EFFECTS OF BILATERAL ARM TRAINING ON SHOULDER

PROPRIOCEPTION AND FUNCTIONAL RECOVERY WITH SHOULDER

SUBLUXATION IN ACUTE STROKE

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 ACKNOWLEDGEMENT

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of _____ university for their contributions to the completion of my project titled
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 TABLE OF CONTENT

TOPICS PAGE NO.

1. EFFECTS OF BILATERAL ARM TRAINING IN

SHOULDER………….(INCLUDING
EXPRIMENTS WITN DATA)
 INTRODUCTION 9 TO 18
 MATERIALS AND METHODS SUBJECT
 METHODS BILATERAL UPPER LIMB
TRAINING EXPERIMENTS TASK
 ANALYSIS METHODS
 RESULTS AND DISCUSSIONS
 CONCLUSION
 EXPERIMENTAL CLINICAL REASONING IN THE
USE OF SLINGS FOR STROKE ATHELETS 19
PATIENTS WITH SHOULDER SUBLUXATION

2. LITERATURE REVIEW
 STROKE
 SHOULDER SUBLUXATION
 TYPES OF MODALITIES USED FOR POST
STROKE SHOULDER SUBLUXATION
 ELECTRICAL STIMULATION
 STRAPPING
 POSITIONING
20 TO 42
 SLING
 TYPES OF SLING
 USED OF SHOULDER SLINGS IN
OCCUPTIONAL THERAPY PRACTICE
 STATEMENT OF PURPOSE
 THEORETICAL FRAMEWORK
 CLINICAL REASONING
 PROCEDURAL REASONING
 NARRATIVE REASONING
 PRAGMATIC REASONING
 CONDITONAL REASONING………
 BIOMECHANICAL FRAME OF
REFERENCE,DEFINTIONS AND

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 VARIABLES……

3. EXPERIMENTAL DATA 43 TO 45

4. RESEARCH METHODOLOGY
 DESIGN
 SUBJECTS 46 TO 54
 ETHICAL CONSIDERATIONS
 DATA COLLECTION
 DATA ANALYSIS
 RESULTS
 RESEARCH QUESTIONS WITH EXPERIMENTS
5. DISCUSSIONS AND LIMITATIONS 55 TO 57

6. SUMMARY, CONCLUSIONS AND 58

RECOMMENDATIONS

7. REFERENCES 59 TO 63

ABSTRACT

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Background/Objectives:

The purpose of this study was to survey the influence on action observation of
meaningful tasks on upper limb function in patients with stroke. Thirty stroke patients
were prospectively randomized to bilateral upper limb training task (BULTT) group
or general upper limb rehabilitation (GULR) group.

Method/Statistical Analysis:

We studied 30 acute stroke patients. The experimental group (N = 15) applied

bilateral upper limb training task (BULTT) and the control group (N = 15) performed
general upper limb rehabilitation (GULR) for the affected side. Both groups executed
5 times per week and 30 minutes per session for 4 weeks. To assess the effects of
intervention, the paired t-test was used to contrast before and after intervention results
of each group. The independent t-test test was used to contrast changes in outcome
measures between the groups.

Findings:

The Fugl-Meyer Assessment (FMA) before-test score BULTT group was 17.00 ±
3.74 and aftertest score was 21.27 ± 4.62. Significant changes in the FMA were
observed in both groups. However, the results from the observation of BULTT were
most significant. The mean change in FMA score was 4.27 ± 2.09 in the BULTT
group and 1.80 ± 1.78 in the GULR group, showing a statistically significant
difference. The BULTT group showed a significant increase in upper limb function
after training intervention.

Improvements/Applications:

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This study demonstrated that action observation of meaningful bilateral upper limb
training in patients with stroke. We present evidence that action observation of
meaningful tasks has a beneficial effect in occupational therapy for movement
disorders after stroke.

Keywords:

stroke, bilateral upper limb training, upper limb motor function, meaningful tasks,
Fugl-Meyer Assessment.

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EFFECTS OF BILATERAL ARM TRAINING ON SHOULDER
PROPRIOCEPTION AND FUNCTIONAL RECOVERY WITH
SHOULDER SUBLUXATION IN ACUTE STROKE

Introduction

Stroke is caused by vascular occlusion such as hypoxia, ischaemia, or infarction, or by

intracranial hemorrhage. Cerebral infarction is the most frequently occurring type.
This is related to the central nervous system being very sensitive to oxygen deficiency
or ischemia in various organs of the body .

Stroke patients generally develop muscle weakness, coordination problems, abnormal

muscle tension, and motor paralysis . Stroke patients with these neurological
symptoms have social, mental and physical impairments, of which 40% have some
dysfunction and 15-30% have sensory disturbances.

A significant reduction in the function of the affected side is generally associated with
reduced use of the injured upper limb in real life. Therefore, it can induce learned
nonuse, which can result in weakened function of the affected side and increase the
restriction of daily life2,5. Bilateral activity is based on the assumption that the right
and left muscle groups are simultaneously activated and similar neural activation
occurs in both cerebral hemispheres .

Simultaneous execution of both upper limbs can also increase activation of the
affected cortical area, which can be attributed to the bilateral distribution of the
channels that transmit commands and the common initiation of motion commands
through simultaneous execution of both upper limbs7,8. It is known that the
enhancement of the efferent connection of the ipsilateral upper limb by activation of
the uninjured brain region improves motor control of the affected upper limb .

Activation of the primary motor and somatosensory cortex of the affected side is
further enhanced by the simultaneous performance of the both upper limbs which is

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compared to the single side of the affected, which is related to the activation of both
the cerebral hemispheres. Also, when performing tasks with both hands, in order to
move of both hands complex interactions between both cerebral hemispheres can
occur and this interaction can promote the effect of the affected upper limb.

Many actions in real life are performed by coordination of both hands. Repeated,
similar tasks used in daily life may improve function even in patients with severe
upper limb paralysis. This treatment approach using both hands is closely related to
daily life and the affected side upper limb is improved functionally to the help
rehabilitation and daily activities of stroke patients. Several studies have demonstrated
the effect of bilateral exercise to induce the recovery of motor function using both the
affected and less affected upper limbs.

These studies have reported that bilateral activity in the early level of stroke
rehabilitation improves symmetric body and reduces abnormal muscle tone. In
addition, it has been reported that complex interactions are activated in the cerebrum
for the exercise planning of both upper limbs. Therefore, based on the above facts,
this study investigated the effect of bilateral upper limb training task on upper limb
function in patients with acute stroke.

Improving muscle strength for joint stability is a goal of physical training for the
shoulder. According to Myers and Lephart, the rotator cuff, deltoid, biceps, teres
major, latissimus dorsi, and pectoralis major muscles are responsible for providing
shoulder stabilization. Inman were the first to state that the coactivation force of the
shoulder’s dynamic stabilizers provides the joint stability.

However, joint mechanics and stability may be compromised if such forces are not
equalized. Therefore, in order to achieve joint stability, training must be directed at
attaining proportional strength around the joint. Two main aspects should be taken
into account during strength training: a specific muscle-force level and the force
balance among muscles that act on the same joint. Shoulder-joint stability is the result
of passive and dynamic components.

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The bone geometry, relative intraarticular pressure, glenohumeral labrum, and
capsuloligamentous structures are passive components,whereas dynamic components
are provided by contractile muscle activity coordinated around the joint and
modulated by the neuromuscular system. The basis of passive and dynamic
interactions is the proprioceptive information emerging from mechanoreceptors in
muscles, tendons, joint-capsule ligaments, and skin, which are centrally integrated.

In this context, kinesthesia, joint position, and force sense are described as
proprioception submodalities.Proprioception is essential to motor control and joint
stability during daily activities and sports practice. Thus, proprioception can be
defined as the ability to recognize and to locate the body in relation to its position and
orientation in space.Allegrucci identified kinesthetic deficits in the dominant shoulder
of throwing athletes as a mechanism for shoulder instability.

The same result was found by Safran Conversely, a recent study demonstrated that
athletes have better joint position sense (JPS) than controls matched for age,
suggesting that sport activity could have an effect on proprioception. Despite this
result, the effect of strength training on proprioception remains unclear, although
some authors have described the effects of muscle strengthening on proprioception.
These researchers hypothesized that strength training directly affects the functional
capacity of the dynamic stabilizers. For this reason, it is important to understand the
effects of this training on proprioception so that we can improve the strength-training
protocols to increase joint stability.

However, the effects of different strength-training programs on the JPS of healthy

individuals remain debatable. Therefore, the focus of our study was to (1) evaluate the
effect of 8 weeks of strength training on shoulder JPS and (2) verify whether using the
same or divergent training intensities for the shoulder muscles’ stability produced any
significant effects on JPS. We hypothesized that the JPS would be improved by
strength training and that different strategies to control training intensity would
promote different responses with regard to shoulder proprioception.

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Materials and Method Subjects:

In this study, we randomly divided the 30 study subjects into two groups (Table 1) :
the BULTT group and the GULR group. These participants met the selection criteria
and gave voluntary knowledgeable consent to take part in the study. The
incorporation criteria were as follows:

First, hemiplegic patients with stroke duration less than 6 months Second, a score of ≥
24 in the MMSE-K (Korean version of the Mini-Mental Status Examination)

Thirdly, a level of ≤ Brunnstrom recovery of upper limb stage 3

Fourth, in the line bicection test, patients without unilateral neglect

Fifth, patients without musculoskeletal disorders such as joint building or limited

range of motion.

EXPERIMENTS OF INDIVIDUAL TO INDIVIDUAL ATHLETES PATIENTS

( MALE AND FEMALE)

Characteristics BULTT GROUP (N=15) GURL GROUP

(N=15)
MALE FEMALE MALE =6 AND FEMALE =9 MALE=7
FEMAKE =8
AGE (Y) 61.53 M 62.00 F

MMSE-K 27.60 M 27.80 F

HEIGHT (CM) 165.67 M 166.00 F

WEIGHT (KG) 67.40 M 66.87 F

ONSET OF STROKE 3.60 M 3.20 F

MONTH
SIDE OF HEMIPLEGIA 11 9
4 6

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BULTT: bilateral upper limb training task,
GURL: general upper limb rehabilitation

Materials - Fugl-Meyer Motor Function Assessment(FMA):

Upper limb Subtest: FMA is used to classify hemiplegic patients with stroke as a
Brunnstrom recovery stage and to assess the recovery of function. Fugl-Meyer et al.
developed an assessment tool by defining 50 detailed movements according to the six
stages of recovery of Brunnstrom’s hemiplegic patients. 0 ~ 2 points are given
depending on the performance of the evaluation item. 0 point is not performed, 1
point is performed partially, and 2 points are divided into complete execution. The
overall score ranges from 0 to 100, including upper and lower limbs.

