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 trauma—damage 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 (n=10): - 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 (n=10): - Consisted of anchor tape in isolation. - Strapping reapplied when needed. • Control group (n=12): 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 nosignificant 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. Wasn’t 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 withelbow 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 isn’t much research out there, especially new research, possibly due to knowledge that this method really doesn’t 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. <http://thomasland.metapress.com/content/3tkx7xec2dtgxqkh/fulltext>

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. <http://informahealthcare.com/doi/pdf/10.3109/09638280903127685>. • 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.ebrsr.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.