Date post: | 24-Jun-2015 |
Category: |
Health & Medicine |
Upload: | adewumi-adeagbo |
View: | 1,259 times |
Download: | 3 times |
13/04/2023
PREVENTION AND PHYSIOTHERAPY MANAGEMENT OF HEMIPLEGIC
SHOULDER PAIN (HSP)
BY
ADEAGBO, CALEB ADEWUMIPhysiotherapist
13/04/2023
Outline• Introduction• Definition • Epidemiology• Functional anatomy of the shoulder and
changes following a stroke• Causes• Pathophysiology• Clinical presentation and findings• Prevention and Management• Conclusion• References
2
13/04/2023
Introduction
• Hemiplegic shoulder pain (HSP) is
among the four most common, yet
preventable, medical complications
that stroke survivors may experience (Rajaratnam et al, 2007; Zhu et al, 2013; Suriya-
amarit et al, 2014).
3
13/04/2023
Introduction cont
• HSP can occur in the 2nd week after stroke
and it is independent of age and gender (Vuagnat and Chantraine, 2003; Ward, 2007; Bello and Amedzo,
2009).
• Despite the high incidence of HSP, the
literature is full of conflicting reports about
the epidemiology, risk factors, and
management (Lindgren et al, 2007; Dromerick et al, 2008).4
13/04/2023
Introduction cont
• HSP prolongs rehabilitation of affected
limb and hospital stay thereby affecting
ADL, decreases the QoL and it has
been implicated with withdrawal from
participation in rehabilitation process (Griffin and Bernhardt, 2006; Allen et al, 2010; Suriya-amarit et al,
2014).
5
13/04/2023
Introduction cont
• Therefore prevention and
management of HSP is obviously
important to recovery and well-being
of stroke survivors (Snels et al, 2000; Tyson and
Chissim, 2002; Suriya-amarit et al, 2014).
6
13/04/2023
Definition
• HSP is a shoulder pain that is present
at rest, during passive or active
movement on the hemiplegic side
after stroke with no direct relation to
trauma or injury (Kim et al, 2014).
7
13/04/2023
Definition cont
• HPC is also known as:
Hemiplegic Shoulder Pain Syndrome
(HSPS)
Post Stroke Shoulder Pain (PSSP)
Shoulder Pain in Hemiplegia
Shoulder Pain after Stroke
Painful Hemiplegic Shoulder (PHS)
8
13/04/2023
Epidemiology
• Reports of prevalence of HSP in the literature
vary between 5% and 84% in stroke survival
population (Walsh, 2001; Gustafsson and McKenna, 2006; Griffin
and Bernhardt, 2006). There are a number of reasons
for this variation such as different study
methods, location of the stroke and pain
reaction (Snels et al, 2002; Teasell et al, 2003; Klit et al, 2011; de
Oliveira et al, 2012). 9
13/04/2023
Epidemiology cont
• A prevalence study carried out in Nigeria
by Fabunmi et al, (2014) revealed that 75
(73.5%) of 102 stroke survivors had HSP,
36.3% and 37.3% patients had pain on
left and right shoulders respectively, pain
onset showed that 33.3% developed pain
within first week post stroke.10
13/04/2023
Functional anatomy of the shoulder and changes following a stroke
• An understanding of the normal
functional anatomy of the shoulder
and how it is affected by loss of
motor control following stroke may
inform the prevention and
management of shoulder pain (Smith,
2012). 11
13/04/2023
Functional anatomy of the shoulder and changes following a stroke cont
• The shoulder is formed by a complex
system of articulations:
Glenohumeral joint (GHJ)
Acromioclavicular joint (ACJ)
Sternoclavicular joint (SCJ)
Rotation of the scapula on the thoracic
wall (fig 1)12
Figure 1: the anatomical diagram of the shoulder complex (Smith, 2012).
13/04/2023
13
13/04/2023
Functional anatomy of the shoulder and changes following a stroke cont
• Immediately following stroke there is
an initial flaccid paralysis in over
90% of individuals which is often
replaced by a predictable pattern of
spasticity (Gillen 2011; Kim, 2012, Gould and Barnes,
2013).
