Shoulder Pain in Hemiplegia

Abstract

Development of a painful shoulder in the hemiplegic patient is a significant and serious problem, because it can limit the patient's ability to reach his or her maximum functional potential. Several etiologies of shoulder pain have been identified, such as immobilization of the upper extremity, trauma to the joint structures, including brachial plexus injuries, and subluxation of the gleno-humeral joint. A review of the literature explains the basic anatomy and kinesiology of the shoulder complex, the various etiologies of hemiplegic shoulder pain, and the pros and cons of specific treatment techniques. This knowledge is essential for the occupational therapist to evaluate effectively techniques used to treat the patient with hemiplegic shoulder pain. More effective management of this problem will facilitate the patient's ability to reach his or her maximum functional potential.

Effectiveness of the California Tri-Pull Taping Method for Shoulder Subluxation Poststroke: A Single-Subject ABA Design

“…This muscle activity may be absent when flaccidity occurs after a stroke (Andersen, 1985). Chaco and Wolf (1971) found that subluxation developed within several weeks after a stroke when the arm was flaccid and that normal muscle contraction did not occur in response to loading.…”

“…The causes of inferior subluxation after stroke are unclear, although many factors have been proposed as contributory (Andersen, 1985;Basmajian & Bazant, 1959;Ikai, Tei, Yoshida, Miyano, & Yonemoto, 1998;Moskowitz, Goodman, Smith, Balthazar, & Mellins, 1969;Runyan, 1995). In approximately 90% of patients early poststroke, the affected extremity is initially flaccid (Moskowitz et al, 1969).…”

“…Roy described Van Ouwenaller et al's (1986) report as the most reliable estimate of shoulder pain, with as much as 72% of the population with hemiplegia reporting pain. Other potential causes of shoulder pain are spasticity (Van Ouwenaller et al, 1986); limited shoulder range of motion (ROM), especially in the degree of shoulder external rotation (Ikai et al, 1998;Zorowitz et al, 1996); brachial plexus injuries, especially axillary nerve compression (Shai, Ring, Costeff, & Solzi, 1984) from overstretching of the periarticular tissue (Van Langenberghe & Hogan, 1988) and other impingement syndromes (Ridgway & Byrne, 1999); adhesive capsulitus (frozen shoulder; Ikai et al, 1998;Ridgway & Byrne, 1999); tendonitis (Ridgway & Byrne, 1999), possibly from rotator cuff injuries and tears (Dromerick, Edwards, & Kumar, 2008) or in the long head of the biceps (Dromerick et al, 2008); complex regional pain syndrome (Griffin & Reddin, 1981); and poor position and mishandling (Andersen, 1985;Davis, 2001;Runyan, 1995), especially forcing movement of the arm past 90°of shoulder flexion or abduction before placing the head of the humerus into place or performing ROM on a patient's arm when the scapula is not gliding (Davis, 2001;Griffin & Reddin, 1981). It appears that if a correlation exists between pain and subluxation, it is the result of the increased risk of trauma from improper handling of the subluxed hemiplegic shoulder and overstretching of tissue, possibly leading to impingement problems and tears.…”

“…Although subluxation is regarded by many authorities as a major cause of shoulder pain (Andersen, 1985;Griffin & Reddin, 1981;Van Ouwenaller, Laplace, & Chantraine, 1986), several studies have found no direct correlation between subluxation and shoulder pain (Bohannon & Andrews, 1990;Ikai et al, 1998;Van Langenberghe & Hogan, 1988;Zorowitz, Hughes, Idank, Ikai, & Johnston, 1996). Roy (1988) reviewed the literature on the occurrence of shoulder pain in patients with hemiplegia (not specifically subluxed) and found that reported incidence of pain varied between 5% and 84% of patients in different studies as a result of different definitions of pain and patient selection.…”

A critical review of shoulder subluxation and its association with other post-stroke complications

“…62,63 Following stroke, in the absence of muscle function, soft tissues such as the joint capsule and ligaments provide protection and support to the shoulder joint but only for a limited period of time. 64,65 Gradually, the weight of the arm under the influence of gravity causes the capsule to stretch, leading to inferior subluxation, 4,25 which becomes apparent when the patient is in a gravitydependent position. Activation of shoulder muscles, therefore, has been a key therapeutic intervention in the clinical management of subluxation.…”