Summary of findings:
Using the figures given below in a very rough calculation, we can
assume an order of magnitude of about 15 million cases of stroke
worldwide each year, with around 10 million surviving.
The reported incidence of shoulder subluxation in stroke survivors
varies drastically from 17% to 81%. No doubt this is due to the
differences in the diagnostic techniques used. That gives a
potential population of around 2-8 million worldwide, perhaps 4-5
million as a conservative estimate. Due to the aetiology of stroke, it
is reasonable to assume that the majority of these will be in the
An article from 2001 on the WHO web site says Of the 16.6 million
deaths from CVDs every year,
5.5 million [are due to] to
Another WHO document from 2000 implies that there is little difference
in survival if high-tech medical assistance is or is not available:
With no treatment at all, 61.5% of stroke patients die or become
dependent. Giving aspirin some time after the stroke raises the
chances of a favourable outcome by 0.5%. Access to an organized care
setting in a stroke unit adds a further 2.7%. However, performing a
computed tomography (CT) scan in that setting further increases the
chances of a favourable outcome by only 0.4%. Thus, for stroke
patients in developing countries, aspirin given in a low-tech but
organized setting offers about the same benefit as a typical high-tech
approach in an industrialized country.
David Wiebers MD gives the following information:
Ischemic stroke (the most common type of stroke,
has a 20
percent mortality rate in the first thirty days. Survival is about 65
percent at one year and 50 percent at five years. Between 60 and 70
percent of ischemic stroke survivors have some disability immediately
after the stroke, 40 percent at six months and 30 percent at one year.
Subarachnoid hemorrhage (one of two types of hemorrhagic stroke) has a
40 percent mortality at thirty days. About half of those who survive
are disabled. Statistics for intracerebral hemorrhage (the other major
type) are similar.
B. Shoulder subluxation
A paper that is also listed below, with respect to treatment
possibilities states that:
Subluxation of the glenohumeral joint is a well-recognized
complication experienced by stroke patients. The reported incidence of
shoulder subluxation varies greatly, from 17% to 81%.
Stroke. 1999 May;30(5):963-8.
Prevention of shoulder subluxation after stroke with electrical
Linn SL, Granat MH, Lees KR.
Bioengineering Unit, University of Strathclyde, Glasgow, Scotland.
Full text available at:
With respect to the lower and upper estimates of incidence cited
above, the two papers referred to by the authors are:
This is a study of 100 hemiplegic patients of whom 17 had downward
subluxation of the shoulder joint.
Age Ageing. 1975 Feb;4(1):16-8.
Subluxation of the shoulder in hemiplegia.
Fitzgerald-Finch OP, Gibson II.
Najenson T, Pikielny SS. Malalignment of the glenohumeral joint
following hemiplegia. Ann Phys Med. 1965; 8:9699.
A French study found that:
Shoulder subluxation was observed in 32% of hemiplegic patients.
After multiple regression analysis, the main clinical factors related
to subluxation were motor (p < 0.0001), spasticity of shoulder
adductors (p = 0.028) and age (p = 0.036). Statistically, the risk of
subluxation was divided by 1.62 (1.07, 2.43) for every five years age
growth and by two (1.33, 2.94) when the motricity index went up by ten
points. CONCLUSION: This study shows that the age could play an
independent part. The loss of elasticity of the periarticular tissues
when ageing could have a protective role.
Published in Ann Readapt Med Phys. 2002 Nov;45(9):505-9.
[Clinical factors associate with shoulder subluxation in stroke
[Article in French]
Daviet JC, Salle JY, Borie MJ, Munoz M, Rebeyrotte I, Dudognon P.
Departement de medecine physique et de readaptation, hopital J.
Rebeyrol, CHU Dupuytren, 87042 Limoges
A Canadian study of a new diagnostic procedure reported that of 72
hemiplegic stroke patients examined, 36 had a shoulder subluxation,
giving an incidence of 50%.
Arch Phys Med Rehabil. 1993 Feb;74(2):188-93.
A radiological measure of shoulder subluxation in hemiplegia: its
reliability and validity.
Boyd EA, Goudreau L, O'Riain MD, Grinnell DM, Torrance GM, Gaylard A.
Occupational Therapy Department, Rehabilitation Centre, Ottawa,
A British study found an incidence of 54%
Scand J Rehabil Med. 1988;20(4):161-6.
