Shoulder Subluxation

Initially after stroke, one may experience a flaccid stage where the arm is limp, hangs down, and has no movement. Soft tissue can become overstretched from the effects of gravity and improper handling of the arm. Stroke patients who have their arm unsupported and/or handled inappropriately by caregivers (i.e. pulling on the arm) are at higher risk for traction neuropathy and injury. It is important that caregivers of stroke patients are properly trained in handling the hemiplegic arm especially when shoulder subluxation is present. Lap trays or pillows can provide support when the person is seated.

ARM SLINGS

Arm slings are often used on the flaccid arm. Their use, however, does not cure or prevent shoulder subluxation and can have disadvantages such as causing poor alignment and interfering with proper arm swing. The main uses of a sling for the hemiplegic arm are for support, protection against injury, and to prevent or reduce pain. A sling can be beneficial when out in public because it will alert others not to pull or grab the stroke patient by the arm. Slings are best used during walking especially if for long distances. It is best to avoid slings that bring the arm across the body with the hand and forearm on the abdomen. This position is already a problematic pattern for the stroke patient who has muscle tightness and spasticity that bends the arm and pulls it across the body. Wearing this type of sling can contribute to muscle contractures especially if worn frequently. Stroke victims should focus on trying to use their affected arm as much as possible and only use slings when necessary. As tone returns to the shoulder muscles, the risk of shoulder subluxation decreases and slings can be withdrawn.

Determining if a stroke patient would benefit from a sling is based on several factors. A patient may benefit from the sling if the following are true:

The sling reduces arm/hand edema.

The sling improves balance when walking.

The patient does not attend to the affected arm and does not try to protect it.

The caregiver and/or patient can put the sling on properly.

A sling may not be indicated in the following cases:

The patient has active movement of the arm and the sling hinders this movement.

The patient is at risk for contractures of the arm due to sling positioning.

The sling is uncomfortable or causes undue pressure on the neck.

The sling contributes to unilateral neglect of the arm.

There are various types of slings for hemiplegia and subluxation. One sling that may provide better positioning of the arm when compared to other slings is the GivMohr sling. It was designed by an occupational and physical therapist desiring to develop a more effective positioning device for the flaccid arm. It is meant for stroke patients who can walk or have potential to walk. It is intended to reduce subluxation when worn, help with shoulder pain, allow for arm swing, and provide joint compression to facilitate return of movement to the hemiplegic arm. An example of this type of sling is below.

Shoulder taping or strapping has been used by therapists, however, most research studies have not supported that this technique helps with pain, range of motion, or subluxation of the hemiplegic arm. As a therapist, I have seen some patients acquire pain relief with taping so it may be beneficial depending on the individual. It is best to work with a therapist to determine what type of treatment works for you. Another treatment strategy has been neuromuscular electrical stimulation (NMES). NMES has shown some success with prevention and treatment of subluxation in research studies. Ask your therapist if this type of treatment is appropriate as it may be contraindicated for certain patients. Range of motion of the subluxed shoulder should be taught to the patient and family by a therapist or medical staff. When subluxation is present, it is best to avoid pulleys and uncontrolled range of motion exercises. If the patient has cognitive deficits, neglect, or is impulsive, it would be best to have a trained caregiver to move the hemiplegic or paralyzed arm. Range of motion can help prevent contractures and pain if done correctly.