18 F I S I O T E R A P I E M AART 1980 P A IN FU L SHOULDER IN H EM IP LEG IA — PREVENTION AND TR EA TM EN T S. IR W IN -C A R R U T H E R S , N at. Dip. Physio., D ip. Physio. E d. (P ta.)f and M. J. R U N N A L L S , Dip. Physio. (Cape Town), C .T .P .(C ap e Town)* SU M M AR Y T he p a in fu l shoulder which occurs in hem iplegia, is discussed. Possible m echanism s causing the pain, pre­ ventative m easures based on the neurodevelopm ental approach to treatm ent and therapeutic m easures in­ cluding treatm ent by m eans o f passive m ovem ent, are described. A painful sh o u ld er is all too often a lim iting factor in the reh ab ilitatio n of ad u lt hem iplegic patients and yet in the m ajo rity of cases this prob lem should n o t arise if the p atien t is handled correctly from the onset o f the hem iplegia. P ain is fre q u e n tly , associated with a subluxation of th e glenohum eral jo in t b u t is m ore o ften d u e to super­ im posed trau m a th a n to the subluxation itself. C om ­ pletely painless subluxations of m ore than 2,5 cm have been noted in th e flaccid stage. N evertheless, it is evident th a t prev ention of subluxation will contribute to the avoidance of a painful shoulder. In th e norm al person, inferior subluxation of the glenohum eral jo in t is prevented by a locking m echanism (B asm ajian, 1978) d ependent upon th e angle o f the glenoid fossa. W hen the subject is in a n upright position the scapula is stabilised in slight lateral ro tatio n and th e hum erus hangs vertically. In this position the superior p a rt of the capsule and the corticohum eral ligam ent are tau t and it is im possible to subluxate the head of the h um erous dow nw ards, even when heavy weights are suspended from th e arm . T he capsule and ligam ent are supported in this fun ction by activity in supraspinatus and, to a lesser degree, in som e of the horizontal, posterior fibres of deltoid. B asm ajian (1967) points out, however, th a t a relative abduction of the hum erus to ab o u t 15° is sufficient to allow considerable dow nward subluxation of the head of the hum erus. In th e flaccid stage o f hem iplegia two factors would appear to interfere w ith this in h eren t stability o f the glenohum eral jo in t in the u p rig h t position. F irstly , in­ activity of the up p er fibres o f trapezius and of serratus an terio r results in m edial ro tatio n of the in ferio r angle of the scapula w ith consequent dow nw ards angling of the glenoid fossa and relative abduction o f the hum erus. Secondly, inactivity o f su praspinatus and the horizontal fibres of deltoid allows the unopposed w eight of the arm to stretch th e cortico-hum eral ligam ent and superior capsule. In the absence o f any stretch reflex activity in the muscles acting upon the glenohum eral joint, trau m a is easily superim posed upon th e already subluxed joint, usually by tractio n on th e hemiplegic arm as the p a tie n t is m oved a b o u t in bed o r from the bed to a chair. As spasticity develops, the scapula becom es fixed in retractio n and m edial ro tatio n due to spasticity in the rhom boids and the lower fibres o f trapezius, re­ inforced by latissim us dorsi. H yperton us in subscapu- laris, infraspinatus and teres m inor now contributes to * Senior L ecturer and H ead of D ep artm en t U niversity o f Stellenbosch and Tygerberg H ospital, Parow vallei t S enior L ecturer U niversity o f Stellenbosch and T yger­ berg H ospital, Parow vallei Received 12 D ecem ber 1979. OPSOM M ING Die pynlike skouer wat by hem iplee voorkom , word bespreek. Die m o o n tlike m eganism es w aardeur die pyn veroorsaak kan word, voorkom ende m aatreels gebaseer op die neuro-ontw ikkelingsbenadering to t behandeling en terapeutiese stappe, insluitende behandeling deur m iddel van passiewe beweging, w ord beskryf. the subluxation o f the head of th e hum erus from th e dow nw ards tilted glenoid fossa (Bobath, 1978). T h e r e ^ is a resistance to p ro tractio n and lateral ro tatio n ot, the scapula and if the arm is m oved above the h o ri­ zontal th e capsule and synovium , as well as su p ra­ spinatus, are com pressed against th e acrom ion process of the scapula. T his type of trau m a occurred frequently in the days when reciprocal pulley exercises were pop u ­ lar fo r hemiplegics, and is still seen all to frequently as a result of passive stretching o f the glenohum eral jo in t w ithout adequate p rio r atten tio n to inhibition of spasticity and m ob ilisatio n o f the scapula. R epeated m inor traum a resulting from any of the above m echanism s will set up a capsulitis which, unless treated prom ptly, m