Biomechanical properties of the glenohumeral joint capsule in hemiplegic shoulder pain

Background

Although many hemiplegic shoulder patients have been suffering from limited range of motion, it is not fully established whether the pathologic biomechanics are same in hemiplegic shoulder pain and adhesive capsulitis. Therefore we aimed to investigate biomechanical properties of glenohumeral joint capsules of hemiplegic shoulder pain with limited range of motions.

Methods

Participants were 14 patients with hemiplegic shoulder pain, 10 controls, and 42 adhesive capsulitis patients matched with the hemiplegic shoulder pain group for sex, age, and range of motion. Demographic data, clinical variables, and sonographic findings were comparable between hemiplegic shoulder pain and adhesive capsulitis groups. We compared capsular capacity, maximal pressure, and capsular stiffness of glenohumeral joint capsule among the 3 groups.

Findings

Hemiplegic shoulder pain and adhesive capsulitis groups had smaller capsular capacity and higher maximal pressure than controls. The capsular stiffness of hemiplegic shoulder pain group was higher than that of controls (P = 0.001) but lower than that of adhesive capsulitis group (P < 0.001).

Interpretation

The stiffness of glenohumeral joint capsules in hemiplegic shoulder pain and adhesive capsulitis patients was substantially higher than that in controls, suggesting that hemiplegic shoulder pain patients had stiffer capsules as adhesive capsulitis patients did although the severities were different. This finding implicates that hemiplegic shoulder pain may share common pathologic properties of tighter capsules with adhesive capsulitis. However, there may be additional mechanisms contributing to range of motion limitation in hemiplegic shoulder pain because capsular stiffness in those patients was not as severe as that in adhesive capsulitis patients with similar range of motion limitation.     

Complex regional pain syndrome in stroke patients

The objective of this study was to investigate the incidence, and the factors influencing the development, of complex regional pain syndrome-I in the upper extremity in hemiplegic patients within the first 28 weeks following a stroke. We followed up 82 stroke patients. All patients were evaluated at weeks 2, 6, 14 and 28 after suffering a stroke. Outcomes were assessed using passive range of motion of shoulder, presence of subluxation, Ashworth score, Motricity index arm score, Brunnstrom stages and depression score. The incidence of complex regional pain syndrome-I was 48.8% in the first 28 weeks. Significant correlation was found between complex regional pain syndrome-I and the presence of subluxation, Ashworth score, Motricity index arm score, Brunnstrom stage and depression score (r=0.259, P=0.019; r=0.271, P=0.014; r=-0.393, P<0.001; r=-0.385, P<0.001; r=0.293, P=0.008, respectively). In this study, there was a relationship between complex regional pain syndrome-I and subluxation, loss of range of motion, spasticity of shoulder muscles and muscle strength. In order to prevent the development of complex regional pain syndrome-I, exercises directed at increasing the range of motion for the glenohumeral joint, strengthening shoulder muscles and reduction of spasticity will establish the integrity of the shoulder joint.     

The role of capsular distention in adhesive capsulitis

OBJECTIVE: To explore the efficacy of capsular distension in the treatment of adhesive capsulitis of the shoulder joint. DESIGN: Prospective study. SETTING: Musculoskeletal clinic. PARTICIPANTS: Twenty-two patients (18 women, 4 men; mean age, 41.3y; range, 29-54y) with adhesive capsulitis of shoulder joint. Nineteen patients had Hannafin stage II and 3 patients had Hannafin stage III adhesive capsulitis. All patients had continuous pain and significant range of motion (ROM) limitations of the shoulder joint despite a minimum of 3 months of physical therapy (PT). INTERVENTION: Capsular distension with saline under fluoroscopic control, followed by a PT program. Main Outcome Measures: L'Insalata Shoulder Rating Questionnaire (LSRQ) score and Hannafin ROM assessment protocol. RESULTS: In the 19 patients with stage II adhesive capsulitis, the mean LSRQ score and range of abduction improved from predistention values of 49.8 degrees and 87.2 degrees to postdistension mean values of 88.1 degrees and 117.6 degrees at minimum of 1 year postdistention, respectively (P<.05). However, in the 3 patients with stage III adhesive capsulitis, the mean LSRQ score and range of abduction changed from predistention values of 41.2 degrees and 84.1 degrees to postdistension mean values of 57.8 degrees and 90.4 degrees at minimum of 1 year postdistention, respectively (P>.05). CONCLUSIONS: The treatment modality should be individualized on the basis of the stage of the adhesive capsulitis, and the distension procedure should be reserved for patients in stage II who do not progress despite participating in a PT program.     

