What is the role of patient positioning in the prevention of hemiplegic shoulder pain?

Answer

When positioning the patient, caregivers should maintain the patient in reflex-inhibiting postures in order to avoid common hemiplegic complications, including spasticity and contractures. A literature review by Carr and Kenney found consensus on some positions considered proper for hemiplegic patients.^[59]However, there was disagreement for other positions regarding the 9 "key points of control", as follows:

Head and neck
Shoulder
Elbow
Wrist
Fingers
Trunk
Hip
Knee
Ankle/foot

Many of the authors also warned that hemiplegic patients should avoid supine-lying positions as much as possible because abnormal reflex activity is highest in this position.

Since the scope of this article is specific to the shoulder, discussion of proper positioning is limited to the head and neck (which have an indirect effect on the upper extremity and the upper limb. The consensus position for the head and neck was found to be midline or turned to the affected side, which encourages patient attention to the environment of the affected side and may be beneficial for those patients with neglect. If sidebent, turn away from the affected side.

The shoulder should be protracted, with the arm brought forward to counteract the scapular tendency for retraction. The arm should be positioned in varying degrees of external rotation, abduction, and flexion. Positioning for the remainder of the upper extremity is as follows:

Elbow - Extension
Forearm - Supination
Wrist - Neutral
Fingers - Extended
Thumb - Abducted

The above positions are not supported by all authors, including Cailliet. Cailliet has recommended that the head be laterally flexed and rotated toward the unaffected side, and that the hand and fingers be supported in a wrist-extended and finger-flexed position.^[10]

Carr and Kenney have stated that "current understanding seems to suggest that attendance to posture is likely to be an important element in maximizing patients' functional gains and quality of life."^[59]For this reason, emphasize patient and caregiver education regarding proper positioning.

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