Musculoskeletal Problems in Stroke Survivors

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Musculoskeletal Problems in Stroke SurvivorsRichard Kendall, DO11

Department of PM&R, University of Utah, Salt Lake City, Utah

Musculoskeletal problems in stoke survivors are common reasons for disability and pain. Shoulder pain is present in 24% of stroke survivors among all complications, second only to depression in 26%. Diagnosis and treatment of the various shoulder pain etiologies can signicantly improve quality of life in these patients. This article reviews the common etiologies and treatments of shoulder and hip pain in stroke survivors. Key words: hip pain, stroke, shoulder pain, rehabilitation

usculoskeletal problems in stroke survivors are very common. While some have relatively minor pain or functional limitations from these problems, for many it is a major factor in their quality of life. Specically, shoulder pain is highly prevalent in stroke survivors, as is hip pain. In this review article, we will discuss the common etiologies of shoulder and hip pain in stroke survivors and their treatments. Shoulder pain is second only to depression among complications seen in stroke survivors.1 The incidence of poststroke shoulder pain (PSSP) has been documented between 24% and 84%.13 This varies widely as some authors have looked at reports of pain in the shoulder, irrespective of etiology,1,2 whereas others have focused on specic etiologies, such as subacromial impingement4 or glenohumeral subluxation.3,5 The causes of shoulder pain in hemiplegia include subacromial impingement, rotator cuff tears, glenohumeral subluxation, spasticity, adhesive capsulitis, complex regional pain syndrome (CRPS), and a combination of syndromes. Etiologies Shoulder impingement/rotator cuff tear is perhaps the most common etiology recognized.3 Ultrasound evaluation of the shoulder has shown a 71% incidence of new rotator cuff tears after 2 weeks of acute inpatient rehabilitation in patients with a Brunnstrom score of 03 versus no new occurrences of rotator cuff tear in a group with a Brunnstrom score of 46.6 In contrast, Lee et al evaluated 71 patients with shoulder pain and

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found only 10% with supraspinatus tendonosis and 3% with partial rotator cuff tears. In this study there was no association of rotator cuff pathology with Brunnstrom stage.7 Imaging evaluation of older individuals, however, does not necessarily predict the anatomic cause of pain. Shoulder pain in the general population is estimated at between 1% and 2.5%, with the greatest proportion of this in the 5th to 7th decade of life. Milgrom has shown a prevalence of >50% full or partial rotator cuff tears in asymptomatic 60 year olds and 80% in subjects over 80 years old.8 These typical agerelated changes can be the result of synovial hypertrophy in the subacromial bursa and/or osteophytic changes of the acromioclavicular (AC) joint, which narrows the subacromial space. Adhesive capsulitis of the glenohumeral joint is another common nding in the hemiplegic patient. Most commonly a restriction of exion, abduction, and external rotation of the affected shoulder is seen on passive range of motion testing. Reduced joint volume on arthrography has been shown in 50% to 75% of patients with poststroke shoulder pain.9,10 This tightening of the capsular ligaments limits full motion of the joint. Glenohumeral subluxation can occur in 50% to 81% of poststroke patients3,5 with shoulder pain. This is commonly seen within the rst 3 weeks after stroke in patients with accid paralysis. The glenohumeral joint is supported loosely byTop Stroke Rehabil 2010;17(3):173178 2010 Thomas Land Publishers, Inc. www.thomasland.com doi: 10.1310/tsr1703-173