There are 33 items in the upper part of the test, which is 66 points. The details of
upper limb examination are 18 items for shoulder/elbow/forearm, 5 items for wrist, 7
items for hand (finger), and 3 items for upper limb coordination ability. Sanford et al.
reported an interrater reliability of 0.96 for upper limb examination . In this study,
only upper limb test items were used for upper limb function evaluation.

Methods-Bilateral Upper Limb Training Experiments Task:

Subjects were divided into BULTT group (15 patients) and GULR group (15
patients). The experiment was conducted for 5 weeks each week for 30 minutes for 4
weeks. The BULTT group performed the bilateral upper limb training task and the
GULR group performed general upper limb rehabilitation. The posture for bilateral
upper limb activity is to sit on the backrest chair and place both upper limbs on the
table, and the hip, knee, and ankle joints are flexed 90 degrees. And the patient is
allowed to maintain the correct posture by inducing the patient to use the backrest or
the footrest according to the physical condition so that the same weight is applied to
both legs from the center of the chair.

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Table 2 experiments summarizes the results of the bilateral upper limb training task
with reference to the programs of Desrosiers et al. and Lewis & Byblow.

PROGRAM METHOD
Wipping The patient wipes the table by placing both hands with the fingers
table with together locked or both hands without the fingers together locked in
towel parallel on a towel, pushing and pulling the table forward, left and
right. Elbow joints move with flexion and extension, and shoulder
joints move with horizontal adduction and horizontal abduction. As
the elbow joint moves, the scapular of the affected upper limb is not
retracted.
Mimiceing The patient mimics the action of drinking a cylindrical plastic cup with
the finger togerht locked to the mouth. Shoulder and elbow joints move
drinking with flexion

Moving The patient should hold the block (4cm × 4cm × 4cm) placed in front
blocks to of the table with finger together locked and move it into a box located
boxes at eye level of 30 cm. Keep your finger locked and move the elbows in
the flexion direction. The block is picked up mainly with the less
affected fingers. When placed in the box, the shoulder joint moves in
the flexion direction and the elbow joint moves in the extension
direction.

Bilateral Upper Limb Experiments Training Task by athletes patients

Analysis Methods

The results of the collected data were analyzed using SPSS (ver. 12.0) statistical
program. The general characteristics of the subjects were descriptive statistics and
chi-squared test was used for the homogeneity test between the BULTT group and the
GULR group. Shapiro Wilk test was used to confirm normality, and the paired t-test
was used to compare FMA before and after intervention. The independent t-test was
also conducted to compare groups after intervention. The statistical significance level
was 0.05.

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Results and Discussion

Comparison of Results (Fma Score) Before and After The Intervention: Upper limb
motor function in both groups before and after treatment is shown in Table 3. The
changes of FMA before and after the application of bilateral upper limb training task
were significantly improved from 17.00 to 21.27.

Experiments Comparison of Results (FMA Score) Before and After the

Intervention

BULTT group GURL group -----

(n = 15) (n=15)
Pretest posttest Pretest posttest ---
FMA 17.00 21.27 17.27 19.07 -----
(3.74) (4.62) (4.59) (5.31)
P .000**** .002**** ----

Experiments Comparison of Results Between the BULTT Group and GULR

Groups
MEAN CHANGE

BULTT GROUP N=15 GURL GROUP N=15

FMA 4.27 ( 2.09) 1.80 (1.78)
P .002***** --

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Discussion

In this study, we investigated the effect of bilateral upper limb training on upper limb
function in acute stroke patients. In the selection of the subjects, the MMSE-K
revealed that the cognitive impairment was considered as a result of 24 out of 30 total
score, or visual perception ability including neglect and homonymous hemianopsia in
the line by section were excluded from this study. We also excluded patients with
musculoskeletal disorders such as contracture of joints or limitation of range of
motion, and patients with complete voluntary movement of the affected upper limb
without assistance.

The subjects selected for the study were less than 6 months in the stroke diagnosis. In
addition, the subject is a patient with Brunnstrom recovery of upper limb stagy 3 or
less who needs active assistance because of the voluntary movement of the affected
upper limb and the difficulty of one hand moving of the affected limb without
assistance. There were no cognitive impairment, visual perception disabilities, or
musculoskeletal disorders. Bilateral upper limb training was consisted of
supplementing and modifying the less affected upper limb so as to lead to various
movements of the affected upper limb, referring to the previous studies. During the
application of the program, the subjects crossed the fingers of both hands and
performed activities with their hands clipped.

The fingers together locked may prevent the associated reaction by reducing the
spasticity of the flexion pattern of the affected upper limb by abduction of the affected
fingers and also increasing the sensation and perception of the affected side since the
fingers together locked are held in the midline of the body22. In this study, BULTT
improved the upper limb function more than GULT, and there was a significant
difference between the two groups before and after the intervention. When any
activity begins on both sides, the motor cortex of both hemispheres simultaneously
activates and inhibits the functions of the other side.

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Previous studies on stroke patients have emphasized the importance of simultaneous
exercises on the bilateral upper limb and reported that normal movement of the upper
limb through coordination of both hands plays an important role in the quality of
performance in daily life. reported improved upper limb function when repeated
bilateral upper limb training was applied to stroke patients.

Lewis & Byblow also suggested using the affected and less affected upper limb
simultaneously to improve the function of the upper limb. Recovery of upper limb
function has a direct impact on performing independent activities and activities of
daily living. The results of this study show that BULTT performance in acute stroke
patients is effective in improving the function of the affected upper limb in stroke
patients.

In this study, generalized interpretation of all stroke patients is limited because only
limited patients who meet the selection criteria were studied. Further evaluation of
factors that may have an additional effect on upper limb function was not considered
and further evaluation should be performed to further clarify the relationship between
bilateral tasks and upper limb function. Therefore, additional studies should be
conducted to investigate the effect of bilateral upper limb activity on patients’
rehabilitation process in various aspects.

Conclusion

The purpose of this study was to investigate the effect of bilateral upper limb activity
on upper extremity function into acute stroke patients. Thirty patients were selected
based on the selection criteria, and 15 subjects were divided into two groups, one was
an experimental group applying bilateral upper limb training task and the other was a
general upper limb rehabilitation group. FMA was used to compare upper limb
functions before and after intervention for 4 weeks. The results were as follows. First,
there was a significant change in upper limb function before and after intervention in
BULTT and GULR, but it was more effective in BULTT (p<0.001) Second, there was
significant improvement in bilateral upper limb activities after intervention.

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 Experiments Clinical Reasoning in the Use of Slings for Stroke
Athelets Patients with Shoulder Subluxation

DR. SUMMARY ABOUT STROKES IN PATIENTS

Stroke is one of the leading causes of long-term disability (Lloyd-Jones, D., et al.,
2009). About 50% of the stroke survivors over the age of 64 have hemiparesis, and
about 26% of the stroke survivor lost independence in activities of daily living
(American Heart Association, 2011). Shoulder subluxation is one of the complications
of stroke aftermath, which could lead to the loss of arm function and consequently
results in loss of independence in activities of daily living.

Among various modalities applied to manage shoulder subluxation, the literature

reported that shoulder slings are frequently used despite the low evidence for its
efficacy (Dieruf, Poole, Gregory, Rodriguez, & Spizman, 2005; Foongchomcheay,
Ada, & Canning, 2005; Gustafsson & Yates, 2008; Morley, Clarke, English, &
Helliwell, 2002). In the current literature, the study of the use of sling in post-stroke
rehabilitation is rare.

The efficacy of the use of shoulder sling has not been researched recently. There is
little to no study that surveyed the current occupational therapy practitioners probing
for the reason in the use of shoulder slings. In addition, the inconsistency between the
low level of evidence and the perceived prevalence of the use of sling has not been
addressed recently. Considering the large population of stroke patients and the
significance of the arm function for human occupation, the investigation in the use of
shoulder sling in the post-stroke rehabilitation should be conducted with the utmost
urgency.

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 LITERATURE REVIEW

Stroke, also known as cerebral vascular accident (CVA), is the third leading cause of
death in America. About 795,000 people are affected by stroke each year (American
Heart Association, 2011; Center for Disease Control, 2011). Shoulder subluxation is a
2 possible secondary complication from stroke. Stroke frequently results in muscle
paralysis or flaccidity in a stroke patients’ upper extremity, which could lead to
shoulder subluxation (Williams, Taffs, & Minuk, 1988).

The loss of arm function resulting from shoulder subluxation negatively affects the
person’s ability to participate in his/her meaningful occupations. Occupational therapy
practitioners are encouraged to use evidence-based practice to prevent and manage
shoulder subluxation. Current evidence-based interventions for shoulder subluxation
include modalities such as electrical stimulation, positioning, and strapping. On the
other hand, the use of shoulder slings has limited research to support its effectiveness
in treating shoulder subluxation (Gustafsson & Yates, 2008).

Despite the fact that shoulder slings are not supported by high level evidence,
Gustafsson and Yates (2008) reported that occupational therapy practitioners
prescribed slings for shoulder subluxation more often than other modalities that were
supported by stronger evidence. Therefore, the purpose of this study was to uncover
the occupational therapy practitioners’ clinical reasoning in choosing a sling for
individuals with post-stroke shoulder subluxation or at risk for shoulder subluxation.

Stroke

Stroke, also termed cerebral vascular accident (CVA), is a neurological condition with
a lesion in the brain. There are two types of strokes, ischemic stroke and hemorrhagic
stroke. The more prevalent type of stroke is ischemic stroke. Ischemic stroke accounts
for 87% of the stroke population (Center for Disease Control, 2011). Ischemic stroke
is caused by restriction of blood to the brain that leads to damage in brain cells.
Hemorrhagic stroke occurs when the weakened blood vessel in the brain ruptures due

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to high blood pressure. The blood that flew out of the blood vessel compresses the
brain cells, which ultimately causes damage to the region of the brain. The effects of
stroke vary. The location and extent of the brain cell damage determine the severity of
the stroke. Stroke limits the person’s cognitive and physical abilities. Stroke
commonly affects one side of the cerebral hemisphere which may affect the
contralateral side of the body, both upper and lower extremity. This condition is
called hemiplegia or hemiparesis.

Shoulder subluxation

One of the most common complications that occur in the upper extremity after a
stroke is shoulder subluxation. Shoulder subluxation is defined as partial dislocation
of the glenohumeral joint (shoulder joint). The stability of the glenohumeral joint
depends on the rotator cuff muscles and ligaments. Muscle paralysis or flaccidity of
the upper extremity resulted from stroke significantly reduces or disables the ability of
rotator cuff muscles to maintain normal muscle tone.

