February 2009, VOLUME 192
NUMBER 2

Recommend & Share

February 2009, Volume 192, Number 2

Musculoskeletal Imaging

Original Research

Sonography of Patients with Hemiplegic Shoulder Pain After Stroke: Correlation with Motor Recovery Stage

+ Affiliations:
1Department of Radiology, School of Medicine, Pusan National University Hospital, 10-1, Ami-Dong, Seo-gu, Busan 602-739, Korea.

2Medical Research Institute, Pusan National University, Busan, Korea.

3Department of Rehabilitation Medicine, College of Medicine, Pusan National University Hospital, Busan, Korea.

4Department of Radiology, Busan Paik Hospital, Inje University, Busan, Korea.

5Department of Biomedical Engineering Lab, School of Medicine, Pusan National University, Busan, Korea.

Citation: American Journal of Roentgenology. 2009;192: W40-W44. 10.2214/AJR.07.3978

ABSTRACT
Next section

OBJECTIVE. This study was performed to clarify the cause of shoulder pain using sonography and to evaluate the relationship between the sonographic findings and the motor recovery stages in stroke patients with hemiplegic shoulder pain.

SUBJECTS AND METHODS. Between March 2005 and January 2007, 71 consecutive stroke patients with hemiplegic shoulder pain underwent shoulder sonography. For comparison, bilateral shoulder joints were evaluated in 20 of the 71 patients. The interpretations of the sonographic findings were based on the findings of previously published studies. Whether a correlation existed between the sonographic findings and the motor recovery stages was determined.

RESULTS. Subacromial–subdeltoid (SA–SD) bursal effusion (n = 36) was the most common abnormality seen on sonography. Tendinosis of the supraspinatus tendon (n = 7), partial-thickness tear of the supraspinatus tendon (n = 6), and full-thickness tear of the supraspinatus tendon (n = 2) were also noted. Biceps tendon sheath effusion (n = 39) and normal findings without any biceps tendon sheath effusion (n = 13) were detected. Clinicians managed each patient's shoulder pain on the basis of the sonographic findings. No statistically significant correlation was found between the grade of sonographic findings and Brunnstrom stage (p = 0.183). A shoulder with hemiplegia had a higher number of abnormal sonographic findings than a noninvolved shoulder (p = 0.007).

CONCLUSION. The cause of shoulder pain was variable and there was no correlation between the stages of motor recovery and the grades of sonographic findings in patients with hemiplegic shoulder pain.

Keywords: hemiplegia, rotator cuff pathology, shoulder pain, sonography, stroke

Introduction
Previous sectionNext section

Shoulder pain is a common complication after stroke and has a significant impact on patient rehabilitation [1]. Shoulder pain can also decrease the functional performance of activities as well as the instrumental activities of daily living. The clinical management of hemiplegic shoulder pain usually consists of the administration of oral analgesics, intraarticular injection of corticosteroids, the use of physical modalities, and therapeutic exercise [2]. To determine the most effective treatment protocol, it is necessary to understand the cause of shoulder pain. Therefore, imaging techniques that depict abnormalities of the shoulder girdle are required in patients with hemiplegic shoulder pain. Knowledge of the status of the rotator cuff tendons before the commencement of physical therapy or during physical therapy is especially helpful.

The primary noninvasive methods to diagnose rotator cuff abnormalities are sonography and MRI [3, 4]. However, it is difficult to perform shoulder MRI or MR arthrography in stroke patients with hemiplegia because of limited and intolerable positioning of the patients. Although there are some limitations in the usual dynamic examination of this population, sonography is a noninvasive, widely available, and inexpensive imaging technique that can be used for soft-tissue assessment. It combines direct multi planar structural evaluation with dynamic investigation of movement, thereby providing both anatomic and functional elements to the assessment.

