evidence based nursing stroke 1

7/24/2019 Evidence Based Nursing Stroke 1

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26 VOLUME 27 NUMBER 1 SEPTEMBER 2005 AXON

By Cydnee Seneviratne,

Karen L. Then, and Marlene Reimer

AbstractApproximately 84% of all stroke patients with hemiplegia

will experience shoulder injury and pain. The importance

of maintaining proper posture while positioning and

transferring a stroke patient is key to decreasing risk forshoulder injury. Shoulder subluxation injury post-stroke is

a consequence of sustained hemiplegia and spasticity.

Current research evidence suggests that using therapies

such as gentle range of motion and functional electrical

stimulation may reduce and prevent shoulder subluxation

and hemiplegic shoulder pain. However, physiotherapists

are currently the only professionals who can implement

such therapies. Considering that stroke care provided by

neuroscience nurses includes transferring, positioning

and assisting in activities of daily living, it is clear that

nurses are an important part of the therapy process.

Therefore, the question is: What is the role of the

neuroscience nurse in the reduction and prevention of

shoulder pain post-stroke? The purposes of this paper

are to i) discuss the causes of shoulder subluxation and

related pain post-stroke, ii) review current best practice in

prevention and treatment of shoulder subluxation, and iii)

explore ways in which the acute neuroscience nurse can

prevent or reduce shoulder subluxation in the hemiplegic

stroke patient.

Stroke is the primary cause of long-term adult disability in

Canada (Canadian Stroke Network, 2004). Hemiplegia is a

common disability experienced post-stroke. As many as

84% of stroke survivors with hemiplegia will develop

shoulder subluxation and related shoulder pain (Teasell,Bhogal, Foley, & Speechley, 2004). Currently, there is

much clinical discussion by physiatrists, nurses and

therapists who work in the area of stroke rehabilitation

about shoulder pain and subluxation post-stroke. Clinical

discussions range from proper positioning and proper

range of motion to the use of electrical stimulation therapy

to strengthen shoulder muscles as an adjunct to

physiotherapy exercises. Most stroke rehabilitation

discussion and research papers examine and explore

treatment of shoulder pain, management of shoulder

subluxation through consistent range-of-motion exercises

and the efficacy of electrical stimulation as a preventive

therapy (Ada & Foongchomcheay, 2002; Gilmore,

Spaulding, & Vandervoort, 2004; Price & Pandyan, 2001;

Rathfon, 1994; Spaulding, 1999; Teasell et al., 2004;

Turner-Stokes & Jackson, 2002; Vuagnat & Chantraine,

2003; Walsh, 2001). In addition, therapists and nurses have

multiple definitions of what causes post-stroke subluxationand shoulder pain, which has led to uncertainty around

each disciplines role in prevention of this injury

(Pomeroy, Niven, Barrow, Faragher, & Tallis, 2001).

Nurses not only have multiple definitions about the cause,

but also are generally unaware of interventions to treat and

champion the prevention of shoulder subluxation and

shoulder pain post-stroke.

However, physiotherapists are currently the only

professionals who are consistently implementing such

therapies. Stroke care provided by neuroscience nurses

includes range-of-motion exercises, transferring,

positioning and assisting in activities of daily living.These nursing interventions are rehabilitative in nature,

which clearly indicates that neuroscience nurses are an

important part of an interdisciplinary team and must

champion best practices in stroke rehabilitation

(Goulding, Thompson, & Beech, 2004). The purposes of

this paper are to discuss the causes of shoulder

subluxation and related pain post-stroke, review current

best practice in prevention and treatment of shoulder

subluxation and explore ways in which the acute

neuroscience nurse can prevent or reduce shoulder

subluxation in the hemiplegic stroke patient.

Post-stroke shoulder subluxationStroke patients who have upper extremity hemiplegia as a

lingering deficit are at risk for shoulder injury and related

pain. Possible causes of shoulder pain are spasticity of

shoulder, which occurs after an initial stage of flaccidity,

restricted shoulder range of motion and contractures,

sustained hemiplegic posture and shoulder

(glenohumeral) subluxation (Ada & Foongchomcheay,

2002; Moskowitz, Goodman, Smith, Balthazar, &

Mellins, 1969; Teasell et al., 2004; Tobis, 1957).

