Factors Associated with Post Stroke Shoulder Subluxation

Article information

Kosin Med J. 2015;30(1):59-67
Publication date (electronic) : 2015 January 20
doi : https://doi.org/10.7180/kmj.2015.30.1.59
1Department of Physical Medicine and Rehabilitation, Kosin University College of Medicine, Busan, Korea
2Department of Physical Medicine and Rehabilitation, Dong Eui Hospital, Busan, Korea
Corresponding Author:Young Joo Sim, Department of Physical Medicine and Rehabilitation, College of Medicine, Kosin University, Gospel Hospital, 262, Gamcheon-ro, Seo-gu, Busan, Korea TEL: +82-51-990-6261 FAX: +82-51-241-2019 E-mail: oggum@naver.com
Received 2013 September 12; 2014 January 15; Accepted 2014 February 03.

Abstract

Abstract

Objectives

Shoulder subluxation is common complication after stroke. And it can result in delayed neurological recovery in hemiplegic stroke patients. The aim of this study is identifying the incidence and associating factors of shoulder subluxation in stroke patients.

Methods

Stroke patients from 1 rehabilitation center from January 2008 to January 2012 were enrolled in the present study. The basic demographic data were registered at the time of admission or transfer to rehabilitation center. To assess the shoulder subluxation, we have used fingers'breadth method and plain radiography. We diagnosed shoulder subluxation with vertical distance (VD) were more than 12.4cm on plain anteroposteior view. And then shoulder subluxation was analyzed with associated factors.

Results

Of 154 stroke patients, this retrospective study included 109 patients who met the inclusion criteria, 28 patients had shoulder subluxation. After univariated analysis, shoulder subluxation was significantly associated with motor power of shoulder and elbow, loss of proprioception, stroke duration and functional ability. Especially elbow extensor less than poor grade is mostly related to shoulder subluxation among the motor powers. Then multivariated analysis was carried out including all significant subjects, elbow extensor less than poor grade, loss of proprioception and stroke duration more than 6 months were related to shoulder subluxation.

Conclusions

Post stroke shoulder subluxation was commonly observed, and the incidence was 25.6% in this study. Shoulder subluxation was correlated with muscle power of elbow(less than F grade), loss of proprioception and stroke duration more than 6 months

Fig 1.

(A) Schematic description of shoulder subluxation. VD (vertical distance) is the distance from the most inferolateral acromial point (a) to the most upperpoint (b) of the humeral head. (B) And radiologic measurement of VD in shoulder anteropostrior plane film.

Baseline demographics (n=109).

Clinical examination at admission (n=109).

Univariate analysis of factors associated with subluxation (n = 28).

