So first of all, thank you all so much for attending our National Grand Rounds event for October. Our event is titled How to Integrate MSK into Other Areas of Physiatry Stroke Rehabilitation. And I would like to welcome our faculty this evening, Dr. Richard Harvey, as well as our moderator, Dr. Sarah Wong. And before we get started, I'm just going to run through a few housekeeping slides here. So this activity is being recorded and will be made available on our Academy's online learning portal. For the best attendee experience during this activity, please be sure to mute your microphone when you're not speaking. You're also invited and encouraged to keep your camera on and to select hide non-video participant as well. So this will ensure that your speakers are prominent on the screen. And then if you do have any questions, we encourage questions and please go ahead and use that raise your hand feature or you are welcome to unmute yourself and you can also use the chat feature. And just so you know, we do have 15 minutes at the end of the hour for a Q&A, but we may not be able to field every question. And just so you can see some of our features here are mute and unmute and start video in our chat features reactions. Okay. And then just to run through our quick agenda this evening, we are going to begin with our introductions and then we'll pass it off to Dr. Harvey to begin his presentation. And then we'll finish up with a Q&A. And from here, I would like to pass it over to Dr. Wang, who's going to introduce Dr. Harvey. Thank you. I'm excited to introduce Dr. Harvey. He is the David W. Trott Clinical Chair of the Brain Innovation Center at the Shirley Ryan Ability Lab and the Wesley and Suzanne Dixon Stroke Chair of Stroke Rehabilitation Research. He's a professor for Northwestern University's Feinberg School of Medicine in both the Department of Physical Medicine and Rehabilitation, as well as Physical Therapy and Human Movement Sciences. His research has focused primarily on novel approaches to motor recovery post-stroke. Dr. Harvey, I'll let you take it away. Thank you, Sarah. Let me share my screen here. Right, so thank you for having me and and signing into zoom this evening to listen to me talk. I am, I guess I'm at that point in my career where people are interested in, in what I say, which I guess maybe it's been true all along but I don't know, you sometimes wonder that as you go through your career, like does anyone really care what I'm doing or what. And I think lately people have started to show me that maybe they appreciate a little bit but I have to say, so I you know originally I was asked you know can you tell a little bit about how you're, how you got into your career and, and, and, you know, I do focus on stroke real rehabilitation and it's kind of unusual but you have to understand that back when I finished medical school in 1988 and entered into physical medicine and rehabilitation. There was no really really was no fellowships that were certified. And so, you could do a fellowship but you could do it on almost anything as long as somebody was interested in mentoring you. So, in 1992 I trained in, I started, I finished training and human are at the Medical College of Ohio which is now the University of Toledo Medical Center. And during that time it's a very small program and it was a young program at that time and in fact I, we only had two per class, it was a four year program, including the internship, and my class filled the residency for the first time so we were the and they for the first time had a senior class in PM&R. So that's how new a program it was, but it was kind of a, it was a cool program is very intimate, and I really didn't think I had good training although there was a lot of self learning that happened at that time. I did actually do research while I was there and I published a paper, and that paper was very simple. It was insulin administration by the hemiplegic patient stabilization of an insulin pen with a new device. I had no plan at that time to be a stroke specialist I was just looking for a case to do and I got a poster out of it but I went on and actually wrote a manuscript and it was a cool manuscript because the co authors included a CRRN and an occupational therapist. So, it really was interdisciplinary, and it fit well with the, with the Red Journal, which is where it was published as a clinical notes. Interestingly, after I became an attending at the Rehabilitation Institute of Chicago, Elliot Roth was, had been my mentor during fellowship, and was the chair at that point, and one of the board members had a father who had a stroke and was a diabetic and he was, he was struggling with how his dad could do his own insulin and Elliot said hey you Interestingly, I, I shared my paper with this board member, he got so excited about he made a bunch of the devices, and he wanted to market them and have them you know sold on a market and I was like well that wasn't really the intention because the hemiplegic patient makes the device himself and it's part of their rehabilitation program, and then they use it to help them, you know, do their insulin pen and he thought that was kind of like, you know, what you could you could make money off of this and I'm like, that's not what it's all about. But anyway, it never went on the market, but it was a cute paper and I think it helped me get my fellowship at the Rehabilitation Institute of Chicago. While I was a fellow there I actually submitted a grant to the American Heart Association for a