ay progress to the loosely- called “ fro zen ” shoulder. A lthough treatm en t at the very first h in t of pain is usually effective it is obviously very m uch b etter to prevent trau m a to the jo in t in the first place. T his m ay be achieved by correct posi­ tioning and handling, prevention o f subluxation, in h i­ bition of spasticity (and m obilisation of the scapula) and early re-education o f m ovem ent. POSITIO NING A N D H A N D L IN G T his involves careful instruction of nursing personnel and counselling of the p atien t and his fam ily. D uring the early stages the patient, as far as is possible, should n o t be nursed supine as this position e n ­ courages retractio n of the scapula. H e should nursed on each side alternately, w ith th e s h o u ld e r ! , girdle p ro tracted and the arm extended forw ards in the neu tral position (Figs. 1 and 2). W hen th e p atient is being turned tow ards his sound side th e affected arm m ust be fully supported and his arm and u p p er trunk should be brought forw ards by grasping him behind the scapula (Fig. 3) and n o t by pulling on his arm . If it is necessary fo r him to sit in bed, his trunk must be com pletely upright, his shoulder-girdle p ro ­ tracted and his arm supported forw ards on a bed- table or on pillows (Fig. 4). Sitting ou t in a chair is p referable to sitting in bed, b u t it is very easy to cause trau m a to the shoulder jo in t if th e transfer from bed to ch air is clum sily perform ed. T odd an'ifi D avies (1977) give th e correct way o f perform ing this m anoeuvre, the therapist or nurse supporting un d er the p a tie n t’s shoulders w ith h e r hands over the scapulae (Figs. 5 and 6). O nce o u t in a chair, the affected arm m ay be supported forw ards eith er on a table o r in a trough attached to the arm o f th e chair. F req u en tly unaw areness of, and in atten tio n tow ards, his affected side causes the p atien t to leave his arm dangling over the side o f th e ch air w ithout any form R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) M ARCH 1980 P H Y S I O T H E R A P Y 19 Fig. 1. Positioning on sound side. Fig. 2. Positioning on affected side. Fig. 3. Turning onto sound side. Fig. 4. Sitting in bed. Figs. 5 and 6. Moving from lying to sitting on side of bed. of support. In this position the scapula is retracted and the hum erus is frequently slightly abducted, predispos­ ing to subluxation. N ursing staff and fam ily must, from the beginning, be show n how to increase the p atien t’s aw areness o f his affected side. H is bed should be positioned so th a t he has to look across his affected side at the rest o f th e room ; he should be approached ipn the affected side, fed and given a b edpan from th a t Jlide. V isitors should sit on th a t side, and holding his affected hand will increase sensory aw areness. As soon as he is able to do so, provided th a t th e scapula is m obile, he should be show n how to m ove his affected arm w ith his sound arm . In o rd er to do this he clasps his hands with fingers interlaced and w ith th e affected thum b upperm ost. H e is ta u g h t first to extend his arm s forw ards until both scapulae are p ro tracted and elbows extended. H is palm s should be together, with thum bs facing upw ards, and th e m ov em ent should tak e place sym m etrically with hands in the midline (Fig. 7). O nce he can achieve this he can be taught to lift his arm s upw ards through the full range of elevation thro u g h flexion. PREV EN TIO N OF SU BLU XA TIO N O ccasionally during the flaccid stage additional sup­ p o rt m ay be needed to control subluxation. Slings are contraindicated on several counts. T hey contribute to th e p a tie n t’s lack of aw areness of th e affected arm , they im m obilize th e joints o f th e arm and they re­ inforce the developing spastic synergy. T h e sustained stretch which triceps undergoes w ithin a sling will lead to progressive inhibition o f triceps and, recip ro ­ cally, to increased activity in biceps (Stockmeyer, 1967). T he use of a sling also disturbs balance, interferes w ith facilitation of w alking and m akes a reciprocal arm sw ing im possible. It is also im possible to inhibit associated reactions in th e arm . F req u en tly the han d hangs over the edge of the sling, resulting in oedem a and in pain w hen w eightbearing on a flat hand is attem pted. B obath (1978) describes an effective m ethod o f p re ­ venting subluxation whilst allow ing full range of m ove­ m ent in elevation th ro u g h flexion. It consists o f a cuff which fastens around th e upper arm and is suspended by a figure-of-eight band around the