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Faculty of Medicine

Department of Neurological Rehabilitation

Anwar Aftab Shah

Assessment of the influence of paralyzed arm shoulder joint pain for

effectiveness of stroke patient’s rehabilitation

Medicine

Ass.Professor Dr. Lina Varzaityte

Kaunas, 2018

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TABLE OF CONTENTS

1. TITLE PAGE 1

2. TABLE OF CONTENTS 2

3. SUMMARY 3

4. SANTRAUKA 4

5. ACKNOWLEDGEMENTS 5

6. CONFLICT OF INTEREST 5

7. ETHICS COMMITTEE CLEARANCE 6

8. ABBREVIATIONS LIST 7

9. INTRODUCTION 8

10. AIM AND OBJECTIVES OF THE THESIS 9

11. LITERATURE REVIEW 10

12. RESEARCH METHODOLOGY AND METHODS 17

13. RESULTS 18

14. DISCUSSION OF THE RESULTS 18

15. CONCLUSION 24

16. PRATICAL RECOMMENDATIONS 24

17. LITERATURE LIST 25

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SUMMARY

Author: Anwar Aftab Shah

Title: Assessment of the influence of paralyzed arm shoulder joint pain for effectiveness of stroke

patient’s rehabilitation

Aim: To assess the influence of hemiplegic shoulder pain for the effectiveness of stroke patient’s

rehabilitation.

Objectives:

1. To assess the effectiveness of stroke patient’s rehabilitation with hemiplegic shoulder pain.

2. To assess the effectiveness of stroke patient’s rehabilitation without hemiplegic shoulder pain

3. To compare the effectiveness of stroke patient’s rehabilitation between the group of hemiplegic

shoulder pain and the group without.

Methodology: A randomized selection of 40 patient archives were analysed to check the effectiveness

of the stroke patient’s rehabilitation using Barthel index score before and after rehabilitation therapy

for comparison. There were two groups in the study, the control group (n=27) who were without

shoulder pain, therefore only underwent basic rehabilitation programme and the research group (n=13)

who had experienced shoulder pain therefore given additional TENS therapy to the basic rehabilitation

programme.

Study participants: 40 patients referred to neurological rehabilitation department in LUSHKK for

rehabilitation therapy prior to stroke.

Results: In the control group of the 27 patients, 59.3% were males while in the research group 53.8%

of the 13 patients were. The majority of the patients in both groups had suffered IS, in the control

group 66.7% and in the research 76.9%. Similarly, left-sided hemiplegia was more apparent as 62% of

the control and 56% of the research presented with it. The Barthel Index means of the two groups at

beginning were similar with the control group being 18.16.2 and the research group being 18.56.6

respectively. After the therapy both groups showed improvement in their Barthel index scores as the

control group 39.421.5 and research group 43.8 13.4, but due to the p=0.381 )when the data of both

post therapy were compared it is thought to be statistically not significant.

Conclusion: The rehabilitation effectiveness of hemiplegic shoulder pain of stroke patients was

statistically sufficient as p=0.003. The rehabilitation effectiveness of hemiplegic stroke patients

without shoulder pain was statistically sufficient as p=0.004. The rehabilitation of both control and

research groups showed effectiveness from the rehabilitation programme. However, when comparing

the research and control group there is no statistically significant (p=0.381).

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SANTRAUKA

Autorius: Anwar Aftab Shah

Pavadinimas: Paralyžiuotos rankos peties sąnario skausmo įtaka asmenų, patyrusių insultą,

reabilitacijos efektyvumui

Tikslas: Įvertinti paralyžiuotos rankos peties sąnario skausmo įtaką asmenų, patyrusių insultą,

reabilitacijos efektyvumui.

Uždaviniai:

1. Įvertinti reabilitacijos efektyvumą asmenų, persirgusių insultu, kuriems nustatytas paralyžiuotos

rankos peties sąnario skausmas.

2. Įvertinti reabilitacijos efektyvumą asmenų, persirgusių insultu, kuriems nenustatytas paralyžiuotos

rankos peties sąnario skausmas.

3. Palyginti reabilitacijos efektyvumą tarp asmenų, persirgusių insultu, kuriems nustatytas ir

nenustatytas paralyžiuotos rankos peties sąnario skausmas.

Metodika: Atlikta atsitiktinės atrankos 40 pacientų ligos istorijų analizė, asmenų persirgusių galvos

smegenų insultu. Reabilitacijos efektyvumas vertintas skaičiuojant Barthel indekso balų vidurkių sumą

prieš ir po reabilitacijos. Tyrime dalyvavo dvi grupės, kontrolinė grupė (n = 27), kuriems nenustatytas

paralyžiuotos rankos peties sąnario skausmas, taikyta tik bazinė reabilitacijos programa, ir tiriamoji

grupė (n = 13), kuriems nustatytas paralyžiuotos rankos peties sąnario skausmas. Jiems papildomai

taikyta TENS kartu su bazine reabilitacijos programa.

