify the predictors of changes of gait efficiency.

RESULTS

Energy cost and energy consumption were lower and walking endurance was higher when walking with an arm sling than when without an arm sling. Spasticity (p = .02), shoulder pain (p = .03), consistency of handedness and sling position worn (p = .02), function of upper extremity (p = .03) and walking aids (p = .01) were predictors of gait efficiency.

CONCLUSION

An arm sling may improve gait efficiency in individuals with hemiplegia and shoulder subluxation able to walk with a single cane, who have consistency in handedness and sling position, and with good upper extremity function, including no shoulder pain and reduced spasticity.

A systematic review of randomised controlled trials assessing effectiveness of prosthetic and orthotic interventions

BACKGROUND

Assistive products are items which allow older people and people with disabilities to be able to live a healthy, productive and dignified life. It has been estimated that approximately 1.5% of the world's population need a prosthesis or orthosis.

OBJECTIVE

The objective of this study was to systematically identify and review the evidence from randomized controlled trials assessing effectiveness and cost-effectiveness of prosthetic and orthotic interventions.

METHODS

Literature searches, completed in September 2015, were carried out in fourteen databases between years 1995 and 2015. The search results were independently screened by two reviewers. For the purpose of this manuscript, only randomized controlled trials which examined interventions using orthotic or prosthetic devices were selected for data extraction and synthesis.

RESULTS

A total of 342 randomised controlled trials were identified (319 English language and 23 non-English language). Only 4 of these randomised controlled trials examined prosthetic interventions and the rest examined orthotic interventions. These orthotic interventions were categorised based on the medical conditions/injuries of the participants. From these studies, this review focused on the medical condition/injuries with the highest number of randomised controlled trials (osteoarthritis, fracture, stroke, carpal tunnel syndrome, plantar fasciitis, anterior cruciate ligament, diabetic foot, rheumatoid and juvenile idiopathic arthritis, ankle sprain, cerebral palsy, lateral epicondylitis and low back pain). The included articles were assessed for risk of bias using the Cochrane Risk of Bias tool. Details of the clinical population examined, the type of orthotic/prosthetic intervention, the comparator/s and the outcome measures were extracted. Effect sizes and odds ratios were calculated for all outcome measures, where possible.

CONCLUSIONS

At present, for prosthetic and orthotic interventions, the scientific literature does not provide sufficient high quality research to allow strong conclusions on their effectiveness and cost-effectiveness.

Traditional manual acupuncture combined with rehabilitation therapy for shoulder hand syndrome after stroke within the Chinese healthcare system: a systematic review and meta-analysis

OBJECTIVE

To investigate the effectiveness of traditional manual acupuncture combined with rehabilitation therapy versus rehabilitation therapy alone for shoulder hand syndrome after stroke.

DATA SOURCES

PubMed, EMBASE, the Cochrane Library, Chinese Biomedicine Database, China National Knowledge Infrastructure, VIP Information Database, Wan Fang Database and reference lists of the eligible studies were searched up to July 2017 for relevant studies.

METHODS

Randomized controlled trials that compared the combined effects of traditional manual acupuncture and rehabilitation therapy to rehabilitation therapy alone for shoulder hand syndrome after stroke were included. Two reviewers independently screened the searched records, extracted the data and assessed risk of bias of the included studies. The treatment effect sizes were pooled in a meta-analysis using RevMan 5.3 software.

RESULTS

A total of 20 studies involving 1918 participants were included in this study. Compared to rehabilitation therapy alone, the combined therapy significantly reduced pain on the visual analogue scale and improved limb movement on the Fugl-Meyer Assessment scale and the performance of activities of daily living (ADL) on the Barthel Index scale or Modified Barthel Index scale. Of these, the visual analogue scale score changes were significantly higher (mean difference = 1.49, 95% confidence interval = 1.15-1.82, P < 0.00001) favoring the combined therapy after treatment, with severe heterogeneity ( I² = 71%, P = 0.0005).

