Hemiplegic Shoulder Subluxation

Introduction

[1]Radiographic image showing glenohumeral subluxation

Shoulder subluxation is one of the major complications experienced among stroke survivors.Glenohumeral subluxation (GHS) is a inferior displacement of humeral head from the glenoid fossa. [2] [3] The glenohumeral joint is the most vulnerable joint in the shoulder complex to sublux due to its anatomical structure being stabilized only by surrounding muscles, the joint capsules and ligamentous structures.And also being an extremely mobile joint, it sacrifices stability for mobility.[4][1]

The association between GHS and other poststroke complications such as pain and poor motor recovery is uncertain.[5] But in long term due to GHS may lead to the adhesive capsulitits, reduce proprioception causing shoulder pain that may increase over time. This may delay the recovery of upper extremity function and  a key factor in post-stroke disability is the involvement of the upper limb.[6][7]

Epidemiology

The incidence of shoulder subluxation in patients following a stroke varies from 7–81% (depending on the measurement methods used and the time frames over which it is assessed) and 73% occur in the acute stage In a 10-month follow-up study, shoulder subluxation was shown to be further aggravated in 67% of patients over time. [6]

Pathomechanics and Risk factors

Studies had shown that the supraspinatus, and to a lesser extent the posterior deltoid muscles, played a key role in maintaining glenohumeral alignment and in preventing downward subluxation of the humerus.[8]

In 1959, Basmajian and Bazant offered a theory to explain the development of GHS . During the flaccid stage, the trunk tends to lean or shorten toward the hemiplegic side, which causes the scapula to descend from its normal horizontal level. The trapezium and the serratus anterior also become flaccid, causing the scapula to rotate downwardly. Without normal tone, the rotator cuff can no longer maintain the integrity of the GHJ. These conditions contribute to a subluxing GHJ. During the spastic stage, the pectoralis major and minor, rhomboideus, elevator scapulae, and latissimus dorsi can become hypertonic, further rotating the scapula downward, causing GHS. In contrary, other studies had not shown a relationship between scapular orientation and GHS. Severe loss of motor function and apparent absence of supraspinatus muscle contraction are potential risk factors for GHS, [8]

Other factors contributing to subluxation include improper positioning, lack of support in the upright position, and pulling on the hemiplegic arm when the patient is transferred.[8]

Assessment

Several method for the assessment of Shoulder subluxation.

Radiographic measurements ( X- ray and ultrasound ) considered a standard measurement, have been used in several studies to assess the effectiveness of therapy or development of GHS over time. But due to the several problems, such as costs, exposure to radiation, specialized eqiupments or delayed feedback for therapeutic choices, make measurements difficult to put into practice in many clinical settings.[8][5]

So other method commonly used is Fingerbreadth palpation method.

Fingerbreadth Palpation Method

Patients were seated in a chair or wheelchair with both feet flat on the ground or on a footrest. The physical therapist first assessed the unaffected side to palpate the gap between the acromion and the head of the humerus, and this assessment was repeated on the affected shoulder. Shoulders were positioned in neutral rotation, with the arm hanging by the side (thumb pointing forward) close to the body with no abduction. Some patients who demonstrated high tone were unable to hang their affected arm freely by the side. For these patients, the shoulder was maintained in internal rotation with slight elbow flexion and the forearm resting on their lap. Glenohumeral subluxation was defined as a palpable gap between the inferior aspect of the acromion and the superior aspect of the humeral head that is ½ fingerbreadth or more. A 0–5 grading scheme was used:
Patient Position to assess glenohumeral subluxation via fingerbreadth palpation method
0=no subluxation,

1=½ fingerbreadth gap,

2=1 fingerbreadth gap,

3=1½ fingerbreadth gap,

4=2 fingerbreadth gap, and

5=2½ fingerbreadth gap.[5]

Evidence Based Physical Therapy Management

Education

Caregivers/Health Professionals/Relatives need to be informed on the importance of proper handling of the arm. Stroke patients who have their arm unsupported and/or handled inappropriately by caregivers (pulling on the arm) are at a higher risk for traction neuropathy and injury. Hence, it is essential that caregivers of stroke survivors are adequately trained in handling the hemiplegic arm especially when shoulder subluxation is present.[2][7][9]

