Hemiplegic Shoulder Pain Update - PowerPoint Presentation

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Hemiplegic Shoulder Pain Update

Andrew E. Kirsteins M.D.

FAAPM&R (Sports and Neuromuscular Med)

Cone Health Physical Medicine

and Rehabilitation

Slide2

Purpose

Review common causes of Hemiplegic Shoulder Pain (HSP)- Focus on Post stroke

Diagnosis using PE and Imaging Studies

Introduce Musculoskeletal Ultrasound (MSK US) as an aid to diagnosis of HSP

Hands on demo

Please check out Sept 2013 Am L PM&R Ozcakar et al- Utility of MSK US in Rehab settings

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Shoulder Pain

General Population

Post Stroke Population

3

rd

most common MSK c/o in primary MD office

2

nd most common reason for referral to Ortho/Sports~70% pain is from Rotator cuff disorders

Occurs in up to 72% stroke pts in the first year-

Van Ouwenaller C, Laplace PM, Chantraine A. Painful shoulder in hemiplegia. 

Arch Phys Med Rehabil. 

1986; 67: 23–26

Common reason for poor rehab outcome,QOL

Several pain generators have been proposed, complex

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Post Stroke Shoulder Pain=HSP

Overall prevalence 17% at 2wks, 20% at 1mo,23% at 6mo.

Ratnasabaphthy et al 2003,Clinical Rehab

Prevalence Rehab pop. 60% @ 4mo,35% @ 6mo

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Post Stroke Shoulder Pain Risk Factors

Significant weakness

L neglect

Sensory deficits

Advanced age

Spasticity

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Nociceptive

Neuropathic

Subluxation theory

Subacromial Impingement

Bicipital tendon

Spasticity related

Adhesive capsulitis

RSD

Brachial plexopathy

Central Post stroke Pain

Hemiplegic shoulder pain etiology

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Nociceptive Shoulder Pain

Hemiplegic Shoulder Pain Update

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Does Subluxation Cause HSP?

Pro

Con

Traction on joint capsule during flaccid stage

Subluxation more common in Shoulder Hand Syndrome-

Dursun et al 2000

Most HSP occurs during spastic stage-

Van Ouwenwaller et al 1986

Neuromuscular Electrical Stim reduces pain but not subluxation-

Yu et al

No correlation between pain and subluxation

Bohannon et al 1990

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Ultrasound measurement of shoulder subluxation

X Ray

Ultrasound

Xray evaluation requires multiple views,measurements after imaging

Long axis view allows measurement during image acquisition-

Park GY, Kim JM, Sohn SI, et al. Ultrasonographic measurement of shoulder subluxation in patients with post-stroke hemiplegia. J Rehabil Med 2007; 39:

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Subacromial Impingement Syndrome

Marwan Alqunaee, RCSI, Rose Galvin, BSc (Physio), PhD, Tom Fahey, MD, FRCGPDiagnostic Accuracy of Clinical Tests for Subacromial Impingement Syndrome: A Systematic Review and Meta-Analysis 

Archives of Physical Medicine and Rehabilitation

, Volume 93, Issue 2, February 2012, Pages 229–236

Any

rotator cuff pathology in the subacromial space

Includes Supraspinatus, Infraspinatus,Teres Minor and Subscapularis

Stages IncludeStage 1-BursitisStage 2-Partial TearStage 3- Full thickness Tear

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Sensitivity and Specificity

A SeNsitive test when Negative rules OUT=SNNOUT, (true positive identification)

A SPecific test when Positive rules IN=SPPIN’ (true negative identification)

Difficult to establish Sensitivity and specificity in studies if there is no “Gold Standard”, or if different “Gold Standards” are used

So for diagnostic PE or imaging studies either surgical findings or MRI is used as “Gold Standard”

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Subacromial Impingement Syndrome=SIS

