Ultrasound in Treatment of Painful Shoulders in Patients with Hemiplegia

Transcription

1 Ultrsound in Tretment of Pinful Shoulders in Ptients with Hemiplegi MARGARET K. INABA, M.P.A., nd MARIJEAN PIORKOWSKI, B.S. A study of thirty-three ptients ws conducted to test the hypothesis tht ultrsound reduces pin in the pinful shoulders of ptients with hemiplegi. Three types of tretment were given for four-week period: rnge-of-motion exercise nd positioning; rnge-of-motion exercise, positioning, nd ultrsound; or rnge-of-motion exercise, positioning, nd mock ultrsound. No significnt difference ws found mong tretments in reduction of pin s mesured by chnge in rnge of motion. Ihe rehbilittion progrm for the ptient with hemiplegi is frequently prolonged by the problem of pinful shoulder. Although shoulder pin is frequent occurrence, the etiology is disputed nd the tretments re not lwys stisfctory. The purpose of this study ws to test the hypothesis tht tretment with ultrsound would reduce pin in the shoulders of ptients with hemiplegi. In survey of one hundred consecutive cses of hemiplegi, Peszczynski nd Rrdin found tht thirty-eight ptients complined of pinful shoulder. 1 Two mnifesttions were considered shoulder subluxtion nd swollen Mrs. Inb, who ws Physicl Therpy Supervisor, Physicl Therpy Deprtment, Rncho Los Amigos Hospitl, Downey, Cliforni, when the study ws conducted, is currently Consultnt, Blue Cross South, 3540 Wilshire Boulevrd, Los Angeles, Cliforni Mrs. Piorkowski, who ws Physicl Therpist, Reserch Section, Rncho Los Amigos Hospitl, Downey, Cliforni, when the study ws conducted, is currently Instructor, Physicl Therpy Deprtment, Long Bech Generl Hospitl, 2597 Redondo Avenue, Long Bech, Cliforni hnds; however, subluxtion ws lso found in those ptients who did not complin of pinful shoulder. The occurrence of subluxtion with pinful shoulder thus ws not significnt fctor. The uthors believed tht longitudinl study of the subluxtion fctor would show more positive correltion with the occurrence of pinful shoulder. Swollen hnds were found more frequently in ptients with pinful shoulders thn in ptients without pinful shoulders. This ltter finding supports, in prt, the theory tht the utonomic nervous system plys key role in the pinful shoulder. How frequently is shoulder-hnd syndrome found in ptients with hemiplegi? Steinbrocker nd Argyros reported tht the syndrome ws provoked or ssocited in 6 percent of posthemiplegic ptients. 2 Moskowitz nd his co-workers 3 stted tht this syndrome ws n occsionl occurrence but greed with Tobis 4 tht relxtion of the shoulder cpsule could lso be ssocited with pin resulting from trction on the extremity. Osteoporosis in long-term hemiplegic limbs is nother fctor which must be considered in ptients with posthemiplegic shoulder pin. Pnin nd others, in n interesting pper, described decresed bone density leding to Volume 52 / Number 7, July