However, controversy exists regarding whether shoulder

Post-stroke

shoulder subluxation:

A concern for

neuroscience nurses


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subluxation causes post-stroke shoulder pain. Tobis

(1957) suggested because of flaccidity in the hemiplegic

shoulder joint, subluxation and pain occurs as the weight

of the unsupported arm pulls and stretches the shoulder

capsule and ligaments. However, researchers have not

been able to determine a relationship between shoulder

subluxation and pain (Bohannon & Andrews, 1990;

Zorowitz, Idank, Ikai, Hughes, & Johnston, 1995).

Nevertheless, Ada and Foongchomcheay (2002)

suggested severe untreated post-stroke shoulder

subluxation might eventually lead to chronic hemiplegic

shoulder pain and other shoulder injuries due to

immobility of the shoulder joint.

The shoulder joint consists of a complex series of joints: the

acromioclavicular, sternoclaviclar and the glenohumeral

joints. These joints have a wide range of motion that al lows

extreme mobility in the shoulder. The glenohumeral joint is

supported by the rotator cuff (supraspinatus muscle and

tendon), which keeps the humeral head in position and

moveable in the joint. In order for such mobility to occur,

stability of the joint is sacrificed, thereby exposing the

glenohumeral joint, in particular, to sprains, disease

processes, dislocation or to subluxation (Porth, 2005).

Shoulder subluxation is defined by Teasell et al. (2004) as

changes in the mechanical integrity of the glenohumeral

joint causing a palpable gap between the acromion and

humeral head (p. 6). Subluxation of a joint is a partial

dislocation wherein the joint and the humeral bone end

remain in partial contact via the connecting muscle or

ligament (Porth, 2005). In the initial phase of upper arm

hemiplegia, the supraspinatus muscle that supports the

humeral head into the glenohumeral joint is flaccid. Due to

flaccidity of this muscle, the arm is unsupported and is

pulled or stretched causing the humeral head to sublux

downward out of the shoulder joint (Teasell et al., 2004). Ifa hemiplegic arm is not supported properly during the

flaccid stage of hemiplegia and subluxation occurs, the

subsequent contracture will create permanent shoulder pain,

hinder movement and, ultimately, halt the patients

rehabilitation.

Prevention and treatmentIn the clinical setting, it is common to observe stroke

patients with their hemiplegic arm hanging lower than

their unaffected arm while in a seated position. The

unsupported arm hanging at the side of the patient or their

wheelchair, especially in the critical flaccid stage of the

hemiplegic arm, typically leads to shoulder subluxation.According to Teasell et al. (2004) improper positioning

in bed, lack of support while the patient is in the upright

position or pulling on the hemiplegic arm when

transferring the patient all contribute to glenohumeral

subluxation (p. 6). All of these contributing factors are

preventable and are factors that all disciplines, including

nurses, can control by championing best practice when

transferring and positioning patients in the bed or

wheelchair. Management of stroke patients with shoulder

subluxation and shoulder pain is the most ideal when it is

prevented from occurring in the first place (Walsh, 2001).

Strategies and/or interventions that neuroscience nurses

can employ to aid in preventing shoulder subluxation and

shoulder pain will be discussed in the nursing implications

section of the paper.

Post-stroke shoulder subluxation is a preventable injury but,

when it does occur, treatments are available that can aid in

strengthening the shoulder joint and decreasing pain (Teasell

et al., 2004; Walsh, 2001). The following is a review of

some strategies that have been shown to be effective intreating shoulder subluxation and shoulder pain.

Shoulder supports

The use of shoulder supports is common early after stroke

to decrease glenohumeral subluxation and support the

shoulder joint. Examples of shoulder supports are the

Henderson shoulder ring, Bobath role, Harris hemi-sling,

Rolyan humeral cuff sling, Cavalier shoulder support, arm

trough or lapboard and shoulder strapping (Brooke, de

Lateur, Diana-Rigby, & Questad, 1991; Morin & Bravo,

1997; Spaulding, 1999; Williams, Taffs, & Minuk, 1988;

Zorowitz et al., 1995). Conclusions about which shoulder

sling or supports are most beneficial are mixed andcontroversial (Spaulding, 1999; Teasell et al., 2004). Some

researchers support the use of the hemi-sling and

Henderson shoulder ring as they are the easiest of the

supports to apply, thereby ensuring that the shoulder is in

proper alignment and increasing prevention of shoulder

subluxation (Brooke et al., 1991; Morin & Bravo, 1997).

