Current and future interventions for glenohumeral subluxation in hemiplegia secondary to stroke

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.

Effects of scapulo-humeral training on ultrasonographic and clinical evaluations in stroke: a randomized controlled trial

BACKGROUND

After stroke, the effects of focused scapulo-humeral training with simultaneous assessment of the changes in shoulder subluxation, related muscle thicknesses and upper limb performance have not been studied in the literature.

OBJECTIVES

This study aimed to investigate the effects of an 8-week scapulo-humeral training program in addition to conventional rehabilitation on upper extremity/trunk functions, shoulder pain, and sonographic measurements of the shoulder joint and periscapular muscles.

METHODS

Thirty stroke individuals were randomly separated into two groups as Group I-scapulo-humeral training (5F/10 M) and Group II - control (5F/10 M). Conventional rehabilitation program was applied to both groups, and a scapulo-humeral training exercise protocol was added for the scapulo-humeral group. All the treatments were applied for 1 hour/day, 3 days/week, 8 weeks. Clinical evaluations were made using the Fugl Meyer Assessment-Upper Extremity(FMA-UE), Action Research Arm Test(ARAT), ABILHAND, Visual Analog Scale, and Trunk Impairment Scale(TIS). Ultrasound was used to measure serratus anterior/lower trapezius muscle thicknesses, and acromion-greater tubercule/acromio-humeral distances.

RESULTS

FMA-UE, ARAT, ABILHAND and TIS scores increased in both groups, with greater increases in most parameters in the scapulo-humeral training group. Shoulder pain decreased only in the scapulo-humeral training group. Subacromial distances were decreased on the paretic side, and muscle thicknesses increased on both sides in the scapulo-humeral training group, and in the control group, only serratus anterior muscle thickness increased on the paretic side (p < 0.05 for all).

CONCLUSIONS

Additional scapulo-humeral exercises to conventional rehabilitation was seen to improve upper extremity/trunk performance and shoulder pain, and to increase scapula stabilizer muscle thicknesses in stroke individuals with mild-moderate upper extremity disability.

Repetitive peripheral magnetic stimulation for preventing shoulder subluxation after stroke: a randomized controlled trial

BACKGROUND

Shoulder subluxation caused by paralysis after stroke is a serious issue affecting shoulder pain and functional prognosis. However, its preventive treatment has not been fully investigated.

AIM

To investigate the effects of repetitive peripheral magnetic stimulation (rPMS) on the prevention of shoulder subluxation.

DESIGN

A single-center, parallel-group, prospective randomized, open-blinded, end-point study.

SETTING

Convalescent rehabilitation ward.

POPULATION

We included 50 inpatients in the convalescent rehabilitation ward with post-stroke, having upper limb paralysis, and the acromio-humeral interval (AHI) was within 1/2 finger-breadth.

METHODS

A blinded computer-based allocation system was used to randomly assign patients into two groups: 1) conventional rehabilitation plus rPMS therapy (rPMS group, N=25); and 2) conventional rehabilitation alone (control group, N=25). Blinded assessors evaluated the patients before the intervention (T0), 6 weeks after (T1), and 12 weeks after (T2). The primary outcome was the change in AHIs from T0 to T1 between the groups. In contrast, the secondary outcomes were shoulder pain, spasticity, active range of motion, and Fugl-Meyer Assessment upper extremity (FMA-UE) score.

RESULTS

Twenty-two patients in the rPMS group and 24 in the control group completed T1, whereas 16 in the rPMS group and 11 in the control group completed T2. The change in AHI was significantly lower in the rPMS group than in the control group ([95% CI, -5.15 to -0.390], P=0.023). Within-group analysis showed that AHI in the rPMS group did not change significantly, whereas it increased in the control group (P=0.004). There were no significant differences between T1 and T2 within or between the groups. Moreover, AHI did not show differences in patients with severe impairment but decreased in the rPMS group in patients with mild impairment (P=0.001).