History- pain with overhead activity, nocturnal pain

Exam-Hawkins Kennedy

passive

forward flexion/int rotation only useful test in a hemiplegic patient Sensitivity 74%

Imaging- Ultrasound can identify all 3 stages of SIS bursitis,partial tear and full thickness tear

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Diagnostic accuracy of Ultrasound for RCT

Smith et al, Clin Radiol 66 (2011) 1036-1048

Given limitation of history (communication deficit) and exam (given UE weakness), imaging assume greater importance

Partial thickness RCT Sen 84%, Sp 89%

Full thickness RCT Sen 96%, Sp 93%

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PHYSICAL FINDINGS AND SONOGRAPHY OF HEMIPLEGIC SHOULDER IN

PATIENTS after ACUTE STROKE DURING

REHABILITATION-Huang et al J Rehabil Med 2010; 42: 21–26

Methods

Results at D/C

N=57, cross sectional

Good vs Poor Motor groups based on Brunnstrom

Excluded prior shoulder problems

Recorded pain using VAS-but pain not an inclusion criteria

Assessed at admission and discharge (LOS 27d for good,32d for poor motor)

Pain

:68% Poor motor, 35% Good motor

US abnormalities

Poor

Motor

- 50% biceps tendinopathy,47% Supraspinatus tear,44% Subacromial bursitis

US abnormalities Good Motor –

30% biceps,22% subacromial bursitis,17% supraspinatus

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Sonography of Patients with Hemiplegic shoulder pain after stroke

 Lee et al Am J Roentgen 2009 Feb;192(2):

n=71, 20 pts had bilateral shoulders scanned

Subacromial bursal effusion seen in 36 shoulders

Biceps tendon sheath effusion in 39 shoulders

Supraspinatus tendinosis (7),partial tear (6) and full tear (2)

Abnormalities more common in hemiplegic shoulder p=.007 vs uninvolved side

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Sonography and physical findings in stroke patients with hemiplegic shoulders: A longitudinal study

Ya Ping Pong et al, J of Rehab med 2012,(44),553-557

76 first time CVA, no hx of shoulder problems

Scanned during acute rehab and at 6 mo

Underwent standard inpt rehab program 1 hour PT and 1 hr OT 5d/wk

Brunnstrom score,ROM, Ashworth,10pt NRS

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Sonography and physical findings in stroke patients with hemiplegic shoulders: A longitudinal study

Ya Ping Pong et al, J of Rehab med 2012,(44),553-557

Acute (D/C from Rehab)

Chronic (6mo post D/C)

Subacromial effusion 30.3%

Supraspinatus tear 30.3%

Biceps tendon 39.5%

Subscapularis 9.2%

Pain score 2.71/10

Subacromial effusion 13.2%

Supraspinatus tear 40.8%

Biceps tendon 57.9%

Subscapularis 22.4%

Pain score 3.99/10

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Subacromial Bursitis

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MRI findings in hemiplegic shoulder pain

Shah et al Stroke 2008 June 39(6)

>3mo since CVA, pain score >4,n=89,65% L HP

Supraspinatus tear 26% partial, 6% Full

Supraspinatus tendinopathy 51%

Infraspinatus tear 13% partial, 2% Full

Infraspinatus tendinopathy 19%

Subscapularis tear 1%Teres minor tear 1%

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MRI findings in hemiplegic shoulder pain

Shah et al Stroke 2008 June 39(6)

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Adhesive Capsulitis or Frozen Shoulder

Few imaging studies

X ray Arthrogram

Rizk et al,

Arch Phys Med Rehabil.  1984; 65(5):254-6

30 Patients mean 3 months post CVA, Reduced ROM and pain, electrically silent EMG of shoulder muscles

23/30 had reduced capsular volume consistent with adhesive capsulitis

Arthrogram and Exam -Lo et al., Arch Phys Med Rehabil. 84(12):1786-91, 2003 Dec

32 pt with HSP<1 year post CVA

50% had adhesive capsulitis

22% Rotator cuff tears

16% Shoulder Hand

Greater ROM correlated with greater joint volume on arthrogram

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HSP- Spasticity related

Older studies (eg Van Ouwenwaller) find that HSP more common in spastic shoulders

