Slide 1

Andrew E. Kirsteins M.D. FAAPM&R (Sports and Neuromuscular Med) Cone Health Physical Medicine and Rehabilitation

Slide 2

Purpose Review common causes of Hemiplegic Shoulder Pain (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 al- Utility of MSK US in Rehab settings

Slide 3

Shoulder Pain General Population Post Stroke Population 3 rd most common MSK c/o in primary MD office 2 nd most common reason for referral to Ortho/Sports ~70% pain is from Rotator cuff disorders Occurs in up to 72% stroke pts in the first year- Van Ouwenaller C, Laplace PM, Chantraine A. Painful shoulder in hemiplegia. Arch Phys Med Rehabil. 1986; 67: 2326 Common reason for poor rehab outcome,QOL Several pain generators have been proposed, complex

Slide 4

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

Slide 5

Post Stroke Shoulder Pain Risk Factors Significant weakness L neglect Sensory deficits Advanced age Spasticity

Slide 6

Nociceptive Neuropathic Subluxation theory Subacromial Impingement Bicipital tendon Spasticity related Adhesive capsulitis RSD Brachial plexopathy Central Post stroke Pain Hemiplegic shoulder pain etiology

Slide 7

Hemiplegic Shoulder Pain Update

Slide 8

Does Subluxation Cause HSP? Pro Con Traction on joint capsule during flaccid stage Subluxation more common in Shoulder Hand Syndrome- Dursun et al 2000 Most HSP occurs during 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

Slide 9

Ultrasound measurement of shoulder subluxation X Ray Ultrasound Xray evaluation requires multiple views,measurements after imaging Long axis view allows measurement during image acquisition- Park GY, Kim JM, Sohn SI, et al. Ultrasonographic measurement of shoulder subluxation in patients with post- stroke hemiplegia. J Rehabil Med 2007; 39:

Slide 10

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 229236 Any rotator cuff pathology in the subacromial space Includes Supraspinatus, Infraspinatus,Teres Minor and Subscapularis Stages Include Stage 1-Bursitis Stage 2-Partial Tear Stage 3- Full thickness Tear

Slide 11

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

Slide 12

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

Slide 13

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%

Slide 14

PHYSICAL FINDINGS AND SONOGRAPHY OF HEMIPLEGIC SHOULDER IN PATIENTS after ACUTE STROKE DURING REHABILITATION-Huang et al J Rehabil Med 2010; 42: 2126 Methods Results at D/C N=57, cross sectional 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) Pain:68% Poor motor, 35% 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

Slide 15

Sonography of Patients with Hemiplegic shoulder pain after stroke 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

Slide 16

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

Slide 17

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% Supraspinatus tear 30.3% Biceps tendon 39.5% Subscapularis 9.2% Pain score 2.71/10 Subacromial effusion 13.2% Supraspinatus tear 40.8% Biceps tendon 57.9% Subscapularis 22.4% Pain score 3.99/10

Slide 18

Slide 19

Subacromial Bursitis

Slide 20

Slide 21

Slide 22

Slide 23

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%

Slide 24

MRI findings in hemiplegic shoulder pain Shah et al Stroke 2008 June 39(6)

Slide 25

Adhesive Capsulitis or Frozen Shoulder Few imaging studies X ray Arthrogram Rizk et al, Arch Phys Med Rehabil. 1984; 65(5):254-6 Arch Phys Med Rehabil. 1984; 65(5):254-6 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 Arthrogram and Exam -Lo et al., Arch Phys Med Rehabil. 84(12):1786-91, 2003 Dec 32 pt with HSP

RSD=CRPS Type 1 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 specicity 0.69 Reference - Pain Med 2007 May-Jun;8(4):326, editorial can be found in Pain Med 2007 May- Jun;8(4):289, commentary can be found in Pain Med 2009 Apr;10(3 ):598Pain Med 2007 May-Jun;8(4):326, editorial can be found in Pain Med 2007 May- Jun;8(4):289, commentary can be found in Pain Med 2009 Apr;10(3 ):598

Slide 31

Bone scan for diagnosis of RSD Review of Hi quality studies Review of Low 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%) 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):288J 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 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%) 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):1347Eur J Pain 2012 Nov;16(10):1347

Slide 32

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 standardBudapest diagnostic criteria as reference standard for diagnosis of CRPS, 3-phase bone scintigraphy had sensitivity 40% specificity 76.5% positive likelihood ratio 1.73 negative likelihood ratio 0.78 Reference - Br J Anaesth 2012 Apr;108(4):655Br J Anaesth 2012 Apr;108(4):655

Slide 33

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?

Slide 34

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