Shoulder subluxation after stroke can be quite puzzling for therapists to treat. Can these three treatment methods save a shoulder?
How a shoulder subluxation rears its ugly head can vary greatly–it may develop more quickly with some patients than others, it may be painful or even go completely unnoticed. As therapists, regardless of the how or when, we consistently try to prevent shoulder subluxation from happening and reduce the severity if it does happen… but are we truly being effective?
Should we be grabbing that sling to support their shoulder? Does e-stim help reduce the degree of translation? Is taping effective for prevention? Let’s dive in and strengthen our evidence-based application.
For strategies on how to help your patients maintain dignity and respect when dealing with dysphagia after stroke, download our ‘Say This, Not That’ handouts here!
Why does Shoulder Subluxation Happen?
Glenohumeral subluxation happens in up to 81% of patients post-stroke. The shoulder joint is multiaxial and has three degrees of freedom–flexion/extension, abduction/adduction, and internal/external rotation . The joint relies on the rotator cuff musculature–supraspinatus, infraspinatus, teres minor and subscapularis– as well as other surrounding musculature to keep everything aligned and to give the joint the ability to have smooth and efficient arthrokinematics.
During the initial period post-stroke, when the affected side may be flaccid, the rotator cuff musculature is not able to provide the stability it normally does to the joint. This instability combined with the pull of gravity and improper positioning can lead to lengthening of tissues and the separation of the humeral head from the glenoid fossa, also known as a subluxation.
Flaccidity is not our only enemy when it comes to developing a subluxation. Even if your patient has some degree of active movement in their affected arm, spasticity can also be a factor in developing a subluxation as it often creates a significant imbalance in the movement patterns of a joint or limb. If the spasticity is strong enough, it can even pull the humerus out of alignment.
Subluxation may also be influenced by other predisposing factors, according to some research. One study found that “subluxation occurs more frequently in patients with a known presence of fluid in the subhumeral and subdeltoid bursae and in patients with reduced functional capacity.” This is interesting to think about and can lead us to the conclusion that there are multiple factors that can help us identify those who are at more risk of developing a shoulder subluxation… versus assuming the patient is at risk solely because they present with hemiplegia.
What Interventions are Available…and What Do They Do?
Slings
Prevention & Management: Slings are what we grab first, right? In fairness, a sling or orthotic has been shown time and time again to be effective at reducing shoulder subluxation while it’s in place and worn correctly. But there is no evidence that using a sling can prevent a shoulder subluxation from happening or that it can have a long-term effect on the reduction of an already existing subluxation. One study compared 3 groups (2 with sling and 1 without sling) and found that shoulder subluxation seemed to reduce over time in the group of patients who did not wear a sling. This information alone should make us rethink our ‘one-sling-fits-all’ mindset!
Clinical Application: It goes without saying that more research needs to be completed (as with many areas of practice), but we should always be striving to tailor our choice of interventions, so they are specific to our patient’s needs. In the case of a sling, there is still a useful application even if it’s not going to make a difference in the degree of shoulder subluxation. A sling could be beneficial in protecting your patient’s limb during transfers, or it may be helpful in reduction of pain associated with subluxation. But if there is no pain and the limb seems to stay in a good position during functional mobility…leaving the sling out of it may be the way to go!
Taping
Prevention & Management: There is minimal evidence clarifying whether taping is effective at prevention of shoulder subluxation, but there is plentiful research that indicates that taping methods–both kinesiology and inelastic tape–can reduce present shoulder subluxation and reduce pain associated with it. Other studies found that while unable to prevent subluxation, specific techniques have been found to result in improvements in shoulder flexion and proximal arm function.
Clinical Application: With taping showing consistent results in the reduction of shoulder subluxation and pain, this should be a staple in your stroke rehab toolbox! There may be a few reasons you wouldn’t move forward with this, such as patients with fragile skin or sensitivities to adhesives, but with the equipment being both inexpensive and accessible… we need to be moving our thoughts away from slings and more toward taping!
E-stim
Prevention & Management: Some studies have shown that e-stim combined with other treatments or approaches has been effective in preventing and reducing subluxation in the acute phase of stroke but has not been effective in the chronic stage.
Clinical Application: Therapists have been using e-stim for many different indications for decades and we all know well that parameters matter if you want to achieve a specific purpose or goal. The main consideration for e-stim with shoulder subluxation is timing! If we can provide this treatment early in the patient’s recovery from stroke, we will have a better chance of preventing and managing shoulder subluxation. If you can utilize e-stim during the acute or subacute phases in stroke rehabilitation, go for it!
Where Do I Go from Here?
Make sure to look at your patient as a whole and see what they specifically need in their plan of care–a blanket plan of action will not be as effective as a patient-centered plan of care. If you are treating your patient in the acute or subacute phase of stroke rehab, e-stim may be a great starting point as a preventative measure. If shoulder subluxation is unfortunately already present, taping would then be a smart move to prevent further separation & pain prevention. If that limb looks unstable during transfers or is causing high pain–it may be time to consider our old friend the sling.
So, it’s all about being up to date with the latest research in combination with the clinical presentation and needs of your patient–if something is not working well enough to meet their needs, do not be afraid to move on and try something else!
If you are interested in learning more about Stroke Rehab and upgrading your practice, check out our fantastic, 7 Contact Hour course, In-Patient Stroke Rehab: 14 strategies to get your patient HOME! to get great techniques and tips to get your patients back to where they want to be: back home!
Ruth Polillo, MSPT, CBIS: Ruth graduated with a Master of Science in Physical therapy degree from Thomas Jefferson University in 2005, and has gained experience in every setting a therapist can work in. She is a co-founding member of ARC & an enthusiastic presenter! Ruth is passionate about continuing education and making hands-on clinical skills available to clinicians.
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