Title: Is Strapping/Kinesiological Taping for the Painful Hemiplegic Shoulder an Effective Intervention?
1Is Strapping/Kinesiological Taping for the
Painful Hemiplegic Shoulder an Effective
Intervention?
- Julianne Genochio
- April Lovelace
- Tim Tollefson
- Christian Butler
- Ben Flores
- Chris McSharry
2Learning Objectives
- At the conclusion of this presentation the
listener will be able to - List the common causes of hemiplegic shoulder
pain - List the most common approaches to treatment of
hemiplegic shoulder pain - Discuss the purported benefits of the use of
straps/tape in treatment and prevention of
hemiplegic shoulder pain - Discuss two ways in which tape is applied to the
hemiplegic shoulder - Discuss research findings regarding the
effectiveness of straps/tape in treatment of
glenohumeral joint subluxation - Discuss research findings regarding the effects
of straps/tape on ROM, function, and arm muscle
tone - Discuss what research has shown regarding the
effects of straps/tape on the changes of
hemiplegic shoulder pain post-stroke
3Hemiplegic Shoulder Characteristics
- Definition of hemiplegia severe or complete loss
of motor function - Onset of hemiplegia can adversely affect the
normal mechanics of the shoulder complex through
various mechanisms - loss of motor control, secondary changes to
surrounding soft tissue, and glenohumeral joint
subluxation - changes compromise the stability of the shoulder
complex and place individual joints at risk - Abnormal tone patterns
- Patients initially present with flaccidity.
- Several days to weeks post-stroke muscle tone
can progress to spasticity
Bender et al., 2001
4Glenohumeral Subluxation
- Occurs in 17-66 of patients with post-stroke
hemiplegia - In most cases, involves inferior displacement of
the humeral head relative to the glenoid fossa - GH subluxation often develops when UE is flaccid
- Stability of the GH joint relies on muscular,
capsular and ligamentous integrity - GH joint no longer receiving muscular support
when UE is flaccid - Exacerbated by improper handling
- Identified with a positive sulcus sign
- Scapular instability can also contribute to GH
subluxation - Paralysis in stabilizing muscles can lead to a
protracted and depressed
scapula - Postural asymmetry can also lead to protracted
and depressed scapula - Humeral head more likely to sublux
Fotiadis et al., 2005 Paci et al., 2005 Paci et
al., 2007
5Hemiplegic Shoulder Pain
- Incidence occurs in up to 84 of stroke patients
with hemiplegic UE (Griffin et al, 2007) - Etiology causes not clearly identified, but
thought to have multiple contributing factors
including - Subluxation
- Spasticity
- Loss of ROM (especially ? external rotation)
- Muscle imbalance, joint and soft tissue
overstretch - Rotator cuff tears
- Soft tissue traumadamage to capsule, ligaments,
tendons - Glenohumeral adhesive capsulitis
- Shoulder hand syndrome
- Poor positioning/improper handling techniques!!
Bender McKenna, 2001 Teasell et al., 2009
Snels et al., 2000
6Hemiplegic Shoulder Pain
- Onset
- Time frame is extensive and not uniform
- Experience of pain can
- Limit the ability of the patient to reach their
maximum functional capacity - Lead to minimal participtation in rehabilitative
process due to pain - Fotiadis, 2005 Teasell et al., 2009
7Treatment for Hemiplegic Shoulder Pain
- Common approaches according to survey given to
various HCPs - Prevention/education proper handling and
positioning of UE immediately post-stroke - Physical Therapy ROM and functional training
- Local injection of corticosteroids and/or
anesthetics - Oral medications
- Sling/orthoses/taping
- only about 4 of HCPs chose this as a primary
approach! - More commonly utilized as a supplement
- FES and TENS are other approaches utilized in the
treatment of hemiplegic shoulder pain
Hanger et al., 2000 Snels et al., 2000
8Use of External Support Devices
- Common sources of external support include
- Slings
- Arm troughs
- Kinesiological tape
- Purported benefits
- Prevent glenohumeral subluxation
- Prevent trauma to shoulder joint
- structures and tissue
- Decrease/prevent pain
- Maintain and/or assist in improving ROM
- Assist in improving function
Griffin Bernhardt, 2005 Hanger et al., 2000
9Taping and Pain
- Purpose of taping
- to facilitate or inhibit the musculature and
promote normal alignment of the scapula in
relation to the thorax, humerus and clavicle - Suggested mechanisms of pain reduction
- Proprioceptor feedback serves as a reminder to
both patient and HCPs to handle UE properly - Maintain ROM
- Prevent assumption of internally rotated shoulder
as seen in spastic UEs - Sensory stimulation
- Reduce GH subluxation
- Prevent rotator cuff injury
- Reduce soft tissue overstretch
Ancliffe, 1992 Hanger et al., 2000 Bender et
al., 2001
10Taping the Painful Hemiplegic Shoulder
- 1)_As described by Ancliffe (1992)
- Utilizes 5cm wide tape
- 1st strip of tape applied to shoulder ½ way along
length of clavicle - - continued across deltoid in diagonal
- direction, wraps around upper arm
- - terminates ¼ of the way along
- spine of scapula
- 2nd strip applied in same direction
- but 2 cm below.