Mechanical Approaches

Shoulder support or orthosis while in situ may reduce the subluxation temporarily.[3]

Positioning

Lap trays, Pillows and foam support help to keep the arm and shoulder supported in the correct position. Good positioning will help reduce strain on your ligaments and prevent frozen shoulder from occurring.[2][7][10]

Slings

Studies has shown the effectiveness of slings to prevent GHS but no investigation assessed the effectiveness of slings in relation to the duration of their use. Supports from slings have various purposes: realigning scapular symmetry, supporting the forearm in a flexed arm position, improving anatomic alignment with an auxiliary support, or supporting the shoulder with a cuff.[8]

The use of slings has been considered a contraindication by some authors because slings can facilitate an increase in flexor tone and synergistic patterns, cause reflex sympathetic dystrophy, restrain functional recovery, obstruct arm swing during walking, and for some, impair body image.[8]

On the other hand, slings are generally more simple for caregivers to use than functional electrical stimulation (FES) or strapping, and they can be combined with the other treatments. Reviewing the literature and knowing the structural characteristics of slings can help identify the best treatment for preventing and treating GHS.[8]

Strappings

Shoulder strapping has been shown to be useful in the first period after stroke. Shoulder strapping is used clinically in patients with stroke, with a variety of techniques being employed; however, White et al. had brought out two main trends emerging from the literatures.

  • Longitudinal strapping method

It involves two to three strips of strapping that are applied with a cephalad tension over the anterior, middle and posterior deltoid to end over the shoulder complex, sometimes with an anchor strip applied.

  • Circumferential strapping method

It involves the application of strapping around the shoulder joint, originating on the clavicle, wrapping around the deltoid to go under the axilla (over a protective pad) and ending on the spine of the scapula.

The result of the study done by White et al, 2018 shows that longitudinal strapping of the shoulder in patients with stroke seems to positively influence shoulder subluxation and pain.[11]

Tapping

California Tri pull Taping Method
A study conducted by Chatterjee et al found California Tri-pull Taping method to reduces pain, improves active shoulder flexion, and improves distal UE functional ability. This appears to be a promising early adjunctive treatment for clients who have suffered a stroke and demonstrate pain in a subluxed shoulder. This taping method allows the patients to participate in all active UE exercises as well as all ADL's. However, there was no follow-up to determine if the effects demonstrated were maintained.[12]

Neuromuscular Approaches: Neuromuscular electrical stimulation

Electrical stimulation can prevent shoulder subluxation and decrease shoulder pain in acute phase, but this effect was not maintained after the withdrawal of treatment in later follow ups.[1][3]

Table 1: Recommendations for Use of NMES in Hemiplegic Shoulder Subluxation[13]
Indication Patient Position Electrode Placement Parameter Recommendations
Prevention or treatment of

shoulder sublux resulting

from UE flaccidity poststroke

Patient sitting with arm support One channel over muscle belly of supraspinatus

and posterior deltoid. Avoid upper trapezius fibres

and excessive shoulder shrug. Applying a second channel to stimulate the long

head of biceps can be beneficial in correcting humeral head alignment.

NMES waveform: symmetric or asymmetric biphasic PC

Frequency: 30–35 Hz

Pulse duration: 250–350 ms

Current amplitude: sufficient to produce a smooth,sustained muscle contraction and reduction of shoulder sublux

Work–rest cycle: ON:OFF 10–15 s ON time with progressively

shorter rest time (30 s ON time, 2 s OFF time). Rampup

time (1–4 s) is set to ensure patient comfort; longer

ramp-down time may be required to prevent pain or tissue

stretching when the arm sags due to gravity.

