1. Hemiplegic Shoulder Pain Update
Andrew E. Kirsteins M.D.
FAAPM&R (Sports and Neuromuscular Med)
Cone Health Physical Medicine and Rehabilitation

2. Purpose
Review common causes of Hemiplegic Shoulder Pain (HSP)- Focus on Post stroke
Diagnosis using PE and Imaging Studies
Introduce Musculoskeletal Ultrasound (MSK US) as an aid to diagnosis of HSP
Hands on demo
Please check out Sept 2013 Am L PM&R Ozcakar et al- Utility of MSK US in Rehab settings

3. Shoulder Pain General Population Post Stroke Population
3rd most common MSK c/o in primary MD office
2nd most common reason for referral to Ortho/Sports
~70% pain is from Rotator cuff disorders
Occurs in up to 72% stroke pts in the first year-Van Ouwenaller C, Laplace PM, Chantraine A. Painful shoulder in hemiplegia. Arch Phys Med Rehabil. 1986; 67: 23–26
Common reason for poor rehab outcome,QOL
Several pain generators have been proposed, complex

4. Post Stroke Shoulder Pain=HSP
Overall prevalence 17% at 2wks, 20% at 1mo,23% at 6mo. Ratnasabaphthy et al 2003,Clinical Rehab
Prevalence Rehab pop. 6mo

5. Post Stroke Shoulder Pain Risk Factors
Significant weakness
L neglect
Sensory deficits
Advanced age
Spasticity

6. Hemiplegic shoulder pain etiology
Nociceptive
Neuropathic
Subluxation theory
Subacromial Impingement
Bicipital tendon
Spasticity related
Adhesive capsulitis
RSD
Brachial plexopathy
Central Post stroke Pain

7. Nociceptive Shoulder Pain
Hemiplegic Shoulder Pain Update

8. Does Subluxation Cause HSP?
Pro
Con
Traction on joint capsule during flaccid stage
Subluxation more common in Shoulder Hand Syndrome-Dursun et al 2000
Most HSP occurs during spastic stage-Van Ouwenwaller et al 1986
Neuromuscular Electrical Stim reduces pain but not subluxation- Yu et al
No correlation between pain and subluxation Bohannon et al 1990

9. Ultrasound measurement of shoulder subluxation
X Ray
Ultrasound
Xray evaluation requires multiple views,measurements after imaging
Long axis view allows measurement during image acquisition-Park GY, Kim JM, Sohn SI, et al. Ultrasonographic measurement of shoulder subluxation in patients with post-stroke hemiplegia. J Rehabil Med 2007; 39:

10. Subacromial Impingement Syndrome Marwan Alqunaee, RCSI, Rose Galvin, BSc (Physio), PhD, Tom Fahey, MD, FRCGPDiagnostic Accuracy of Clinical Tests for Subacromial Impingement Syndrome: A Systematic Review and Meta-Analysis Archives of Physical Medicine and Rehabilitation, Volume 93, Issue 2, February 2012, Pages 229–236
Any rotator cuff pathology in the subacromial space
Includes Supraspinatus, Infraspinatus,Teres Minor and Subscapularis
Stages Include
Stage 1-Bursitis
Stage 2-Partial Tear
Stage 3- Full thickness Tear

11. Sensitivity and Specificity
A SeNsitive test when Negative rules OUT=SNNOUT, (true positive identification)
A SPecific test when Positive rules IN=SPPIN’ (true negative identification)
Difficult to establish Sensitivity and specificity in studies if there is no “Gold Standard”, or if different “Gold Standards” are used
So for diagnostic PE or imaging studies either surgical findings or MRI is used as “Gold Standard”

12. Subacromial Impingement Syndrome=SIS
History- pain with overhead activity, nocturnal pain
Exam-Hawkins Kennedy passive forward flexion/int rotation only useful test in a hemiplegic patient Sensitivity 74%
Imaging- Ultrasound can identify all 3 stages of SIS bursitis,partial tear and full thickness tear

13. Diagnostic accuracy of Ultrasound for RCT Smith et al, Clin Radiol 66 (2011) 1036-1048
Given limitation of history (communication deficit) and exam (given UE weakness), imaging assume greater importance
Partial thickness RCT Sen 84%, Sp 89%
Full thickness RCT Sen 96%, Sp 93%

14. Methods Results at D/C N=57, cross sectional
PHYSICAL FINDINGS AND SONOGRAPHY OF HEMIPLEGIC SHOULDER IN PATIENTS after ACUTE STROKE DURING REHABILITATION-Huang et al J Rehabil Med 2010; 42: 21–26
Methods
Results at D/C
N=57, cross sectional
Good vs Poor Motor groups based on Brunnstrom
Excluded prior shoulder problems
Recorded pain using VAS-but pain not an inclusion criteria
Assessed at admission and discharge (LOS 27d for good,32d for poor motor)
Pain:68% Poor motor, 35% Good motor
US abnormalities Poor Motor- 50% biceps tendinopathy,47% Supraspinatus tear,44% Subacromial bursitis
US abnormalities Good Motor – 30% biceps,22% subacromial bursitis,17% supraspinatus