Chronic shoulder pain: part I. Evaluation and diagnosis

Shoulder pain is defined as chronic when it has been present for longer than six months. Common conditions that can result in chronic shoulder pain include rotator cuff disorders, adhesive capsulitis, shoulder instability, and shoulder arthritis. Rotator cuff disorders include tendinopathy, partial tears, and complete tears. A clinical decision rule that is helpful in the diagnosis of rotator cuff tears includes pain with overhead activity, weakness on empty can and external rotation tests, and a positive impingement sign. Adhesive capsulitis can be associated with diabetes and thyroid disorders. Clinical presentation includes diffuse shoulder pain with restricted passive range of motion on examination. Acromioclavicular osteoarthritis presents with superior shoulder pain, acromioclavicular joint tenderness, and a painful cross-body adduction test. In patients who are older than 50 years, glenohumeral osteoarthritis usually presents as gradual pain and loss of motion. In patients younger than 40 years, glenohumeral instability generally presents with a history of dislocation or subluxation events. Positive apprehension and relocation are consistent with the diagnosis. Imaging studies, indicated when diagnosis remains unclear or management would be altered, include plain radiographs, magnetic resonance imaging, ultrasonography, and computed tomography scans. Plain radiographs may help diagnose massive rotator cuff tears, shoulder instability, and shoulder arthritis. Magnetic resonance imaging and ultrasonography are preferred for rotator cuff disorders. For shoulder instability, magnetic resonance imaging arthrogram is preferred over magnetic resonance imaging.     

Shoulder pain in hemiplegia

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.     

Glenohumeral joint subluxation and reflex sympathetic dystrophy in hemiplegic patients

OBJECTIVE: To examine the relation between glenohumeral joint subluxation and reflex sympathetic dystrophy (RSD) in hemiplegic patients. DESIGN: Case-control study. SETTING: Inpatient rehabilitation hospital. PATIENTS: Thirty-five hemiplegic patients with RSD (RSD group) and 35 hemiplegic patients without RSD (non-RSD group) were included in the study. Patients with rotator cuff rupture, brachial plexus injury, or spasticity greater than stage 2 on the Ashworth scale were excluded. MAIN OUTCOME MEASURES: Both the RSD and non-RSD groups were assessed for presence and grade of subluxation from radiographs using a 5-point categorization. The degree of shoulder pain of the non-RSD group was assessed by a visual analogue scale of 10 points. RESULTS: Glenohumeral subluxation was found in 74.3% of the RSD and 40% of the non-RSD group (p = .004). In the non-RSD group, 78.6% of the patients with subluxation and 38.1% of the patients without subluxation reported shoulder pain (p = .019). No correlation was found between the degree of shoulder pain and grade of subluxation in the non-RSD group (p = .152). CONCLUSION: Findings from this study suggest that shoulder subluxation may be a causative factor for RSD. Therefore, prevention and appropriate treatment of glenohumeral joint subluxation should be included in rehabilitation of hemiplegic patients.     

