Running head: MASSAGE FOR POST-STROKE SPASTIC HEMIPLEGIA 1

MASSAGE FOR POST-STROKE SPASTIC HEMIPLEGIA 2

The Effects of Massage Therapy on Post-Stroke Spastic Hemiplegia: A Case Report

Ana Caselatto

caselattodantasa@mymacewan.ca

MacEwan University

Address: 10700 104 Ave NW, Edmonton, AB T5J 4S2

June 25, 2020

Abstract Word Count: 270

Report Word Count: 3994

Acknowledgements

The author extends her gratitude to the staff and faculty of the Massage Therapy Program at MacEwan University for their support and resources. A special thank you to Lois Wihlidal, Pamela Cushing and Jeff Moggach who provided continuous guidance and encouragement during the completion of this case report. The author would also like to thank her peers for the valuable insights and her partner for assisting in the review of this work.

Abstract

Background: A stroke occurs when an intracerebral thrombus and/or hemorrhage deprive the brain of oxygen, impacting central nervous system control. One of its most common complications, spasticity, is a motor impairment characterized by muscle hypertonicity, stiffness and tendon jerks that prevent voluntary movement. While treatment usually involves medication and physical therapy, survivors turn to massage hoping to improve pain and reduce disability.

Objective: This study had the purpose of analysing the effects of massage therapy (MT) on shoulder pain, spasticity and arm function in a stroke patient.

Method: A 53-year-old male presented with spastic hemiplegia caused by stroke, and complaints of shoulder pain and functional limitation of his arm. A massage intervention was conducted for six weeks by a massage therapy student in the fifth semester at MacEwan University. Treatment aimed at relieving pain and restoring arm function by decreasing spasticity, increasing range of motion (ROM) and reducing hand edema. His assessment included a cervical scan and progress was recorded weekly with the Numeric Pain Rating Scale (NPRS), goniometry and figure-of-eight tape measurement. The Disability of the Arm, Shoulder and Hand (DASH) questionnaire was administered on the second, fourth and last visits. Swedish techniques, myofascial release, proprioceptive neuromuscular facilitation and manual lymphatic drainage were applied.

Results: Pain decreased for two consecutive weeks, shoulder and elbow ROM increased, and hand edema reduced post-treatment. There was no remarkable improvement in arm disability.

Conclusion: Results suggest massage may temporarily reduce pain and effects related to spasticity, such as ROM restriction and edema. Future research is needed to analyse long-lasting outcomes of massage and functional improvement.

Key Words: spasticity, hemiplegia, stroke, massage therapy

Introduction

Cerebrovascular Accidents (CVA), or strokes, are the second leading cause of death globally, besides being the third most common cause of disability amongst the adult population.1 The condition is an upper motor neuron syndrome due to lesion of the pyramidal tract in the central nervous system that can be caused by intracerebral thrombosis and/or hemorrhage, depriving the brain of oxygen.2,3 While the extent of its consequences can vary widely based on the type of stroke, area of the brain affected, and severity, 85% of survivors experience at least one symptomatic complication up to fours days after having a CVA while still in the hospital.4

Some of the most reported complications post-stroke, accounting for 80% of the cases, involve motor impairments, which have a great impact on these patients’ daily affairs and general quality of life.4 Such debilities include hemiplegia, spasticity, weakness, stiffness and numbness of the limb contralateral to the side of the brain affected, besides pain.2,3,4 Research suggests that patients showing early signs of hemiplegia after an ischemic or hemorrhagic stroke are more likely to develop spasticity and hemiplegic shoulder pain in the later stages of their rehabilitation.5,6

The post-stroke spasticity is a complex disorder characterized by increased muscle tone and tendon jerks that result in difficulty to voluntarily engage motor units and generate movement, in addition to a higher resistance to passive stretches.7 Over time, the combination of this muscle overactivity and the disuse of the limb can cause contracture of soft tissue, abnormal posture and promote secondary complications.7 Although it could have multi-factorial causes in stroke patients, the hemiplegic shoulder pain may also result from this spastic cycle as the incidence is higher when there is impaired arm function.5 Other common complications of CVA are recurrent strokes, epileptic seizures, respiratory and urinary tract infections, thromboembolism, depression and anxiety.4

