Stroke Connection - November/December 2009 - (Page 19)
Does shoulder subluxation cause pain? The shoulder is the most common source of pain among people with stroke. Research is not definitive as to whether or not subluxation increases risk for shoulder pain. Other conditions such as stiffness (hypertonicity) and decreased range of motion, particularly in turning the arm away from the body (external rotation), are known to contribute to shoulder pain. It is important for stroke survivors to work with their physical therapist or physician to determine the extent to which subluxation might be contributing to shoulder pain. With improved arm function and strength, the risk for shoulder subluxation decreases. Shoulder strapping involves the use of athletic tape on the shoulder to reduce subluxation. Studies of strapping have shown limited benefit; however, it may be helpful for short-term treatment. With training from a professional, a caregiver can learn to apply strapping. Like neuromuscular electrical stimulation, skin irritation is a common side effect of shoulder strapping. Other positioning devices may be used to support the shoulder while in a wheelchair or bed. Wheelchair devices such as lap trays and arm troughs may be effective for reducing shoulder subluxation. It is important to position the device and the arm correctly to prevent over-correction of the condition. Proper positioning in bed may be accomplished with pillows. For lying on the back, pillows should be placed under the forearm. This allows the upper arm to rest on the mattress. Ask a physical therapist to teach you proper positioning for each lying position. When caring for someone with stroke, follow careful What can I do to manage or prevent shoulder subluxation? A physical therapist will apply his or her expertise and understanding of research to work with you to develop an appropriate treatment plan. The following are prevention and management strategies I recommend. Activities to improve arm function and strength may be used as specific interventions to address shoulder subluxation. These activities may include • constraint-induced movement therapy (forcing the use of the affected arm by restraining the unaffected arm with a sling); • mental practice with motor imagery (rehearsing a physical activity by memory without body movement); and • task-specific training (relearning a given task by training specifically for that task). With improved function and strength, the risk for shoulder subluxation decreases. Work closely with your physical therapist to ensure that the shoulder joint is protected during all exercise and training activities. Neuromuscular electrical stimulation uses electrical currents to activate weak shoulder muscles by placing electrodes on the skin. This is often effective for reducing subluxation, but it can be painful and irritating to the skin, so it may only be practical for short-term relief right after a stroke has occurred, when the arm is most likely to regain strength rapidly. For some survivors, neuromuscular stimulation can be used at home. A physical therapist can help you learn to use it safely. Shoulder slings of many different styles and designs have patient handling procedures. It is important to protect the survivor’s weak arm when helping to transfer from bed to a chair, for example, or when walking. Never pull on the affected arm when helping the person move. Likewise, during activities such as dressing and bathing, it is important to monitor the position of the arm. For example, when putting on a shirt, always put the affected arm into its sleeve first. Range of motion exercises must also be done properly to prevent shoulder subluxation and pain. Overhead exercises without appropriate support of the shoulder blade have been shown to substantially increase the risk of shoulder pain after stroke. Shoulder subluxation is common following a stroke. Proper support for the shoulder is the key to prevention and treatment. By working closely with your physical therapist and physician, you can find the treatment plan that is right for you. Learn more about conditions physical therapists can treat and find a physical therapist in your area at moveforwardpt.com. been developed to reduce subluxation. Slings that support the weight of the arm while allowing the elbow to straighten (such as the GivMohr™ Sling and Rolyan® Hemi Arm Sling) are the best option for reducing subluxation while promoting use of the arm, which is vital to recovery. Slings that hold the elbow bent and the forearm close to the body (such as the triangular sling) promote stiffness that can lead to shoulder pain and should not be used for long periods of time. Because slings vary significantly in style, it is best to work with a physical therapist to choose the most appropriate style and learn how to wear it correctly. An incorrectly fitted sling can do more harm than good. About the author Dr. Julie Tilson is a physical therapist and assistant professor in the Division of Biokinesiology and Physical Therapy at the University of Southern California in Los Angeles. She has specialized in stroke rehabilitation since 1998 and has been involved in research to improve stroke recovery since 2005. November | December 2009 S T R O K E C O N N E C T I O N
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