Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Reviews
Year : 2022 | Month : April | Volume : 16 | Issue : 4 | Page : YE01 - YE05 Full Version

Physical Therapy in Hemiplegic Shoulder Pain: A Systematic Review


Published: April 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/52483.16266
Roshan Lal Meena, Tarun Kumar, Sandeep Singh

1. Assistant Professor, Department of Physiotherapy, Pandit Deendayal Upadhyaya National Institute for the Persons with Physical Disabilities, (University of Delhi), Delhi, India. 2. Assistant Professor, Department of Physiotherapy, Amar Jyoti Institute of Physiotherapy, (University of Delhi), Delhi, India. 3. Assistant Professor, Department of Physiotherapy, Punjabi University, Patiala, Punjab, India.

Correspondence Address :
Tarun Kumar,
G-37, Jagat Puri, Delhi-110051, India.
E-mail: physiotarun29@gmail.com

Abstract

Introduction: Shoulder joint pain in hemiplegic patients is a common complication which interferes with the therapeutic exercises, influences activities of daily living, social participation and delays the recovery process. Various treatment methods have been given to prevent and manage the Hemiplegic Shoulder Pain (HSP). The purpose of present systematic review was to find the study which is most effective in HSP.

Aim: To determine the most effective method used in physical therapy for the management of HSP.

Materials and Methods: In the present systematic review, a search of PubMed, Physiotherapy Evidence Database (PEDro), CINHAL, Scopus database, Google Scholar, Cochrane Library Register of control trials and bibliography was conducted from January 2016 to March 2020. Randomised clinical trials were included in the review. The methodological quality of the identified Randomised Controlled Trials (RCTs) was assessed using the McMaster Critical Appraisal Tool. The RCTs which scored less than 9 out of 15 or below 64.2% on McMaster Critical Appraisal Tool were not included into the systematic review.

Results: A total of 1337 citations were identified, however, only six RCTs matched the eligibility criteria and were included in the review. The identified studies were similar in design. Investigated diverse physical therapy modalities that were applied for dissimilar periods, and outcome measures assessed at different periods which shown inconsistent results.

Conclusion: This systematic review found evidence for improvement in HSP in those treated with Kinesiotaping (KT) and Electromyography (EMG) triggered Neuromuscular Electrical Stimulaton (NMES) with bilateral arm training. However, more number of RCTs needed to substantiate the results.

Keywords

Conservative management, Motor impairment, Physiotherapy, Post stroke, Rehabilitation

Pain in the shoulder joint in patients with hemiplegia after stroke is a common complication, with a prevalence of 16-84% worldwide (1),(2),(3),(4). The HSP, can inhibit contraction of muscles around shoulder complex, that interferes with exercises, delays the recovery in the motor function, influences activities of daily living and social participation [5,6]. Pain in acute stage following stroke prolongs hospitalisation, and negatively affects the patient’s quality of life. The HSP adversely affects the recovery of arm function and independence in activities of daily living (7). Hemiplegic shoulder pain is associated with a greater severity of motor impairment, however, no single aetiology has been found as a cause of HSP (8).The possible causes of HSP are shoulder subluxation, rotator cuff tears, rotator cuff tendinopathy and deltoid tendinopathy and bicipital and supraspinatus tendon tenderness (9). The Glenohumeral Subluxation (GHS), is often identified as one of the major causes of HSP (10),(11),(12). The shoulder subluxation in patients with HSP has been found to be associated with rotator cuff tears, thus it may be an indirect cause of HSP (1). The presence of GHS is commonly accepted to be an important risk factor for developing a shoulder hand syndrome (13) or other complications such as decreased range of motion, plexus brachialis injuries, adhesive changes, and sub-acromial impingement (14),(15). Patients with severe arm weakness and/or shoulder subluxation within 72 hours of stroke are at significantly higher risk of HSP at 8-10 weeks (16).

Clinical observations suggest that shoulder pain does not occur until spasticity develops. In the later stage, when patient develops spasticity in the arm and shoulder girdle muscle, the shoulder exhibits adduction, internal rotation, limited range of motion with pain (17). On the other hand, the stroke patients with a flaccid shoulder have a high incidence of shoulder subluxation that results in shoulder soft tissue injury and pain (18),(19). Muscle weakness after stroke is considered to be one of the major causes of the HSP as the muscles do not contract effectively against the gravity and fail to keep the head of humerus in the glenoid fossa. The soft tissues around the shoulder joint get stretched gradually and torn, that results in HSP.