Tiriamieji dalyviai: 40 pacientų, persirgusių insultu, kurie gydėsi LSMULKK Neuroreabilitacijos

skyriuje.

Rezultatai: kontrolinėje grupėje didžioji dalis tiriamųjų buvo vyrai - 59,3 proc., o tiriamojoje grupėje -

53,8 proc. Dauguma abiejų grupių pacientų patyrė išeminį galvos smegenų insultą, kontrolinėje

grupėje - 66,7 proc, o tiriamojoje - 76,9 proc. Didžiąjai daliai pacientų nustatyta kairių galūnių

hemiplėzės: kontrolinėje grupėje - 62 proc., tiriamojoje - 56 proc. Barthel indekso balų vidurkių suma

reabilitacijos pradžioje kontrolinės grupės buvo 18,1±6,2, tyriamosios - 18,5±6,6. Po reabilitacijos

Barthel indekso balų vidurkių suma kontrolinės grupės buvo 39,4±21,5, tyriamosios - 43,8 ±13,4.

Tačiau lyginant abiejų grupių reabilitacijos efektyvumą po reabilitacijos, statistiškai nereikšmingas

skirtumas negautas (p=0,381).

Išvados: Asmenų, persirgusių insultu, kuriems nustatytas paralyžiuotos rankos peties sąnario

skausmas, stebėtas statistiškai reikšmingas reabilitacijos efektyvumas (p=0,003). Asmenų, persirgusių

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insultu, kuriems nenustatytas paralyžiuotos rankos peties sąnario skausmas, stebėtas statistiškai

reikšmingas reabilitacijos efektyvumas (p=0,004). Tačiau lyginant reabilitacijos efektyvumą tarp

kontrolinės ir tiriamosios grupių statistiškai reikšmingas skirtumas negautas (p=0,381).

ACKNOWLEDGEMENT

It has been a privilege to work alongside my supervisor Dr. Lina Varzaityte, and I am extremely

appreciative of the guidance and support that she has given me throughout this thesis research. I

would like to thank Dr.Rokas Semeskevicius, for his help in the collection of the patient history and

organisation.

CONFLICT OF INTEREST

The author reports no conflict of interest.

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ETHICS COMMITTEE CLEARANCE

Title of thesis: Assessment of the influence of paralyzed arm shoulder joint pain for effectiveness of

stroke patient’s rehabilitation.

Number of Issue: BEC-MF-281

Date of Issue: 06-03-2018

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ABBREVIATIONS LIST

VAS- Visual Analog Score

PSS- Penn Shoulder Score

MMAS- Modified Muscle Ashworth Scale

ROM- Range Of Motion

CVA- Cerebrovascular Accident

TBI- Traumatic Brain Injury

FES- Functional Electrical Stimulation

TENS- Transcutaneous Electrical Nerve Stimulation

LUHS- Lithuanian University of Health Sciences

UK- United Kingdom

USA- United States of America

OCSP- Oxfordshire Community Stroke Project

TOAST- Trial of Org 10172 in Acute Stroke Treatment

LDL- Low-density Lipoprotein

IHD- Ischemic Heart Disease

UTIs- Urinary Tract Infections

HS- Haemorrhagic Stroke

IS- Ischemic Stroke

DVT- Deep Vein Thrombosis

PE- Pulmonary Embolism

QOL- Quality Of Life

CRPS- Complex Regional Pain Syndrome

NSAIDs- Non-Steroidal Anti-Inflammatory Drugs

NMES- Neuromuscular Electrical Stimulation

KT- Kinesiology Taping

BTX- Botulinum toxin type A

Min- Minimum

Max- Maximum

CI- Confidence Interval

LUHSKK- Lithuanian University of Health Sciences Kauno Klinkos

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INTRODUCTION

In the past years, a large number of people suffering from strokes have had complications of shoulder

pain. The prevalence of shoulder pain in post-stroke differ between studies as some approximate at 22-

23% in patients whom survived while almost 54-55% of whom are in rehabilitation centres prior to

stroke [1]. This chronic disability is understood to impact the person’s daily live in all aspects such as

personally as well as socially. The quality of life can be assessed in various domains including Visual

Analog Scale (VAS), Penn Shoulder Score (PSS), Modified Muscle Ashworth Score (MMAS), Range

Of Motion (ROM) [1,2,3].

In Lithuania no scientific studies have been conducted on pain management in post stroke patients

with shoulder pain after stroke. Despite shoulder pain being one of the most common complication

deficit after stroke. The cause of the pain it thought to be multifactorial as it is suspected multiple

components can result in the pain formation. Hemiplegic shoulder pain can result in considerable

distress and decrease in activity which can hold back the rehabilitation of the patients [2].

