Shoulder Pain in Hemiplegia - Treatment Modalities and Rehabilitation

What Is Hemiplegia?

As the name indicates, ‘hemi’ means half, and ‘plegia’ means paralysis. It is characterized by paralysis of one-half of the body, including the shoulders. Hemiplegia usually results from stroke, also known as cerebrovascular accident. Hemiplegia is often used to refer to the wide variety of motor problems caused by stroke. Shoulder pain in patients with hemiplegia may be due to several factors, including hypotonicity (decreased muscle tone or weak muscle) and loss of voluntary movement, which are direct impairments. It can also be due to soft tissue damage or trauma from improper hospital transfers, which is an indirect impairment caused by healthcare workers or caregivers.

Individuals with stroke differ widely in their approach to processing information and behaviors. A lesion (tissue or cellular damage) in the cerebrum of the brain is present in stroke-affected patients. In addition, the lesion can be either in the left or right hemispheres of the brain.

1. Left Hemisphere Lesion: The patients with left hemisphere lesions have right hemiplegia and demonstrate difficulties processing information sequentially. They tend to be cautious, anxious, and disorganized.

2. Right Hemisphere Lesion: The patients with right hemisphere lesions have left hemiplegia and demonstrate difficulty in spatial perceptual tasks (orientation of the surroundings), such as brushing hair and packing a bag. They tend to be quick and impulsive.

What Are the Causes?

A stroke, also known as a cerebrovascular accident, occurs when the blood supply to the brain is interrupted or stopped. It can be due to sudden injury or trauma to the brain. It can also be due to tumors or abscesses in the brain. Brain infections like meningitis and encephalitis can also lead to hemiplegia. Infantile hemiplegia can be due to brain injuries that occur after birth.

What Are the Symptoms?

• In hemiplegia, the asymmetry between affected and unaffected sides is evident while walking.

• The patient finds difficulty in grasping objects.

• The affected side of the body is weak and sore.

  Related Topics

  ---

  Why does paresthesia progress in post-polio syndrome?

  Can massage worsen shoulder pain caused by muscle spasms and tapered nerve?

  I have shoulder pain since yesterday after getting up from the bed. What to do?

• Patients with hemiplegia tend to fall in the direction of weakness.

• Visual disturbances can be seen in hemiplegic patients.

• The patient will have an altered walking pattern.

• The patient has difficulty walking, getting up, and lying down.

• Shoulder pain can be due to shoulder humeral luxation and spasticity.

• Shoulder Subluxation: It is common after a cerebrovascular accident. It occurs when the humerus (bone in the upper arm) dislocates from the shoulder joint due to paralyzed muscles. It can drop down from the humerus because of the inability of the muscles to hold it in place. Shoulder subluxation alters the arm's mobility, producing pain in motion.

• Spasticity: Stroke can influence the motor function of the shoulder by making the muscles rigid and stiff. If the patient tries to move, a cramp or spasm is felt, and the patient struggles with movements.

How Is Shoulder Pain Diagnosed?

A series of X-rays are taken to see if the joint is dislocated. MRI (magnetic resonance imaging) and CT (computed tomography) are taken to find any other structural abnormality of the surrounding soft tissues. Electromyography is done to assess muscles and nerve abnormalities. It is a procedure in which electricity is passed through electrodes, and diagnosis is conferred through the response to that stimulation.

What Are the Treatment Modalities Available?

• Occupational therapy (OT) is done to reposition the dislocated arm. This therapy is done with the help of pillows, armrests, and cushions. The patient is properly positioned in a neutral position in lying and sitting.

• A sling should be wrapped around the arm to prevent mobility and aid in positioning the arm correctly.

• NSAIDs (non-steroidal anti-inflammatory drugs) can be prescribed to the patients for pain relief, along with muscle relaxants to ease the joint spasms.

• In conditions where the joint is inflamed (swollen), Corticosteroid injections are recommended to reduce the swelling.

• Suprascapular nerve blocks are given in the affected shoulder to relieve chronic pain. It is a procedure in which anesthesia is injected into the affected shoulder in the suprascapular region (present in the shoulder bone).

• Botulinum toxins are injected into the shoulder to reduce the activity of the muscles, and this will help reduce pain.

• Many interventions like electrical stimulation, therapeutic Kinesio taping, extracorporeal shock wave therapy, and cryotherapy are also effective.

• Surgery is done if the above-said conservative measures fail to relieve pain.

• Electrical Stimulation (E-Stim): In this process, electrical stimulation is targeted on the affected area to help decrease the subluxation (dislocation). E-stim, along with a few exercises, can significantly improve muscle function. It also prevents damage caused due to stretching in the joint and brings back the normal range of motion (ROM).

• Transcutaneous Electrical Nerve Stimulation (TENS): High-intensity stimulation has been proven effective in improving the range of motion. In this technique, electrical stimulation is sent to the skin above the standard threshold, and it will elicit a painful sensation and allow the muscles to contract.

• Therapeutic Kinesio Taping (KT): In this, a tape called the kinesiology tape is wrapped around the skin to provide stability and muscle strength. It will improve neuromuscular function and provide mechanical support to shoulder muscles in motion. The kinesiology taping can help reduce pain, improve the range of motion, and provide stability.

• Extracorporeal Shock Wave Therapy (ESWT): It is a non-invasive method in which sound waves are sent to the affected area at short intervals. This therapy stimulates tissue healing and reduces inflammation.

• Cryotherapy: In this method, ice is applied to the affected shoulder. It helps in reducing pain.

What Are the Rehabilitation Exercises for Shoulder Subluxation?

These exercises are aimed at rewiring the brain to enhance proper muscle movements and orienting the shoulder to make appropriate movements. It should be done in repetitions to stimulate the brain for rewiring.

1. Punching Movements: Sit near a table on a chair and place the affected forearm on the table extended. Keep an object like a water bottle on the table straight in line along the extended arm. Try to push the bottle gently in a punching motion by making a fist and bringing the bottle back to its original position using the other hand. Repeat this ten times.

2. Pushing Movements: Sit near a table on a chair and place the affected forearm on the table extended. Keep an object like a water bottle on the table near the wrist and in a straight line along the extended arm. Try to keep the elbow stable, push the water bottle towards the body, and bring it back to its original position using the other hand. Repeat this ten times.

Conclusion:

Shoulder pain is a common complication in hemiplegic patients. Shoulder subluxation disables the patient by excruciating pain and restricting the range of motion. If the issue is not addressed at the right time, it will lead to poor quality of life and difficulty performing daily chores. Preventing movements that cause pain should be strictly avoided. Giving adequate rest and undergoing rehabilitation will help improve the symptoms. Conventional techniques, along with physiotherapy, can significantly reduce pain and restore function. Many interventions can reduce pain and improve mobility, like kinesiotaping, electrical stimulation, extracorporeal shock wave therapy, and cryotherapy. If these interventions fail to reduce pain, then surgery is the last resort.