14
13/04/2023
Functional anatomy of the shoulder and changes following a stroke cont
• Alteration in the alignment of skeletal
components of the shoulder complex
can be described in both the flaccid
and spastic stages of paralysis after
stroke and each has been implicated
in the causation of HSP (Turner-Stokes and
Jackson, 2002).15
13/04/2023
Causes
• The causes of HSP are uncertain but it is
associated with upper limb weakness,
abnormal muscle tone, glenohumeral
subluxation, limited shoulder external
rotation ROM, sensory inattention, sensory
impairment, complex regional pain syndrome
(CRPS) and prior shoulder pathology (Tyson and
Chissim, 2002; Chae, 2007; Dromerick et al, 2008; Joy et al, 2012).
16
13/04/2023
Causes cont• Several clinical diagnoses have been
proposed as causes of HSP, these
including rotator cuff tendonitis,
subacromial bursitis, bicipital
tendonitis, adhesive capsulitis, brachial
neuralgias, sympathetically mediated
pain, and referred pain (Lo et al, 2003, Chae et
al, 2007). 17
13/04/2023
Pathophysiology
• Because of the wide array of
pathologies potentially underlying the
development of HSP, the precise
aetiology is difficult to assess (Maxwell and
Nguyen, 2013). It is impossible to treat HSP
effectively without first understanding
the mechanism of the complication.
18
13/04/2023
Pathophysiology cont• Three specific types of possible
pathological processes that can cause
HSP are:
Soft tissue lesions
Impaired motor control (specifically muscle
tone changes)
Altered peripheral and central nervous
system activity19
13/04/2023
Clinical presentation and findings
• Common symptoms by patients with
HSP include the following:
Pain with or without movement of the
hemiplegic shoulder
Reduced mobility of the hemiplegic
shoulder
Tenderness around the hemiplegic shoulder
Swelling/oedema 20
13/04/2023
Clinical presentation and findings cont
• The physical examination of a patient with
HSP is extensive because there is need to
assess the involved musculoskeletal and
neurologic conditions. It should include
observation, palpation, musculoskeletal
and neurologic examination.
21
13/04/2023
HSP outcome measures
Faces Pain Scale
Verbal Rating Scales (VRS)
Numeric Rating Scales (NRS)
Visual Analogue Scale (VAS)
Physiotherapist graded (VAS)
Ritchie Articular Index (for shoulder pain)
ShoulderQ (for shoulder pain)
Graded Chronic Pain Disability Score
Shoulder lateral rotation ROM to the point of
pain (SROMP)
22
13/04/2023
Prevention and Management
• Poor handling and positioning of the
affected upper limb in stroke patients
contribute toward shoulder pain (Walsh, 2001).
The mobility of the recovering stroke
patient is dependent on the assistance of
physiotherapists, nurses, doctors, family
members and patient’s own efforts.23
13/04/2023
Prevention and Management cont
• The ideal management of HSP is to
prevent it from happening in the first
place. Various strategies have been
employed in the prophylaxis of HSP.
For effective prophylaxis, it must be
begin immediately after stroke (Snels et
al, 2000; Tyson and Chissim, 2002; Griffin and Bernhardt,
2006). 24
13/04/2023
Handling of the hemiplegic upper limb
• Good handing technique of the
hemiplegic upper extremity day and
night is recommended to prevent HSP
because it prevent trauma to soft
tissues. It is recommended that support
is provided both proximally and distally
to the upper extremity (Smith, 2012).
25
13/04/2023
Positioning hemiplegic shoulder
• Maintaining the upper limb in the
correct position is fundamental to
preventing and managing HSP. The
recommended position for the affected
upper limb is abduction, external
rotation and with the shoulder slightly
flexed (Smith, 2012).26
13/04/2023
Positioning hemiplegic shoulder cont
• Positioning of the hemiplegic
shoulder in different positions
Side lying on hemiplegic side (fig 2).
Side lying on unaffected side (fig 2).
Lying on back (fig 3).
Sitting in bed (fig 3).
Sitting up (fig 4).27
13/04/2023
Figure 2: Side lying in hemiplegic patient (Smith, 2012).
28
13/04/2023
Figure 3: Lying on back and sitting in bed in hemiplegic patient (Smith, 2012).
29
13/04/2023
Figure 4: sitting on a chair in hemiplegic patient (Smith, 2012).
30
13/04/2023
Slings and other devices
• Use of slings is controversial because
they hold the arm in a flexed
position, inhibit shoulder movement.
