Submissions from Readers

Shoulder out of socket

by Harold
(Oklahoma)

Question: What can you do if your shoulder has dropped out of its socket after a stroke?


Answer: Shoulder subluxation is a common occurence after stroke. Some treatment strategies used involve supporting the affected arm, electrical stimulation, strengthening, and hemiplegic arm slings (hemi slings).

You can support the affected limb by placing it on a tray or pillow when seated. There are special lap and half trays made for wheelchairs.

When walking, you might want to consider a hemi sling to help hold the humeral head in alignment. Many therapists will recommend hemi slings, however, most research hasn't proved or disproved that slings are beneficial for subluxation. Slings can be helpful in protecting the arm though since they will provide some support to a flaccid extremity and will alert others not to touch or pull on your arm. I often will recommend patients to wear slings in public but to remove them at home so the arm can be used more. It is best to avoid slings that bring your arm into internal rotation (i.e. elbow bent with hand placed on abdomen). The GivMohr sling developed by an occupational and physical therapist is a nice sling that does not pull the arm across the body but provides support. To research various slings, you can search "hemi-slings" or "slings for subluxation" on the internet. Talk to your therapist to see if a sling may be beneficial to you.

Electrical stimulation (e-stim) has been used on shoulder muscles to help decrease subluxation. Several studies have show e-stim to help reduce subluxation especially when combined with exercises. There are several contraindications for e-stim so check with your therapist and doctor to see if this is an option for you.

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Stroke patient w/Subluxation and rotator cuff issues
by: Jennifer Anderson

Hello,

I am a massage therapist and I just picked up a new client who has experienced multiple strokes and is unable to walk, talk or eat on his own. I have been selected as his massage therapist to massage his upper body but I do have some concerns as to making sure the massage is comfortable and things I can suggest to the family to help with the subluxation in his left shoulder and rotator cuff in his right. The doctors refuse to perform surgery due to his health condition. So as a massage therapist what can I suggest or do in my treatment to help him get the mobility back in his arms? Thank you in advance for any suggestions you might have.

Respectfully,
Jennifer Anderson, LMT

Reply from Stroke-rehab.com: I would probably avoid making suggestions for exercises for stroke as I believe this would be out of the scope of practice of a massage therapist unless you have had special training/education on doing exercises with stroke patients. I do think it would be within your scope of practice to show family how to help massage, position, manage edema, or perhaps do stretches. Since I am a not a massage therapist, I do not know what falls within your scope of practice exactly, but I would definitely stay within those guidelines and make sure it applies to patients with medical conditions such as stroke.

You could definitely mention things to avoid such as pulling on the arm and avoiding awkward positions. You could print out information from the internet for them, but I would express to the family that the information is not medical advice and strictly information you found on the internet that you think may be helpful. You can find information about subluxation, doing range of motion, and managing spasticity on my website as well as many other sources on the internet. The pages from my website include:

http://www.stroke-rehab.com/hemiplegia.html

http://www.stroke-rehab.com/shoulder-subluxation.html

http://www.stroke-rehab.com/spasticity.html

http://www.stroke-rehab.com/stroke-rehab-exercises.html (see the passive range of motion video on this page, but realize this person has no limitations and a stroke patient with subluxation should be ranged to probably no more than 90 degrees of shoulder flexion or less if pain occurs before 90 degrees).

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Shoulder Subluxation and GivMohr Sling

by Fran

Question: I had an AVM 30 years ago & often suffered from shoulder subluxation during long walks especially when fatigued. It is now a constant pain & my dr suggested to see a PT specialist in Strokes/AVM. What can I do meanwhile to ease the constant ache? I did buy a sling for long distance however, it is the one that keeps the arm across the abdomen which does not help the situation. I want to order the Givmohr Sling, but it states a therapist must position this. Any suggestions?

Answer: The GivMohr sling comes with instructions for donning so you should be able to figure out how to put it on. There is also instructions on their website as well as a sizing chart. The sizing chart can be found at www.givmohrsling.com/order.htm. Once you contact a therapist, you might try kinesiotaping. This isn't always effective, but I have met some patients that have been satisfied with taping, and it wouldn't hurt to try.