Shoulder subluxation, spasticity, rotator cuff tears, and adhesive capsulitis have been suggested as causes of shoulder pain in stroke patients. We hypothesized that the cause of shoulder pain will be different according to the motor recovery stage. Therefore, we proposed the possibility of a correlation between abnormalities of the shoulder girdle as depicted on sonography and the motor recovery stage of the involved upper limb in patients with hemiplegic shoulder pain. The purpose of this study was to clarify the cause of shoulder pain using sonography and to evaluate the relationship between the sonographic findings and the motor recovery stages in stroke patients.

Subjects and Methods
Previous sectionNext section
Patients

Between March 2005 and January 2007, 71 consecutive patients (46 men and 26 women; age range, 23–78 years; mean age, 60 years) with hemiplegic shoulders caused by a cerebrovascular accident (CVA) were included in this study. Patients with quadriplegia or hemiplegia caused by events other than CVA and those with shoulder or dislocation as seen on radiographs were excluded from the study.

Thirty-eight of the 71 patients had left hemiplegia and 34 had right hemiplegia. Forty-nine subjects had suffered cerebral infarctions and 23 subjects had cerebral hemorrhages. There were no patients with pure motor stroke in this study. All patients were examined with sonography because of shoulder pain before or during rehabilitation. Both shoulders were examined in 20 of the 71 patients. To obtain knowledge about the relationship between the frequency of abnormal sonographic findings and hemiplegia, we compared the sonographic findings of the hemiplegic shoulder with those of the contralateral shoulder. The mean duration from stoke onset to shoulder sonography was 91 days (range, 16–451 days).

To assess motor recovery of the affected upper limb in hemiplegic patients, we applied the use of Brunnstrom staging [5], which is generally accepted for rehabilitation medicine. The lowest stage, flaccid stage and no voluntary movement, was stage 1, and the highest stage, isolated joint movement and not normal movement, was stage 6. Prominent spasticity occurs at stage 3–4. We classified the six Brunnstrom stages into three stages by combining two adjacent stages (stage 1–2, 3–4, 5–6) according to the similarity of the effect of hemiplegic shoulder movement. The patients had motor function of various stages at the time of the sonography examinations. Therefore, we attempted to ascertain whether the sonographic findings were significantly correlated with the stage of motor recovery. The institutional review board of our institution approved this study and informed consent was obtained from all patients or caregivers.

Sonography Examination

Sonography was performed using a 12-17–MHz high-resolution electronic linear-array transducer (iU22 ultrasound system, Philips Healthcare) with optimized settings and automatic variable frequency adjustment depending on the focal depth. We examined only one shoulder joint with hemiplegia in 51 patients and bilateral sides in 21 patients.

We evaluated the biceps tendons, the rotator cuffs, the rotator cuff interval, the sub acromial–subdeltoid (SA–SD) bursae, the acromioclavicular (AC) joint, and the posterior glenohumeral joint in each patient. Most patients underwent shoulder sonography while seated on a wheelchair. The usual scanning techniques, as reported previously [6, 7], were used; however, the usual techniques were difficult for hemiplegic patients because of limited positions of movement. Therefore, we examined the shoulder girdle while the shoulder was in a position similar to that used for the usual dynamic examination, inducing passive movement with the help of an assistant as long as the patient could tolerate the pain. The rotator cuff is routinely imaged in the coronal (longitudinal) and transverse planes. Each sonographic examination was performed by one of two radiologists with 15 and 9 years of experience in musculo skeletal sonography and unaware of the clinical details about the patients.

Imaging Analysis

We evaluated the sonography examinations for the presence or absence of a rotator cuff tear or tendinosis, effusion or synovial thickening of the glenohumeral joint or rotator cuff interval, SA–SD bursal fluid or wall thickening, and abnormalities of the long head of the biceps tendon. Decisions regarding the imaging inter pretations were based on the findings of previously published studies and were made by the radiol ogist who performed the sonography examination. Any subsequent inter pretation was made by consensus of two radiologists.