CONCLUSIONS

The rPMS may be a new modality for preventing shoulder subluxation. The association between motor impairment and the sustained effect needs to be further examined.

CLINICAL REHABILITATION IMPACT

Applying rPMS to the muscles of the paralyzed shoulder after a stroke may prevent shoulder subluxation.

Magnetic resonance imaging findings in painful hemiplegic shoulder patients with or without subluxation: A retrospective cohort study

The relationship between hemiplegic shoulder pain (HSP) and subluxation is unclear. This study aimed to determine the differences of magnetic resonance imaging (MRI) findings in HSP patients with or without subluxation after stroke, and to analyze the etiology of shoulder pain. This retrospective study included 53 patients with HSP after stroke from September 2013 to February 2020. Patients underwent MRI of the shoulder because of shoulder pain. Clinical characteristics, including age, sex, stroke duration, body mass index, stroke type, visual analog scale score, Brunnstrom stage, and MRI arthrography findings of the affected shoulder, were recorded. Patients were classified into the glenohumeral subluxation (GHS) group (n = 27) or non-glenohumeral subluxation (nGHS) group (n = 26). We found that patients with HSP may be prone to bursa effusion, rotator cuff injury, ligament injury, and cartilage injury, even though there was no significant difference between the GHS and nGHS groups. MRI revealed 14 cases of long bicipital tendon-glenoid labrum injury (51.8%) in the GHS group and 6 cases (23.1%) in the nGHS group (p = 0.030). We also found 10 cases (37%) of glenoid labrum injury in the GHS group and 2 cases (7.7%) in the nGHS group (p = 0.026). Eight cases (29.6%) and 1 case (3.8%) of bone marrow edema were found in the GHS and nGHS groups, respectively (p = 0.033). Compared with painful hemiplegic shoulder patients without subluxation, patients with subluxation may be more susceptible to some injuries, such as long bicipital tendon-glenoid labrum injury, glenoid labrum injury, and bone marrow edema. During rehabilitation, physicians need to pay attention to these injuries.

Elastic Dynamic Sling on Subluxation of Hemiplegic Shoulder in Patients with Subacute Stroke: A Multicenter Randomized Controlled Trial

Background: Shoulder subluxation occurs in 17−64% of hemiplegic patients after stroke and develops mostly during the first three weeks of hemiplegia. A range of shoulder orthoses has been used in rehabilitation to prevent subluxation. However, there is little evidence of their efficacy. AIM: This study aimed to investigate whether there is a difference in the subluxation distance, pain, and functional level of the hemiplegic upper extremity among patients with two different shoulder orthoses. Design: This is a prospective, randomized controlled trial with intention-to-treat analysis. SETTING: Multicenter, rehabilitation medicine department of two university hospitals in South Korea. Population: Forty-one patients with subacute stroke with shoulder subluxation with greater than 0.5 finger width within 4 weeks of stroke were recruited between January 2016 and October 2021. Methods: The experimental group used an elastic dynamic sling while sitting and standing to support the affected arm for eight weeks. The control group used a Bobath sling while sitting and standing. The primary outcome was to assess the distance of the shoulder subluxation on radiography. The secondary outcomes were upper-extremity function, muscle power, activities of daily living, pain and spasticity. Result: The horizontal distance showed significant improvement in the elastic dynamic sling group, but there were no significant differences in the vertical distance between the elastic dynamic and Bobath sling groups. Both groups showed improvements in upper-extremity movements and independence in daily living after 4 and 8 weeks of using shoulder orthoses, and the differences within the groups were significant (p < 0.05). However, there were no significant differences in upper-extremity movements and independence in daily living between the two groups. Conclusions: The subluxation distance showed better results in the elastic dynamic sling, which has both proximal and distal parts, than in the Bobath sling, which holds only the proximal part. Both shoulder orthoses showed improvements in the modified Barthel index, upper-extremity function, and manual muscle testing.

