Positioning

One high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. (Ada et al., 2005) examined the effect of positioning the affected shoulder in lying and in sitting for improving function in 31 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. 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 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. No between-group difference was found for functional status as measured by Item 6 of the Motor Assessment Scale (MAS).

Conclusion: There is moderate evidence (level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that static shoulder positioning of the hemiplegic arm during supine lying and sitting does not improve function in patients witch acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

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 in 31 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. 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.

Conclusion: There is moderate evidence (level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that static shoulder positioning of the hemiplegic arm during supine lying and sitting prevents external rotation shoulder contracture in patients witch acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

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 flexion contracture in 31 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. 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. No between-group difference was found for passive shoulder flexion contracture (measured by a fluid-filled gravity goniometer).

Conclusion: There is moderate evidence (level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that static shoulder positioning of the hemiplegic arm during supine lying and sitting does not prevent shoulder flexion contractures in patients witch acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

One high quality RCT (Ada et al., 2005) examined the effect of positioning the affected shoulder in lying and in sitting for reducing pain in 31 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. 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. No between-group difference was found for pain level on the Visual Analogue Scale.

Conclusion: There is moderate evidence (level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that static shoulder positioning of the hemiplegic arm during supine lying and sitting does not reduce shoulder pain in patients acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

One high quality RCT (de Jong et al., 2006) have investigated the effects of static arm positioning in sitting and lying positions for reducing shoulder abduction contracture in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. This high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. 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 subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and upper limb hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease.. 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.

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 moderate evidence (level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that static positioning of the hemiplegic arm while in lying reduces shoulder abduction contracture in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

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 for decreasing shoulder external rotation contracture in patients witch subacute phase.

The first high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. (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 subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. 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 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 RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. (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 subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and upper limb hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease.. 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. 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.

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 decrease external rotation shoulder contracture in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

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.

One high quality RCT (de Jong et al., 2006) have investigated the effects of static arm positioning in sitting and lying positions for decreasing flexion contracture in patients witch subacute phase. This high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. 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 subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and upper limb hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease.. 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. No between-group difference was found for shoulder flexion contracture as measured by a masked fluid-filled goniometer.

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 moderate evidence (level 1b) from one high quality RCTs that static positioning of the hemiplegic arm during supine lying and sitting does not improve external rotation shoulder contracture in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Note: Sample size issues may have resulted in a study that was insufficiently powered to find significant difference.

One high quality RCT (de Jong et al., 2006) have investigated the effects of static arm positioning in sitting and lying positions for improving functional independence in patients witch subacute phase. This high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. 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 subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and upper limb hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease.. 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. 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 subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and upper limb hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease.. 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. No between-group difference was found for functional independence as measured using the Barthel Index.

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 moderate evidence (level 1b) from one high quality RCTs that static positioning of the hemiplegic arm during supine lying and sitting does not improve functional independence in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Note: Sample size issues may have resulted in a study that was insufficiently powered to find significant difference.

One high quality RCT (de Jong et al., 2006) have investigated the effects of static arm positioning in sitting and lying positions for improving range of motion of elbow extension and forearm supination in patients witch subacute phase. This high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. 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 subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and upper limb hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease.. 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. 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 subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and upper limb hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease.. 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. No between-group difference was found for range of motion of elbow extension or forearm supination as measured by a masked fluid-filled goniometer.

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 moderate evidence (level 1b) from one high quality RCTs that static positioning of the hemiplegic arm during supine lying and sitting does not improve range of motion of elbow extension or forearm supination in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Note: Sample size issues may have resulted in a study that was insufficiently powered to find significant difference.

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, for prevention of shoulder pain in patients witch subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

The first high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. (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 subacute 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.

Note: As indicated by the authors, the study was insufficiently powered to provide conclusive results.

The second high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. (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 subacute stroke and upper limb hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease.. 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. No between-group difference was found 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 reduce pain in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

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.

Note: Again sample size issues may have resulted in a study that was insufficiently powered to find significant difference.

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 external shoulder rotation contracture in 32 patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. 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.

Conclusion: There is moderate evidence (level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that static positioning of the hemiplegic arm during supine lying and sitting does not decrease external rotation shoulder contracture in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

One high quality RCT (Gustafsson & McKenna, 2006) examined the effectiveness of positioning the affected arm in 2 static positions (1 sitting, 1 lying) for improving functional independence 32 patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. 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 functional independence using the modified Barthel Index.

