Hemiplegic Shoulder Pain Update Andrew E. Kirsteins M.D. FAAPM&R (Sports and Neuromuscular Med) Cone Health Physical Medicine and Rehabilitation
Transcript
Slide 1
Andrew E. Kirsteins M.D. FAAPM&R (Sports and Neuromuscular
Med) Cone Health Physical Medicine and Rehabilitation
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Purpose Review common causes of Hemiplegic Shoulder Pain (HSP)-
Focus on Post stroke Diagnosis using PE and Imaging Studies
Introduce Musculoskeletal Ultrasound (MSK US) as an aid to
diagnosis of HSP Hands on demo Please check out Sept 2013 Am L
PM&R Ozcakar et al- Utility of MSK US in Rehab settings
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Shoulder Pain General Population Post Stroke Population 3 rd
most common MSK c/o in primary MD office 2 nd most common reason
for referral to Ortho/Sports ~70% pain is from Rotator cuff
disorders Occurs in up to 72% stroke pts in the first year- Van
Ouwenaller C, Laplace PM, Chantraine A. Painful shoulder in
hemiplegia. Arch Phys Med Rehabil. 1986; 67: 2326 Common reason for
poor rehab outcome,QOL Several pain generators have been proposed,
complex
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Post Stroke Shoulder Pain=HSP Overall prevalence 17% at 2wks,
20% at 1mo,23% at 6mo. Ratnasabaphthy et al 2003,Clinical Rehab
Prevalence Rehab pop. 60% @ 4mo,35% @ 6mo
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Post Stroke Shoulder Pain Risk Factors Significant weakness L
neglect Sensory deficits Advanced age Spasticity
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Nociceptive Neuropathic Subluxation theory Subacromial
Impingement Bicipital tendon Spasticity related Adhesive capsulitis
RSD Brachial plexopathy Central Post stroke Pain Hemiplegic
shoulder pain etiology
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Hemiplegic Shoulder Pain Update
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Does Subluxation Cause HSP? Pro Con Traction on joint capsule
during flaccid stage Subluxation more common in Shoulder Hand
Syndrome- Dursun et al 2000 Most HSP occurs during spastic stage-
Van Ouwenwaller et al 1986 Neuromuscular Electrical Stim reduces
pain but not subluxation- Yu et al No correlation between pain and
subluxation Bohannon et al 1990
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Ultrasound measurement of shoulder subluxation X Ray Ultrasound
Xray evaluation requires multiple views,measurements after imaging
Long axis view allows measurement during image acquisition- Park
GY, Kim JM, Sohn SI, et al. Ultrasonographic measurement of
shoulder subluxation in patients with post- stroke hemiplegia. J
Rehabil Med 2007; 39:
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Subacromial Impingement Syndrome Marwan Alqunaee, RCSI, Rose
Galvin, BSc (Physio), PhD, Tom Fahey, MD, FRCGPDiagnostic Accuracy
of Clinical Tests for Subacromial Impingement Syndrome: A
Systematic Review and Meta-Analysis Archives of Physical Medicine
and Rehabilitation, Volume 93, Issue 2, February 2012, Pages 229236
Any rotator cuff pathology in the subacromial space Includes
Supraspinatus, Infraspinatus,Teres Minor and Subscapularis Stages
Include Stage 1-Bursitis Stage 2-Partial Tear Stage 3- Full
thickness Tear
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Sensitivity and Specificity A SeNsitive test when Negative
rules OUT=SNNOUT, (true positive identification) A SPecific test
when Positive rules IN=SPPIN (true negative identification)
Difficult to establish Sensitivity and specificity in studies if
there is no Gold Standard, or if different Gold Standards are used
So for diagnostic PE or imaging studies either surgical findings or
MRI is used as Gold Standard