Multivariate analysis of risk factors associated with shoulder subluxation

References

1. Zorowitz RD, Hughes MB, Idank D, Ikai T, Johnston MV. Shoulder pain and subluxation after stroke: correlation or coincidence? Am J Occup Ther 1996;50:194–201.
2. Najenson T, Yacubovich E, Pikielni SS. Rotator cuff injury in shoulder joints of hemiplegic patients. Scand J Rehabil Med 1971;3:131–7.
3. Roy CW, Sands MR, Hill LD. Shoulder pain in acutely admitted hemiplegics. Clin Rehabil 1994;8:334–40.
4. Paci M, Nannetti L, Rinaldi LA. Glenohumeral subluxation in hemiplegia: An overview. J Rehabil Res Dev 2005;42:557–68.
5. Crossens-Sills J, Schenkman M. Analysis of shoulder pain, range of motion, and subluxation in patients with hemiplegia. Phys Ther 1985;65:731.
6. Savage R, Robertson L. Relationship between adult hemiplegic shoulder pain and depression. Physiother Can 1982;34:86–90.
7. Shai G, Ring H, Costeff H, Solzi P. Glenohumeral malalignment in the hemiplegic shoulder. An early radiologic sign. Scand J Rehabil Med 1984;16:133–6.
8. Turner-Stokes L, Jackson D. Shoulder pain after stroke: a review of the evidence base to inform the development of an integrated care pathway. Clin Rehabil 2002;16:276–98.
9. Moskowitz H, Goodman CR, Smith E, Balthazar E, Mellins HZ. Hemiplegic shoulder. N Y State J Med 1969;69:548–50.
10. Prevost R, Arsenault AB, Dutil E, Drovin G. Rotation of the scapula and shoulder subluxation in hemiplegia. Arch Phys Med Rehabil 1987;68:786–90.
11. Bohannon RW, Andrews AW. Shoulder subluxation and pain in stroke patients. Am J Occup Ther 1990;44:507–9.
12. Braddom RL, Physical Medicine & Rehabilitation, 4th ed Philadelphia: Elsevier Saunders; 2010. p. p823–5.
13. Delisa JA, Gans BM. Rehabilitation medicine: Principles and practice 2nd ed.th ed. Philadelphia: JB Lippincott Co; 1993. p. 814–5.
14. Stiles RG, Otte MT. Imaging of the shoulder. Radiology 1993;188:603–13.
15. Han GH, Park TH, Jang KE. Radiologic evaluation of the shoulder subluxation in hemiplegic patients. J Korean Acad Rehab Med 1993;17:226–34.
16. Basmajian JV, Bazant FJ. Factors preventing downward dislocation in the adducted shoulder joint. J Bone Joint Surg 1959;41:1182–6.
17. Ikai T, Yonemoto K, Miyano S, Talejara T. Interval change of the shoulder subluxation in hemiplegic patients. Jpn J Rehabil Med 1992;29:569–75.
18. Suethanapornkul S, Kuptniratsaikul PS, Kuptniratsaikul V, Uthensut P, Dajpratha P, Wongwisethkarn J. Post stroke shoulder subluxation and shoulder pain: a cohort multicenter study. J Med Assoc Thai 2008;91:1885–92.
19. Najenson T, Pikienly SS. Malalignment of the glenohumeral joint following hemiplegia. a review of 500 cases. Ann Phys Med 1965;8:96–9.
20. Daviet JC, Salle JY, Borie MJ, Munoz M, Rebey-rotte I, Dudognon P. Clinical factors associate with shoulder subluxation in stroke patients. Ann Readapt Med Phys 2002;45:505–9.
21. Chang JJ, Tsau JC, Lin YT. Predictors of shoulder subluxation in stroke patients. Gaoxiong Yi Xue Ke Xue Za Zhi 1995;11:250–6.
22. Nyenson T, Pikienly SS. Malalignment of the glenohumeral Joint following hemiplegia. Ann Phys Med 1965;8:96–9.
23. Calliet R. Shoulder pain 3rd ed.th ed. Philadelphia: FA Davis; 1991. p. 198–201.

Article information Continued

Fig 1.

(A) Schematic description of shoulder subluxation. VD (vertical distance) is the distance from the most inferolateral acromial point (a) to the most upperpoint (b) of the humeral head. (B) And radiologic measurement of VD in shoulder anteropostrior plane film.

Table 1.

Baseline demographics (n=109).

Baseline variables Number(%) Mean±SD
Sex    
male 67 (61.4%)  
female 42 (38.5%)  
Height(cm)   165.3±8.56
≤160 24 (24.5%)  
161–180 70 (71.4%)  
≥181 4 (4.1%)  
Age(yrs)   55.6±13.19
≤40 14 (12.8%)  
41–60 52 (47.7%)  
≥61 43 (39.4%)  
BMI   22.9±2.95
≤21 21 (21.6%)  
21–23 35 (36.1%)  
23–25 20 (20.6%)  
≥25 21 (21.6%)  
Type of Stroke    
Brain hemorrhage 66 (60.6%)  
Brain infarction 43 (39.4%)  
Weakness side    
Left 43 (39.4%)  
Right 52 (47.7%)  
Bilateral 14 (12.8%)  

Table 2.