The signs suggestive of a partial-thickness cuff tear included a heterogeneous tendon with hypoechoic areas (> 3 mm) that did not reach both sides of the tendon or a large linear echogenic focus within the cuff substance (i.e., a purely intra-substance tear) and a hypoechoic defect that involved the articular or bursal surface [810]. Sonographic findings for a full-thickness rotator cuff tear included nonvisualization or absence of cuff tissue, a full-thickness hypoechoic defect, visualization of the underlying hyaline cartilage, and a heterogeneously hypoechoic cuff with bursal fluid [10, 11]. A heterogeneous tendon with an increase of more than 8 mm in tendon thickness was considered to indicate tendinosis [11]. Tendon sheath fluid was hypoechoic or anechoic, freely displaceable, and compressible and did not exhibit any color Doppler signal [12]. The SA–SD bursa was imaged as a hypoechoic line, 1 to 2 mm thick with a variable amount of peribursal echogenic fat, located between the deltoid muscle and the supra spinatus and infraspinatus tendons. Therefore, we determined the established criterion for SA–SD bursitis to be a hypoechoic fluid-filled bursa more than 2 mm thick [13]. To evaluate a frozen shoulder, we carefully investigated thickening of the coracohumeral ligament, effusion, or synovial thickening in the rotator cuff interval, referencing MRI findings of frozen shoulder because dynamic scanning of the sliding pattern of the supraspinatus tendon beneath the acromion during lateral passive elevation of the arm was difficult and incorrect in the patients with hemiplegic shoulder [14, 15].

To determine whether a correlation exists between the sonographic findings and the Brunnstrom stages of motor recovery, we classified the sonographic findings into five grades according to the clinical significance based on a consensus of the clinician and the radiologist. The sonographic grades were determined as follows: grade 1, normal or effusion of the biceps tendon sheath; grade 2, tendinosis of the supraspinatus; grade 3, SA–SD bursitis; grade 4, a partial-thickness tear of the rotator cuff; and grade 5, a full-thickness tear of the rotator cuff. In cases with more than two abnormal sonographic findings, we graded the cases on the basis of the most severe finding. These sonographic findings were compared with the motor recovery stage of the affected upper extremities in all patients.

Statistical Analysis

Statistical analysis was performed using Spearman's correlation coefficient, which was calculated using commercially available statistical software (SPSS, version 10.0, SPSS) for Microsoft Windows to determine whether a correlation exists between the sonographic findings and the Brunnstrom staging of motor recovery. For comparison of a hemiplegic shoulder and a contralateral shoulder, we used the chi-square test. A p value of less than 0.05 was considered to indicate a statistically significant difference.

Results
Previous sectionNext section

We were able to evaluate adequately the rotator cuff, the long head of the biceps tendon and tendon sheath, the rotator cuff interval, the SA–SD bursa, the AC joint, and the posterior glenohumeral joint in all study patients (Figs. 1A, 1B, 1C and 2). In the hemiplegic shoulders, effusion within the SA–SD bursa (n = 36) was the most common abnormality depicted on sonography. Tendinosis of the supraspinatus tendon (n = 7), partial-thickness tear of the supraspinatus tendon (n = 6), and full-thickness tear of the supraspinatus tendon (n = 2) were seen. Biceps tendon sheath effusion (n = 39) and normal findings without any biceps tendon sheath effusion (n = 13) were also noted. Twenty patients showed two abnormal sonographic findings and six patients showed three abnormal sonographic findings.

figure
View larger version (113K)
Fig. 1A 42-year-old man with left hemiplegia caused by cerebral infarction and modified stage 1 of motor function in left upper arm. On physical examination, there was tenderness in subacromial–subdeltoid (SA–SD) bursal area. HH = humeral head. Long-axis sonographic view of left supraspinatus insertion shows swelling and heterogeneous echogenicity (arrows) that was interpreted as tendinosis.

figure
View larger version (107K)
Fig. 1B 42-year-old man with left hemiplegia caused by cerebral infarction and modified stage 1 of motor function in left upper arm. On physical examination, there was tenderness in subacromial–subdeltoid (SA–SD) bursal area. HH = humeral head. Small amount of effusion (arrows) at SA–SD bursa is noted on short-axis sonographic view of left supraspinatus insertion.

