Andrew E. Kirsteins M.D.
FAAPM&R (Sports and Neuromuscular Med)
Cone Health Physical Medicine and Rehabilitation
Purpose
 Review common causes of Hemiplegic Shoulder Pain
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(HSP)- Focus on Post stroke
Diagnosis using PE and Imaging Studies
Introduce Musculoskeletal Ultrasound (MSK US) as an
aid to diagnosis of HSP
Hands on demo
Please check out Sept 2013 Am L PM&R Ozcakar et alUtility of MSK US in Rehab settings
Shoulder Pain
General Population
Post Stroke Population
 3rd most common MSK c/o in
 Occurs in up to 72% stroke
primary MD office
 2nd most common reason for
referral to Ortho/Sports
 ~70% pain is from Rotator
cuff disorders
pts in the first year-Van
Ouwenaller C, Laplace PM, Chantraine
A. Painful shoulder in hemiplegia. Arch
Phys Med Rehabil. 1986; 67: 23–26
 Common reason for poor
rehab outcome,QOL
 Several pain generators have
been proposed, complex
Post Stroke Shoulder Pain=HSP
 Overall prevalence 17% at 2wks, 20% at 1mo,23% at
6mo. Ratnasabaphthy et al 2003,Clinical Rehab
 Prevalence Rehab pop. 60% @ 4mo,35% @ 6mo
Post Stroke Shoulder Pain Risk
Factors
 Significant weakness
 L neglect
 Sensory deficits
 Advanced age
 Spasticity
Hemiplegic shoulder pain etiology
Nociceptive
Neuropathic
 Subluxation theory
 RSD
 Subacromial Impingement
 Brachial plexopathy
 Bicipital tendon
 Central Post stroke Pain
 Spasticity related
 Adhesive capsulitis
Hemiplegic Shoulder Pain Update
Does Subluxation Cause HSP?
Pro
Con
 Traction on joint capsule
 Most HSP occurs during
during flaccid stage
 Subluxation more common in
Shoulder Hand SyndromeDursun et al 2000
spastic stage-Van Ouwenwaller et al
1986
 Neuromuscular Electrical
Stim reduces pain but not
subluxation- Yu et al
 No correlation between pain
and subluxation Bohannon et al
1990
Ultrasound measurement of
shoulder subluxation
X Ray
Ultrasound
 Xray evaluation requires
 Long axis view allows
multiple views,measurements
after imaging
measurement during image
acquisition-Park GY, Kim JM,
Sohn SI, et al. Ultrasonographic
measurement of shoulder
subluxation in patients with poststroke hemiplegia. J Rehabil Med
2007; 39:
Subacromial Impingement Syndrome Marwan Alqunaee,
RCSI, Rose Galvin, BSc (Physio), PhD, Tom Fahey, MD, FRCGPDiagnostic Accuracy of Clinical Tests for
Subacromial Impingement Syndrome: A Systematic Review and Meta-Analysis Archives of Physical
Medicine and Rehabilitation, Volume 93, Issue 2, February 2012, Pages 229–236
 Any rotator cuff pathology in the subacromial space
 Includes Supraspinatus, Infraspinatus,Teres Minor and
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Subscapularis
Stages Include
Stage 1-Bursitis
Stage 2-Partial Tear
Stage 3- Full thickness Tear
Sensitivity and Specificity
 A SeNsitive test when Negative rules
OUT=SNNOUT, (true positive identification)
 A SPecific test when Positive rules IN=SPPIN’ (true
negative identification)
 Difficult to establish Sensitivity and specificity in
studies if there is no “Gold Standard”, or if
different “Gold Standards” are used