The pain severity varies from individuals as it depends on the location of the lesion and the etiology.

Shoulder pain can present in those that suffered either a Cerebrovascular Accident (CVA) or in

Traumatic Brain Injury (TBI) which may have sustained the injuries at the initial time of the event.

The pathological changes possible are dislocation, soft tissue tear or damage, shoulder girdle fractures

or nerve traction injuries that occur after the fall must be excluded in brain injured patients.

Additionally, specific pathologic processes which occur secondary to the spasticity, weakness or

neglect in brain injury patients should be followed up [3].

In the literature there are several studies on experimental treatment possibilities and studies into

comparative therapy effectiveness to improve the pain in the shoulder. In an overall view, some

treatment options showed to be more effective than others but duration of the treatments also varied as

some were as short as a few weeks while others were for several months. The initial treatment of

rehabilitation is always physical therapy and if showing to be ineffective other alternatives are used in

place or with combination.

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AIM AND OBJECTIVE OF THE THESIS

Aim of the study:

To assess the influence of hemiplegic shoulder pain for effectiveness of stroke patient’s rehabilitation.

The objectives of the research:

1. To assess the effectiveness of stroke patient’s rehabilitation with hemiplegic shoulder pain.

2. To assess the effectiveness of stroke patient’s rehabilitation without hemiplegic shoulder pain

3. To compare the effectiveness of stroke patient’s rehabilitation between the group of hemiplegic

shoulder pain and the group without.

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LITERATURE REVIEW

1. Definition of Stroke

The definition of stroke is that it is a clinical syndrome, in which there are neurological deficits

because of acute focal injury to the central nervous system which cause a rapid onset of focal

neurological signs, lasting more than 24 hours or leading to death. It is caused by a disruption of blood

supply to particular regions of the brain [1,4,5]. As there are varied causes from many different clinical

syndromes it’s classified as an umbrella term [5].

2. Prevalence of Stroke

The prevalence of stroke annually, is that 15 to 17 million people suffer from the cerebrovascular

disease [4,6]. Stroke is a major cause of morbidity and mortality in the adult peoples worldwide, from

survivors most have disability, as from the 17 million around the world 5 million are left significantly

disabled and approximately 32 million are living with the effects of suffering a stroke [4,7,8].

The individuals who suffer from stroke are estimated at annual incidence ranging between 144 to 148

per 100,000 people globally [9]. In the United Kingdom (UK) and United States of America (USA),

stroke is the third most common cause of death, recorded at more than 60,000 and 160,000 deaths

annually respectively. In contrast to the world, it is the second most common cause at 9% of all deaths

[4,10].

The amount of deaths from stroke in the western countries have an incidence which is rising with age

as only 12% of deaths from stroke are of individuals under the age of 65 years of age but over 60% of

the world’s stroke occur in people in under 75 years old. However, deaths by stroke have fallen over a

period of 20 years in the UK by 19%. In contrast, to less developed nations worldwide where they

have increased [4,10]. This indicating the impact of stroke is increasing. In a recent study on a global

platform, there is been an up rise by 25% in stroke between 20 to 64 years, 113% surge in stroke

survivors, overall stroke has gone up by 70%, as a result 36% more deaths from this cause [4]. When

looking at the gender of the population at 85 years and over slightly more males are affected at 25%

compared to the opposite gender being only 20% [4].

3. Causes and Risk Factors of Stroke

The cause of stroke is subdivided ischemic or haemorrhagic [10]. Ischemic stroke account for about

80% all strokes. The classification can be either done by Oxfordshire Community Stroke Project

(OCSP) system which is in emergency rooms and conveys the prognosis or Trial of Org 10172 in

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Acute Stroke Treatment (TOAST) system which identifies the mechanism that leads to vessel

occlusion and important daily management [4,10,11].

The definition of ischemic is identical to stroke except the symptoms do not last more than 24 hours,

if events last longer it is arbitrary [4,10,11]. The second possible cause of stroke is haemorrhagic

which accounts for 20% of all strokes, it most commonly due to hypertensive small-vessel disease

resulting from lipohyalinotic aneurysms rupture [4,10,11]. The patients with primary cerebral

haemorrhage, two thirds of them are diagnosed with pre-existing or newly diagnosed hypertension

[4,10]. The occurrence of stroke as a consequence of haemorrhage, 75% of them are intracerebral

while the remaining are subarachnoid, 85% of ruptures of subarachnoid arise in the saccular aneurysm

of the base of the brain [4,11].

