How can one protect against
the pain of an impaired shoulder?
By Dr Barend ter Haar1
Under various clinical scenarios, not least post CVA/stroke, many individuals end up with high levels of pain in the shoulder. This is often the result of damage to the shoulder joint arising from gravity pulling the upper arm out of the joint.
Early appropriate intervention can protect against this damage, and thereby also giving greater opportunity for recovery. Tina Roesler, an internationally known rehabilitation physiotherapist, presenting at the June 2024 European Seating Symposium, reviewed the background behind hemiparetic shoulder function, and a case study of what appropriate intervention we might offer.
Various neurological disorders are associated with hemiparetic or impaired shoulder function. These disorders include stroke, traumatic brain injury, various neuromuscular degenerative diseases, spinal cord injury, brachial plexus injury, and other trauma-induced upper extremity injuries.
The Statistics
Stroke is the most common. The World Stroke Organisation calculates that there are over 12.2 million new cases a year. 63% of strokes every year are in people under 70. One in four people over the age of 25 will have a stroke in their lifetime. 15 to 30% of survivors are permanently disabled.
Why focus on the upper extremities? The reason is that the prevalence of hemiparetic shoulder pain (HSP) has been observed in up to 47% of patients, and for stroke patients the incidence of HSP has been reported in up to 84% of the patients studied. The aetiology is multifactorial – glenohumeral subluxation at the shoulder joint, abnormal tone, impingement, soft tissue trauma, brachial plexus neuropathy, previous upper extremity pathology, for example.
Early intervention
The best treatment is appropriate positioning and support of the humerus, forearm, and hand: early intervention (with ROM and exercise) is critical. Subluxation (Figure 1) arising from the lack of support leads to pain and discomfort, limited range of motion, increased tone, stretching of ligaments, tendons, and nerve roots, and loss of upper extremity function.
Figure 1. A subluxed shoulder joint
Figure 1. A subluxed shoulder joint
To protect the upper extremities, a functional support is needed. First, this should support the elbow at the correct height so that the humerus is not being pulled out of its socket, and appropriate proprioception is provided to the shoulder joint.
If the person is in either a static chair or wheelchair, there should be a means to adjust the height of the arm support to achieve this aim.
Next, there should be a means to rotate the forearm medially. Third, the hand should be supported in an anatomically correct position, and not palm down.
An ideal tool for this is the recently released BodypointR Dynamic Arm Support (DAS)2 (Figure 2), designed by the prominent Belgian physiotherapist, Bart Van der Heyden, to achieve this aim.
Figure 2. The Bodypoint Dynamic Arm Support
Figure 2. The Bodypoint Dynamic Arm Support
Case study
‘N’, an 80 year old lady who had had a stroke, and this had compromised her right side. She had no cognitive impairment. She was able to foot propel independently. She had upper extremity sensation, but not initiating movement voluntarily. She needed minimal assistance for transfers.
She was released from hospital with just a sling for ‘support’, and in a chair that was completely inappropriate for her needs (Figure 3):
Figure 3. ‘N’ at discharge from hospital
Figure 3. ‘N’ at discharge from hospital
This chair was the wrong size for her, and had no appropriate skin protection cushion, nor appropriate secondary positioning supports. As a result, within a few weeks the use of her right arm had decreased due to inactivity, and discomfort in her shoulder had started.
N has now been supplied with a chair (Figure 4) that is an appropriate size for her hip width, and for her feet to reach the floor for self-propelling, has a pressure care cushion, has a pelvic positioning belt, and has had a Bodypoint DAS fitted onto the right arm of the chair, and is now starting to recover, pain free.
Figure 4. ‘N’ in her new chair with appropriate supports
Figure 4. ‘N’ in her new chair with appropriate supports
Christie Hamstra, N’s physiotherapist, told us: “I have used this new Dynamic Arm Support in two instances now, one with a client who had a stroke four years before use, and one (N) who had a stroke 2 months before use.
"I am impressed with the amount of adjustability and customization that is available within the product to get the upper extremity, including the hand, into an optimum position.
“N, implementing the dynamic movement into early recovery with the DAS I believe will help to prevent some of the sequelae that can often happen with a flaccid upper extremity, while gaining some return of function.”
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