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Subacromial Impingement Syndrome=SIS History- pain with
overhead activity, nocturnal pain Exam-Hawkins Kennedy passive
forward flexion/int rotation only useful test in a hemiplegic
patient Sensitivity 74% Imaging- Ultrasound can identify all 3
stages of SIS bursitis,partial tear and full thickness tear
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Diagnostic accuracy of Ultrasound for RCT Smith et al, Clin
Radiol 66 (2011) 1036-1048 Given limitation of history
(communication deficit) and exam (given UE weakness), imaging
assume greater importance Partial thickness RCT Sen 84%, Sp 89%
Full thickness RCT Sen 96%, Sp 93%
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PHYSICAL FINDINGS AND SONOGRAPHY OF HEMIPLEGIC SHOULDER IN
PATIENTS after ACUTE STROKE DURING REHABILITATION-Huang et al J
Rehabil Med 2010; 42: 2126 Methods Results at D/C N=57, cross
sectional Good vs Poor Motor groups based on Brunnstrom Excluded
prior shoulder problems Recorded pain using VAS-but pain not an
inclusion criteria Assessed at admission and discharge (LOS 27d for
good,32d for poor motor) Pain:68% Poor motor, 35% Good motor US
abnormalities Poor Motor- 50% biceps tendinopathy,47% Supraspinatus
tear,44% Subacromial bursitis US abnormalities Good Motor 30%
biceps,22% subacromial bursitis,17% supraspinatus
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Sonography of Patients with Hemiplegic shoulder pain after
stroke Sonography of Patients with Hemiplegic shoulder pain after
stroke Lee et al Am J Roentgen 2009 Feb;192(2): n=71, 20 pts had
bilateral shoulders scanned Subacromial bursal effusion seen in 36
shoulders Biceps tendon sheath effusion in 39 shoulders
Supraspinatus tendinosis (7),partial tear (6) and full tear (2)
Abnormalities more common in hemiplegic shoulder p=.007 vs
uninvolved side
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Sonography and physical findings in stroke patients with
hemiplegic shoulders: A longitudinal study Ya Ping Pong et al, J of
Rehab med 2012,(44),553-557 76 first time CVA, no hx of shoulder
problems Scanned during acute rehab and at 6 mo Underwent standard
inpt rehab program 1 hour PT and 1 hr OT 5d/wk Brunnstrom
score,ROM, Ashworth,10pt NRS
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Sonography and physical findings in stroke patients with
hemiplegic shoulders: A longitudinal study Ya Ping Pong et al, J of
Rehab med 2012,(44),553-557 Acute (D/C from Rehab) Chronic (6mo
post D/C) Subacromial effusion 30.3% Supraspinatus tear 30.3%
Biceps tendon 39.5% Subscapularis 9.2% Pain score 2.71/10
Subacromial effusion 13.2% Supraspinatus tear 40.8% Biceps tendon
57.9% Subscapularis 22.4% Pain score 3.99/10
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Subacromial Bursitis
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MRI findings in hemiplegic shoulder pain Shah et al Stroke 2008
June 39(6) >3mo since CVA, pain score >4,n=89,65% L HP
Supraspinatus tear 26% partial, 6% Full Supraspinatus tendinopathy
51% Infraspinatus tear 13% partial, 2% Full Infraspinatus
tendinopathy 19% Subscapularis tear 1% Teres minor tear 1%
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MRI findings in hemiplegic shoulder pain Shah et al Stroke 2008
June 39(6)
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Adhesive Capsulitis or Frozen Shoulder Few imaging studies X
ray Arthrogram Rizk et al, Arch Phys Med Rehabil. 1984; 65(5):254-6
Arch Phys Med Rehabil. 1984; 65(5):254-6 30 Patients mean 3 months
post CVA, Reduced ROM and pain, electrically silent EMG of shoulder
muscles 23/30 had reduced capsular volume consistent with adhesive
capsulitis Arthrogram and Exam -Lo et al., Arch Phys Med Rehabil.