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Consequently, the flaccid or paretic upper extremity imposes a gravitational pull on
the glenohumeral joint. The gravitational pull ultimately leads to the damage to the
glenohumeral joint. It has been reported that the prevalence of shoulder subluxation in
stroke patients is 17% to 81% (Paci, Nannetti, & Rinaldi, 2005; Zorowitz, Idank, Ikai,
Hughes, & Johnston, 1995). There are three types of shoulder subluxation: anterior,
inferior, and antero-inferior subluxation. The most common type of subluxation is the
antero-inferior shoulder subluxation (Morin & Bravo, 1997). If a shoulder subluxation
is not managed properly, it may lead to severe pain, brachial plexus injury, and
subacromial impingement (Brooke, Lateur, Diana-Rigby, & Questad, 1991; Dieruf et
al., 2005; Foongchomchaey et al., 2005; Morleyet al., 2002). The pain and immobility
of the shoulder limit the ability to perform 4 critical and valuable occupations, such as
independence in self-care, work, and valued leisure activities. Consequently, the
disability related to shoulder subluxation significantly alters the person’s life role and
affects their identity. Therefore, preventing and addressing shoulder subluxation is
essential in occupational therapy practice (Peter & Lee, 2003).

Types of modalities used for post-stroke shoulder subluxation

Various modalities are used to manage post-stroke shoulder subluxation. The

modalities commonly used include electrical stimulation, strapping, and slings.
Positioning the hemiplegic arm while in a wheelchair or on the bed is also a widely
practiced treatment approach.

Electrical Stimulation

Different types of electrical stimulation are used for the treatment of post-stroke
shoulder subluxation. Neuromuscular electrical stimulation (NMES) provides
electrical stimulation to contract paralyzed muscles through an intact lower motor
pathway and elicits muscle response or muscle contraction to the strokeaffected
muscles (Chae & Sheffler, 2009). The main effects of NMES are muscle conditioning
and reduction of spasticity. Muscles that are usually treated by NMES are the
supraspinatus and the posterior deltoid, which play a critical role in maintaining the
glenohumeral alignment (Paci et al., 2005; Price & Pandyan, 2001).

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Functional electrical stimulation (FES) applies NMES to facilitate accomplishment of
functional tasks. FES is designed to correlate a stroke patient’s volitional movement
and the provision of electrical stimulation so that functional performance can be
achieved (Chae & Sheffler, 2009). Transcutaneous electrical nerve stimulation
(TENS) is used for controlling the shoulder pain based on the gate-control theory of
pain (Vasudevan & Vasudevan, 2008).

The stimulation frequency applied for the treatment ranges from 30Hz to 60Hz (Paci
et al., 2005: Ada & Foongchomcheay, 2002; Fil, Armutlu, Atay, Kerimoglu, & Elibol,
2011). The common practice protocol for electrical stimulation is to gradually
increase the duration of stimulation up to six hours per day (Paci et al., 2005). There
are two systematic review and meta-analysis that support the efficacy of electrical
stimulation for reducing shoulder subluxation. A systematic review by Price and
Pandyan (2001), which reviewed five randomized control studies, suggested that
electrical stimulation could be used to reduce the severity of the shoulder subluxation.

The metaanalysis by Ada and Foongchomcheay (2002) stratified the included studies
in two categories by the criterion whether the study included participants with a stroke
that occurred within two months or more than two months prior to the study.
According to the findings by Ada and Foongchomcheay (2002), the use of electrical
stimulation within two months after a stroke reduced the shoulder subluxation by 6.5
mm compared to the control group without electrical stimulation, whereas electrical
stimulation that was applied later than two months after stroke showed only 1.9 mm
reduction compared to the control group.

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In a recent randomized controlled study of 48 participants in an acute setting (within
two days from the onset of stroke), high voltage pulsed galvanic stimulation at 60Hz
was prescribed to the study group participants for 20 minutes per day for an average
of 12 days. The study group showed no sign of subluxation, while 37.5% of the
control group exhibited shoulder subluxation (Fil et al., 2011). The efficacy of early
intervention with FES for the reduction of shoulder subluxation was also supported by
a randomized controlled study with 50 participants by Koyuncu, Nakipoglu-Yuzer,
Dogan, and Ozgirgin (2010). The control group received the standard rehabilitation
program, while the study group received FES treatment on supraspinatus and
posterior deltoid muscles in addition to the standard treatment.

The median time from the onset of stroke to the beginning of the standard
rehabilitation program was 180 days for the study group and 90 days for the control
group. The results demonstrated that the study group exhibited less subluxation than
the control group, and the difference of shoulder subluxation measurements between
the two groups was statistically significant (Koyuncu et al., 2010). The efficacy of the
early application of electrical stimulation for functional improvement was reported in
the same meta-analysis by Ada and Foongchomcheay (2002). The study participants
who received the treatment with electrical stimulation within two months from the
stroke onset scored the functional measurement scale of the upper limb that was 19%

22
superior to the score of the control group. On the other hand, the participants who
received the treatment with electrical stimulation later than two months after the
stroke onset did not have the functional improvement that was significantly different
from the score of the control group (Ada & Foongchomcheay, 2002). Fil, et al. (2011)
mentioned above also measured the upper limb function of the study participants
using the Motor Assessment Scale.

The study group exhibited the higher scores, though the differences did not reach
statistical significance (Fil, et al., 2011). On the other hand, the efficacy of electrical
stimulation for the purpose of pain reduction is inconclusive. A systematic review by
Price and Pandyan (2001) reported no significant pain reduction measured by the
pain-free range of motion in the affected upper limb. Another randomized controlled
study suggested that electrical stimulation was effective for pain reduction in patients
whose stroke onset is within 77 weeks or less, but ineffective for those who had a
stroke more than 77 weeks ago (Chae, et al., 2007).

Strapping

Along with slings and positioning techniques using supports from pillows and lap
trays, strapping is one of the biomechanical approaches to manage shoulder
subluxation. The stroke-affected shoulder is strapped with a variety of techniques
using adhesive tapes in order to maintain the alignment of the glenohumeral joint.
Depending on the orientation of the tape, it either promotes or inhibits the movement
of the limb.

The administration of strapping requires further training and is considered as

advanced practice in the field of occupational therapy (Vasudevan & Vasudevan,
2008). Strapping has several advantages over the other biomechanical modalities,
such as slings and lap trays. Strapping allows movement of the affected limb while
maintaining the joint integrity, whereas slings hold the arm in one position which may
lead to possible muscle shortening due to disuse (Hanger, et al., 2000).

23
Strapping can be worn constantly for several days until it needs to be replaced from
overstretching. On the other hand, the use of slings and lap trays are limited in
application contexts and cannot be applied continuously throughout the day (Hanger,
et al., 2000). The proprioceptive stimuli provided through strapping may also be
beneficial to patients with neglect or poor proprioception (Ancliffe, 1992; Griffin &
Bernhards, 2006; Hanger, et al., 2000; Peters & Lee, 2003).

One of the causes of post-stroke shoulder subluxation is mishandling of the affected

shoulder by medical staff or caregivers. Strapping also provides a visual reminder to
the handler and may facilitate proper handling techniques (Ancliffe, 1992; Griffin &
Bernhardt, 2006; Hanger, et al., 2000; Morin & Bravo, 1997) 8 Several studies
focused on the effect of strapping on pain reduction.

Ancliffe (1992), and Griffin and Bernhardt (2006) supported the efficacy of strapping
in the pain reduction in stroke patients in the acute and the sub-acute setting. Ancliffe
(1992) conducted a pilot study with eight stroke patients who were admitted to the
hospital within 48 hours after the onset of the stroke. Eight subjects were randomly
assigned to either a study group or a control group. The study group received
strapping on the affected shoulder. The control group did not receive strapping.

The patients in the study group experienced significantly longer days of pain-free
days (mean = 21 days), while the mean pain-free day of the control group was 5.5
days (Ancliffe, 1992). A randomized controlled study by Griffin and Bernhardt
(2006) measured the number of pain-free days among the patients who had a stroke
within three weeks. The study group maintained strapping for four weeks in addition
to the standard stroke care, while the control group received standard care only. The
difference of pain-free days between the two groups was statistically significant. The
mean pain-free days of the study group was 26.2, while that of the control group was
19.1(Griffin & Bernhardt, 2006).

24
The randomized controlled trial of Hanger, et al (2000) applied strapping to 49 acute
stroke patients throughout the hospitalization period (median 25 days), while other 49
patients in the control group did not receive strapping. Shoulder pain was assessed by
pain-free range of motion in shoulder lateral abduction. Arm function was measured
by the Motor Assessment Scale. Patients’ overall functional status was measured by
the Functional Independence Measure (FIM). Although the result did not achieve
statistical significance, the researchers concluded that the improvement in motor
function and pain 9 reduction observed in the study implied the potential of strapping
as an effective treatment modality (Hanger, et al., 2000).

Appel , Mayston and Perry (2011) tested the efficacy of strapping on functional
improvement in the stroke-affected limb. Their small randomized controlled study
recruited a total of 13 acute stroke patients whose stroke onset was within 10 days.
Six patients in the study group received strapping treatment for one month in addition
to routine rehabilitation, while seven patients in the control group received only
routine rehabilitation. The level of arm function was measured by the Motor
Assessment Scale, the Arm section of the Fugl Meyer Scale, and the Nine Hole Peg
Test. The study found a small-to-moderate effect size on functional improvement in
the study group (Appel et al., 2011).

Strapping was also shown to be effective in supporting a subluxed shoulder when

used concurrently with the sling (Morin & Bravo, 1997). In a single group study by
Morin and Bravo (1997), 15 hemiplegic patients with shoulder subluxation of at least
one half finger widths were treated with both strapping and a sling for five days. X-
ray of the patients’ subluxed shoulders were taken on the first and last day of the
treatment and three days after the completion of the treatment. The average baseline
subluxation among the patients was 11.73mm, while the measurement at the last day
of the treatment was 2.05mm, indicating an 86% reduction.

25
However, three days after the support from strapping and the sling were removed, the
subluxation level increased to10.17mm. Morin and Bravo (1997) concluded that the
clinical value of this reduction was insignificant although 1.5mm reduction from the
baseline was statistically significant. 10 In summary, an outlook of the efficacy in the
use of strapping is positive. However, strapping is a relatively new treatment modality
for the management of shoulder subluxation. Currently a variety of strapping
techniques were used in the literature, and the long-term effects of strapping on the
shoulder subluxation have not been reported yet (Paci et al., 2005).

Positioning

The use of lap trays and pillows to support the stroke-affected upper limb is
recommended in the Clinical Practice Guideline for the post-stroke rehabilitation
issued by the Department of Health and Human Services (Paci et al. 2005; U.S.Dept.
of Health and Human Services. 1995). The Canadian Best Practice Recommendations
for Stroke Care recommends positioning and supporting the affected limb for the
purpose of shoulder pain management with middle to low level evidence (Lindsay,
Gubitz, & Bayley, 2010).