Due to the wide range of possible clinical manifestations with which these patients might present, treatment typically involves a multidisciplinary team of specialists, as well as medication. A cohort study from 2014 reported that 30 minutes of daily physiotherapy exercises during the first 15 weeks post-stroke, combined with neurorehabilitation, was the most effective care to improve limb function, gait, balance, as well as to regain autonomy in activities of daily living.8 While conventional physiotherapy is the most common approach to rehabilitate motor impairments, specifically during the acute stage, a 2002 survey showed that almost half of CVA survivors sought at least one modality of complementary and alternative medicine (CAM), such as massage therapy, to improve pain and disability as well as for psychological outcomes.9

Besides inducing general relaxation, which has an impact on pain perception and sleeping patterns, slow rhythmic massage strokes were shown to reduce muscle stiffness that can cause permanent structural changes related to spasticity.10,11 In a randomized control trial of 50 stroke patients, 79% of those treated exclusively with traditional Thai massage experienced relief of spasticity, in comparison to only 52% of the group treated with physiotherapy reporting the same results.12 Researchers reasoned that techniques that promote passive stretch to spastic muscle, such as petrissage and proprioceptive neuromuscular facilitation used in western massage approaches, could reduce motor neuron excitability and decrease spasticity, bringing the pain levels down and improving limb function.12 Another study conducted with chronic stroke patients revealed that myofascial release could decrease rigidity of muscles on the hemiplegic side and improve overall balance abilities.11

Although massage therapy has been increasingly performed as an adjunctive practice in stroke rehabilitation, and available literature shows the efficacy of several techniques for that purpose, there is limited research dedicated to the value of massage intervention alone to assist patients with multiple post-stroke complications.11,12 An analysis of a treatment plan combining techniques that were researched separately in previous literature is pertinent to professionals of the massage field, as it contributes to the implementation of an effective treatment protocol for this condition. This study had the purpose of determining the effects of massage therapy on shoulder pain, spasticity and arm function in a stroke patient.

Methods

Patient Information

A 53-year-old male presented to the MacEwan Massage Therapy Student Clinic with left-side hemiplegia and spasticity of the left upper and lower limbs in a flexed pattern. He had complaints of left shoulder pain and functional limitation of his left arm. His pain was described as achy but becoming sharp when aggravated with excessive movement of the arm and/or after a vigorous day, preventing him from falling asleep. Other symptoms acknowledged during flareups were heaviness of the forearm and hand, and tingling and numbness of the extremities. He was unable to use his left hand and had difficulty performing any daily activity involving the arm, including lifting and carrying objects or dressing without help. Pain relief was experienced with swimming and the use of transcutaneous electrical stimulation.

After aortic dissection surgery in 2013, the patient had two strokes which occurred one year apart, the first in 2014 and the latest in July of 2015. The cause reported was a dislodged blood clot from the surgical procedure, which affected the right hemisphere of the patient’s brain resulting in a left-side hemiplegia. The patient had MRI and CT scan examinations after both CVAs, under the request of the family physician who managed his case throughout this series of events. Immediately after the first stroke, he attended physiotherapy for three months to recover function of his left leg and be able to walk again.

Although the second stroke was not as debilitating as his first, the patient noticed an exacerbation of his symptoms. He had one seizure episode after the first stroke but did not experience seizures again after being prescribed a low-dose anticonvulsant (LamotrigineTM). Other drugs being taken daily included ValsartanTM and MetoprololTM for hypertension control, RosuvastatinTM and DabigatranTM for blood clot prevention, and dietary complements such as CentrumTM, vitamins C and B-complex and turmeric for its anti-inflammatory properties. The patient had no remarkable medical history prior to the heart surgery.

At the time of treatment, the patient also attended a physical rehabilitation program at a gym twice a week, had been receiving acupuncture treatment for two years and had monthly checkups with a family doctor. Besides helping with daily housework, he volunteered once a week pushing a cart with boxes at a hospital facility. This patient had a strong support network with a wife and two children. His overall goal with massage treatment was to reduce shoulder pain and increase function of the left arm and hand.

Clinical Findings

A full cervical scan was conducted to determine whether the signs and symptoms could be due to pathology of the peripheral joints, the cervical spine or both.13,14 Active range of motion showed limited cervical side flexion bilaterally and slightly decreased rotation to both sides. The end-feel on cervical passive ROM was tissue stretch for all movements with pulling sensations on muscles on the opposite side tested, especially during side flexion. The myotome testing revealed a strong right side, but weakness of all motions tested for C4 nerve root and below – deltoids, biceps, triceps, thumb extension and hand intrinsics.

