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Management of Shoulder Subluxation After Stroke

Management of Shoulder Subluxation After Stroke
Salvador Bondoc, OTD, OTR/L, FAOTA
May 17, 2013
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 This text-based course is a transcript of the live webinar titled, "Management of Shoulder Subluxation After Stroke", presented by Salvador Bondoc, OTD, OTR/L, BCPR, CHT, FAOTA

>> Salvador Bondoc:  It is my pleasure to be in your virtual presence to present a topic that I am very fascinated with.  I am sure you are all curious about the issue of shoulder subluxation and pain in persons who have had a stroke.  Who with us today currently has a patient with stroke and just happens to have a shoulder subluxation problem?  It seems about half of you have a patient currently who is dealing with shoulder pain and/or subluxation.  I hope that you learn some clinical pearls from this presentation that you may incorporate readily in your plan of care either today or in the very near future.  I also want to thank you for taking the time in your busy day to listen and participate in this program. 

Introduction

Learning Objectives

Our learning objectives for today and what we hope to accomplish by the end of the presentation are as follows:

  • Be able to describe the prevalence and the pathomechanics of stroke-related glenohumeral (GH) pain and subluxation.  It is also known as hemiplegic shoulder pain and subluxation in the literature or HSP.  If you see that acronym in stroke literature, it refers to the shoulder.
  • State the evidence for managing glenohumeral subluxation and pain associated with stroke.
  • Be able to design an intervention plan to address glenohumeral subluxation and pain.

Outline

What I have done for this program is to structure my PowerPoint into two parts.  Hopefully over the next two hours we can go in depth into these topics.  The first part is background information about hemiplegic shoulder pain and subluxation where I will give an overview of stroke and hemiplegic shoulder.  We will also review anatomechanics of the shoulder and discuss treatment considerations.  We will then segue to the next part which is evidence-based management and clinical recommendation.  If we have some time I will also present a small research case study that a graduate student and I conducted about two years ago.  This study presents another potential dimension of treatment to add to your approach.

Hemiplegic Shoulder Pain and Subluxation- Section 1

Stroke is the leading cause of long-term disability in North America according to a variety of sources including The American Heart Association.  There are nearly 5,000,000 clients who have incurred a stroke and are what we consider survivors.  What is quite staggering though is that there are about 700,000 of new strokes that occur every year. 

There are at least two important disabling factors that are identified by many researchers that are the primary determinants of rehabilitation outcomes.  The first is cognitive impairment and the second is motor impairment, especially with the upper extremity.  The recovery of the upper extremities tends to be a lot slower compared to other parts of the body in part due to the size of the motor map of the upper extremities. Eighty percent of patients who have had a stroke have some sort of upper extremity impairment, particularly paresis.  Unfortunately with this high prevalence, there are few models that can precisely predict the recovery in stroke.  

UE Recovery After Stroke

Figure 1. This figure shows the results of the Copenhagen Stroke Study.

Figure 1 represents a large scale stroke study conducted by Nakayama and colleagues.  As you can see, upper extremity recovery varies. You see 69% of the participants had severe to moderate deficits, and 13% (orange) had an upper extremity that was nonfunctional.  If you combine them together, that is more than 4/5 or 80% that are moderately impaired or nonfunctional as their best outcome possible.  However, this population study was conducted in 1994, which means that there were not cutting-edge interventions such as CIMT and some of the technologies that we have today.


salvador bondoc

Salvador Bondoc, OTD, OTR/L, FAOTA

SALVADOR BONDOC, OTD, OTR/L, FAOTA is an Associate Professor of Occupational Therapy at Quinnipiac University where he has taught foundational neurosciences and neurological rehabilitation content in the combined Bachelor of Health Sciences/Master of Occupational Therapy program at Quinnipiac University since 2006. His research interests include upper extremity interventions with the stroke population, and balance and postural control in the well and frail elderly. Dr. Bondoc is also an active clinician in outpatient neurological/orthopedic rehabilitation and inpatient geriatric rehabilitation settings.

Dr. Bondoc was honored as Fellow of the American Occupational Therapy Association for his Leadership and Clinical Excellence in Evidence-based Physical Rehabilitation in 2012; and granted the Award of Merit for scholarship and clinical practice by the Connecticut Occupational Therapy Association in 2013.



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