Other authors recommended the use of all supports

including the Bobath roll and shoulder strapping as long as

health care professionals properly assess individual patient

needs in order to ensure the correct choice regarding which

shoulder support will benefit the stroke patient (Williams et

al., 1988; Zorowitz et al., 1995). Also, Zorowitz et al.

(1995) noted that health care professionals should knowhow to apply and use shoulder supports properly and should

ensure that the patient and their family are also adequately

educated. In contrast, there are disadvantages to using

shoulder supports to prevent or reduce shoulder

subluxation. Shoulder supports can encourage flexor

synergies, inhibit arm swing, contribute to contracture

formation and decrease body image causing the patient to

further avoid using [their] arm (Teasell et al., 2004). When

a stroke patient wears a shoulder support, movement of the

arm is not only inhibited, but a decreased body image may

deter the patient from engaging in any rehabilitative

exercises. This, in turn, may delay and alter the

rehabilitation experience for the stroke patient. In addition,

shoulder supports in combination with adhesive shoulder

strapping can cause skin irritation (Morin & Bravo, 1997;

Walsh, 2001). Nevertheless, most researchers agree that

despite such disadvantages, shoulder supports are the best

method of supporting a flaccid hemiplegic arm when a

stroke patient is standing or transferring (Spaulding, 1999;

Teasell et al., 2004). All research studies examined for this

paper suggested that more research is required as there is a

paucity of research evidence to support the use of shoulder

supports or slings.


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Electrical stimulation

Electrical stimulation (ES) as a treatment for shoulder

pain and subluxation can be administered through

different electrical devices, two of which are:

transcutaneous electrical nerve stimulation (TENS) and

functional electrical stimulation (FES). First, TENS units

provide pain relief by transmitting electrical energy

through the skin to peripheral nerve fibres in the muscle

(Porth, 2005). In a randomized controlled trial conducted

by Leandri et al. (1990), high and low intensity TENS

stimulation versus placebo was evaluated in decreasing

shoulder pain. The researchers concluded that high

intensity TENS was effective in decreasing shoulder pain

and was effective in improving passive range of motion of

the shoulder joint. Second, FES was used to stimulate

paralyzed or flaccid muscles in the hemiplegic arm in

order to prevent shoulder subluxation (Teasell et al.,

2004). FES is administered using electrodes on the surface

of the skin or by implanted electrodes. Researchers have

demonstrated that FES is effective in preventing shoulder

subluxation, and determined that it is also effective in

improving pain, range of motion and arm function

(Chantraine, Baribeault, Uebelhart, & Gremion, 1999;Faghri et al., 1994).

Additionally, Ada and Foongchomcheay (2002) conducted

a systematic review of the effect of ES on the prevention

and reduction of shoulder subluxation and pain post-

stroke. The outcome of this review indicated that ES

administered to a stroke patient could aid in the prevention

of shoulder subluxation. The key point in this review was

that ES, when added to conventional therapy, should be

administered early in the patients recovery process rather

than late. Conventional therapy was defined as regular

physiotherapy sessions. As well, a systematic review

conducted by Price and Pandyan (2001) sought todetermine the efficacy of any form of surface ES when

used after stroke to prevent or treat shoulder pain and

increase passive humeral lateral rotation (p. 6). The

outcome of this review revealed that randomized

controlled trials have yet to confirm or refute the positive

effect of ES on reports of pain in the shoulder after stroke.

However, reduction in passive humeral lateral rotation

does appear to be a result of ES. According to Teasell et al.

(2004), ES, specifically functional electrical stimulation

(FES), can improve hemiplegic shoulder outcomes such as

tone, subluxation, pain and range of motion. Given such

improvements, ES is an important treatment for shoulder

pain and shoulder subluxation.