 So for diagnostic PE or imaging studies either
surgical findings or MRI is used as “Gold Standard”
Subacromial Impingement Syndrome=SIS
 History- pain with overhead activity, nocturnal pain
 Exam-Hawkins Kennedy passive forward flexion/int
rotation only useful test in a hemiplegic patient
Sensitivity 74%
 Imaging- Ultrasound can identify all 3 stages of SIS
bursitis,partial tear and full thickness tear
Diagnostic accuracy of Ultrasound
for RCT Smith et al, Clin Radiol 66 (2011) 1036-1048
 Given limitation of history (communication deficit)
and exam (given UE weakness), imaging assume
greater importance
 Partial thickness RCT Sen 84%, Sp 89%
 Full thickness RCT Sen 96%, Sp 93%
PHYSICAL FINDINGS AND SONOGRAPHY OF HEMIPLEGIC SHOULDER IN
PATIENTS after ACUTE STROKE DURING REHABILITATION-Huang et al J Rehabil
Med 2010; 42: 21–26
Methods
Results at D/C
 N=57, cross sectional
 Pain:68% Poor motor, 35%
 Good vs Poor Motor groups
based on Brunnstrom
 Excluded prior shoulder
problems
 Recorded pain using VAS-but
pain not an inclusion criteria
 Assessed at admission and
discharge (LOS 27d for
good,32d for poor motor)
Good motor
 US abnormalities Poor
Motor- 50% biceps
tendinopathy,47%
Supraspinatus tear,44%
Subacromial bursitis
 US abnormalities Good
Motor – 30% biceps,22%
subacromial bursitis,17%
supraspinatus
Sonography of Patients with Hemiplegic shoulder
pain after stroke Lee et al Am J Roentgen 2009 Feb;192(2):
 n=71, 20 pts had bilateral shoulders scanned
 Subacromial bursal effusion seen in 36 shoulders
 Biceps tendon sheath effusion in 39 shoulders
 Supraspinatus tendinosis (7),partial tear (6) and full
tear (2)
 Abnormalities more common in hemiplegic shoulder
p=.007 vs uninvolved side
Sonography and physical findings in stroke patients with
hemiplegic shoulders: A longitudinal study Ya Ping Pong et al, J of
Rehab med 2012,(44),553-557
 76 first time CVA, no hx of shoulder problems
 Scanned during acute rehab and at 6 mo
 Underwent standard inpt rehab program 1 hour PT
and 1 hr OT 5d/wk
 Brunnstrom score,ROM, Ashworth,10pt NRS
Sonography and physical findings in stroke patients
with hemiplegic shoulders: A longitudinal study Ya Ping
Pong et al, J of Rehab med 2012,(44),553-557
Acute (D/C from Rehab)
Chronic (6mo post D/C)
 Subacromial effusion 30.3%
 Subacromial effusion 13.2%
 Supraspinatus tear 30.3%
 Supraspinatus tear 40.8%
 Biceps tendon 39.5%
 Biceps tendon 57.9%
 Subscapularis 9.2%
 Subscapularis 22.4%
 Pain score 2.71/10
 Pain score 3.99/10
Subacromial Bursitis
MRI findings in hemiplegic
shoulder pain Shah et al Stroke 2008 June 39(6)
 >3mo since CVA, pain score >4,n=89,65% L HP
 Supraspinatus tear 26% partial, 6% Full
 Supraspinatus tendinopathy 51%
 Infraspinatus tear 13% partial, 2% Full
 Infraspinatus tendinopathy 19%
 Subscapularis tear 1%
 Teres minor tear 1%
MRI findings in hemiplegic
shoulder pain Shah et al Stroke 2008 June 39(6)
Adhesive Capsulitis or Frozen
Shoulder
 Few imaging studies
 X ray Arthrogram Rizk et al,
Arch Phys Med Rehabil. 1984;
65(5):254-6
 Arthrogram and Exam -Lo et
al., Arch Phys Med Rehabil.