Conclusion: There is moderate evidence (level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that static positioning of the hemiplegic arm during supine lying and sitting does not improve functional independence in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

One high quality RCT (Gustafsson & McKenna, 2006) examined the effectiveness of positioning the affected arm in 2 static positions (1 sitting, 1 lying) for improving motor activity in 32 patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. 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 motor recovery as measured by the Motor Assessment Scale.

Conclusion: There is moderate evidence (level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that static positioning of the hemiplegic arm during supine lying and sitting does not improve motor activity in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

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 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 on shoulder pain as measured by the Ritchie Articular Index and the Visual Analogue Scale.

Conclusion: There is moderate evidence (level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. that static positioning of the hemiplegic arm during supine lying and sitting does not decrease shoulder pain in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Three surveys (Chatterton et al., 2001, Rowat, 2001, Mee & Bee, 2007) investigated clinician preferences for whether a patient should lie on the affected vs. unaffected side for optimal rehabilitation.

The first survey by Chatterton et al. (2001) of 436 physiotherapists found that 97% recommended side lying on the non-affected side post-stroke and 92% side lying on affected side. 85% “frequently recommended” side lying on the unaffected side while 66% “frequently recommended” side lying on the affected side. Sitting in an armchair was recommended by 98%.

The second survey by Rowat (2001) of nurses and five other disciplines examined preferred practice in positioning post-stroke. 80% of clinicians indicated that the best position for an unconscious patient was lying on the non-affected side to encourage functional recovery of the paretic side and avoid complications such as pressure sores. There was a lack of consensus on the effectiveness of other positions including positioning on the affected side in conscious or unconscious patients.

The third survey by Mee & Bee, (2007) surveyed nurses, physiotherapists and occupational therapists in Singapore hospitals. Most indicated that they perceived that the best position for an unconscious patient with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease. was side lying on the unaffected side. However, nurses working on a neurology ward perceived that supine lying with 30o angle was the best position.

Conclusion: There is insufficient scientific evidence (level 5) indicating whether lying on the affected or unaffected side is best for optimal strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. rehabilitation. However three surveys found that clinicians prefer their patients who have had a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. to be positioned on their unaffected side.

One case-control study (Elizabeth et al., 1993) and one repeated measures study (Chatterton et al., 2000) examined whether side lying vs. flat supine lying vs. lying propped up at an angle is the most effective for optimal arterial O2 saturation.

The case-control study by Elizabeth et al. (1993) examined arterial oxygen saturation in 10 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. positioned for one hour in the following positions (in a set sequence): lying supine, lying on the right side, lying on the left side and lying propped up at 45° compared to a matched control group (n=10), of patients with other medical conditions. When in side lying and flat supine positions, mean O2 saturation was significantly lower in the patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. than the controls, however when patients were propped at 45°, the group difference was not significant. The findings suggest that it may be beneficial for patients to be propped up while lying during acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. rehabilitation, to reduce the blood flow to the dependent lung that often results from side lying (especially when lying on the affected side) thus preventing hypoxemia.

The repeated-measures study by Chatterton et al. (2000) examined the within-subject difference in arterial oxygen saturation of 24 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. who spent 1 hour in various positions – lying on affected side with the head of the bed at a 45° incline, lying on unaffected side at 45° incline, sitting up in bed inclined at 70° and sitting in an armchair. There were no significant differences in oxygen saturation values between any of the positions and saturation values were maintained at acceptable values while the subject was lying on the affected side or the unaffected side while the bed was inclined at 45°.

Note: The affected shoulder while lying on the affected side was flexed with the scapula protracted and the affected shoulder while lying on the unaffected side was slightly flexed with scapula in neutral and the unaffected shoulder flexed with scapula protracted.

Conclusion: There is conflicting evidence (level 4) between one case-control study that found that positioning a patient with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. in bed in a propped supine lying position at a 45° allows for significantly more 02 saturation than positioning the patient in a side lying position (affected or unaffected side) and one repeated measures clinical study that found no difference in 02 saturation in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. who were positioned in side lying (affected or unaffected side) at 45° vs. lying supine and propped up at an angle of 70° vs. sitting fully upright.

