Download physical examination

PAINFUL POST STROKE
SYNDROMES:
SPOTLIGHT ON THE SHOULDER
Richard D. Zorowitz, M.D.
Associate Professor of PM&R
The Johns Hopkins University School of Medicine
Chairman, Department of PM&R
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DISCLOSURES
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Allergan, Inc./Medergy Medical – Advisory
Board
Bioness, Inc. – Research Safety Monitor
Victhom Human Bionics – Advisory Board
NDI Medical/SPR Therapeutics – Advisory
Board
No conflict of interest between these activities and presentation material.
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OBJECTIVES
Describe the anatomy and
pathophysiology of the shoulder
 Discuss the clinical examination and
diagnostic testing of the hemiplegic
shoulder
 Discuss treatment approaches to various
diagnoses involving the hemiplegic
shoulder

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EPIDEMIOLOGY
Shoulder pathology occurs in up to 85%
of patients with spastic symptoms, up to
18% of patients with flaccid symptoms
 Turkish study: 63.5% incidence of
shoulder pain in stroke patients
 Can begin as early as 2 weeks post-stroke
but typically occurs within 2-3 months

Van Ouwenaller C, Laplace PM, Chantraine A. Arch Phys Med Rehabil. Jan1986;67(1):23-26.
Aras MD, Gokkaya NK, Comert D, et al. Am J Phys Med Rehabil. Sep 2004;83(9):713-719.
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FACTORS
Flaccidity or spastic muscle imbalance of
glenohumeral joint
 Contracture
 Complex regional pain syndrome (CRPS)
 Rotator cuff injury
 ?? Shoulder subluxation ??

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ANATOMY
Well-approximated glenohumeral joint
 Proper glenoid fossa angle (forward and
upward)
 Proper scapular alignment with vertebral
column
 Stabilized by musculature: supraspinatus,
deltoid, latissimus dorsi

Cailliet R. The shoulder in the hemiplegic patient. In: Shoulder Pain, 3rd ed. FA Davis; 1991:193-226.
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ANATOMY
Stabilized to smaller degree by shoulder
capsule (supports humerus)
 Trapezius, serratus anterior, rhomboids
provide proper scapular alignment
 Latissimus dorsi works to depress scapula
 Erector spinae muscle tone, with righting
reflex, maintains vertebral column in
upright alignment

Cailliet R. The shoulder in the hemiplegic patient. In: Shoulder Pain, 3rd ed. FA Davis; 1991:193-226.
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PATHOPHYSIOLOGY:
Flaccid Stage

Areflexia:
– Loss of muscle tone
– Loss of volitional motor activity
– Loss of muscle stretch reflexes
– Variable loss of sensation
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PATHOPHYSIOLOGY:
Flaccid Stage

Shoulder capsule: thin, 2 layers
– Stratum synovium (inner)
 Highly vascular but poorly innervated
 Insensitive to pain but highly reactive to heat and cold
– Stratum fibrosum (outer)
 Poorly vascularized but richly
innervated, predisposing to
pain from stretch
 In flaccid shoulder may
predispose capsule to
irreversible damage and the
shoulder to pain
Faghri PD, Rodgers MM, Glaser RM, et al. Arch Phys Med Rehabil. Jan 1994;75(1):73-9.
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PATHOPHYSIOLOGY:
Flaccid Stage
Using 3-dimensional radiographic technique that
determines true position of humeral head in
relation to scapula, less downward rotation of
glenoid fossa than originally expected
 No significant relationship found between extent
of scapular orientation, severity of subluxation
 CONCLUSION: scapular position does not
contribute as much to inferior subluxation as was
originally thought

Culham EG, Noce RR, Bagg SD. Arch Phys Med Rehabil. Sep 1995;76(9):857-864.
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PATHOPHYSIOLOGY:
Spastic Stage
Subscapularis, pectoralis major: internal
rotation of humerus (? which contributes
more)
 Pronator quadratus, pronator teres, flexor
carpi radialis: pronation of forearm
 Rhomboids: scapular depression,
downward rotation

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PATHOPHYSIOLOGY:
Spastic Stage
Latissimus dorsi: adduction, extension,
internal rotation of humerus
 Biceps brachii: further depresses head of
humerus , flexes elbow

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PATHOPHYSIOLOGY:
Spastic Stage

Co-contraction: failure of antagonist
muscles to relax when agonist muscles
contract
– During internal rotation, excessive spasticity
of subscapularis, pectoralis major, latissimus
dorsi, teres major overwhelms the external
rotators (supraspinatus, infraspinatus, teres
minor)
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PATHOPHYSIOLOGY:
Spastic Stage

Co-contraction: failure of antagonist
muscles to relax when agonist muscles
contract
– Rhomboids, causing downward and outward
rotation of the scapula, overwhelm trapezius,
serratus anterior muscles
– Unilateral paraspinal muscles overwhelm
contralateral side, causing lateral flexion of
spine toward affected side
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PATHOPHYSIOLOGY:
Synergy Stage
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Shoulder/scapular
depression (downward
rotation and retraction)
Humeral
adduction/internal
rotation
Elbow flexion
Forearm pronation (rarely
supination)
Wrist/finger flexion
(thumb-in-hand position)
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HISTORY
Reduced mobility
 Tenderness
 Swelling/edema
 Pain with movement