CONCLUSION

Current evidence suggests that traditional manual acupuncture integrated with rehabilitation therapy is more effective in alleviating pain, improving limb movement and ADL. However, considering the relatively low quality of available evidence, further rigorously designed and large-scale randomized controlled trials are needed to confirm the results.

Rehabilitation Interventions for Upper Limb Function in the First Four Weeks Following Stroke: A Systematic Review and Meta-Analysis of the Evidence

OBJECTIVE

To investigate the therapeutic interventions reported in the research literature and synthesize their effectiveness in improving upper limb (UL) function in the first 4 weeks poststroke.

DATA SOURCES

Electronic databases and trial registries were searched from inception until June 2016, in addition to searching systematic reviews by hand.

STUDY SELECTION

Randomized controlled trials (RCTs), controlled trials, and interventional studies with pre/posttest design were included for adults within 4 weeks of any type of stroke with UL impairment. Participants all received an intervention of any physiotherapeutic or occupational therapeutic technique designed to address impairment or activity of the affected UL, which could be compared with usual care, sham, or another technique.

DATA EXTRACTION

Two reviewers independently assessed eligibility of full texts, and methodological quality of included studies was assessed using the Cochrane Risk of Bias Tool.

DATA SYNTHESIS

A total of 104 trials (83 RCTs, 21 nonrandomized studies) were included (N=5225 participants). Meta-analyses of RCTs only (20 comparisons) and narrative syntheses were completed. Key findings included significant positive effects for modified constraint-induced movement therapy (mCIMT) (standardized mean difference [SMD]=1.09; 95% confidence interval [CI], .21-1.97) and task-specific training (SMD=.37; 95% CI, .05-.68). Evidence was found to support supplementary use of biofeedback and electrical stimulation. Use of Bobath therapy was not supported.

CONCLUSIONS

Use of mCIMT and task-specific training was supported, as was supplementary use of biofeedback and electrical simulation, within the acute phase poststroke. Further high-quality studies into the initial 4 weeks poststroke are needed to determine therapies for targeted functional UL outcomes.

Shoulder pain after stroke - experiences, consequences in daily life and effects of interventions: a qualitative study

PURPOSE

To describe experiences of shoulder pain after stroke, how pain affects daily life and perceived effects of interventions.

METHOD

A qualitative interview study including 13 community-dwelling persons (six women; median age 65 years) with persistent shoulder pain after stroke.

RESULTS

Three categories emerged from the content analysis. In "Multiple pain characteristics" an insidious pain onset was reported. The pain existed both day and night and could be located around the shoulder girdle but also have radiation to the arm and hand. An explanation of the pain was seldom given. In "Limitations caused by the pain" it was described how the pain negatively influenced personal care, household activities and leisure, but also could lead to emotional reactions. In "Multiple pain interventions with various effects" a variety of interventions were described. Self-management interventions with gentle movements were perceived most effective. A restraint attitude to pain medication due to side effects was reported.

CONCLUSIONS

Shoulder pain after stroke can lead to a variety of pain characteristics. As the pain is complex and may affect many important areas in a person's life, multidisciplinary rehabilitation interventions are important. Implications for rehabilitation Shoulder pain after stroke can lead to a variety of pain characteristics with radiation to the arm and hand Shoulder pain often influence personal care, household activities and leisure negatively, which may lead to emotional reactions Self-management interventions with gentle movements are perceived most effective As the shoulder pain after stroke is complex, interventions by a multidisciplinary team may be needed.

Shoulder orthoses for the prevention and reduction of hemiplegic shoulder pain and subluxation: systematic review

Objectives:

To determine whether shoulder orthoses prevent or reduce gleno-humeral subluxation and hemiplegic shoulder pain.

Data sources:

OVID SP, MEDLINE, AMED, CINAHL, PEDro and the Cochrane Central Register of Controlled Trials.

