|Year : 2019 | Volume
| Issue : 3 | Page : 47-49
Influence of different inclination angles on middle deltoid muscle activity in stroke patients with shoulder subluxation: protocol for a cross-sectional study
Navjyoti Gupta, Subhasish Chatterjee
Department of Neurophysiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Mullana, Ambala, Haryana, India
|Date of Submission||11-May-2019|
|Date of Acceptance||13-Jul-2019|
|Date of Web Publication||9-Sep-2019|
Department of Neurophysiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Mullana, Ambala, Haryana
Source of Support: None, Conflict of Interest: None
Background and objective: Glenohumeral subluxation is a common complication that is a palpable gap between the acromion and humeral head and causes mechanical integrity change in the joint. Electromyography is a method used to assess and capture skeletal muscle electrical activity and assess the strength of muscle that controls motor neurons. The objective of this study is to investigate whether different inclination angles influence middle deltoid muscle activity in patients with glenohumeral subluxation.
Subjects and methods: It is a cross-sectional study in which 30 stroke patients with shoulder subluxation were included. Recruitment started from September, 2018. The study was completed in July 2019. Uncooperative patients or those who develop reflex sympathetic dystrophy or have psychological problems were excluded from this study. Purposeful sampling was used to collect samples. Glenohumeral subluxation will be assessed. Electromyography surface electrodes will be used to capture the middle deltoid muscle activity. The study is conducted in the Neurophysiology Unit of Neurophysiotherapy Research Lab of the Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation (India). Ethical approval was obtained from Institutional Ethical Committee (IEC) of Maharishi Markandeshwar University (IEC/MMU 2018/1114) on March 24, 2018.
Outcome measures: Primary outcome measure is electromyography motor unit action potential parameter. Secondary outcome measures are amplitude, duration, and rise time.
Discussion: Results from this study will provide evidence whether patient exercise performance without changing patient position but only adjusting bed/couch angles can improve the motor function of stroke patients. The study findings may help therapists and patients to prescribe exercise in what particular degree to get good results from the therapy.
Trial registration: The study was registered with Clinical Trials Registry-India on September 17, 2018 (registration No. CTRI/2018/09/015732).
Keywords: cross-sectional study; deltoid muscle; electromyogram; exercise; inclination angle; rehabilitation; shoulder subluxation
|How to cite this article:|
Gupta N, Chatterjee S. Influence of different inclination angles on middle deltoid muscle activity in stroke patients with shoulder subluxation: protocol for a cross-sectional study. Clin Trials Orthop Disord 2019;4:47-9
|How to cite this URL:|
Gupta N, Chatterjee S. Influence of different inclination angles on middle deltoid muscle activity in stroke patients with shoulder subluxation: protocol for a cross-sectional study. Clin Trials Orthop Disord [serial online] 2019 [cited 2020 Aug 7];4:47-9. Available from: http://www.clinicalto.com/text.asp?2019/4/3/47/265974
| Introduction|| |
Subluxation of shoulder joint is the most common musculoskeletal complication after stroke., Humeral head translation occurs more frequently than glenoid cavity translation,. The incidence of subluxation of shoulder joint in the stroke population is reported to be 17–80%., The stability of glenohumeral joint relies on the integrity of muscular and capsuloligamentous structure rather than bony conformation., Because of lack of muscle function, under the force of gravity, the arm is mostly stretched to the capsule, resulting in shoulder subluxation. The muscles injured in the shoulder subluxation are mainly rotator cuff (supraspinatus) and deltoid muscle, which decrease the stability of the shoulder joint.
Muscle activity is influenced by the change in surface angle. In a previous study involving athletes competing at national and international level, Saeterbakken et al. measured the electromyography (EMG) activity in performing 6RM competition style bench press (flat bench-wide grip) with medium and narrow grip widths on a flat bench versus inclined and declined bench positions with a wide grip. They concluded that muscle activity was affected by changing the surface angle. In addition, an athlete who experiences pain while lifting heavy weight when training may get benefits through changing surface angle.
The main focus in treating shoulder subluxation is to minimize the instability and strength the muscles surrounding the joint. Therefore, a previous study addressed on strengthening the deltoid muscle which is a large shoulder muscle group. Besides the arm elevation, the major role of deltoid muscle is to sustain the humerus stably in the glenoid.
Blache et al. proposed that glenohumeral subluxation may be reduced if the base of support is reduced and the center of mass is raised as this requires greater postural muscle activity.