Gentle/passive range of motion

As discussed earlier, chronic shoulder subluxation in a

stroke patient can eventually lead to shoulder pain due to

contracture formation and spasticity. Teasell et al. (2004)

states, The association of spasticity, muscle imbalance

and a frozen shoulder with shoulder pain suggests that a

therapeutic approach designed to improve range of

motion of the hemiplegic shoulder will improve pain (p.

20). In fact, an immobile joint ravaged with contractures

and spasticity would benefit from passive range-of-

motion exercises to reduce pain. In a randomized

controlled trial conducted by Partridge, Edwards, Mee,

and Van Langenberghe (1990), shoulder pain was reduced

after initiation of a regimen of passive range of motion

based on the Bobath (1970/1990) method. Partridge et al.

(1990) found that, compared to cryotherapy or local cold

therapy, the Bobath method of encouraging normal

positioning and neutral postures during passive range of

motion improved pain. In addition, using a quasi-

randomized controlled trial design, Kumar, Metter,

Mehta, and Chew (1990) explored the incidence of

shoulder pain in patients after receiving three distinct

rehabilitation exercise regimens. Patients were

randomized to use an overhead pulley system, a shoulder

rest on wheels (skateboard) or receive range of motion

with the therapist. The researchers found that aggressive

use of the pulley system or skateboard increased shoulder

pain significantly as compared to passive range of

motion. The researchers concluded that a stroke patient

who suffers from hemiplegic shoulder pain could benefit

from passive or gentle range of motion in order to

decrease intensity and frequency of pain.

Shoulder supports, electrical stimulation, and passive or

gentle range of motion are treatments that can be used to

prevent and decrease the incidence of shoulder subluxation

and shoulder pain. Knowledge of individual patient needs

regarding body image, and education about how to

incorporate such treatments into their rehabilitative plan are

also important issues for health care professionals to

consider when caring for a stroke patient with shoulder

subluxation and pain. A collaborative approach is required

by all health care professionals to ensure that such

treatments are implemented properly and to ensure

knowledge about the potential for this injury is known and,

therefore, prevented.

Implications for neuroscience nursingThe role of neuroscience nurses in the prevention and

treatment of shoulder subluxation and shoulder pain has

been discussed minimally in the literature. According to

Rowat (2001), because of a lack of research to guide

nursing practices such as active range of motion, proper

positioning and transfers, nursing practice varies from unit

to unit and from hospital to hospital. Such diverse

practices and understandings of specialized stroke care

can lead to further injury for patients who have and are at

risk for shoulder subluxation and shoulder pain. The

following is a discussion of ways in which neurosciencenurses can prevent, treat, and reduce shoulder subluxation

and pain in stroke patients early in their rehabilitation

program.

Range of motion exercises

Given evidence that passive range of motion early in the

care of stroke patients can prevent shoulder subluxation

(Kumar et al., 1990; Teasell et al., 2004), it is crucial that

neuroscience nurses incorporate range of motion as part of

care provided to stroke patients with upper extremity

hemiplegia. In nursing programs across Canada, nursing


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students are taught the fundamentals of active and passive

range-of-motion exercises. Lab and clinical instructors on

neuroscience units teach nursing students how to perform

range-of-motion exercises and encourage students to use

these exercises when caring for stroke patients with

hemiplegia. Neuroscience nurses use range-of-motion

exercises to facilitate movement and use of the affected

arm. However, neuroscience nurses can also aid in

preventing shoulder subluxation simply by employing

range-of-motion exercises specific to the shoulder area.

Range-of-motion exercises for the shoulder joint include

flexion-extension, abduction-adduction, as well as

external and internal rotation (Alexander, Hiduke, &

Stevens, 1999; Hoeman, 2002). Such range-of-motion

exercises should be implemented using proper shoulder

and arm movement in order to encourage normal posture

alignment (Bobath 1970/1990). Proper positioning of the

arm is critical during the early stage of hemiplegia post-

stroke because of flaccidity and related instability of the

arm (Teasell et al., 2004). Even using basic range-of-

motion exercises improperly can cause injury to the

shoulder and increase the stroke patients risk for shoulder

subluxation. Therefore, care must be taken when usingrange-of-motion exercises in the shoulder area and nurses

should be aware of proper alignment and positioning of

the joint.