The patient’s upper extremity reflexes were diminished on the right side and absent on the left and, while the Babinski test was negative on the left side with no response to the stimulus, it was positive on the right side. When tested for sensation and dermatomes, the patient had normal responses on the right side, but decreased overall sensation of the left side, in particular, distally to the left elbow. During further assessment of the patient’s shoulder, all movements on the left side were severely restricted with capsular end-feels on flexion, extension and abduction. The patient was unable to perform medial and lateral rotation. Relevant special tests were not performed due to pain or had unreliable results due to the patient’s limitation of ROM.

On a scale of zero to 10, zero indicating no pain at all and 10 meaning the worst imaginable pain, such as placing a hand on a hot burner, the patient’s pain at the first visit was at six, the worst was rated as eight and the lowest was a two. 13,15 A postural analysis revealed slight side flexion of the neck to the left side, depression and retraction of the left scapula and internal rotation of the glenohumeral joint. The spasticity restricted his elbow extension to 75, the forearm was pronated, the wrist had slight ulnar deviation and the fingers were fully flexed into a fist with adduction of the thumb. He also presented with circumducted gait, which involved excessive hip hike and shoulder elevation on the left side to promote balance. On palpation of the left arm, the patient had rigidity of biceps brachii and deltoids, hypotonicity of wrist extensors and swelling of the left hand.

Assessment Measures

The patient’s shoulder pain was monitored using the Numeric Pain Rating Scale (NPRS) at the beginning of each appointment. This 11-point scale goes from zero to 10, and the patient was instructed to choose the number that best defined his pain at the moment.15 As a baseline to use the scale, zero represents no pain and 10 indicates the worst imaginable pain, such as placing the hand on a hot burner.15 Previous literature presented the NPRS as a valid tool to determine pain intensity.15 The edema of his hand was recorded with figure-of-eight measurement of the wrist before and after each intervention, and the right hand was also measured to establish a baseline for comparison. The method consisted of placing the tape’s zero mark over the ulnar styloid process, going under the palmar surface to the radial styloid, continuing across the dorsal surface of the hand until the fifth metacarpal, under the palmar aspect, and then moving from the second metacarpal across the dorsum again and back to the starting point.13,16,17 Research supports the validity of figure-of-eight to measure hand edema.16,17

The ROM of the patient’s shoulder and elbow was assessed using a standard goniometer only post-treatment due to time constraints, since the patient required the therapist’s assistance to undress, get on and off the table, as well as to dress before leaving. The measurements of shoulder extension were taken in supine on the first two visits but modified to sitting position from the fourth visit on to accommodate the patient’s discomfort. All the other ranges of motion were consistently measured in supine post-treatment. Goniometry has been shown to be a reliable measurement tool in previous research. 18,19

To analyse how the arm’s functional disability affected the patient’s daily life, the Disability of the Arm, Shoulder and Hand (DASH) questionnaire was administered. With a total of 30 self-reported closed questions, the DASH has a maximum score of 100 and higher scores indicate an elevated level of disability.20 A significant clinical improvement is represented by a change of at least 10.8 points in the patient’s score.21 This questionnaire has been shown to be a dependable method to assess patients with arm dysfunction related to several causes, including strokes.20 The patient was requested to answer the survey prior to the first full length massage on the second appointment, and pre-treatment again on the fourth and last visits.

Therapist and Clinic Descriptions

A massage therapy student in her fifth of six semesters of a 2,200-hour diploma program at MacEwan University in Edmonton, AB, conducted the assessment and treatment of this case. The sessions took place at the student clinic located on the third floor of the Robbins Health Learning Center, which was accessible by elevator and equipped with 15 height-adjustable massage tables, adjustable lighting and curtains drawn for privacy. All necessary materials, such as linens, pillows, lotions and assessment tools were readily available.