It may be inferred from the abovementioned studies that, the aetiology of HSP is multifactorial. The stroke patients with flaccid shoulder in the acute stage have a high incidence of shoulder subluxation due to poor protective functions that results in soft tissue stretching, injury and pain. In the chronic stage, when patients develop spasticity in the arm and shoulder girdle muscles, the shoulder joint exhibits a particular synergistic pattern that leads to functional limitations and pain. Therefore, HSP may either be developed in the acute or in the chronic stage, if not given an appropriate intervention.

To decrease the incidence and to prevent and manage HSP, many therapeutic techniques have been proposed which include proper positioning, shoulder sling and strapping (20), functional electrical stimulation (21), kinesiology tapping (22), physical modalities (23), sub-acromial hyaluronic acid injections (24), and subcutaneous needling (25). However, none of these studies have shown to be significantly superior to others. Therefore, the research question of the present review was to find out “Which treatment method of physiotherapy is more effective in patients with HSP?”

Material and Methods

The systematic review was reported in line with the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) statement to find out the more efficient physiotherapy methods in patients with HSP in the available RCTs. A medical literature search was carried out in the following database Medline, CINAHL, PEDro, Scopus database, Google Scholar and Cochrane Library register of control trials from January 2016 to March 2020. The language of the studies was restricted to English. The search was performed using keywords- hemiplegic shoulder, HSP, HSP and subluxation, shoulder pain and shoulder sling, shoulder taping, exercise therapy, physical therapy and shoulder rehabilitation. The title and abstracts of the literatures were reviewed and the potential ones were chosen, then checked full texts of the selected articles according to the inclusion and exclusion criteria. A total of six RCTs met the inclusion criteria, were included in the present systematic review [9,26-30]. Studies included a total of 270 participants. Three studies observed the effectiveness of the therapeutic KT. The fourth study compared between the effects of actimove, shoulder lift and no shoulder sling, whereas fifth study compared the effects of modified wheel chair arm support and routine physiotherapy versus Ordinary wheel chair with ordinary armrest for assistance and, the sixth and last study compared the effects EMG-Triggered NMES, Transcutaneous Electrical Nerve Stimulation (TENS), and bilateral arm training to both the groups.

Literature Search and Identification of Relevant Studies

Following establishment of review protocol (design of the study, intervention, inclusion and exclusion criteria, outcome measures, adverse events and time frames), two authors allocated the database search and screened titles and abstracts of the studies. The studies published in the language other than the English were excluded. All the potential titles, abstracts and full texts were reviewed independently for inclusion and exclusion criteria. Disagreements were checked by the third reviewer regarding inclusion and was resolved through discussion. A total of 1337 articles were identified in the initial search. Out of 1337 articles, 542 were removed for duplication, 38 potentially relevant articles were selected and 757 were excluded from the study. The full text of 38 articles were obtained to check eligibility, in those, 32 were excluded because they failed to meet the inclusion criteria. Only six RCTs were included in the final systematic review (Table/Fig 1).

Study Design

The systematic review included the RCTs with the following inclusion and exclusion search criteria- RCTs, trials published in English, trials conducted on the patients with HSP and/or subluxation, which included any of the physiotherapeutic approach for the management of HSP such as physical therapy exercises, or electrotherapy modalities (electrical stimulation), or therapeutic KT, or shoulder sling. The RCTs which used a patient reported functional outcome measures for HSP were also included into the review. The RCTs that scored less than 9 out of 15 or below 64.2% on McMaster critical appraisal tool were not included into the systematic review. The systematic review excluded the following studies: non RCTs, literature reviews, pilot studies, duplicate studies, case studies, case reports, studies without integrated data (Table/Fig 2), outlines the inclusion and exclusion criteria. The studies that used any invasive interventions such as surgical interventions, acupuncture, and needling and injections for the management of hemiplegic shoulder have also been excluded.

Outcome Measures

Studies which utilised patient reported measures such as Fugle-Meyer Assessment for Upper Extremity (FMA-UE), or Modified Barthel Index (MI), or Modified Ashworth Scale (MAS), pain rating scales such as Visual Analogue Scale (VAS), or, Numerical Rating Scale (NRS), or Shoulder Pain and Disability Index (SPADI); were included in the systematic review.

