Shoulder pain in hemiplegia cannot be ignored

Shoulder pain in hemiplegia is a common adverse factor that affects the patient's rehabilitation treatment process. According to statistics, 27%~62% of patients will experience shoulder pain within 4 weeks after hemiplegia, but shoulder pain may also occur very late.

The development of shoulder pain in hemiplegia is generally typical, usually occurring at the end of passive upper limb activity, especially abduction and flexion of the shoulder joint. Shoulder pain may also occur when the upper limb is in a certain posture. Usually, the patient can accurately point out the location of pain in the early stage, but it will become more and more vague as the disease progresses, indicating the spread of pain.

Although shoulder pain generally occurs after hemiplegia, there is no shoulder pain at the onset of the disease. Obviously, shoulder pain is caused by certain factors after hemiplegia.

Common possible causes of shoulder pain

1. Disorders in coordination of humeral and scapula movement

Before discussing, we need to know its normal movement law. "Scapulohumeral rhythm" means that when the upper limb is abducted, the scapula also moves along with the movement of the humerus. Under normal circumstances, the angle ratio of humeral movement to scapula movement is 2:1, that is, when the shoulder joint is abducted 120 degrees. The glenohumeral joint moves 80 degrees and the scapula rotates 40 degrees externally. When the tension is normal, the entire movement is smooth and regular. If the shoulder joint is not abducted with the rotation of the scapula, our upper limbs cannot be abducted to 180 degrees under normal circumstances. Therefore, when the scapulohumeral rhythm changes, the rotation of the scapula is delayed when the affected limb is lifted, and it cannot be fully rotated, so the structure between the acromion and the humeral head will be squeezed and pain will occur. The common cause of changes in scapulohumeral rhythm is that the tension around the scapula is inconsistent with the tension of the upper arm. Therefore, when the patient's limb muscle tension is significantly increased, there may be no shoulder pain, because the spastic upper limb moves slowly, so the scapula has time to slowly rotate externally, so there will be no shoulder pain. Similarly, patients with low muscle tension may also have no shoulder pain.



Humeral external rotation disorder

If the patient's upper limb cannot be externally rotated during passive upper limb activity, the greater tuberosity of the humerus is blocked by the coracoscapulohumeral joint, causing pain. Because the upper limbs of hemiplegic patients are in a spastic position for a long time, the upper limbs are adducted and internally rotated, causing spasm and shortening of the muscles of the shoulder joint internal rotation, and upper limb external rotation disorder, which increases the probability of shoulder pain.

Shoulder subluxation

Although shoulder subluxation does not directly cause shoulder pain, when the shoulder joint is subluxated, the shoulder joint stability mechanism is destroyed, and it is more likely to cause shoulder joint injury and cause pain.

Shoulder periarthritis and joint capsule adhesion

It often occurs after long-term immobilization of the shoulder joint. The shoulder joint lacks active activity, which makes the venous blood and lymph flow poor or even stagnant, slows blood circulation, and causes tissue edema. When the shoulder joint is passively pulled, tissue edema is aggravated, serous fibrous exudates increase, and pain is induced.

Shoulder-hand syndrome

Pain often occurs in the early and late stages of shoulder-hand syndrome, and the pain disappears at the end.



Shoulder pain treatment

Avoid activities that cause shoulder pain

Improper upper limb placement in bed, pulling or squeezing the shoulder joint when turning over.

Within the passive range of motion, the scapula does not enter the normal position and the humerus does not rotate externally.

Pulling the patient's upper limbs when helping the patient to transfer from bed to chair.

Incorrectly lifting the patient against the backrest of the wheelchair.

Lifting the upper limbs from the distal end during nursing activities.

Using pulleys for interactive activities: People often mistakenly believe that if the patient uses a pulley to do upper limb interactive exercises, the patient's hands are tied to the handles, and the patient repeatedly pulls the affected limb with the healthy limb to do arm flexion and lifting movements, he can maintain the full range of motion of the shoulder joint. But on the contrary, trying to force the upper limb to rotate internally and lift it just hurts the patient's shoulder joint. Because the pulley exercise of the shoulder joint does not fully rotate the scapula and externally rotate the humerus, it should not be used for passive lifting exercises of the affected limb.

Active arm lifting exercises are too intense, causing acute damage to the muscles around the shoulder joint.



Joint mobilization

Can be used to relieve pain and increase joint mobility. This technology is mainly applicable to the following aspects.

The most effective treatment for pain is when the joint is painful rather than stiff, that is, the joint has movement but cannot actively complete the movement.

Pain only occurs at the end of the joint movement or the end of the upward movement seems to be mechanically blocked, which may be because the humeral head cannot move downward in the glenoid cavity.



Cold therapy

Applying ice or cold towels to the shoulder is a good way to relieve pain and reduce spasms.



Fumigation wax therapy

Promote blood circulation around the shoulder joint and reduce inflammation.



Physical factor therapy

Medium frequency, Viagra, red light, etc.



Drug therapy

Local anesthesia can temporarily relieve severe pain, but this relief is short-lived if the cause of the pain is not eliminated.



How to prevent shoulder pain

Protect the shoulder joint and avoid the triggering factors of shoulder pain.

Correct posture for at least 30 minutes every day:

(1) Side-lying position: Try to lie on the side of the hemiplegia in the correct posture, while fully extending the shoulder.

(2) Position when sitting in a wheelchair: glenohumeral joint in neutral position, upper limbs placed on the armrests.

Patients should be encouraged to continue correct, painless self-help exercises for the upper limbs.

Before doing passive movements of the upper limbs, the scapula should be fully loosened.

Any posture and activity that causes pain should be changed immediately and stopped or performed in a painless manner.

Avoid activities that cause painful shoulder injuries.



Conclusion

If a patient without shoulder pain suddenly develops shoulder pain one day, the therapist should avoid the recurrence of shoulder pain and terminate treatment or keep the pain within a painless range. It is important to avoid repeated minor injuries to the shoulder joint and its surrounding soft tissues.