Efficacy and safety of kinesiology tape for hemiplegic shoulder pain: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The aim of this study was to examine the efficacy and safety of kinesiology tape in treating hemiplegic shoulder pain.

METHODS

Web of Science, MEDLINE, Embase, Cochrane Library, six other English databases and three Chinese databases (CNKI, VIP, Wan Fang) were searched for randomized controlled trials published prior to December 13, 2020 in English or Chinese on the use of kinesiology tape for hemiplegic shoulder pain.

RESULTS

Fourteen randomized controlled trials (679 patients) of good PEDro quality (6.43 ± 1.09) were included in this meta-analysis. The pooled results for pain (SMD -0.92, 95% CI -1.10 to -0.74, P< 0.001, 10 RCTs, 539 patients), range of motion (SMD 2.27, 95% CI 1.23 to 3.32, P< 0.001, 7 studies, 320 patients), the acromion humeral distance (SMD -0.62, 95% CI -0.88 to -0.37, P< 0.001, 7 RCTs, 246 patients) and the FMA-UE score (SMD 0.66, 95% CI 0.41 to 0.91, P< 0.001, 5 RCTs, 263 patients) suggested that therapeutic kinesiology tape relieved pain, increased ROM, shortened the acromion humeral distance and improved upper extremity motor function to a greater extent than the sham or blank control conditions. The pooled results for individual activity (SMD 0.42, 95% CI -0.22 to 1.07, P= 0.199, 5 RCTs, 199 patients) and quality of life (SMD 0.308, 95% CI -0.288 to 0.903, P= 0.311, 1 RCT, 44 patients) showed that the kinesiology tape group was not significantly different from the sham or blank control group. Publication bias was not observed. No adverse events were reported in any of the included studies.

CONCLUSION

KT relieved pain and improved the ROM, DAH and FMA-UE score in patients with HSP to a greater extent than did the sham KT or blank control conditions. The effects on independence in activities of daily living and quality of life and whether this method is superior to active treatment in patients with HSP were not verified. More rigorous, reasonably designed RCTs with large sample sizes are still needed in the future.

The reliability and effectiveness of shoulder joint evaluation by ultrasonography in stroke patients: deltoid muscle thickness, acromion-humeral distance, acromion-lesser tuberosity distance

[Purpose] This study aimed to evaluate the reliability of the intraclass correlation coefficient (ICC) in measuring deltoid muscle thickness (DMT) at different angles, acromion-humeral distance (AHD), and acromion nodule tuberosity (ALT) distance in a resting position in stroke patients using ultrasonography. [Participants and Methods] We included 40 stroke patients. During the measurement of parameters by ultrasonography, we measured the deltoid muscle thickness on both sides at three test angles (0°, 30°, and 60° abduction) and AHD and ALT on both sides at 0° angle. The ICC was used to assess intra- and interrater reliability. The relationship between the hemiplegic and non-hemiplegic sides and each angle were analyzed using a two-way repeated-measure analysis of variance (ANOVA). [Results] When the shoulders were at three testing angles (0°, 30°, and 60° abduction), the deltoid muscle thickness of the hemiplegic and non-hemiplegic sides showed good reliability; the AHD and ALT of the shoulder joint at 0° angle equally showed good reliability. There was a significant difference in each abduction angle of the shoulder joint between the thickness of the hemiplegic and non-hemiplegic deltoid. [Conclusion] Measuring deltoid muscle thickness by ultrasonography showed excellent reliability and can be used in stroke patients.

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.

Effects of position-triggered electrical stimulation on post-stroke hemiparetic shoulder subluxation

BACKGROUND

Shoulder subluxation is a frequent complication after stroke causing joint instability, shoulder pain, decreased activities of daily living, and impedance to rehabilitation progress. Electrical stimulation (ES) is considered an effective modality to reduce shoulder subluxation in acute stroke. However, few studies have investigated the effect of position-triggered ES, which induces active muscle contraction though accurate motion detection.