However, slings are considered to be
the best devices for supporting the
paretic limb (fig 5; fig 6) (Ada et al, 2005)
31
13/04/2023
Figure 5: shoulder slings (Orthocare, 2009).32
13/04/2023
Figure 6: functional shoulder sling (Neuro-Lux) and X-ray of the shoulder without and with the functional shoulder sling (Neuro-Lux) (Hartwig et al, 2012).
33
13/04/2023
Strapping the hemiplegic shoulder
• Strapping of the hemiplegic shoulder
is used as a method for preventing or
reducing shoulder subluxation and
may provide a certain level of
sensory stimulation. (Hanger et al, 2000).
34
13/04/2023
Physiotherapy management
Electrophysical/electrotherapy agents
Electrical neuromuscular stimulation
Cryotherapy
Soft tissue manipulation (massage
using analgesic lubricant)
Therapeutic exercises:35
13/04/2023
Drug treatment
• Analgesic, anti-inflammatory, and
antispastic drugs have all been used
to treat HSP. Simple analgesics and
nonsteroidal anti-inflammatory drugs
should be tried first. Antispasmodic
medication may be helpful in
spasticity of cerebral origin. 36
13/04/2023
Conclusion• HSP should be viewed as a largely
preventable complication of stroke and
it is the responsibility of all members
rehabilitating and taking care of the
patient to ensure they handle
vulnerable upper limb with care during
positioning, transferring and assisting
in ADL. 37
13/04/2023 38
References• Ada L, Foongchomcheay A, Canning CG (2005). Supportive devices for preventing and
treating subluxation of the shoulder after stroke. Stroke 36: 1818-1819
• Allen ZA, Shanahan EM, Crotty M (2010). Does suprascapular nerve block reduce shoulder pain following stroke: a double-blind randomized controlled trial with masked outcome assessment. BioMedCentral Neurology 10(83): 1-5
• Bello AI, Amedzo MY (2009). Relative Effectiveness of Transcutaneous Electrical Nerve Stimulation and Hot Packs in the Management of Hemiplegic Shoulder Pain. Journal of the Nigeria Society of Physiotherapy 17: 1-6
• Chae J, Mascarenhas D, Yu DT, Kirsteins A, Elovic EP, Flanagan SR, Harvey RL, Zorowitz RD, Fang Z (2007). Poststroke Shoulder Pain: Its Relationship to Motor Impairment, Activity Limitation, and Quality of Life. Archives of Physical Medicine and Rehabilitation 88: 298-301
• de Oliveira RA, de Andrade DC, Machado AG, Teixeira MJ (2012). Central post stroke pain: somatosensory abnormalities and the presence of associated myofascial pain syndrome. BioMedCentral Neurology 12: 89.
•
• Dromerick AW, Edwards DF, Kumar A (2008). Hemiplegic Shoulder Pain Syndrome: Frequency and Characteristics during Inpatient Stroke Rehabilitation Archives of Physical Medicine and Rehabilitation 89: 1589-1593.
13/04/2023 39
References cont• Fabunmi A, Awolola E, Fowodu O, Amusat S (2014). Shoulder pain among stroke
survivors: prevalence and pattern. The Journal of Pain 15(4): 37 • Gillen G (2011). Cerebrovascular accident/stroke. In Pendleton HM, Schultz-Krohn W
Pedretti’s Occupational Therapy Practice Skills for Physical Dysfunction. Seventh edition. Page 844-880 Elsevier Mosby, St Louis MO.
• Gould R, Barnes SS (2013).Shoulder Pain in Hemiplegia. Available @
http://emedicine.medscape.com/article/328793-overview Retrieved on October 07, 2014
• Griffin A, Bernhardt J (2006). Strapping the hemiplegic shoulder prevents development of pain during rehabilitation: a randomized controlled trial Clinical Rehabilitation 20: 287-295
• Gustafsson L, McKenna K (2006). A programme of static positional stretches does not reduce hemiplegic shoulder pain or maintain shoulder range of motion - a randomized controlled trial Clinical Rehabilitation 20: 277-286
• Hanger HC, Whitewood P, Brown G, Ball MC, Harper J, Cox R, Sainsbury R (2000). A randomized controlled trial of strapping to prevent poststroke shoulder pain. Clinical Rehabilitation 14: 370-380.