- - an anchor tape secured the two ends and
11Taping the painful Hemiplegic Shoulder
- 2) As described by Hanger (2000)
- 3 lengths of nonstretch tape (Elastoplast Sports
tape) applied over an under tape to prevent skin
reaction. - Arm supported by elbow by second person
- 2 supporting tapes were applied.
- 5cm above elbow, both anterior/posterior,
- moving up the arm and crossing at the
- apex of the shoulder.
- 1 tape applied from the medial third of the
- clavicle, around the surgival neck of humerus
- and along the spine of the scapula to its
- medial thrid.
- Difficult to apply and uses large amounts of
- tape, leading to increased risk of skin
irritation.
12Taping the Hemiplegic Shoulder
- 3)_As described by Morin and Bravo
- Difficult to apply and uses large amounts of
tape, leading to increased risk of skin irritation
13Taping the Painful Hemiplegic Shoulder
- As described by Griffin Bernhardt (2006)
- Therapeutic strapping (n10)
- - Same technique as used by Ancliffe. (using
light wt Fixamull tape) - - Anchor tape secured the two ends and on it
was written - do not wet, do not remove
- - Strapping reapplied every 3-4 days.
- Placebo strapping (n10)
- - Consisted of anchor tape in isolation.
- - Strapping reapplied when needed.
- Control group (n12) Received normal
- standard care
- Strapping (therapeutic and placebo)
- continued for a four-week period.
14Studied Effects
- Shoulder Pain (RAI)
- Range of Motion (SSAF)
- Arm Muscle Tone (Modified Ashworth)
- Function (MAS, upper arm component)
15Shoulder Pain
- Measured with Ritchie Articular Index ( of
pain-free days) - -Pain was considered developed when the RAI
elicited a response of 2 or 3 on one or more
days. - Therapeutic strapping group
- - Mean of 26.2 (/- 3.9) pain-free days.
- Placebo strapping group
- - Mean of 19.1 (/- 10.8) pain-free days.
- Control group
- - Mean of 15.9 (/- 11.6) pain-free days.
- Both therapeutic and placebo strapping had
significant difference when compared to no
strapping, but no significant difference between
either strapping technique.
Griffin Bernhardt, 2006
16ROM
- Measured passive flexion, abduction, and external
rotation. - Neither the therapeutic strapping nor the control
group showed marked changes in range of motion
over 4 weeks. - Placebo strapping group lost ROM in each
direction. - Wasnt considered to be a significant amount
- Despite potential for strapping to inhibit
movement, no indication that either therapeutic
or placebo strapping resulted in significant
reduction in ROM.
Griffin Bernhardt, 2006
17Arm Muscle Tone
- Measured with the Modified Ashworth Scale
- No significant differences in tone
- Placebo group had some reduction in tone (not
significant)
Griffin Bernhardt, 2006
18Function
- Measured with Motor Assessment Scale
-
- Some patients experienced improvements in
shoulder function. - -1 in therapeutic group achieved a MAS score of
4 - -2 in the placebo group achieved MAS scores of
5 - -2 in control group achieved MAS scores of 3
- However, median of all groups stayed low
- Therapeutic 1
- Placebo 1
- Control 0
- Strapping had no effect on function
Griffin and Bernhardt, 2006
19Subluxation
- No studies have evaluated strapping effects
- Other devices evaluated using radiographs
- Conventional triangular sling, Hook-Hemi Harness,
Plexiglass lap tray, Bobath shoulder roll, Arm
Trough, GivMohr sling - Average vertical subluxation pre 12 mm
- Slings with elbow extension 4mm reduction
- Slings with elbow flexion 10mm reduction
- Devices with elbow flexion 13mm reduction
- Wheelchair attachments 15mm reduction
Moodie et al., 1986 Williams et al., 1988
Brooke et al., 1991 Zorowitz et al., 1995
20Subluxation
- Firmer device greater initial reduction
- - Strapping/taping is least firm device
- Elbow flexion greater initial reduction
- - Strapping/taping has elbow extended
- Therefore strapping/taping likely has minimal
reduction
21Current Data on subluxation
- A systematic review of randomized controlled
trials was published 2010 by Koog, Jin, Yoon, and
Min looking at interventions for hemiplegic
shoulder pain. - -Looked at 518 articles (Medline, Embase,
Cinahl, and Cochrane registered trials) - -Considered 36 studies to be potentially
eligible - -Excluded 28 based on duplication of one
study, inappropriate studies, preventive
treatments, and indirect pain measures. - Found lack of correlation between HSP and
subluxation. - Treating any single cause of HSP may not be an
optimal method. - Further research needs to be done to determine if
treating multiple causes involved in HSP will
achieve pain reduction, or if HSP improvement and
treating its cause are separate.