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Subluxed Shoulder

Question:I have a patient with about a 1 1/2-2 finger subluxation. What can I do to treat it, and can I do shoulder ROM exercises? Their wrist and fingers are painful during ROM.

Answer: Range of motion exercises can be done with patients that have shoulder subluxation, but you have to be careful when you bring the arm above 90 degrees of shoulder flexion due to misalignment and impingement issues. It's easier to do shoulder range of motion with the patient in supine (lying on their back). You have to keep the shoulder in good alignment, reduce the subluxation, make sure the scapula upwardly rotates with overhead movement, and make sure to externally rotate the humerus if performing abduction (lifting to the side). I usually have the thumb pointing toward the ceiling for shoulder flexion. Do not force the arm up, pull on the arm, and stop if the patient experiences pain. I always mobilize the scapula prior to trying to doing shoulder range of motion which usually helps alleviate pain and allows for more shoulder movement. It is important to do elbow, wrist, and finger range of motion as well. If the patient is not doing range of motion, they will continue to be stiff and experience pain when someone attempts to move their arm.

Other methods to help with shoulder subluxation are to keep the arm supported, position arm in good alignment, kinesiotaping, and electrical stimulation in attempt to strenghthen the rotator cuff muscles.

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PROM and subluxation from CVA

Question If there is a subluxation on a arm which is flaccid, do we perform range of motion or not?

Answer: It is okay in most cases to perform range of motion on a flaccid hemiplegic upper extremity. Of course one should always check with their therapist first to make sure there are no contraindications and also to learn the correct technique for range of motion. Range of motion should only be performed in a pain free range, the scapula should be upwardly rotating if shoulder range occurs above 90 degrees, the arm should not be pulled on, and the shoulder should be aligned correctly. In my opinion, the best position for passive range of motion of a flaccid arm is with the patient in supine. It is often difficult to achieve optimal alignment with the patient in sitting due to the paralysis and heaviness of the arm, and I find it can usually be done in supine without eliciting pain.

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Moderate to severe shoulder subluxation after stroke

by roberta newman
(springfield, va, usa)

Question: Patient does not wear GivMohr sling because it cuts across her R lateral neck and she feels it contributes to neck spasms/pain later in the day. Because she does not like it, she does not wear it. What sling would you otherwise recommend? I am her home health OT. I was checking out the unilateral hemi sling, by Sammons Preston, which looks to be more comfortable. It features a single strap across the chest and under the R arm (L arm is affected limb) and encases the humeral head and proximal upper arm. What do you think? She is post-R CVA/L hemiplegia since january 2011.

I appreciate your counsel, as well as any treatment ideas (other than PROM, SROM, and e-stim, the latter which she cannot tolerate at all).

Answer: None of the slings will stop or cure subluxation so in my opinion I would use whatever the patient finds comfortable. If worn correctly, the GivMohr sling should not be on the neck but over the middle to lower portion of the upper trap. If she already has a GivMohr sling, I would make sure that it is fitting properly according to their website. The sling you have suggested may work fine, but you never really know until the patient tries it on. I don't even recommend wearing a sling when a patient is sitting around but rather to just prop the arm. If the person is ambulating frequently or for long distances then a sling may be more appropriate.

As far as other options, you might try kinesiotaping. Many patients like the kinesiotape and have less pain when it is applied. If they have sensitive skin, you can put milk of magnesia on the skin first and let it dry then apply the tape.

Some research has shown that e-stim may help reduce subluxation if it is done early and on a regular daily basis.

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Subluxed Shoulder Treatment

Question: How soon should a subluxed shoulder be treated after a stoke has occurred?

Answer: You can begin at any time to take measures to help a subluxed shoulder. You want to minimize pain if present and position the arm to support it and prevent further stretching of weak structures. The one piece of advice I would give to someone though is not to obstruct the arm from moving. I am not a fan of slings that hold the arm across the body and restrict arm movement. These put the arm in an unfavorable position for stroke patients and prevent the patient from moving the arm. There are other ways to more effectively address subluxation which are addressed at www.stroke-rehab.com/shoulder-subluxation.html.

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shoulder subluxation

by jeenat
(india)

Question: What is the best way for treating shoulder subluxation of the hemiplegic side..is it taping, elctrical stimulation or slings.
Should we give hand exercises when there is subluxation?

