Shoulder pain in hemiplegia—a literature review

Pulsed Radiofrequency Neuromodulation for Post-Stroke Shoulder Pain in Patients with Hemorrhagic Stroke

OBJECTIVE

Post-stroke shoulder pain (PSSP) is a common complication that limits the range of motion (ROM) of the shoulder, the patient's rehabilitation and in turn, affects the patients' quality of life (QoL). Several treatment modalities such as sling, positioning, strapping, functional electrical stimulation, and nerve block have been suggested in literatures, however none of the treatments had long-term effects for PSSP. In this study, the authors evaluated clinical efficacy of pulsed radiofrequency (PRF) neuromodulation on the suprascapular nerve for PSSP, and suggested it as a potential treatment with long-term effect.

METHODS

This retrospective case series was conducted at a single center, a private practice institution. From 2013 to 2021, 13 patients with PSSP underwent PRF neuromodulation of the suprascapular nerve. The primary outcome measure was the Visual analog scale (VAS) score. The secondary outcome measurements included the shoulder ROM, Disability assessment scale (DAS), modified Ashworth scale, modified Rankin scale (mRS), and EuroQol-5 dimension-3L questionnaire (EQ-5D-3L) scores. These parameters were evaluated before PRF modulation, immediately after PRF modulation, and every 3 months until the final follow-up visit.

RESULTS

Six men and seven women were enrolled, and all patients were followed-up for a minimum of 12 months. The mean VAS score was 7.07 points before PRF neuromodulation and 2.38 points immediately post-procedure. Shoulder ROM for abduction and flexion, DAS for pain, mRS, and EQ-5D-3L demonstrated marked improvement. No complications were reported.

CONCLUSION

PRF neuromodulation of the suprascapular nerve is an effective modality in patients with PSSP, and has long-term effect of pain relief, improvement of QoL.

Exploring the Capabilities of Harmony for Upper-Limb Stroke Therapy

Harmony is a bimanual upper-limb exoskeleton designed for post-stroke rehabilitation. It moves the subject's shoulders and arms through their entire ranges of motion while maintaining natural coordination, is capable of force/torque control of each joint, and is equipped with sensors to measure motions and interaction forces. With these capabilities Harmony has the potential to assess motor function and create individualized therapy regimens. As a first step, five stroke survivors underwent rehabilitation sessions practicing multijoint movements with the device. Each participant performed a total of 1130 motions over seven hours of therapy with no adverse effects reported by participants or the attending therapist, supporting the suitability of Harmony for use in a clinical setting. Donning and doffing time averaged 3.5 minutes and decreased with therapist experience. Reported levels of stress, anxiety, and pain indicate that the Harmony safely assisted in the completion of the trained movements and has great potential to motivate and engage patients. We developed a novel methodology for assessing coordination capability and results from the study indicate that Harmony can enable therapists to identify neuromuscular weakness and maladaptive coordination patterns and develop targeted interventions to address these aspects of upper-limb function. The results suggest Harmony's feasibility and show promising improvements, motivating future study to gain statistical support.

Observation of arm behaviour in healthy elderly people: Implications for contracture prevention after stroke

The purpose of this study was to observe normal arm movement in healthy older adults to determine the duration, frequency, and purpose of arm elevation and external rotation to guide clinical practice in the prevention of contracture. An observational study was undertaken in the homes and local community of 21 older people mean age 73 (SD 7) years. Participants' arm movements were observed for a median time of 254 (IQR 85) min during the day. The duration (min/hr) and frequency (movements/hr) which the arm spent in positions of 45 degrees to 90 degrees elevation, > 90 degrees elevation, and external rotation, as well as the purpose (manipulating, holding, reaching, pulling/pushing, or gesturing) for which these positions were adopted, were recorded. Participants' arms spent little time (3.6 min/hr) at 45 to 90 degrees elevation and almost no time (0.6 min/hr) at > 90 degrees elevation or external rotation (0.6 min/hr). Participants' arms moved to > 90 degrees elevation 13 times/hr and into external rotation 18 times/hr. Participants moved momentarily to elevation > 45 degrees and external rotation in order to reach for objects, while holding objects was the primary reason for maintaining positions for > 2 s. It may be possible to minimise the incidence of shoulder contracture in those patients with stroke who have regained some shoulder muscle activity by placing at-risk muscles in lengthened positions while replicating these features of everyday activities.

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.

The immediate effect of handling technique on range of movement in the hemiplegic shoulder

PURPOSE

To assess the immediate effect of two different handling. techniques on range of flexion in the hemiplegic shoulder.

METHOD

A randomized controlled design with within-subject comparison was used. Range of shoulder flexion was measured using a bubble goniometer. Range of passive movement was compared as the weak arm was lifted using an 'axilla hold' (when the gleno-humeral joint is supported and held in external rotation) and a 'distal hold' (when the arm is lifted at the forearm without shoulder support). Twenty-two people with arm weakness following stroke were recruited. They were inpatients or attending a day hospital in two NHS trusts, with no previous limitation of range or function of their arm. A paired t-test was used for analysis.

RESULTS

Mean shoulder flexion for the axilla hold was 115.2 degrees (SD 38.45), and 97.7 degrees (SD 44.7) for the distal hold. This difference was significant at p < 0.001 (95% confidence interval (95% CI) 7.96, 26.88).

CONCLUSIONS

Lifting the hemiplegic arm by holding the humerus under the axilla and maintaining external rotation produces greater range of flexion at the hemiplegic shoulder than a 'distal hold'.

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.

Reliability of a measure of post-stroke shoulder pain in patients with and without aphasia and/or unilateral spatial neglect

OBJECTIVE

To determine the inter/intra-rater reliability of expert physiotherapists (PTs) measuring post-stroke shoulder pain with 100 mm vertical visual analogue scales (VAS; intensity, frequency and affective response) and a categorical site-of-pain scale.

DESIGN

Three PTs independently rated subjects (normal clinical procedure but with a standardized starting position) on three days, at the same time of day, during one week in a randomized order determined by a nested latin square. Reliability for VAS scores was determined with the intraclass correlation coefficient (ICC) and for site-of-pain with the kappa statistic (kappa). Acceptable reliability was set at 0.75. The limits of agreement were also calculated.

SETTING

Community.

SUBJECTS

Thirty-three patients, mean time post stroke 42 months (range 7-360).

RESULTS

Mean inter-rater reliability was 0.79 for intensity, 0.75 for frequency and 0.62 for affective response (ICC). The limits of agreement were wide and rater bias was significant for 6/27 ratings. Mean intra-rater reliability was 0.70 for intensity, 0.77 for frequency and 0.69 for affective response (ICC). For site-of-pain inter-rater reliability ranged from 0.156 (kappa) to 0.385 (kappa) and intrarater reliability ranged from 0.300 (kappa) to 0.559 (kappa).

CONCLUSIONS

Although inter-rater reliability was acceptable for intensity and frequency there was a consistently large systematic bias between pairs of raters. Agreement might be improved if a standardized assessment procedure was used and/or if training in pain behaviour interpretation was provided.