trainee grant, and I actually got a grant to study the use of e-dimer to screen for DVT and stroke rehabilitation. And the idea that there are freestanding rehab centers back then not all freestanding rehab centers had, you know, full composite of laboratory testing available. And so, you know, doing a screening test before you send somebody out for a possible DVT was great idea. And so that one ended up getting published. But it wasn't until after my fellowship that it was published. And that was back in around 1994. During that time I was also, I was actually a research fellow at that point and did further research more in the epidemiology of epidemiologic techniques to study rehabilitation medicine. Part of that I participated in a very nice program that no longer exists called the Research Enrichment Program for Physiatrists, which was partly supported by the National Institutes of Disability and Rehabilitation Research, but also by the No, it was all by the NIDRR. And that was a nice program. I later became a faculty member for that program until it finished. I also did the Rehabilitation Medicine Scientist Training Program, as many know, still exists and is co-supported by the NIH and the AAP. Very early on, it was structured very differently then than it is now, but I did end up publishing a paper ultimately from that called the Effectiveness of Anticoagulant and Antiplatelet Agents in Preventing Venous Thromboembolism During Stroke Rehabilitation. Now you would think that my career would then be to study DVT in stroke, but as it goes, you know, what you do in your training helps train you to do research. If you do, if you train and research, you learn how to do research, but that doesn't necessarily guide your career. What ended up happening is I was then employed by the Rehabilitation Institute of Chicago. And because I was an inpatient physician, and at RIC and even now at the Shirley Ryan Ability Lab, if you're an inpatient physician, you are on service 365 days a year. You do not have off service. There's no on-off service. So as an inpatient physician, it's very difficult to do research. I did actually write an NIH grant once. I did not get funded on the NIH grant. But where I really found my comfort zone, especially in terms of being able to be an inpatient doc and do research, was through industry sponsored research, which I spent most of my career doing. If I consider the key thing that I actually studied over a 10 year period, it was using low frequency transcranial magnetic stimulation for upper limb recovery after stroke. This was sponsored by the Nextim Corporation. Again, I'm mentioning companies not to sell their products, but more to give you an idea of how these relationships work. This is a small European company. It's still around. And we did three trials. We did a very early pilot trial, which is sort of one that I would almost call a phase one trial, where we're trying to figure out how we're actually going to do the stimulation with patients. That was never published, but it produced some pilot data that helped us move on to the next trial, which was the NIES trial, which was published. And that trial did not show that low frequency transcranial magnetic stimulation worked. It was a failure to show efficacy. But we also, at that time, used a sham coil that the company made. And the company then revealed to us that, well, maybe that coil was delivering power to the cortex. And so given that, they said, can we do this trial again, but with a different sham coil? So we did. And that was the EFIT trial, which we actually just published earlier this year. The EFIT trial, which also failed to show that low frequency transcranial magnetic stimulation improves upper limb recovery when combined with therapy. But still, 10 years of my life doing clinical trials with no positive results. You learn a lot doing that. It's kind of disappointing, but you still publish. You can publish negative trials. And in fact, the EFIT trial was considered, it's highlighted as one of the negative trials for 2023. They're trying to make more emphasis of trials that show negative findings because they've often been buried. And that's not the right way to do research. You should respect negative trials as much as positive. So the people at Nexstim, very small company. I knew everyone in that company. Once they finished with me, another young company, the president of this small company called Phadenesis, was contacting European colleagues to see if there was somebody in the U.S. they could connect with to help with a study to look at a pharyngeal stimulator for dysphagia after stroke. And the people at Nexstim hooked me up with that. So key message here is that once you start working with corporations, other companies are going to find out about you. And it's a way to actually get more research opportunities. So we did do that clinical trial. That clinical trial ended early, but it ended up actually getting FDA approved. So this pharyngeal stimulator is available on the market in the U.S. Then Phadenesis was being looked at by Nestle Corporation to purchase and take over. So at the time that Nestle was looking at Phadenesis, they were looking at a dysphagia detection system. And so they asked me to be the national PI for this clinical trial. That clinical trial also ended early because of a lack of efficacy on an interim analysis, problems with the device actually doing what it was intended to do. So I am the king of negative trials, but these are not the only research opportunities