Current Evidences in the

understanding and
management of
Shoulder in Hemiplegia
Phinoj K. Abraham, MOTh (Neurosciences)
Occupational Therapist, Hamad Medical Corporation, Qatar
21-10-2015 1
Learning Objectives
• Discuss research findings regarding the
biomechanics of shoulder joint stability

• Report evidence behind treatment

techniques
and management for the hemiplegic
shoulder,
both ‘hypotonic’ and ‘hyper tonic’ shoulder 2

• Understand the role of the OT in the

Anatomy & Biomechanics of
Shoulder joint
1. Glenoheumaral
Joint
2. Sub deltoid joint
3. Acromioclavicular
Joint
4. Scapulothoracic
Joint
5. Sternoclavicular
(Shoulder Pain, Rene Cailliet M.D., Joint 3
1991)
6. 1st Costosternal
Shoulder Biomechanics
• Stability

• Static Stabilization

• Dynamic Stabilization

• Mobility

• 30 of freedom

• Scapulo-heumeral Rhythm
4
Static Stabilization
• Primarily by

• Rotator Interval Capsule

(superior capsule, superior GH
ligament, and coracohumeral
ligament)

• Also assisted by
• Degree of glenoid inclination
*
• Passive tension of the intact 5
supraspinatus muscle**
• Negative intra-articular
*Degree of glenoid inclination
• Literature from 1987-2001
• 1987 – Prevost et. al, - 3D X-ray
• 1995 – Culham et. al, - Linear and angular
measures of
scapular and humeral
orientation
• 2001 – Price & Pandyan – Sensor based
scapular
locator system
6
“Severity of subluxation is not linked with a
Robert Teasell MD et al., (2013) Hemiplegic shoulder pain p. 8; The Evidence-
particular
Based Review scapular(EBRSR)
of Stroke Rehabilitation resting position after
www.ebrsr.com
**Role of Muscles around
shoulder in GH stability

• EMG studies showed that the muscles

around shoulder joint are eclectically silent in
the relaxed unloaded limb, even when the
limb is tugged vigorously downward 1

1)Basmajian, Bazant & MacConaill (1959, 1969) Cross reference from 7

‘Joint Strcture & Function: A comprehensive Analysis – Cynthia
Norkins – 5th Edn p. 253
Role of Muscles Contd…

• ….the ‘reinforcing passive tension (muscle

tone) of supraspinatous and subscapularis
muscles are actually contributing to static
shoulder stability than any active muscle
contraction’ 1

1) Joint Structure & Function: A comprehensive Analysis – Cynthia 8

Norkins – 5th Edn p. 253
Section Summary
• In a normal shoulder, the static stability
is contributed by a passive mechanism

9
Hemiplegic shoulder
> Hypotonic Shoulder
> Hypertonic Shoulder

10
Hypotonic Shoulder

1) Hemiplegic Shoulder
Subluxation (HSS)

2) Hand Edema

11
1) Shoulder Subluxation

1.1) Pathophysiology
• Hypotonicity in supraspinatous muscle +
Weight of the limb

1.2) Scapular Rotation

• …is unrelated to hemiplegic shoulder
subluxation

1) Joint Structure and function – Cynthia Norkins 4th Edn. P 249 12

2) Robert Teasell MD et al., Hemiplegic shoulder pain (2013) p. 21; Retrieved
from The Evidence-Based Review of Stroke Rehabilitation (EBRSR)
www.ebrsr.com
1. Shoulder Subluxation Contd...
1.3) Shoulder Subluxation & Shoulder Pain

• 8 large studies support, (between 1984 -

2008) 11 do not support (between 1965 -
2009) role of subluxation in pain

• Not all patients with subluxation have pain!

Robert Teasell MD et al., Hemiplegic shoulder pain (2013) p. 21; Retrieved from
13
The Evidence-Based Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com
1. Shoulder Subluxation Contd...
1.4) Relationship between severity of shoulder
subluxation and soft tissue injury
• “Shoulder subluxation lateral distance,
measured by physical examination, is a
predictor for supraspinatus tendonitis - ≥2.25
cm

Shih-Wei Huang et. al, J Rehabil Med

2012; 44: 733–739
14
 Management of shoulder
subluxation
i) POSITIONING
A. Bed Positioning .