There are numerous risk factors to consider when looking at stroke, the first is age which is the

strongest risk factor for both ischemic and haemorrhagic as it 25 times higher risk for 74-85 year olds

to get a stroke than 45-54 year olds [4,11]. The other important aspects to consider is are gender and

ethnicity, male are at high risk due to the fact they have greater life expectancy but more women suffer

strokes during their lifetime [4,11,12]. In the UK individuals for African-Caribbean and African-

American there is an increased prevalence of stroke compared to Caucasians [4,11,12]. Also in the UK

South Asian populations have a greater stroke mortality than Caucasians and this thought to be because

of increased central obesity, insulin resistance and diabetes mellitus [4,11,12].

Systemic problems also have an influence on possibility of stroke, hypertension is one of the major

factors for ischemic as well as haemorrhagic stroke occurrence, as every 7.5-10 mmHg increase over

the normal diastolic range or a 20mmHg increase in the systolic implies doubling the chance of stroke

as an outcome [4,11,12]. In a randomized trial it supported by controlling and treating blood pressure

problems even when in ‘normal’ blood pressure levels it can prevent stroke [4,11]. Similarly,

individuals with Diabetes Mellitus also double their chances of stroke as it can contribute to both

atherosclerosis and large vessel diseases [4,11].

Individuals with hypercholesterolemia and high levels of low-density lipoprotein (LDL) before were

strong risk factors for ischemic heart disease (IHD) but less common in cause of stroke but in recent

data studies it is showing their relationship with ischemic stroke but it may be obscured because of

negative association with intracerebral haemorrhage [4,11]. Cardiovascular disorders such as IHD,

peripheral vascular disease, cardiac failure and atrial fibrillation all present with the risk of stroke.

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Atrial fibrillation is the most important aspect to control and potentially prevent as it five-fold increase

risk of stroke occurrence. In elderly, it carries an annual risk of stroke of 5% or more [4,11,12].

4. Complications of Stroke

Prior to stroke most medical complications occurs within the first few weeks. The complications can

hinder the functional recovery resulting in a worse outcome and interference with rehabilitative

therapies acting as a barrier [13,14]. In previous studies it was found out that there is a high incidence

for complications prior to stroke ranging from 45%-95% but had many limitations as they were

published on individual complications rather than on incidence of all complications taken together

[15].

Furthermore, there is a correlation between infections prior to stroke recorded as in a recent study in

India in multi-centres between both haemorrhagic stroke (HS) and Ischemic Stroke (IS) patients;

21.2% had a chest infection while 8.7% had urinary tract infections (UTIs) [15]. In comparison,

another multi-centre study obtained in Scotland; chest infection accounting for in 22% of patients,

UTIs forming as a complication in 23% of the stroke survivors [14]. In a comparative review of nine

studies carried over the globe in different years the data collected about post-stroke complications

showed that UTIs were more prominent than chest infections; the former ranged between 6.3%-30.5%,

while the latter occurred in 4-22% of the stroke victims [13].

In a study carried in Norway, the resulted obtained showing complications obtained in a 12 week

period since stroke occurrence; 82.4% of the participants experienced at least 1 or more complications

during the time frame. The neurological problems observed were quite mixed as some aspects were

common while other were not; stroke recurrence was 5.3%, seizures 2.5% [16]. Similarly, a study

carried in South Korea showed; the results for neurological complications in total occurred in 21.1% of

patients; reoccurrence 2%, seizures 1%, ischemic stroke progression 17.1%, symptomatic

haemorrhagic transformation 3% [17]. Similarly, the multi-centre studies carried out in Scotland

illustrated the same correlation; recurrent stroke was 9% and seizures 3%. However, in India the

results collected were antagonistic as reoccurrence was only 1.3% while seizure accounted for almost

three times as much at 3.8% [14,15]. The mortality and morbidity rates in hospital of patients with

acute stroke ranges between 7.6-30%, of these values 80% of the deaths are neurological while non-

neurological deaths account for 17%. The collaboration study indicated that there was no difference in

the rate of death during the first few days of admission whether it was to the stroke unit or the general

neurology convention ward. The cause of the neurological deaths in both groups in the first 3 days was

either continuous increase in intracranial pressure or herniation [18].

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The severity of depression post-stroke has no accurate estimate, but minor symptoms of depression

appear in most patients. It was thought that neurotransmitter pathways at specific neuroanatomical

sites were causing the depression but it has been proven to be unsupported information [13]. The

incidence of psychological complications such as depression, anxiety, emotionalism and confusion

varied among studies. The study carried out in Asia looking at the complications post-stroke in ten

countries across the continent showed on average that 4% of the patients diagnosed with depression

[18]. In the comparative review study, depression was recorded in 4 of the 9 studies, from the

population-based studies which recorded the results, the prevalence of depression was about 33% at

any time during the follow-up [13]. Similarly, the studies carried out in India and Scotland shows the

same correspondence; as in the first study depression was 18.1%, anxiety 5.4%, emotionalism and

confusion both were 5.6% each, while in the Scottish study, depression 16%, anxiety 14 %,

emotionalism 16%, confusion 36% [14,15]. Depression can also be a contributor to post-stroke

mortality, also patients are less likely to take part in rehabilitative therapies as well as taking

medication. Therefore, having a poorer recovery compared to others without depression [13].