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the capsular, coracohumeral, and glenohumeral ligaments, which allow for its wide circular range of movement. The tendons of the rotator cuff muscles, deltoid, and biceps give the joint its greatest stability. With the loss of muscular support and loss of normal laxity in the glenohumeral capsule, the joint may have up to an inch of anterior or inferior subluxation. Several authors have noted correlations between subluxation and axillary nerve traction injury,11 brachial plexus traction,12 rotator cuff tears,3 and CRPS.13 Altered Mechanics in Hemiplegic Shoulder and Pain Understanding the change in musculoskeletal mechanics of the shoulder following stroke is important to develop strategies that may prevent certain etiologies of shoulder pain. PSSP has been associated with more severe upper limb motor impairment2,14 in observational studies of patients admitted to inpatient rehabilitation units. This may be due to a multitude of factors, including altered scapulothoracic motion, muscle spasticity or contractures, and improper handling or positioning of the accid shoulder. The shoulder complex has intricate interactions among the joints to accomplish full range of motion. Due to the large range of motion allowed by the joints, it is the interplay of muscle forces that is the major supportive factor in the scapulothroacic and glenohumeral joints. The discoordinated movement in these joints has a signicant impact in PSSP, as the altered strength, motor control, and kinesthetic awareness may contribute to the increased incidence of rotator cuff tears in individuals in inpatient rehabilitation.6,15 This is more evident in individuals with a lower Brunnstrom upper extremity score, as the ability to control the scapular stabilizers is reduced.15,16 The apparent shrugging motion of patients with synergistic movement patterns during arm and hand movement further alters the normal scapular upward rotation necessary for glenohumeral abduction. As the arm is abducted, the humerus will elevate slightly on the glenoid if there is weakness of the rotator cuff. In an individual who has osteoarthritis in the AC joint, subacromial bursal thickening, or limited scapular upward rotation, the subacromial space will be

narrowed which increases the risk of impingement on the supraspinatus tendon and might cause a tear with repetition. This may occur more frequently in individuals with subscapularis or pectoral spasticity, which limits humeral external rotation. This can lead to earlier impingement from the greater tubercle abutting the underside of the acromium. Diagnosis of Shoulder Pain Syndromes The diagnosis of musculoskeletal problems is based on a thorough history, physical examination, and appropriate diagnostic studies. Most musculoskeletal pain complaints that lack a history of trauma are often overuse or overload type injuries. A prior history of shoulder pain, including rotator cuffs tears, impingement, glenohumeral dislocations, AC joint subluxation, clavicular fractures, scapular fractures, and prior shoulder surgeries should be noted. Obtaining a detailed history of this sort may be complicated by cognitive and communication decits in the poststroke population, however clarifying a history consistent with a symptomatic rotator cuff tears in this age group is important as these may become symptomatic or worsen depending on severity of motor impairment.6 The physical examination should first evaluate the resting position of the shoulder in both a seated and upright posture. The amount of subluxation of the glenohumeral joint should be noted. Inferior glenohumeral subluxation is easily and reliably tested with the ngerbreadth test.17,18 Next, passive and active range of motion of the glenohumeral joint should be carefully evaluated. Specic note should be made of any limitations in passive external rotation, exion, and abduction, which are most commonly limited with adhesive capsulitis. Also the presence of spasticity in the pectoralis muscles, subscapularis, and latissimus dorsi should be noted. Active range of motion evaluation should not only include the quantity of range but also evaluate the presence of synergistic movements during shoulder abduction. This may be done according to the Brunnstrom stage, which is a scale of stages from 1 indicating accid paralysis progressing to spasticity with basic synergistic movements, some control of synergistic movements, to complex isolated joint movements

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with control over synergy, to 6 indicating normal movements. Specically the ability to upwardly rotate the scapula and to control the scapular stabilizers should be evaluated. This may be done with the scapular slide test, as described by Kibler19 (Table 1). The clinical application of this test has been evaluated with uoroscopy in the hemiplegic shoulder population and shows good correlation to clinical ndings.16 In individuals who can reliably report pain intensity and location, the evaluation should include common impingement tests such as Neers sign, Hawkins test, or Yocums test, as well as Speeds test or Yergasons test for bicep tendon function (Table 1). These tests including their sensitivities and specificities are published elsewhere.20 Magnetic resonance imaging (MRI) may play a role in diagnosis of PSSP, however the interpretation of imaging must take into consideration the relatively high prevalence of asymptomatic degenerative changes in this population. Nonetheless, in individuals who have focal weakness of the external rotators but otherwise relatively spared strength in the upper limb, the possibility of full thickness rotator cuff tears should be investigated with MRI or musculoskeletal ultrasound where available. Similarly, limited painful range of motion in the absence of spasticity may indicate adhesive capsulitis, fracture, or dislocation and should be imaged prior to treatment. Treatment of Impingment Symptoms Impingement symptoms are mechanical in nature and can often be addressed by removal of the inciting activities. The basis for treatment of impingement symptoms is to address theTable 1. Shoulder physical examination manuversTest description

