Shoulder subluxation is a common occurrence after stroke and can be due to muscle weakness or spasticity. It is characterized by the upper arm bone (humerus) dropping out of the shoulder socket. The muscles may be too weak to hold the arm bone securely into the shoulder socket or spasticity can cause subluxation by pulling the bone into an abnormal position. Both muscle weakness and spasticity can cause the shoulder blade (scapula) to be abnormally positioned as well.
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 and arm slings can be used when the person is standing or walking.
Arm slings are often used on the flaccid arm. Their use, however can have disadvantages such as causing poor alignment and emphasizing positions that can lead to stiffness and contracture so proper fit and directions on use of sling must be accurate. 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 avoid wearing slings that bring the arm across the body with the hand and forearm on the abdomen for prolonged periods. 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, support their arm when seated, and slings can be worn during transfers or walking. As tone returns to the shoulder muscles, the risk of shoulder subluxation decreases and slings can be withdrawn.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 and/or posture 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.
The sling helps alleviate pain.
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 shoulder subluxation. I was recently contacted by a gentleman who designed a sling for his girlfriend that had experienced a stroke. This gentlemen made 11 different slings before he came up with a design that helped alleviate the pain his girlfriend was having and that also impressed the therapists and doctors working with her. This gentlemen now makes and sells these slings. I tried one of the slings with a patient who had subluxation and pain, and it worked wonders for her. The sling is made so that you can wear it at night as well. My patient was very excited that it alleviated her nighttime pain. Of course this is only one patient, but the gentleman reports he is getting other positive feedback from other stroke patients and therapists throughout the country. The website where his slings are available for purchase is sites.google.com/site/subluxationsling/.
The sling he designed looks like this:
Another sling that may provide better positioning of the arm when walking 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, research studies are lacking regarding whether taping 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.
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