shoulders (Fig. 8). It is found in practice th a t a th in layer of fo am -rubber un d er th e cuff prevents slipping and allows the cuff to be fastened less tightly, whilst an elasticated band around the shoulders adds to com fort. T his m ethod does n ot interfere at all with m ovem ent o f the elbow, fo rearm and hand. A n earlier m ethod consisting of a small pad in the axilla, again held by a figure-of-eight bandage, is not recom m ended as it results in slight abd u ctio n of the hum erus and this may, in turn, p re ­ dispose to subluxation. IN HIBITION OF SPASTICITY C orrect positioning and handling, as outlined above, will do m uch to prevent the developm ent of spasticity and fixation of th e scapula. As tone starts to increase, spasticity first becom es evident distally, in the flexors of th e w rist and fingers. A t this stage a foam -rubber “sp read er” m ay be effective n o t only in inhibiting this distal spasticity but also in retarding the developm ent o f flexor spasticity th roughout the arm . As spasticity, R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 20 F I S I O T E R A P I E MAART 1980 i.e. increased tone, develops, so also does the degree o f reciprocal activ ity change. D istally w e find complete reciprocal inhibition w ith a dom inance of flexor activity over extensor activity, whereas proxim ally there develops a contratcion of opposing muscle groups. T his is p articu larly evident around the scapula which m ay becom e com pletely im m obile, although in a position of retractio n and dow nw ards ro ta tio n of the glenoid fossa, reflecting the relative dom inance of the spastic m uscle groups. Since the m ost com m on cause of pain in the shoulder of a hem iplegic p atien t is pinching of th e capsule and synovium when the hum erus is forced into flexion o r abd u ctio n against an im m obile scapula, this excessive co-contraction m ust be prevented and full scapular m obility established. In addition, the overactivity o f subscapularis, in fra­ spinatus and teres m in o r which contributes to the depression of th e hum eral head in the glenoid fossa m ust be inhibited. If spasticity is strong, p relim in ary red u ctio n of tone m ay be achieved by moving the tru n k over the affected shoulder. In supine the affected side of the tru n k is elongated and the affected arm is abducted as far as is possible w ithout enco untering resistance. T h e p atien t is then asked to bring his sound arm and leg across his body and roll onto his affected side. A fte r several repetitions a reduction in tone will be felt and the scapula may then be m obilized in supine o r in side- lying on the sound side. In eith er case th e affected side m ust be fully elongated and the scapula p ro ­ tracted before elevation and depression of th e scapula are superim posed. T he arm is supported in a reflex- inhibiting p a tte rn of forw ard extension and outw ard ro tatio n • of th e shoulder, extension of the elbow, supinatioh of th e forearm , extension of th e w rist and fingers and ex te n sio n /a b d u c tio n of the thum b. W hen th e scapula m oves freely the arm is taken gradually into full elevation. If pain is encountered the arm m ust be m oved dow n a few degrees and the scapula fully p ro tracted before continuing tow ards elevation. Provided th a t th e scapula is kept m obile the p atien t can, him self, carry out self-inhibition in sitting or lying as described earlier. E A R L Y R E -E D 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 m uscle groups gives stability and postural fixation proxim ally, b u t never interferes w ith m ovem ent. D istally a g reater degree o f reciprocal inhibition allows quick m ovem ents to occur freely, bu t these skilled m ovem ents w ould n o t be possible w ithout th e aforem entioned proxim al fixation. In the flaccid stage of hem iplegia the p a tie n t lacks the norm al degree of postural stability and proxim al fixation which w ould protect his shoulder from traum a and during this stage of treatm en t early w eight-bearing is indi­ cated in o rder to stim ulate sufficient co-contraction to stabilise the glenohum eral joint. W eight-bearing activi­ ties m ust not, how ever, be static. Static holding of positions will lead to excessive co-contraction and re­ su ltan t fixation of b o th scapula and glenohum eral joint. Suitably m obile w eight-bearing activities a r / show n in th e accom panying sketches (Figs. 9 - 12). A n essential prerequisite fo r all these activities is weight- tra n sfe r to and elongation of the tru n k on the affected side of the body. A s spasticity develops, certain m uscle groups d