I've had. I have worked with industry looking at all of these different areas of management, all in the area of stroke. I have not actually studied anything outside of stroke rehabilitation throughout my career, but staying within my specialty has been very rewarding because as you do this kind of research in all these different areas, you learn a whole ton. So I'm one of these people who knows a whole lot about a very little area in the world of healthcare. Still, stroke is a big area in rehabilitation and is the most common neurological injury that we actually deal with on the inpatient side. So hopefully my experience contributes to the general knowledge of stroke rehabilitation in our field. And with that, this is about applying musculoskeletal medicine in areas that are not focused on musculoskeletal medicine. And this is stroke rehabilitation. And when they asked me, well, what would you talk about? Obviously, the answer is hemiplegic shoulder pain. So I have some opinions about hemiplegic shoulder pain, and I know there are a couple of people on today who are former residents or who are current residents, and they probably already know what my opinions are. But the key thing is that hemiplegic shoulder pain is complicated, and we should approach it as a complicated problem as opposed to just a simple problem with very simple. So I'll just start out with a case, you know, here we have a 66-year-old man with left hemiplegia who complains of pain in his left shoulder. So the likely cause is in, you know, you can see the four answers. Now, there may be a lot of people who might think that subluxation is the correct answer, but the point of this little case is that subluxation is not the right answer. It could be a contributor, but it's probably not the whole answer. The correct answer here is that it's likely multifactorial. And in most cases, when you're talking about hemiplegic shoulder pain, you're talking about a multifactorial problem. Because pain and stroke is common, and the sources of pain are multiple. And I've listed them here with the rates. But the key thing is in this nice little graphic here is that there's a lot of overlap for causes of pain, so that if you have spasticity that can contribute to shoulder pain, which can also contribute to headache, which in some part could be, there could be a component of neuropathic pain. And of course, there's a musculoskeletal issues around the shoulder itself. So it's definitely, the diagnostic sorting can be challenging. So as a physiatrist, the first thing I want to think about when I think about hemiplegic shoulder pain is the shoulder joint itself. Obviously, a very complex joint. You have the glenohumeral joint, but you also have the acromioclavicular joint, and you have the scapulothoracic system as well. The shoulder has the greatest range of motion of any joint in the body because the glenoid fossa is so shallow, and the joint is supported by the rotator cuff. The key thing in hemiplegia is that the rotator cuff is now paralyzed, or at least partially paralyzed. And that can include a period of flaccidity followed by a period of hypertonia. And you can have actual spasticity that also contributes. And given that the mechanics around the shoulder are very complex, that spasticity, that hypertonia, that flaccidity, and a mixture of all of them together can lead to really bad mechanics around the shoulder. And bad joint mechanics lead to inflammation, and inflammation leads to pain. So I was taught in my residency that when you abduct your shoulder, there's a two-to-one ratio of two degrees of glenohumeral motion to one degree of scapular upward rotation. And when you think about it, in order for the body to do that smooth motion where you tilt that scapula and abduct that humerus, you have to have a lot of muscles that are working in coordination with each other, which we can call muscle synergies. We usually use synergies to refer to abnormal muscle synergies. But when we normally move, like when we pitch a ball or serve a tennis ball, that shoulder motion is also, that movement is occurring because of normal muscle synergies that are working in relation to each other to do a skilled movement. So that movement, that smooth, normal synergy of movement around the shoulder after a stroke is not going to work for it. It just doesn't. And in fact, once you start getting hypertonia, there can be problems with the scapula actually misbehaving in a sense that, and this isn't 100%, this isn't in all patients, but you can actually, you know, look at your patient and pick up on some of this. And this is where I encourage people that if you're looking at a hemiplegic shoulder, there's a couple of things you want to do. First, you actually do want to look at it. You want to look at the shoulder blade and have the patient either abduct if they can or passively abduct them carefully and see what the scapula does. In some cases, it actually may retract because of hypertonia and you get a downward rotation of the scapula while you're attempting to abduct the shoulder. It's sort of like a spastic response to the motion around the glenohumeral joint. In active movement, you can see similar abnormal synergies that lead to a malalignment of how the scapula is related to the humerus during attempted shoulder abduct. And as I said, if the mechanics of the movement are altered because of flaccidity, hypertonia, or overt spasticity, you can have shoulder impingement because if the scapula doesn't rotate properly, then as you abduct, you're