Lap trays or arm troughs attached to the wheelchair support the stroke-affected upper
limb while sitting. Some literature recommended the use of lap trays for not only
supporting the affected limb but also for keeping the arm in abduction and external
rotation to counteract the effect of flexion synergy (Brooke et al. 1991). Gustafsson
and Yates (2008) reported the prevailing use of pillows by the medical staff as a
support while patients were in bed. However, there is no evidence to support the
application of a pillow.

Sling

A sling can be used to decrease stress and the gravitational pull on the glenohumeral
joint in order to maintain the anatomical alignment of the shoulder. The use of sling is
best to be combined with an exercise program in order to prevent soft tissue
contractures that may result from keeping the affected arm in a stationary position for
a prolonged period of time (Brook et al. 1991; Vasudevan & Vasudevan, 2008 ).
26
Although early intensive therapy to mobilize the affected upper extremities has been
shown to improve arm function and prevent contractures from shoulder subluxation, it
was suggested that this type of therapy should be avoided for the first seven days after
the appearance of the shoulder subluxation in order to prevent worsening of the
shoulder subluxation (Dieruf et al. 2005).

types of slings

A variety of shoulder slings were designed and applied in poststroke rehabilitation.

The Bobath sling is designed to provide comfort for the patients and to manage
shoulder subluxation (Brooke et al. 1991; Morely et al. 2002). The straps go behind
the unaffected side as well as the affected side with the shoulder subluxation.
Additional straps within the two straps on each side of the shoulder connect together
in a figure-of-eight across the trunk. In addition, the shoulder with the subluxation has
a pad beneath the proximal humerus for support.

The pad is designed to position the humerus into abduction and to avoid internal
rotation of the humerus. The main purpose of the Bobath sling is to decrease the
shoulder subluxation, normalize muscle tone, as well as prevent internal rotation of
the humerus and a flexed-arm position.

This technique is aimed to decrease the chance of developing contractures by placing

the arm in a neutral position and allowing arm movement (Brooke et al. 1991; Morely
et al. 2002). The Rolyan sling has an arm cuff that holds the humerus of the affected
extremity proximally. The Roylan sling is designed to allow adjustment of both
vertical and rotational position of the humerus.

The Rolyan sling also provides a bilateral axillary support to correct the subluxation.
The sling has straps that position the humeral head. There is also a brace placed
between the scapulae to provide support. Overall, this sling positions the humerus in
external rotation and the scapula in a retracted position in order to decrease shoulder
subluxation (Morley et al. 2002; Williams et al., 1988; Zorowitz et al., 1995). Moodie,
Brisbin and Morgan (1986) indicated that the original triangular sling has proved to
27
be the most effective, comparing to the Bobath, Hook hemi harness, arm trough, and
lap tray in reducing shoulder subluxation.

However, there are several disadvantages with the conventional triangular sling. The
triangular sling positions the shoulder in an adducted and internally rotated position,
which may lead to a flexor synergy pattern of the affected upper extremity (Morley et
al. 2002). Brooke et al. (1991) described that the Harris hemisling consists of an
elbow pad and an additional pad that supports the wrist and hand.

The wrist and hand straps have adjustable loops extended from each of the two pads
to wrap around the patient’s trunk. The elbow straps run in front and behind the
shoulder. The Harris sling is designed to provide optimal shoulder support and
comfort. The study by Brooke et al. (1991) with 10 study participants compared the
degree of subluxation in the affected shoulder that was supported by the Harris sling
to that of the non-affected shoulder.

The results indicated, “Harris hemisling provided good correction and was
consistent.” (pp. 585). Mortimer (as cited in Morley, et al., 2002) studied two types of
hemi slings, the Devore and Denny sling, and the other type of hemi sling with a
‘criss-cross back’. Mortimer concluded that there was no objective evidence provided
to support the use of both types of slings. In addition, Mortimer (as cited in Morley, et
al., 2002) stated as follows.

The resultant position of the upper limb within all of the hemi slings is one of
shoulder adduction, flexion and internal rotation, with the upper limb 13 being
strapped to the body, with similar disadvantages to those associated with a triangular
sling. (Morley, et al., 2002, pp. 212) GivMohr sling is a uniquely designed sling that
allows weight bearing and functional mobility of the arm during walking. The
GivMohr sling is designed to normalize muscle tone by applying joint compression on
the upper extremity of the affected shoulder.

28
The sling is found to be effective with patients with shoulder subluxation because of
how the sling positioning the shoulder. GivMohr sling positions the arm in a
functional position where the shoulder is externally rotated with a small amount of
abduction and the elbow is in an extended position (Dieruf et al. 2005).

The Givmohr sling is highly adjustable. Dieruf et al. (2005) described the design of
the GivMohr sling as follows. The sling holds the arm …with a modified figure-8
strap of nonelastic webbing that loops around the anterior aspect of the unaffected
shoulder and axilla and crosses between the scapulae. These straps are adjustable with
buckles to modify the fit. (p2325) effectiveness of the slings.

Various studies have compared the effectiveness of each sling in reducing and/or
managing shoulder subluxation. Radiology analysis was often used to measure before
and after results. In addition, the radiographs were also used to compare the
unaffected shoulder with the affected shoulder as a measure of improvement with the
affected shoulder after wearing a shoulder sling. Vertical and horizontal
displacements of the arm were two factors in measuring the degree of shoulder
subluxation (Brooke et al. 1991; Williams et al. 1988; Zorowitz et al. 1995).
Williams (1998) compared the effectiveness of two slings, the Henderson sling and
the Bobath sling, in reducing shoulder subluxation.

This study also compared the effectiveness of each sling against the subluxed
shoulder with no sling. The Henderson sling has a strip of polyethylene foam that
saggitally surrounds the affected shoulder. The foam is secured by a strap that runs
through the chest, axilla, and the back to connect the front and back sides of the foam.
Twenty-six subjects participated in this study. All of the participants had hemiplegia
(either left or right) with shoulder subluxation. Out of the 26 subjects, 22 subjects had
a Brunnstrom’s stage of recovery of one to three, indicating that their involved upper
extremities were nonfunctional.

29
The other four subjects were in Brunnstrom’s stage of recovery four to six. Those four
subjects had some control of their arm movements. Anteroposterior radiographs were
taken both on the uninvolved shoulder and the involved shoulder in order to compare
the alignment of the two shoulders before and after using the sling. Each of the 26
participants received either the Bobath sling or the Henderson sling. The results
showed that there was no significant difference in the effectiveness of the Bobath
sling comparing to the Henderson sling. Both had a mean alignment of 5mm with the
26 subjects. The difference between the Bobath and the Henderson sling in correcting
shoulder subluxation was 0.6mm, which was not significant. When comparing the
involved shoulder without using shoulder sling to the involved shoulder with one of
the two slings, there was a significant difference in the measurement of subluxation.

The results from Brooke et al. (1991) and Zorowitz et al. (1995) indicated that the
Bobath roll, comparing to the Harris hemisling and the Roylan sling, was the least
effective in reducing the displacement of the affected shoulder.

In particular, the study by Brook et al. (1991) indicated that the Bobath sling was not
effective in treating vertical and horizontal subluxation when comparing to the Harris
sling. This study recruited ten subjects with shoulder subluxation from stroke. The
results showed that the Harris sling had significant improvement in correcting the
vertical alignment of the shoulder. The results of the Harris sling averaged 37.8mm in
vertical distance, as comparing to 38.5mm of the uninvolved shoulder. The Bobath
sling did not have a significant result in the mean vertical correction of the shoulder
subluxation when compared to the mean measurement of the uninvolved arm. The
Bobath sling was found to have an average of 43.2mm in vertical correction of the
subluxed shoulder comparing to the mean vertical distance of the uninvolved arm of
38.5mm (Brooke et al., 1991).

In addition, Moodie et al (1986) indicated that the Bobath sling was not able to reduce
subluxation to 20% of normal shoulder alignment. The study by Zorowitz et al.
(1995) showed that the Rolyan cuff sling produced the best total asymmetry
correction of the shoulder when comparing to subjects with no support, Hemisling,
Bobath, and the Cavalier sling. For correcting both vertical and horizontal
displacement of the shoulder, Zorowitz et al. (1995) and Morley et al. (2002)
30
indicated that the Rolyan humeral cuff sling was the most effective comparing to the
single strap hemi sling or the Bobath sling. Dieruf et al. (2005) also explained that
although the Rolyan cuff sling was the best at correcting the total displacement of
shoulder subluxation, its effectiveness of correcting vertical displacement was not
significant comparing to the GivMohr sling. Comparing to the Bobath sling and the
Rolyan humeral cuff sling, the single strap hemi sling, which is similar to the Harris
hemisling, was the best in correcting vertical 16 displacement of the affected
shoulder. (Zorowitz et al. 1995). The study by Zorowitz et al. (1995) consisted of 20
subjects. Each subject wore three types of the shoulder slings in sequence, first the
single strap hemisling, second the Rolyan sling, and third the Bobath sling. Results
showed that single strap hemi sling had the best vertical correction in 55% of the
subjects (11 subjects), the Rolyan sling 40% of the subjects (8 subjects), and the
Bobath 20% of the subjects (4 subjects).

The overall results indicated that both the Harris hemisling and the single strap hemi
sling were effective in correcting vertical displacement for shoulder subluxation
(Brooke et al. 1991;Morley et al. 2002; Zorowitz et al. 1995). The study by Dieruf et
al. (2005) showed that the GivMohr sling greatly reduced vertical displacement of the
shoulder while preventing overcorrection of both vertical and horizontal displacement
of the affected shoulder compared to the Rolyan humeral cuff sling. However, Dieruf
et al. (2005) concluded that neither the GiveMohr sling nor the Rolyan humeral cuff
sling had a significant impact in correcting horizontal displacement. In fact, some
researchers suggested that horizontal displacement was often caused by the use of
shoulder slings itself, not by shoulder subluxation (Dieruf et al. 2005; Zorowitz et al.
1995).

Overall, as evidenced by Williams et al. (1998), Brooke et al. (1991) and Zorowitz et
al. (1995), the use of shoulder slings exhibited a significant reduction of subluxation
in the affected shoulder when compared to the affected shoulder with no support at
all. However, each sling type showed various degree of efficacy in reducing shoulder
subluxation. The literature frequently warned the disadvantage of some sling types
that 17 facilitate the flexor synergy pattern and increase the risk of contracture
(Moodie et al., 1986; Morley et al., 2002).

31
Use of shoulder slings in occupational therapy practice with including
experiments

Management of the shoulder subluxation with supportive devices, such as slings or

arm trough, is a challenge. Lack of agreement on the cause of shoulder subluxation
and absence of large scale randomized controlled studies for treatment modalities
make it difficult for healthcare practitioners to navigate for sound clinical decision
(Dieruf et al., 2005; Foongchomcheay et al., 2005; Morley et al., 2002) Gustafsson
and Yates (2008) conducted a survey-based study to investigate if the current
occupational therapy practice for stroke patients with shoulder subluxation correlated
with the available evidence in the literature. In this study, occupational therapy
practitioners completed the survey.

