Hemiplegic Shoulder Pain - Physical Therapy

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sive elevation and are a likely cause of impingement. An important question to be addressed is how much ROM is "enough." All medical professionals seem "programmed" to take each joint through its full ROM. As previously noted, complete ROM to a young physical therapist is not necessarily complete ROM to a geriatric stroke patient. Perhaps a more realistic goal is the maintenance of painfree functional ROM in the shoulder. The affected arm must be pain free to serve even in an assistive role. 38 Functional ROM has been defined as flexion to 100 degrees, abduction to 90 degrees, lateral rotation to 30 degrees, and medial rotation to 70 degrees. 90 Another aspect to be considered is whether abduction should be included in passive exercise, in view of its tendency to cause soft tissue impingement. Some authorities recommend that abduction should be performed only in the scapular plane, that is, 30 degrees to 40 degrees from the frontal plane, 3,34 because lateral rotation is not required to prevent impingement. 27 Curtailing the amplitude of passive abduction in exercise programs might preserve functional ROM and minimize impingement pain. If impingement during ROM is determined to be the etiological factor in pain, then the amplitude of passive motion should be kept within the pain-free range. 15 Caldwell et al reported that pain subsided in 43% of their patients with HSP when the amplitude of passive ROM was limited. 15 Should the patient begin to complain of pain during passive ROM, a thorough evaluation to assess the cause of pain should be conducted before pain and stiffness become established. Diagnosis of Established Painful Conditions If a patient has an established painful, stiff shoulder, the first step in treatment is the identification of the cause. A carefully detailed medical history is important to determine the prestroke history of any shoulder pathological conditions and to identify any known trauma that occurred after the stroke, such as falls. 23,27 A correct diagnosis of the cause is essential if the patient is to be helped." A thorough diagnostic examination of the neck and shoulder should be conducted to identify cervical spine pathological factors, rotator cuff or biceps brachii tendinitis, or GHJ or acromioclavicular joint arthritis. 42,99 Confirmatory evidence of rotator cuff tears and adhesive capsulitis can be obtained with arthrography. Radiographs can rule out humeral fracture 3 and ectopic ossification. 105 Electrophysiological studies can be used to identify brachial plexus injurv. Shoulder-hand syndrome may be confirmed by a positive response to stellate ganglion block. 58 Conservative Management If subluxation is identified as the causative agent, several treatment methods exist. Pain and stiffness in a subluxated shoulder, however, are not necessarily a result of subluxation. 15,102 Krempen et al examined 37 patients with pain and subluxation and found 16 patients had other, orthopedic causes for the pain." Conservative orthopedic management of patients with diagnoses of tendinitis, bursitis, and rotator cuff tears is similar. The goals of treatment are pain reduction and improvement of ROM. Symptoms may be reduced with oral anti-inflammatory agents and analgesics and injections of lidocaine and steroids into trigger points, the subacromial bursae, or the joint space. 27,28,42,106 As pain decreases, active, passive, and assistive exercises are used to improve ROM. Applications of heat, cold, phonophoresis, and transcutaneous electrical nerve stimulation may be effective in relieving pain and encouraging motion. 106 Applications of heat, however, have not been proven to be of particular benefit in the treatment of HSP. Liao et al found no significant difference in the amount of improvement in ROM between patients treated with exercise only versus those treated with a combination of heat and exercise therapy; exercise appeared to be the most effective treatment. 4 Thus far, in studies of hemiplegic patients with unstated etiologic factors of pain, ultrasound 22 and TENS 6 have not been found to decrease pain or to contribute to increased range of shoulder motion. If an injury to the upper trunk has been diagnosed, the brachial plexus must be protected until regeneration can occur. 53 The shoulder should be splinted in 45 degrees of abduction, a treatment similar to that of postsurgical repair of the upper trunk. 107 Care must be taken to prevent further traction injury until regeneration occurs. The prognosis for recovery of function varies widely. 23 Although evidence exists that adhesive capsulitis in nonhemiplegic patients is a self-limited disease resolving in one to three years, (see the article by C. T. Wadsworth in this issue), the same does not appear to be true of hemiplegic adhesive capsulitis. 