figure
View larger version (134K)
Fig. 1C 42-year-old man with left hemiplegia caused by cerebral infarction and modified stage 1 of motor function in left upper arm. On physical examination, there was tenderness in subacromial–subdeltoid (SA–SD) bursal area. HH = humeral head. Effusion (thin arrows) at biceps tendon sheath on long-axis sonographic view of long head of biceps tendon (thick arrow) is noted. Sonography grade was interpreted as 3.

figure
View larger version (114K)
Fig. 2 58-year-old woman with left hemiplegia due to cerebral infarction. Patient had modified stage 2 motor recovery, and rotator cuff tear was suspected on physical examination. Only anechoic fluid collection (arrows) is seen at tendon sheath on long-axis sonographic view of long head of biceps tendon. Sonography grade was interpreted as 1.

figure
View larger version (47K)
Fig. 3 42-year-old man with left hemiplegic shoulder pain and flaccid-state motor function (modified stage 1). Sonographic findings were expected to be low grade on the basis of physical examination. Long-axis sonographic view of supraspinatus insertion shows distinct hypoechoic defect (cursors) in articular surface of tendon that represents partial-thickness tear. Sonography grade was interpreted as 4. HH = humeral head.

In 20 contralateral shoulders, biceps tendon sheath effusion (n = 9), normal findings (n = 7), effusion within the SA–SD bursa (n = 6), tendinosis (n = 2), and a partial-thickness tear of the supraspinatus tendon (n = 1) were seen on the sonography examinations. There were no cases of effusion or synovial thickening within the posterior glenohumeral joint and rotator cuff interval.

The relationships between the grades of sonographic findings and the stages of motor recovery are summarized in Table 1. No statistical correlation was observed between the grade of sonographic findings and the Brunnstrom stages (p = 0.183, Spearman's correlation coefficient) (Fig. 3). In comparisons of the hemiplegic shoulder and the contralateral side, the shoulder with hemiplegia had a higher number of abnormal sonographic findings than the noninvolved shoulder (p = 0.007, chi-square test).

TABLE 1: Correlation Between the Modified Stages of Motor Recovery and Sonographic Grades

Discussion
Previous sectionNext section

Shoulder pain can delay rehabilitation and functional recuperation because the painful joint may mask improvement of motor function [2]. The incidence of shoulder pain has been reported in up to 72% of patients within 1 year of stroke onset [3]. Hemiplegic shoulder pain usually appears within the first few weeks after a stroke. It is more frequently associated with a spastic than a flaccid stage. Factors cited for the multifactorial basis of hemiplegic shoulder pain include rotator cuff disease, subluxation, spasticity, and reflex sympathetic dystrophy. Despite numerous theories and studies, the mechanisms underlying a painful shoulder in hemiplegic patients are still poorly understood. Therefore, it is important for the clinician to identify the precise cause of hemiplegic shoulder pain to obtain a good treatment outcome.

Brunnstrom [14] developed a test in which movement patterns are evaluated and motor function is rated according to the stages of motor recovery. In our study, variable sonographic findings were seen in patients with hemiplegic shoulder pain and there was no significant correlation with the sonography grades and the motor recovery stages. Many patients, even those with severe shoulder pain, had normal sonographic findings. Therefore, we cannot expect clinic ally detected shoulder abnormalities to be described according to the motor recovery stage. Moreover, in stage 3–4 (modified stage 2), which represents prominent spasticity, clinicians usually complain of the greater difficulty in performing physical examinations as compared with the other stages. The estimation of the cause of shoulder pain in this stage based on only a physical examination is usually impossible and is occasionally confusing for clinicians. There fore, the use of imaging techniques is necessary and the use of less complicated and noninvasive methods is required in these patients. In our study, although there were some limitations in the dynamic sonography examinations, we could visualize the rotator cuff including the biceps tendon and SA–SD bursa in all patients.