The results showed that occupational therapy practitioners frequently chose treatment
techniques that did not have significant supporting evidence, such as pillows (98%)
and slings (61%). On the other hand, treatment modalities with high evidence, such as
electrical stimulation, were used less frequently (39%). The discrepancy between the
frequently-used clinical practice and evidence-based practice was significant.
However, this study did not include an investigation on the clinical reasoning behind
the choice of the low evidence techniques.

As there is literature that investigated the clinical reasoning in the use of supporting
device, the reason for prevailing use of supporting device remains unknown. The
reason for the persistent use of sling has not been investigated to this day. In addition,
the discrepancy between the frequency in using sling and the level of supporting
evidence has not been addressed recently. Some studies explained that the sling plays
a 18 protective role for paralyzed upper limb during the transfer (Griffin & Bernhardt,
2006; Gustafsson & Yates, 2008). As stroke patients recover and regain mobility, the
protection for the stroke-affected limb becomes a valid concern.

32
Smith and Okamoto (1981) formulated a guideline for selecting slings for the
hemiplegic patient in the occupational therapy practice. The factors to be considered
when selecting a sling included appropriate joint positioning, weight distribution,
effect of changes in body positioning, allowance for hand function, effect on skin
integrity, cost, durability, and easy donning/doffing to facilitate patient’s compliance
(Smith & Okamoto, 1981). The guideline emphasized the importance of
individualized therapy in the decision process when determining and selecting an
appropriate sling within the patient’s physical and personal context. For instance, a
patient with strong neglect may need a sling that limits mobility in order to protect the
limb, while a patient without neglect should use a sling that allows movements and
discourages the flexion synergy. This guideline provides a path for possible clinical
reasoning which occupational therapists might apply.

Statement of Purpose

The purpose of this study is to survey occupational therapy practitioners practicing in

the state of California in order to investigate the prevalence and the clinical reasoning
in the use of shoulder sling in the management of post-stroke shoulder subluxation.
Although different types of slings are often used in occupational therapy practice in
post-stroke rehabilitation, there is no substantial evidence that supports the efficacy of
slings to manage shoulder subluxations.

There is limited research to the clinical reasoning behind the use of sling and the
selection of different types of slings. We regard that it is critical to examine the
current state of occupational therapy practice that involves the use 19 of shoulder
sling. Investigation of the clinical reasoning for the use of sling will provide a better
understanding of the clinical context that defies the evidence against the sling. Our
survey will also guide the direction of future research related to the treatment
modality for the individuals with post-stroke shoulder subluxation. In addition,
investigation of the clinical reasoning will bring an attention to and thus re-evaluation
of the practice that is prevalent without evidence (Gustafsson & Yates, 2008).

33
To investigate the clinical reasoning for the use of the sling in the post-stroke
rehabilitation, we developed a questionnaire to survey occupational therapy
practitioners who practice in stroke rehabilitation in California. The survey is
designed to answer the following research questions.

1. What is the prevalence of the use of shoulder sling in the post-stroke occupational
therapy practice across the clinical settings?

2. What is the clinical reasoning for using the sling?

3. What types of sling are commonly used in the post-stroke occupational therapy
practice?

4. What is the clinical reasoning for the selection of the particular sling?

Theoretical Framework

Clinical reasoning

Occupational therapists are encouraged to use evidence to guide practice. Deploy &
Gitlow (as cited in Gustafsson & Yates, 2008) defined evidence based practice as
research evidence that supports the efficacy of the interventions. Deploy and Gitlow
(as cited in Gustafsson & Yates, 2008) also explained the efficacy of an intervention
is further 20 determined by the practitioner’s clinical reasoning to make optimal
decisions in choosing the intervention that best fit the individual (as cited in
Gustafsson & Yates, 2008).

Clinical reasoning is a thought process used by occupational therapy practitioners to

guide the best possible intervention for the patients. Rogers (1983) stated that clinical
reasoning is a critical core of clinical practice. Clinical reasoning process incorporates
multiple modes of thought process that include scientific thought process,
phenomenological thought process, and situational/pragmatic thought process (Schell
& Cervero, 1993) Different forms of clinical reasoning are employed for different
purpose, or for responding to specific clinical need (Schell & Cervero, 1993). There
34
are different types of clinical reasoning; procedural reasoning, narrative reasoning,
pragmatic reasoning, conditional reasoning, and interactive reasoning.

Procedural reasoning

Procedural reasoning provides a biomedical and biomechanical approach to clinical

problem solving (Pedretti, Pendelton, & Scholtz-Krohn, 2006). An example of
procedural reasoning is that an occupational therapist determines the most effective
modality to address shoulder subluxation based on patient’s muscle tone or motor
recovery stages after stroke. (Mendez & Neufeld, 2003; Pedretti et al., 2006; Schell &
Cervero, 1993). In case of prescribing a shoulder sling to a stroke patient, the
examples of procedural reasoning are to correct glenohumeral alignment of the
subluxed shoulder, to protect affected upper extremity during transfers, or to reduce
stress from the gravitational pull when the patient is seated or standing.

Narrative reasoning

Narrative reasoning follows a phenomenological approach that identifies the values,

goals, or preference of the patient and guides intervention based on what is important
to the patient (Pedretti et al., 2006). Narrative reasoning incorporates 21 patient’s
motivation, action, and compliance to the prescribed intervention by matching the
treatment to the patient’s needs. Occupational therapy practitioners gather information
from the patients through active listening to formulate narrative reasoning for the
treatment.

Examples of narrative reasoning in selecting a shoulder sling for the patient are the
comfort of the sling, good appearance that does not impair the body image, or easy
donning/doffing. How easy or difficult it is to don or doff the sling may also affect the
patient’s level of compliance. Patient may not feel comfortable wearing a sling in
public due to impoverished image of disability. Narrative reasoning incorporates such
narrative from the patient’s perspective in order to facilitate the patient’s active
participation in therapy (Mendez & Neufeld, 2003; Pedretti et al. 2006; Schell &
Cervero, 1993). Pragmatic reasoning.

35
Pragmatic reasoning

Pragmatic uses a situational approach. This reasoning takes in consideration of

organizational, political, or economic realities that surround the clinical practice. Such
external factors can affect occupational therapists decision in selecting interventions
for patients. The lack of financial resources can limit the choices of intervention that
may be beneficial to the patient.

Another external factor may be that the shoulder sling prescription was made by the
physician and the therapist simply has to plan an intervention following the
prescription. In certain sling that has more complex structure, patients may need to
have the assistance from a caregiver to don and doff, which could be inconvenient for
both the patient and the caregiver. In such a case, the occupational therapy
practitioner may settle for a sling that is easily worn, instead of prescribing the most
effective one.

The modalities readily available or not available at the facility may also affect the
occupational therapy practitioner’s decisionmaking. If the clinic does not have
electrical stimulation, the therapist has no choice but to use a sling to manage
shoulder subluxation. In addition, the occupational therapists may have a particular
vendor where the sling may be readily accessible. Many external factors can affect the
occupational therapy practitioner’s decision in prescribing a certain sling. In some
cases, it is important for occupational therapy practitioners to use pragmatic reasoning
to accommodate to the situational demand in choosing the intervention (Mendez &
Neufeld, 2003; Pedretti et al. 2006; Schell & Cervero, 1993).

Conditional reasoning

Conditional reasoning is a predictive approach that incorporates the present context

and future scenario and formulates the intervention that focuses on the long term
outcomes. Conditional reasoning also builds on therapist’s experience in order to
hypothesize the expected outcome of the treatment for the patient and be able to make
the best decision in choosing the best possible intervention (Mendez & Neufeld, 2003;
Pedretti et al. 2006; Schell & Cervero, 1993). This type of reasoning often requires re-
36
appraisal of the intervention in the course of treatment (Pedretti et al., 2006).
Interactive reasoning.

Interactive reasoning

Interactive occurs when the patient and the occupational therapy practitioner
communicates with one another. It is essential for occupational therapy practitioners
to use interactive reasoning in order to understand the client and find out what
motivates the client. Similar to Narrative reasoning, interactive reasoning will also
assist to identify patient’s specific factors such as level of comfort when wearing the
sling or how the donning and doffing of the sling may affect patient’s fatigue level.
(Mendez & Neufeld, 2003; Pedretti et al. 2006; Schell & Cervero, 1993). Interactive
reasoning navigates the occupational therapy practitioner toward better understanding
of the patient as a whole person, instead of a subject in the medical 23 intervention.
As a consequence, interactive reasoning helps therapists to access patient’s
phenomenological view of the illness experience and facilitates formulation of more
finely tailored treatment for the patient (Schell & Cervero, 1993).

Biomechanical frame of reference

This study investigates the clinical reasoning in the use of sling and is concerned with
the body function of the patient. Biomechanical frame of reference concerns with
strength, range of motion, endurance, and kinetics of the human body. The
biomechanical frame of reference also applies to adaptive equipment that facilitates
the maintenance or improvement of strength, endurance, range of motion, and
kinesiology of a person and consequently establishes or restores a person’s functional
skills (Sladyk, Jacobs, & MacRae, 2010).

This study is largely guided by the biomechanical frame of reference because the use
of shoulder slings is aimed towards preventing or reducing the severity of shoulder
subluxation and shoulder slings are evaluated based on the efficacy in improving the
client factors of the alignment in the stroke-affected shoulder. Occupational therapy
practitioners who work with stroke patients with shoulder subluxation may be more

37
likely to utilize the biomechanical frame of reference in their clinical reasoning when
making decisions in the use of shoulder slings.

Definitions and Variables

Sling

In this study, the sling is a supportive device that a stroke patient wears on his/her
body to manage or prevent shoulder subluxation. The types of slings surveyed in this
24 study include the Bobath sling, the Rolyan sling, the Harris hemisling, the
GivMohr sling, C.V.A. sling, North Coast Hemi sling, and an orthopedic (triangular)
sling.

Shoulder subluxation

Shoulder subluxation is defined as a partial or incomplete dislocation of the shoulder

joint. Shoulder subluxation occurs when muscles around the shoulder complex are
paralyzed due to stroke and the structural integrity of muscles, joint capsules and
ligaments is lost (Thomas, 1997; Paci et al., 2005).

Occupational therapist / occupational therapy practitioner

In this study, the terms, occupational therapist and occupational therapy practitioner,
are used interchangeably, and they include both occupational therapists and certified
occupational therapy assistants. The American Occupational Therapy Association
defines occupational therapist as an individual who is nationally certified to practice
occupational therapy and met state requirements for licensure or registration: The
occupational therapy assistant is defined as an individual who is nationally certified to
practice occupational therapy under the supervision and in partnership with the
occupational therapist (American Occupational Therapy Association, 2010a).