Degree of pain and grade of subluxation in the painful hemiplegic
Van Langenberghe HV, Hogan BM.
Physiology Department, King's College, London, UK
To summarize the articles listed below:
I have only found two passing references in one article to the use of
biofeedback specifically with respect to shoulder subluxation, and the
abstracts of both papers cited do not mention subluxation as such.
The main treatment options seem to be either external support or
A number of devices exist for external support. Those listed in the
papers found include: Harris hemisling, Bobath sling (Bobath axillary
roll), Rolyan humeral cuff, Cavalier support, arm trough or lap board.
There is some controversy among occupational therapists about which
is the best. The authors of one article recommend that each patient
should be evaluated with a number of devices in order to find the one
most suitable for that individual case. One study reported that
strapping was ineffective.
Electrical stimulation of the shoulder muscle can reduce or prevent
subluxation. It appears to be more effective when used early after
stroke for prevention. It also seems that the preventative effect
lasts only as long as the treatment is maintained. A number of
different electrical stimulation techniques are available. In one
study, patients preferred percutaneous (intramuscular) neuromuscular
electric stimulation (perc-NMES) over transcutaneous neuromuscular
electric stimulation (trans-NMES) on account of it being less painful.
There is also a report of miniature injectable neuromuscular
stimulators (BIONS) being used.
Electroacupuncture has been reported to be a useful adjuvant therapy.
The first trial is aimed at preventing chronic shoulder subluxation
after stroke by stimulating deltoid and supraspinatus muscles daily
for six weeks. Results of five subjects showed reductions of shoulder
subluxation only for experimental subjects and muscle thickness
increases in stimulated muscles.
BIONS are microminiature, single channel stimulators that can be
injected into muscles. They receive power and individually addressable
commands from an external magnetic field.
CLINICAL TRIALS OF BION INJECTABLE NEUROMUSCULAR STIMULATORS
Anne-Caroline Dupont1, Stephen D. Bagg2, Janet L. Creasy2, Carlo
Romano3, Delia Romano3, Gerald E. Loeb1 and Frances J.R. Richmond1
1AE Mann Institute for Biomedical Engineering, Los Angeles, CA, USA
2Queens University, Kingston, Ontario, Canada
3Istituto Ortopedico Gaetano Pini, Milan, Italy
Full text: http://ami.usc.edu/Projects/Bion/docs/IFESS01-Bclin.pdf
A paper from Australia reports a meta-analysis of 7 clinical trials on
the efficacy of electrical stimulation of the shoulder muscles, and
concludes: Analysis found that, when added to conventional therapy,
electrical stimulation prevented on average 6.5mm of shoulder
subluxation (weighted mean difference, 95% CI 4.4 to 8.6) but only
reduced it by 1.9mm (weighted mean difference, 95% CI -2.3 to 6.1)
compared with conventional therapy alone. Therefore, evidence supports
the use of electrical stimulation early after stroke for the
prevention of, but not late after stroke for the reduction of,
Published in Australian J Physiotherapy 2002;48(4):257-67.
Efficacy of electrical stimulation in preventing or reducing
subluxation of the shoulder after stroke: a meta-analysis.
Ada L, Foongchomcheay A.
The University of Sydney, Australia.
An American study found that percutaneous (intramuscular)
neuromuscular electric stimulation (perc-NMES) is less painful than
transcutaneous neuromuscular electric stimulation (trans-NMES) for
treating shoulder subluxation in hemiplegia and was preferred by 9 out
of the 10 patients in the study.
Arch Phys Med Rehabil. 2001 Jun;82(6):756-60. Comparing
stimulation-induced pain during percutaneous (intramuscular) and
transcutaneous neuromuscular electric stimulation for treating
shoulder subluxation in hemiplegia.
Yu DT, Chae J, Walker ME, Hart RL, Petroski GF.
Department of Physical Medicine and Rehabilitation, MetroHealth
Medical Center, Cleveland, OH 44109
European experience with perc-NMES:
StIM System for the Treatment of Painful Shoulder Subluxation in
Chronic Hemiplegia: The First European Experience
G.J. Renzenbrink, J.M.M. Jannink-Nijlant, M.J. IJzerman
Roessingh, dept. rehabilitation medicine, Enschede, the Netherlands
A Cochrane review of 4 studies of electric stimulation for post-stroke
shoulder pain concluded that: ES reduced the severity of glenohumeral
subluxation (SMD -1.13; 95% CI -1.66 to -0.60), but there was no
significant effect on upper limb motor recovery (SMD 0.24; 95% CI
-0.14-0.62) or upper limb spasticity (WMD 0.05; 95% CI -0.28-0.37).