The results of a recent survey of physicians in The Netherlands showed that most believe that steroid injections are effective in the treatment of hemiplegic shoulder pain [15]. In clinical practice physiatrists frequently treat patients with hemiplegic shoulder pain with steroid injections. Moreover, the clinical presentation of hemiplegic shoulder pain mimics that of a frozen shoulder. However, local injection with corticosteroids has been shown to provide disappointing results when used for hemiplegic shoulder pain unless used specifically in the context of inflammatory lesions, such as rotator cuff or bicipital tendinitis, or tears associated with secondary subacromial bursitis [16]. In patients with increasing spasticity, high-grade sonographic findings, such as a rotator cuff tear or bursitis, were expected. However, the degree of motor recovery did not correlate with the sonography grades in our study. Therefore, the identification of soft-tissue changes using MRI or sonography is important to ensure proper management of hemiplegic shoulder pain, although we do not understand the complex pathology of shoulder pain in hemiplegic patients with only an evaluation of soft tissues of the shoulder.

Shoulder pain of hemiplegic patients may occur for many reasons. Many investigators have suggested that shoulder subluxation is a major cause of shoulder pain [17, 18]. Panjabi [19] proposed a model to explain the stabilizing mechanisms of the spine that appears to be well suited to the shoulder complex. In the shoulder, the articular geometry, capsuloligamentous structures, muscles, and neural networks all contribute to stability. The basic pathology is the loss of centering of the humeral head within the glenoid fossa. This phenomenon is usually reserved for patients with loss of the static stabilizers of the shoulder. The loss of the normal constant load tension of the rotator cuff in CVA patients results in the sequelae of motion around a nonphysiologic axis. However, several investigators have reported no correlation between pain and subluxation [3]. Even in our study, although we did not evaluate shoulder subluxation as described by Brooke et al. [20], we ascertained that there was no gross subluxation or dislocation of the shoulder joints as seen on radiographs of the shoulder in all patients. In addition, patients with a subluxed hemiplegic shoulder were excluded from this study.

Spasticity has been mentioned as a possible cause of shoulder pain because it can cause irritation of the soft tissues—notably, of the various ligaments and muscles of the shoulder girdle that are particularly prone to pain in view of the high concentration of neuroreceptors in that region [2]. From their study, Van Ouwenaller et al. [17] concluded that spasticity is the prime factor and the one factor most frequently encountered in the genesis of shoulder pain in the hemiplegic patient. O'Sullivan and Schmitz [21] mentioned that abnormal muscle tone results in abnormal scapulohumeral rhythm and contributes to increased glenohumeral friction–compression stress in the spastic stage. These investigators suggested that incorrect handling of the patients therefore results in improper dynamic motor control and that rotator cuff tearing may occur. The number of patients with stage 3 and 4 (modified stage 2) at the time of sonography was 32 (45%) in our study. However, among patients with stage 2 there was no full-thickness tear and a partial-thickness tear was seen in only three patients (9%).

Although rotator cuff tears may be expected in some stroke patients, some investigators have suggested that these tears do not occur more commonly in stroke survivors than in an age-matched healthy population [3]. Even in our study, full-thickness tears of the rotator cuff were present in only 3% of patients. Adhesive capsulitis may also be more common in hemiplegic patients than in the general population and can cause a limitation in the range of motion of the shoulder joint. Adhesive changes seen on arthrograms have been reported in as many as 54.6% of stroke survivors [22]. Ikai et al. [1] stated that they found no relation between shoulder subluxation and pain and that adhesive capsulitis is the primary cause of shoulder pain. Although we were unable to assess adhesive capsulitis with only sonography and physical examinations, we evaluated sonography examinations for the presence or absence of synovial proliferations in the rotator cuff interval, representing adhesive capsulitis. In our study, no case of adhesive capsulitis was seen on sonography. Clinicians managed shoulder pain on the basis of our sonography results, and none of the patients was treated for a frozen shoulder.

