Painful shoulder in hemiplegia: Prevention and treatment

The painful shoulder which occurs in hemiplegia, is discussed. Possible mechanisms causing the pain, preventative measures based on the neurodevelopmental approach to treatment and therapeutic measures including treatment by means of passive movement, are described.

A painful shoulder is all too often a limiting factor in the rehabilitation of adult hemiplegic patients and yet in the m ajority of cases this problem should not arise if the patient is handled correctly from the onset of the hemiplegia. P ain is freq u en tly , associated with a subluxation of the glenohum eral join t but is m ore often due to super imposed traum a than to the subluxation itself. Com pletely painless subluxations of more than 2,5 cm have been noted in the flaccid stage. Nevertheless, it is evident that prevention of subluxation will contribute to the avoidance of a painful shoulder. In the normal person, inferior subluxation of the glenohum eral joint is prevented by a locking mechanism (Basmajian, 1978) dependent upon the angle of the glenoid fossa. When the subject is in an upright position the scapula is stabilised in slight lateral rotation and the humerus hangs vertically. In this position the superior part of the capsule and the corticohum eral ligam ent are taut and it is impossible to subluxate the head of the hum erous downwards, even when heavy weights are suspended from the arm . The capsule and ligament are supported in this function by activity in supraspinatus and, to a lesser degree, in some of the horizontal, posterior fibres of deltoid. Basmajian (1967) points out, however, that a relative abduction of the hum erus to about 15° is sufficient to allow considerable downward subluxation of the head of the humerus.
In the flaccid stage of hemiplegia two factors would appear to interfere with this inherent stability of the glenohum eral joint in the upright position. Firstly, in activity of the upper fibres of trapezius and of serratus anterior results in medial rotation of the inferior angle of the scapula with consequent downwards angling of the glenoid fossa and relative abduction of the humerus. Secondly, inactivity of supraspinatus and the horizontal fibres of deltoid allows the unopposed weight of the arm to stretch the cortico-hum eral ligam ent and superior capsule. In the absence of any stretch reflex activity in the muscles acting upon the glenohum eral joint, traum a is easily superimposed upon the already subluxed joint, usually by traction on the hemiplegic arm as the patient is moved about in bed or from the bed to a chair.
As spasticity develops, the scapula becomes fixed in retraction and m edial rotation due to spasticity in the rhom boids and the lower fibres of trapezius, re inforced by latissim us dorsi. H ypertonus in subscapularis, infraspinatus and teres m inor now contributes to the subluxation of the head of the hum erus from the downwards tilted glenoid fossa (Bobath, 1978). T h e re^ is a resistance to protraction and lateral rotation ot, the scapula and if the arm is moved above the ho ri zontal the capsule and synovium, as well as supra spinatus, are compressed against the acrom ion process of the scapula. This type of traum a occurred frequently in the days when reciprocal pulley exercises were popu lar for hemiplegics, and is still seen all to frequently as a result of passive stretching of the glenohum eral joint w ithout adequate prior attention to inhibition of spasticity and m obilisation of the scapula.
R epeated m inor traum a resulting from any of the above mechanisms will set up a capsulitis which, unless treated prom ptly, may progress to the looselycalled " frozen" shoulder. A lthough treatm ent at the very first hint of pain is usually effective it is obviously very much better to prevent traum a to the joint in the first place. This may be achieved by correct posi tioning and handling, prevention of subluxation, inhi bition of spasticity (and m obilisation of the scapula) and early re-education of movement.

POSITIONING AND HA N DLIN G
This involves careful instruction of nursing personnel and counselling of the patient and his family. During the early stages the patient, as far as is possible, should not be nursed supine as this position en courages retraction of the scapula. He should nursed on each side alternately, with the sh o u ld e r!, girdle protracted and the arm extended forw ards in the neutral position (Figs. 1 and 2). W hen the patient is being turned towards his sound side the affected arm must be fully supported and his arm and upper trunk should be brought forwards by grasping him behind the scapula (Fig. 3) and not by pulling on his arm.
If it is necessary for him to sit in bed, his trunk must be completely upright, his shoulder-girdle p ro tracted and his arm supported forwards on a bedtable or on pillows (Fig. 4). Sitting out in a chair is preferable to sitting in bed, but it is very easy to cause traum a to the shoulder joint if the transfer from bed to chair is clumsily perform ed. Todd an'ifi Davies (1977) give the correct way of perform ing this m anoeuvre, the therapist or nurse supporting under the patient's shoulders with her hands over the scapulae (Figs. 5 and 6). Once out in a chair, the affected arm may be supported forwards either on a table or in a trough attached to the arm of the chair.
Frequently unawareness of, and inattention towards, his affected side causes the patient to leave his arm dangling over the side of the chair w ithout any form of support. In this position the scapula is retracted and the humerus is frequently slightly abducted, predispos ing to subluxation. N ursing staff and fam ily must, from the beginning, be shown how to increase the patient's awareness of his affected side. His bed should be positioned so that he has to look across his affected side at the rest of the room ; he should be approached ipn the affected side, fed and given a bedpan from that Jlide. Visitors should sit on th at side, and holding his affected hand will increase sensory awareness. As soon as he is able to do so, provided th at the scapula is m obile, he should be shown how to move his affected arm with his sound arm. In order to do this he clasps his hands with fingers interlaced and with the affected thum b upperm ost. H e is taught first to extend his arm s forwards until both scapulae are protracted and elbows extended. His palms should be together, with thum bs facing upwards, and the m ovem ent should take place sym metrically with hands in the midline (Fig. 7). Once he can achieve this he can be taught to lift his arms upwards through the full range of elevation through flexion.