Positioning and transfers

Neuroscience nurses continually position, reposition and

transfer stroke patients over a 24-hour period. Not unlike

range-of-motion exercises, positioning and transfers are

nursing interventions that neuroscience nurses employ for

reasons such as comfort, pain relief and for mobility. In

order to be mobile, stroke patients depend greatly on the

assistance and interventions provided by nurses,

therapists, other professionals and family (Walsh, 2001).Walsh suggested that handling, positioning, and

transferring on a day-to-day basis can exert great stress on

the vulnerable shoulder (p. 645). During times when a

stroke patient is transferred to and from a wheelchair,

chair or bed, and is positioned in bed, they are at risk for

shoulder injury. Thus, proper positioning plays an

important role in reducing the risk of shoulder subluxation

and subsequent chronic pain.

However, nurses and other health care professionals

views regarding proper positioning vary. Carr and Kenney

(1992), during their review of proper positioning of the

stroke patient, found general agreement that post-stroke

shoulder joint should be protracted with the arm slightly

forward and in proper spinal alignment. As well, in a study

conducted by Dean, Mackey, and Katrak (2000), stroke

patients were exposed to extended positioning of the

affected arm in order to improve shoulder range of motion

and pain. However, results were inconclusive. That being

said, the main finding of reviews of proper positioning

suggested the affected arm must always be supported when

positioned and during transfers (Carr & Kenney, 1995;

Teasell et al., 2004).

In addition, proper positioning of a stroke patient remains

undefined due to a lack of consensus of best practice

(Goulding et al., 2004). Research conducted by Rowat

(2001) using mailed questionnaires examined beliefs held

about proper positioning of stroke patients by nurses and

therapists who worked on either a stroke unit, neurological

unit or general medical unit. Results indicated a lack of

consensus. However, an important conclusion from the

study was that specialization in an area increased

awareness, understanding and knowledge of the

importance of positioning of stroke patients (Rowat, 2001).

In another study, Pomeroy et al. (2001) examined

interventions used by nurses and therapists to position

stroke patients. More than 175 different types of

interventions were reported and, in addition, reports varied

between nurses and therapists. It is clear that further

research is indicated in the area of positioning and

transferring stroke patients due to a lack of consensus and

lack of research studies (Teasell et al., 2004).

None of the aforementioned nursing interventions should

be performed or implemented without collaboration

between nurses, therapists and other health care

professionals. Due to the fact that therapists work and care

for stroke patients mainly during one-hour therapy

sessions, collaboration is a key factor in order to ensure

around-the-clock rehabilitation for stroke patients

(Seneviratne & Reimer, 2004). If a stroke patient has been

diagnosed with shoulder subluxation, the sharing of skills

and knowledge between therapists and nurses should

enhance treatment of subluxation beyond set therapy

sessions. According to Goulding et al. (2004) it is

important that care management plans should be

multidisciplinary and there should be shared learning

within the multidisciplinary team of each professions

skills and knowledge (p. 538). That is, education betweennurses and therapists can occur through collaborative

practice and can ultimately enhance care provided to stroke

patients. Furthermore, education for families about

different interventions used by health care professionals to

prevent and treat shoulder subluxation and shoulder pain is

essential (Zorowitz et al., 1995).

DiscussionIn an atmosphere of interdisciplinary collaboration,

neuroscience nurses can be champions of best practice.

This can be achieved, for example, through collegial

discussion of current research evidence regarding

prevention and treatment of shoulder subluxation. Healthcare organizations and managers encourage nurses to

utilize best practice and research outcomes to inform their

clinical practice. Instead of repeating customary practices,

nurses can evolve, change and adapt their practice to

incorporate quality research findings into practice. Hynes

(2000) asserts that to combine research, patient choices

and clinical decisions together, a new level of evidence

is created that informs nursing practice (p. 453). Ciliska,

Pinelli, DiCenso, and Cullum (2001) suggested that, in

addition to research, evidence-based practice is informed


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through multiple sources such as clinician expertise,

available resources and individual patient preferences.