More recent study by Huang et al showed a weak correlation between spasticity and HSP

?Role of ultrasound imaging may be to guide needle for EMG into the subscapularis

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Neuropathic shoulder pain

Hemiplegic Shoulder Pain Update

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HSP Neuropathic-CRPS

CRPS type 1= RSD

Shoulder hand syndrome subtype occurs after CVA

Incidence reported as 12-25%

(

Edgley

SR et

al,PM&R Supp 1 March 2009 S28)Wide variation due to method of diagnosis (some studies reported much higher incidence with less strcit diagnostic criteria)

Slide29

Sensitivity and Specificity

A SeNsitive test when Negative rules OUT=SNNOUT

A SPecific test when Positive rules IN=SPPIN

Difficult to establish Sensitivity and specificity in studies if there is no “Gold Standard”, or if different “Gold Standards” are used

Slide30

RSD=CRPS Type 1

International Association for the Study of Pain (IASP) clinical diagnostic criteria (

Revised

Budapest criteria

)

continuing pain disproportionate to original injury

must have reports of at least 1 symptom in 3 of 4 categories sensory - allodynia and/or hyperesthesia vasomotor - temperature asymmetry and/or skin color changes and/or skin color asymmetry

sudomotor/edema

- edema and/or sweating changes and/or sweating asymmetry

motor/trophic

- decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (in hair, nails, or skin)

must have at least 1 sign at time of evaluation in 2 or more categories

sensory

- allodynia (to light touch and/or temperature and/or deep somatic pressure and/or joint movement) and/or hyperalgesia (to pinprick)

vasomotor

- evidence of temperature asymmetry (> 1 degree C [1.8 degrees F]) and/or skin color changes and/or skin color asymmetry

sudomotor/edema -evidence of edema and/or sweating changes and/or sweating asymmetry

motor/trophic - evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (in hair, nails, or skin)

no other diagnosis can better explain signs or symptoms

sensitivity 0.85 and specificity 0.69

Reference -

Pain Med 2007 May-Jun;8(4):326, editorial can be found in

Pain Med 2007 May-Jun;8(4):289, commentary can be found in

Pain Med 2009 Apr;10(3

):598

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Bone scan for diagnosis of RSD

Review of Hi quality studies

Review of Low quality studies

pooled diagnostic performance of bone scintigraphy for CRPS type I in analysis of 21 studies

sensitivity 79% (range 14%-100%)

specificity 88% (range 60%-100%)

criteria for CRPS on triple-phase bone scan included diffusely increased uptake, especially increased periarticular uptake in multiple joints Reference -

J Hand Surg Am 2012 Feb;37(2):288

systematic review of 12 diagnostic cohort studies evaluating bone scintigraphy (3 phase scintigraphy in 11 studies, 5 phase scintigraphy in 1 study) for diagnosis of CRPS type I in 882 patients

all studies had ≥ methodologic limitation including

6 studies lacked valid reference standard for CRPS 1

unclear if index test interpretation was blinded to reference standard in all studies

pooled diagnostic performance of 3-phase bone scintigraphy for CRPS type I in analysis of 6 studies with valid reference standard

sensitivity 80% (95% CI 44%-95%)

specificity 73% (95% CI 40%-91%)

positive likelihood ratio 2.92 (95% CI 1.33-6.43)

negative likelihood ratio 0.28 (95% CI 0.1-0.76)

Reference -

Eur J Pain 2012 Nov;16(10):1347

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Bone Scan RSD

based on 3 diagnostic cohort studies with inconsistent results all 3 studies had lack of reporting if index test interpretation was blinded to reference standard 116 with suspected CRPS had clinical evaluation and were assessed using 3-phase bone scintigraphy