going to slam the humeral head up against the acromion and that shoulder impingement, of course, can cause pain. And when you have impingement, when you have poor mechanics around the glenohumeral joint, you can, as they say, get inflammation. Most people who look at people with hemiplegic shoulder pain will notice that when they do passively move them, if they're not fully flaccid, you will find that they are more difficult to abduct beyond 90 degrees. And that's likely because of either pure impingement or it can also be because of some indolent inflammation that's leading to early adhesive capsulitis that leads to reduction of the range of motion in abduction. But if there is adhesive capsulitis, you'll probably see some reduction in external rotation as well as other ranges of movement. With spastic dystonia, with inflammation of the supraspinatus tendon, the subacromial bursa, maybe the shoulder capsule itself, that inflammation will contribute to the pain. A patient gets very tired of the pain, they get irritated by the pain, so they protect the shoulder. And how do they protect the shoulder? They adduct their humerus, they internally rotate, and they tuck their forearm underneath their chest in their upper abdominal region. And so because they spend a lot of their time like that with the inflammation, you're going to see that adhesive capsulitis develop. And the other thing that happens is the scapula becomes firmly fixed to the chest wall. It's really interesting that I've really gotten my therapist to consistently train family members on how to do scapular mobilization with people at home. Because a patient with hemiplegia cannot mobilize their own scapula well. It has to be done by a second person. So my therapists teach family members and caregivers how to do this. Now whether they follow through is another issue. But in patients I've seen come from nursing homes, who've been in nursing homes, and they come to me, when I look at their shoulder, invariably when I try to mobilize their scapula, it doesn't move at all. It's just fixed to the chest wall. I had a video that I made about, I don't know, 12, 13 years ago that showed how I examine a hemiplegic shoulder and I don't have a really good picture of it and I can't find a video. Essentially what I do when I examine a patient with stroke who has pain in their shoulder is I lie them supine so that all the hypertonia is sort of relaxed. I get you get them to put their head down their legs down so they're totally relaxed and then I move the scapula to see okay with tone removed how much mobility is there and when I do that do I do I get some movement do I find some tightness is it still firmly fixed or can I fully mobilize it. If I can't then one goal of course is to get that mobilized and teach family how to maintain that flexibility in the in the scapula. Then I also stabilize the scapula and then I feel what the glenohumeral range is like with the scapula fix and then I try if I can rotate the scapula I rotate it in a sort of two-to-one ratio with the humerus and see how much abduction I can get and I get a good sense of what the soft tissue tightness is beyond what the hypertonia is but I don't tend to do those I don't tend to do shoulder range of motion with the patient sitting up because they've got so much hypertonia I'm probably just going to cause pain which is not helpful for that situation. So examine the patient and supine with them relaxed and that's the best way. It's nice that I have a big hand because I can fit my fingers around most scapulas but you can't just scoop your fingers around the medial edge and pull and you can feel how tight that scapula is and if you do it on a couple normal people you get an idea of the difference between that and somebody who has a really tight scapula. So for years and years and years probably PM&R docs and the rehabilitation healthcare system contributed to a lot of problems with hemiplegic shoulder pain because of the wheelchairs we used we had those slingback chairs we didn't have we didn't give the patient very good posture in the chair they were slumped forward so that contributes to and we didn't give up good arm support and so that contributed to a curved thoracic spine and from rotation of the shoulder and shoulder subluxation with downward rotation of the scapula all contributing to hemiplegic shoulder pain. Now to get to some data I mean there is data out there on hemiplegic shoulder pain and one of the areas that has been looked at is rotator cuff tears. Obviously rotator cuff tears can contribute to shoulder pain and maybe a consequence of impingement. They are prevalent in the elderly already. It's well known that elderly people who have no reported shoulder problems or have some shoulder problems often have a rotator cuff tear that they have no idea they had. The incidence of rotator cuff tear in hemiplegic limb is as high as 40% which is different higher than the non hemiplegic side. However others have found that there's no relationship between hemiplegic arm and rotator cuff tear. Rotator cuff tears can actually occur during rehabilitation that's been documented as well so protecting the arm during therapy is important. So that comes to proper positioning in bed, in the chair, use of arm boards, arm supports. Again as I mentioned earlier regular scapular mobilization and proper shoulder range of motion. Getting family to assist with doing stretching for the shoulder is really important. I'm not a big believer in those patients who who take their hand