Positioning

NOTE: Three of the four studies that investigated the effects of static arm positioning investigated both sitting and lying positions and thus it is not possible to differentiate benefits of positioning in lying versus sitting. These four studies are therefore summarized together.

 Four high quality RCTs (one in acute: Ada et al., 2005, two in sub-acute: Dean et al., 2000, de Jong et al., 2006, and one in chronic stroke: Gustafsson & McKenna, 2006) have studied the effect of static arm positioning where the arm is placed in a specific position that is thought to be advantageous in reducing negative outcomes such as shoulder contracture and pain, and in enhancing positive outcomes such as arm movements and function.

In Acute

One high quality RCT (Ada et al., 2005) examined the effect of positioning the affected shoulder in lying and in sitting for the prevention of shoulder contracture and pain, and for improving function in 31 patients with acute stroke. Both the intervention group (n=15) and the control group (n=16) received upper extremity exercises approximately 5 x 10-minute sessions per week for 4 weeks while also receiving standard upper limb care (including slings and supports). In addition, the treatment group (n=15) received static positioning of the affected arm in two different positions a day (1 lying, 1 sitting), each for 30 minutes per day, 5 days per week, for 4 weeks. The lying static position consisted of lying supine with the arm in comfortable full external rotation and 45° of abduction with elbow flexion. The sitting position consisted of sitting at a table, with both the shoulder and elbow in 90° flexion. Between-group post-scores showed significantly less development of external rotation shoulder contracture for the intervention group compared to the control group, as measured by a fluid-filled gravity goniometer. No between-group difference was found for passive shoulder flexion contracture (also measured by a fluid-filled gravity goniometer), functional status as measured by Item 6 of the Motor Assessment Scale (MAS) and pain level on the Visual Analogue Scale.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that static shoulder positioning of the hemiplegic arm during supine lying and sitting prevents external rotation shoulder contracture but does not prevent shoulder flexion contractures, shoulder pain, or improve function in acute stroke.

In Subacute

Two high quality RCTs (Dean et al., 2000, de Jong et al., 2006) have investigated the effects of static arm positioning in sitting and lying positions in the sub-acute phase.

The first high quality RCT (Dean et al., 2000) investigated the effectiveness of three positions (2 lying, 1 sitting) to reduce shoulder pain and increase range of motion on the affected arm, combined with regular rehabilitation in 23 patients with sub-acute stroke. Patients were randomly assigned to a treatment group (n=10) or a control group (n=13). The intervention group received treatment daily for 6 weeks with each position being held for 20 minutes per day. For the first lying position, in supine, the shoulder was placed in maximal comfortable abduction and external rotation with the elbow flexed. The second lying position was in supine with the shoulder in 90° of abduction, maximal tolerable external rotation and elbow flexion. For the sitting position the shoulder was placed forward at 90° flexion, elbow and wrist in extension and a cylinder was placed in the hand to allow for web space stretch. The control group received typical multidisciplinary rehabilitation only. No significant between group differences were found post-intervention for pain while at rest or while dressing as measured by the Visual Analogue Scale, nor for active, pain-free abduction or passive external rotation contracture as measured by a standard goniometer and a gravity goniometer.
NOTE: As indicated by the authors, the study was insufficiently powered to provide conclusive results.

The second high quality RCT (de Jong et al., 2006) examined the effectiveness of a contracture preventing arm positioning procedure (while lying supine) combined with traditional physical and occupational therapy treatment for 19 patients with sub-acute stroke and upper limb hemiplegia. Individuals in the experimental group (n=10) were positioned while lying supine with their affected arm in maximum comfortable shoulder abduction, external rotation, elbow extension and supination of the forearm without pain for 5 weeks, 2 x 30-minute sessions per day, five days per week, in addition to conventional rehabilitation. The arm was supported by a pillow and maintained in the position using a sandbag. The control group (n=9) received conventional rehabilitation only. At five weeks post treatment, there was significantly less shoulder abduction contracture in the experimental group, as measured by a masked fluid-filled goniometer, and significant improvements, as measured by the Fugl-Meyer Assessment for the upper extremity, in the ability to make selective movements with the affected arm when compared to the control group. No between-group difference was found for passive range of motion of shoulder external rotation, shoulder flexion, elbow extension or forearm supination as measured by a masked fluid-filled goniometer, for functional independence as measured using the Barthel Index, and for pain at the end range of passive motion.
NOTE: 10 of the subjects from the experimental group went on to complete another 5 weeks of treatment - the data is not statistically analyzed in the paper and thus it was not included in this review.

Conclusions: There is evidence (level 1a) from two high quality RCTs that static positioning of the hemiplegic arm during supine lying and sitting does not improve external rotation shoulder contracture and prevention of pain in patients with sub-acute stroke. NOTE: the reader is alerted that the sample sizes in both studies were small: thus they may not have been sufficiently powered (due to insufficient sample size) to find conclusive results. Hence we have indicated level 1a evidence but have removed the term strong that is usually associated with level 1a evidence.  However, there is moderate evidence (level 1b) from one high quality RCT that static positioning of the hemiplegic arm while in lying improves shoulder abduction contracture and the ability to make selective movements (as measured by the Fugl Meyer Assessment) but does not improve functional independence, shoulder flexion contracture, elbow (extension) and forearm range of motion (supination) in patients with sub-acute stroke. NOTE: Again sample size issues may have resulted in a study that was insufficiently powered to find significant difference.

In Chronic

One high quality RCT (Gustafsson & McKenna, 2006) examined the effectiveness of positioning the affected arm in 2 static positions (1 sitting, 1 lying) for decreasing contracture and shoulder pain in 32 patients with chronic stroke. Individuals in the intervention group (n=17) received static positioning treatment 2 x 20-minute sessions per day for 4 weeks. Lying in supine, the individual's affected arm was placed in 90° shoulder abduction, maximal comfortable external rotation, elbow flexion and supination for 20 minutes daily over 4 weeks. As well, whenever lying in bed and not placed in this static position, the patients in the intervention group used a pillow to support the affected arm in a position midway between external and internal rotation and not horizontally adducted. During sitting, individuals in the intervention group had their shoulder supported in 90° abduction with elbow extended and forearm in neutral for 20 minutes daily over 4 weeks. As well, whenever the patients in the intervention group were in a sitting position over the four-week period (when not in static position), their affected arm was positioned, using a Otto Bock modular arm rest support attached to the arm of their wheelchair, alongside the trunk in 10-15° of shoulder abduction and midway between external and internal rotation. Individuals in the control group (n=15) received locally fabricated cushion supports for their affected upper limb when seated and when in bed. The results revealed no significant between group difference for external shoulder rotation contracture as measured by a universal goniometer, shoulder pain as measured by the Ritchie Articular Index and the Visual Analogue Scale, motor recovery as measured by the Motor Assessment Scale and functional independence using the modified Barthel Index.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that static positioning of the hemiplegic arm during supine lying and sitting does not improve external rotation shoulder contracture, pain, motor recovery or functional independence in patients with chronic stroke.