Hemiplegic Shoulder Pain: Approach to Diagnosis and Management

Содержание

Слайд 2

Disclosures None

Disclosures

None

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Objectives Identify the neurogenic and mechanical factors which contribute to HSP

Objectives

Identify the neurogenic and mechanical factors which contribute to HSP
Prescribe appropriate

treatments for the identified factors in each patient with HSP
Understand the level of evidence supporting treatments for HSP
Слайд 4

Outline Basics Definition, Incidence, Prognosis Anatomy Factors Neurogenic Mechanical Diagnosis Management Suggested Treatment Algorithm

Outline

Basics
Definition, Incidence, Prognosis
Anatomy
Factors
Neurogenic
Mechanical
Diagnosis
Management
Suggested Treatment Algorithm

Слайд 5

Basics CVA: 795,000 per year; 3rd for mortality, 1st for disability;

Basics

CVA: 795,000 per year; 3rd for mortality, 1st for disability; costs

$18.8 billion annually
Hemiplegia: present in 50%, persists in 70%
HSP: commonly reported 70% (range 16-84%)

Roger 2012; Aoyagi 2004; Bohannon 1986

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HSP Risk Factors Impaired motor control Diminished proprioception Tactile extinction Abnormal

HSP Risk Factors

Impaired motor control
Diminished proprioception
Tactile extinction
Abnormal sensation
Elbow flexor spasticity
Restricted ROM

for shoulder abduction/ER
Trophic changes
Type 2 diabetes mellitus
Adhesive capsulitis
Complex regional pain syndrome
Supraspinatus or long head biceps injury

Roosink 2011; Barlak 2009; Dromerick 2008

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HSP Prognosis Lower Barthel score at 12 weeks Lower chance of

HSP Prognosis

Lower Barthel score at 12 weeks
Lower chance of return

home
Resolution within first 5 weeks predicts good long-term function

Roy 1994; Murie-Fernandez 2012; Higgins 2005

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Anatomy Shoulder: complex ball-and-socket joint Agility at the cost of stability

Anatomy

Shoulder: complex ball-and-socket joint
Agility at the cost of stability
Static stabilizers
Glenohumeral ligaments
Dynamic

stabilizers
Rotator cuff
Periscapular musculature

Kalichman 2011; Smith 2012

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Mechanisms of Injury Cause is likely multifactorial Weakness, spasticity, sensory loss,

Mechanisms of Injury

Cause is likely multifactorial
Weakness, spasticity, sensory loss, instability
Classification
Better by

etiology than symptoms
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Neurogenic Factors Upper Motor Neuron (UMN) injury Paralysis, spasticity, central post-stroke

Neurogenic Factors

Upper Motor Neuron (UMN) injury
Paralysis, spasticity, central post-stroke pain, central

sensitization
Lower Motor Neuron (LMN) injury
Peripheral neuropathy, brachial plexus injury, complex regional pain syndrome
Слайд 11

UMN Disorders Weakness Disrupts cervicothoraic posture, shoulder stability Spasticity Overactive pectorals,

UMN Disorders

Weakness
Disrupts cervicothoraic posture, shoulder stability
Spasticity
Overactive pectorals, subscapularis, biceps
85% with spasticity

had HSP (vs. 18% without)
Subscapular nerve block can reduce pain
Brachial plexus injury
Traction injury suspected
Suprascapular and axillary nerves most affected

Van Ouwenaller 1986; Hecht 1992; Kaplan 1977; Moskowitz 1963; Chino 1980

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UMN Disorders Complex Regional Pain Syndrome (CRPS) Type 1 (previously RSD),

UMN Disorders

Complex Regional Pain Syndrome (CRPS)
Type 1 (previously RSD), Type 2

(causalgia)
Incidence up to 23% of all HSP cases
Central post-stroke pain (CPSP)
Also termed thalamic pain syndrome, thought due to lesion in spinothalamic tract
Alterations in serotonin and norepinephrine

Van Ouwenaller 1986

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Mechanical Factors Shoulder subluxation Rotator cuff injury Glenohumeral joint disorders Adhesive capsulitis Myofascial pain Direct trauma

Mechanical Factors

Shoulder subluxation
Rotator cuff injury
Glenohumeral joint disorders
Adhesive capsulitis
Myofascial pain
Direct trauma

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Diagnosis History, physical examination, special tests/maneuvers Imaging (XR, MRI, US) Electrodiagnosis Diagnostic injections (nerve, muscle, joint)

Diagnosis

History, physical examination, special tests/maneuvers
Imaging (XR, MRI, US)
Electrodiagnosis
Diagnostic injections (nerve, muscle,

joint)
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Diagnosis: Exam Observation ROM AROM, then PROM Palpation Assess for bulk,