AIM

To investigate whether position-triggered ES was more effective in reducing acute hemiplegic shoulder subluxation after stroke than passive ES.

DESIGN

Single-blind, randomized controlled trial.

SETTING

University hospital rehabilitation center.

POPULATION

Fifty post-stroke subacute hemiparetic patients with shoulder subluxation.

METHODS

Patients were randomly assigned into two groups. The position-triggered ES group received 30-minute ES sessions, 5 days per week for 3 weeks with specially modified Novastim® CU-FS1 for motion triggering. The passive ES group received the same protocol without motion triggering. The vertical distance (VD) and the joint distance (JD), relative VD and JD (rVD, rJD), upper extremity component of Fugl-Meyer Motor Assessment (FMAupper), Motricity Index (MI), Manual Function Test (MFT), and peak torque of affected shoulder abductor (PT) were assessed at baseline (T0), end of electrical stimulation session (T1), and 3 weeks (T2) after treatment.

RESULTS

Repeated-measures analysis of variance revealed significant interaction between TIME and INTERVENTION on JD and rJD, indicating that shoulder subluxation was significantly more reduced in position-triggered ES than in passive ES (p<0.05). However, FMAupper, MI, MFT, and PT did not show this significance. The change of (Δ)JD , ΔrVD, and ΔrJD in the motion-triggered ES group improved significantly more at T1 than in the passive ES group (p<0.05). This significant improvement was not seen at T2.

CONCLUSIONS

Position-triggered ES may be more effective than passive ES in improving post-stroke shoulder subluxation; however, this effect was not maintained after the withdrawal of stimulation.

CLINICAL REHABILITATION IMPACT

Position-triggered ES may be useful to reducing post-stroke shoulder subluxation.

Poststroke Pain

Pain is common but often underrecognized after stroke. Poststroke pain (PSP) hinders recovery, impairs quality of life, and is associated with the psychological state of patients with stroke. The most common subtypes of PSP include central PSP, complex regional pain syndrome, shoulder pain, spasticity-related pain, and headache. The pathophysiologies of these PSP subtypes are not yet clearly understood, and PSP is refractory to conventional treatment in many patients. However, recent studies have proposed potential pathophysiologies of PSP subtypes, which may help prioritize therapies that target specific mechanisms.

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.

Cryoneurolysis and Percutaneous Peripheral Nerve Stimulation to Treat Acute Pain

Two regional analgesic modalities currently cleared by the U.S. Food and Drug Administration hold promise to provide postoperative analgesia free of many of the limitations of both opioids and local anesthetic-based techniques. Cryoneurolysis uses exceptionally low temperature to reversibly ablate a peripheral nerve, resulting in temporary analgesia. Where applicable, it offers a unique option given its extended duration of action measured in weeks to months after a single application. Percutaneous peripheral nerve stimulation involves inserting an insulated lead through a needle to lie adjacent to a peripheral nerve. Analgesia is produced by introducing electrical current with an external pulse generator. It is a unique regional analgesic in that it does not induce sensory, motor, or proprioception deficits and is cleared for up to 60 days of use. However, both modalities have limited validation when applied to acute pain, and randomized, controlled trials are required to define both benefits and risks.

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.

Reliability of ultrasonographic measurement of the supraspinatus thickness at different angles of shoulder abduction in patients with stroke

[Purpose] The primary purpose of this study was to evaluate the usefulness of the intraclass correlation coefficient for evaluating the reliability of the measurement of the supraspinatus thickness on shoulder ultrasonography at different angles in a resting position in patients with stroke. [Participants and Methods] The study included 20 patients with stroke. The supraspinatus thickness was measured on both sides on ultrasonography, with the participants’ shoulders in abduction at 3 testing angles (0°, 30°, and 60° abduction). Each measurement was performed three times, and the average of the three measurements was recorded. The intraclass correlation coefficient was calculated, with the supraspinatus thickness measured twice at an interval of 24 hours as the factor. [Results] All intraclass correlation coefficients for the hemiplegic and normal sides were greater than 0.93 when the shoulders were at the three testing angles. [Conclusion] In this investigation, the reliability of measuring the supraspinatus thickness on shoulder ultrasonography at each angle for 3 times was evaluated and was found to be excellent.