84(12):1786-91, 2003 Dec 32 pt with HSP
RSD=CRPS Type 1 International Association for the Study of Pain
(IASP) clinical diagnostic criteria (Revised Budapest criteria)
continuing pain disproportionate to original injury must have
reports of at least 1 symptom in 3 of 4 categories sensory -
allodynia and/or hyperesthesia vasomotor - temperature asymmetry
and/or skin color changes and/or skin color asymmetry
sudomotor/edema - edema and/or sweating changes and/or sweating
asymmetry motor/trophic - decreased range of motion and/or motor
dysfunction (weakness, tremor, dystonia) and/or trophic changes (in
hair, nails, or skin) must have at least 1 sign at time of
evaluation in 2 or more categories sensory - allodynia (to light
touch and/or temperature and/or deep somatic pressure and/or joint
movement) and/or hyperalgesia (to pinprick) vasomotor - evidence of
temperature asymmetry (> 1 degree C [1.8 degrees F]) and/or skin
color changes and/or skin color asymmetry sudomotor/edema -evidence
of edema and/or sweating changes and/or sweating asymmetry
motor/trophic - evidence of decreased range of motion and/or motor
dysfunction (weakness, tremor, dystonia) and/or trophic changes (in
hair, nails, or skin) no other diagnosis can better explain signs
or symptoms sensitivity 0.85 and specicity 0.69 Reference - Pain
Med 2007 May-Jun;8(4):326, editorial can be found in Pain Med 2007
May- Jun;8(4):289, commentary can be found in Pain Med 2009
Apr;10(3 ):598Pain Med 2007 May-Jun;8(4):326, editorial can be
found in Pain Med 2007 May- Jun;8(4):289, commentary can be found
in Pain Med 2009 Apr;10(3 ):598
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Bone scan for diagnosis of RSD Review of Hi quality studies
Review of Low quality studies pooled diagnostic performance of bone
scintigraphy for CRPS type I in analysis of 21 studies sensitivity
79% (range 14%-100%) specificity 88% (range 60%-100%) criteria for
CRPS on triple-phase bone scan included diffusely increased uptake,
especially increased periarticular uptake in multiple joints
Reference - J Hand Surg Am 2012 Feb;37(2):288J Hand Surg Am 2012
Feb;37(2):288 systematic review of 12 diagnostic cohort studies
evaluating bone scintigraphy (3 phase scintigraphy in 11 studies, 5
phase scintigraphy in 1 study) for diagnosis of CRPS type I in 882
patients all studies had methodologic limitation including 6
studies lacked valid reference standard for CRPS 1 unclear if index
test interpretation was blinded to reference standard in all
studies pooled diagnostic performance of 3-phase bone scintigraphy
for CRPS type I in analysis of 6 studies with valid reference
standard sensitivity 80% (95% CI 44%-95%) specificity 73% (95% CI
40%-91%) positive likelihood ratio 2.92 (95% CI 1.33-6.43) negative
likelihood ratio 0.28 (95% CI 0.1-0.76) Reference - Eur J Pain 2012
Nov;16(10):1347Eur J Pain 2012 Nov;16(10):1347
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Bone Scan RSD based on 3 diagnostic cohort studies with
inconsistent results all 3 studies had lack of reporting if index
test interpretation was blinded to reference standard 116 with
suspected CRPS had clinical evaluation and were assessed using
3-phase bone scintigraphy 69 (59.5%) had CRPS using Budapest
diagnostic criteria as reference standardBudapest diagnostic
criteria as reference standard for diagnosis of CRPS, 3-phase bone
scintigraphy had sensitivity 40% specificity 76.5% positive
likelihood ratio 1.73 negative likelihood ratio 0.78 Reference - Br
J Anaesth 2012 Apr;108(4):655Br J Anaesth 2012 Apr;108(4):655
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Neuropathic (non RSD) HSP etiology Zeilig et al Pain. 2013
Feb;154(2):263-71 30 CVA pts N=14 HSP, 16 without HSP> 6 mo post
15 healthy controls HSP group had increased parietal involvement
HSP group had higher pain/temp threshold vs CVA pt without HSP in
UE and LE No vasomotor or sudomotor signs (no RSD) Is HSP part of a
central post stroke pain syndrome?
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Fig. 3 Higher rates of pathologically evoked pain were found in
the affected shoulder of the hemiplegic shoulder pain (HSP) group
compared to that of the nonhemiplegic shoulder pain (NHSP) group,
including: hyperpathia ( p