PREVENTION OF SUBLUXATION
Occasionally during the flaccid stage additional sup port may be needed to control subluxation. Slings are contraindicated on several counts. They contribute to the patient's lack of awareness of the affected arm, they immobilize the joints of the arm and they re inforce the developing spastic synergy. The sustained stretch which triceps undergoes within a sling will lead to progressive inhibition of triceps and, recipro cally, to increased activity in biceps (Stockmeyer, 1967). The use of a sling also disturbs balance, interferes with facilitation of walking and makes a reciprocal armswing impossible. It is also impossible to inhibit associated reactions in the arm . Frequently the hand hangs over the edge of the sling, resulting in oedema and in pain when weightbearing on a flat hand is attem pted. Bobath (1978) describes an effective m ethod of pre venting subluxation whilst allowing full range of move ment in elevation through flexion. It consists of a cuff which fastens around the upper arm and is suspended by a figure-of-eight band around the shoulders (Fig. 8). It is found in practice th at a thin layer of foam -rubber under the cuff prevents slipping and allows the cuff to be fastened less tightly, whilst an elasticated band around the shoulders adds to comfort. This m ethod does not interfere at all with movement of the elbow, forearm and hand. An earlier m ethod consisting of a small pad in the axilla, again held by a figure-of-eight bandage, is not recom mended as it results in slight abduction of the hum erus and this may, in turn, pre dispose to subluxation.

INHIBITION OF SPASTICITY
Correct positioning and handling, as outlined above, will do much to prevent the developm ent of spasticity and fixation of the scapula. As tone starts to increase, spasticity first becomes evident distally, in the flexors of the wrist and fingers. At this stage a foam -rubber "spreader" may be effective not only in inhibiting this distal spasticity but also in retarding the developm ent of flexor spasticity throughout the arm . As spasticity, MAART 1980 i.e. increased tone, develops, so also does the degree o f reciprocal activity change. D istally we find complete reciprocal inhibition with a dominance of flexor activity over extensor activity, whereas proximally there develops a contratcion of opposing muscle groups. This is particularly evident around the scapula which may become completely immobile, although in a position of retraction and downwards rotation of the glenoid fossa, reflecting the relative dom inance of the spastic muscle groups. Since the most common cause of pain in the shoulder of a hemiplegic patient is pinching of the capsule and synovium when the hum erus is forced into flexion or abduction against an im m obile scapula, this excessive co-contraction must be prevented and full scapular mobility established. In addition, the overactivity of subscapularis, infra spinatus and teres m inor which contributes to the depression of the hum eral head in the glenoid fossa must be inhibited.
If spasticity is strong, prelim inary reduction of tone may be achieved by moving the trunk over the affected shoulder. In supine the affected side of the trunk is elongated and the affected arm is abducted as far as is possible w ithout encountering resistance. The patient is then asked to bring his sound arm and leg across his body and roll onto his affected side. A fter several repetitions a reduction in tone will be felt and the scapula may then be mobilized in supine or in sidelying on the sound side. In either case the affected side must be fully elongated and the scapula pro tracted before elevation and depression of the scapula are superimposed. The arm is supported in a reflexinhibiting pattern of forward extension and outward rotation • of the shoulder, extension of the elbow, supinatioh of the forearm , extension of the wrist and fingers and extension/abduction of the thum b. W hen the scapula moves freely the arm is taken gradually into full elevation. If pain is encountered the arm must be moved down a few degrees and the scapula fully protracted before continuing towards elevation. Provided that the scapula is kept mobile the patient can, himself, carry out self-inhibition in sitting or lying as described earlier.

