Vol. 22 Issue 23
Taping of the Glenohumeral Joint
Does this approach work for patients with shoulder subluxation after stroke?
Despite the commonality of shoulder subluxation secondary to a cerebrovascular accident (CVA), the verdict in rehabilitation research as to the best methodology for treatment is still unknown. Therapists use a variety of techniques including slings, biofeedback, electrical stimulation and constraint-induced movement therapy (CIMT) to treat glenohumeral subluxation.
Taping or strapping, as it is sometimes called in the literature, is one method for addressing glenohumeral subluxation secondary to hemiplegia caused by a CVA. But among all the other ways to address subluxation, the question arises: does it work?
Glenohumeral subluxation is a secondary complication to hemiplegia caused by a CVA, in which the head of the humerus drops out of the joint. Across the literature, anywhere from 17 to 66 percent of patients experience a shoulder subluxation after a CVA (Peters & Lee, 2003).
Patients with such a subluxation experience pain and decreased ability to perform activities of daily living. In fact, the pain caused by a glenohumeral subluxation has not been isolated. Some research even claims that shoulder subluxation is not the etiology for shoulder pain experienced post-CVA.
Theories for the pain caused by a subluxation include the possibilities that either the periarticular tissue of the shoulder gets overstretched, or the tendons of the supraspinatus get overstretched. In most causes, pain develops in the shoulder over time with a subluxation, as the tissues and tendons remain on a constant stretch (Paci, Nannetti & Rinaldi, 2005). However, a patient may experience a subluxation without any signs of pain.
Assessing a Shoulder Subluxation
Assessment of a glenohumeral subluxation is not universal. Some therapists assess through use of palpation, measuring the severity of the subluxation with the number of fingers fitting in the space between the acromion and the humerus. The other method for assessing a shoulder subluxation is called anthropometrical evaluation, in which a caliper will be used to measure the length of the subluxation in centimeters. Even the protocol for this assessment is not standard, with some therapists measuring from the acromion to the head of the humerus and some measuring from the acromion to the lateral epicondyle of the humerus. With experience, it is possible to visually assess the existence of a shoulder subluxation.
Why Shoulder Taping?
Taping a shoulder subluxation due to hemiplegia is a fairly simple way to treat a subluxation and is noninvasive to the patient. Unlike a sling, it does not affect other joints or muscles of the upper extremity, leaving them free to move and engage in activities of daily living. A therapist can tape a shoulder as part of outpatient therapy and send the patient home with support of the glenohumeral joint until the next treatment session. Most often patients do not remove the taping and it can usually hold for a couple of days.
Taping provides proprioceptive feedback, which may provide benefits in the treatment of both hypo- and hypertonicity. Also, tape can easily be removed if the patient experiences too much pain or discomfort. Lastly, taping is cost-effective compared to other occupational therapy treatments such as electrical stimulation or neurodevelopmental treatment.
The issues with shoulder taping include the variety of protocols used by therapists and its danger to skin integrity. For older adults, skin integrity may be an issue and certain tapes can easily tear thin or fragile skin. Some patients may have skin reactions to taping or skin breakdown can occur if tape is left on the skin too long. A therapist must be vigilant in checking skin integrity if using a taping protocol. Patients and caregivers must also be educated to perform skin checks, removing tape and contacting the therapist if any problems are noted.
Therapists can choose from a variety of existing protocols for taping the affected shoulder; the chosen protocol may not be the best one for the patient, and can lead to little or no improvement of the subluxation. Furthermore, even if the right protocol is selected, an untrained therapist can apply the tape incorrectly, providing the patient with little or no benefit. Lastly, it may be difficult to isolate taping as beneficial because it is only one option for treatment of a subluxation. Most often, therapists use a combination of treatments in an effort to address pain and the return to functional use.
The Evidence on Shoulder Taping
In a literature review exploring the evidence for taping as an effective treatment for shoulder subluxation secondary to hemiplegia caused by a CVA, the results were mixed. Evidence demonstrated that taping was beneficial early after a stroke, but its benefit faded after a short time. Also, taping was shown to be more beneficial when coupled with a sling. In several studies, taping was shown to delay and decrease shoulder pain from a subluxation (Paci, et. al, 2005).
In another literature review, the authors determined a lack of impact from shoulder taping due to a lack of studies supporting it as a successful treatment protocol (Van Pepper, Kwakkel, Wood-Dauphinee, Hendriks, Van der Wees, & Deeker, 2004).
In an intense case study, however, shoulder taping was shown to not only reduce pain but also increase passive range of motion in the shoulder. Independence and active participation in activities of daily living also increased, most likely due to deceases in pain (Peters & Lee, 2003).
In a patient with central cord syndrome, shoulder taping was shown to decrease the subluxation coupled with electrical stimulation (Peterson, 2004).
Unfortunately, not many studies have been conducted across the literature to establish definitively whether shoulder taping is effective as a treatment for glenohumeral subluxation due to hemiplegia from a CVA. Although there is not consistent support across the literature for shoulder taping as a treatment for subluxation secondary to hemiplegia caused by CVA, other treatment protocols have not been strongly supported in the literature either.
Therapists must continue to engage in evidence-based research to establish the most efficient protocols for addressing shoulder subluxation. Until further defined, patients may benefit from multiple forms of treatment to explore what works best for each individual.
References available at www.advanceweb.com/OT or upon request.
Joy D. Voltz, OTR/L, OTD, works for Creighton University in the Office of Interprofessional Scholarship, Service and Education (OISSE) and does pro bono practice in health ministry in the community. You are encouraged to reach her at firstname.lastname@example.org.