you know one hand their hemiplegic hand with their other hand and pull up because that's not controlling the scapula well at all. Obviously pain management is important if they are having shoulder pain. Use medications acetaminophen, non-steroidals, opioids if necessary because it's important to control the pain so that they can tolerate proper therapy. And then motor relearning with proper shoulder mechanics when they start to have emerging arm movement. If the pain persists it is worthwhile early on. I'm talking as you know early on like if a patient continues to complain about hemiplegic shoulder pain for you know three, four, five days in a row during inpatient stay. Get the x-rays just make sure they didn't have any you know some bony abnormality that was unknown prior. And then I usually refer a patient for diagnostic ultrasound to see what soft tissue changes there are and if appropriate a steroid injection. The ultrasound can of course show soft tissue pathology and the research that's available has shown that there's often inflammation especially in the biceps long head tendon and the supraspinatus as well as the sub deltoid bursa and to a certain extent these other two structures. The glenohumeral joint is usually the painful joint too and in a real sense that is a target as well for potential treatment of inflammation for pain reduction. Now I have not talked much about subluxation up until now so what about subluxation? In my career I have heard so many people say well this patient has subluxation so that's why they have pain or this patient has subluxation so we need to give them a sling or this patient has pain so let's put them in a sling or you know it usually just it's sort of like this the story is always they have pain they have subluxation they need to be in a sling that's pretty much what you do and what I always say to my trainees is if a patient who is an athlete came into your musculoskeletal clinic and said to you doc I have shoulder pain would you say oh you have shoulder pain I'll put you in a sling and you can go home now no of course not we would do a diagnostic workup we figure out what the pain generators are we figure out you know how we can reduce the inflammation and pain and then we put them in a proper rehab program to resolve the problem and it's true for hemiplegic shoulder pain as well so subluxation does occur in hemiplegic shoulder it's because of the flaccidity of the muscles so that that support of the gland of the humerus in the glenoid fossa is limited and what you see is that that that subluxation is most obvious early after stroke during that flaccid period which is what you see early after stroke but as spasticity develops as hypertonia develops you actually may notice that that subluxation reduces especially when the patient goes from sitting to standing I see that all the time where sitting you go oh yeah there's like two fingers subluxation but then I stand them up and I feel it again and there's half a finger breath and sometimes it's the same as the other side because the hypertonia of standing just brings that right up now that doesn't mean that mechanics are going to be so correct around the shoulder but it does tell you that subluxation is a dynamic thing but what is really interesting and it's been documented in literature is that subluxation seem early shoulder pain usually happens later during the flaccid period I actually rarely see patients who even have subluxation complain of pain but as that hypertonia comes in and they start getting that bad mechanics I describe and they start describing that they have shown so if unmanaged early subluxation may result in injury such as rotator cuff injury or inflammation but it's not definitely the cause of hemiplegic shoulder pain it is a contributor it should be managed but it's not the main reason people have shoulder pain but it's part of that overall mechanical problem with the shoulder after hemiplegia now subluxation predicts shoulder pain in the future but my feeling is that this is because both subluxation and pain are associated with severe hemiplegia the more severe the hemiplegia the more likely you are to get pain the more severe the hemiplegia the more likely you are to have subluxation but that does not necessarily mean that the two are directly connected with I believe the severe hemiplegia is probably more directed because those patients get more hypertonia more spasticity they're more likely to get it he's capsulitis whether or not there's having some so there are some I believe there are some people who are more in my age group but on tonight and they might remember who this guy is Barney Fife you younger people may not know him but there was a show that was in reruns when I was a kid called the Andy Griffith show about a sheriff in a small town called Mayberry and his deputy who was a goofball was named Barney Fife and Barney always used to say to his boss Andy when problems came up in their small town Andy you got a nip it in the bud and I say that also about hemiplegic shoulder pain if the patient's complaining of pain get on top of it diagnostically get the imaging that's necessary if there's inflammation treat it and then get them into proper therapy because though the early pain that you usually see with hemiplegic shoulder pain is likely nociceptive from local inflammation and a joint and poor mechanics and maybe tissue disruption the later pain and a shoulder that patients have is likely to be neuropathic because of increased sensitization and of the crew