EARLY R E-ED U C A T IO N O F M O V E M E N T
In the norm al person a relative degree of co contraction of opposing muscle groups gives stability and postural fixation proxim ally, b u t never interferes with movement. D istally a greater degree of reciprocal inhibition allows quick movem ents to occur freely, but these skilled movem ents would not be possible w ithout the aforem entioned proxim al fixation. In the flaccid stage of hem iplegia the patient lacks the norm al degree of postural stability and proximal fixation which would protect his shoulder from traum a and during this stage of treatm ent early weight-bearing is indi cated in order to stim ulate sufficient co-contraction to stabilise the glenohum eral joint. W eight-bearing activi ties m ust not, however, be static. Static holding of positions will lead to excessive co-contraction and re sultant fixation of both scapula and glenohum eral joint. Suitably mobile weight-bearing activities a r / shown in the accom panying sketches (Figs. 9 -12). An essential prerequisite for all these activities is weighttransfer to and elongation of the trunk on the affected side of the body.
As spasticity develops, certain muscle groups dom i nate patterns of posture and m ovem ent and their antagonists become progressively inhibited. The patient cannot stabilise the scapula in protraction and o u t wards rotation; he cannot reach forwards with extended elbow or raise his arm above shoulder level because of the spasticity of the opposing muscles. This spasti city can be inhibited as described in the previous section but the problem of activating the apparently "w eak" muscles rem ains and until the patient has full control of both scapular and glenohum eral move ments the possibility of traum a to the glenohum eral joint rem ains. Following inhibition, techniques of pro prioceptive stim ulation (tapping) may be needed to activate patterns of m ovem ent in elevation. Firstly the patient needs to be given the ability to hold the arm in w hatever position it is placed. Only after this has been achieved can facilitation of active m ovem ent towards that position be attem pted. Suitable activities at this stage o f treatm ent are shown in figures 13 -16.

Figs. 9 -1 2 . Mobile weight-bearing
If this program m e is followed, the probability of gleno-humeral problems will be reduced to a minimum. However, if they do occur, it seems that the associated pain is less intense; as the inert joint structures are probably the ones affected the complication is readily treatable by passive m obilisation techniques according to M aitland (1977). T reatm ent is therefore directed at the pain. It has been found that passive lateral ro ta tion of the glenohum eral joint is very often limited and that this is the most painful m ovem ent. Lateral rotation of the glenohum eral joint is of course en hanced by retraction of the scapula and this could possibly be a precursor to the painful shoulder syn drome.

TREATMENT PROCEDURE
The passive m obilisation techniques used to treat this condition are directed towards relieving pain. C areful assessment is the crux of successful treatm ent. The assessment is complicated both by the frequent absence of active m ovem ent and by the fact that spasticity may prevent passive m ovem ent of the gleno hum eral joint. It is, however, possible to plot a graph of the intensity of pain on the y-axis against the range of passive movem ents of the klenohum eral joint (usually flexion) provoking pain on the x-axis (a move ment diagram, M aitland, 1977) and to assess the pain reaction to passive movem ent, ensuring a fairly accu rate estim ation of " irritability ". The use of passive accessory movem ents at the limit of the physiological range is advised if up to 80% of the passive physio logical range is painfree. From this inform ation it is possible to plan treatm ent and to determ ine the neces sary techniques, dosage and frequency of treatm ent.
Before commencing either objective assessment or treatm ent by passive m obilisation techniques, it is essential to inhibit spasticity and to position the patient correctly. The appropriate inhibiting techniques as previously indicated must be fulfilled. The patient should then be positioned in lying with his head on a small pillow so that the glenohum eral joint can move freely. The hemiplegic side m ust be elongated and the hemiplegic leg must also be placed in a reflex in hibiting pattern. By virtue of the very starting posi tions needed to achieve the m obilisation techniques proposed, it will be seen that the scapula is brought into the protracted position. D uring the early rehabi litation phase G rade I -1 1 1 * passive accessory move ments (longitudinal or posterior-anterior movem ents re spectively with the glenohum eral joint in the neutral position (Fig. 17) are usually required. In old-established hemiplegia, it is often necessary to take the shoulder to the limits of the physiological range of forward flexion and to execute G rade I -III passive accessory movem ents (usually longitudinal or postero-anterior * A passive accessory m ovem ent is a joint m ovem ent which cannot norm ally be perform ed actively and has to be executed by an external force or the hands of the physiotherapist. ch n ique. Once the pain has been relieved it is essential to reinforce the preventative program m e by checking both the nursing procedures w ithin the hospi tal and the handling by the fam ily at home. The patient should once again be instructed as to the im portance of putting his gleno-humeral joint through its full range at least once a day.