2 frgility with corresponding incidence of frcture, skeletl pin, nd disturbed mobility. 5 Since the question of etiology of shoulder pin is equivocl, tretment choice is lso uncertin. Tobis proposed shoulder joint support by sling during the dy nd positioning t night to reduce cpsulr stretch. 4 Swn described stellte gnglion procine blocks s effective in treting the shoulder-hnd syndrome. 6 Lorenze nd co-workers reported tht cold pcks temporrily reduce pin. 7 The question remins: Is shoulder pin result of hemiplegi or is it n independent vrible? Moskowitz stted tht, in popultion of the sme ge tht hd not hd strokes, n pprecible incidence of shoulder pin would be present for vrious resons. 8 If this is true, then tretment cn be chosen in the sme mnner s one chooses to tret the ptient with nonhemiplegic pinful shoulder. Review of the literture on tretment of ptients with nonhemiplegic shoulder pin reveled tht Lehmnn supported the use of ultrsound for perirthritic, rheumtoid, nd degenertive joint diseses when joint contrctures resulting from cpsulr tightness nd scrring hd occurred. 9 He stted tht the use of ultrsound ws vluble for relief of muscle tightness, sprins, nd shoulder-hnd syndrome. Although no written evidence ws found dvocting the use of ultrsound for the pinful hemiplegic shoulder, the results in tretment of other shoulder problems reviewed by Lehmnn support the ide tht ultrsound might be useful for the ptient with hemiplegi. METHOD The subjects chosen were ptients with hemiplegi who hd shoulder pin occurring within the rnge of 0 to 90 degrees of flexion or bduction of the rm. Ptients with nonloclized pin of the entire upper extremity were not included in the study. All ptients were hospitlized t Rncho Los Amigos Hospitl between August 1965 nd June Tretment for ll ptients included rnge-ofmotion exercise nd rm positioning for four weeks. Self-rnge-of-motion exercises for shoulder flexion, bduction, nd externl rottion were performed with pulley equipment three times every dy. Ech motion ws repeted five times during ech session. Positioning progrms TABLE 1 Men nd Stndrd Devitions of Age of Three Groups of Ptients with Hemiplegi Number Men Stndrd of Age Devition Group Ptients (yers) (yers) 1 Control Tretment Plcebo TABLE 2 Number of Ptients in Ech Group According to Side of Hemiplegi Group 1 Group 2 Group 3 Side Control Tretment Plcebo Right Left X 2 = 4.99 (not significnt). TABLE 3 Number of Men nd Women in Ech Group Group 1 Group 2 Group 3 Sex Control Tretment Plcebo Men Women X 2 = 4.99 (not significnt). TABLE 4 Time Lpse between Onset of Dignosis nd Dte Plced on Study for Ech Group of Ptients with Hemiplegi Number Men Stndrd of Time Lpse Devition Group Ptients (months) (months) 1 Control Tretment Plcebo One ptient hd uncertin time lpse nd ws not included in these dt. were ttempted twenty-four hours dy; however, mintining the optimum position ws difficult. The rm ws positioned in mximum pin-free bduction nd externl rottion through the use of pillows or slings when the ptient ws in bed nd with troughs, overhed suspension slings, or pillows when he ws in wheelchir. 738 PHYSICAL THERAPY

3 TABLE 5 Anlysis of Vrince between Three Tretment Groups of Ptients with Hemiplegi: Time Lpse from Onset of Hemiplegi to Dte Plced on Study Vrince df Meji Squre F P Groups >.05 Subjects Totl 31 Three groups of ptients were formed by rndom ssignment. Group 1 received rnge-ofmotion exercises nd positioning only. Group 2 received ultrsound prior to one exercise session. Ech ptient ws given minimum of fifteen tretments. Ultrsound ws dministered with moving sound hed nd minerl oil coupling. Wttge ws 0.5 to 2 wtts per squre centimeter nd ws determined by ptient tolernce. Prvertebrl nd shoulder joint res ech received one five-minute tretment. Group 3 received the sme tretment s Group 2 except the ultrsound energy ws turned off. Shoulder rnge of motion ws mesured by universl double-rmed goniometer nd recorded before nd fter the four-week tretment period. Increse in mobility of the shoulder ws considered n indirect indictor of Flexion Abduction i n internl rottion Abduction in externl rottion decrese in pin. The following rm motions were mesured by physicl therpist who hd no knowledge of ptient group ssignment: flexion, bduction with the rm internlly rotted, bduction with the rm externlly rotted, nd externl rottion with the rm dducted. Three mesurements were tken for ech motion nd ech ws rounded off to the nerest 5 degrees. If two mesurements were the sme, this ws the ccepted mesurement. If ll three mesurements were different, the verge mesurement ws used. Ptients were lso evluted before nd fter tretment for protective rections nd complints of pin. RESULTS Four fctors were considered importnt to test the comprbility of the three smples: ge, sex, side of involvement, nd time lpse since onset of hemiplegi. The ge rnge for the three groups ws forty-seven to sixty-nine yers. The three groups were similr in ge s exemplified by mens nd stndrd devitions (Tb. 1). Sex of the ptient nd side of involvement showed no significnt difference mong the groups (Tbs. 2 nd 3). Time lpse between the onset of hemiplegi nd dmission to the study is shown in Tble 4. TABLE 6 Men nd Stndrd Devition of Pretretment Shoulder Rnge of Motion for Ech Motion nd Ech Tretment Group Motion Number of Stndrd Group Ptients Men Devition 1 Control Tretment Plcebo Control Tretment Plcebo Control Tretment Plcebo Externl ttion 1 Control Tretment Plcebo The rnge of motion for one ptient ws not mesured. Volume 52 / Number 7, July