Treatment schedule: progress to 2–4 h/d on the basis of

muscle fatigue

Session frequency: 7 d/wk for 4–6 wk or until voluntary

control has been restored

Facilitation of Movement

Exercises

In the early phase of rehabilitation passive range of motion exercises has been shown to be effective in preventing shoulder subluxation among stroke patients. Range-of-motion exercises for the shoulder joint include flexion-extension, abduction-adduction and external-internal rotation. It is important to know that if the exercises are improperly carried out, it can cause injury to the shoulder and increase the stroke patient’s risk for shoulder subluxation.[2] Also, weight bearing exercises on the affected upper extremity proved to be beneficial. From a seated position on your bed or bench, prop yourself up on your affected arm by placing your affected arm about a foot away from your body. Then lean into it. If the patient feels comfort, this position should last for 10 seconds or so. And if otherwise, it should be stopped immediately.[10]

A pilot study done by Dohle et al, 2013 had conclued training with the linear shoulder robot improved shoulder stability, motor power, and resulted in improved functional outcomes that were robust 3 months after training.[4]

Study done by Jung el al, 2019 has shown that 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.[6]

Resources

References

  1. 1.0 1.1 1.2 Linn SL, Granat MH, Lees KR. Prevention of shoulder subluxation after stroke with electrical stimulation. Stroke. 1999 May;30(5):963-8.
  2. 2.0 2.1 2.2 2.3 Seneviratne C, Then KL, Reimer M, Then KL, Reimer M. Post-stroke shoulder subluxation: a concern for neuroscience nurses. AXONE-DARTMOUTH THEN HALIFAX NOVA SCOTIA-. 2005 Sep 1;27(1):26.
  3. 3.0 3.1 3.2 Arya KN, Pandian S, Vikas, Puri V. Rehabilitation methods for reducing shoulder subluxation in post-stroke hemiparesis: a systematic review. Topics in stroke rehabilitation. 2018 Jan 2;25(1):68-81.
  4. 4.0 4.1 Dohle CI, Rykman A, Chang J, Volpe BT. Pilot study of a robotic protocol to treat shoulder subluxation in patients with chronic stroke. Journal of neuroengineering and rehabilitation. 2013 Dec;10(1):88.
  5. 5.0 5.1 5.2 Kumar P, Mardon M, Bradley M, Gray S, Swinkels A. Assessment of glenohumeral subluxation in poststroke hemiplegia: Comparison between ultrasound and fingerbreadth palpation methods. Physical therapy. 2014 Nov 1;94(11):1622-31.
  6. 6.0 6.1 6.2 Jung KM, Choi JD. The Effects of Active Shoulder Exercise with a Sling Suspension System on Shoulder Subluxation, Proprioception, and Upper Extremity Function in Patients with Acute Stroke. Medical science monitor: international medical journal of experimental and clinical research. 2019;25:4849.
  7. 7.0 7.1 7.2 https://www.stroke-rehab.com/shoulder-subluxation.html (Accessed 6th May, 2018)
  8. 8.0 8.1 8.2 8.3 8.4 8.5 8.6 Paci M, Nannetti L, Rinaldi LA. Glenohumeral subluxation in hemiplegia: An overview. Journal of Rehabilitation Research & Development. 2005 Jul 1;42(4).
  9. Duncan PW, Zorowitz R, Bates B, Choi JY, Glasberg JJ, Graham GD, Katz RC, Lamberty K, Reker D. Management of adult stroke rehabilitation care: a clinical practice guideline. stroke. 2005 Sep 1;36(9):e100-43.
  10. 10.0 10.1 https://www.flintrehab.com/2016/shoulder-rehab-exercises-to-alleviate-pain-and-improve-mobility/ (Accessed on 6th May, 2018)
  11. Comley-White N, Mudzi W, Musenge E. Effects of shoulder strapping in patients with stroke: A randomised control trial. The South African journal of physiotherapy. 2018;74(1).
  12. Chatterjee S, Hayner KA, Arumugam N, Goyal M, Midha D, Arora A, Sharma S, Kumar SP. The California tri-pull taping method in the treatment of shoulder subluxation after stroke: a randomized clinical trial. North American journal of medical sciences. 2016 Apr;8(4):175.
  13. Nussbaum EL, Houghton P, Anthony J, Rennie S, Shay BL, Hoens AM. Neuromuscular electrical stimulation for treatment of muscle impairment: critical review and recommendations for clinical practice. Physiotherapy Canada. 2017;69(5):1-76.