with all nociceptive pain and if you leave it untreated it will become neuropathic pain in the long run I do want to talk about injections because I mentioned that inter-articular steroid infections are appropriate some have looked at higher on acid I'm not going to really focus on that because there's not a lot of data botulinum toxin has been looked at to treat the spasticity and therefore potentially reduce the bad mechanics this this fourth plot down below shows some of the research that has been done Marcian was that in 2012 she was at RIC I worked with her on that project you can see that actually the majority of the case the studies actually leaned on the side of favoring reduction of pain so spasticity is probably a contributor managing spasticity is good now all these studies use different approaches to which muscles do you treat and what doses you give but the bottom line is when you do a proper injection with botulinum toxin you find the muscles that are hypertonic you figure out which ones are contributing to the bad mechanics the poor movement which ones are getting away a proper function and then you inject accordingly to reduce the spasticity and and rebalance the muscles and the best way to do that is feel the muscles get your hands in there touch the you know get your fingers around the pectoralis major get your fingers around the the latissimus dorsi and the teres major feel the the muscles as you do some range around the glenohumeral joint and figure out which muscles are are the big players here and inject them and it does it doesn't solve the problem it helps contribute to reducing some of the pain because it allows you to do better mechanics around the shoulder I'm super skip super skip I'm sorry I think it's supposed to be sub scapular nerve block rather than super scapular sub scapular nerve blocks have been looked at a lot that is blocking a a actually it is super scapular nerve block which freaks the the that's for pain management and that has indeed shown to have some reduction in pain not a lot of people do it as far as I can tell there may be some on on this session tonight who do do them we don't do that much where I work terms of slings I'm not a big sling fan this one is definitely out because of course it puts the patient exactly the position that they want to be in anyway which is protect that shoulder and keep it from ranging appropriately internally rotated abducted and that's just going to lead to loss of range of motion so this one's right out we use this sling a lot for ambulation and this is really just to help the therapist not have to worry about the shoulder getting traumatized while walking it puts the arm in a proper position so these are used for walking only this one in these cuff slings I I only really use them if there's persistent subluxation and if there's pain with traction on the arm because that tells me that the subluxation itself and the track down or traction on the shoulder is causing them pain so it's really there for pain relief if there's really no pain with downward traction which most patients really don't have I don't bother with this because it doesn't really make a difference some patients feel like just feel it makes them better so I guess that's fine but it probably does not have a lot of effect on the actual mechanics of the shoulder or even the position of the spinal femoral joint there's been mixed results with clinical trials on taping it does tend to lean towards favorable for taping so though I don't think it's necessary something that my patient should have done if the therapist wish to use it I think that's just fine I I don't have a problem with tape surface neuromuscular electrical stimulation has been used a lot now originally it was used probably to help therapists control the position of the shoulder while they're doing upper limb activities later on though it was seen that using electrical stimulation for six hours a day could actually reduce the pain now it wasn't doing it probably because it was treating subluxation it was probably doing it more so because it induced sensory neuromodulation to reduce that decent that hypersensitization with response to pain around the shoulder it may reduce subluxation by muscle hypertrophy but that's unclear but doing six hours of neuromuscular electrical stimulation a day with surface electrodes is not that practical you have to put the electrodes on every day there can be skin reactions to using these things and surface stimulation at that level can be irritating to many patients so I worked with John Chay and his group this actually goes way back to the 1990s when I was a faculty member for the research enrichment program this young resident named David you wanted to do a study with with percutaneous electrical stimulation it's actually putting the wires into the muscles in order to correct some subluxation and hemiplegic patients in order to reduce their pain and of course I raised the issue then you know the pain is not just from subluxation you could correct the subluxation and it may not treat the pain. Pain is a multifactorial problem and he was a bold young resident so he argued with me which is fine because I love residents to argue with me but ultimately we did come to the conclusion that yeah he can't expect this alone to treat the hemiplegic shoulder. So later on I knew his I knew his mentor John Chay at Metro Health in Cleveland and John Chay and I had a conversation later on when this whole argument thing got back to him and he said yeah I believe