Diagnosis: Exam

Observation
ROM
AROM, then PROM
Palpation
Assess for bulk, focal tenderness
Sensation
Dermatomes, peripheral nerves (e.g.,

axillary)
Reflexes
C5-C8, UMN signs, spasticity
Strength
Слайд 16

Diagnosis: Exam Special tests Neer, Hawkins, Jobe, O’Brien, HBB/HBN Instability: Apprehension,

Diagnosis: Exam

Special tests
Neer, Hawkins, Jobe, O’Brien, HBB/HBN
Instability: Apprehension, Sulcus
Diagnostic Injections
Nerve blocks

(stellate ganglion, peripheral nerve)
Joint/tendon injections (GHJ, SA/SD bursa, etc)
Trigger point injections
Слайд 17

Слайд 18

Key Exam Maneuvers Vasudevan & Browne 2014

Key Exam Maneuvers

Vasudevan & Browne 2014

Слайд 19

Diagnosis: Imaging Radiography AP: assess for fracture, subluxation ER: calcific tendinopathy;

Diagnosis: Imaging

Radiography
AP: assess for fracture, subluxation
ER: calcific tendinopathy; IR: Hill-Sachs lesion
Scapular

Y: acromial impingement
Axillary: shoulder instability
Magnetic Resonance Imaging
Arthrography: labral tear, adhesive capsulitis
Ultrasonography
May help assess for adhesive capsulitis
Advantage of serial assessments at low cost
More injuries noted for those admitted at Brunnstrom I-III vs IV-VI

Pong 2009; Huang 2010; Lee 2009

Слайд 20

Diagnosis: Imaging Relationship of imaging and HSP Lo et al study:

Diagnosis: Imaging

Relationship of imaging and HSP
Lo et al study:
HSP cohort:

50% adhesive capsulitis, 44% shoulder subluxation, 22% rotator cuff tears, 16% CRPS Type 1
Arthrography helpful to detect adhesive capsulitis
Most cases within 2 months from CVA onset
MRI findings in chronic stroke: synovial capsule thickening/enhancement, rotator cuff enhancement
No difference in cuff tendinopathy, joint effusion, subacromial bursal fluid, ACJ arthrosis, muscle atrophy

Lo 2003; Tavora 2010

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Management Prevention through positioning Flaccid stage: risk for injury Suggested: abduction,

Management

Prevention through positioning
Flaccid stage: risk for injury
Suggested: abduction, ER, flexion
But no

consensus, none proven superior
Strapping and slings
Tape perpendicular to inhibit, parallel to promote
Only small studies to support vs. sham taping
Slings and arm troughs help minimize shoulder subluxation
Improvements in HR, gait speed, decreased O2 rate with sling use in a cross-over study

Wanklyn 1996, Braus 1994, Murie-Fernandez 2012; Thelan 2008; Han 2011

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Physical Therapy Mechanical Factors PROM exercises within pain-free range can reduce

Physical Therapy

Mechanical Factors
PROM exercises within pain-free range can reduce reports of

shoulder pain by 43%
Overhead pulley exercises increase cuff injury risk
Neither Bobath nor Brunnstrom superior
CPM: increased shoulder stability but no change to motor impairment, pain, tone, disability
Robotic devices: improved function at 8 months

Caldwell 1969; Kumar 1990; Walsh 2001; Lynch 2005; Masiero 2007

Слайд 23

Physical Therapy Neurogenic Factors TENS: high intensity > low intensity or

Physical Therapy

Neurogenic Factors
TENS: high intensity > low intensity or placebo
FES: to

reduce shoulder subluxation/instability
More effective in acute vs chronic HSP after 6 wks Tx
FES + PT is superior to PT alone (RCT, n=50)
Cochrane: improves pain-free ROM and reduces subluxation, does not affect pain or impairment
Intramuscular FES: reduced pain at 1 year, but no change to strength/sensation

Leandri 1990; Walsh 2001; Want 2000; Koyuncu 2010; Price 2001; Chae 2005; David 2010

Слайд 24

FES Vasudevan & Browne 2014

FES

Vasudevan & Browne 2014

Слайд 25

Physical Therapy Neurogenic Factors EMG biofeedback and relaxation: 150 min x

Physical Therapy

Neurogenic Factors
EMG biofeedback and relaxation: 150 min x 5 days

biofeedback or 30 min x 2 days relaxation exercises led to improved ROM, tone, reduced pain at 2 weeks

Williams 1982

Слайд 26

Interventional Neurogenic Factors Botulinum toxin (presynaptic Ach inhibitor) Several small studies

Interventional

Neurogenic Factors
Botulinum toxin (presynaptic Ach inhibitor)
Several small studies show favorable results

for both ROM and pain; others do not
One study vs corticosteroid
Some studies include intraarticular toxin
Nocioceptive effect?
Sympathetic blocks (for CRPS)
Central pain covered later in this talk
Rehab considerations: pain/edema control, isometric and stress-loading exercises, concurrent psychotherapy

