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Thirty minutes of positioning reduces the development of shoulder external rotation contracture after stroke: A randomized controlled trial

https://doi.org/10.1016/j.apmr.2004.02.031Get rights and content

Abstract

Ada L, Goddard E, McCully J, Stavrinos T, Bampton J. Thirty minutes of positioning reduces the development of shoulder external rotation contracture after stroke: a randomized controlled trial.

Objective

To determine the efficacy of positioning the affected shoulder in flexion and external rotation to prevent contracture shortly after stroke.

Design

Prospective, parallel-group, randomized controlled trial.

Setting

Four metropolitan mixed rehabilitation units.

Participants

A volunteer sample of 36 subjects (minus 5 dropouts), whose mean age was 68 years and had had their first stroke within the past 20 days.

Interventions

The experimental group received two 30-minute sessions a day, 5 days a week, for 4 weeks, during which the affected upper limb was placed in maximum comfortable external rotation and 90° of flexion. Both the experimental and control groups received up to 10 minutes of shoulder exercises and standard upper-limb care.

Main outcome measures

Contracture was measured as the maximum passive shoulder external rotation and flexion of the affected side as compared with the intact side. Measures were taken at 2 and 6 weeks after stroke by an assessor blinded to group allocation.

Results

The 30-minute program of positioning the shoulder in maximum external rotation significantly reduced the development of contractures in the experimental group, compared with the control group (P=.03). The 30-minute program of positioning the shoulder in 90° of flexion did not prevent contractures in the experimental group as compared with the control group (P=.88).

Conclusions

At least 30 minutes a day of positioning the affected shoulder in external rotation should be started as soon as possible for stroke patients who have little activity in the upper arm.

Section snippets

Design

The study was a randomized controlled trial. Subjects were measured before and after 4 weeks of participation in a shoulder positioning program consisting of two 30-minute sessions a day 5 days a week. Patients were measured at discharge if their stay was less than 4 weeks. Measurement and positioning was done at separate times to eliminate possible short-term effects of the intervention. An assessor blinded to group allocation carried out measurements.

Participants

Subjects were recruited from the

Contracture

By posttest, loss of shoulder external rotation range was significantly greater (F1,29=4.2, P=.05) in the control group than in the experimental group (fig 2A). The result was the same if the loss of ROM was expressed as a contracture (ie, loss as a percentage of intact range). By posttest, the control group had developed a significantly larger internal rotator contracture than the experimental group (F1,29=4.9, P=.03). In addition, there were fewer subjects with pain on maximum passive

Discussion

This study’s major finding is that implementing the positioning program described here early after stroke for people who have little or no upper arm activity inhibits the development of external rotation but not of flexion contracture. In addition, the partial prevention of external rotation contracture had no effect on upper-arm function, although there was little recovery of function in either group during the 4-week intervention period.

This is the first study to show a significant effect of

Conclusions

We recommend that stroke patients with little upper-limb function undergo a program of positioning the affected shoulder in maximum comfortable external rotation at least 30 minutes a day. The program should be commenced as soon as possible after the stroke.

Acknowledgement

We acknowledge assistance of the staff of the Physiotherapy and Occupational Therapy Departments of Balmain Hospital, Royal Prince Alfred Hospital, Bankstown Hospital, Lady Davidson Private Hospital, and Concord Repatriation General Hospital. In particular, we thank Esther Tucker, Shelley Murtagh, and Lisa Russell from Balmain Hospital and Simone Dorsch from Bankstown Hospital for their diligence in carrying out the positioning program. Thanks to Stephen Chan for drawing the diagrams of

References (31)

  • R.L. Joynt

    The source of shoulder pain in hemiplegia

    Arch Phys Med Rehabil

    (1992)
  • R. Kumar et al.

    Shoulder pain in hemiplegia

    Am J Phys Med Rehabil

    (1990)
  • C.S. Nepomunceno et al.

    Shoulder arthrography in hemiplegic patients

    Arch Phys Med Rehabil

    (1974)
  • M. Peszczynski et al.

    The incidence of painful shoulder in hemiplegia

    Pol Med Sci Hist Bull

    (1965)
  • J.M. Williams

    Use of electromyographic biofeedback for pain reduction in the spastic hemiplegic shoulder

    Physiother Can

    (1982)
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