Evaluation of supraspinatus muscle changes in the shoulder joint of stroke patients with hemiplegic and shoulder subluxation using ultrasonography: comparison between affected and unaffected sides

[Purpose] The shoulder joint has a very unstable structure yet a significantly wide range of motion. Weakness of the muscles around the shoulder joint may cause shoulder joint subluxation. This study aimed to determine changes in supraspinatus muscle thickness between different shoulder abduction angles using ultrasonography and to compare differences in supraspinatus muscle thickness changes between the affected and unaffected sides depending on shoulder joint subluxation. [Participants and Methods] Forty hemiplegic patients with stroke were recruited (20 patients with and 20 without shoulder subluxation). Using ultrasonography, we measured supraspinatus muscle thickness at three shoulder joint abduction angles and calculated the differences in supraspinatus muscle thickness. Depending on subluxation, we separately analyzed the thickness and variations in the supraspinatus muscle on both the affected and unaffected sides. [Results] In stroke patients with shoulder subluxation, the difference in supraspinatus muscle thickness was significantly less in the affected side than in the unaffected side. [Conclusion] The thickness and rate of supraspinatus muscle thickness change was significantly less in the affected side than in the unaffected side in stroke patients with shoulder subluxation.     

The effectiveness of functional electrical stimulation for the treatment of shoulder subluxation and shoulder pain in hemiplegic patients: A randomized controlled trial

Purpose.?To investigate the effect of functional electrical stimulation (FES) for the treatment of shoulder subluxation and shoulder pain in hemiplegic patients.

Method.?A total of 50 hemiplegic patients with shoulder subluxation and shoulder pain were included in the study. The patients were randomly divided into the study and control groups. All patients were put on a rehabilitation program using conventional methods while the study group patients were additionally applied FES to supraspinatus and posterior deltoid muscles. The shoulder pain of all patients during resting, passive range of motion (PROM) and active range of motion (AROM) was measured with the visual analog scale (VAS) while the shoulder subluxation levels were evaluated with the classification developed by Van Langenberghe and by using the millimetric measurements on anteroposterior shoulder X-ray before and after the physical treatment and rehabilitation program and compared.

Results.?Comparison of the resting AROM vs. PROM VAS value changes showed no significant difference between the groups. There was a significant difference between the two groups for the amount of change in shoulder subluxation in favor of the study group.

Conclusions.?The results of our study have shown that applying FES treatment to the supraspinatus and posterior deltoid muscles in addition to conventional treatment when treating the subluxation in hemiplegic patients is more beneficial than conventional treatment by itself.     

Adhesive capsulitis: evaluation of a treatment coupling capsular distension and intensive rehabilitation]

INTRODUCTION: Adhesive capsulitis is a clinical entity characterized by a loss of motion and a decrease of the joint volume capacity. Results of clinical trials have shown that distensions can help to decrease pain and increase the range of motion. OBJECTIVE: The purpose of the study was to measure the effect of repeated distension arthrography combined with an intensive program of rehabilitation on pain, range of motion, and occupational outcome in patients with adhesive capsulitis. DESIGN: 39 cases of idiopathic capsulitis (7 cases) or secondary capsulitis (19 post-traumatic, 13 post-surgery of the rotator cuff) were included in the study. Intervention consisted of an intensive program of passive and active physiotherapy during one? Week and then distension arthrography, performed 3 times at 1- week intervals, with steroid injections in the glenohumeral joint and 1 in the subacromial space. RESULTS: Lateral elevation improved substantially after the first week of physiotherapy and medial rotation after the first distension. Pain intensity decreased after the first distension. After the third distension, very small changes were noted. Results did not differ by etiology of capsulitis. At the end of the program, 9 of 17 patients could return to their previous job. CONCLUSIONS: Two repeated arthrographic distensions with steroid injection and an intensive program of physiotherapy improves the range of motion and the painful condition associated with capsulitis and allows for a rapid return to employment. A third distension does not seem to provide a further benefit, as has been found by other studies.     