Two studies used a repeated measures design (Wojner et al., 2002, Wojner et al., 2005) examined the effect of different angles of supine lying on blood flow velocity in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

The first repeated measures cross-over study (Wojner et al., 2002) examined the effect of three positions on middle cerebral artery mean flow velocities (measured with Transcranial Doppler sonogrophy) in 11 patients with acute ischemic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Measurements were made over a single session of unspecified length at 30°, 15°, 0° head of bed angle, with a 2 minutes stabilization period between angle change and measurement. Mean flow velocity increased significantly when the head of bed was lowered to flat position (0°) compared to the 2 other angles. Mean arterial pressure, heart pulse and pulse pressure remained stable. Findings from this small sample suggest that patients with acute ischemic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. would benefit from a flat position as it promotes an increase in flow to ischemic brain tissue.

The second repeated measures cross-over study (Wojner et al., 2005) investigated the effect of bed positioning on residual blood flow velocity in acutely occluded arteries in 20 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. The middle cerebral artery mean flow velocity in twenty patients with acute (< 24 hours) ischemic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. was measured with Transcranial Doppler sonogrophy, over a single session of an unspecified length with the head of the patient’s bed positioned at 0°, 15° and 30°, with a 15 minute stabilization period between angle change and measurement. Mean flow velocity increased in all patients after lowering to 0° but no change was noted in mean arterial pressure, pulsatility index and heart rate. Results indicated that patients with acute ischemic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. may benefit from flatter head of bed positioning as it promotes residual blood flow to ischemic brain tissue.

Conclusion: There is limited evidence (level 2b) from two repeated measures studies that lying supine in bed with the head of the bed flat (i.e. 0°) is the most optimal position for enhancing blood flow to the brain for patients with acute ischemic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Two repeated measures studies (Moodie et al., 1986, Brooke et al., 1991) investigated the effectiveness of arm troughs and lap trays for preventing shoulder subluxation during chair/wheelchair sitting.

One repeated measures study (Moodie et al., 1986) examined the effectiveness of five supportive devices during sitting (conventional triangular sling, the Bobath shoulder roll, the Hook-Hemi Harness, the plexiglass lap tray and the arm trough) for managing hemiplegic shoulder subluxation in 10 individuals with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Degree of subluxation was determined in this study by comparing the width of glenohumerol space in the affected shoulder vs. the unaffected shoulder. The study took place over a 45-minute session and involved 7 x-rays per participant. First the unaffected shoulder was x-rayed as a control, followed by the affected shoulder (unsupported) and finally the affected shoulder was x-rayed while supported by each of the 5 support devices. Results indicated a significant reduction in shoulder subluxation for the devices meant for use while chair/wheelchair sitting (the plexiglass lap tray and the arm trough).

Note: Moodie et al. also mention in their study that the arm trough immobilized the affected limb, unnecessarily limiting sensory and motor input. In contrast the lap tray allows bilateral activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
to occur.

A second repeated measures study (Brooke et al., 1991) examined the effect of three shoulder supports (Harris Hemisling, the Bobath sling, and the arm trough or lap board) on hemiplegic shoulder subluxation in individuals (n= 10) following some type of recent brain damage (6 had ischemic infarcts). The lap tray was used in certain conditions instead of the arm trough such as when the arm was not adequately placed in the latter support. The study used x-ray to measure for subluxation. Regarding the supports meant for use while sitting (arm trough or lap board), results showed that they tended to overcorrect for vertical subluxation and correct well for horizonal subluxation. The authors also stated that the use of an arm trough decreased shoulder adduction and internal rotation and facilitated independent transfers compared to a lapboard.

Note: Boyd et al. (1999) compared the results of two surveys done in 1984 and 1994 to investigate frequency of use and intended purpose of arm supports post-stroke. Occupational therapists and other rehabilitations staff at facilities listed in the Canadian Hospital directory completed the questionnaires. The lapboard and arm trough were two of the three most frequently used supports at both given times. Also at both times, the most frequent reason chosen to use a lapboard was to increase awareness of the arm. Similarly the main reason chosen to use an arm trough was to protect the arm. However, these 2 reasons for using the devices were chosen notably less in 1994 then they were in 1984.

Conclusion: There is conflicting evidence (level 4) between two repeated measures studies, with one of study finding that arm troughs and lapboards correctly reduce subluxation for patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and the other finding that arm troughs and lapboards tend to overcorrect subluxation for patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Three repeated measures studies (Zorowitz et al., 1995, Moodie et al., 1986, Brooke et al., 1991) one quasi-experimental studyAn experimental study in which the participants are not randomized to receive treatments and as such the investigators lack control over allocation to interventions. This study design is inferior to a randomized controlled trial (RCT) but is valuable in answering research questions when an RCT is not possible either because of ethical constraints or logistic restraints.
(Hurd et al., 1974) and one survey (Foongchomcheay et al., 2005) examined the effectiveness of using supports for the reduction of shoulder subluxation in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. as measured by x-ray over a single session.