biomechanical decits and restore normal motion to the glenohumeral and scapulothoracic joints.21,22 In the hemiplegic patient, this may be difcult due to the multitude of mechanical problems described previously. Therapeutic treatment should be approached on an individual basis as each person will be managed differently based on past history of shoulder disorders, weakness, spasticity, and cognitive and communication abilities. Individuals who have adequate abduction strength and scapular stabilization but excess internal rotation may fair better with full can compared to empty can exercises due to less subacromial space narrowing.23 Individuals who have limited external rotation, possibly due to spasticity or contracture of the subscapularis and pectoralis muscles, will need range of motion, antispasticity medication, or local botulinum toxin injections24,25 to correct the motion decit prior to active strengthening exercises. Individuals who continue to have impingement symptoms may benet in the short term from a subacromial injection of corticosteroid.4,26,27 This, however, may not be as effective in individuals who have concomitant subluxation.4 Treatment of Adhesive Capsulitis Limited range of motion of the glenohumeral joint, especially in external rotation, abduction, and exion may be due to a contracted joint capsule. Joint capsular contracture has been demonstrated by various authors using arthrography9,10 and physical examination. Prior to making this diagnosis, one must be careful to determine whether spasticity or muscular contracture is the primary cause of limited range of motion.

Shoulder test Scapular Slide Test Neers sign Hawkins test Yocums test Speeds test Yergasons test

Pathology identied

Full passive exion of the arm in internal rotation Forward exion of the arm to 90, with elbow bent, then forceful passive internal rotation to reproduce pain Patient reaches affected limb to place hand on opposite shoulder, then elevate elbow, without shrugging shoulder. Elevation of the shoulder with the forearm supinated against resistance Arm at 0 abduction and elbow at 90with patient resisting supination.

Supraspinatus impingment Supraspinatus impingement Supraspinatus impingement Biceps tendonitis Pain at bicipital groove

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Avoiding swath-type slings and an internally rotated humerus and performing daily range of motion exercises that specically focus on the internal rotators and adductors can aid in prevention of adhesive capsulitis. Intraarticular injection therapy for adhesive capsulitis and shoulder pain has had mixed results. Dekker28 and Mitra29 have demonstrated positive benet in a case series. In contrast, Snels et al found no difference in shoulder pain, range of motion, or arm function scores after blinded intraarticular injection in a randomized clinical trial.30 A recent systematic review of randomized controlled trials for hemiplegic shoulder pain found no trials supporting intraarticular injections.31 These results must be interpreted cautiously however, as some of the trials used a blind intraarticular injection technique that has been shown to have very low intraarticular accuracy rates of 27% to 42%.32,33 Treatment of Glenohumeral Subluxation For patients with shoulder subluxation, even in those without pain, most practitioners would argue that some treatment of the subluxation is important. At a minimum, proper supportive positioning in a standing and seated position and proper handling of the arm by health care workers or caregivers during transfers and hygiene activities are important to prevent injury to the joint. However proper shoulder care does not seem to prevent development of pain or subluxation.34 Most recently, the use of intramuscular electrical stimulation techniques has proven benecial in reducing pain in the short35 and long term,36 which holds great promise for future treatment. Hip Pain in Stroke Survivors Although not as common as shoulder pain, hip pain can be debilitating and limit ambulation and activities of daily living in stroke survivors. Frequent causes of hip pain include hip abductor weakness, gluteus medius tendonosis, greater trochanteric pain syndrome, hip external rotator strain (piriformis, obturator internus, inferior or superior gemellus), fracture, heterotopic ossication, or myofascial pain with or without spasticity.

Pain over the greater trochanter is fairly common in the general population, with up to 20% of individuals who present to a spine clinic receiving the diagnosis of greater trochanteric pain syndrome (GTPS).37 GTPS is found more commonly in women and in individuals with a high body mass index, ipsilateral knee osteoarthritis, and low back pain.38 A common etiology is weakness of the hip abductors. As the hip abductors struggle to maintain a neutral position of the hip joint with weight bearing, the pelvis can tilt downward. This will result in a relative hip adduction during stance, which may cause pain...

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