15. Sonography of Patients with Hemiplegic shoulder pain after stroke  Lee et al Am J Roentgen 2009 Feb;192(2):
n=71, 20 pts had bilateral shoulders scanned
Subacromial bursal effusion seen in 36 shoulders
Biceps tendon sheath effusion in 39 shoulders
Supraspinatus tendinosis (7),partial tear (6) and full tear (2)
Abnormalities more common in hemiplegic shoulder p=.007 vs uninvolved side

16. 76 first time CVA, no hx of shoulder problems
Sonography and physical findings in stroke patients with hemiplegic shoulders: A longitudinal study Ya Ping Pong et al, J of Rehab med 2012,(44),
76 first time CVA, no hx of shoulder problems
Scanned during acute rehab and at 6 mo
Underwent standard inpt rehab program 1 hour PT and 1 hr OT 5d/wk
Brunnstrom score,ROM, Ashworth,10pt NRS

17. Sonography and physical findings in stroke patients with hemiplegic shoulders: A longitudinal study Ya Ping Pong et al, J of Rehab med 2012,(44),
Acute (D/C from Rehab)
Chronic (6mo post D/C)
Subacromial effusion 30.3%
Supraspinatus tear 30.3%
Biceps tendon 39.5%
Subscapularis 9.2%
Pain score 2.71/10
Subacromial effusion 13.2%
Supraspinatus tear 40.8%
Biceps tendon 57.9%
Subscapularis 22.4%
Pain score 3.99/10

19. Subacromial Bursitis

23. MRI findings in hemiplegic shoulder pain Shah et al Stroke 2008 June 39(6)
>3mo since CVA, pain score >4,n=89,65% L HP
Supraspinatus tear 26% partial, 6% Full
Supraspinatus tendinopathy 51%
Infraspinatus tear 13% partial, 2% Full
Infraspinatus tendinopathy 19%
Subscapularis tear 1%
Teres minor tear 1%

24. MRI findings in hemiplegic shoulder pain Shah et al Stroke 2008 June 39(6)

25. Adhesive Capsulitis or Frozen Shoulder
Few imaging studies
X ray Arthrogram Rizk et al, Arch Phys Med Rehabil.  1984; 65(5):254-6
30 Patients mean 3 months post CVA, Reduced ROM and pain, electrically silent EMG of shoulder muscles
23/30 had reduced capsular volume consistent with adhesive capsulitis
Arthrogram and Exam -Lo et al., Arch Phys Med Rehabil. 84(12): , 2003 Dec
32 pt with HSP<1 year post CVA
50% had adhesive capsulitis
22% Rotator cuff tears
16% Shoulder Hand
Greater ROM correlated with greater joint volume on arthrogram

26. HSP- Spasticity related
Older studies (eg Van Ouwenwaller) find that HSP more common in spastic shoulders
More recent study by Huang et al showed a weak correlation between spasticity and HSP
?Role of ultrasound imaging may be to guide needle for EMG into the subscapularis

27. Neuropathic shoulder pain
Hemiplegic Shoulder Pain Update

28. HSP Neuropathic-CRPS CRPS type 1= RSD
Shoulder hand syndrome subtype occurs after CVA
Incidence reported as 12-25% (Edgley SR et al,PM&R Supp 1 March 2009 S28)
Wide variation due to method of diagnosis (some studies reported much higher incidence with less strcit diagnostic criteria)

29. Sensitivity and Specificity
A SeNsitive test when Negative rules OUT=SNNOUT
A SPecific test when Positive rules IN=SPPIN
Difficult to establish Sensitivity and specificity in studies if there is no “Gold Standard”, or if different “Gold Standards” are used

30. RSD=CRPS Type 1
International Association for the Study of Pain (IASP) clinical diagnostic criteria (Revised Budapest criteria)
continuing pain disproportionate to original injury
must have reports of at least 1 symptom in 3 of 4 categories
sensory - allodynia and/or hyperesthesia
vasomotor - temperature asymmetry and/or skin color changes and/or skin color asymmetry
sudomotor/edema - edema and/or sweating changes and/or sweating asymmetry
motor/trophic - decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (in hair, nails, or skin)
must have at least 1 sign at time of evaluation in 2 or more categories
sensory - allodynia (to light touch and/or temperature and/or deep somatic pressure and/or joint movement) and/or hyperalgesia (to pinprick)
vasomotor - evidence of temperature asymmetry (> 1 degree C [1.8 degrees F]) and/or skin color changes and/or skin color asymmetry
sudomotor/edema -evidence of edema and/or sweating changes and/or sweating asymmetry
motor/trophic - evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (in hair, nails, or skin)
no other diagnosis can better explain signs or symptoms
sensitivity 0.85 and specificity 0.69
Reference - Pain Med 2007 May-Jun;8(4):326, editorial can be found in Pain Med 2007 May-Jun;8(4):289, commentary can be found in Pain Med 2009 Apr;10(3):598