Time

The trials conducted on the patients with HSP for not less than three weeks with a maximum period of eight weeks including follow-up period were considered for the systematic review. The studies those did not collect the outcome data of all the subjects within the stipulated time frames were excluded from the review.

Methodological Quality

The methodological quality of the studies was assessed by using the McMaster critical Review Form for Quantitative studies (31). The tool comprises of 15 items that assesses study purpose, design, sample, outcomes, interventions, results and clinical implications. Fourteen items of the tool assesses quantitative data with the response of yes or no, whereas, one item assesses qualitative data i.e., type of study design. The studies were awarded one point for each ‘yes’ and zero for ‘no’ or ‘not addressed’ response. The raw data (total quantitative score of the study out of 14) were calculated and expressed in percentage divided by 14 and multiplying by 100 (Table/Fig 3) (9),(26),(27),(28),(29),(30).

Results

Six studies were screened for the review which did trial on a total of 270 participants. Three studies saw the effectiveness of the therapeutic KT conducted by Huang YC et al., Huang YC et al., Yang L et al., reported p-value <0.05 (9),(26),(30). The fourth study compared the effects of Actimove versus shoulder lift versus no shoulder sling. Actimove group reported more pain at rest (p=0.036). The shoulder subluxation remained unchanged in the Actimove group (-2.77% or 0.27 mm). The fifth study compared the effects of modified wheel chair arm support and routine physiotherapy versus ordinary wheel chair with ordinary armrest for assistance. The study showed improvement in shoulder pain (p<0.001) (Table/Fig 4) dd: (9),(26),(27),(28),(29),(30). The sixth and last study compared the effects of EMG-Triggered NMES TENS, and bilateral arm training to both the groups and found to lower the pain intensity during active and passive shoulder movement (p=0.007 and p=0.008), lower worst pain intensity (p=0.003), and greater pain-free passive shoulder abduction (p=0.001) and internal rotation (p=0.004) at follow-up.

Therapeutic Kinesiotaping (KT): Haung YC et al., used KT and sham taping on participants with HSP during the hospital stay. The therapeutic KT was aimed to provide proprioception, biofeedback, facilitation of muscle strength and to improve joint stability (26). Both the therapeutic KT and sham KT was performed by the same physiotherapist; and the therapist was blind which KT was the therapeutic one. The KT was applied for three days followed by one day rest to avoid continuous tension on the shoulder. The authors found that the therapeutic KT may limit the development of HSP and improve pain free shoulder flexion in subacute stroke patients at risk during the rehabilitation (p=0.01 in experimental group and p=0.78 in the control group).

Huang YC et al., have applied KT to both the experimental and the control group. The application of KT to the experimental and control group was applied in the same manner, however; the KT was applied to the control group without the tension. Moreover, the KT in the control group did not cross the joint line. There was significant improvement in the pain and range of motion of the shoulder after three weeks of the KT application. Authors suggested, KT as an alternative treatment option for the patients with HSP (Table/Fig 5) (9),(26),(27),(28),(29),(30).

Yang L et al., (2018) conducted RCT on HSP. The experimental and control group received therapeutic kinesiology taping and placebo taping respectively. The therapeutic KT was aimed to activate the neuromuscular functions and to produce mechanical support to the shoulder joint and also to facilitate the supraspinatus, deltoid, and teres minor muscles. The experimental group showed immediate improvement in terms of pain intensity, magnitude of subluxation, and muscle activity, whereas, no significant changes were observed in the control group. The study revealed that the effectiveness of kinesiology taping for HSP might be good alternative for relieving shoulder pain, improving the active range of motion, subluxation, and muscle activity of the shoulder (30).

Arm slings: Van Bladel A et al.,conducted RCT on patients with severe upper limb impairments. They used two devices actimove sling and the shoulder lift. The control group was not given any sling whereas, other two groups were given actimove sling and shoulder lift respectively for three weeks. The study stated that wearing a shoulder sling does not seem to prevent pain and shoulder subluxation. Contrary to that there was reduction in the acromio-humeral-distance in the control group who was not given any kind of sling during the study period.The study suggested that prescribing a sling might not be the preferred treatment approach since it may actually inhibit active correction (28).