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PHYSICAL EXAMINATION
Atrophy
 Asymmetry
 Swelling/edema
 Tenderness
 Range of motion (ROM)
 Pain with motion
 Palpable gap between acromion, humeral
head

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PHYSICAL EXAMINATION

Forward flexion
– Arm straightened, brought
upward through frontal
plane
– Moved as far as patient can
go above head
– For recording purposes, 0
degrees defined as straight
down at patient's side, 180
degrees straight up
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PHYSICAL EXAMINATION

Shoulder Abduction
– Arm kept straightened
while raised, abducted
– Hand should face
outward, not forward,
as forward flexion
– ROM measured in
degrees as described
for forward flexion
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PHYSICAL EXAMINATION

External Rotation ROM
at 90 Degrees of
Abduction
– Position in sitting with arm
at 90 degrees, fingers
pointing upward, palm
facing anteriorly
– Elbow, shoulder supported
to prevent muscle
contraction
– Examiner rotates forearm
anteriorly as much as
possible
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PHYSICAL EXAMINATION

Internal Rotation ROM
at 90 Degrees of
Abduction
– Position in sitting with arm
at 90 degrees, fingers
pointing downward, palm
facing posteriorly
– Elbow, shoulder supported
to prevent muscle
contraction
– Examiner rotates forearm
posteriorly as much as
possible
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PHYSICAL EXAMINATION

Laxity Test
– Position in supine
– Stabilize scapula
– Slide humeral head
anteriorly, posteriorly
within glenoid fossa to
evaluate joint stability
– Note axial load applied
to elbow
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PHYSICAL EXAMINATION

Impingement Test
– Position in sitting
– Internally rotate arm
with thumb facing
downward
– Abduct, forward flex
arm
– If present, patient
experiences pain as
arm abducted
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PHYSICAL EXAMINATION

Shoulder
Subluxation
– Position in sitting
– Palpate between
acromion, humeral
head
– Use fingerbreadths or
calipers
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PHYSICAL EXAMINATION
Manual muscle testing: strength, tone
 Sensory evaluation
 Reflexes
 Neglect
 Apraxia

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DIAGNOSTIC STUDIES
Radiographs (?)
 Bone scan: CRPS (?)
 EMG/Nerve Conduction Study: Brachial
Plexus Injury (?)
 Injections: therapeutic also

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DIFFERENTIAL DIAGNOSIS
Shoulder Subluxation
 Spasticity
 Complex Regional Pain Syndrome
 Adhesive Capsulitis
 Bursitis/Tendonitis: Impingement
 Co-morbid Conditions:

– Osteoarthritis
– Rotator Cuff Dysfunction
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SHOULDER SUBLUXATION
Incidence as high as 81%
 Treatment controversial

Najenson T, Yacubovich E, Pikielni SS. Scand J Rehabil Med. 1971;3(3):131-137.
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SHOULDER SUBLUXATION
Slings, arm boards, troughs, lap trays not
proven to be effective: may result in
overcorrection
 Slings also may cause lateral subluxation,
impair proprioception, interfere with
functional activities, promote undesirable
synergy patterns
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SHOULDER SUBLUXATION

Neuromuscular electrical stimulation
(NMES) proven moderately successful in
the prevention, treatment of pain, but not
necessarily subluxation
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SPASTICITY
Range of motion, stretching exercises
 Positioning: suppress evolution of synergy
patterns
 Antispasticity medications: dantrolene,
tizanidine
 Motor point blocks: botulinum toxin,
phenol

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COMPLEX REGIONAL PAIN
SYNDROME
Physical/occupational therapy: range of
motion, positioning, desensitization, TENS
 Medications: NSAIDs, steroids,
neuropathic agents
 Injections: stellate ganglion block, Bier
block
 Ablation: radiofrequency
 Surgery: sympathectomy

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ADHESIVE CAPSULITIS
Also known as “frozen
shoulder”
 Shoulder capsule,
connective tissue
surrounding
glenohumeral joint
becomes inflamed,
stiff, thus gratly
restricting motion,
causing chronic pain

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ADHESIVE CAPSULITIS
Manual mobilization exercises
 Medications: acetaminoiphen, NSAIDs,
steroids, neuropathic agents
 Injection: steroid, anesthetic
 Arthrography: distention
 Surgery: manipulation under anesthesia,
capsular release
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SUBACROMIAL/
SUBDELTOID BURSITIS
Physical modalities: range of motion
 Medications: NSAIDs, steroids
 Injection: steroids, anesthetics
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OBJECTIVES
Describe the anatomy and
pathophysiology of the shoulder
 Discuss the clinical examination and
diagnostic testing of the hemiplegic
shoulder
 Discuss treatment approaches to various
diagnoses involving the hemiplegic
shoulder

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