• Hartwig M, Gelbrich G, Griewing B (2012). Functional orthosis in shoulder joint subluxation after ischaemic brain stroke to avoid post-hemiplegic shoulder–hand syndrome: a randomized clinical trial. Clinical Rehabilitation 26(9): 807-816
• Joy AK, Ozukum I, Nilachandra L, Khelendro T, Nandabir Y, Kunjabasi W (2012). Prevalence of Hemiplegic Shoulder Pain in Post-stroke Patients – A Hospital Based Study. Indian Journal of Physical Medicine and Rehabilitation 23(1): 15-19
13/04/2023 40
References cont• Kim CT (2012). Stroke Rehabilitation. Available @
http://www.intechopen.com/books/rehabilitation-medicine/stroke-rehabilitation Retrieved on October 07, 2014
• Kim YH, Jung SJ, Yang EJ, Paik NJ (2014). Clinical and Sonographic Risk Factors for Hemiplegic Shoulder Pain: A Longitudinal Observational Study. Journal of Rehabilitation Medicine 46: 81–87
• Klit H, Finnerup NB, Overvad K, Andersen G, Jensen TS (2011). Pain following stroke: a population-based follow-up study. Public Library of Science (PLOS) One 6(11): 27607.
• Lindgren I, Jönsson A, Norrving B, Lindgren A (2007). Shoulder Pain after Stroke: A Prospective Population-Based Study. Stroke 38: 343-348
• Lo SF, Chen SY, Lin HC, Jim YF, Meng NH, Kao MJ (2003). Arthrographic and clinical findings in patients with hemiplegic shoulder pain. Archives of Physical Medicine and Rehabilitation 84: 1786-1791.
• Maxwell AMW, Nguyen VQC (2013). Management of Hemiplegic Shoulder Pain. Current Physical and Medical Rehabilitation Reports 1: 1–8
13/04/2023 41
References cont• Orthocare (2009). Arm Slings. Available @
http://www.orthocare.com.au/products.asp?category=342 Retrieved on October 11, 2014
• Rajaratnam BS, Venketasubramanian N, Kumar PV, Goh JC, Chan YH (2007). Predictability of Simple Clinical Tests to Identify Shoulder Pain after Stroke. Archives of Physical Medicine and Rehabilitation 88: 1016-1021.
• Smith M (2012). Management of hemiplegic shoulder pain following stroke. Nursing Standard 26(44): 35-44.
• Snels IA, Dekker JH, van der Lee JH, Lankhorst GJ, Beckerman H, Bouter LM (2002).
Treating patients with hemiplegic shoulder pain. American Journal of Physical Medicine and Rehabilitation 81(2): 150-160
• Snels IAK, Beckerman H, Lankhorst GJ (2000). Treatment of hemiplegic shoulder pain in
the Netherlands: results of a national survey Clinical Rehabilitation 14: 20–27 • Suriya-amarit D, Gaogasigam C, Siriphorn A, Boonyong S (2014). Effect of Interferential
Current Stimulation in Management of Hemiplegic Shoulder Pain. Archives of Physical Medicine and Rehabilitation 95: 1441-1446
• Teasell RW, Foley NC, Bhogal SK, Speechley MR (2003). An evidence- based review of stroke
rehabilitation. Topics in Stroke Rehabilitation 10(1): 29-58.
13/04/2023 42
References cont• Turner-Stokes L, Jackson D (2002). Shoulder pain after stroke: a review
of the evidence base to inform the development of an integrated care pathway. Clinical Rehabilitation 16: 276–298
• Tyson SF, Chissim C (2002). The immediate effect of handling technique on range of movement in the hemiplegic shoulder Clinical Rehabilitation 16: 137–140
• Vuagnat H, Chantraine A (2003). Shoulder pain in hemiplegia revisited:
contribution of Functional Electrical Stimulation and other therapies Journal of Rehabilitation Medicine 35: 49–56
• Walsh K (2001). Management of shoulder pain in patients with stroke.
Postgraduate Medical Journal 77: 645–649 • Ward AB (2007). Hemiplegic shoulder pain. Journal of Neurology,
Neurosurgery and Psychiatric 78:789. • Zhu Y, Su B, Li N, Jin HZ (2013). Pain management of hemiplegic
shoulder pain post stroke in patients from Nanjing, China. Neural Regeneration Research 8(25): 2389-2398.
13/04/2023 43
Thank You for
listening