Physical Medicine and Rehabilitation (85)

Glenohumeral joint subluxation and reflex sympathetic dystrophy in hemiplegic patients. (Kocaeli University, Kocaeli, Turkey) Arch Phys Med Rehabil 1999; 81:944–946. This is a case‐controlled study of the relationship between glenohumeral joint subluxation and reflex sympathetic dystrophy (RSD) in hemiplegic patients set in an inpatient rehabilitation hospital. Thirty‐five hemiplegic patients with RSD (RSD group) and 35 hemiplegic patients without RSD (non‐RSD group) were included in this study. Patients with rotator cuff rupture, brachial plexus injury, or spasticity greater than stage 2 on the Ashworth scale were excluded. Both the RSD and non‐RSD groups were assessed for presence and grade of subluxation from radiographs using a 5‐point categorization. The degree of shoulder pain of the non‐RSD group was assessed by a visual analogue scale of 10 points. Glenohumeral subluxation was found in 74.3% of the RSD group and 40% of the non‐RSD group (P = 0.004). In the non‐RSD group, 78.6% of the patients with subluxation and 38.1% of the patients without subluxation reported shoulder pain (P = 0.019). No correlation was found between the degree of shoulder pain and grade of subluxation in the non‐RSD group (P = 0.152). Conclude that the findings suggest that shoulder subluxation may be a causative factor for RSD. Therefore, prevention and appropriate treatment of glenohumeral joint subluxation should be included in rehabilitation of hemiplegic patients. Comment by Miles Day, MD. The purpose of this study was to examine the relationship between shoulder subluxation in hemiplegic patients and reflex sympathetic dystrophy. They also examined if subluxation is associated with shoulder pain and the grade of subluxation in patients with subluxation and no reflex sympathetic dystrophy (RSD). Patients with injuries to the rotator cuff of the brachial plexus, marked spasticity, and major trauma to joint structures were excluded as these can be precipitating factors for RSD. The study noted a significantly higher presence of shoulder subluxation within the RSD group and the presence of pain was significantly high in patients with shoulder subluxation in the non‐RSD group. The take home message of this article is that any measure or treatment that can be applied to the glenohumeral joint should be performed to eliminate the possibility of the patient developing RSD and subsequently hindering further rehabilitation in these patients.     

Hemiplegic shoulder pain

This article reviews the literature relevant to the possible causes, prevention, and treatment of hemiplegic shoulder pain. Shoulder pain and stiffness impede the rehabilitation of patients with hemiplegia. The cause of this complication is unknown, but it may be related to the severity of neurological deficits, preexisting or posthemiplegic soft tissue injury, subluxation, brachial plexus injury, or shoulder-hand syndrome. Shoulder pain may be preventable if risk factors can be identified and appropriate prophylaxis applied. Resolution of the condition depends on diagnosis and effective treatment at the onset of the symptoms. More clinical research is needed to clarify the cause of hemiplegic shoulder pain and to document the efficacy of prophylactic and treatment methods.     

Evaluation of two support methods for the subluxated shoulder of hemiplegic patients

One of the most troublesome complications in the rehabilitation of hemiplegic patients is inferior subluxation of the glenohumeral joint. The purpose of this study was to determine which of two shoulder supports, the Bobath shoulder roll or the Henderson shoulder ring, would be more effective in the management of hemiplegic patients with a subluxated glenohumeral joint. To determine the degree of subluxation and the amount of reduction after application of a shoulder support, radiographs were taken of 26 hemiplegic patients with subluxated shoulders. Radiographs of the unsupported affected shoulder were compared with radiographs of the same shoulder with each support applied. Radiographs of the unaffected shoulder were used as a comparison in determining the amount of subluxation. An analysis of variance revealed no significant difference in the reduction of inferior subluxation between the two types of shoulder support. A significant difference in subluxation, however, existed between measurements of the unsupported affected shoulder and the unaffected shoulder (p less than .001) and between measurements of the unsupported affected shoulder and the supported affected shoulder (p less than .001). The results of this study demonstrate the benefits of the Bobath shoulder roll and the Henderson shoulder ring in the management of hemiplegic patients with subluxated shoulders.     