In the plane of the scapula during abduction, the middle and anterior deltoid muscle is aligned to raise the humerus. When the humerus elevates, superior dislocation diminishes as the translatory component of deltoid muscle shifts increasingly towards glenoid fossa but when the arm moves horizontally, the rotatory component of deltoid muscle must counteract the increased torque of gravity. Once the arm is above the horizontal, the torque of gravity diminishes and the moment arm of the deltoid muscle gets large., Glenohumeral subluxation has been shown to affect the recovery of motor function of stroke patients.
The purpose of this study is to investigate whether different inclination angles influence middle deltoid muscle activity in stroke patients with shoulder subluxation.
| Subjects and methods|| |
This is a cross-sectional study [Figure 1]. Ethical approval was obtained from Institutional Ethical Committee (IEC) of Maharishi Markandeshwar University (IEC/MMU 2018/1114) on March 24, 2018 [Additional file 1]. [Additional file 1] The study was performed in accordance with the guideline developed by Indian Council of Medical Research and the Helsinki Declaration and registered with the Clinical Trials Registry-India (CTRI) (registration No. CTRI/2018/09/015732) on September 17, 2018. This study followed the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidance for protocol reporting [Additional file 2]. [Additional file 2] The single-center study with the single group design is conducted in the Neurophysiology Unit of Neurophysiotherapy Research Lab of the Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation (India). Stroke patients suffering from shoulder subluxation was approached for consent [Additional files 3 [Additional file 3] and 4 [Additional file 4]]. Prior to commencement of the procedure, patients are instructed to perform the procedure so that they can well understand it.
|Figure 1: Study flow chart|
Note: EMG: Electromyography; MUAP: motor unit action potential.
Click here to view
The purpose of this study is to determine whether different surface inclination angles i.e., 0˚, 15˚, 25˚, 35˚, 45˚, 60˚ affect the deltoid muscle activity in a stroke population with shoulder subluxation.
Inclusion criteria: patients meeting all of the following criteria are considered for inclusion: a) having hemorrhagic and ischemic stroke; b) having shoulder subluxation; c) either gender; d) age at 25–70 years; e) Mini-mental State Examination score more than 23.
Exclusion criteria: patients meeting one or more of the following criteria are rejected from this study: a) being medically unstable; b) uncooperative patients; c) psychological disease; d) reflex sympathetic dystrophy, or clavicle fracture.
The principle investigator of this study should undertake sufficient training prior to commencement of the study.
Patient’s sulcus sign is evaluated using an aerospace digital vernier caliper (New Delhi, India). Measurement is taken from tip of acromion to superior head of humeral head in millimeter. The study was performed by the physiotherapists.
Participants will be recruited from Inpatient Department of Maharishi Markandeshwar Institute of Medical Science and Research (MMIMS&R) and Outpatient Department of Maharishi Markandeshwar Institute of Physiotherapy and Réhabilitation (MMIPR) (MMDU, Mullana, Ambala, Haryana, India).
Demographic data, Mini-mental State Examination for cognitive impairment, sulcus sign to measure subluxation, motor unit action potential (MUAP) parameters (including amplitude, duration, recruitment pattern, and rise time).
EMG MUAP parameters, including amplitude, duration, recruitment pattern, and rise time.
Ethical approval was obtained from Institutional Ethical Committee (IEC) of Maharishi Markandeshwar University (IEC/MMU 2018/1114) on March 24, 2018.
Sample size estimation
Sample size was assumed to be 30. This study is performed based on patient availability, as no pilot study is available related to the study.
SPSS 20.0 software (IBM, Armonk, NY, USA) will be used. The Shapiro-wilk test will be used to analyze the normality because the data is less than 50. After checking the normality, depending on data distribution, parametric or non-parametric test will be decided. If the data are normally distributed, then repeated measures analysis of variance will be used. If data are not normally distributed, then the non-parametric Friedman test will be applied to the study.
| Discussion|| |
Patients with stroke have to perform many exercises in different positions. To perform those exercises in different positions is sometime painful and tiring. Therefore, if a therapist knows the best angle at which muscle can be activated to the maximum extent, then it will be easy to perform exercise in that angle.
The bed is tilted in the degree at which muscle is recruited at the maximum degree. This can reduce the fatigue the patient gets while turning from one position to another position.
Ellis et al. investigated the effect of co-activation of upper extremity configuration on pattern shoulder abduction, elbow flexion, shoulder adduction, and elbow extension. Hatton et al. found that reducing the base of support during exercise may improve the glenohumeral subluxation of patients with stroke. Ackland et al. reported that there is a difference in moment arm between different muscle subregions (deltoid, muscle pectoralis major, latissimus dorsi, subscapularis, infraspinatus, etc.) in upper limb during abduction in the coronal plane and flexion in the sagittal plane.