Treatment of Glenohumeral Subluxation: A Review of the Literature and Considerations for Pediatric Population

OBJECTIVE

The aim of this review was to identify treatment strategies in the research literature to inform all health professionals on best practice strategies when addressing glenohumeral subluxation.

DESIGN

Articles were identified by searching electronic databases. Two reviewers independently appraised the methodological quality of the selected studies. Discrepancies were resolved after corroboration of results.

RESULTS

Research literature pertaining to five major treatment strategies was found (n = 40 peer-reviewed publications), spanning evidence levels I-V. The greatest number of studies concerned neuromuscular electrical stimulation (n = 19), five of which were level I studies, followed by manual preventive strategies, such as slings (n = 20), three of which were level I studies.

CONCLUSIONS

These findings indicate that the most high-quality research supports using neuromuscular electrical stimulation or manual preventive studies, although no studies used direct comparison methods to ascertain relative merits of each type of intervention when compared with others. No evidence suggested that harm was done by using neuromuscular electrical stimulation or manual preventive methods. This literature review suggests that the identified treatment strategies should be considered by clinicians as the treatment of choice for GHS. No literature was identified that reviewed treatment strategies in a pediatric population; however, the authors considerations for treatment in the pediatric population were included.

The Effects of Active Shoulder Exercise with a Sling Suspension System on Shoulder Subluxation, Proprioception, and Upper Extremity Function in Patients with Acute Stroke

BACKGROUND The aim of this study was to investigate the effect of active shoulder exercise with a sling suspension system on shoulder subluxation, proprioception, and upper extremity function in patients with acute stroke. MATERIAL AND METHODS Thirty-six patients with acute stroke and shoulder subluxation were randomly assigned into two groups. The study group (n=18) received active shoulder exercise with a sling suspension system, and the control group (n=18) received bilateral arm training for 40 minutes, for five days a week, for four weeks. The outcome measures before and after the intervention included measurement of shoulder subluxation distance, shoulder proprioception, the Fugl-Meyer assessment (FMA) scale, and the manual function test (MFT). RESULTS Comparison of the study group with the control group showed significant differences in all outcome scores post-intervention (p<0.05). The study group had significant improvement in shoulder subluxation distance, shoulder proprioception, the FMA score, and the MFT compared with the control group. There was a significant difference in shoulder subluxation (p=0.001), shoulder proprioception (p=0.046), the FMA score (p=0.002), and the MFT (p=0.007) between the two groups, which favored the study group. CONCLUSIONS Active shoulder exercise with a sling suspension system may be effective in reducing shoulder subluxation, improving proprioception, and upper extremity function in patients following acute stroke.

The Effect of Kinesiology Taping on the Hemiplegic Shoulder Pain: A Randomized Controlled Trial

Objective

The purpose of the study was to explore the effect of kinesiology taping on hemiplegic shoulder pain (HSP) in terms of pain intensity, magnitude of subluxation, muscle activity, and active range of motion (AROM).

Design

Double-blind, placebo-controlled clinical trial.

Setting

the Rehabilitation Center of the West China Hospital.

Participants

Nineteen individuals suffering from HSP were recruited in this study.

Intervention

Patients were randomly assigned into the taping group or control group. The taping group received therapeutic kinesiology taping and conventional treatment, while the control group received placebo taping (applied without tension) and conventional treatment.

Main Outcome Measures

The shoulder pain intensity (numerical pain rating scale), magnitude of subluxation, muscle activity (measured by surface electromyography (sEMG)), and shoulder active range of movement (AROM) were assessed at the baseline, on the first day (immediately after taping) and 4 weeks after treatment (without taping).