Sonography is known as a useful and widely available technique that can be used to assess shoulder pain [12]. High-resolution real-time sonography has been shown to be a successful imaging technique with which to assess both rotator cuff and non–rotator cuff disorders [4]. Sonography offers dynamic capabilities with which to examine patients in multiple scanning planes and with specific arm positions or movements in addition to having the ability to focus the examination on the precise region of maximum discomfort [4]. Although the usefulness of sonography greatly depends on the skill of the operator, Middleton et al. [23] showed that in experienced hands sonography has a low level of interobserver variability for the detection, classification, and localization of rotator cuff tears. All of our study patients complained of shoulder pain after stroke onset and subsequently sonography was requested with the expectation of depicting abnormalities of the soft tissues of the shoulder girdle. The clinicians were able to manage adequately the shoulder pain of patients according to the sonographic findings.

This study has some limitations. First, we did not perform reference standard techniques such as shoulder MRI, MR arthrography, arthroscopy, or open surgery for diagnostic confirmation. Therefore, we could not evaluate the glenoid labrum. However, MR examinations of CVA patients with hemiplegic shoulder were actually impossible to perform because of limitations of positioning and involuntary movements of the affected upper limbs. The clinicians formulated treatment plans on the basis of the sonographic findings and clinical manifestations. Second, the duration of this study was short and we enrolled only a small number of patients. In the future, more long-term follow-up of hemiplegic patients will be needed. In addition, evaluation of the changes in sonographic findings according to the stages of motor recovery in the same patient will be useful.

In conclusion, there was no correlation between the stages of motor recovery and the grades of sonographic findings in patients with hemiplegic shoulder pain. Therefore, we could not estimate the pathology of the shoulder joint according to the motor recovery stage. However, sonography was an essential method by which to evaluate soft-tissue changes of the shoulder girdle and was helpful to determine effective treatment methods for CVA patients with hemiplegic shoulder pain.

Address correspondence to I. S. Lee ().

WEB

This is a Web exclusive article.