15
Lying on Unaffected side Lying on Affected side
i) Positioning Contd…
• Effectiveness of bed positioning ?

“ There is consensus (Level 3) opinion that

proper positioning of the hemiplegic
shoulder helps to avoid subluxation.
However, there is conflicting (Level 4)
evidence that prolonged positioning
prevents loss of active or passive range of
motion, or reduces pain.”
Robert Teasell MD et al., Hemiplegic shoulder pain (2013) p. 21;
Retrieved from
16
The Evidence-Based Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com
 i) Positioning Contd…
B. Slings and other aids (like lap boards)
Advantages Disadvantages
• reduction of the vertical • Immobilization of the
& horizontal component
of shoulder subluxation; adducted paretic arm
• delayed onset of in internal rotation
shoulder pain
• Restricted use of the
• increased muscle tone in
the flaccid shoulder paretic arm during
muscles ADL.
• increased passive range • Lateral subluxation
of motion (PROM) of the
shoulder.
17
KNGF Clinical Practice Guidelines for physical therapy in patients with stroke,
Supplement to the Dutch Journal of Physical Therapy Volume 114 / Issue 5 / 2004
P. 129
 i) Positioning Contd…
• Effectiveness of Slings and other aids ?
“the commonly used hemiplegic sling has no
appreciable effect on ultimate range of motion,
shoulder subluxation, pain or peripheral nerve traction
injury.” (1974)1

“There is limited (Level 2) evidence that shoulder

slings prevent subluxation associated with
hemiplegic shoulder pain, although there is also
limited (Level 2) evidence that one device or
1. method
Marvin M Hurd, et al Shoulderis
slingno betterfriend
for hemiplegia: than
or Foe?another.” (2012)
Arch phys Med Rehabil
2
1974; 55:519-22
18
2. Robert Teasell MD et al., Hemiplegic shoulder pain p. 21; The Evidence-Based Review of
Stroke Rehabilitation
i) Positioning Contd…
Clinical Implications

• Use a sling only as a preventive measure in

patients with stroke who report a painful
shoulder in vertical postures.
• Since wearing a sling restricts the freedom of
motion of the paretic arm, it should be worn
as briefly as possible.

KNGF Clinical Practice Guidelines for physical therapy in patients with stroke,
Supplement to the Dutch Journal of Physical Therapy 19
Volume 114 / Issue 5 / 2004 P. 129
ii) Strapping the Hemiplegic
Shoulder
• Strapping: has the theoretical advantage
of reducing GHS while preserving the
range of motion of the shoulder joint,

• Three different forms of strapping the

hemiplegic shoulder proposed by 3 | Hanger et al. 2000
authors
• Ancliffe 1992:
• Morin & Bravo 1997:
20
• Hanger et al. 2000:
Morin & Bravo 1997
 Strapping Contd…
• Effectiveness of Strapping ?
“strapping techniques are not effective in reducing
or preventing glenohumeral subluxation in the
vertical direction (diastasis)” 1
There is conflicting (Level 4) evidence that
strapping the hemiplegic shoulder reduces the
development of pain. There is moderate (Level 1b)
evidence that strapping does not improve upper
limb function or range of motion. 2
21
1) KNGF Clinical Practice Guidelines Volume 114 / Issue 5 / 2004 P. 129
2) EBRSR Robert Teasell MD et al., Hemiplegic shoulder pain (2013)
iii) ROM Exercises, Passive
modalities, NSAID’s

“Aggressive range of motion exercises (i.e.

pullies) results in a markedly increased
incidence of painful shoulder; a gentle range of
motion program is preferred. Adding ultrasound
treatments is not helpful while NSAIDs may be
helpful.”
22
1. Robert Teasell MD et al., Hemiplegic shoulder pain p. 21; The Evidence-Based
Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com
iv) Electrical Stimulation in the
Hemiplegic Shoulder

“There is strong (Level 1a) evidence that that

electrical stimulation helps to prevent the
development of shoulder subluxation and reduce
shoulder subluxation (Level 1a)”

1. Robert Teasell MD et al., Hemiplegic shoulder pain p. 21; The Evidence-Based 23

Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com
2) Hand Edema
• Fact Sheet
• Hand edema may be an isolated problem or
occur as a symptom of shoulder-hand
syndrome.

• The etiology is unclear.

• The most widely accepted explanation is of

increased venous congestion related to
prolonged dependency and loss of MUSCLE
PUMPING FUNCTION in the paretic limb (Leibovitz
1. Robert 24
et al. Teasell
2007)MD et al., Upper extremity Interventions. P 122; The Evidence-
Based Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com
2) Hand Edema Contd…
• 83% of 85 acute stroke patients suffered from
hand edema not associated with shoulder-
hand syndrome.

• Volumetric assessments of the hand appear

to provide the best estimation; while the
reliability of clinical evaluation through visual
inspection is poor

• Hand Edema as a Prognostic Indicator?