Shoulder pain in hemiplegia: statistical relationship with five variables

The incidence of shoulder pain and the statistical relationship between it and five other variables (patient age, time since onset of hemiplegia, range of hemiplegic shoulder external rotation, spasticity and weakness) were investigated retrospectively. Of 50 consecutive hemiplegic patients whose records were reviewed, 36 had shoulder pain. The variables significantly (p less than 0.01) correlated with shoulder pain were: time since onset of hemiplegia (r = 0.45) and ROSER (r = -0.61). The relationship between shoulder pain and range of shoulder motion remained significant when other factors were partialled out. The relationship between shoulder pain and time since onset was not significant when the affect of range of shoulder motion was partialled out. Therefore, range of shoulder external rotation was considered the factor related most significantly to shoulder pain. This finding suggests that shoulder pain demonstrated by hemiplegia patients may be, in part, a manifestation of adhesive capsulitis.     

Randomized Controlled Trial for Efficacy of Intra-Articular Injection for Adhesive Capsulitis: Ultrasonography-Guided Versus Blind Technique

Lee H-J, Lim K-B, Kim D-Y, Lee K-T. Randomized controlled trial for efficacy of intra-articular injection for adhesive capsulitis: ultrasonography-guided versus blind technique.ObjectiveTo evaluate the clinical effect of ultrasonography (US)-guided intra-articular injections compared with a blind (unguided) technique for the treatment of adhesive capsulitis.DesignRandomized controlled trial.SettingOutpatient rehabilitation clinic.ParticipantsPatients (N=43) diagnosed as having adhesive capsulitis after clinical examinations and radiologic and ultrasonographic study.InterventionUnder either US-guided or a blind technique, patients received a 20-mg intra-articular injection of triamcinolone mixed with 1.5mL 2% lidocaine and 4mL normal saline in the first week followed by 5 weekly injections of sodium hyaluronate.Main Outcome MeasuresA visual analog scale for pain intensity, range of motion (ROM) of the shoulder (flexion, abduction, external rotation, and internal rotation), and general shoulder function during daily activities at preinjection as a baseline and then every week after injection for 6 weeks for each patient.ResultsTwenty patients out of 22 in the blind injection group and 20 out of 21 in the US-guided group finished the entire 6-week study period. The improvement in pain intensity, ROM, and shoulder function score was significantly greater in the US-guided injection group than in the blind injection group by the second week postinjection (P<.05). However, there were no further significant differences in the improvement between the 2 groups beyond the third week.ConclusionsUS-guided intra-articular injections may offer advantages over a blind technique for the treatment of adhesive capsulitis and may deliver clinical benefits during the first few weeks of treatment. This finding suggests that the improved targeting to the intra-articular space by using US can result in better treatment of adhesive capsulitis.     

Suprascapular nerve block for pain relief in adhesive capsulitis: comparison of 2 different techniques

OBJECTIVE: To evaluate the clinical effectiveness of 2 suprascapular nerve block techniques in adhesive capsulitis. DESIGN: A single-blinded, randomized, comparative clinical trial. SETTING: Physical medicine and rehabilitation department of a university hospital in Turkey. PARTICIPANTS: Forty-one patients with adhesive capsulitis. INTERVENTIONS: Suprascapular nerve block with patients randomly divided into 2 groups: group A, needle tip guided by superficial bony landmarks, or group B, near-nerve electromyographically guided technique. MAIN OUTCOME MEASURES: Visual analog scale (VAS) score for pain severity and range of motion (ROM) were assessed before the injection and at 10 and 60 minutes after it. RESULTS: Active and passive ROM changes and VAS score changes from baseline were statistically significant for each group (P<.05). Passive ROM changes within time after the injection were statistically significant between the 2 groups in all planes except glenohumeral abduction. Achieved VAS score changes in the groups within time were significantly different from each other (P=.001). The VAS score difference after the suprascapular nerve block was more prominent in the near-nerve electromyography group. CONCLUSION: The near-nerve electromyography technique for suprascapular nerve block was more successful in providing and maintaining pain relief for up to 60 minutes.     