Uhl et al. reported that in weight-bearing exercises, different amounts of arm support and force resulted in different demands on the shoulder musculature. Chatterjee et al. reported that California tri-pull taping is effective in relieving subluxation pain, alleviating limited range of motion, and enhancing arm function in hemiplegic patients.
| Trial status|| |
Recruitment started from September 2018. The study was completed in July 2019.
Additional file 1: Ethical approval documentation.
Additional file 2: SPIRIT checklist.
Additional file 3: Certificate of consent.
Additional file 4: Information sheet.
Concept of the work, literature retrieval, and manuscript preparation and review: NG; manuscript preparation and revision: SC. Both authors gave final approval for publication.
Conflicts of interest
The authors have no conflicts of interest to declare.
Institutional review board statement
Ethical approval was obtained from Institutional ethical committee (IEC) of Maharishi Markandeshwar University with allotted number IEC/MMU 2018/1114 on March 24, 2018.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the forms, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity.
This study followed the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidance for protocol reporting.
The statistical methods of this study will be reviewed by the biostatistician of Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation in India.
Copyright license agreement
The Copyright License Agreement has been signed by both authors before publication.
Data sharing statement
Individual participant data will not be shared with anyone.
Checked twice by iThenticate.
Externally peer reviewed.
Open access statement
This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
P-Reviewer: Dong YZ; C-Editors: Zhao M, Li JY; S-Editor: Li CH; L-Editor: Song LP; T-Editor: Jia Y
| References|| |
Faghri PD, Rodgers MM, Glaser RM, Bors JG. The effects of functional electrical stimulation on shoulder subluxation, arm function recovery, and shoulder pain in hemiplegic stroke patients. Arch Phys Med Rehabil
Snels IA, Beckerman H, ten Kate JJ, Lankhorst GJ, Bouter LM. Measuring subluxation of the hemiplegic shoulder: reliability of a method. Neurorehabil Neural Repair
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
Kumar P, Mardon M, Bradley M, Gray S, Swinkels A. Assessment of glenohumeral subluxation in poststroke hemiplegia: comparison between ultrasound and fingerbreadth palpation methods. Phys Ther
Dajpratham P, Sura P, Lektrakul N, Chanchairujira G. Efficacy of shoulder slings in shoulder subluxation of stroke patients. J Med Assoc Thai
Borsa PA, Timmons MK, Sauers EL. Scapular-positioning patterns during humeral elevation in unimpaired shoulders. J Athl Train
Blache Y, Begon M, Michaud B, Desmoulins L, Allard P, Dal Maso F. Muscle function in glenohumeral joint stability during lifting task. PLoS One
Paci M, Nannetti L, Rinaldi LA. Glenohumeral subluxation in hemiplegia: An overview. J Rehabil Res Dev
Chatterjee S, Hayner KA, Arumugam N, et al. The California tri ‐ pull taping method in the treatment of shoulder subluxation after stroke: a randomized clinical trial. North Am J Med Sci
Yates A, Yates AV, Donlin AA, Beneck GJ, Schick EE. The influence of surface angle inclination on muscle activity during Pilates based exercises. J Bodyw Mov Ther
Saeterbakken AH, Mo DA, Scott S, Andersen V. The effects of bench press variations in competitive athletes on muscle activity and performance. J Hum Kinet
Jaggi A, Alexander S. Rehabilitation for shoulder instability – current approaches. Open Orthop J
Rosso C, Mueller AM, Mckenzie B, et al. Bulk effect of the deltoid muscle on the glenohumeral joint. J Exp Orthop
Ellis MD, Lan Y, Yao J, Dewald JP. Robotic quantification of upper extremity loss of independent joint control or flexion synergy in individuals with hemiparetic stroke?: a review of paradigms addressing the effects of shoulder abduction loading. J Neuroeng Rehabil
Ackland DC, Pak P, Richardson M, Pandy MG. Moment arms of the muscles crossing the anatomical shoulder. J Anat
Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther
Hatem SM, Saussez G, Della Faille M, et al. Rehabilitation of motor function after atroke: a multiple systematic review focused on techniques to stimulate upper extremity recovery. Front Hum Neurosci
Hatton NJ, Stockley RC. To sit or stand? A preliminary, cross sectional study to investigate if there is a difference in glenohumeral subluxation in sitting or standing in people following stroke. Arch Physiother
Uhl TL, Carver TJ, Mattacola CG, Mair SD, Nitz AJ. Shoulder musculature activation during upper extremity weight-bearing exercise. J Orthop Sports Phys Ther