It’s controversial
1. Robert Teasell MD et al., Upper extremity Interventions. P 122; The Evidence- 25
Based Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com
Treatment of Hand Edema
• 3 treatment approaches have been studied1
• passive motion exercises,
• neuromuscular stimulation and
• intermittent pneumatic compression

• Effectiveness of these interventions

“ Continuous passive motion and electrical
stimulation might be effective treatments for hand
edema, while intermittent pneumatic compression is
not.” 26
1. Robert Teasell MD et al., Upper extremity Interventions. P 122; The Evidence-
Based Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com
Section Summary
• Proper bed position may helps to avoid
subluxation
• Shoulder slings can be used a s a preventive
measure and it should be worn as briefly as
possible.
• Strapping will not help to prevent / reduce
shoulder subluxation
• Gentle ROM exercises helps to prevent
secondary complications
• FES may help to prevent / reduce shoulder
subluxation 27

• Passive ROM exercises and electrical stimulation

Hemiplegic shoulder
> Hypotonic Shoulder
> Hypertonic Shoulder

28
Hypertonic Shoulder
• Causes : Multifactorial
• Spasticity & spastic muscle imbalance (Neural
elements induced)
• Tightness / Contracture (Non Neural Elements or
biomechanical elements induced)
• Associated Reactions / Position induced
• Consequences of high tone:
• Impaired skin care (axilla and hand)
• Impaired ADLs (dressing)
• Impaired range of motion 29

• Shoulder pain
Spastic Muscle Imbalance
• Imbalance between agonist and antagonist
• Agonist in synergy pattern become strong and
tight
• Stretching of these muscle cause pain
• Flexor synergy is common in hemiplegic U/E with
predominating spasticity in shoulder internal
rotators
• Among these spastic muscle imbalance is most
common in subscapularis and pectoralis major
1. Robert Teasell MD et al., Hemiplegic shoulder pain p. 21; The Evidence-Based 30
Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com
Subscapularis Spasticity Disorder (SSD)
• Normally, subscapularis are
inhibited in shoulder abduction and
allow the heumerus to externally
rotate

• In flexor synergy pattern, the

subscapularis is tonically active
limiting external rotation, shoulder
abduction and flexion 1 This leads
to shoulder impingement
• In SSD, shoulder Ext. Rotation will
be most painful and restricted 31
Robert Teasell MD et al., Hemiplegic shoulder pain p. 21; The Evidence-Based
Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com
Pectoralis Spasticity Disorder (PSD)
• Characterized by motion being most
limited and pain produced on abduction

32
Common associated problems
1. Rotator cuff disorders
• shoulder pain is not commonly associated with
rotator cuff disorders.
• Partial tears of the rotator cuff musculature are
common and it is always difficult determining
whether they were present premorbidly even in
previously asymptomatic patients.
• Najenson et al. (1971)

2. Frozen (or) contracted shoulder (Adhesive

capsulitis)
• Majorly affected the capsule of shoulder joint
3. Shoulder hand syndrome / RSD (CRPS) 33

4. Myofacial syndrome / trigger points

Management of hypertonic shoulder
• Positioning
• Promote position that is opposite to flexor pattern
• Position for extended periods of time (up to 1 hour
or more)
• Use pillow, air splint, casting etc…
• ROM exercises
• As mentioned in the previous section.
• Medical Management
• Botilinium toxin – effects are un cleare 1
• Deinnervation of the subscapularis improve ROM
34
than pectoralis major
Conclusions Regarding Spastic
Hemiplegic Shoulder
‘There is an association between spasticity
and the development of hemiplegic shoulder
pain’

‘Spasticity and subsequent frozen shoulder

are the most likely causes of hemiplegic
shoulder pain’
Robert Teasell MD et al., Hemiplegic shoulder pain p. 21; The Evidence-Based 35
Review of Stroke Rehabilitation (EBRSR) www.ebrsr.com
Major References
1. Joint Structure and function (2005), 4th edn. By Pamela
K Levangie and Cynthia C. Norkins. FA Davis
Publication
2. Shoulder Pain, Rene Calliate MD, (1980) FA Davis
publication
3. Robert Teasell MD et al., Hemiplegic shoulder pain p.
21; The Evidence-Based Review of Stroke
Rehabilitation (EBRSR) www.ebrsr.com
4. KNGF Clinical Practice Guidelines for physical therapy
in patients with stroke,Supplement to the Dutch Journal
of Physical Therapy Volume 114 / Issue 5 / 2004 P. 129
5. Relationship between Severity of Shoulder Subluxation 36
and Soft-Tissue Injury IN Hemiplegic Stroke Patients
Shih-Wei Huang et. al, J Rehabil Med 2012; 44: 733–
739
37

37
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