A comparison of two shoulder strapping techniques in patients with stroke

Abstract

Background Despite it being used clinically, there is limited, inconclusive literature available on shoulder strapping techniques for patients with stroke. Of the published techniques, circumferential strapping seems to show the most positive results. However, in South Africa, variations of a longitudinal technique are applied most often. This study aimed to establish if longitudinal or circumferential strapping techniques would have an impact on a patient's upper limb tone, subluxation, motor function or pain, post stroke and how they compared to each other. Participants This study recruited 56 participants within two weeks of having a stroke, presenting with upper limb involvement (hemiplegia). Participants were excluded if they had receptive aphasia and/or were medically unstable. Method The study was a longitudinal randomised controlled trial comprising of three groups: a control, longitudinal strapping and circumferential strapping groups. Patients with stroke who met the inclusion criteria were assessed at baseline, week one, week two and week six post baseline assessments. The participants were assessed for shoulder subluxation (finger width measurement system), shoulder pain (Ritchie Articular Index), upper limb motor function (upper limb subscales six, seven and eight of the Motor Assessment Scale) and muscle tone (Modified Ashworth Scale). The intervention groups were strapped for two weeks. The sample size for the study was originally calculated at 15 participants however we felt that this should be larger and thus using the central limit theorem a minimum of 30 participants per group was calculated. Demographic data were analysed using descriptive statistics and are presented in tables using frequencies and percentages for the following variables: age, gender and side of stroke. The two-sample test of proportions was used to determine differences among the groups over the study period. The overall within group effect was tested using the Cochran's Q test. The generalized estimated equations were was used to determine the overall effects of the intervention overtime adjusting for groups as well as using population levels. Ethical approval was granted by the Human Research Ethics Committee at the University of the Witwatersrand and informed consent was obtained from all participants prior to the study. Results The total number of participants recruited into the study over three years was 56. The number of participants in the control, circumferential and longitudinal groups was 19, 15 and 22 respectively. Data showed that the study participants were generally young with a mean age of 49.4 (± 13.8) years. There were more females (51.8%) than males and the majority ofthe study sample (60.7%) had a right cerebrovascular accident. Longitudinal strapping decreased shoulder subluxation and pain, but not tone, however, across all of the outcome measures the changes did not reach statistical significance. Circumferential strapping had no significant effect on any of the outcomes compared to the control group, however, it prevented the shoulder pain from worsening, but it had no positive effect on shoulder subluxation post stroke. Improvement in upper limb motor function was observed for all three groups with only a significant improvement in upper arm function being observed for the circumferential group. Conclusion and implications Overall, the study showed positive trends in changes in the shoulder post stroke but no significant differences were found between the groups in any of the outcomes, even when both intervention groups were combined and analysed against the control participants. Looking at the trends, however, the longitudinal technique, with its positive effect on shoulder subluxation and pain, would appear to be the preferred method of the two. Although the study produced overall results that did not have statistical significance one cannot discredit the use of the strapping. Even if strapping had purely a placebo effect it would still serve a purpose by creating awareness in the patient, caregivers and medical personal and thus ensure more cautious handling of the affected upper limb. Thus, when rehabilitating the shoulder post stroke, there appears to be enough clinical evidence to suggest that strapping, more precisely longitudinal strapping, of the hemiplegic shoulder may be used.