Answer: Research has shown that electrical stimulation may be effective in preventing the development of subluxation. Research has not found this to be true with slings. Sometimes slings or taping can help with pain, however, you have to be careful that slings are not putting the arm in a position that encourages contracture or misalignment. It is okay to do hand/arm exercises with a subluxed shoulder but avoid overhead pulleys or any overhead activities that may compromise the shoulder. Generally anything below 90 degrees of shoulder flexion is fine. Here is some information you can review based on research:

http://www.ebrsr.com/uploads/Module-11_hemiplegic-shoulder_001.pdf

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subluxation sling

QuestionI need a sling to reduce shoulder subluxation while sitting and performing activity with the "sander box". I like the GivMohr sling but dont know if it will allow movement and also still provide support when sitting.
Thank you.

Answer: I honestly wouldn't think you need a sling when doing a weight bearing activity such as the bilateral sander. Slings are more often used to support an arm that is hanging down not an arm that is up on a surface like it would be when doing the sander (I'm assuming you have some movement in the arm and are not just pulling a totally flaccid arm around with the sander). Research has shown that slings are not that effective, but I do know that some patients feel more comfortable with them on. If you feel more comfortable with support around your shoulder, then you could use a hemi arm sling like the ones found at Pattersonmedical.com or you could try the subluxsling at subluxsling.com. These slings leave your hands free. If you are having shoulder pain when you use the sander, then I would stop using it or adapt the way you are doing the activity so you have minimal or no pain.

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Acute Stage Arm Positioning

by Satheesh
(India - Delhi)

Question:We are helpless to prevent internal rotation of the shoulder, forearm pronation and wrist flexion on the affected side limb while sleeping or during other activities in acute stage. Proper positioning and support also not helpful. How we can prevent this?

Answer: I would probably try a wrist/hand splint for the wrist. There are splints that are adjustable so if the patient has too much tone, the wrist or finger portion of the splint can be angled into more flexion if needed. This will allow for stretch and better positioning. Along with a hand splint, I might try a firm pillow between the arm and body to help block the arm from pulling across the body. Most positioning charts for stroke will show a pillow under the arm, but you can try to place one between the arm and body. If the patient has a hand splint, it will often help block the hand from coming up over the pillow and across the body. Do not put patient in a position that causes pain. If the tone is too high, this still may not work. You can also have the patient try lying on their side to get a better arm position. If all of these attempts are futile, I would advise the patient to see a MD regarding spasticity treatment which may include meds or injections.

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E-stim for subluxation

Question: The physician has cleared my pt for e-stim for shoulder subluxation. We have gotten good results with increased movement of shoulder extension but not so much with elevation. Is there an ideal amount of time or pattern of alternating exercise with the stim? Is vibration better than tapping? We have ordered the subluxsling and plan to use estim while wearing it and facilitating activity.
Thank you for any feedback you can share.

Answer: I recommend reviewing http://www.ebrsr.com/uploads/Module-11_hemiplegic-shoulder_001.pdf. It has a summary of research done for shoulder pain and subluxation with the techniques used. It may give you some helpful insight into working with the shoulder and what treatments have been successful in the past.

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Getting arm to move

by Barbara
(Holderness, NH)

Question: My husband has little or no arm movement and subluxation of his shoulder but no pain. Would it be useful to try the subluxsling with him even though pain isn't the issue?

Answer: There is minimal evidence that slings are helpful with preventing or stopping subluxation. I personally am not a big fan of slings unless a patient has a very flaccid arm and is up walking a lot. If the patient is mainly sitting throughout the day, I would just recommend supporting the arm on a wide armrest, firm pillow, or a tray/trough if in a wheelchair. This will help prevent edema or excessive pull on the arm. If there is no pain, I personally would not worry about it unless your MD tells you otherwise (or unless your husband meets the criteria above of having an extremely flaccid arm but is already up walking frequently).

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Shoulder Subluxation
by: Anonymous

Shoulder subluxation is not a good thing. While lying make sure pillow should be supported up to shoulder level. Whenever he is sitting pillow would be supported from axilla. Apart that subluxation leads to unnecessary stretching the peripheral nerves might be suffered by (CRPS)shoulder hand syndrome in future.