Therapeutic Intervention

Some contraindications and cautions were considered during the treatment planning due to history of CVA, medications taken by the patient and overall decrease in sensation and mobility.22 The massage was limited to 45 minutes to prevent overload of the cardiovascular system and hydrotherapy was avoided because of the presence of sensory changes and edema.22,24 The pressure was kept light to prevent bruising, also considering the patient’s inability to provide accurate feedback.22,23 To encourage relaxation, decrease nervous system firing and reduce spasticity, all strokes were performed slowly and in a rhythmical manner.22,24 After the first ten minutes in side-lying to better access the left shoulder area, supine positioning was maintained for the remaining of the treatment to allow for comfort and safety, and to limit the patient’s effort.22,23,24

The patient attended six appointments, of which the first visit and the initial 15 minutes of the second and last visits were dedicated to physical assessment. Forty-five minutes of each appointment, from the second through the sixth, were used for massage with the goal of reducing shoulder pain and restoring mobility and function of the arm. The visits started with a short interview to assess the patient’s current condition and response to the previous intervention, followed by tape measurement of edema of the left hand to monitor his progress. After the treatment, the therapist took another figure-of-eight measurement of the hand and recorded shoulder and elbow ROM with a goniometer.

The treatment developed to reduce pain and increase arm function is detailed in Table 1 and is supported by recent literature. The only adjustment made to the initial plan was the pressure used during petrissage, which was slightly increased in every session based on the patient’s response.

Table 1. Treatment Plan: A standardized routine was performed for five consecutive weeks.

Duration

Technique

Application

Purpose

Right side-lying

10min

Swedish techniques

Segmental effleurage and petrissage on left shoulder

Decrease pain and resting muscle tension; increase ROM; improve postural imbalances10,11,22,24,26

Supine

1min

Compressions

Bilateral gentle muscle squeezing from shoulders to toes

Body integration; bring awareness to affected side22,24,26

4min

Manual Lymphatic Drainage (MLD)

Cervical and axillary lymph nodes pump and superficial LDT

Reduce edema on left hand22,24

3min

Myofascial Release (MFR)

Skin rolling and cross-handed MFR on elbow and forearm

Lengthen fascia, increase mobility11,12,22,24

2min

Effleurage

Slow superficial strokes along the left arm

Increase local blood and lymph flow10,11,22,24,26

10min

Petrissage

Slow strokes and kneading to upper arm and forearm

Decrease spasticity and hypertonicity10,11,22,24,26

2min

Passive mobilization

Passive ROM of wrist and MCPs

Maintain joint health, prevent contractures22,25

3min

Proprioceptive Neuromuscular Facilitation (PNF)

Hold-relax: passive stretch on elbow and forearm flexors without active contraction by the patient

Improve ROM; bring awareness to affected limb12,22

3min

Effleurage

Slow superficial strokes along the left arm

Increase local blood and lymph flow10,11,22,24,26

6min

Foot massage

Effleurage, knuckles and thumb kneading

Increase local blood and lymph flow, reduce edema; relaxation; full body integration11,22,24

1min

Compressions

Bilateral gentle muscle squeezing from shoulders to toes

Body integration; bring awareness to affected side22,24,26

The patient’s spasticity responded quickly to treatment, particularly after the application of MFR and PNF. The elbow and joints of the wrist and hand would slowly leave the flexed pattern to remain in extension until the end of the massage. The overactivity of flexor muscles returned gradually as the patient left a state of full relaxation and initiated active movements in order to stand from the table or get dressed. Other massage outcomes, such as the decrease in edema and pain, however, were longer-lasting and persisted for days following the intervention. Throughout the six weeks of treatment, the patient reported that his shoulder pain would return slowly until reaching its peak two days prior to the next massage, coinciding with his workout schedule. All massages were administered two days after his most demanding exercise routine at the physical rehabilitation program. On the last visit the patient claimed he had over-exercised and since then had been experiencing more pain than usual.

Since the patient was already attending physical rehabilitation, the suggested homecare had the purpose of prolonging results achieved during the treatment until his next visit without intensifying his exercise routine. The therapist demonstrated and provided clear instructions for the patient to perform hold-relax PNF on his left hand once a day by using his right hand to slowly bring the left wrist and fingers into extension, causing a light stretch with caution to not trigger undesired contractions, and holding that position for six seconds. After a break of two seconds, he would start another cycle from his newly acquired range, repeating the hold-relax practice for a total of three times. The patient was also recommended to increase his water intake post-treatment by a couple extra glasses.