38
Variables

To investigate the clinical reasoning in the use of shoulder sling, and to answer our
research questions, we used the conceptual description by Creswell (2009) which
interrelates the variables in the descriptive statistical data, research questions, and the
survey questions in order to provide a clear mapping of the research process. The
statistical data that are obtained through the survey questions were cross-referenced to
investigate the 25 correlation among the variables. The table below describes the
inter-related construct of our research questions, variables, and the survey questions.

39
EXPERIMENTAL DATA

Variable Name Research Question Survey Question

(See Appendix A)
Independent variable 1: Descriptive research 1. How many stroke
Prevalence of the sling question 1: What is the patients with shoulder
use prevalence of the sling subluxation or at risk of
use in the post-stroke shoulder subluxation did
occupational therapy you see in the last 12
practice across the clinical months? 2. Among those
settings? stroke patients,
approximately for what
percentage of them did
you use a shoulder sling?
Dependent variable 1: Descriptive research 3. What was the reason
Clinical reasoning for question 2: What is the for using a shoulder sling
the sling use clinical reasoning for the for those patients?
sling use?

Moderating variable 1: 7. Which clinical setting

Factors that may best describes your
influence correlation current work place? 8.
between Independent How many years have
variable 1 and you been working as an
Dependent variable 1 occupational therapy
practitioner? 9. You are a
COTA/OTR with
bachelor’s degree/OTR
with master’s degree/OTR
with doctor’s degree. 11.
You have you been
working with stroke
patients Less than 1 year /
1-5 years / 6-10 years /
more than 10 years. 12.
Indicate if you have any
additional training. 13.
Indicate if you have any
additional training in
these areas.

40
Independent variable 2: Descriptive research 4. In the last 12 months,
Types of shoulder sling question 3: What types of did you use the following
used sling are commonly used slings? 5. Which sling did
in the poststroke you use MOST in the last
occupational therapy 12 months?
practice?
Dependent variable 2: Descriptive research 6. What is your clinical
Clinical reasoning for question 4: What is the reasoning for choosing the
the selection of sling clinical reasoning for the one you used most?
selection of the sling?

Moderating variable 2: 7. Which clinical setting

Factors that may best describes your
influence correlation current work place? 8.
between Independent How many years have
variable 2 and you been working as an
Dependent variable 2 occupational therapy
practitioner? 9. You are a
COTA/OTR with
bachelor’s degree/OTR
with master’s degree/OTR
with doctor’s degree. 11.
You have you been
working with stroke
patients; Less than 1
year / 1-5 years / 6-10
years / more than 10
years. 12. Indicate if you
have any additional
training. 13. Indicate if
you have any additional
training in these areas.
NDT/Neuro-IFRAH:
Electrical Stimulation
(FES or NMES):
Taping/strapping: Other
training not listed

41
 RESARCH METHODOLOGY

Design

This study employed a quantitative descriptive design in order to illustrate the current
occupational therapy practice phenomenon in the use of shoulder sling for the post-
stroke shoulder subluxation. We conducted online and onsite surveys using a
selfreport questionnaire which we developed to identify the prevalence of the use of
sling, the clinical reasoning in the use of sling, types of slings that occupational
therapy practitioners prescribe, and the clinical reasoning behind the selection of
slings (See Appendix A). The questionnaire used for the online survey and the onsite
surveys were identical (See Appendix A and B).

Subjects

The target population of this study was the occupational therapy practitioners in the
state of California who practice in stroke rehabilitation across the various clinical
settings. The clinical settings of the occupational therapy stroke rehabilitation
included acute and sub-acute care facilities, acute rehabilitation facilities, skilled
nursing facilities, home care, and outpatient clinic. Due to the exploratory nature of
this study, a convenience sampling method was used. The online survey was
conducted among 2,000 members of the Occupational Therapy Association of
California (OTAC).

We estimated that about 1,200 OTAC members practiced in the clinical field related
to post-stroke rehabilitation. This estimation was calculated by applying the national
level ratio based on the workforce study by American Occupational Therapy
Association (AOTA, 2010b). According to AOTA’s work force study (2010b), about
59% of its members worked in clinical settings that include stroke rehabilitation.

42
The onsite survey was conducted 28 among the attendees of OTAC’s Spring
Symposium which took place on March 31, and April 1, 2012 in Anaheim, California.
The approximate number of the total attendees was 500, based on verbal
communication with the OTAC staff. The inclusion criterion for sampling was that
the participant of this study must be an occupational therapy practitioner who is
practicing in the field of stroke rehabilitation at the time of the survey under the
licensure of either Occupational Therapist Registered (OTR) or Certified
Occupational Therapy Assistant (COTA).

Ethical consideration

The research participant recruitment was conducted with the consideration of

Occupational Therapy Code of Ethics to ensure the research participants’ autonomy
and confidentiality. The approval from Dominican University Institutional Review
Board for the Protection of Human Subjects (IRBPHS) was obtained prior to the
implementation of this study (IRBPHS identification number 9031). Anonymity of
the research participant was maintained by excluding survey questions that solicit the
participants’ personal identification information.

For those participants who provided us with their contact information through
Request for CVA Sling Survey Result Information (Appendix C), we collected the
form separately from the survey to maintain their anonymity. The collected forms
were stored in a locked box in the office of the thesis advisor, Dr. Kitsum Li, in the
Occupational Therapy Department until the research results were ready to be
distributed. The access to the research result request forms was limited to the thesis
advisor and the student researchers, Simon Chi and Naoko Murai. All data and
records are scheduled to be destroyed after a period of one year following completion
of the research project.To maintain the research participants’ autonomy, we provided
the participants with information in the invitation for research participation describing
the purpose and procedure of our research, potential risks and benefits to the
participants, and cost or reimbursement to the participants (Appendix D).

43
The information provided to the participants included the statements that the
participation to this research is voluntary, and that the participants’ response to our
survey serves as their consent of participation. Research Participant’s Bill of Rights
(Appendix E) was provided to the participants addressing the participants’ autonomy.
For online survey, same information was provided prior to the start of the survey, and
participants were reminded that response to the survey served as consent of
participation (Appendix B).

Data collection ( e

Data collection

Data were collected through an anonymous expreriments using a self-report data and
some questions, CVA Shoulder Sling task (Appendix A and B), which we developed
in order to identify the prevalence of sling use, types of slings that occupational
therapy practitioners prescribe, and the clinical reasoning for the selection of slings.
Data were collected between January 30 and April 1, 2012.

Two modes of data collection were used: online experiments and onsite experiments
with printed questionnaire. Both online experiments (Appendix B) and paper survey
experiments (Appendix A) retained identical formats in the questionnaire in order to
prevent extraneous factors that may influence survey participants’ responses. Online
survey and experiments was distributed on January 30, 2012, among OTAC members
through e-blast service provided by OTAC (Appendix F). In order to enhance 30
research participant recruitment, a reminder announcement was distributed on
February 22, 2012 (Appendix G).

Research participants were also recruited at OTAC Spring Symposium which took
place on March 31 and April 1, 2012, in Anaheim, California. Printed questionnaires
(Appendix A) were handed out to those who agree to participate in our research and
were collected onsite. Since majority of the symposium attendees were expected to be
a member of OTAC, we took measure to prevent double entries in both online and
onsite experiments and survey by the same individual.

44
Before the attendees agreed to participate in the onsite survey, we provided a verbal
reminder that the same survey and experiments was offered online previously. We
placed a graphic of penguin on the prominent places in both online and onsite surveys
to aid the study participants recalling if they had already responded to the online
survey previously.

Data analysis

Descriptive statistics was used to delineate the prevalence of the use of sling and its
clinical reasoning. Additional analysis, using z-test for proportion, was conducted to
further assist our understanding in the factors that influence the use of slings and its
clinical reasoning.

Results

A total of 168 California occupational therapy practitioners completed the

experiments and survey. The online experiments and survey yielded 129 participants,
and the onsite survey at OTAC’s Spring Symposium yielded additional 39
participants. The followings are the results of the survey categorized by the
corresponding research questions.

Research Question 1

‘What is the prevalence of the use of slings in the post- stroke occupational therapy
practice across the clinical settings?’

Survey experimental questions that corresponds to Research Question 1

experimental Question 1: ‘ How many stroke patients with shoulder subluxation or

at risk of shoulder subluxation did you see in the last 12 months?’

All 168 respondents answered this question. Ninety two participants reported that they
provided occupational therapy to less than 12 post-stroke patients in the last 12
months. Forty one respondents reported that they have seen 12 to 23 patients, while
45
twenty one respondents reported seeing 24 to 35 patients. Fourteen respondents
reported that they have seen more than 35 patients.

experimental Question 2: ‘ Among those stroke patients, approximately for what

percentage of them did you use a shoulder sling?’

All 168 respondents answered this question. The multiple choice answers offered in
this question were

“None of them”, “1 – 25%”, “26-50%”, “51 – 75%”, “76 – 99%”, and

“All of them” (Figure 1). Thirty one respondents replied “None of them.
” Seventy eight respondents replied “1 – 25%”. Nineteen replied to “26 – 50%”.
Twenty replied to “51 – 75%”. Thirteen replied “76-99%”.

Seven replied “All of them”. The result indicated that 81.5% of the respondents
prescribed a shoulder sling to their patients. On average, 28.4% of stroke patients with
shoulder subluxation or a risk of shoulder subluxation were prescribed shoulder slings
by the respondents. This average ratio of the patients who were prescribed shoulder
slings was calculated by multiplying the midpoint percentage of each choice range
and the frequency of each choice.

46
Experimental Research Question 2

‘What is the clinical reasoning for using the sling?’

Survey question that correspond to Research Question 2

experimental Question 3: ‘ What was the reason for using a shoulder sling for those
patients?’

Fourteen clinical reasoning choices plus the choice of “other” were offered in this
question. Among the clinical reasoning choices, the procedural reasoning choices
offered were “To correct glenohumeral alignment of subluxed shoulder”, “To
maintain proper glenohumeral alignment”, “To reduce shoulder pain”, “To reduce
arm/hand edema”, “To protect the affected upper extremity during transfers”, “To
reduce stress from gravitational pull while a patient is standing or walking”, and “To
reduce stress from gravitational pull while a patient is seated”. The pragmatic

47
reasoning choices offered were “Physician prescribed it”, “Because other treatment
modalities were not available”. “Because I am not trained or licensed to use other
modalities” and “Because I am not aware of other treatment modalities”. The
conditional reasoning choices offered were “Because I have good result with the
shoulder sling”, “Because I have experience in the shoulder sling”, and “To alert
others not to pull or grab the patient by the arm”. The respondents were asked to
select as many choices as applicable. The result of this question is exhibited in Figure
2. One hundred forty respondents answered this question. The results indicated that
the most frequently occurring clinical reasoning among these respondents’ choices
was “To reduce stress from gravitational pull while a patient is standing

or walking” (count = 100). The second most frequently chosen clinical reasoning was
“To protect the upper extremity during transfer” (count = 93). The third most
frequently chosen clinical reasoning was “To reduce shoulder pain” (count=87). The
fourth was “To maintain proper glenohumeral alignment” (count=77), and the fifth
was “To correct glenohumeral Reason for Using Sling Number of respondents = 140
34 alignment of subluxed shoulder” (count=59).