84(12):1786-91, 2003 Dec
 32 pt with HSP<1 year post
 30 Patients mean 3 months
post CVA, Reduced ROM
and pain, electrically silent
EMG of shoulder muscles
 23/30 had reduced capsular
volume consistent with
adhesive capsulitis
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CVA
50% had adhesive
capsulitis
22% Rotator cuff tears
16% Shoulder Hand
Greater ROM correlated
with greater joint volume
on arthrogram
HSP- Spasticity related
 Older studies (eg Van Ouwenwaller) find that HSP
more common in spastic shoulders
 More recent study by Huang et al showed a weak
correlation between spasticity and HSP
 ?Role of ultrasound imaging may be to guide needle
for EMG into the subscapularis
Hemiplegic Shoulder Pain Update
HSP Neuropathic-CRPS
 CRPS type 1= RSD
 Shoulder hand syndrome subtype occurs after CVA
 Incidence reported as 12-25% (Edgley SR et al,PM&R Supp 1 March
2009 S28)
 Wide variation due to method of diagnosis (some
studies reported much higher incidence with less strcit
diagnostic criteria)
Sensitivity and Specificity
 A SeNsitive test when Negative rules
OUT=SNNOUT
 A SPecific test when Positive rules IN=SPPIN
 Difficult to establish Sensitivity and specificity in
studies if there is no “Gold Standard”, or if
different “Gold Standards” are used
RSD=CRPS Type 1
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International Association for the Study of Pain (IASP) clinical diagnostic criteria (Revised Budapest
criteria)
continuing pain disproportionate to original injury
must have reports of at least 1 symptom in 3 of 4 categories
 sensory - allodynia and/or hyperesthesia
 vasomotor - temperature asymmetry and/or skin color changes and/or skin color asymmetry
 sudomotor/edema - edema and/or sweating changes and/or sweating asymmetry
 motor/trophic - decreased range of motion and/or motor dysfunction (weakness, tremor,
dystonia) and/or trophic changes (in hair, nails, or skin)
must have at least 1 sign at time of evaluation in 2 or more categories
 sensory - allodynia (to light touch and/or temperature and/or deep somatic pressure and/or joint
movement) and/or hyperalgesia (to pinprick)
 vasomotor - evidence of temperature asymmetry (> 1 degree C [1.8 degrees F]) and/or skin color
changes and/or skin color asymmetry
 sudomotor/edema -evidence of edema and/or sweating changes and/or sweating asymmetry
 motor/trophic - evidence of decreased range of motion and/or motor dysfunction (weakness,
tremor, dystonia) and/or trophic changes (in hair, nails, or skin)
no other diagnosis can better explain signs or symptoms
sensitivity 0.85 and specificity 0.69
Reference - Pain Med 2007 May-Jun;8(4):326, editorial can be found in Pain Med 2007 MayJun;8(4):289, commentary can be found in Pain Med 2009 Apr;10(3):598
Bone scan for diagnosis of RSD
Review of Hi quality
studies
 pooled diagnostic performance of
bone scintigraphy for CRPS type I
in analysis of 21 studies
 sensitivity 79% (range
14%-100%)
 specificity 88% (range
60%-100%)
Review of Low quality studies
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6 studies lacked valid reference standard for CRPS 1
unclear if index test interpretation was blinded to
reference standard in all studies
pooled diagnostic performance of 3-phase bone
scintigraphy for CRPS type I in analysis of 6 studies
with valid reference standard
 sensitivity 80% (95%
CI 44%-95%)
 specificity 73% (95%
CI 40%-91%)
 criteria for CRPS on triple-phase
bone scan included diffusely
increased uptake, especially
increased periarticular uptake in
multiple joints Reference - J Hand
Surg Am 2012 Feb;37(2):288
systematic review of 12 diagnostic cohort studies
evaluating bone scintigraphy (3 phase scintigraphy in
11 studies, 5 phase scintigraphy in 1 study) for diagnosis
of CRPS type I in 882 patients
all studies had ≥ methodologic limitation including
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positive likelihood ratio 2.92 (95% CI 1.33-6.43)
negative likelihood ratio 0.28 (95% CI 0.1-0.76)
Reference - Eur J Pain 2012 Nov;16(10):1347
Bone Scan RSD
 based on 3 diagnostic cohort studies with inconsistent
results all 3 studies had lack of reporting if index test
interpretation was blinded to reference standard 116 with
suspected CRPS had clinical evaluation and were assessed
using 3-phase bone scintigraphy
 69 (59.5%) had CRPS using Budapest diagnostic criteria as
reference standard
 for diagnosis of CRPS, 3-phase bone scintigraphy had
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sensitivity 40%
specificity 76.5%
positive likelihood ratio 1.73
negative likelihood ratio 0.78
 Reference - Br J Anaesth 2012 Apr;108(4):655
Neuropathic (non RSD) HSP etiology Zeilig et al
Pain. 2013 Feb;154(2):263-71
 30 CVA pts N=14 HSP, 16 without HSP> 6 mo post
 15 healthy controls
 HSP group had increased parietal involvement
 HSP group had higher pain/temp threshold vs CVA pt
without HSP in UE and LE
 No vasomotor or sudomotor signs (no RSD)
 Is HSP part of a central post stroke pain
syndrome?