om i­ nate p attern s of posture and m ovem ent and their antagonists becom e progressively inhibited. T h e p atien t cannot stabilise the scapula in p ro tractio n and o u t­ w ards ro tatio n ; he can n o t reach forw ards w ith extended elbow o r raise his arm above shoulder level because of the spasticity of the opposing muscles. T his spasti­ city can be inhibited as described in the previous section b u t the problem of activating the apparently “w eak” m uscles rem ains and u n til th e p a tie n t has full control of b o th scapular and glenohum eral m ove­ m ents the possibility of trau m a to the glenohum eral jo in t rem ains. Follow ing inhibition, techniques of p ro ­ prioceptive stim ulation (tapping) m ay be needed to activate p atterns of m ovem ent in elevation. F irstly the p atien t needs to be given the ability to hold th e arm in w hatever position it is placed. O nly after this has been achieved can facilitation of active m ovem ent tow ards th a t position be attem pted. Suitable activities a t this stage o f treatm ent are show n in figures 13 -1 6 . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) MARCH 1980 P H Y S I O T H E R A P Y 21 Figs. 9 - 1 2 . M obile weight-bearing If this program m e is follow ed, the p ro b ab ility o f gleno-hum eral problem s will be reduced to a m inim um . H ow ever, if they do occur, it seems th a t th e associated pain is less intense; as the inert jo in t structures are probably the ones affected the com plication is readily treatab le by passive m obilisation techniques according to M aitland (1977). T reatm en t is th erefore directed at the pain. It has been found th a t passive lateral ro ta ­ tion of the glenohum eral jo in t is very often lim ited and th a t this is the m ost painful m ovem ent. L ateral ro ta tio n o f the glenohum eral jo in t is o f course en­ hanced by retractio n of the scapula and this could possibly be a precu rso r to the painful shoulder syn­ drom e. TREA TM EN T PRO CED UR E T he passive m obilisation techniques used to treat this condition are directed tow ards relieving pain. C areful assessm ent is the crux o f successful treatm ent. T he assessm ent is com plicated both by th e frequent absence of active m ovem ent and by th e fact th a t spasticity m ay prevent passive m ovem ent o f the gleno­ hum eral joint. It is, however, possible to p lo t a graph o f the intensity o f pain on the y-axis against the range of passive m ovem ents of the k lenohum eral joint (usually flexion) provoking pain on the x-axis (a m ove­ m ent diagram , M aitland, 1977) and to assess th e pain reaction to passive m ovem ent, ensuring a fairly accu­ rate estim ation o f “ irrita b ility ”. T h e use o f passive accessory m ovem ents at the lim it of th e physiological range is advised if up to 80% o f th e passive physio­ logical range is painfree. F rom this info rm atio n it is possible to p lan treatm en t and to determ ine th e neces­ sary techniques, dosage and frequency of treatm ent. B efore com m encing either objective assessm ent or treatm en t by passive m obilisation techniques, it is essential to inhibit spasticity and to position the p atien t correctly. T he ap p ro p riate inhibiting techniques as previously indicated m ust be fulfilled. T h e p atien t should then be positioned in lying w ith his head o n a sm all pillow so th a t th e glenohum eral jo in t can m ove freely. T h e hem iplegic side m ust be elongated and th e hem iplegic leg m ust also be placed in a reflex in ­ hibiting p attern . By virtue of the very starting posi­ tions needed to achieve the m obilisation techniques proposed, it will be seen th at the scapula is brought into the p ro tracted position. D uring the early reh ab i­ litation phase G rade I - 1 1 1 * passive accessory m ove­ m ents (longitudinal o r p o sterio r-an terio r m ovem ents re­ spectively w ith the glenohum eral jo in t in the n eu tral position (Fig. 17) are usually required. In old-established hem iplegia, it is o ften necessary to take the shoulder to the limits of the physiological range of forw ard flexion and to execute G rade I - III passive accessory m ovem ents (usually longitudinal o r postero-anterior * A passive accessory m ovem ent is a jo in t m ovem ent w hich cannot norm ally be p erform ed actively and has to be executed by an external force o r the han d s o f the physiotherapist. II III G rades o f m ovem ent I IV A B L im it R ange o f physiological or accessory m ovem ent R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 22 F I S I O T E R A P I E M AART 1980 <£? m ovem ents) (Fig. 18). T h e p o sitio n could o