Self-care for patients with frozen shoulder

"Frozen shoulder" syndrome (adhesive capsulitis or pericapsulitis) refers to any kind of shoulder pain or to limited active or passive glenohumeral joint motions. Treatment options include both Chinese and western medical therapies. However, the key to recovery lies in self-care. This article addresses both Chinese and western treatments for frozen shoulder and suggests optimal treatments and self-care approaches for this debilitating condition. Health professionals can help patients ease their pain and increase joint activity in order to prevent frozen shoulder from turning into chronic adhesive capsulitis.     

Hemiplegic shoulder pain: implications for occupational therapy treatment

BACKGROUND: Hemiplegic shoulder pain is common after stroke causing hemiplegia. It adversely affects the recovery of arm function and independence in activities of daily living. Subluxation, abnormal tone and limited range of motion or capsular constrictions have been reported as potential causes. Other factors such as rotator cuff tears, brachial plexus injury, shoulder-hand syndrome and other pre-existing pathological conditions may also be associated with hemiplegic shoulder pain. The etiology remains unclear, but hemiplegic shoulder pain may result from a combination of the above factors. SCOPE: This literature review examines the possible causes of hemiplegic shoulder pain and discusses the implications for occupational therapy treatment. Occupational therapy interventions include proper positioning, facilitation of movement through purposeful therapeutic activities, increasing passive range of motion, implementation of external supports and treatment of shoulder-hand syndrome. PRACTICE IMPLICATIONS: Understanding the processes involved will assist with effective assessment, treatment and prevention of hemiplegic shoulder pain. This will facilitate clients' participation in rehabilitation programs and move them towards attainment of optimal function.     

Arthrographic findings in hemiplegic shoulders

To discover the influence of hemiplegia on arthrographic changes in hemiplegic shoulders, we compared arthrographic findings from paralyzed and nonparalyzed shoulders in 77 patients with hemiplegia. The correlation between arthrographic changes in paralyzed shoulders and characteristics of the hemiplegic condition was also investigated. Hemiplegic changes were considered to be responsible for adhesive changes in affected shoulders because those changes were found in paralyzed shoulders at a statistically significant higher rate (54.6%) than in the nonparalyzed side (32.5%). The occurrence rate of contrast leakage from capsule tear on the subscapular bursa and the bicipital tendon sleeve was higher on the nonparalyzed side than on the paralyzed side. It is suggested that capsular contracture due to hemiplegia prohibits capsular tear during arthrographic maneuvers. No significant difference was found in the occurrence of rotator cuff tear between the paralyzed and the nonparalyzed shoulder. Those changes on the paralyzed side were not correlated with any characteristics of hemiplegics except for shoulder pain prior to the onset of hemiplegia.     

Adhesive capsulitis: a sticky issue

The shoulder is a very complex joint that is crucial to many activities of daily living. Decreased shoulder mobility is a serious clinical finding. A global decrease in shoulder range of motion is called adhesive capsulitis, referring to the actual adherence of the shoulder capsule to the humeral head. Adhesive capsulitis is a syndrome defined as idiopathic restriction of shoulder movement that is usually painful at onset. Secondary causes include alteration of the supporting structures of and around the shoulder, and autoimmune, endocrine or other systemic diseases. The three defined stages of this condition are the painful stage, the adhesive stage and the recovery stage. Although recovery is usually spontaneous, treatment with intra-articular corticosteroids and gentle but persistent physical therapy may provide a better outcome, resulting in little functional compromise.