The first repeated measures study (Zorowitz et al., 1995) examined the effectiveness of 4 supports (single-strap hemisling, Bobath Roll, Rolyan humeral cuff and Cavalier support) for reducing shoulder subluxation in 20 patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. The study took place over one session and involved 6 separate x-rays. First the unaffected shoulder was x-rayed for use as a control, followed by the affected shoulder (unsupported) and finally the affected shoulder was x-rayed while supported by each of the 4 slings/supports. The results indicated that vertical subluxation was virtually eliminated by the use of the single-strap hemisling. As well, the Rolyan humeral cuff sling was found to significantly reduce total subluxation asymmetry compared to wearing no sling. No significant pre-post differences were found for the Bobath Roll or the Cavalier support.

The second repeated measures study (Moodie et al., 1986) investigated the effects of using 5 different shoulder supports (conventional triangular sling, Bobath roll, Hook-Hemi harness, plexiglass lap tray and arm trough) on reducing shoulder subluxation in clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. during the subacute phase. The study involved 10 individuals with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. who received 7 x-rays over a 45-minute session. First the unaffected shoulder was x-rayed as a control, followed by the affected shoulder (unsupported) and finally the affected shoulder was x-rayed while supported by each of the 5 support devices. Regarding the devices meant for use while ambulating (i.e. the conventional triangular sling, Bobath roll and Hook-Hemi harness) a significant reduction in shoulder subluxation was found for the conventional triangular sling only, measured by comparing the x-rays of before and during use of the device. The authors concluded however, that although the conventional triangular sling may reduce shoulder subluxation, it did not fulfill some other requirements of upper extremity positioning, primarily the reinforcement of spastic flexor pattern.

A third repeated measures study (Brooke et al., 1991) examined the effect of three shoulder supports (Harris hemisling, the Bobath sling, and the arm trough or lap board) on hemiplegic shoulder subluxation in individuals (n= 10) following some type of recent brain damage (6 had ischemic infarcts). The lap tray was used in certain conditions instead of the arm trough such as when the arm was not adequately placed in the latter support. The study used x-ray to measure for subluxation. Regarding the supports meant for use while ambulating (Harris hemisling and Bobath sling), results showed that both the supports corrected subluxation notably, however the Bobath sling was more variable in it’s effectiveness, caused problems (distracted the glenhumeral joint horizontally) and was significantly less effective at correcting subluxation compared to the Harris hemisling.

One quasi-experimental studyAn experimental study in which the participants are not randomized to receive treatments and as such the investigators lack control over allocation to interventions. This study design is inferior to a randomized controlled trial (RCT) but is valuable in answering research questions when an RCT is not possible either because of ethical constraints or logistic restraints.
(Hurd et al., 1974) investigated the effectiveness of using a hemisling to reduce shoulder subluxation and pain in 14 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Individuals in the experimental group (n=7) wore the hemisling following initial assessment and were evaluated approximately 2-3 weeks later, and assessed again at 3-7 months post strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. The control group (n=7) wore no sling for the whole time period. No appreciable between group differences were found for shoulder subluxation, pain, range of motion or peripheral nerve injuries. It is to be noted that the outcome measures are not clearly outlined in the study nor is it stated whether or not any blinding took place.

In the survey, Foongchomcheay et al. (2005) investigated the practices of 210 hospitals in Australia on the devices they use to prevent shoulder subluxation after strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Findings indicated that the majority of physiotherapists prescribed slings (collar and cuff) for shoulder subluxation and inadequate arm strength, to be worn at all times out of bed to help prevent shoulder subluxation.

Conclusion: There is limited evidence (level 2b) from three repeated measures studies that wearing certain types of slings and supports significantly reduces shoulder subluxation while wearing the support. Specifically, one of the studies found that a single strap sling eliminates vertical subluxation, a Rolyan humeral cuff significantly reduces total shoulder subluxation and the Bobath roll and the Cavalier support do not reduce subluxation, the second repeated measures study found that the triangular sling but not the Bobath roll or Hook-Hemi harness improves shoulder subluxation, and the third repeated measures study found that the Harris hemisling reduces vertical and horizontal subluxation significantly better than the Bobath sling. One poorly designed quasi-experimental studyAn experimental study in which the participants are not randomized to receive treatments and as such the investigators lack control over allocation to interventions. This study design is inferior to a randomized controlled trial (RCT) but is valuable in answering research questions when an RCT is not possible either because of ethical constraints or logistic restraints.
found that a hemisling does not improve subluxation, pain or range of motion over a 6-month period.