Venous thromboembolism such as deep vein thrombosis (DVT) also are a major post-stroke concern

especially patients with limb paralysis, as 50% DVT occurs in the first 2 weeks prior to hemiparetic

stroke of patients not given thrombolytic prophylaxis. The most serious complication leading to a

pulmonary embolism (PE), which is an early cause of death and most fatal between second and fourth

weeks after stroke. The incidence in patients shows greater variation although frequency has declined

in recent years due to thrombo-prophylaxis [13]. In an USA and Scotland study, looking at

complications after stroke, patients were given thrombo-prophylaxis and the occurrence DVT 2%, PE

1% [14,19].

Complications of immobility which is one of the three categorises of post-stroke complications. It

comprised of falls, infections, venous thromboembolism, pressure sores and pain [20]. In 2015 a study

from Norway, falls occurred in 29% of the cohort and ranged from 2.2%- 26% reported [20]. When

observing the complications of immobility in an Indian study, frequency of falls and bedsores who

results showed; 1.6% falls, 4% bedsores [15]. Similarly, in a more recent study carried in Asian the

results were quite similar; falls 2.4%, pressure sores 2.6% [18]. In contrast, studies done in European

(Norway, Scotland) showed a much higher recurrence of falls and pressure sores; Norwegian study

from 2008, 25% had non-serious falls, 3.3% serious falls, 2.9% pressure sores. The Scottish study

showed that 21% non-serious falls, 5% serious falls, pressure sores 21%.

5. Shoulder Pain prior to stroke

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Chronic pain is a frequent complication after stroke effecting up to half of stroke patients, also it is

associated with depression, cognitive dysfunction and impaired quality of life (QOL) having a

negative effect [21,22]. Hemiplegic shoulder pain is one of the most common complications after

stroke with a prevalence between 29-84% effecting QOL, inhibiting recovery and rehabilitation [23-

26]. Longitudinal studies suggested that 75% of stroke patients get shoulder pain within the first year

[28]. However, the cause is not well known but suggested to be multiple factors which contribute to

the shoulder such as adhesive capsulitis, rotator cuff disorder, myofascial pain, complex regional pain

syndrome (CRPS), shoulder hand syndrome and secondarily to gleno-humeral joint stiffness [23-27,

29]. CRPS is characterized by pain in combination with sensory, autonomic, trophic and motor

changes, if no nerve injury is found then it called CRPS-I and if found it called CRPS-II [30].

5.1. Medical Treatment options for shoulder pain

Drug therapy used for shoulder pain can be analgesic, anti-inflammatory and antispastic drugs [2].

Non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics are tried firstly as they can be given

orally or via injection [2,3,30]. A study done on 68 patients with hemiplegic shoulder pain revealed

complete resolution by using oral steroids and intensive rehabilitation [2]. If suspected spasticity of

cerebral origin, antispasmodic drugs are prescribed such as locally or systematically such as the use of

benzodiazepines to combat both the pain and general spasticity but it can inhibit and relax techniques

in physiotherapy [2,3].

5.2. Non-Medical Treatment options for shoulder pain

Physiotherapy is an important in improving shoulder girdle recruitment; can be divided into two

approaches; ones that focus on localized mechanical ones or ones that view neurological problems

[2,3]. Splinting and shoulder supports is vital in positioning and preventing the formation of

contractures [2,3]. Physical therapy association between spasticity, muscle imbalance and painful

frozen shoulder suggests the treatment helps improve ROM for hemiplegic shoulders which should

lower the pain [31].

Occupational therapy aims to improve relevant performing skills or developing and teaching

compensatory techniques to overcome lost skills. The three interventions for stroke patients are self-

care activities, training of leisure activities and advice and instruction regarding assistive devices.

Additionally, they educate and share information with caregivers to perform and provide assistance

[32].

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TENS used for analgesic technique to mask pain by giving lower intensity, higher frequency

stimulation to cutaneous peripheral nerves without muscle contraction but if high intensity then muscle

contractions occurs [2,31,33,40]. TENS may reduce spasticity and improve function if it is initially

considered as a single treatment intervention. The supraspinatus and deltoid muscles are most

commonly used in painful hemiplegic shoulders [31,33-35]. It was established that high intensity

TENS showed improvements in passive ROM, as well as very satisfactory pain relief [2].

Neuromuscular electrical stimulation (NMES) and TENS are widely used to reduce pain in clinical

practise [27]. NMES transmits electrical impulses through the skin, stimulating superficial nerves and

muscle groups. It reduces shoulder subluxation and prevents further joint separation by strengthening

the posterior deltoid and supraspinatus muscles [34]. NMES helps preventing atrophy, relaxed muscle

spasm, increase in blood supply and nutrient to the muscles as well as re-education of the muscle [27].