Koog, Jin, Yoon, Min, 2010
22Current Recommendations in Rehab
- Ottawa Methods Group
- - Using Cochrane Collaboration methods they
identified and synthesized evidence from
comparative controlled trials. - -Formed an expert panel, which set criteria for
grading stregth of the evidence and provided
recommendations. -
- They developed 147 positive recommendations of
clinical benefit concerning the use of different
types of physical rehabilitation interventions
involved in post-stroke rehabilitiation. - In regards to shoulder subluxation
- -FES versus control level I (RCT) and level II
(CCT) Grade A - -Bobath support versus control- level II (CCT)
Grade B - -Henderson support versus control- level II
(CCT) Grade B - -Strapping vs no straping- level 1 (RCT) Grade C
Ottawa Panel, 2006
23Taping the Painful Hemiplegic Shoulder
- As described by Hanger et al (2000)
- Utilizes 4 lengths of nonstretch Elastoplast
Sports tape - Two main supporting tape strips begin 5 cm
proximal to elbow on anterior and posterior
aspects of arm and extend vertically - Anterior tape comes across top of shoulder and
terminates on spine of scapula - Posterior tape comes across top of shoulder and
terminates on clavicle
Both lengths of tape anchored at proximal and
distal ends with horizontal lengths of tape
24Hanger et al
- Randomized Control Trial comparing shoulder
strapping with no strapping of the hemiplegic
shoulder - Objective was to determine whether strapping the
shoulder would reduce pain, preserve ROM, and
improve function - Both groups received standard physical therapy
rehabilitation - The treatment group was strapped for 6 weeks, the
control group did not receive strapping
25Shoulder Pain
- Visual Analog Scale (VAS)
- 98 pts 49 in strapping group, 49 in control
group - Taping removed reapplied by the same therapist
every 2-3 days to minimize stretching - Both groups were allowed to use other methods of
intervention, including slings - Measurements were taken initially (day 1), at 6
weeks (the end of treatment) and again at week 14
Hanger et al
26Shoulder Pain
- Results
- Strapping the shoulder did not prevent shoulder
pain, nor maintain ROM - It was found in this study that pain free ROM was
lost early after stroke and that early
intervention is important - The authors concluded that there was no evidence
that the strapping works in reducing pain. - By using an explanatory analysis, it was found
that the strapped group did have less pain at the
end of the treatment phase, but that the results
were not statistically significant
Hanger et al
27PT Implication on taping for ROM and Spasticity
- Conclusion
- Taping has no effect on ROM
- More important is timely intervention
- The sooner the better meaning the earlier the
patient is given treatment post-stroke, the
better the outcome
Hanger et al, 2000
28PT Implication on Taping for Function
- Conclusion
- Taping has not been shown to cause a significant
improvement in function - However, taping may provide sensory feedback
- therefore taping may provide opportunity to apply
augmented knowledge of results
Hanger et al
29PT Implication on Taping for Pain
- Taping may delay onset of pain
- The longer patients go without pain, the greater
window of opportunity PTs have to work on
function - Taping the hemiplegic shoulder to decrease pain
is of minimal cost and is non-invasive - Want to decrease hemiplegic shoulder pain in any
way possible, as it is associated with a poor
functional outcome - Mechanism for delayed pain onset unknown
- Contributing factors to delayed pain onset could
include - Extra sensory feedback
- Reminder to the patient to maintain proper
positioning - Encourages proper handling techniques by HCPs
- Evidence suggests proper handling techniques can
decrease incidence of hemiplegic shoulder pain - Placebo effect
Fotiadis et al., 2005
30PT Implication for Taping Technique
- There is no evidence to suggest that any single
method of taping is superior to the others in
reduction of pain - Choice of taping technique should be based upon