Nurses can use a combination of these four sources to

explore clinical questions and to promote evidence-based

nursing. Nurses can be active in incorporating current

research into their practice by joining literature review

clubs or committees that are exploring best practices for

their patient population.

However, barriers do exist that can hinder development and

implementation of best practices regarding shouldersubluxation and shoulder pain on a neuroscience or

specialized stroke unit. The first barrier is that it may be

difficult to find nurses and therapists who share a common

interest in shoulder supports, passive range of motion,

electrical stimulation and simple positioning strategies as

collaborative therapies to prevent and treat shoulder pain.

Nurses do not agree that it is their job to implement stroke

rehabilitation therapies such as electrical stimulation into

their acute neuroscience practice. In addition, therapists

have suggested that nurses have a role in stroke

rehabilitation that does not include using designated

physiotherapy or occupational therapy techniques.

Nevertheless, other therapists and nurses have stated the

opposite, noting the need for collaborative efforts in order

to improve patient outcomes.

Secondly, finding nurses to join a literature review group

or best practice in stroke rehabilitation committee, for

example, may be a challenge. According to DiCenso,

Cullum, and Ciliska (1998), barriers to the use of research

to inform practice are: lack of time, limited access to

literature, lack of training regarding literature searches and

critical appraisal, a closed work environment that does not

promote literature searches and a focus on practical skill

rather than intellectual knowledge. This may, in fact, prove

to be the greatest barrier because nurses do not readilyjump at opportuni ties for incorpora ting research into

practice.

Thirdly, according to Graham and Logan (2004), issues

such as decision-making practices, rules, regulations and

local organizational politics may be barriers to change.

In order to overcome this barrier, assessment of the

practice environment is critical. Open discussions with

managers, nurses, and therapists would only begin to

break down such barriers. As well, encouraging early

adopters or nursing practice innovators such as nurse

scientists to educate others in the importance of research

evidence will begin to foster the formation of acommunity of evidence-based practice (Estabrooks,

2003).

Neuroscience nurses work closely with stroke patients who

are at risk for shoulder subluxation and pain, thus it is

essential that nurses take up the challenge of incorporating

new and innovative practices to prevent and treat this injury.

However, it should be reiterated that neuroscience nurses

have the skills and knowledge regarding range of motion,

positioning and transfers of stroke patients. Incorporating

new knowledge of how such nursing interventions can be

used in conjunction with physiotherapy and occupational

therapy would not only enhance interdisciplinary

collaboration in the care and rehabilitation of stroke patients,

but would also prevent injuries such as shoulder subluxation

and related pain.

ConclusionShoulder subluxation and shoulder pain are important and

critical issues for stroke patients who have upper

extremity hemiplegia. Conclusions regarding shoulder

supports, electrical stimulation and passive range of

motion as interventions to prevent and treat shoulder

subluxation and related pain are controversial.

Nevertheless, consensus does exist regarding the need to

support the affected arm when positioning and transferringstroke patients in order to decrease risk for shoulder

subluxation. Nurses and therapists who provide range-of-

motion exercises, position and transfer stroke patients

need to collaborate in order to enhance the care provided

to stroke patients. As stroke rehabilitation is a 24-hour

process, nurses should collaborate with therapists and

other health care professionals in order to increase

understanding of potential complications related to post-

stroke hemiplegia, and to promote evidence-based

neuroscience practice beyond one-hour therapy sessions.

Neuroscience nurses are well-positioned, due to the

comprehensive care they negotiate with stroke patients

and their families, to champion collaborative practice and

the incorporation of current research into stroke care by

being open to and facilitating education between

disciplines.

About the authorsCydnee Seneviratne, RN, MN, PhD(C), is an Instructor and

Doctoral Candidate, and Karen L. Then, RN, ACNP, PhD, is

an Associate Professor, University of Calgary, Faculty of

Nursing. Marlene Reimer, RN, PhD, CNN(C), is Professor

and Dean, University of Manitoba, Faculty of Nursing. If

you have any questions or comments about the paper, please

contact Cydnee Seneviratne at [email protected].

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