Results

All patients completed the trials. There were no significant differences between groups at the baseline. The taping group showed immediate improvement on the first day after taping in terms of pain intensity, magnitude of subluxation, and muscle activity (p < 0.05), whereas no significant changes seen in the control group (p > 0.05). After 4 weeks of treatment, the taping group showed significant changes in pain intensity, magnitude of subluxation, muscle activity, and AROM (p < 0.05). And significant differences in pain intensity and muscle activity could be seen between the two groups (p < 0.05).

Conclusion

The results indicate that the kinesiology taping is effective in reducing the shoulder pain and subluxation and increasing muscle activity and AROM for patients with HSP after stroke.

Musculoskeletal Ultrasonography Assessment of Functional Magnetic Stimulation on the Effect of Glenohumeral Subluxation in Acute Poststroke Hemiplegic Patients

Background

Glenohumeral subluxation (GHS) is common in patients with acute hemiplegia caused by stroke. GHS and upper limb function are closely related.

Objective

Using musculoskeletal ultrasonography (MSUS) to objectively evaluate the efficacy of functional magnetic stimulation (FMS) in the treatment of GHS in acute hemiplegic patients after stroke.

Methods

The study used prospective case control study. Stroke patients with GHS were recruited and assigned to control group and FMS group. Control group received electrode stimulation at the supraspinatus and deltoid muscles of the hemiplegic side, while FMS group was stimulated at the same locations. Before and after treatment, the distances of the acromion-greater tuberosity (AGT), acromion-lesser tuberosity (ALT), acromiohumeral distance (AHD), supraspinatus thickness (SST), and deltoid muscle thickness (DMT) in patients' bilateral shoulder joint were measured by MSUS, respectively. Meanwhile, Fugl-Meyer Assessment (FMA) was used to evaluate the improvement of upper limb function.

Results

30 patients were recruited. After FMS treatment, there was a significant decrease in the difference value between ipsilateral side and contralateral side of AGT [t = 8.595, P < 0.01], ALT [t = 11.435, P < 0.01], AHD [t = 8.375, P < 0.01], SST [t = 15.394, P < 0.01], and DMT [t = 24.935, P < 0.01], and FMA score increased [t = −13.315, P < 0.01]. Compared with control group, FMS group decreased more significantly in the difference value between ipsilateral side and contralateral side of AGT [t = 2.161, P < 0.05], ALT [t = 3.332, P < 0.01], AHD [t = 8.768, P < 0.01], SST [t = 6.244, P < 0.01], and the DMT [t = 3.238, P < 0.01], and FMA score increased more significantly in FMS group [t = 7.194, P < 0.01].

Conclusion

The study preliminarily shows that the MSUS can objectively and dynamically evaluate the treatment effect of GHS in hemiplegic patients. Meanwhile, compared with control group, the FMS is more effective and has fewer side effects, and the long-term effect of FMS is worth further study. This trial is registered with ChiCTR1800015352.

Ultrasonographic assessment of neuromuscular electrical stimulation efficacy on glenohumeral subluxation in patients with hemiplegia: a randomized-controlled study

Objectives

This study aims to investigate the short-term effects of neuromuscular electrical stimulation (NMES) on glenohumeral subluxation (GHS) in stroke patients.

Patients and methods

This prospective, randomized-controlled study included 24 unilateral hemiplegic patients (10 males, 14 females; mean age 64.1±14.8 years; range 22 to 84 years) with GHS as assessed by ultrasonography between December 2013 and September 2014. The patients were randomly divided into two groups as those in the NMES group (n=12) who were treated with NMES to supraspinatus, upper trapezius, and posterior deltoid muscles combined with conventional physiotherapy and as those in the control group (n=12) who were received conventional physiotherapy alone. Clinical (the Brunnstrom Motor Recovery Stage, Visual Analog Scale [VAS] for Pain and Shoulder Disability Questionnaire [SDQ]) and ultrasonographic (acromion-greater tuberosity distance, thicknesses of supraspinatus, upper trapezius, and posterior deltoid muscles) variables were evaluated before and after treatment in both groups.