Comment from Stroke-rehab.com - Many patients have subluxation that do not have pain or develop CRPS. The important thing to remember is to position the arm, handle the arm with care, and to perform passive range of motion (PROM) as instructed by your therapist (shoulder blade needs to rotate when raising the arm). To help you determine if your loved one needs a sling, you can review www.stroke-rehab.com/shoulder-subluxation.html which outlines when a patient may need a sling.

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name of subluxsling
by: Anonymous

I am very interested in the name of the sling that helped decrease your pain. I have a patient with pain from subluxation. Thank you.

ANSWER: GO TO SUBLUXSLING.COM

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Subluxsling
by: Barbara

This slubluxsling is apparently a huge improvement over other slings. Have you looked it up?

Answer: Yes, I have actually recommended it to some patients, but I don't think all patients need a sling, and I find that many patients won't wear a sling even if they do get one. I had a patient who loved this sling due to it helping with the pain. I like that this sling seems to help improve shoulder posture (my observation). No sling, however, helps the arm move again nor is there good evidence that slings in general stop subluxation. If a patient wants a sling, and especially if they are having pain, I tell them about this sling, but in many cases I do not suggest slings.

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Weight Training after Shoulder subluxation 10 years post stroke

Question: Is it safe or contraindicated to have a person 10 years post stroke with shoulder subluxation engage in weight training with a personal trainer?

Answer: The stroke patient should consult with a physician to make sure the shoulder is stable for weight training. If a person has moderate to good movement in the affected arm, has only a small residual subluxation from a previous stroke, and has no pain from lifting weights then it shouldn't be a problem. Since I do not know the condition of the specific patient though, I cannot say for sure and recommend that they get their MD's clearance.

I highly recommend discontinuing any exercises that cause pain and sometimes pain is delayed so it may not always be clear which exercises cause pain. I start slow with my patients and will systematically add exercises as they are able making sure that any new exercise does not adversely affect them.

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Subluxation of the Shoulder
by: Anonymous

Yesterday we were told my husband had a two finger subluxation in his shoulder. My husband had a Afib stroke four years ago. He is getting acute therapy for his arm and shoulder and the therapist was concerned about the severity of the subluxation. Today she could not find the subluxation and even had two other therapist check. Does this happen? Should we be concerned it may return?

Stroke Rehab reply: This is rather unusual. I wouldn't expect to see a 2 finger subluxation and then it not be there a few days later especially since he is four years post stroke. Make sure they check for laxity/instability in the shoulder joint to make sure structures are intact and that the joint is not excessively mobile. If there is not instability and no subluxation is present, then I would not be concerned. If there is instability, then there might be risk of subluxation/dislocation. You will need to talk to the therapist working with your husband to truly know the condition of the shoulder and what precautions/exercises they recommend.

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Subluxed Arm and Kinesiology tape

by Ruth
(FL)

Question: Is the use of Kinesiology tape helpful and will it over time help reconnect the muscles and shoulder areas?

Answer: The muscles don't actually detach from the shoulder area with a subluxation. Often the muscles are weak and the upper arm bone (humerus) does not sit securely into its socket. As a result, there is a noticeable gap or indentation between the head of the humerus and the socket. Kinesiology tape can provide some extra support to the joint, however, it will not be strong enough to hold the humerus into the socket nor will it correct the subluxation. In my experience, Kinesiology tape can help with pain in some patients, and many patients I have used it on like the feeling of extra support. However, according to the Evidenced Based Review of Stroke Rehabilitation (EBRSR), the evidence is conflicting on whether strapping helps with pain, and there is moderate evidence that it does not help with limb function or range of motion. You can read other finding of the EBRSR regarding upper extremity hemiplegia at http://ebrsr.com/sites/default/files/Chapter11_HemiplegicShoulder_FINAL__16ed.pdf

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Shoulder Subluxation and Weight Bearing

by Julie
(ohio)

Question: Can you do weight bearing on a flaccid arm with shoulder subluxation?

Answer: One should always check with their therapist regarding questions about specific exercises, but in general there is no reason why weight bearing should be a problem for someone who has a subluxed shoulder due to a stroke. With a flaccid arm, one may need some support to keep the arm from buckling and the patient should avoid positions that cause too much pain.

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