- Ease of application
- Avoidance of applying to uncomfortable areas
- Use of stretch tape like elastic kinesiotape
31Take Home Message
- Conclusion
- Taping Does Not significantly reduce subluxation
or pain - Tape is applied superficially to skin while
underlying deep tissue and structures are still
unsupported - Firmer supports are better in reducing subluxed
shoulder than taping - There isnt much research out there, especially
new research, possibly due to knowledge that this
method really doesnt help - So Why are Therapists using it -Mikey
32Review Learning Objectives
- At the conclusion of this presentation the
listener will be able to - List the common causes of hemiplegic shoulder
pain - List the most common approaches to treatment of
hemiplegic shoulder pain - Discuss the purported benefits of the use of
straps/tape in treatment and prevention of
hemiplegic shoulder pain - Discuss two ways in which tape is applied to the
hemiplegic shoulder - Discuss research findings regarding the
effectiveness of straps/tape in treatment of
glenohumeral joint subluxation - Discuss research findings regarding the effects
of straps/tape on ROM, function, and arm muscle
tone - Discuss what research has shown regarding the
effects of straps/tape on the changes of
hemiplegic shoulder pain post-stroke
33References
- Ancliffe, J. (1992) Strapping the Shoulder in
Patients Following a Cerebrovascular
Accident (CVA) a Pilot Study. Australian
Physiotherapy, 38 (1) 37-40. - Bender, L., McKenna, K. (2001) Hemiplegic
Shoulder Pain Defining the Problem and its
management. Disability and Rehabilitation, 23
(16) 698-705. - Brooke, M.M., de Lateur, B.J., Diana-Rigby, G.C.,
Questad, K.A. (1991) Shoulder Subluxation in
Hemiplegia Effects of Three Different Kinds of
Supports. Archives of Physical Medicine and
Rehabilitation, 72 (8) 582-582. - Fotiadis, F., Grouios, G., Ypsilanti, A.,
Hatzinikolaou, K. (2005) Hemiplegic Shoulder
Syndrome Possible Underlying Neurophysiological
Mechanisms. Physical Therapy Reviews, 10 (1)
51-58. - Griffin, A., Bernhardt, J. (2006) Strapping the
Hemiplegic Shoulder Prevents Development of
Pain during Rehabilitation a Randomized
Controlled Trial. Clinical Rehabilitation, 20
(4) 287-295. - Hanger, H.C., Whitewood, P., Brown, G., Ball,
M.C., Harper, J., Cox, R., Sainsbury, R. (2000)
A Randomized Controlled Trial of Strapping to
Prevent Post-Stroke Shoulder Pain. Clinical
Rehabilitation, 14 (4) 370-380. - Khadilkar, A., K. Phillips, C. Lamothe, J.
Sarnecka, S. Milne, and N. Jean. "Ottawa Panel
Evidence-based Clinical Practice Guidelines for
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34References
- Koog, Y et al. Interventions for Hemiplegic
Shoulder Pain Systematic Review of Randomised
Controlled Trials. 32.4 (2010) 282-91. PubMed.
Web. 22 Apr. 2010. lthttp//informahealthcare.com/
doi/pdf/10.3109/09638280903127685gt. - Moodie, N.B., Bribin, J., Morgan, AMG. (1986)
Subluxation of the Glenohumeral Joint in
Hemiplegia Evaluation of Supportive Devices.
Physiotherapy Canada, 38 151-157. - Paci, M., Nannetti, L., Rinaldi, L.A. (2005)
Glenohumeral Subluxation in Hemiplegia An
Overview. Journal of Rehabilitation Research
Development, 42 (4) 557- 568. - Paci, M., Nannetti, L., Taiti, P., Baccini, M.,
Pasquini, J., Rinaldi, L. (2007) Shoulder
Subluxation after Stroke Relationships with
Pain and Motor Recovery. Physiotherapy Research
International, 12 (2) 95-104. - Snels, I.A.K, Beckerman, H., Lankhorst, G.J.,
Bouter, L.M. (2000) Treatment of Hemiplegic
Shoulder Pain in the Netherlands Results of a
National Survey. Clinical Rehabilitation, 14 (1)
20-27. - Teasell, R., Foley, N., Bhogal, S. (2008).
Version 11 Painfulhemiplegic shoulder. Obtained
from the WWW April 25, 2010 at http//www.ebrs
r.com/reviews_details.php - Zorowitz, R.D., Idank, D., Ikai, T., Hughes,
M.B., Johnston, M.V. (1995) Shoulder Subluxation
after Stroke a Comparison of Four Supports.
Archives of Physical Medicine and
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