Results

The SDQ index, acromion-greater tuberosity distance, and supraspinatus muscle thickness were improved in the NMES group, compared to the control group (for all p<0.05). The VAS-pain scores decreased in both groups. There was no statistically significant alterations in the other measurements in both groups (for all p>0.05). The percentage change (%) of the VAS-pain scores was not significantly different between two groups (p=0.03).

Conclusion

Our study results showed that GHS decreased after 20 sessions of NMES treatment. Based on these findings, ultrasonography appears to be a proper imaging tool for the evaluation of GHS in stroke patients.

Effectiveness of neuromuscular electrical stimulation for management of shoulder subluxation post-stroke: a systematic review with meta-analysis

Objectives:

To examine the effectiveness of neuromuscular electrical stimulation (NMES) for the management of shoulder subluxation after stroke including assessment of short (1 hour or less) and long (more than one hour) daily treatment duration.

Data sources:

MEDLINE, CENTRAL, CINAHL, WOS, KoreaMed, RISS and reference lists from inception to January 2017

Review methods:

We considered randomized controlled trials that reported neuromuscular electrical stimulation for the treatment of shoulder subluxation post-stroke. Two reviewers independently selected trials for inclusion, assessed trial quality, and extracted data.

Results:

Eleven studies were included (432 participants); seven studies were good quality, four were fair. There was a significant treatment effect of neuromuscular electrical stimulation for reduction of subluxation for persons with acute and subacute stroke (SMD:–1.11; 95% CI:–1.53, –0.68) with either short (SMD:–0.91; 95% CI:–1.43, –0.40) or long (SMD:–1.49; 95% CI:–2.31, –0.67) daily treatment duration. The effect for patients with chronic stroke was not significant (SMD:–1.25; 95% CI:–2.60, 0.11). There was no significant effect of neuromuscular electrical stimulation on arm function or shoulder pain.

Conclusion:

This meta-analysis suggests a beneficial effect of neuromuscular electrical stimulation, with either short or long daily treatment duration, for reducing shoulder subluxation in persons with acute and subacute stroke. No significant benefits were observed for persons with chronic stroke or for improving arm function or reducing shoulder pain.

Demystifying Poststroke Pain: From Etiology to Treatment

Pain after stroke is commonly reported but often incompletely managed, which prevents optimal recovery. This situation occurs in part because of the esoteric nature of poststroke pain and its limited presence in current discussions of stroke management. The major specific afflictions that affect patients with stroke who experience pain include central poststroke pain, complex regional pain syndrome, and pain associated with spasticity and shoulder subluxation. Each disorder carries its own intricacies that require specific approaches to treatment and understanding. This review aims to present and clarify the major pain syndromes that affect patients who have experienced a stroke in order to aid in their diagnosis and treatment.

Intra-rater and inter-rater reliability of ultrasonographic measurements of acromion-greater tuberosity distance in patients with post-stroke hemiplegia

BACKGROUND

Glenohumeral subluxation (GHS) is reported in up to 81% of patients with stroke. Ultrasonographic measurements of GHS by measuring the acromion-greater tuberosity (AGT) have been found to be reliable for experienced raters.

OBJECTIVES

The primary aim was to assess the intra-rater reliability of measurements of AGT distance in people with stroke following a short course of rater training. A secondary aim was to compare the inter-rater reliability of these measurements between novice and experienced raters.

METHODS

Patients with stroke (n = 16; 5 men, 11 women; 74 ± 10 years) with 1-sided weakness who gave informed consent were recruited. Ultrasonographic measurements were recorded at the bedside by two physiotherapists with patients seated upright in a hospital chair. Reliability was assessed by intra-class correlation coefficients (ICCs) and the standard error of measurements (SEM). Minimum detectable change (MDC90) scores were used to estimate the magnitude of change that is likely to exceed measurement error.