12,42 A vigorous program of ice or heat applications and active and passive exercises can be combined with anti-inflammatory and analgesic medications, oral corticosteroids, and muscle relaxants. 41 Suprascapular nerve blocks, 108 corticosteroid injections into trigger points, and stellate ganglion blocks have been reported to be beneficial. 23 Antispasmodic medications may supplement inhibition and relaxation techniques. 16 Motor-point blocks of the trapezius 16 and pectoralis major 109,110 muscles may aid in controlling spasticity. In the management of SHS, early recognition is the key to a favorable prognosis; prompt treatment is essential to prevent permanent disability. 58,60,111 An aggressive exercise program is an essential component of treatment. 27,59 Active muscle contraction and joint movements are important, as are light weightbearing activities. Exercise must be performed within the pain-free range and frequently for short periods during the day. Modalities such as heat or ice treatments or TENS may be used to increase sensory input and reduce pain. 28,71,112 Although TENS has been reported as helpful in the management of reflex sympathetic dystrophies, no research results appear to be reported on the effectiveness of TENS in hemiplegic SHS. Aggressive and prompt management of hand edema is important, because prolonged edema will precipitate perhaps irreversible hand stiffness. 27 Dependent positions of the hand should be avoided; an elevated position is preferable. Intermittent pneumatic compression may be of value in reducing hand edeipa, 23,90,113 and an elastic glove is helpful also in controlling edema. 71 Systemic administration of corticosteroids for two to three weeks is recommended by several authorities for the management of SHS. 27,59,71 Davis et al reported a complete resolution of symptoms in 68 hemiplegic patients using oral steroids in combination with an intensive rehabilitation program. 57 A sympathetic block followed by intensive rehabilitation is cited as the most effective treatrnent by Some researchers. 58,61,111 Sympathectomy is suggested in refractory cases. 58,59,111 The emotional state of patients with severe HSP has been described as tense, hyperresponsive to pain, overemotional, apathetic, and emotionally dependent. 23 Whether such emotional states contrib- 1890 PHYSICAL THERAPY Downloaded from http://ptjournal.apta.org/ by guest on December 15, 2012
ute to the development of HSP or emerge as a result of the pain is unknown. 111 In any event, appropriate psychological management is important for successful treatment. 23 Surgical Management Surgical release of soft tissue may be of value if conservative methods have failed and if shoulder motion has become severely limited and painful. 112 Recent improvements in rehabilitation techniques have decreased the need for surgical intervention. 75 The most frequently described surgical management involves resection of the subscapularis and pectoralis major tendons 15,114 and release of the capsule 115 ; insertions of the latissimus dorsi and teres major muscles also may be necessary. 116,117 Surgical release does not result in improved ROM without an intensive postoperative program of exercise and splinting to maintain and increase abduction and external rotation. 15,117 The indications for surgery include ROM limitation to the point of functional impairment (ie, abduction to 45 degrees and lateral rotation to 15 degrees or less 15 ), pain of such intensity that it interferes with skin hygiene 114 or prevents participation in rehabilitation, 15 and progressively decreasing ROM resulting from increased internal rotator muscle spasticity. 15,109,117 Factors affecting the patient's rehabilitation potential, such as cognitive awareness, sensory and perceptual deficits, and communication disorders, also should be considered. 15 Surgery usually is delayed until at least six months after the stroke when spontaneous recovery is fairly complete. 114 Surgery is contraindicated in the presence of etiological factors other than soft tissue contracture or if postoperative therapy is unavailable. 15 Surgery for thalamic pain is not indicated. 15,118 The reported magnitude of an increase in ROM after surgery is not great. Caldwell et al reported that the lateral rotation range was poor, although most patients regained 90 degrees of abduction; some patients developed active abduction postoperatively that had not been observed preoperatively. 