Informed Consent

The patient gave the therapist verbal consent to conduct an initial assessment and the treatment plan was discussed with him once the assessment was concluded. The approach was designed to meet the patient’s main goals and was in accordance with the therapist’s clinical findings. A verbal and written consent was obtained from the patient prior to the first massage intervention; he was informed in detail about how the treatment was going to be conducted, his right to interrupt or modify it at any moment, the techniques used and their benefits, as well as about the confidentiality of all the information discussed with the therapist. The patient’s discomfort and sensitivity to specific work were assessed at every visit and he was encouraged to ask questions and provide feedback as desired.

Results

Other than a reduction in the fourth and fifth visits, the level of pain reported pre-treatment was unchanged overall.

Figure 1. Pre-treatment NPRS for shoulder pain. Zero represents no pain at all and 10 means the worst pain imaginable, such as placing a hand on a hot burner.13,15

Edema post-treatment was reduced in every session, as shown in Figure 2, bringing the measurements of the left hand close to the standard of his right hand. Nonetheless, swelling was present at the beginning of each appointment at the same amount found in the previous week before treatment.

Figure 2. Figure-of-Eight Measurement: Hand edema was assessed with tape measure of the wrist before and after intervention, using the non-affected hand as a baseline. Only pre-treatment readings were taken on visits two and three. No measurements were taken on visit one.

All shoulder and elbow ranges increased post-treatment, as shown in Figure 3, with the most notable result found in elbow extension.

Figure 3. ROM of Shoulder and Elbow: Measured using a standard goniometer after every intervention.

The total score of the DASH questionnaire shown in Figure 4 revealed a decrease in disability level until the fourth appointment. There was a significant increase by the last visit.

Figure 4. DASH Questionnaire. With a total of 30 questions about how the limb’s pain and impairment affect quality of life, high scores in a range from zero to 100 indicate elevated level of disability.20 The minimum change for a significant improvement is 10.8 DASH points.21

The patient was diligent with homecare and appeared satisfied with the improvements in ROM and edema reduction attained after every session. He reported immediate pain relief after receiving the treatments and, according to him, this outcome would persist for up to three days following the intervention, improving his sleep and overall mood. The patient expressed gratitude for the treatment provided and reiterated he planned to continue receiving massage therapy, hopefully more frequently, to maintain the quality of sleep reflected by pain relief.

Answers indicating a rise in the last score of the questionnaire were related to the severity of pain, tingling and weakness experienced in the previous week, as well as to the extent to which such problems interfered with social activities in the period. Besides questions from the survey about arm function, the patient also remarked that, before the treatment, he could not remember being able to keep his elbow straight or his left hand out of a fist position without holding it with the right hand, as he noticed happening during the massages. Palpation on the last visit revealed a decrease in rigidity of biceps brachii and deltoids. His final postural analysis showed slight improvements in shoulder retraction and side-flexion of the neck. No significant improvements were found with myotomes, reflexes or sensation assessments.

Discussion

The outcomes of this study demonstrate massage therapy has a positive impact on spasticity and shoulder pain. The patient also reported immediate pain relief post-treatment, improving his sleep for the three following nights. These results are in line with findings demonstrated by previous literature.5,10,12,25,26,27,28 According to one study of 118 subjects, the benefit of massage, over other approaches that promote pain relief, relaxation and sleep, was that patients perceive massage as a different method than a task-oriented or procedural touch.10 In terms of physiological aspects, this pain relief is possible due to a decrease in spinal nociceptive reflexes, usually elevated in cases of chronic pain, and general parasympathetic nervous system response caused by application of pressure varying from light to moderate.26,27 Nonetheless, past the period of relief, the patient’s pain perception would slowly increase until the next appointment, peaking at two days before the next visit, when he had the most vigorous activity routine of his physical rehabilitation program. Such exercises occurring in between his weekly massage interventions might explain why the pre-treatment NPRS did not change significantly and was rated at six throughout the treatment.

Another result observed was the increase in shoulder and elbow ROM, as supported by other research linking massage and spasticity.22,29 The passive stretch and decrease in nervous system firing promoted by massage strokes can restore muscle length and reduce guarding, leading to ROM improvement.22,24,29 It was observed that elbow flexors responded quickly to techniques applied, allowing full extension of the joint until the end of the treatment; however, the target joints would go back to slight flexion as the patient stood up from the table. In the same way, a decrease in spasticity was produced in the wrist and fingers flexors, facilitating passive extension of the hand that would persist until the end of each intervention.29

Edema of the left hand improved after every treatment; however, results seemed to be temporary as it was present at the beginning of all appointments. Despite the fact edema is detected in about 37% of stroke patients, its exact cause is still unclear.30 Leibovitz and colleagues argued that, besides impaired lymphatic and venous return, it is possible that vasomotor dysfunction occurs as a result of sympathetic hyperactivity.30 Peripheral swelling is also a common side-effect of some of the medications taken daily by the patient, such as MetoprololTM.23 Both hypotheses suggest that, while techniques such as manual lymphatic drainage may assist in reducing fluid retention, they must be performed on a management basis, since edema will likely reoccur with aggravation of spasticity.