you what do you think the real issue with with neuromuscular electrical stimulation is? I think it has to do a neuromodulation and maybe some effect on muscle hypertrophy. Exactly I agree with you. So we went ahead I got invited to be part of this large trial where we put in four percutaneous electrodes one in the supraspinatus, posterior deltoid, middle deltoid and upper trapezius. That was quite a procedure it was a tough procedure I have to say for a physiatrist because it took a while it's kind of like a mini surgery and then we gave them six hours of stimulation a day over six weeks. It was really nice because the percutaneous electrodes don't cause that surface stimulation so the skin irritation is not there and you know it's all set in there and it sits there and you use it every day for six weeks. This study actually showed good efficacy even out to six months well beyond the time that the electrodes were in and treating it. So percutaneous neuromuscular electrical stimulation probably does work it probably works through desensitizing the overly sensitized neuropathic pain that occurs in chronic hemiplegic shoulder pain. Later on, which they had figured this out earlier, Dante's group discovered that a single electrode was sufficient and so they they did another study showing that a single electrode has similar efficacy and so now this product is available on the market. So again industry-sponsored research there was some NIH funding and all of that there's currently a study going on with Richard Wilson out at MetroHealth who's a protege of John Chase looking at this intervention further. There are other kinds of electrodes products out there for treating hemiplegic shoulder pain as well and so there are products on the market. So that's sort of where I stand with hemiplegic shoulder pain. Just to summarize, I think that the key things is that beyond the neuropathic aspects of it, when patients have hemiplegic shoulder pain, do a really good exam. Get your hands in there, figure out what muscles have hypertonia, where is the instability, do you have soft tissue tightness, if ultrasound is necessary to find where inflammation is, find it, treat it with anti-inflammatories, with injections, get the patient into proper therapy, doing proper mechanics, teach the family how to manage the scapula, teach the patient how to properly manage their shoulder and protect it, and for the most part you actually don't really see hemiplegic shoulder pain in those circumstances if you manage it well upfront by nipping it in the bud. And with that I'd be happy to take some questions, complaints, arguments, love arguments. We're available. Y'all buy into that, okay. That's perfect. Either that or you're all tired. This is actually close to bedtime for me, so I'm going to go to bed early, get up early kind of guy. Sarah, before we start, Sarah and I said we'd just talk about our kids if nobody had any questions. I don't know if she wants to talk about her kids. Sarah could talk about the annual assembly program coming up and get you excited about that. I can't. Everybody should register for annual assembly if you haven't already. Ronald, if you want to just unmute, feel free to ask a question. Thank you. Yes. I'm mostly retired, and not doing much, any rehab, only electrodiagnosis. But I always thought that the additional range that you might get from the subluxation would make self-range easier. I mean, when I was doing more rehab in my early days, the different therapists had different reactions, and I've sometimes listened, and once about 20 years ago was involved in discussing the acute hospital consultation in stroke, which was mostly my clinical work when I was younger. I mean, most of my rehab was in a group of three physiatrists. One of us was on hospital duty in a community hospital. But I wonder if you could comment on that, that the ligamentous laxity around the shoulder might somehow be connected with not so much scapular mobility, which I appreciate the way you emphasize today. But rather going to human. Yeah. You know, it's not so much that the ligaments get lax in hemiplegia. It's the rotator cuff muscles that get lax. And so what happens is that if you range the shoulder taking advantage of that laxity, you're going to end up stressing the soft tissue that's there. So the joint capsule, the biceps tendon, and the supraspinatus tendons, which, you know, supraspinatus has a big tendinous piece to it. It's not all muscle. Those are still collagen, and they still have a limited flexibility, and they will end up getting torn if the shoulder's not mechanically managed. And then those micro tears lead to inflammation, and then that's where the whole cycle of pain begins. So the best approach is actually, despite the additional apparent flexibility that they have there, is to still properly range them with proper mechanics. So get the scapula to move. You'll see the OTs do this a lot where they're working on a table where they help the patient. They assist the patient in reaching, and when they do it, they also have their hand on their back and make sure the scapula goes with it to maintain that mechanics. And we find that generally if we do that, that they don't develop hemiplegic shoulder pain. But I appreciate the question, Ron. And Ron, I'm sure you remember the Andy Griffith show. I think you do. We have one question in the chat, and then we'll get to the next hand that's raised. Does your treatment approach change at all in patients with cancer or metastatic cancer that have