Post-stroke

shoulder subluxation:
A concern for
neuroscience nurses
By Cydnee Seneviratne,
Karen L. Then, and Marlene Reimer

Abstract

Approximately 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 for
shoulder 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
26

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 subluxation
and 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 subluxation

Stroke 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

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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 allows
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). If
a 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 treatment

In 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
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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 in
treating 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 and
controversial (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 know
how 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 poststroke. 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 to
determine 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-of28

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 quasirandomized 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 nursing

The 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 neuroscience
nurses 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 poststroke because of flaccidity and related instability of the
arm (Teasell et al., 2004). Even using basic range-ofmotion exercises improperly can cause injury to the
shoulder and increase the stroke patients risk for shoulder
subluxation. Therefore, care must be taken when using
range-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).

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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 between
nurses 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).

Discussion

In 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. Health
care 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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29

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 shoulder
subluxation 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 readily
jump at opportunities for incorporating 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 a
community of evidence-based practice (Estabrooks,
2003).

References

Ada, L., & Foongchomcheay, A. (2002). Efficacy of

electrical stimulation in preventing or reducing subluxation of the
shoulder after stroke: A meta-analysis. Australian Journal of
Physiotherapy, 48, 257-267.

30

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.

Conclusion

Shoulder 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 transferring
stroke patients in order to decrease risk for shoulder
subluxation. Nurses and therapists who provide range-ofmotion 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 poststroke 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 authors

Cydnee 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 ccsenevi@ucalgary.ca.

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