RESULTS

Mean ± SD AGT distances on the affected and unaffected sides for rater 1 were 2.2 ± 0.7 and 1.7 ± 0.4 cm, respectively. Corresponding values for rater 2 were 2.5 ± 0.6 and 2.0 ± 0.4 cm. Intra-class correlation coefficient values for the affected and unaffected shoulders for rater 1 were 0.96 and 0.91, respectively. Corresponding values for rater 2 were 0.95 and 0.90.SEM and MDC90 for both affected and unaffected shoulders were ≤ 0.2 cm. Inter-rater reliability coefficients were 0.86 (affected) and 0.76 (unaffected) shoulders.

CONCLUSION

Ultrasonographic measurement of AGT distance demonstrates excellent intra-rater reliability for a novice rater. Inter-rater reliability of ultrasonographic measurement of AGT also demonstrates good reliability between novice and experienced raters.

Assessment of glenohumeral subluxation in poststroke hemiplegia: comparison between ultrasound and fingerbreadth palpation methods

BACKGROUND

Glenohumeral subluxation (GHS) is a common poststroke complication. Treatment of GHS is hampered by the lack of objective, real-time clinical measurements.

OBJECTIVE

The aims of this study were: (1) to compare an ultrasound method of GHS measurement with the fingerbreadth palpation method using a receiver operating characteristic curve (ROC) and (2) to report the sensitivity and specificity of this method.

DESIGN

A prospective study was conducted.

SETTING

The study was conducted in local hospitals and day centers in the southwest of England.

PATIENTS

One hundred five patients who had one-sided weakness following a first-time stroke (51 men, 54 women; mean age=71 years, SD=11) and who gave informed consent were enrolled in the study.

MEASUREMENTS

Ultrasound measurements of acromion-greater tuberosity (AGT) distance were used for the assessment of GHS. Measurements were undertaken on both shoulders by a research physical therapist trained in shoulder ultrasound with the patient seated in a standardized position. Fingerbreadth palpation assessment of GHS was undertaken by a clinical physical therapist based at the hospital, who also visited the day centers.

RESULTS

The area under the ROC curve was 0.73 (95% confidence interval [95% CI]=0.63, 0.83), suggesting that the ultrasound method has good agreement compared with the fingerbreadth palpation method. A cutoff point of ≥0.2 cm AGT measurement difference between affected and unaffected shoulders generated a sensitivity of 68% (95% CI=51%, 75%), a specificity of 62% (95% CI=47%, 80%), a positive likelihood ratio of 1.79 (95% CI=1.1, 2.9), and a negative likelihood ratio of 0.55 (95% CI=0.4, 0.8).

LIMITATIONS

Clinical therapists involved in the routine care of patients conducted the fingerbreadth palpation method. It is likely that they were aware of the patients' subluxation status.

CONCLUSION

The ultrasound method can detect minor asymmetry (≤0.5 cm) and has the potential advantage over the fingerbreadth palpation method of identifying patients with minor subluxation.

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.].

Upper limb rehabilitation following stroke: current evidence and future perspectives

Stroke is a leading cause of disability worldwide, with its risk increasing with age. Upper limb hemiparesis is common and associated with persistent impairments and associated disabilities. Older stroke populations often suffer multiple comorbidities and restoring independence is complex. Recovery of upper limb function can be crucial for individuals to return to independent living and to participate in community life. This review describes upper limb recovery post-stroke, and some of the new therapeutic approaches available to promote recovery. Technologies (including virtual reality and telehealth) offer the opportunity for more home-based therapies, longer programs and greater access to rehabilitation for older individuals. However, the trials continue to exclude older individuals, so acceptability is poorly understood. Upper limb rehabilitation remains a research frontier, which has been energized by new technologies, but is grounded by the basic need to find ways to allow older individuals to recover independence. This paper aims to review the applicability and generalizability of current research to the older stoke survivor. Future research priorities need to be tailored to consider the older mean age of individuals in stroke rehabilitation.