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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 1 DISCLOSURES 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. 2 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 3 4 5 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. 6 FACTORS Flaccidity or spastic muscle imbalance of glenohumeral joint Contracture Complex regional pain syndrome (CRPS) Rotator cuff injury ?? Shoulder subluxation ?? 7 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. 8 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. 9 PATHOPHYSIOLOGY: Flaccid Stage Areflexia: – Loss of muscle tone – Loss of volitional motor activity – Loss of muscle stretch reflexes – Variable loss of sensation 14 15 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. 16 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. 17 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 18 PATHOPHYSIOLOGY: Spastic Stage Latissimus dorsi: adduction, extension, internal rotation of humerus Biceps brachii: further depresses head of humerus , flexes elbow 19 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) 20 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 21 PATHOPHYSIOLOGY: Synergy Stage Shoulder/scapular depression (downward rotation and retraction) Humeral adduction/internal rotation Elbow flexion Forearm pronation (rarely supination) Wrist/finger flexion (thumb-in-hand position) 22 HISTORY Reduced mobility Tenderness Swelling/edema Pain with movement 23 PHYSICAL EXAMINATION Atrophy Asymmetry Swelling/edema Tenderness Range of motion (ROM) Pain with motion Palpable gap between acromion, humeral head 24 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 25 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 26 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 27 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 28 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 29 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 30 PHYSICAL EXAMINATION Shoulder Subluxation – Position in sitting – Palpate between acromion, humeral head – Use fingerbreadths or calipers 31 PHYSICAL EXAMINATION Manual muscle testing: strength, tone Sensory evaluation Reflexes Neglect Apraxia 32 DIAGNOSTIC STUDIES Radiographs (?) Bone scan: CRPS (?) EMG/Nerve Conduction Study: Brachial Plexus Injury (?) Injections: therapeutic also 33 DIFFERENTIAL DIAGNOSIS Shoulder Subluxation Spasticity Complex Regional Pain Syndrome Adhesive Capsulitis Bursitis/Tendonitis: Impingement Co-morbid Conditions: – Osteoarthritis – Rotator Cuff Dysfunction 34 SHOULDER SUBLUXATION Incidence as high as 81% Treatment controversial Najenson T, Yacubovich E, Pikielni SS. Scand J Rehabil Med. 1971;3(3):131-137. 35 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 36 37 38 39 41 SHOULDER SUBLUXATION Neuromuscular electrical stimulation (NMES) proven moderately successful in the prevention, treatment of pain, but not necessarily subluxation 42 SPASTICITY Range of motion, stretching exercises Positioning: suppress evolution of synergy patterns Antispasticity medications: dantrolene, tizanidine Motor point blocks: botulinum toxin, phenol 43 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 44 ADHESIVE CAPSULITIS Also known as “frozen shoulder” Shoulder capsule, connective tissue surrounding glenohumeral joint becomes inflamed, stiff, thus gratly restricting motion, causing chronic pain 45 ADHESIVE CAPSULITIS Manual mobilization exercises Medications: acetaminoiphen, NSAIDs, steroids, neuropathic agents Injection: steroid, anesthetic Arthrography: distention Surgery: manipulation under anesthesia, capsular release 46 47 SUBACROMIAL/ SUBDELTOID BURSITIS Physical modalities: range of motion Medications: NSAIDs, steroids Injection: steroids, anesthetics 48 49 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 50 51