This study had a number of limitations. One of them was the time constraint, considering chronic symptoms are believed to improve over longer-term treatments.10,22,29 Limiting the intervention to one appointment per week also prevented an objective analysis of the outcomes, since the patient could not avoid external aggravating factors between visits, such as intense physical activity two days prior to his appointments. Over-exercising was the cause attributed by the patient to the increase in pain reported on the last visit, affecting the final DASH questionnaire score. Future studies applied more frequently could provide valuable data regarding the effects of massage on stroke patients, in particular concerning quality of sleep and changes in symptoms while performing activities of daily living. Another important factor is that the patient was on medication, as well as attending acupuncture and physical rehabilitation while receiving this treatment; therefore, there is difficulty determining the effectiveness of a standardized massage routine alone for the stroke complications with which he presented. It is also relevant to note that there were no follow-up appointments since the patient’s last visit, which would be useful to monitor the consistency of results.29

Despite the mentioned limitations, this study concludes MT can produce a positive impact in the management of spasticity due to CVA, especially to temporarily reduce pain and increase ROM. Further research with broader sample sizes are still required to evaluate if extensive massage interventions can reduce disability and promote long-term changes on stroke patients with spastic hemiplegia.

References

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3. Sommerfeld DK, Eek EUB, Svensson AK, et al. Spasticity after stroke: Its occurrence and association with motor impairments and activity limitations. Stroke. 2004;35(1):134–139. doi:10.1161/01.STR.0000105386.05173.5E.

4. Langhorne P, Stott DJ, Robertson L, et al. Medical complications after stroke: A multicenter study. Stroke. 2000;31:1223–1229. doi:10.1161/01.STR.31.6.1223.

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8. Marque P, Gasq D, Castel-Lacanal E, De Boissezon X, Loubinoux I. Post-stroke hemiplegia rehabilitation: Evolution of the concepts. Ann Phys Rehab Med. 2014;57(8):520-529. doi:10.1016/j.rehab.2014.08.004.

9. Hart J. Poststroke recovery: Emerging complementary therapies. Alt Compl Ther. 2010;16(5):277–80. doi:10.1089/act.2010.16506.

10. Mok E, Woo CP. The effects of slow-stroke back massage on anxiety and shoulder pain in elderly stroke patients. Complement Ther Nurs Midwifery. 2004;10(4):209-216. doi:10.1016/j.ctnm.2004.05.006.

11. Park DJ, Hwang YI. A pilot study of balance performance benefit of myofascial release, with a tennis ball, in chronic stroke patients. J Bodyw Mov Ther. 2016;20(1):98–103. doi:10.1016/j.jbmt.2015.06.009.

12. Thanakiatpinyo T, Suwannatrai S, Suwannatrai U, et al. The efficacy of traditional Thai massage in decreasing spasticity in elderly stroke patients. Clin Interv Aging. 2014;9:1311–1319. doi:10.2147/CIA.S66416.

13. Wihlidal L. MTST 155: Assessment for Massage Therapists I. Edmonton, AB: MacEwan University; 2019:47-55.

14. Magee DJ. Orthopedic Physical Assessment. 6th ed. St. Louis, MO: Elsevier; 2014.

15. Ferreira-Valente MA, Pais-Ribeiro JL, Jensen MP. Validity of four pain intensity rating scales. Pain. 2011;152(10):2399-2404. doi:10.1016/j.pain.2011.07.005.

16. Pellecchia GL. Figure-of-eight method of measuring hand size: Reliability and concurrent validity. J Hand Ther. 2003;16(4):300–304. doi:10.1197/S0894-1130(03)00154-6.

17. Leard JS, Breglio L, Fraga L, et al. Reliability and concurrent validity of the figure-of-eight method of measuring hand size in patients with hand pathology. J Orthop Sports Phys Ther. 2004;34(6):355–340. doi:10.2519/jospt.2004.34.6.335.