Clinical examination at admission (n=109).

Baseline variables Number(%) Mean±SD
Shoulder MMT    
Flexor ≤ 2 63 (57.8%)  
Flexor > 3 46 (42.2%)  
Extensor ≤ 2 61 (56.0%)  
Extensor > 3 48 (44.0%)  
Elbow MMT    
Flexor ≤ 2 52 (47.7%)  
Flexor > 3 57 (52.3%)  
Extensor ≤ 2 54 (49.5%)  
Extensor > 3 55 (50.5%)  
Loss of Proprioception    
No 51 (46.8%)  
Yes 58 (53.2%)  
MAS    
0 59 (54.1%)  
≥ 1 50 (45.9%)  
LOM    
No 36 (33.0%)  
Yes 73 (67.0%)  
Ambulation    
Independent 21 (19.3%)  
Impossible or dependent 88 (80.7%)  
MBI   54.7±20.57
≤75 62 (56.9%)  
≥76 47 (43.1%)  
MMSE   21.7±6.44
≤24 49 (50.0%)  
≥25 49 (50.0%)  
Pre Stroke History    
No 98 (89.9%)  
Yes 11 (10.1%)  
Duration(months)    
< 6 92 (84.4%)  
≥ 6 17 (15.6%)  
CO-morbid disease    
Diabetes mellitus 25 (22.9%)  
Hypertension 56 (51.4%)  
Osteoporosis 5 (4.6%)  

Table 3.

Univariate analysis of factors associated with subluxation (n = 28).

Baseline variables Subluxation (%) P-value
Yes No
Female sex 12 (28.6) 30 (71.4) 0.655
Age 41–60 14 (26.9) 53 (75.7) 0.829
BMI ≥ 25 6 (28.6) 15 (71.4) 0.776
Height < 160 7 (29.2) 17 (70.8) 0.788
MMT      
Shoulder flexor ≤ 2 22 (34.9) 41 (65.1) 0.014∗
Shoulder extensor ≤ 2 20 (32.8) 41 (67.2) 0.077
Elbow flexor ≤ 2 19 (36.5) 33 (63.5) 0.016∗
Elbow extensor ≤ 2 22 (40.7) 32 (59.3) 0.000
Hemorrhagic type of stroke 19 (29.2) 47 (70.8) 0.377
Pre Stroke History 3 (27.3) 8 (72.8) 1.000
Left hemiplegia 15 (34.9) 28 (65.1) 0.115
Spasticity(MAS) ≥ 1 16 (32.0) 34 (68.0) 0.555
Cognitive ability(MMSE-K) < 24 11 (22.4) 38 (77.6) 0.815
Loss of proprioception 19 (32.8) 39 (67.2) 0.007
6 months after stroke onset 8 (47.1) 9 (52.9) 0.037∗
Limited range of motion 21 (28.8) 52 (71.2) 0.356
Independent ambulation 6 (28.6) 15 (71.4) 0.783
Diabetes mellitus 5 (20.0) 20 (80.0) 0.604
Hypertension 15 (26.8) 41 (73.2) 0.829
Osteoporosis 2 (40.0) 3 (60.0) 0.601
Functional ability (MBI) ≤ 75 20 (32.3) 42 (67.7) 0.048∗

P-value < 0.05

P-value < 0.01

Table 4.

Multivariate analysis of risk factors associated with shoulder subluxation

  Odd Ratio 95% CI P-value
MMT of elbow extensor ≤ 2 17.91 1.74–184.41 0.015∗
Loss of proprioception 3.29 1.07–10.13 0.038∗
Duration after stroke onset ≥ 6 months 3.42 1.01–11.58 0.049∗
Functional ability (MBI) ≤ 75 1.68 0.51–5.50 0.390

P-value < 0.05