Review methods:

We included: randomised or quasi-randomised controlled trials, controlled before and after studies and observational studies. Two reviewers independently screened, critically appraised papers using the PEDro tool, and extracted data. A descriptive synthesis was performed as there were insufficient data for meta-analysis.

Results:

Eight studies were included, totalling 186 participants: One randomised controlled trial with 41 participants, one quasi-randomised with 14 participants, one before and after controlled study with 40 participants and five observational studies with 91 participants met the inclusion criteria. Findings suggest that applying an orthosis to an already subluxed shoulder immediately reduced vertical subluxation on X-ray but improvements were not maintained when orthosis was removed. Orthoses with both proximal and distal attachments improved shoulder pain in the majority of stroke patients when worn for four weeks (starting several days or weeks post-stroke). There was no increase in adverse effects of contracture, spasticity or hand oedema when compared to no orthosis. Orthoses were generally well-tolerated and most patients rated the orthosis as comfortable to wear.

Conclusion:

Observational studies suggest that orthoses reduce vertical subluxation whilst in-situ. Available evidence from heterogeneous studies after stroke suggests that orthoses may reduce pain and are well-tolerated with prolonged use. No studies have tested whether subluxation and pain can be prevented by immediate post-stroke application of orthoses.

A systematic review of questionnaires to assess patient satisfaction with limb orthoses

BACKGROUND

Assessment of patient satisfaction with orthosis is a key point for clinical practice and research, requiring questionnaires with robust psychometric properties.

OBJECTIVES

To identify which validated questionnaires are used to investigate patient satisfaction with orthosis in limb orthotics and to analyse (1) their main fields of clinical application, (2) the orthosis-related features analysed by the questionnaires and (3) the strength of their psychometric properties.

STUDY DESIGN

Systematic review.

METHODS

A literature search using MEDLINE (PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scopus databases for original articles published within the last 20 years was performed.

RESULTS

A total of 106 papers pertaining to various clinical fields were selected. The main features of patient satisfaction with orthosis analysed were as follows: aesthetic, ease in donning and doffing the device, time of orthotic use and comfort.

CONCLUSION

Of the questionnaires used to investigate patient satisfaction with orthosis, only four are adequately validated for this purpose: two for generic orthotic use (Quebec User Evaluation of Satisfaction with assistive Technology 2.0 and Client Satisfaction with Device of Orthotics and Prosthetic Users' Survey) and two for specific application with orthopaedic shoes (Questionnaire for the Usability Evaluation of orthopaedic shoes and Monitor Orthopaedic Shoes). Further development, refinement and validation of outcome measures in this field are warranted.

CLINICAL RELEVANCE

Given the importance of analysing patient satisfaction with orthosis (PSwO), appropriate instruments to assess outcome are needed. This article reviews the currently available instruments and reflects on how future studies could be focused on the development, refinement and validation of outcome measures in this field.

Clinical reasoning in the use of slings for patients with shoulder subluxation after stroke: a glimpse of the practice phenomenon in california

Literature reports the frequent use of shoulder slings by occupational therapists for the management of shoulder subluxation after stroke despite the low evidence for its efficacy. To understand the clinical contexts that defy current research evidence, a survey was distributed among California occupational therapists. One hundred sixty-eight participants responded to the survey, answering questions regarding the occurrences and clinical reasoning in the use of the shoulder sling with patients after stroke. Use of the shoulder sling was reported by 81.5% of the respondents. However, the actual sling prescription was limited to 28.4% of their patients. Slings were primarily prescribed for upper extremity management during functional mobility and for pain reduction. The orthopedic sling was the most frequently used sling. Reasons to use the orthopedic sling were largely based on pragmatic reasoning such as convenience and cost factors. On the contrary, therapists with advanced training were found to be more likely to apply procedural reasoning when choosing the proper sling for their patients. [OTJR: Occupation, Participation and Health. 2013;33(4):228-235.].