References
Previous sectionNext section
1. Ikai T, Tei K, Yoshida K, Miyano S, Yonemoto K. Evaluation and treatment of shoulder subluxation in hemiplegia: relationship between subluxation and pain. Am J Phys Med Rehabil 1998; 77:421 –426 [Google Scholar]
2. Lo SF, Chen SY, Lin HC, Jim YF, Meng NH, Kao MJ. Arthrographic and clinical findings in patients with hemiplegic shoulder pain. Arch Phys Med Rehabil 2003; 84:1786 –1791 [Google Scholar]
3. Bachmann GF, Melzer C, Heinrichs CM, Mohring B, Rominger MB. Diagnosis of rotator cuff lesions: comparison of US and MRI on 38 joint specimens. Eur Radiol 1997; 7:192–197 [Google Scholar]
4. Read JW, Perko M. Shoulder ultrasound: diagnostic accuracy for impingement syndrome, rotator cuff tear, and biceps tendon pathology. J Shoulder Elbow Surg 1998; 7:264–271 [Google Scholar]
5. Brandstater ME. Basic aspects of impairment evaluation in stroke patients. In: Chino N, Melvin JL, eds. Functional evaluation of stroke patients. New York, NY: Springer-Verlag,1996 : 9–18 [Google Scholar]
6. Moosikasuwan JB, Miller TT, Burke BJ. Rotator cuff tears: clinical, radiographic, and US findings. RadioGraphics 2005; 25:1591 –1607 [Google Scholar]
7. Teefey SA, Middleton WD, Yamaguchi K. Shoulder sonography: state of the art. Radiol Clin North Am 1999; 37:767–785 [Google Scholar]
8. Middleton WD, Reinus WR, Totty WG, Melson CL, Murphy WA. Ultrasonographic evaluation of the rotator cuff and biceps tendon. J Bone Joint Surg Am 1986; 68:440–450 [Google Scholar]
9. van Holsbeeck MT, Kolowich PA, Eyler WR, et al. US depiction of partial-thickness tear of the rotator cuff. Radiology 1995; 197:443 –446 [Google Scholar]
10. Jacobson JA, Lancaster S, Prasad A, van Holsbeeck MT, Craig JG, Kolowich P. Full-thickness and partial-thickness supraspinatus tendon tears: value of US signs in diagnosis. Radiology 2004; 230:234 –242 [Google Scholar]
11. Taboury J. Ultrasonography of the tendons of the rotator cuffs of the shoulder [in French]. Ann Radiol (Paris) 1995; 38:275 –279 [Google Scholar]
12. O'Connor PJ, Rankine J, Gibbon WW, Richardson A, Winter F, Miller JH. Interobserver variation in sonography of the painful shoulder. J Clin Ultrasound 2005; 33:53–56 [Google Scholar]
13. Naredo E, Aguado P, De Miguel E, et al. Painful shoulder: comparison of physical examination and ultrasonographic findings. Ann Rheum Dis 2002; 61:132–136 [Google Scholar]
14. Brunnstrom S. Movement therapy in hemiplegia: a neurophysiological approach. New York, NY: Harper & Row,1970 [Google Scholar]
15. Snels IA, Beckerman H, Lankhorst GJ, Bouter LM. Treatment of hemiplegic shoulder pain in the Netherlands: results of a national survey. Clin Rehabil 2000; 14:20–27 [Google Scholar]
16. Turner-Stokes L, Jackson D. Shoulder pain after stroke: a review of the evidence base to inform the development of an integrated care pathway. Clin Rehabil 2002; 16:276–298 [Google Scholar]
17. Van Ouwenaller C, Laplace PM, Chantraine A. Painful shoulder in hemiplegia. Arch Phys Med Rehabil 1986; 67:23–26 [Google Scholar]
18. Chaco J, Wolf E. Subluxation of the glenohumeral joint in hemiplegia. Am J Phys Med 1971; 50:139–143 [Google Scholar]
19. Panjabi MM. The stabilizing system of the spine. I. Function, dysfunction, adaptation, and enhancement. J Spinal Dis 1992; 5:383 –389 [Google Scholar]
20. Brooke MM, de Lateur BJ, Diana-Rigby GC, Questad KA. Shoulder subluxation in hemiplegia: effects of three different supports. Arch Phys Med Rehabil 1991; 72:582–586 [Google Scholar]
21. O'Sullivan SB, Schmitz TJ. Physical rehabilitation: assessment and treatment, 3rd ed. Philadelphia, PA: FA Davis,1995 : 327–360 [Google Scholar]
22. Rizk TE, Christopher RP, Pinals RS, Salazar JE, Higgins C. Arthrographic studies in painful hemiplegic shoulders. Arch Phys Med Rehabil 1984; 65:254 –256 [Google Scholar]
23. Middleton WD, Teefey SA, Yamaguchi K. Sonography of the rotator cuff: analysis of interobserver variability. AJR 2004; 183:1465 –1468 [Abstract] [Google Scholar]

Recommended Articles

Sonography of Patients with Hemiplegic Shoulder Pain After Stroke: Correlation with Motor Recovery Stage

Full Access,
American Journal of Roentgenology. 2009;192:501-508. 10.2214/AJR.07.3959
Abstract | Full Text | PDF (903 KB) | PDF Plus (1031 KB) 
Full Access, , ,
American Journal of Roentgenology. 2009;192:496-499. 10.2214/AJR.08.1254
Abstract | Full Text | PDF (611 KB) | PDF Plus (640 KB) 
Full Access, , , , , ,
American Journal of Roentgenology. 2009;192:487-495. 10.2214/AJR.08.1316
Abstract | Full Text | PDF (1931 KB) | PDF Plus (1425 KB) 
Full Access, , , , ,
American Journal of Roentgenology. 2009;192:W45-W52. 10.2214/AJR.07.3934
Abstract | Full Text | PDF (725 KB) | PDF Plus (776 KB) 
Full Access, , ,
American Journal of Roentgenology. 2009;192:W53-W62. 10.2214/AJR.08.1585
Abstract | Full Text | PDF (1198 KB) | PDF Plus (1214 KB) 
Full Access, , , , ,
American Journal of Roentgenology. 2010;195:567-576. 10.2214/AJR.10.4406
Abstract | Full Text | PDF (1538 KB) | PDF Plus (1225 KB)