48
The top 3 choices represent interventions to address functional mobility and pain
reduction. The fourth and the fifth choices represent the remediation of the
glenohumeral alignment. Among 89 respondents who chose the clinical reasoning for
correction or maintenance of glenohumeral alignment, 85 respondents also chose the
clinical reasoning choices for functional mobility or for pain reduction, and 4
respondents chose these two reasons as a sole reason for the sling use. The least
chosen clinical reasoning for using shoulder sling for stroke patients with shoulder
subluxation are “ Because I am not trained or licensed to use other modalities”
(count= 2) and “Because I am not aware of other treatment modalities” (count=2).

Experimental Research Question 3.

‘What types of sling are commonly used in the post stroke occupational therapy
practice?’ Survey questions that correspond to Research Question 3.

Experimental Question 4: ‘In the last 12 months, did you use the following slings?’

One hundred thirty four respondents answered this question. Sling choices given in
this question were GivMohr sling, Bobath sling, orthopedic (triangle) sling, North
Coast hemi sling, C.V.A sling, Rolyan sling, and other types of slings that were not
offered in the questionnaire choice. The respondents were allowed to select multiple
slings as applicable. The result of this question was exhibited In the last 12 months,
did you use the following slings? Number of respondents = 134 35 Figure 3. The most
frequently used sling was the orthopedic (triangle) sling (count = 81), followed by the
GivMohr sling (count = 71). The count for the Rolyan sling was 33; that of the Harris
hemi sling was 29; the C.V.A. sling was 23; the Bobath sling was 10. Twenty one
respondents indicated that they used other type of slings, such as Brown hemi sling
and Patterson Medical Glenohumeral Joint Sling.

49
 DISCUSSIONS AND LIMITATION
METHODS
Sample
This study was conducted according to recommendations
from the Research Ethics Committee (Registration No.
23875C). A total of 90 male undergraduates (age ¼ 20.8
6
1.42 years, height ¼ 177.2 6 5.60 cm, weight ¼ 72.6 6
7.14 kg) were recruited for this study. They were
randomly
distributed in 3 groups: group 1 performed exercises at
the
same intensity, group 2 performed exercises at different
intensities, and the control group performed no upper
body
exercise. All participants were right handed
21
and asymp-
tomatic, with no history of injury or shoulder instability.
All
participants signed an informed consent document before
entering the study.
Experimental Procedures
Participants were instructed not to perform upper body
strength exercises for 1 month before the training
program.
This procedure was adopted to reduce the influence of
previous exercises on the study results. The test
apparatus was
constructed in our laboratory, as described previously,
9
and

50
shown to be reliable. We did not find a significant test-
retest
difference (P ¼ .820). We applied the intraclass
correlation
coefficient (ICC) and verified an ICC of 0.71 and
standard
error of measurement of 1.298. The accuracy of the
angular
measurements was 6 18. Participants were in a seated
position
with the shoulder and elbow flexed (both to 908; Figure
1).
For 8 weeks, groups 1 and 2 attended the strength-
training program 3 sessions per week (Monday, Wednes-

METHODS
Sample
This study was conducted according to recommendations
from the Research Ethics Committee (Registration No.
23875C). A total of 90 male undergraduates (age ¼ 20.8 6
1.42 years, height ¼ 177.2 6 5.60 cm, weight ¼ 72.6 6
7.14 kg) were recruited for this study. They were randomly
distributed in 3 groups: group 1 performed exercises at the
same intensity, group 2 performed exercises at different
intensities, and the control group performed no upper body

exercise. All participants were right handed

21
and asymp-
tomatic, with no history of injury or shoulder instability. All
participants signed an informed consent document before
entering the study.
Experimental Procedures
Participants were instructed not to perform upper body
strength exercises for 1 month before the training program.
This procedure was adopted to reduce the influence of
previous exercises on the study results. The test apparatus was

51
constructed in our laboratory, as described previously,
9
and
shown to be reliable. We did not find a significant test-retest
difference (P ¼ .820). We applied the intraclass correlation
coefficient (ICC) and verified an ICC of 0.71 and standard
error of measurement of 1.298. The accuracy of the angular
measurements was 6 18. Participants were in a seated position
with the shoulder and elbow flexed (both to 908; Figure 1).
For 8 weeks, groups 1 and 2 attended the strength-
training program 3 sessions per week (Monday, Wednes-
Musculoskeletal pain and disorders are a major public health issue with a significant
burden on health care systems and loss of work ability and productivity [1–5]. Neck
and shoulder pains are among the most common musculoskeletal disorders with
individual costs ranging from minor episodes of pain to severe and chronic disability
[6, 7]. Arm and hand pain are less prevalent than neck and shoulder pain but still have
major impact on sickness absence [5]. Pain in the neck, shoulder, and arm is related to
physical work stressors as repetitive work, forceful exertions, static muscle
contractions, awkward postures, and psychosocial factors [2, 8]. Among others,
laboratory technicians—known to perform repetitive and monotonous arm/hand work
tasks— show a high prevalence of such pains [9, 10]. Specific strength training
reveals promising results in rehabilitation of neck and shoulder pain among office
workers [11–14] where even a single set of strength training to failure 3 times a week
provides moderate reductions of headache and neck pain [12, 15]. The rehabilitative
effect of specific strength training on pain in the neck and shoulders has also been
shown among laboratory technicians, where a 20-week, 1-hour a week intervention
was undertaken during working hours [16–18]. Despite these promising results
effective longterm implementation of strength training at the workplace and during
working hours remains challenging. Discussion and
Limitation

Discussion

This study confirmed the study by Gustafsson and Yates (2008) that reported the
frequent use of slings in post-stroke rehabilitation by the occupational therapy
practitioners they surveyed (61% of their survey respondents used a shoulder sling).
In our results, as much as 81.5% of the surveyed occupational therapy practitioners
reported the use of shoulder sling in the practice.

However, the actual prescription of the sling was limited to only 28.4% of the stroke
patients with shoulder subluxation or at risk of shoulder subluxation. Our result
implies that occupational therapy practitioners use discretion and apply individualized

52
clinical reasoning in the use of shoulder sling for the management of shoulder
subluxation. Specific clinical contexts emerged in the use of shoulder sling. Shoulder
slings were often used in the context of supporting the involved upper limb during
functional mobility and in pain management.

The use of shoulder sling solely for correcting subluxation and maintaining joint
integrity was very rare. From our results, the use of shoulder sling for functional
mobility was one of the primary contexts when the shoulder sling was applied.
However, efficacy study of the use of shoulder sling in functional mobility is rare.
Two studies investigated the effects of shoulder slings on walking speed, energy
consumption, and the gait pattern (Han et al., 2011; Yavuzer & Ergin, 2002). The
results of these studies exhibited positive effects.

The study by Yavuzer and Ergin (2002) with study participants demonstrated the use
of the arm sling decreased the walking speed and improved the gait pattern in stroke
patients with hemiparesis, comparing to their walking speed and gait without an arm
sling. Han et al. (2011) reported that study participants with post-stroke hemiparesis
demonstrated increased gait speed and reduced oxygen consumption when they
walked with an arm sling on the affected limb, compared to the gait speed and oxygen
consumption while walking without an arm sling. However, whether or not the
shoulder sling is the best modality for functional mobility should be further examined.
The efficacy of the shoulder sling specifically for pain reduction has yet to be
demonstrated. The complex etiology of shoulder pain with or without subluxation in
strokeaffected upper limb increases the challenge of its clinical management.
Attention should be called upon to the practitioners’ reliance on the shoulder sling for
pain management without investigation and evidence.

This study revealed the high prevalence in the use of the orthopedic (triangular) sling
and the Givmohr sling. The clinical reasoning patterns for using these two most
chosen slings were distinctively different. While the GivMohr sling was chosen
mainly for the management of joint integrity, the orthopedic (triangular) sling was
chosen because of non-procedural reasoning, such as cost, the high availability in the
facility, easy donning/doffing, and other external influence, such as “Physician
prescribed it”.
53
The clinical reasoning pattern in selecting the orthopedic (triangular) sling exhibited a
deviation from the original clinical reasoning to use a sling, which was intended for
the clinical management in the context of functional mobility and the pain
management. Although the orthopedic (triangular) sling provides support to the
humerus, its adverse effects of encouraging immobilization and flexor synergy were
well documented (Moodie et al., 1986; Morley et al., 2002).

These incongruent reasoning patterns between the prescription and the selection of
shoulder slings implicated that the occupational therapy practitioners’ clinical
management might have been compromised by convenience and cost factors.
Considering the shoulder sling is not a reimbursable item by the payer of the health
care services, pragmatic clinical reasoning appears to have won over the originally
intended procedural reasoning in actual practices. The attainment of additional
trainings in post-stroke rehabilitation appeared to have an influence on the practice
patterns in the use of shoulder slings.

Our results indicated that practitioners with additional trainings demonstrated the
lower usage of the orthopedic (triangular) sling, higher reliance on procedural
reasoning, and the lower reliance on pragmatic reasoning. These results imply that
additional trainings may have increased awareness of the possible adverse effects
from certain sling types and enhanced therapists’ assertiveness in procedural
reasoning that promotes better clinical management.

The results of our study indicate that the current practice phenomenon in the use of
shoulder sling does not represent the best practice in post-stroke rehabilitation. The
practice that resorts to convenience and cost factors may not be serving the best
interest of our stroke patients. Considering the high prevalence of stroke conditions in
our current population and the importance of arm functions, occupational therapy
practitioners are encouraged to advocate for patients by calling for increased research,
stepping up their post-graduate professional development education, and promoting
the best practice available with increased assertiveness in the health care industry.
54
Limitation

This study has several limitations. The sampling was limited within one organization
whose membership represents only 15% of the registered California occupational
therapy practitioners, thus the results may not represent the entire practice
phenomenon in California. The study relied on a multiple choice self-report survey.
This method may not have captured the whole range of clinical reasoning employed
in post-stroke rehabilitation. To address this limitation, study participants were
allowed to select all applicable clinical reasoning choices in the survey and put in
additional answer to the “other” choice when appropriate. The data on the prevalence
in the use of shoulder sling should be interpreted with caution. The data were not
based on the actual clinical records and were relied on the assumptive calculation
using midpoint range of the multiple choice answers offered in the questionnaire.