FES is used to prevent the gleno-humeral joint from stretching, subluxation and for shoulder pain and

improve function [2,36]. The use of electrical currents stimulates the nerves connected to the

unresponsive muscles, aim to cause movements or function. In the shoulder it is used on muscles

which take the humeral head within glenoid fossa. The frequency used for FES is between 10-50Hz

and directly stimulates nerve or motor point but not the fibres of the muscle itself [36].

The use of kinesiology taping (KT) is widely used for musculoskeletal pain, as it increases the

mobility of the joint as well as strengthening the muscle, facilitating proprioception, reducing swelling

and improving the blood circulation. By doing this KT can be beneficial for reducing pain, increasing

ROM, and enhancing performance of daily tasks [37]. KT is formed of elastic cotton tape which can

stretch up to 140% of its original length, it is directly attached to skin for use but should be changed

every 3-4 days [38].

Steroid injections are commonly used for local anti-inflammatory effect, but can impede cartilage

metabolism and cause joint destruction, so alternatively hyaluronic acid injections can be used as they

protect cartilage and inhibit degeneration as well as better metabolism of synovial fluids, tendons and

ligaments [23,24]. Botulinum toxin type A (BTX) is used for numerous conditions including spasticity,

dystonia, myoclonus, muscle spasms and variety of pain syndromes [25]. The use of intra-muscular

injections of BTX for controlling spasticity is popular. However, patients who are allergic to it use

other forms of needling therapies such as acupuncture or dry needling [9]. The use of warm

acupuncture can relieve pain and improve the ROM of the shoulder [39]. The use of bee venom for

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acupuncture can be used as it reportedly has anti-arthritic, ant-inflammatory, analgesic and anti-

nociceptive effects [7].

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RESEARCH METHODOLOGY AND METHODS OF THE THESIS

1. Research method and data collection

The study carried out was a retrospective research conducted in the Lithuanian University of Health

Sciences Kauno Klinkos (LUHSKK) within the Department of Neurological Rehabilitation. The study

was carried out during January and February 2018, from the patients enlisted in the department

database. As for the fact that the patients were not present, consent was not obtained due to this factor

each were just listed with a number. The size of the study population consisted of 40 patients. The

patients were picked anonymously using a contingent which was that they had stroke. The whole

population underwent basic rehabilitation program, which includes physical therapy, occupational

therapy, social worker consultation, speech therapy and massage therapy. The control group was

comprised of 27 patients without shoulder pain. Additionally, the research group of 13 patients who

had the suffered from hemiplegic shoulder pain were treated with TENS.

2. Self- filled Questionnaire

The data for the research was collected randomly in terms of patients as long as they met the one

requirement of having suffered a stroke. The information taken from the patient histories were in

regards to answering the questions which had been formulated. The question were divided into

sections:

i. General information. This part was comprised of basic details such as age, gender and the

side of hemiplegia the patient had suffered.

ii. Prior to the treatment information.

iii. Post treatment information.

The same scales were used in pre and post treatment questions, to clarify the beginning results to the

end results. The effectiveness of rehabilitation was measured by Barthel Index change throughout the

rehabilitation.

3. Statistical analysis

Statistical data analysis was made by standard software; Statistica and Excel. For the evaluation of

continuous values the following statistical characteristics were used mean, median, standard deviation;

the data are statistically significant as they are p<0.05.

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RESULTS AND THEIR DISCUSSION

1. Patient Characteristics

A total of 40 patients were included in the study, 27 patients in the control group and 13 patients in the

research group. The control group was comprised of 16 males (59.3%) and 11 females (40.7%). The

median on the controlled was calculated to be 72 years with the range being 29 years as patients were

from 52 years to 81 years. The research group was made up of 7 males (53.8%) and 6 females

(46.2%). The median for the trial group was recorded to 69 years of age, with the range being 42 years

as applicants were from 51 to 93 years of age (Table 1).

Table 1: Characteristics of control and trial patients Controlled Group Research Group change

around

Gender Male (n (%)) 16 (59,3 %) 7 (53,8 %)

Female (n (%)) 11 (40,7 %) 6 (46,2 %)

Age (median(range)) 72 (52-81) year 69 (51-93) years

Furthermore, within the research group of the 13 patients, 10 patients were diagnosed with IS (76.9%)

while 3 were due to HS (23.1%). Figure 1 illustrates proportionally the side of hemiplegia among the

candidates of trial groups. Left sided hemiplegia was present in 8 (62%) and right sided hemiplegia

was 5 (38%).

Figure 1: The percentage of sides of hemiplegia in Research Group

Data were analysed using descriptive statistics. Total number of patients = 13.