Clin Rehabil. 2001 Feb;15(1):5-19.
Electrical stimulation for preventing and treating post-stroke
shoulder pain: a systematic Cochrane review.
Price CI, Pandyan AD.
Geriatric Medicine, Newcastle University and Northumbria Healthcare
NHS Trust, Newcastle upon Tyne, UK
A Scottish study compared 40 stroke patients who were or were not
given electrical stimulation to prevent shoulder subluxation.
Treatment started within 48 hours of the stroke and continued for 4
weeks. Patients were assessed at the end of treatment and after a
further 8 weeks. The authors concluded: The treatment group had
significantly less subluxation and pain after the treatment period,
but at the end of the follow-up period there were no significant
differences between the 2 groups. CONCLUSIONS: Electrical stimulation
can prevent shoulder subluxation, but this effect was not maintained
after the withdrawal of treatment.
Stroke. 1999 May;30(5):963-8.
Prevention of shoulder subluxation after stroke with electrical
Linn SL, Granat MH, Lees KR.
Bioengineering Unit, University of Strathclyde, Glasgow, Scotland.
Full text available at:
The authors of the above study also make the following comments about
the use of slings:
Traditionally, slings have been applied to prevent or reduce shoulder
subluxation after stroke. The most effective slings have the drawback
of holding the limb in a poor position that is likely to cause soft
tissue contracture and have a disadvantageous effect on symmetry,
balance, and body image
They give the following four references in support of that statement:
Three citations to book chapters:
Bobath B. Adult Hemiplegia: Evaluation and Treatment. 3rd ed. London,
UK: Heinemann Medical Books; 1990:106107.
Carr JH, Shepherd RB. A Motor Learning Programme for Stroke. 2nd ed.
London, UK: Butterworth-Heinemann; 1987:151154.
Davis PM. Steps to Follow. New York, NY: Springer-Verlag;
The Harris hemisling gave good vertical correction of subluxation and
compared closely to the uninvolved shoulder. The Bobath sling did not
correct the subluxation as well, and the mean difference between the
two slings was significant. The arm trough or lap board was less
effective and tended to overcorrect. The Harris hemisling and arm
trough or lap board had horizontal measurements similar to the
uninvolved shoulders. The Bobath sling, however, distracted the
glenohumeral joint horizontally and was more variable. The mean
horizontal difference between the Harris hemisling and the Bobath
sling was significant. These results support the effectiveness and
specificity of shoulder support to decrease subluxation after
Arch Phys Med Rehabil. 1991 Jul;72(8):582-6.
Shoulder subluxation in hemiplegia: effects of three different
Brooke MM, de Lateur BJ, Diana-Rigby GC, Questad KA.
Department of Rehabilitation Medicine, Tufts University, Boston, MA
The use of external support systems such as slings and lapboards in
patients with hemiplegia is a subject of controversy among
occupational therapists with respect to what is the most appropriate
system. A biomechanical analysis was conducted in an attempt to
resolve some of these issues. The analysis was carried out on two
shoulder support systems, a Bobath axillary roll, and a laptray. The
authors concluded: Slings with straps over the unaffected shoulder
provide continuous support for the flaccid extremity. The Bobath
axillary roll may introduce an unwanted lateral force. Lapboards must
be maintained at an appropriate distance from the subluxed shoulder to
Can J Occup Ther. 1999 Oct;66(4):169-75.
Biomechanical analysis of four supports for the subluxed hemiparetic
School of Occupational Therapy, University of Western Ontario, London
Another comparative study in patients caused the authors to conclude
that it is necessary to evaluate several different types of external
supports in each individual patient.
The single-strap hemisling eliminated the vertical asymmetry of
subluxation over the entire study group, but each support corrected
the vertical asymmetry best in some subjects (55%, 20%, 40%, and 5%,
respectively). The Bobath roll and the Cavalier support produced
lateral displacements of the humeral head of the affected shoulder (p
= 0.005, 0.004, respectively). The Rolyan humeral cuff sling
significantly reduced total subluxation asymmetry (p = 0.008), whereas
the single-strap hemisling, Bobath roll, and Cavalier support did not
alter total asymmetry (p = 0.091, 0.283, 0.502, respectively).