had a stroke and have shoulder pain? Well, that's interesting because I can't say that I've had that many patients who have, I assume we're talking about actively treating, who are being actively treated for cancer. I've had plenty of patients who have cancer and even had metastatic cancer that are in remission who end up having a stroke. I can't think of that many that I've had that actually are actively being treated for cancer. We have patients who have cancer who end up with stroke. They often go to our cancer service. But I would say that mechanically, it's probably the same. How we mechanically manage the shoulder would be the same. Whether or not you would do a steroid injection, I would defer to my cancer colleagues as to whether that's reasonable given their immunocompromised state. For the most part, I think that most would not do that. So in that case, what you're gonna do is use other methods for managing the inflammation. But the goal would be to do whatever you can to manage the inflammation. And opioids then become an appropriate approach because the key is to reduce the pain. And if you can reduce the pain, then you can do good exercise that they tolerate. And if they can tolerate the exercise, ultimately that will manage the inflammation and help the tissue. Okay, I'm gonna jump to Stacey's question next because I know she was the one that had her hand raised. Is neuromuscular electrical stimulation used much these days for stroke motor recovery? It is. We use it, sort of the classic one is to use EMG-triggered neuromuscular electrical stimulation for wrist and finger extension. Because we know, especially from work done by Steve Wolf and also that ultimately ended up with Dr. Talbot and the whole constraint-induced movement therapy approach that wrist and finger extension is necessary in order to functionally use the hand. So that is a goal is to regain wrist and finger extension. So EMG-triggered neuromuscular electrical stimulation is where you use EMG electrodes and have the patient do enough wrist and finger extension to trigger, to reach a certain amount of EMG activity in the muscles of the wrist and finger extensors. And then that triggers the stimulator. So they initiate and then the stimulator finishes the job. That has some mixed reviews as to whether or not it actually facilitates motor recovery, but simple to do. And it's certainly something that can be tried. And then we do a lot of FPS. So functional electrical stimulation with our movement, using it for cycle ergometers with the upper limbs for the lower limbs. There's lots of different devices for doing FPS. And again, whether or not that has true efficacy for motor recovery is unclear, but if you can move the body, you get the sensory feedback while you're attempting to move the body. I think the key thing with neuromuscular electrical stimulation is it cannot be passive. The patient has to be actively attempting to move the body with the FPS only assisting to complete. I think we have just a couple more minutes. So next question is what role does obesity play in post-stroke shoulder pain? I would say I'm totally, I don't have any research on this, but if I would say that there's anything that contributes to that, it would be the weight of the upper limb because the heavier the upper limb, the more downward traction there is on a shoulder, which can lead to a soft tissue injury. And again, I may be sounding like, oh yeah, so subluxation is a cause. No, the cause of the pain is gonna be the soft tissue injury. The subluxation is a proximal cause of the soft tissue injury. So the answer to that, of course, is to properly position the patient in bed and in a wheelchair and during walking to make sure that the heavy arm doesn't pull down and cause damage on the shoulder. Again, treating subluxation is not the treatment. Managing subluxation is the preventative piece of this whole thing. Once you have soft tissue damage and inflammation, you need to do other things too. And do you see any relation of painful hand and wrist and hemiparetic extremity to painful hemiparetic shoulder? Only in the context of in your diagnostic workup if it becomes pretty clear that they have complex regional pain syndrome type one, which is the newer name, of course, for reflex sympathetic dystrophy or the classic name in stroke, which is shoulder hand syndrome. So that's that sort of poorly described neuropathic inflammatory condition with pain that's primarily in the MCP joints with hand swelling and shoulder pain. Rarely seen if the patient gets early rehabilitation. The only time I see it now are patients who are sent from acute hospital to nursing home, get very little therapy and then come to inpatient rehab and they have full-fledged complex regional pain syndrome. All the patients that we get directly from the stroke unit onto rehabilitation essentially never get it. So the rates of complex regional pain syndrome have gone down over the years, primarily because the pathway from acute hospital to rehab to home is much faster then. All right, thank you. Well, I think it's eight o'clock. So I think we'll end there. The last question was actually about CRPS type one. So you kind of just went over that. So good job. All right, thanks everybody. Hi, Hillary. Good night. Thank you so much, everyone. Have a great evening.

hemiplegic shoulder pain

stroke rehabilitation

inflammation

shoulder mechanics

subluxation

diagnostic ultrasound

steroid injections

botulinum toxin injections

percutaneous electrical stimulation