18. Hayes K, Walton JR, Szomor ZR, Murrell GA. Reliability of five methods for assessing shoulder range of motion. Aust J Physiother. 2001;47(4):289–294. doi:10.1016/S0004-9514(14)60274-9.

19. van Rijn SF, Zwerus EL, Koenraadt KL, Jacobs WC, van den Bekerom MP, Eygendaal D. The reliability and validity of goniometric elbow measurements in adults: A systematic review of the literature. Shoulder Elbow. 2018;10(4):274–284. doi:10.1177/1758573218774326.

20. Dalton E, Lannin NA, Laver K, et al. Validity, reliability and ease of use of the disabilities of arm, shoulder and hand questionnaire in adults following stroke. Disabil Rehabil. 2017;39(24):2504-2511. doi:10.1080/09638288.2016.1229364.

21. Franchignoni F, Vercelli S, Giordano A, Sartorio F, Bravini E, Ferriero G. Minimal clinically important difference of the disabilities of the arm, shoulder and hand outcome measure (DASH) and its shortened version (QuickDASH). J Orthop Sports Phys Ther. 2014;44(1):30-39. doi:10.2519/jospt.2014.4893.

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25. Li N, Tian F, Wang C, et al. Therapeutic effect of acupuncture and massage for shoulder-hand syndrome in hemiplegia patients: A clinical two-center randomized controlled trial. J Tradit Chin Med. 2012;32(3):343-349. doi:10.1016/s0254-6272(13)60035-7.

26. Backus D, Manella C, Bender A, Sweatman M. Impact of massage therapy on fatigue, pain, and spasticity in people with multiple sclerosis: A pilot study. Int J Ther Massage Bodywork. 2016;9(4):4–13. doi:10.3822/ijtmb.v9i4.327.

27. Roberts L. Effects of patterns of pressure application on resting electromyography during massage. Int J Ther Massage Bodywork. 2011;4(1):4-11. doi:10.3822/ijtmb.4i1.25.

28. Diego MA, Field T. Moderate pressure massage elicits a parasympathetic nervous system response. Int J Neurosci. 2009;119(5):630–638. doi:10.1080/00207450802329605.

29. Manella C, Backus D. Gait characteristics, range of motion, and spasticity changes in response to massage in a person with incomplete spinal cord injury: Case report. Int J Ther Massage Bodywork. 2011;4(1):28–39. doi:10.3822/ijtmb.v4i1.108.

30. Leibovitz A, Baumoehl Y, Roginsky Y, Glick Z, Habot B, Segal R. Edema of the paretic hand in elderly post-stroke nursing patients. Arch Gerontol Geriatr. 2007;44(1):37-42. doi:10.1016/j.archger.2006.02.005.

Hand Edema

Left Hand Before Treatment Visit 2Visit 3 Visit 4 Visit 5Visit 620191918.518.5Left Hand After TreatmentVisit 2Visit 3 Visit 4 Visit 5Visit 60.50.517.517.7517Right Hand Before TreatmentVisit 2Visit 3 Visit 4 Visit 5Visit 618.51817.217.517Right Hand After TreatmentVisit 2Visit 3 Visit 4 Visit 5Visit 60.50.517.217.516.5

Visits

Centimeters

Range of Motion

Visit 1Shoulder flexionShoulder abductionShoulder extensionElbow extension1001052075Visit 2Shoulder flexionShoulder abductionShoulder extensionElbow extension1001052075Visit 3Shoulder flexionShoulder abductionShoulder extensionElbow extension11012023165Visit 4Shoulder flexionShoulder abductionShoulder extensionElbow extension11512119173Visit 5Shoulder flexionShoulder abductionShoulder extensionElbow extension12312334169Visit 6Shoulder flexionShoulder abductionShoulder extensionElbow extension12712537171Normal ROMShoulder flexionShoulder abductionShoulder extensionElbow extension18018050180

Degrees

Disability of Arm, Shoulder and Hand

DASH scoreVisit 2Visit 4Visit 68582.590

Visits

Total Score

Pre-Treatment Shoulder Pain

Visit 1Shoulder pain6Visit 2Shoulder pain6Visit 3Shoulder pain6Visit 4Shoulder pain2Visit 5Shoulder pain4Visit 6Shoulder pain6

Visits

Numeric Pain Rating Scale (NPRS)