4 Although the men number of months between the onset of hemiplegi nd dmission to the study for Group 1 ws lrger thn for Groups 2 nd 3, nlysis of vrince showed tht this difference could hve hppened by chnce (Tb. 5). The pretretment rnge-of-motion test dt re summrized in Tble 6. The only significnt difference between the groups initilly ws in the mens of bduction in externl rottion (Tb. 7). Chnge in this motion ws nlyzed by nlysis of covrince. For other motions, nlysis of vrince of the chnge in rnge of motion ws used to determine if differences mong groups could be ttributed to the effects of the tretments. These chnges in rnge of motion re summrized in Tble 8. Although the men chnges of shoulder flexion nd externl rottion differed from group to group, the differences were not sttisticlly significnt (Tbs. 9, 10, nd 11). On initil evlution, only four of the thirty-one ptients in the study either held their rms protectively or objected to rm movement. These dt were insufficient to nlyze to indicte chnge in pin. DISCUSSION Ultrsound ws not found to be signficntly effective tretment for relief of the pinful shoulder in ptients with hemiplegi. If one ccepts Moskowitz's sttement bout the TABLE 7 Anlysis of Vrince of Pretretment Shoulder Abduction in Externl Rottion Rnge Between Three Tretment Groups Vrince df Men Squre F p Groups Subjects Totl 31 equivlent incidence of pinful shoulder in the nonhemiplegic shoulder s correct, 8 then perhps the pinful shoulder in ptients with hemiplegi is not specific syndrome such s the syndromes identified by Lehmnn. 9 It will not respond to specific tretment regime. This theory my explin the results of this study. Another look t the smple with ech cse of pinful shoulder differentilly dignosed ccording to cuse nd with tretment tilored to the dignosis might hve produced different results. As Peszczynski suggested, longitudinl study of the course of posthemiplegic recovery would lso help identify the mechnism of pin in the ptient. 1 A longitudinl study would lso be helpful in ssessing the tretment nd chnge in tretment needed for pin relief. SUMMARY Three types of tretments were dministered to ptients with hemiplegi who were suffering TABLE 8 Men nd Stndrd Devition of Chnge in Rnge of Motion for Ech Motion nd Ech Group Number of Men Stndrd Motion Group Ptients Chnge Devition Flexion 1 Control Tretment Plcebo Abduction in internl rottion 1 Control Tretment Plcebo Abduction in externl rottion 1 Control Tretment Plcebo Externl rottion 1 Control Tretment Plcebo Adjusted men chnge. 740 PHYSICAL THERAPY