38%

62%

Right Left

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In regards to the control group from the 27 patients, 18 were diagnosed with IS (66.7%) and 7 patients

were diagnosed with HS (33.3%). Figure 2 explains the side of hemiplegia of the patients in the

control group; left sided hemiplegia was present in 16 patients (56%), while right sided hemiplegia

was recorded in 11 patients (44%).

Figure 2: The percentage of sides of hemiplegia in Control Group

Data were analysed using descriptive statistics. Total number of patients = 27.

2. Barthel Index

The Barthel Index was recorded before and prior to rehabilitation in the purpose to establish whether if

the therapy was effective or not. In Table 2 the formulated results of the Barthel index before and after

for the research group. The values obtained indicated the Barthel Index improved as the mean about

doubled from 18.5 to 43.8. The effectiveness could also be seen in the range as the score before was

between 5 to 30, and after 25 to 65. As the p sign was 0.003 implicating it is highly significant.

56%

44%

right left

20

Table 2: Comparison of the Barthel Index before and after rehabilitation of the research group

Barthel Index Mean 18,5

Before rehabilitation (95% CI) Upper border 22,4

Lower border 14,5

Standard Deviation 6,6

Range (min-max) 25 (5-30)

Barthel Index

Mean

43,8

After rehabilitation (95% CI) Upper border 51,9

Lower border 35,7



P= 0.003.

The same data was collected for the control group in the objective of comparison. In Table 3 is figures

of the control group ahead and prior to rehabilitation. The Barthel index score results before

rehabilitation were 18.1, the post-rehabilitation illustrates the score almost doubled (39.4). The range

also demonstrates sufficient as it was between 10 to 30, and after 15-90. The data was of significant

(p=0.004).

Table 3: Comparisons of the Barthel Index before and after rehabilitation of the controlled group

Before Barthel Index Mean 18,1

rehabilitation (95% CI) Upper border 20,6

Lower border 15,7



After Barthel Index

Mean

39,4

rehabilitation (95% CI) Upper border 47,9

Lower border 30,9



P=0.004.

In the comparative view, Table 4 documents both groups results before the rehabilitation programme.

It is established that in both categories the mean is similar, with the control group having 18.1 and the

research group having 18.5. When looking at the CI of both, it is correlative as the lower borders

(control group 15.7, research group 14.5) and upper borders (control group 20.6, research group 22.4)

were close. Similarly, the range justifies the same pattern as the maximum in both is 30 points. The

data is significant (p= 0.042).

21

Table 4: Comparisons of Barthel Index before rehabilitation between both the controlled group and

research group

Controlled Group Research Group

Barthel Index Mean 18,1 18,5

Before rehabilitation (95% CI) Upper border 20,6 22,4

Lower border 15,7 14,5

Standard Deviation 6,2 6,6

Range (min-max) 20 (10-30) 25 (5-30)

P=0.042.

In Table 5 is the observation of the results between both groups prior to rehabilitation. The mean of the

two groups indicates research group had a better outcome overall with it being at 43.8 compared to

39.4 of the control group. The CI values implicates there is overlapping of results range parameters as

the control group borders are between 30.9 to 47.9, in the research group between 35.7 to 51.9. In

contrast, the range of the groups that the research group has better minimum at 25 points compared to

the 15 points recorded for the control group but when looking at the maximum in the research group it

was 65, whereas in the control it was 90. The range of results concluded that the individuals control

groups were classified between total dependency to moderate dependence, alternatively in the research

group it was between severe dependency to moderate dependency. The data was not significant (p=

0.381).

Table 5: Comparisons of the Barthel Index after rehabilitation between both the controlled group

and research group

Controlled Group Research Group

Barthel Index

Mean

39,4

43,8

After rehabilitation (95% CI) Upper border 47,9 51,9

Lower border 30,9 35,7

Standard Deviation 21,5 13,4

Range (min-max) 75 (15-90) 40 (25-65)

P=0.381.

3. Comparison with previous studies

A study carried out in 2008 in Romania looked at management of shoulder pain, comparing the

rehabilitation of 91 patients who were divided into two groups. The first group comprised of 45

patients which were given TENS, the second group made up of 46 patients who were given

galvanic current [29]. In table 6, the results of the study reported an improvement in both groups

but there was a more significant progress in the TENS group. The TENS starting VAS was 8.1 but

by the end of studies have reduced to 3.2. In correlation, the Barthel index also rose from 67.2 to

78.5 points. However, according to Barthel Index the results were not significant

22

Table 6: Comparison of management of shoulder pain

In another study, the effects of TENS were tested on shoulder pain. The study contained 60 patients

which were divided into 3 even groups of 20. The three subdivision which ones receiving high

intensity (3 times threshold intensity), low intensity (threshold intensity) and control placebo group

[40]. The information summarised in table 7 are the results obtained which indicates the high intensity

TENS group showed to be effective as all passive ROM had substantially improved and continue to

increase even a month prior the therapy. The low intensity group also showed improvement but was

not deemed significant as the ROM decline in the recording taken a month later after therapy even

though it was more than the beginning. The control group showed no improvement either apart the

slight increase in the flexion range after therapy due to this factor it was though maybe in the low

intensity and control group the improvement could have been a result of the placebo effect.