69 (59.5%) had CRPS using

Budapest diagnostic criteria as reference standard

for diagnosis of CRPS, 3-phase bone scintigraphy had

sensitivity 40%

specificity 76.5%

positive likelihood ratio 1.73 negative likelihood ratio 0.78Reference - Br J Anaesth 2012 Apr;108(4):655

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Neuropathic (non RSD) HSP etiology

Zeilig

et al Pain. 2013 Feb;154(2):263-71

30 CVA pts N=14 HSP, 16 without HSP> 6 mo post

15 healthy controls

HSP group had increased parietal involvement

HSP group had higher pain/temp threshold vs CVA pt without HSP in UE and LENo vasomotor or sudomotor signs (no RSD)

Is HSP part of a central post stroke pain syndrome?

Slide34

Fig. 3 Higher rates of pathologically evoked pain were found in the affected shoulder of the hemiplegic shoulder pain (HSP) group compared to that of the nonhemiplegic shoulder pain (NHSP) group, including: hyperpathia (

∗p<.05, ***p<.001

Gabi Zeilig , Michal Rivel , Harold Weingarden , Evgeni Gaidoukov , Ruth Defrin

Hemiplegic shoulder pain: Evidence of a neuropathic origin

PAIN Volume 154, Issue 2 2013 263 - 271

http://dx.doi.org/10.1016/j.pain.2012.10.026

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Case study- Mr. H

60 yo M admitted with R hemi due to L PLIC infarct- MMT 3-/5 L deltoid, biceps, MAS 3 in biceps, no swelling in hand, no sensory change

Shoulder pain started during acute rehab-tx with limb protection, analgesics, diclofenac gel

Pain with abd, arm flex, persisted as outpatient, no relief with subacromial injection

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Case study Mr. H

Ultrasound R shoulder- 3mm fluid surrounding the R biceps tendon in the groove on SAX/LAX views, no cuff abnormalities, AC joint ok

R biceps tendon sheath injection under ultrasound guidance

Resolution of R shoulder pain

Completed outpatient PT/OT- no recurrence

Still gets botox injections to forearm and biceps q 3 months

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Case study Mrs. B

75 yo F with R MCA infarct causing L HP, L neglect, L hemisensory deficits, cognitive def

L shoulder pain, limited ROM, pain with all motions of shoulder, no hand swelling

Completed inpt rehab, d/c to SNF, received additional PT/OT

Outpt clinic f/u continued pain requesting more pain meds (on Oxy IR n SNF)

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Case Study Mrs. B

Intra-articular injection of minimal benefit

Pectoralis and biceps botox of helped biceps tone but no improvements with shoulder pain or ROM

Ultrasound of L shoulder-limited study due to problems with positioning shoulder, no evidence of biceps tenosynovitis, + rotator cuff

arthropathy

(cortical irregularity at supraspinatus insertion)

Multifactorial HSP- adhesive capsulitis, +sensory

dysesthesias

Slide39

Summary HSP

HSP is a complex symptom to evaluate

Some cases (?50%) are musculoskeletal

RSD about 10-15%

Sensory dysesthesias may be related to a central post stroke pain syndrome or to more localized spinothalamic involvement (1-10%)

Multifactorial may account for about 30-40% of cases and may be the most difficult to eval/tx

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HSP Summary

New tools such as MSK ultrasound may improve accuracy of HSP diagnosis

Bicipital tendinopathy/tenosynovitis more common than previously thought

Subscapularis tear more common than previously thought in chronic stage

Improved diagnosis can improve treatment

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Hands on Demonstration

Kris Gellert OTR-Hands on Demo of OT eval and treatment of HSP

Anne Kirchmayer MD (FAAPMR Sports and Neuromuscular Med)- MSK US of biceps tendon and subscapularis

Andy Kirsteins MD- MSK of supraspinatus and infraspinatus