5 TABLE 9 Anlysis of Vrince of Chnge in Shoulder Flexion Rnge between Three Tretment Groups Men Vrince df Squre F p Groups 2 1, >.05 Subjects Totl TABLE 11 Anlysis of Vrince of Chnge in Shoulder Externl Rottion Men Vrition df Squres F p Groups >.05 Subjects Totl TABLE 10 Anlysis of Covrince between Three Tretment Groups: Chnge in Shoulder Abduction in Externl Rottion Men Adjusted Vrition df Squres F P Groups Subjects from pinful shoulders: rnge of motion nd positioning; rnge of motion, positioning, nd ultrsound; rnge of motion, positioning, nd mock ultrsound. To determine the effectiveness of tretment, chnge in pin-free rnge of 1. Peszczynski M, Rrdin TE: The incidence of pinful shoulder in hemiplegi. Bull Pol Med Sci Hist 8:21-23, Steinbrocker O, Argyros TG: The shoulder-hnd syndrome: Present sttus s dignostic nd therpeutic entity. Med Clin North Am 43: , Moskowitz E, Bishop HF, Hl P, Shibutni K: Posthemiplegic reflex sympthetic dystrophy. JAMA 167: , Tobis JS: Problems in rehbilittion of the hemiplegic ptient. NY Stte J Med 37: , 1957 REFERENCES motion of the shoulder in flexion, bduction, nd rottion ws tested. Comprison of the men chnges in motion of the three groups showed no significnt difference mong the groups. Lck of chnge in pin-free rnge of motion led to the conclusion tht ultrsound does not reduce pin significntly in the involved shoulders of ptients with hemiplegi. Acknowledgement. Lucy V. McDniel, Ed.D., R.P.T., dvised in ll spects of the study. Jne Lightfoot, R.P.T., Physicl Therpy Deprtment, Rncho Los Amigos Hospitl, did the sttisticl nlysis reported in this study. Elwin Edberg, R.P.T., nd Sndr Shermn, R.P.T.. Physicl Therpy Deprtment, Rncho Los Amigos Hospitl, did the plnning of this study. Jen Kristy Blnkenship, R.P.T., did the testing of ll subjects. 5. Pnin N, Gordy WJ, Pul BJ: Osteoporosis in hemiplegi. Stroke 2:41 47, Swn DM: Shoulder-hnd syndrome following hemiplegi. Neurology 4: , Lorenze EJ, Crntonis G, DeRos AJ: Effect on coronry circultion of cold pcks to hemiplegic shoulders. Arch Phys Med 41: , Moskowitz E: Complictions in the rehbilittion of hemiplegic ptients. Med Clin North Am 53: , Lehmnn JF: Ultrsound Therpy in Therpeutic Het nd Cold 2d ed, edited by S Lict. Bltimore, Wverly Press, Incorported, 1965, chpter 13 Volume 52 / Number 7, July

6 THE AUTHORS Mrgret Inb received bchelor's degree in physicl therpy from the University of Cliforni, nd n M.P.A. in Helth Services Administrtion from the University of Southern Cliforni. She begn working t Rncho Los Amigos Hospitl in 1961 s stff physicl therpist, hd experience s senior nd s physicl therpy supervisor, nd ended her service there s stff ssistnt in 1969 to continue school. In 1970 she becme physicl therpy consultnt for Blue Cross nd Trvelers Insurnce Compny. Mrijen Piorkowski received bchelor of science degree from the University of Cliforni t Los Angeles nd certificte in physicl therpy from Childrens Hospitl in Los Angeles. She hs been employed t the Kiser Hospitl nd in privte prctice. During compiltion of this pper, she ws member of the Reserch Section t Rncho Los Amigos Hospitl. Currently, she is the physicl therpy instructor t Long Bech Generl Hospitl. AMERICAN PHYSICAL THERAPY ASSOCIATION Regionl Instructionl Course October 19-21, 1972 Mrriott Motor Hotel, Phildelphi, Pennsylvni Testing Review nd Expnd Your Knowledge In Two Importnt Ares The Hip H Mnul Testing Antomy nd Kinesology Electricl Testing Stress nd Strength Potentil Electromyogrphy Surgicl Approches Tretment Techniques Among the outstnding fculty will be: Elenor Jne Crlin, Chirmn, Deprtment of Physicl Therpy, School of Medicl Professions, University of Pennsylvni; John Burke, Ph.D., Director, School of Physicl Therpy, Louisin Stte University; Jmes Joyce, M.D., Orthopedic Surgeon, Phildelphi; Florence Kendll, RPT, Bltimore; Mry Pt Murry, Ph.D., Chief, Kinesiology Reserch Lbortory, Veterns Administrtion Center, Wood, Wisconsin; Michel Hrty, M.A., M.B., F.R.C.S., Stff of the School of Allied Medicl Professions nd the Grdute Division of the University of Pennsylvni School of Medicine. PLAN NOW TO ATTEND Detils nd registrtion forms will be published in the August issue of Physicl Therpy. 742 PHYSICAL THERAPY