Summary, Conclusion, and Recommendations

The purpose of this study was to investigate the prevalence and the clinical reasoning
in the use of shoulder sling for the stroke patient with shoulder subluxation or at risk
of shoulder subluxation, and to understand the clinical context in which the use of
sling is continued despite the low evidence for its efficacy. The online survey was
conducted among OTAC members, and the onsite survey was conducted among the
attendees of 2012 OTAC Spring Symposium.

A total of 168 occupational therapy practitioners responded to the survey. The results
implicated the use of sling by the high proportion (81.5%) of the California
occupational therapy practitioners. However, the actual prescription of the sling was
limited to 28.4% of the stroke patients with or at risk of shoulder subluxation, which
implies the use of sling was practiced with discretion and individualized clinical
55
reasoning. Shoulder slings were used most frequently in the context of functional
mobility and in pain management.

The most popular sling was the orthopedic (triangular) sling, followed by the 44
GivMohr sling. The pragmatic reasoning pattern was more prominent in selecting the
orthopedic (triangular) sling, while the procedural reasoning pattern was more
prominent in selecting the GivMohr sling. The study of the clinical reasoning in the
use of shoulder sling is rare. Our study identified the prevalence of the use of sling,
clinical contexts where the sling is used, the most commonly used sling type, and the
reason for its popularity.

The current practice phenomenon in California implicated that the clinical

management may have been compromised by factors such as convenience and cost.
Advanced education in post-stroke rehabilitation appears to have played a critical role
in the promotion of better practice. Future studies are necessary to test the
generalizability of the results from this study, especially the trend in our national and
international practices. Further investigation in the role of professional development
education will be highly beneficial since additional education may serve as a pivotal
point that influences the occupational therapy practice phenomena.

56
 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(4), 257-267.

American Heart Association. (2011). Impact of Stroke (Stroke Statistics). Retrieved

from http://www.strokeassociation.org/STROKEORG/AboutStroke/Impact-of-
StrokeStroke-statistics_UCM_310728_Article.jsp American Occupational Therapy
Association. (2010a).

57
The reference manual of the official documents of the American Occupational
Therapy Association, Inc. Bethesda, MD: AOTA Press American Occupational
Therapy Association. (2010b). Surveying the profession. OT Practice, 15 (16).

Retrieved from: http://www.aota.org/Pubs/OTP/2010/OTP091310.aspx?FT=.pdf

Ancliffe, J. (1992). Strapping the shoulder in patients following a cerebrovascular
accident (CVA): A pilot study. Australian Physiotherapy, 38(1), 37-40.

Appel, C., Mayston, M., & Perry, L. (2011). Feasibility study of a randomized
controlled trial protocol to examine clinical effectiveness of shoulder strapping in
acute stroke patients. Clinical Rehabilitation, 25(9), 833-843.

doi:10.1177/0269215510397392 Brooke, M., de Lateur, B., Diana-Rigby, G., &

Questad, K. (1991).

Shoulder subluxation in hemiplegia: Effects of three different supports. Archives Of

Physical Medicine & Rehabilitation, 72(8), 582-586.

Center for Disease Control and Prevention. (2011). Stroke. Retrieved from
http://www.cdc.gov/stroke 46 Chae, J., Ng, A., Yu, D., Kirsteins, A., Elovic, E.,
Flanagan, S., & ... Fang, Z. (2007).

Intramuscular electrical stimulation for shoulder pain in hemiplegia: does time from
stroke onset predict treatment success?. Neurorehabilitation & Neural Repair, 21(6),
561-567. doi: 10.1177/1545968306298412 Chae, J., & Sheffer, L. (2009).

Neuromuscular electrical stimulation for motor restoration in hemiplegia. In J. Stein,

R. Zorowitz, R. Harvey, R. Macko, C. Winstein (Eds.) , Stroke Recovery &
Rehabilitation (pp. 291-306).

New York, NY: Demos Medical Publishing. Creswell, J. (2009). Research design;
Qualitative, quantitative, and mixed methods approaches. Third edition. Thousand
Oaks, CA: SAGE Publications, Inc. Dieruf, K., Poole, J. L., Gregory, C., Rodriguez,
E. J., & Spizman, C. (2005).
58
Comparative effectiveness of the GivMohr sling in subjects with flaccid upper limbs
on subluxation through radiologic analysis. Archives of Physical Medicine &
Rehabilitation, 86(12), 2324-2329. Retrieved from
http://search.ebscohost.com.ezproxy.dominican.edu/login.aspx?direct=true&db=rz
h&AN=2009097693&site=ehost-live Fil, A., Armutlu, K., Atay, A. O., Kerimoglu,
U., & Elibol, B. (2011).

The effect of electrical stimulation in combination with Bobath techniques in the

prevention of shoulder subluxation in acute stroke patients. Clinical Rehabilitation,
25(1), 51-59. doi:10.1177/0269215510375919 Foongchomcheay, A., Ada, L., &
Canning C.G. (2005). Use of devices to prevent subluxation of the shoulder after
stroke. Physiotherapy Research International. 10(3) 134-145. doi: 10.1002/pri.3 47
Griffin, A., & Bernhardt, J. (2006).

Strapping the hemiplegic shoulder prevents development of pain during

rehabilitation: A randomized controlled trial. Clinical Rehabilitation, 20(4), 287-295.
doi:10.1191/0269215505cr941oa Gustafsson, L. & Yates, K. (2008).

Are we applying interventions with research evidence when targeting secondary

complications of the stroke-affected upper limb. Australian Occupational Therapy
Journal. 56(1), 428-435. doi: 10.1111/j.1440- 1630.2008.00757.x Han, S., Kim, T.,
Jang, S., Kim, M., Park, S., Yoon, P., … Lee, K. (2011).

The effect of an arm sling on energy consumption while walking in hemiplegic

patients: A randomized comparison. Clinical Rehabilitation, 25(1), 36-42.
doi:10.1177/0269215510381167 Hanger, H., Whitewood, P., Brown, G., Ball, M.,
Harper, J., Cox, R., & Sainsbury, R. (2000).

A randomized controlled trial of strapping to prevent post-stroke shoulder pain.

Clinical Rehabilitation, 14(4), 370-380. Koyuncu, E., Nakipoglu-Yuzer, G., Dogan,
A., & Ozgirgin, N. (2010).

59
 The effectiveness of functional electrical stimulation for the treatment of shoulder
subluxation and shoulder pain in hemiplegic patients: A randomized controlled trial.
Disability & Rehabilitation, 32(7), 560-566. doi:10.3109/09638280903183811
Lindsay, M. P., Gubitz, G., & Bayley, M. (2010).

On behalf of the Canadian Stroke Strategy Best Practices and Standards Writing
Group. Canadian Best Practice Recommendations for Stroke Care (Update 2010).
Ottawa, Ontario Canada: Canadian Stroke Network. Retrieved from
http://www.strokebestpractices.ca/index.php/stroke-rehabilitation/ 48 Lloyd-Jones,
D., Adams, R., Carnethon, M., De Simone, G., Ferguson, T., Flegal, K., & ... Hong,
Y. (2009). Heart disease and stroke statistics -- 2009 update: A report from the
American Heart Association Statistics Committee and Stroke Statistics
Subcommittee.

Circulation, 119(3), e21-181. doi:10.1161/CIRCULATIONAHA.108.191261

Mendez, L. & Neufeld, J. (2003). Clinical Reasoning: What is it and why should I
care. Ottawa, ON:CAOTA publications ACE Moodie, N., Brisbin, J., & Morgan, A.
(1986).

Subluxation of the glenohumeral joint in hemiplegia: Evaluation of supportive

devices. Physiotherapy Canada, 38(3), 151- 157. Morin, L., & Bravo, G. (1997).
Strapping the hemiplegic shoulder: A radiographic evaluation of its efficacy to reduce
subluxation. Physiotherapy Canada. 49(2) 103- 108. Morley, A., Clarke, A., English,
S., & Helliwell, S. (2002).

Management of the subluxed low tone shoulder. Physiotherapy. 88(4) 209-217. doi:
10.1016/S0031- 9406(05)60412-9 Paci, M., Nannetti, L., & Rinaldi, L. A. (2005).
Glenohumeral subluxation in hemiplegia: An overview.

Journal of Rehabilitation Research & Development. 42(4) 557-568. doi:

10.1682/JRRD.2004.08.0112 Pedretti, L. W., Pendleton, H. M. H., & Schultz-Krohn,
W. (2006). Pedretti’s occupational therapy: Practice skills for physical dysfunction.

60
St. Louis, Mo: Mosby/Elsevier. 49 Peters, S. B., & Lee, G. P. (2003). Functional
impact of shoulder taping in the hemiplegic upper extremity. Occupational Therapy in
Health Care, 17(2), 35-46. Price, D., & Pandyan, A. D. (2001).

Electrical stimulation for preventing and treating post-stroke shoulder pain: A

systematic Cochrane review. Clinical Rehabilitation, 15(1), 5-19. Rogers, J.C. (1983)
Eleanor clarke slagle lectureship 1983;clinical reasoning’: The ethics, science, and art.

The American Journal of Occupational Therapy 37(9), 601-616. Schell, B.A., &
Cervero, R. M. (1993). Clinical reasoning in occupational therapy: An integrative
review. The American journal of occupational therapy, 47(7), 605- 610. Sladyk, K.,
Jacobs, K., & MacRae, N. (2010). Occupational therapy essentials for clinical
competence. Thorofare, NJ: SLACK Inc. Smith, R., & Okamoto, G. (1981) Checklist
for the prescription of slings for the hemiplegic patient.

The American Journal of Occupational Therapy, 35(2) 91-95.

doi:10.5014/ajot.35.2.91 Thomas, C.L. (1997). Tabers cyclopedic medical dictionary.
Philadelphia, PA: F.A. Davis Company. US Department of Health and Human
Services, Agency for Health Care Policy and Research. (1995). Post-stroke
rehabilitation Clinical Practice Guidelines (AHCPR Publication No. 95-0062).

Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK52428/ 50 Vasudevan, J. M.,

& Vasudevan, S. V. (2008). Hemiplegic shoulder pain: Diagnosis and management.
Clinical Reviews in Physical and Rehabilitation Medicine.

30(3) 207-220. Williams, R., Taffs, L., & Minuk, T. (1988). Evaluation of to support
methods for the subluxated shoulder of hemiplegic patients. Physical Therapy. 68(8),
1209-1214. Yavuzer, G., & Ergin, S. (2002).

Effect of an arm sling on gait pattern in patients with hemiplegia. Archives Of

Physical Medicine & Rehabilitation, 83(7), 960-963. dio:10-1053/apmr.2002.33098
Zorowitz, R., Idank, D., Ikai, T., Hughes, M., & Johnston, M. (1995). Shoulder

61
subluxation after stroke: A comparison of four supports. Archives Of Physical
Medicine & Rehabilitation, 76(8), 763-771.

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