Yelnik 2007; Kong 2007; De Boer 2008; Lim 2008; Castiglione 2011

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Pharmacotherapy NSAIDs, topical lidocaine, antiepileptic agents, TCAs, SSRIs, antispasmodics The problem:

Pharmacotherapy

NSAIDs, topical lidocaine, antiepileptic agents, TCAs, SSRIs, antispasmodics
The problem: not a

single good trial
Corticosteroid injection
Glenohumeral joint or subacromial bursa
Can reduce pain and increase pain-free ROM
Suprascapular nerve block
Potentially superior to corticosteroid at 1 month

Lakse 2009; Chae 2009; Dekker 1997; Snels 2000; Yasar 2011, Allen 2010

Слайд 28

Complementary and alternative medicine Acupuncture Works via neurohormonal mechanism: β-endorphin dynorphin

Complementary and alternative medicine

Acupuncture
Works via neurohormonal mechanism: β-endorphin dynorphin A/B, substance

P, noradrenaline
Benefit in addition to standard PT
Aromatherapy: limited study

Shin 2007; Lee 2012; Shin 2007

Слайд 29

Surgery Typically for adhesive capsulitis (release of capsular adhesions, manipulation under

Surgery

Typically for adhesive capsulitis (release of capsular adhesions, manipulation under anesthesia)

or rotator cuff tendinopathy (acromioplasty, repair)
HSP relieved in all 13 patients after contracture release in one small study

Braun 1971

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Suggested Protocol Step 1: Identify neurogenic factors Step 2: Identify mechanical

Suggested Protocol

Step 1: Identify neurogenic factors
Step 2: Identify mechanical factors
Step 3:

Prevention through positioning
Step 4: Symptom control and rehabilitation
Step 5: pathology based intervention
Слайд 31

Suggested Protocol Strapping/Taping: perpendicular to inhibit, parallel to promote Slings: Flaccid:

Suggested Protocol

Strapping/Taping: perpendicular to inhibit, parallel to promote
Slings:
Flaccid: sitting, ambulating, transferring
Spastic:

avoid prolonged use
Avoid axillary supports
Слайд 32

Suggested Protocol Physical Therapy and Modalities Strive for maximal pain-free ROM

Suggested Protocol

Physical Therapy and Modalities
Strive for maximal pain-free ROM
Avoid overhead pulley

exercises
TENS: best at high intensity
FES: apply to deltoid and supraspinatus for temporary reduction in shoulder subluxation
EMG biofeedback: to encourage early and active participation, maximize psychological control
Слайд 33

Suggested Protocol Pharmacotherapy Neurogenic: Neuropathic pain: AEDs, TCAs, SSRIs Spasticity: antispasmodics

Suggested Protocol

Pharmacotherapy
Neurogenic:
Neuropathic pain: AEDs, TCAs, SSRIs
Spasticity: antispasmodics
Mechanical
NSAIDs and acetaminophen
Rare opioids or

oral steroids
Слайд 34

Suggested Protocol Injection therapy Neurogenic: Botulinum Toxin: IM, possibly even IA

Suggested Protocol

Injection therapy
Neurogenic:
Botulinum Toxin: IM, possibly even IA
Stellate Ganglion Block
Mechanical
Corticosteroid to

GHJ or subacromial bursa
Suprascapular nerve block
Trigger point injections
Слайд 35

Suggested Protocol Complementary and alternative medicine Acupuncture may be superior in

Suggested Protocol

Complementary and alternative medicine
Acupuncture may be superior in combination with

standard PT than PT alone
Aromatherapy has limited positive support
Слайд 36

Suggested Protocol Surgery (after 6 mos failed conservative Tx) Neurogenic: release

Suggested Protocol

Surgery (after 6 mos failed conservative Tx)
Neurogenic: release of contractures
Mechanical:

capsular release, acromioplasty, rotator cuff repair
Слайд 37

Summary HSP is a common complication of CVA which is known

Summary

HSP is a common complication of CVA which is known to

be associated with poor outcomes
HSP is a multifactorial process often encompassing a combination of neurogenic and mechanical factors
They key to management is prevention as able, and concurrent treatment of all contributing factors
Слайд 38

Objectives Identify the neurogenic and mechanical factors which contribute to HSP

Objectives

Identify the neurogenic and mechanical factors which contribute to HSP
Prescribe appropriate

treatments for the identified factors in each patient with HSP
Understand the level of evidence supporting treatments for HSP
Слайд 39

References Contact me for a list john.vasudevan@uphs.upenn.edu Or see: Vasudevan J,

References

Contact me for a list
john.vasudevan@uphs.upenn.edu
Or see: Vasudevan J, Browne B. Hemiplegic

shoulder pain: An approach to diagnosis and management. Phys Med Rehab Clin N Am. 2014;25(2):411-437.
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