Modified wheel chair arm-support: Pan R et al.,in their single blind trial have seen the effect of modified wheel chair arm support in decreasing HSP. The experimental group received the modified wheel chair whereas; the control group was given the ordinary wheel chair. The modified wheel chair included, the board designed to support the arm, with a thick handle equipped at the end of the board which could be held with the hand. Authors noted that both the groups showed improvements in shoulder pain, upper extremity movements, independence of daily living and quality of life during the four weeks of intervention and after the 12 weeks of follow-up, and the difference within groups were significant (p<0.001) the study stated that using the modified wheel chair arm support could lead to the mitigation of HSP and reduction in pain incidence in post stroke individuals (29).

EMG triggered neuromuscular electrical stimulation: Chuang LL et al., conducted a single blind RCT to see the effect of EMG-triggered NMES with bilateral arm training on HSP and arm function in post stroke hemiparetic patients. The study found that EMG-triggered NMES combined with the bilateral arm training was better than the TENS with bilateral arm training for reducing HSP during movement, lessening the worst shoulder pain, and improving pain free shoulder abduction and internal rotation for stroke patients with HSP (27).

Discussion

This review found that there was strong evidence for improvement in patient-reported functional outcomes in those who develop HSP. There was relative consistency between studies across multiple timeframes with sustained HSP after stroke. Nearly all studies that examined HSP reported statistically significant improvements in favour of shoulder pain after stroke, with moderate to large effect sizes in two studies. Conversely, there was an overall improvement in patient-reported functional outcomes in subjects with HSP developed after stroke who participated in any kind of intervention like therapeutic KT, arm sling, modified wheel chair arm support and EMG-electrical stimulation.

Given the above findings, it is reasonable to question the use of any kind of supportive intervention in the management of patients with stroke. Huang YC et al., (2016, 2017) reported that therapeutic KT is effective in HSP in both pain and functional outcome (9),(26). Yang L et al., also found that the KT is an effective measure for reducing shoulder pain and increasing Range of Motion (ROM) (30). Pan R et al., concluded that modified wheel chair arm support for HSP after stroke found that using the modified wheel chair arm support could lead to the mitigation of HSP in stroke patients (29). Chuang LL et al.,results revealed that EMG-triggered NMES combined with bilateral arm training was a better option for reducing HSP during movement (27). Some issues within included studies may have influenced the results of this systematic review. Van Bladel A et al., concluded that reduction of acromio-humeral-distance in the hemiplegic individual with shoulder sling as compared to the hemiplegic individual without shoulder sling. However, this reduction did not prevent shoulder pain and subluxation since it may inhibit activation of muscle for active correction of subluxation (28). The study conducted by Pan R et al., gave incomplete information regarding the control group (29). The moderate methodological quality of included studies was also likely to affect the results of the present review.

Shoulder pain in patients with hemiplegia is a common problem.The HSP leads to gross disability and functional limitations in the upper extremity. The present systematic review has found numerous methods of treatment for an HSP. Therapeutic KT and EMG triggred NMES with bilateral trainer found to be more effective than the others for HSP.

The use of these techniques in the clinical practice would enable the clinicians to manage the patients with HSP in a more controlled and effective manner. The therapeutic KT and EMG triggered NMES could be an alternative treatment for the management of the HSP. Further research of interventions for HSP would benefit from more accurate descriptions of intervention and co-intervention including type, duration, and intensity. Future research should also continue, to embrace the use of reliable and valid outcome measures.

Limitation(s)

The RCTs reviewed for this systematic review had scored 9 out of 15 on McMaster Appraisal Tool however, high quality trails above 9/15 may be needed on the large-scaled sample size to see the effectiveness of therapeutic KT and EMG triggered NMES.

Conclusion

The present systematic review found a strong evidence of improvement in HSP those treated with the KT. The EMG triggered NMES also showed significant improvement in the shoulder pain and abduction and internal rotation movements which can be an adjunct to the exercises. It can be summarised, that, therapeutic KT and EMG triggered NMES are beneficial in improving the shoulder pain and ranges. Shoulder sling might not be the preferred treatment approach for the management of HSP, as it may actually inhibit active correction.

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DOI and Others

DOI: 10.7860/JCDR/2022/52483.16266

Date of Submission: Sep 19, 2021
Date of Peer Review: Nov 08, 2021
Date of Acceptance: Jan 18, 2022
Date of Publishing: Apr 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? NA
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA

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