Hemiplegic Shoulder Subluxation
Original Editor - Fasuba Ayobami
- 1 Introduction
- 2 Epidemiology
- 3 Pathomechanics and Risk factors
- 4 Assessment
- 5 Evidence Based Physical Therapy Management
- 6 Resources
- 7 References
The glenohumeral joint is multiaxial and has a wider range of motion than other joints. In order to achieve such a range of motion, the glenohumeral joint has to sacrifice a more stable bone structure, and this lack is compensated by muscular stability. When a change in normal muscular function occurs eg after a stroke, this presents a potential risk for subluxation.
- During the initial period following a stroke, the hemiplegic arm is flaccid or hypotonic. The shoulder muscles are unable to anchor the humeral head within the glenoid cavity, resulting in a high risk of shoulder subluxation.
- During this period, the affected extremity should be properly supported; the weight of the arm itself may be enough to cause subluxation.
- Glenohumeral subluxation may also occur as a result of adopting incorrect sleeping postures, lack of support when the patient is in a vertical position, or tension on the hemiplegic arm when the patient is being moved from one place to another.
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. 
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.
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.
Other factors contributing to subluxation include
- improper positioning,
- lack of support in the upright position
- pulling on the hemiplegic arm when the patient is transferred.
- Severe loss of motor function and apparent absence of supraspinatus muscle contraction are potential risk factors for GHS, 
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.
So other method commonly used is Fingerbreadth palpation method.
Fingerbreadth Palpation MethodPatients 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:
1=½ fingerbreadth gap,
2=1 fingerbreadth gap,
3=1½ fingerbreadth gap,
4=2 fingerbreadth gap, and
5=2½ fingerbreadth gap.
Evidence Based Physical Therapy Management
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.
Shoulder support or orthosis while in situ may reduce the subluxation temporarily.
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.
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.
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.
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.
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.
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.
Neuromuscular Approaches: Neuromuscular electrical stimulation
|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
Session frequency: 7 d/wk for 4–6 wk or until voluntary
control has been restored
Facilitation of Movement
- 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.Take care as if improperly carried out, it can cause injury to the shoulder and increase the stroke patient’s risk for shoulder subluxation.
- 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.
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.
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.
The 5 minute video below gives some good exercises to use for hemiplegic shoulder.
- Shoulder subluxation
- Linn SL, Granat MH, Lees KR. Prevention of shoulder subluxation after stroke with electrical stimulation. Stroke. 1999 May;30(5):963-8.
- 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.Available from:https://www.tandfonline.com/doi/abs/10.1080/10749357.2017.1383712?scroll=top&needAccess=true&journalCode=ytsr20 (last accessed 25.2.2020)
- Murie-Fernández M, Iragui MC, Gnanakumar V, Meyer M, Foley N, Teasell R. Painful hemiplegic shoulder in stroke patients: causes and management. Neurología (English Edition). 2012 May 1;27(4):234-44.Available from:https://www.elsevier.es/en-revista-neurologia-english-edition--495-articulo-painful-hemiplegic-shoulder-in-stroke-S2173580812000478 (last accessed 25.2.2020)
- https://www.stroke-rehab.com/shoulder-subluxation.html (Accessed 6th May, 2018)
- 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.
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- 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.
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- 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.
- https://www.flintrehab.com/2016/shoulder-rehab-exercises-to-alleviate-pain-and-improve-mobility/ (Accessed on 6th May, 2018)
- 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).
- 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.
- 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.
- 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.
- Bob and Brad Top 3 Exercises for Weak Arm after Stroke (Simple Do-it-yourself) Available from:https://www.youtube.com/watch?v=0GkA21ngLG0 (last accessed 25.2.2020)