Note: The quasi-experimental studyAn experimental study in which the participants are not randomized to receive treatments and as such the investigators lack control over allocation to interventions. This study design is inferior to a randomized controlled trial (RCT) but is valuable in answering research questions when an RCT is not possible either because of ethical constraints or logistic restraints.
was likely insufficiently powered, because of a small sample size, to detect anything other than large differences. Finally, one survey found that the majority of clinicians recommend slings to be worn at all times.

A review of the literature on strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. patient care identified the recommended postures and the rational behind using these postures for individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (Carr & Kenney, 1992). As for the upper extremity while sitting in a chair, all sources agreed to place the shoulder in protraction with the arm brought forward, the wrist in neutral with fingers extended and thumb abducted. An inference was made that the following should be avoided: shoulder extension, adduction and internal rotation; however the recommended amount of shoulder flexion, abduction and external rotation varied as well as the height and number of pillows or tables to support the affected arm. There were two main “schools of thought” where some had the arm straight forward and others had the arm in slightly abduction and external rotation. One of the sources mentioned that both positions were advantageous. For positioning of the elbow there were two “school of thoughts” once again. One was to place the elbow in full extension and the other was to place the elbow in slight flexion. Regarding the hand, the majority opinion was to place the hand in pronation, whether sitting in a chair, or sitting in bed.

Conclusion: While there is insufficient scientific evidence (level 5) that arm positioning during chair-sitting can improve reflex inhibiting postural patterns, one review of the literature on strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. patient care concluded that positioning the affected upper limb while sitting in a chair in shoulder protraction and arm forward, hand pronated, wrist neutral, fingers extended and thumb abducted can encourage reflex-inhibiting patterns in individuals following a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Carr & Kenney (1992) conducted a review of the literature on recommended strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. patient care to identify the optimal position in order to maintain a reflex inhibiting pattern of posture while sitting in bed. The general consensus of the optimal sitting position was as follows: The patient is in an upright position with the head and trunk in midline position. The affected shoulder is in protraction and arm is forward and flex while supported by a pillow. A pillow also supports the trunk. Legs are to be straight and not externally rotated. There is still controversy concerning shoulder abduction in sitting position in bed. Regarding the hand, the majority opinion was to place the hand in pronation, whether sitting in a chair, or sitting in bed. Note: there was no study evaluating the exact benefits of this recommended position.

Conclusion: While there is insufficient scientific evidence (level 5) that arm positioning during bed-sitting can improve reflex inhibiting patterns of posture, one literature review concluded that sitting upright, with head and trunk in midline position, shoulder in protraction and the arm forward and flexed, and legs straight is the most optimal position for improving reflex inhibiting patterns of posture.

One literature review (Seneviratne et al., 2005) examined the current best practice in prevention and treatment of shoulder subluxation and found that the arm must always be supported during transfers in order to avoid glenohumeral subluxation. However, the review revealed a lack of consensus of best practice regarding positioning and transferring in general.

Conclusion: There is insufficient scientific evidence (level 5) regarding whether position handling while transferring from sit to stand has an effect on shoulder subluxation and pain. However, one literature review recommends that the hemiplegic arm should always be supported while transferring the patient from sitting to standing.

Note: While the scientific evidence does not reveal any RCTs it is likely that this type of study is not doable because best practices already recognize the need for support of the arm during transfers.

One literature review (Gilmore et al., 2004) examined the possible causes of shoulder pain and discussed the implications for occupational therapy treatment including handling the patient. The authors stated that, when turning a patient, it is essential that the affected arm be supported and the trunk brought forward by grasping behind the scapula and not pulling on the affected arm. Pulling on the arm could cause trauma or subluxation.

Conclusion: There is insufficient scientific evidence (level 5) regarding whether position handling while turning in bed has an effect on shoulder subluxation and pain. However, one literature review found that carers should grasp behind the scapula when turning the patient in bed.

Note: While the scientific evidence does not reveal any RCTs it is likely that this is because best practices already recognize the need for support of the arm during turning in bed.