15 CONCLUSIONS Patients at highest risk for developing HSP seem to be those with severe upper limb paralysis, particularly if sensory loss and mental confusion also exist. Such a combination of factors not only immobilizes the limb but increases the likelihood for traction injury because the patient cannot protect himself. Increasing age may increase the risk also. Most patients over 50 years of age have significant degenerative changes around the GHJ. Such soft tissue pathological factors can be exacerbated only by events accompanying flaccid paralysis. The acute period after a stroke appears to be a critical time for the prevention of GHJ soft tissue injuries such as rotator cuff tears or brachial plexus injuries. Such trauma, which may go unnoticed in the acute period after a stroke, may cause significant HSP or functional impairment later in rehabilitation. Education of all personnel handling the flaccid arm is imperative if prophylaxis of shoulder injury is to be effective. Failure to provide support for the flaccid arm when the patient is upright may allow shoulder subluxation and consequent painful overstretching of soft tissue or nerve injury or both. The deleterious effects of subluxation may be cumulative. Effective methods for the prevention of subluxation remain to be established in a controlled clinical trial, but electrical stimulation appears promising. Immobilization is a key factor contributing to shoulder stiffness in elderly patients. In patients with hemiplegia, immobilization is promoted by paralysis, spasticity, and, sometimes, brachial plexus injury. Pain is another wellknown immobilizing influence. Lack of passive exercise for the paralyzed shoulder certainly will result in painful contractures. Careless passive exercise techniques without regard to biomechanical principles may cause impingement. Thus, improperly administered exercise may be a cause of trauma, pain, and further immobilization. When pain and stiffness begin to develop, a thorough evaluation of the cause is essential. Conservative management methods may be effective if the treatment is appropriate for the cause. Surgical intervention may be indicated in extreme cases. Early preventive measures, however, remain the key to minimizing the complication of shoulder pain in patients with hemiplegia. Need for Clinical Research Longitudinal studies are needed concerning developments in the shoulder after hemiplegia. Periodic assessments of shoulder status, from the onset until at least one year after the onset of hemiplegia, would add greatly to present knowledge concerning the evolution of HSP. Pertinent aspects to be included in such assessments are active motor function, sensory status, passive ROM, amount of pain associated with passive motion, spasticity, subluxation, and functional ability of the upper limb. Cognitive status and age also should be included. If HSP and limited ROM develop during the longitudinal study, prompt diagnostic steps to identify the cause should be instituted. When etiologic factors of the pain can be established, controlled studies of the relative effectiveness of various treatment methods are essential. The optimum treatment for hemiplegic patients with established diagnoses such as SHS or adhesive capsulitis currently is unknown. Knowledge of the effectiveness of methods for preventing subluxation (ie, electrical stimulation vs positioning alone) would be helpful in determining prophylaxis. Also of clinical importance are controlled studies to establish the relative efficacy of methods such as biofeedback, electrical stimulation, and exercise alone in improving proximal control in the hemiplegic shoulder. The obstacles to clinical research in the area of HSP may seem formidable: Hemiplegic patients admitted to rehabilitation settings differ widely in medical history and prestroke shoulder dysfunction; the time since the stroke varies among patients; and the history of shoulder trauma after the stroke often is impossible to ascertain. Such variables may account for the different responses to treatment and may make the original causes of HSP difficult to determine. Such difficulties might be overcome partially by beginning a longitudinal study immediately after the stroke and by including significant numbers of patients in the study. The HSP syndrome represents such a major obstacle to rehabilitation that systematic studies of the problem are imperative. Controlled research is needed to determine effective prophylaxis and to document the therapeutic efficacy of treatment. REFERENCES 1. Tobis JS: Problems in rehabilitation of the hemiplegic patient. NY State J Med 57:1377- 1380,1957 2. Najenson T, Pikielny SS: Malalignment of the gjenohumeral joint following hemiplegia. Annals of Physical Medicine 8:96-99, 1965 3. Jensen EM: The hemiplegic shoulder. Scand J Rehabil Med 12(Suppl):113-119, 1980 Volume 66 / Number 12, December 1986 1891 Downloaded from http://ptjournal.apta.org/ by guest on December 15, 2012
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