Fig. 3 Higher rates of pathologically evoked pain were found in the affected shoulder of the hemiplegic shoulder pain (HSP) group
compared to that of the nonhemiplegic shoulder pain (NHSP) group, including: hyperpathia ( ∗p<.05, ***p<.001
Gabi Zeilig , Michal Rivel , Harold Weingarden , Evgeni Gaidoukov , Ruth Defrin
Hemiplegic shoulder pain: Evidence of a neuropathic origin
PAIN Volume 154, Issue 2 2013 263 - 271
http://dx.doi.org/10.1016/j.pain.2012.10.026
Case study- Mr. H
 60 yo M admitted with R hemi due to L PLIC infarct-
MMT 3-/5 L deltoid, biceps, MAS 3 in biceps, no
swelling in hand, no sensory change
 Shoulder pain started during acute rehab-tx with limb
protection, analgesics, diclofenac gel
 Pain with abd, arm flex, persisted as outpatient, no
relief with subacromial injection
Case study Mr. H
 Ultrasound R shoulder- 3mm fluid surrounding the R
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biceps tendon in the groove on SAX/LAX views, no
cuff abnormalities, AC joint ok
R biceps tendon sheath injection under ultrasound
guidance
Resolution of R shoulder pain
Completed outpatient PT/OT- no recurrence
Still gets botox injections to forearm and biceps q 3
months
Case study Mrs. B
 75 yo F with R MCA infarct causing L HP, L neglect, L
hemisensory deficits, cognitive def
 L shoulder pain, limited ROM, pain with all motions of
shoulder, no hand swelling
 Completed inpt rehab, d/c to SNF, received additional
PT/OT
 Outpt clinic f/u continued pain requesting more pain
meds (on Oxy IR n SNF)
Case Study Mrs. B
 Intra-articular injection of minimal benefit
 Pectoralis and biceps botox of helped biceps tone but
no improvements with shoulder pain or ROM
 Ultrasound of L shoulder-limited study due to
problems with positioning shoulder, no evidence of
biceps tenosynovitis, + rotator cuff arthropathy
(cortical irregularity at supraspinatus insertion)
 Multifactorial HSP- adhesive capsulitis, +sensory
dysesthesias
Summary HSP
 HSP is a complex symptom to evaluate
 Some cases (?50%) are musculoskeletal
 RSD about 10-15%
 Sensory dysesthesias may be related to a central post
stroke pain syndrome or to more localized
spinothalamic involvement (1-10%)
 Multifactorial may account for about 30-40% of cases
and may be the most difficult to eval/tx
HSP Summary
 New tools such as MSK ultrasound may improve
accuracy of HSP diagnosis
 Bicipital tendinopathy/tenosynovitis more common
than previously thought
 Subscapularis tear more common than previously
thought in chronic stage
 Improved diagnosis can improve treatment
Hands on Demonstration
 Kris Gellert OTR-Hands on Demo of OT eval and
treatment of HSP
 Anne Kirchmayer MD (FAAPMR Sports and
Neuromuscular Med)- MSK US of biceps tendon and
subscapularis
 Andy Kirsteins MD- MSK of supraspinatus and
infraspinatus