Table 7: Comparison of different intensity of TENS on shoulder pain

Before After treatment 1 month after treatment

Mean (SD) High Low Control High Low Control High Low Control

Flexion 52,87

(6,65)

54,25

(7,12)

53,37

(6,13)

63.25

(5.32)

58.37

(6.34)

55.25

(6.87)

65,50

(3,68)

56,37

(6,71)

53,00

(6,36)

Extension 43,75

(4,90)

43,37

(5,51)

44,25

(6,49)

54.75

(5.43)

45.00

(4.93)

44.25

(6.74)

55,75

(4,66)

44,00

(4,68)

43,25

(6,83)

Abduction 49,12

(8,43)

46,12

(6,20)

45,25

(7,69)

60.75

(6.34)

48.50

(5.75)

45.12

(7.41)

61,62

(6,08)

47,25

(6,32)

44,25

(7,21)

External

rotation

42,47

(6,37)

40,50

(2,49)

41,25

(4,09)

54.87

(4.25)

43.12

(3.33)

41.12

(4.76)

55,37

(3,74)

40,87

(3,06)

39,75

(4,28)

Mean (Standard

Deviation)

TENS (45

patients)

Galvanization (46

patients)

Patient information Age 60.7(6.00)

62.5 (5.93)

Before rehabilitation VAS 8.1 (1.24) 7.8(1.00)

Barthel Index 67.2 (9.50) 70.8 (10.00)

After rehabilitation VAS 3.2 (1.70) 5.1 (1.60)

Barthel index 78.5 (5.00) 81.0 (6.20)

23

In recent years, studies have been done into looking for alternative procedures. In studies looking at

the use of hyaluronic acid injections for shoulder pain management has shown to produce positive

results indicating its effectiveness [23,24]. In recent Korean 8 week study, 31 patients were split into

two groups to compare the effectiveness of intra-articular hyaluronic acid injections compared to

steroid injections [24]. The results of trial have been presented in table 8. The results indicate that both

forms of injection are effective in increase the ROM of the joint, but no significant difference between

the two groups so it suggested hyaluronic acid can be considered an alternative when steroid use is

limited.

Table 8: Comparison of hyaluronic and steroid injection for shoulder pain

Alternatively, in modern times trials in Asia have been carried out using warm needling [39]. In the

warm needling trial, both the treatment and control group showed improvement as VAS decreased but

there was a more substantial decline in the treatment group. The treatment group began with a mean

7.391.56, 2 weeks into treatment was recorded to be 1.821.31. In comparison to control which

dropped from 7.021.42 to 4.351.81. The Barthel Index also showed after 2 weeks improvement in

both groups but it was not significant as P=0.25, as the treatment group the mean went from

51.2921.77 to 64.2617.99, while in the control group 47.2821.74 to 57.4520.97. However, at the

3 month follow P<0.01 and therefore significant, the treatment group mean improved to 80.6514.67

and the control group improving to 69.0318.90. Overall, showing warm needling can also be a

sustainable option for therapy in regarding to treating shoulder pain.

Time Period Mean ± Standard

Deviation

Group A

(hyaluronate)

p-value

Time effect

Group B

(steroid

p-value

Time effect

Before Treatment Flexion 122.1± 28.53 122.2±32.00

Abduction 95.7±33.03 82.8±20.45

External rotation 38.5±24.65 27.5±23.02

After treatment Flexion 134.3±28.39 0.003 136.1±36.20 0.014

Abduction 92.1±34.00 0.552 89.7±16.49 0.017

External rotation 50.0±25.79 0.003 41.9±23.90 0.004

24

CONCLUSION

1. The rehabilitation effectiveness of hemiplegic shoulder pain of stroke patients was statistically

sufficient as p=0.003.

2. The rehabilitation effectiveness of hemiplegic stroke patients without shoulder pain was

statistically sufficient as p=0.004.

3. The rehabilitation of both control and research groups showed effectiveness from the

rehabilitation programme. However, when comparing the research and control group there is

no statistically significant (p=0.381).

PRATICAL RECOMMENDATIONS

In regards to the pain relief of each stroke patient with hemiplegic shoulder it should be one of the

goals to improve in the rehabilitation effectiveness. When looking at aspects for improvement, for

future references numerous parameters such as VAS, Functional Independent Measure should be used

readily available so rehabilitation can be monitored to see the effectiveness.

25

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