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Management of Common Shoulder Problems in Upper Motor Neuron Syndrome


Introduction

The shoulder is a common source of pain and impairment in patients who have sustained a cerebrovascular accident, traumatic brain injury (TBI), or other upper motor neuron (UMN) injuries. Impaired motor control, synergistic movement patterns, stimulation of distant movements, muscle paresis, spasticity, and rigidity characterize these injuries. A net imbalance of muscle forces across joints can lead to dynamic and static joint deformities. The most common shoulder problems seen in UMN syndrome are inferior subluxation, limitation of active movement, and contractures with no active movement. Treatment options for the shoulder have been limited and often inadequate.

Inferior Subluxation

Patients with upper motor neuron injury of any etiology can suffer inferior glenohumeral subluxation which can be both painful and limit function. If a patient's symptoms are relieved by manual reduction of the subluxation, the pain is considered mechanical in nature and potentially amenable to surgical reduction. We devised a surgical procedure to reduce the subluxation by using the biceps tendon to support the shoulder.

We performed a retrospective case series of 11 consecutive hemiplegic patients with painful glenohumeral subluxation who underwent surgical reduction with a biceps suspension procedure. Seven patients additionally underwent a shoulder release for contractures. Preoperative and postoperative variables included assessment of pain by visual analog scale (VAS), physical examination parameters, and radiographic evaluation. Additionally, patient satisfaction with the outcome of surgery was determined.

Mean follow-up was 3.2 years (2.0-5.8). The average age was 46.9 years (18-81). There were one male and ten female patients. All patients had pain with passive ROM preoperatively and only one patient complained of pain with passive ROM postoperatively (p < 0.001). Mean postoperative VAS for pain was 1.45 (rage 0-5). All patients noted improved pain after surgery. Ten patients noted that deformity was improved at follow-up. All patients had a sulcus sign preoperatively compared to three patients postoperatively (p < 0.001). When analyzing the seven patients who underwent a shoulder release, there were improvements in extension (p = 0.009), flexion (p = 0.030), abduction (p = 0.040), and external rotation (p = 0.043) from pre- to postoperatively. Ten patients were satisfied with the outcome of surgery. Preoperative radiographs demonstrated inferiorly subluxed glenohumeral joint in all patients. Postoperatively, ten patients had improved glenohumeral position and nine of these patients had complete reduction. Our conclusion was that the biceps suspension procedure can provide pain relief in patients with painful subluxation of the shoulder after upper motor neuron injury. Shoulder release can improve passive ROM in patients with spasticity.

Limitation of Active Movement

Patients with spastic hemiparesis after upper motor neuron (UMN) injury often exhibit limited shoulder movement. Using dynamic poly-EMG, we evaluated the muscle control during attempted active movement. These studies indicated that the anterior deltoid muscle was appropriately active during attempted forward reach. The pectoralis major, latissimus dorsi, teres major, and long head of the triceps showed co-contraction during forward arm movement. We devised a surgical technique to perform fractional lengthenings of these muscles in an attempt to improve active movement and function.

We recently reviewed a consecutive series of 34 adults with UMN injury (23 post-stroke, 11 post-traumatic brain injury), who underwent shoulder tendon fractional lengthenings. Active and passive shoulder motion, spasticity, pain, and satisfaction were considered pre and postoperatively.

There were 15 males and 19 females with a mean age of 44.1 years. Mean follow up was 12.2 months. Mean Modified Ashworth spasticity score was 2.4 preoperatively compared to 1.9 postoperatively (p=0.001). Active flexion, abduction and external rotation improved compared to the normal contralateral side (p<0.001) with most dramatic gains in external rotation. Similarly, passive extension, flexion, abduction, and external rotation improved compared to the normal contralateral side (p < 0.01). 94% (15/16) with preoperative pain had improved pain relief postoperatively with 14 (88%) being pain-free. Thirty-one (92%) were satisfied with the outcome.

Our conclusion was that shoulder tendon lengthenings can be an effective means of pain-relief, improved motion, enhanced active motor function, and decreased spasticity in patients with impaired shoulder movement after UMN injury.

Contractures with No Active Movement

Shoulder adduction and internal rotation contractures commonly develop in patients with upper motor neuron (UMN) injury. Contractures are often painful, cause skin maceration, and impair axillary hygiene.

We reviewed a consecutive series of 36 adults (10 men, 26 women) with spastic hemiplegia from UMN injury, shoulder adduction, and internal rotation contractures, and no active movement, who underwent shoulder tenotomies of the pectoralis major, latissimus dorsi, teres major, and subscapularis were evaluated. Patients were an average age of 52.2 years. Pain, passive motion, and satisfaction were considered preoperatively and postoperatively.

Mean follow-up was 14.3 months. Preoperatively, all patients had limited passive motion that interfered with passive functions. Nineteen patients had pain. After surgery, passive extension, flexion, abduction, and external rotation improved from 50%, 27%, 27%, and 1% to 85%, 70%, 66%, and 56%, respectively, compared with the normal contralateral side (P < .001). All patients with preoperative pain had improved pain relief at follow-up, with 18 (95%) being pain-free. Thirty-five (97%) were satisfied with the outcome of surgery, and all patients reported improved axillary hygiene and skin care. Age, gender, etiology, and chronicity of UMN injury were not associated with improvement in motion.

We concluded that shoulder tenotomy to relieve spastic contractures resulting from UMN injury can be an effective means of pain relief and improved passive range of motion in patients without active motor function.

Department of Orthopaedic Surgery University of Pennsylvania School of Medicine

References:

  1. Namdari S, Keenan MA. Outcome of Surgical Treatment of Painful Inferior Glenohumeral Subluxation in Hemiparetic Patients: The Biceps Suspension Procedure. J Bone Joint Surg Am 2010 Nov 3;92(15):2589-97.

  2. Namdari S, Alosh H, Baldwin K, Mehta S, Keenan MA. Shoulder tenotomies to improve passive motion
    and relieve pain in patients with spastic hemiplegia after upper motor neuron injury. J Shoulder Elbow Surg 2011 Jan 11. [Epub ahead of print]

  3. Namdari S, Alosh H, Baldwin K, Mehta S, Keenan MA. Outcomes of tendon fractional lengthenings in spastic hemiparetics with intact motor control and shoulder contractures. J Shoulder Elbow Surg [In Press]

  4. Namdari S, Keenan MA. Treatment of glenohumeral arthrosis and inferior shoulder subluxation in adult cerebral palsy: case report. J Bone Joint Surg Am. [In Press]

  5. Namdari S, Keenan MA. The Biceps Suspension Procedure for Treatment of Painful Inferior Glenohumeral Subluxation in Hemiparetic Patients: Surgical Technique. J Bone Joint Surg Am [In Press]