31. Bone scan for diagnosis of RSD
Review of Hi quality studies
Review of Low quality studies
pooled diagnostic performance of bone scintigraphy for CRPS type I in analysis of 21 studies
sensitivity 79% (range 14%-100%)
specificity 88% (range 60%-100%)
criteria for CRPS on triple-phase bone scan included diffusely increased uptake, especially increased periarticular uptake in multiple joints Reference - J Hand Surg Am 2012 Feb;37(2):288
systematic review of 12 diagnostic cohort studies evaluating bone scintigraphy (3 phase scintigraphy in 11 studies, 5 phase scintigraphy in 1 study) for diagnosis of CRPS type I in 882 patients
all studies had ≥ methodologic limitation including
6 studies lacked valid reference standard for CRPS 1
unclear if index test interpretation was blinded to reference standard in all studies
pooled diagnostic performance of 3-phase bone scintigraphy for CRPS type I in analysis of 6 studies with valid reference standard
sensitivity 80% (95% CI 44%-95%)
specificity 73% (95% CI 40%-91%)
positive likelihood ratio 2.92 (95% CI )
negative likelihood ratio 0.28 (95% CI )
Reference - Eur J Pain 2012 Nov;16(10):1347

32. Bone Scan RSD
based on 3 diagnostic cohort studies with inconsistent results all 3 studies had lack of reporting if index test interpretation was blinded to reference standard 116 with suspected CRPS had clinical evaluation and were assessed using 3-phase bone scintigraphy
69 (59.5%) had CRPS using Budapest diagnostic criteria as reference standard
for diagnosis of CRPS, 3-phase bone scintigraphy had
sensitivity 40%
specificity 76.5%
positive likelihood ratio 1.73
negative likelihood ratio 0.78
Reference - Br J Anaesth 2012 Apr;108(4):655

33. Neuropathic (non RSD) HSP etiology Zeilig et al Pain
Neuropathic (non RSD) HSP etiology Zeilig et al Pain Feb;154(2):263-71
30 CVA pts N=14 HSP, 16 without HSP> 6 mo post
15 healthy controls
HSP group had increased parietal involvement
HSP group had higher pain/temp threshold vs CVA pt without HSP in UE and LE
No vasomotor or sudomotor signs (no RSD)
Is HSP part of a central post stroke pain syndrome?

34. Fig. 3 Higher rates of pathologically evoked pain were found in the affected shoulder of the hemiplegic shoulder pain (HSP) group compared to that of the nonhemiplegic shoulder pain (NHSP) group, including: hyperpathia ( ∗p<.05, ***p<.001
Gabi Zeilig , Michal Rivel , Harold Weingarden , Evgeni Gaidoukov , Ruth Defrin
Hemiplegic shoulder pain: Evidence of a neuropathic origin
PAIN Volume 154, Issue

35. Case study- Mr. H
60 yo M admitted with R hemi due to L PLIC infarct- MMT 3-/5 L deltoid, biceps, MAS 3 in biceps, no swelling in hand, no sensory change
Shoulder pain started during acute rehab-tx with limb protection, analgesics, diclofenac gel
Pain with abd, arm flex, persisted as outpatient, no relief with subacromial injection

36. Case study Mr. H
Ultrasound R shoulder- 3mm fluid surrounding the R biceps tendon in the groove on SAX/LAX views, no cuff abnormalities, AC joint ok
R biceps tendon sheath injection under ultrasound guidance
Resolution of R shoulder pain
Completed outpatient PT/OT- no recurrence
Still gets botox injections to forearm and biceps q 3 months

37. Case study Mrs. B
75 yo F with R MCA infarct causing L HP, L neglect, L hemisensory deficits, cognitive def
L shoulder pain, limited ROM, pain with all motions of shoulder, no hand swelling
Completed inpt rehab, d/c to SNF, received additional PT/OT
Outpt clinic f/u continued pain requesting more pain meds (on Oxy IR n SNF)

38. Case Study Mrs. B Intra-articular injection of minimal benefit
Pectoralis and biceps botox of helped biceps tone but no improvements with shoulder pain or ROM
Ultrasound of L shoulder-limited study due to problems with positioning shoulder, no evidence of biceps tenosynovitis, + rotator cuff arthropathy (cortical irregularity at supraspinatus insertion)
Multifactorial HSP- adhesive capsulitis, +sensory dysesthesias

39. Summary HSP HSP is a complex symptom to evaluate
Some cases (?50%) are musculoskeletal
RSD about 10-15%
Sensory dysesthesias may be related to a central post stroke pain syndrome or to more localized spinothalamic involvement (1-10%)
Multifactorial may account for about 30-40% of cases and may be the most difficult to eval/tx

40. HSP Summary
New tools such as MSK ultrasound may improve accuracy of HSP diagnosis
Bicipital tendinopathy/tenosynovitis more common than previously thought
Subscapularis tear more common than previously thought in chronic stage
Improved diagnosis can improve treatment

41. Hands on Demonstration
Kris Gellert OTR-Hands on Demo of OT eval and treatment of HSP
Andy Kirsteins MD (FAAPMR Sports and Neuromuscular Med)- MSK US of biceps tendon and subscapularis
Nitin Jain MD (FAAPMR)- MSK of supraspinatus and infraspinatus