CONCLUSION: When treating shoulder subluxation, several different
types of supports should be evaluated to optimize the function of the
affected extremity and the reduction of the shoulder subluxation.
Arch Phys Med Rehabil. 1995 Aug;76(8):763-71.
Shoulder subluxation after stroke: a comparison of four supports.
Zorowitz RD, Idank D, Ikai T, Hughes MB, Johnston MV.
Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey
Medical School, Newark, USA
A New Zealand study found that no benefits were obtained from
strapping the shoulders of patients admitted with acute hemiplegic
stroke for a period of 6 weeks. The authors also concluded: Range of
movement in the hemiplegic shoulder is lost very early and any
preventive treatments need to begin within the first 1-2 days after a
Clin Rehabil. 2000 Aug;14(4):370-80.
A randomized controlled trial of strapping to prevent post-stroke
Hanger HC, Whitewood P, Brown G, Ball MC, Harper J, Cox R, Sainsbury
The Princess Margaret Hospital, Christchurch, New Zealand.
With respect to biofeedback, I found the following statement:
EMG biofeedback has been used in attempts to control shoulder
subluxation, as well as to improve hand function in the upper
Angular Biofeedback Device for Sitting Balance of Stroke Patients
Erbil Dursun, MD; Nigar Hamamci, MD; Semra Donmez, MD; Onder Tuzunalp,
PhD; Aytul Cakci, MD
Kocaeli University Faculty of Medicine, Department of Physical
Medicine and Rehabilitation (E.D., N.H.); the Department of Physical
Medicine and Rehabilitation, Ankara Rehabilitation Center (S.D.,
A.C.); and the Ankara University Faculty of Science, Department of
Electronic Engineering (O.T.), Turkey.
Full text at: http://stroke.ahajournals.org/cgi/content/full/27/8/1354#R4
The authors cite 2 articles in support of this statement. I list them
together with a URL to the abstract, however, shoulder subluxation is
not mentioned specifically in either abstract.:
Basmajian JW, Gowland C, Brandstater ME, Swanson L, Trotter J. EMG
feedback treatment of upper limb in hemiplegic stroke patients: pilot
study. Arch Phys Med Rehabil.. 1982;63:613-616.
Wolf SL, Binder-Macleod SA. Electromyographic biofeedback applications
to the hemiplegic patient: changes in upper extremity. Phys Ther..
I have not found any other references to the use of biofeedback for
Electroacupuncture is mentioned as an adjuvant therapy:
Kaohsiung J Med Sci. 2000 Oct;16(10):525-32. The effect of
electroacupuncture on shoulder subluxation for stroke patients.
Chen CH, Chen TW, Weng MC, Wang WT, Wang YL, Huang MH.
Department of Physicial Medicine and Rehabilitation, Kaohsiung Medical
University Hospital, No. 100, Shih-Chuan 1st Road, Kaohsiung City 807,
COMPANIES OFFERING THERAPEUTIC DEVICES
I have included only a selection of companies offering the products
mentioned above. I hope this will suffice, but please request further
clarification if required.
Curamove, division of Curatronic Ltd
The web site does not indicate the companys location or provide
contact details, but does have a page with a contact form.
Curamove 3000 The technology is known as ElectroMyoGraphic triggered
NeuroMuscular Electrical Stimulation or EMG triggered NMES..
599 Cardigan Road
St. Paul, MN 55126-4099
300 PV, Focus portable NMES devices
301 Moodie Drive, Suite 205
Ottawa, Ontario K2H 9C4 Canada
Toll-Free Phone: 1-800-668-1667
Toll-Free Fax: 1-877-770-9037
Our Rental/Purchase Plan allows for full credit of the first 4-week
rental and 50% of subsequent rentals (6-month maximum) to be applied
toward purchase of most devices. It is also possible to rent one model
of a certain type of equipment and have the credits applied to a
Has the following NMES units:
300 PV, ELPHA 2000, ELPHA 3000, EMS 1000, EMS Plus 2, Focus, Respond
Select. TS 1311 http://www.mylontech.com/products-muscle-stimulation.asp
CEFAR Medical AB Forskningsbyn Ideon, Scheelevägen 19 A, 223 70 Lund
Telefon: 046-38 40 50 Telefax: 046-38 40 60 E-post: email@example.com
EMS devices and accessories
3055 Templeton Rd.
Columbus, OH 43209
The Biosleeve is a wearable NMES garment. One variant is specifically
designed for prevention of shoulder subluxation after stroke. There is
a picture of it in the brochure:
Pepin Manufacturing Inc
Lake City MN
Manunfacturer of Estim EMS units and electrodes
3199 Lake Worth Road
Lake Worth, FL. 33461
EMS units and electrodes
1415 West 3rd Street, Suite 101
Tempe, Arizona 85281
Manufactures and distributes NMES device among other products
Wheelchairs & Medical Equipment of Florida
10300 SW 72nd Street
Miami, FL 33173
Distributes NMES systems from BMR Neurotech
New Brighton-based Compex Technologies Inc., a manufacturer of medical
products, plans to acquire all the assets of BMR Neurotech Inc. for
Compex, formerly Rehabilicare Inc., designs and manufactures
electromedical products used for pain management, rehabilitation and
May 16, 2003
The BION technology for injectable microstimulators has been licensed
to Advanced Bionics Corp, although there is as yet no mention of such
a product on the company web site
The WILMER research group is part of Man Machine Systems and Control.
MMSC is a Department of the Faculty of Design, Engineering and
Production of the Delft University of Technology.
WILMER® products are now commercially available in the Netherlands,
Belgium, Germany, Scandinavia, United Kingdom, U.S.A. and Canada. A
Dutch firm, Ambroise, is manufacturing the prostheses and orthoses and
is setting up a worldwide distributors network. E-mail Ambroise for
more information. firstname.lastname@example.org
The Wilmer orthosis consists of a forearm brace at one specific point
suspended on the shoulder by means of a cap with straps. The cap
transmits the suspension force evenly onto the shoulder. The chest
strap keeps the cap in place. The forearm brace has two fitting areas
transmitting forces between the orthosis and the arm. The hand support
is self adjusting for optimal wearing comfort. Several models are
The main functions are neutralization of shoulder subluxation and
suppression of oedema.
Rolyan Ability One
P.O. Box 1005
N104 W13400 Donges Bay Road
Germantown, WI 53022
Phone: 800-558-8633; 262-251-7840
Fax: 800-545-7758; 262-251-7758
We are extremely proud to announce the acquisition of Smith & Nephew
Rehabilitation by AbilityOne Corporation. Effective immediately, the
company will again be called by its original name, Rolyan.
Rolyan hemi arm sling
Sammons Preston (email: email@example.com ) is part of the Ability
One group and their web site also features the hemi arm sling for
Arm Sling Effectively Supports the Shoulder Following Stroke. Hemi
Shoulder Sling consists of a shoulder saddle and a snug fitting arm
cuff. Three adjustable straps act like the deltoid muscle to secure
the arm into the shoulder socket. This correct positioning can reduce
shoulder pain caused by subluxation.
This appears to be a UK company, but I could not find any address
details on the web site.
Hemi Arm Sling and MFC shoulder orthosis
Frank Stubbs Co., Inc.
Toll Free: (800) 223-1713
Fax: (805) 278-6609
Has the original Harris Hemi Sling
6125 NW 4th St
Lincoln, NE 68521
Diverse shoulder supports
Adaptive Equipment Systems (AES)
Address: 7128 Ambassador Road
Baltimore, MD 21244
Phone: (800) 237-2370
Fax: (800) 617-2370
Address: 6724-A Preston Avenue
Livermore, CA 94551
Phone: (800) 611-4237
Fax: (800) 511-4237
Address: 2615 West Casino Road, Suite B
Everett, WA 98204
Phone: (866) 237-0688
Fax: (877) 237-4214
Rehab Design Concepts, Inc.
14 Dogwood Road
Mohrsville, PA 19541
Lap tray and arm trough
American Medical Supply Center, Inc.
185 Marcy Ave
Brooklyn, New York 11211
Stacks & Stacks
1045 Hensley Street
Richmond, CA 94801
Customer Service. Toll free 1-800-761-5222
23205 Gratiot Avenue, #412
Eastpointe, MI 48021
I searched both on Google and PubMed
for the medical literature and on Google for products
Search terms included: 1. subluxation shoulder stroke 2. subluxation
shoulder hemiplegia 3. subluxation shoulder stroke prevalence 4
subluxation shoulder stroke incidence 5. stroke worldwide incidence
6. stroke percentage survival 7. subluxation shoulder therapy 8.
NEMS stroke 9. arm trough 10. lap board 11. subluxation sling