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Is Strapping/Kinesiological Taping for the Painful Hemiplegic Shoulder an Effective Intervention?

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Is Strapping/Kinesiological Taping for the Painful Hemiplegic Shoulder an Effective Intervention? Julianne Genochio April Lovelace Tim Tollefson – PowerPoint PPT presentation

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Title: Is Strapping/Kinesiological Taping for the Painful Hemiplegic Shoulder an Effective Intervention?


1
Is Strapping/Kinesiological Taping for the
Painful Hemiplegic Shoulder an Effective
Intervention?
  • Julianne Genochio
  • April Lovelace
  • Tim Tollefson
  • Christian Butler
  • Ben Flores
  • Chris McSharry

2
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

3
Hemiplegic 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
4
Glenohumeral 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
5
Hemiplegic 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
6
Hemiplegic 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

7
Treatment 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
8
Use 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
9
Taping 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
10
Taping 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

11
Taping 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.

12
Taping 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

13
Taping 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.

14
Studied Effects
  • Shoulder Pain (RAI)
  • Range of Motion (SSAF)
  • Arm Muscle Tone (Modified Ashworth)
  • Function (MAS, upper arm component)

15
Shoulder 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
16
ROM
  • 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
17
Arm 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
18
Function
  • 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
19
Subluxation
  • 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
20
Subluxation
  • 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

21
Current 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
22
Current 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
23
Taping 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
24
Hanger 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

25
Shoulder 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
26
Shoulder 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
27
PT 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
28
PT 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
29
PT 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
30
PT 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

31
Take 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

32
Review 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

33
References
  • 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
    Post-stroke Rehabilitation." Top Stroke
    Rehabilitation 13.2 (2006) 1-269. PubMed. Web.
    22 Apr. 2010. lthttp//thomasland.metapress
    .com/content/3tkx7xec2dtgxqkh/fulltextgt

34
References
  • 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
    Rehabilitation, 76 (8) 763-771.
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