Shoulder Dysfunction Associated with Stroke

Original Editor - Robin Tacchetti based on the course by Srishti Banerjee
Top Contributors - Robin Tacchetti, Jess Bell, Stacy Schiurring and Kim Jackson

Introduction[edit | edit source]

Shoulder pain is a common complication for patients with hemiplegia,[1][2] and shoulder subluxation of the humeral head is one potential cause of this pain. During the stroke recovery process, up to three quarters of patients experience shoulder subluxation.[3] Glenohumeral subluxation post-stroke usually occurs 2-3 months post-stroke.[4] Hemiplegic shoulder subluxation is more common with left sided hemiplegia.[4]

Glenohumeral subluxation can complicate rehabilitation as shoulder function is necessary for successful transfers, performing activities of daily living, effective hand function and maintaining balance. Additionally, patients with an acute stroke performing rehabilitation with poor upper limb motor function are more vulnerable to soft-tissue injuries, tendonitis and pain. The most common sites of soft tissue injury are the biceps and supraspinatus tendon on the affected side.[5]

Shoulder Mechanics for Glenohumeral Stability[edit | edit source]

For more in-depth reading on the anatomy, clinical characteristics and presentation of glenohumeral subluxation, please see this article.

Stability of the shoulder depends on static and dynamic stabilisers. The glenoid labrum, glenohumeral ligament and the coracohumeral ligaments make up the static stabilisers. The dynamic stabilisers work to keep the humeral head in the glenoid fossa during arm elevation, and are made up of the deltoid and rotator cuff muscles.[5]

Causative Factors[edit | edit source]

There are many factors that lead to subluxation in the hemiplegic population including:

  • Paresis of supraspinatus and posterior deltoid
  • Flaccid muscles, ligaments and capsules leading to overstretching
  • Spasticity of muscles causing muscle imbalance
  • Extremes of passive range of motion by therapist or caregiver[3]
  • Improper positioning
  • Lack of support in the upright position
  • Pulling on the hemiplegic arm when the individual is transferred[6]

Flaccidity[edit | edit source]

Range of motion in the upper extremity is limited following a stroke and gradually worsens after the first month.[4] During the first three weeks, patients post-stroke will present with a lateral trunk lean toward the hemiplegic side and the hemiplegic shoulder muscles become flaccid.[5] [6] This low tone affects the surrounding structures and results in altered alignment of the scapula and humerus.[5] Because the dynamic stabilisers, (rotator cuff, particularly supraspinatus) are hypotonic, they cannot maintain the integrity of the glenohumeral joint.[6] The static stabilisers are overstretched due to the weight of the arm in a dependent position.[5] The humeral head, therefore, displaces inferiorly and anteriorly as a result of the gravitational pull on the arm and muscle hypotonicity.[5]

Spasticity[edit | edit source]

After the flaccid stage post-stroke, hemiplegic patients will enter a spastic stage. The affected shoulder becomes hypertonic causing altered alignment of the scapula. The particular muscles that can become hypertonic include the latissimus dorsi, pectoralis major and minor, levator scapulae and rhomboids.[6] The severity of subluxation and shoulder pain worsen once spasticity develops.[5]

Assessment[edit | edit source]

Two common ways to measure glenohumeral subluxation clinically are palpation and anthropometric measurements.

Fingerbreadth Palpation Method[edit | edit source]

To determine if shoulder subluxation is in fact present, clinicians can use palpation techniques. Two bony landmarks are palpated: the acromion and the head of the humerus determining how many fingers' breadth can fit in the space between the two. The amount of fingers correlate to a subluxation grading system[6]:

A 0–5 grading scheme can be used:[7]

  • 0=no subluxation
  • 1=½ fingerbreadth gap
  • 2=1 fingerbreadth gap
  • 3=1½ fingerbreadth gap
  • 4=2 fingerbreadth gap
  • 5=2½ fingerbreadth gap

Anthropometrical Measurements[edit | edit source]

Anthropometrical measurements utilise tape or a caliper to determine the distance between the acromion and a distal bony landmark. Clinicians typically use the lateral epicondyle of the humerus or the head of the humerus as their distal location. The affected side is then compared to the non affected side.[6]

Prevention and Treatment[edit | edit source]

Positioning and Education[edit | edit source]

Correctly handling and positioning the affected upper extremity is critically important. Training and education should be given to the clinical staff, family/caregivers and to the patient.[5] Tips for handling a hemiplegic arm to prevent subluxation:

  1. When the patient is lying on the hemiplegic side, it is important to glide the scapula a bit forward
  2. Externally rotate the shoulder when abducting the shoulder[8]

The use of lapboards, pillows and supports have been found useful with patients lying in bed or sitting upright in a chair or wheelchair. Utilising these types of supports has been found to decrease inferior displacement of the humerus thereby reducing glenohumeral subluxation.[6] Tips for positioning with pillows include:

  1. The patient is in supine: one pillow should be placed under the patient's head, keeping the head and neck in a neutral position, one supporting the weaker arm, and hip.
  2. Lying on the hemiplegic side: place one or two pillows under the patient's neck to prevent any side flexion or rotation of the neck. This maintains the head and neck in a neutral position. A pillow should be placed under the shoulder.
  3. Lying on the stronger side: place one pillow under the patient's neck and head to keep it in a neutral position with the weaker arm supported on a pillow.
  4. Sitting: encourage the patient to sit in the middle of the chair or wheelchair with arms supported on a pillow and forearm on the pillows, or on the lap.[8]

Slings[edit | edit source]

Shoulder slings have various purposes including supporting the forearm in a flexed position, realigning scapular symmetry, improving anatomic alignment and supporting the shoulder with a cuff. Caregivers tend to prefer slings as they are easier to use over other techniques such as taping.[6] Clinically, slings can be helpful to avoid subluxation during transfers.[5] Slings tend to be controversial because they lend themselves to increasing synergistic patterns and flexor tone. The needs of each patient will dictate whether a sling is beneficial.[6]

**Recent evidence shows that slings with proximal and distal attachments are more effective in preventing subluxation.[9]

Taping[edit | edit source]

Taping is another option to prevent and/or treat subluxation of the glenohumeral joint. Benefits of taping include:

Although there is limited evidence on taping for subluxation, a 2020 study by Deng et al.[10] demonstrated that kinesio taping was beneficial in reducing shoulder subluxation and improving motor function of the upper limb. They concluded that taping benefits may have been due to sensory stimulation, limiting motion and facilitating muscle activation.[10]

Neuromuscular Electrical Stimulation[edit | edit source]

A tool which has shown to be effective in treating and preventing glenohumeral subluxation is neuromuscular electrical stimulation (NMES). The earlier NMES is applied post-stroke, the better the outcome. Either functional electrical stimulation or intra-muscular stimulation can be applied with muscular focus on supraspinatus, posterior deltoid and the long head of biceps. NMES in this population is thought to prevent muscle wasting and promote motor recovery.[5]

See the video by Saebo UK for a demonstration of how to use NMES post-stroke:

Resources[edit | edit source]

References[edit | edit source]

  1. Deng P, Zhao Z, Zhang S, Xiao T, Li Y. Effect of kinesio taping on hemiplegic shoulder pain: A systematic review and meta-analysis of randomized controlled trials. Clinical Rehabilitation. 2021 Mar;35(3):317-31.
  2. Kumar P, Fernando C, Mendoza D, Shah R. Risk and associated factors for hemiplegic shoulder pain in people with stroke: A systematic literature review. Physical Therapy Reviews. 2022 Aug 15;27(3):191-204.
  3. 3.0 3.1 Arya KN, Pandian S, Bhatnagar N, Sharma A. Rehabilitation of the Shoulder Subluxation Based on Ultrasonographic Findings among Post Stroke Subjects: A Case Series. Neurology India. 2021 Sep 1;69(5):1309.
  4. 4.0 4.1 4.2 Anwer S, Alghadir A. Incidence, prevalence, and risk factors of hemiplegic shoulder pain: a systematic review. International journal of environmental research and public health. 2020 Jul;17(14):4962.
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 Razaq S, Azam Rathore F. An overview of pathophysiology, assessment and management strategies of post stroke shoulder subluxation. Pakistan Journal of Neurological Sciences (PJNS). 2016;11(3):42-8.
  6. 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 Paci M, Nannetti L, Rinaldi LA. Glenohumeral subluxation in hemiplegia: An overview. Journal of rehabilitation research & development. 2005 Jul 1;42(4).
  7. Kumar P, Mardon M, Bradley M, Gray S, Swinkels A. Assessment of glenohumeral subluxation in poststroke hemiplegia: comparison between ultrasound and fingerbreadth palpation methods. Phys Ther. 2014 Nov;94(11):1622-31.
  8. 8.0 8.1 Banerjee, S. Shoulder Dysfunction Associated with Neurological Disorders. Plus. 2022
  9. Kim, M.G., Lee, S.A., Park, E.J., Choi, M.K., Kim, J.M., Sohn, M.K., Jee, S.J., Kim, Y.W., Son, J.E., Lee, S.J. and Hwang, K.S., 2022. Elastic Dynamic Sling on Subluxation of Hemiplegic Shoulder in Patients with Subacute Stroke: A Multicenter Randomized Controlled Trial. International Journal of Environmental Research and Public Health, 19(16), p.9975.
  10. 10.0 10.1 Deng P, Zhao Z, Zhang S, Xiao T, Li Y. Effect of kinesio taping on hemiplegic shoulder pain: A systematic review and meta-analysis of randomized controlled trials. Clin Rehabil. 2021 Mar;35(3):317-331.