f course be vice versa. A ssessm ent of the jo in t in the old esta­ blished hem iplegia fo r instance, could reveal th a t it is “h y p erirritab le” , w hereupon the treatm en t techniques and dosage w ould have to be suitably adapted. of movem ent patterns. accessory passive movements in the neutral position. T h e use of passive accessory m ovem ents to tre a t the pain has been found preferable fo r it seem s th a t the use o f passive physiological m ovem ents tends to p ro ­ voke spasticity unless the latter are perform ed very slowly and sm oothly as a m ore sustained type o f R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) M ARCH 1980 P H Y S I O T H E R A P Y 23 o f movement. ^ c h n iq u e . Once the pain has been relieved it is essential to rein fo rce the preventative program m e by checking b o th the nursing procedures w ithin the hospi­ tal and the handling by the fam ily at hom e. T he p atien t should once again be instructed as to the im portance o f p u ttin g his gleno-hum eral jo in t through its full range at least once a day. References 1.1. B asm ajian, J. V. (1967). Proc. exploratroy and analytical survey o f therapeutic exercise. A m . J. Phys. M ed., 46, 975. 2. B asm ajaian, J. V. (1978). M uscles alive, their fu n c­ tions revealed by electrom yography. 4th Ed. B alti­ m ore. T h e W illiam s and W ilkins Com pany. 3. B obath, B. (1978). A dult hem iplegia: evaluation and treatm ent. 2nd Ed. L ondon, W illiam H einem ann. 4. M aitlan d , G. D. (1977). P erip h eral m anipulation. 2nd Ed. L ondon. B utterw orths. 5. Stockm eyer, S. (1967). Proc. exploratory and a n a ­ lytical survey of therapeutic exercise. A m . J. Phys. M ed., 46, 974. 6. T odd, J. M. and D avies, P. M. (1977). In N eurology fo r physiotherapists, Ed. C ash, J. 2nd Ed. L ondon. F a b e r an d F aber. OBITUARY L IL IA N E RA SM US (nee Bradley) 1926 -1979 News th at L ilian E rasm us had passed aw ay suddenly w as received w ith shock in N ovem ber 1979. She was an active m em ber o f the Society and w ill be rem em bered fo r h e r lively p artici­ p atio n in the affairs o f Physiotherapy. L ilian was chairm an of E astern Province B ranch and represented h e r B ranch a t the N .C.R. and N atio n al C ouncil meetings. She also rep re­ sented E astern P rovince on the P riv ate P racti­ tio n ers’ A ssociation. She m atricu lated fro m C ollegiate H ig h School, P o rt E lizab eth and graduated w ith a B.Sc. (Physiotherapy) from the U niversity o f the W it- w atersrand in 1951. On her re tu rn to P o rt E liza­ beth she joined the P rovincial H o sp ital Service and in 1956 opened a p riv ate practice, w ith w hich she continued u n til the tim e o f h e r death. L ilian leaves h e r h usband Clive, o f the SA Police and a fo rm er E astern P rovince and N o rth ern T ransvaal rugby forw ard, and a daughter, S andra, a student at the U niversity of C ape Town. H e r m any frien d s and ex-patients will rem em ­ ber h e r fo r h e r cheerfulness and kindness at all times. SHEILA H E N D R Y (ne£ Wrennal) 1908 -1979 Sheila was b o rn in B irkenhead, E ngland and cam e to South A frica as a young girl. H e r fath er died in active service in E ast A frica during W orld W ar I. She and h e r m o th er lived w ith grandparents G earin g in H erm anus w hilst Sheila w as a bo rd er a t St C yprians. She excelled in gymnastics and games and w as H ead G irl in h e r final year. W hen she finished school, Sheila and h e r m o th er w ent to E ngland, w here she trained as a P hysiotherapist a t G uys H ospital. T hey re ­ turned to South A frica and settled in Johannes­ burg, w here she m et and m arried R idley H endry. Jill, R oger and D u n can w ere b o rn an d received m ost of th eir schooling in Johannesburg. O n R id ley ’s retire m en t they retu rn ed to his hom e in St A ndrews, Scotland. T h e children re ­ ceived th eir U niversity and College education there, b u t returned to South A frica. A fter R id le y ’s death, Sheila spent a year in R ondebosch and then settled in H erm anus, continuing hex P hysiotherapy practice. Sheila never spared h erself in h elping o th er people and was interested in the B otanical Society, C hurch C hoir, B ible Study, SA N TA , O ld T im e D ancing and golf. She was active physically and kept up to date w ith refresher courses in physiotherapy and by attending Sum m er School classes at U .C.T. She still found tim e fo r cooking, baking and gardening. S h eila’s kindness and helpfulness will be missed by m any people. H e r association w ith H erm anus spanned over sixty years. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )