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 Table of Contents  
Year : 2017  |  Volume : 11  |  Issue : 2  |  Page : 49-52

Effect of scapular hold-relax technique on shoulder pain in hemiplegic subjects: A randomized controlled trial

Department of Neurophysiotherapy, Institute of Physiotherapy, KLE University, Belgaum, Karnataka, India

Date of Submission16-Jul-2017
Date of Acceptance02-Sep-2017
Date of Web Publication19-Jan-2018

Correspondence Address:
Dr. Deepak Joshi
Department of Neurophysiotherapy, Institute of Physiotherapy, KLE University, Belgaum, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/PJIAP.PJIAP_11_17

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BACKGROUND AND PURPOSE: Poststroke shoulder pain is one of the most common (34%–86%) and significant problems that impairs the normal functioning and rehabilitation in stroke survivors. The purpose of this study was to examine the effect of scapular proprioceptive neuromuscular facilitation (PNF) on shoulder pain in hemiplegic patients.
METHODS: A total of 30 stroke survivors with hemiplegia were recruited and randomly allocated to Group A (n = 15) and Group B (n = 15). The experimental group was administered conventional treatment plus scapular PNF-hold relax technique, whereas the control group received only conventional treatment comprised of passive shoulder range of motion exercises, stretching exercises, and transcutaneous electrical nerve stimulation (TENS) for 12 sessions (4 sessions per week). The outcome measure used to assess the level of shoulder pain before and after the intervention was visual analog scale (VAS).
RESULTS: Statistical analysis showed significant reduction in poststroke shoulder pain (PSSP) in both the experimental and control groups. Although the relief in PSSP was found, no statistically significant differences could be obtained between the groups.
CONCLUSION: The reduction in shoulder pain observed in both the groups signifies the effectiveness of conventional measures (i.e., passive range of motion exercises, stretching exercises, and TENS) in relieving the shoulder pain in hemiplegic patients. Clinically, it was seen that the experimental group exhibited better improvement around the shoulder. Hence, it can be stated that scapular PNF has a positive impact on PSSP, but it demands more vigorous future researches to prove the hypothesis correct statistically.

Keywords: Hemiplegia, hold-relax technique, poststroke shoulder pain, scapular proprioceptive neuromuscular facilitation

How to cite this article:
Chitra J, Joshi D. Effect of scapular hold-relax technique on shoulder pain in hemiplegic subjects: A randomized controlled trial. Physiother - J Indian Assoc Physiother 2017;11:49-52

How to cite this URL:
Chitra J, Joshi D. Effect of scapular hold-relax technique on shoulder pain in hemiplegic subjects: A randomized controlled trial. Physiother - J Indian Assoc Physiother [serial online] 2017 [cited 2023 Feb 9];11:49-52. Available from: https://www.pjiap.org/text.asp?2017/11/2/49/223697

  Introduction Top

Stroke is a clinical syndrome characterized by the sudden development of a persistent focal neurological deficit secondary to a vascular event.[1] One of the most significant and frequently occurring complications of stroke is shoulder pain, with the prevalence between 34% and 86%.[2] Poststroke shoulder pain (PSSP) usually commences between 2 weeks to 2 months [3],[4] after onset of stroke. The cause of PSSP is said to be multifactorial.[5] Many underlying pathologies that may contribute to hemiplegic shoulder pain are adhesive capsulitis (50%), glenohumeral subluxation (44%), rotator cuff tear (22%), shoulder-hand syndrome (16%),[4] and other disorders such as heterotrophic ossification, thalamic syndrome, and brachial plexus injury.[6]

Existing methods being utilized for the management for PSSP involve basic range of motion exercises, heating modalities, stretching of the spastic muscles, facilitatory and inhibitory techniques; these treatment methods are not specifically directed to the pathology. Other treatment techniques employed for PSSP are oral analgesics, strapping, transcutaneous electrical nerve stimulation (TENS), ultrasound, and various other approaches; more aggressive measures such as regional anesthesia, desensitization, sympathectomy, intra-articular corticosteroids, intramuscular botulinum injections for intractable sympathetic disorders, and spasticity.[3],[6]

Following any painful disorder, there occurs an imbalance in the surrounding muscles secondary to inhibition and failure in proper and timed activation. Evidence has proved the importance of reducing pain level, developing awareness in deep stabilizing muscles, and correct the muscle activation rather than the isolated muscle training when training the patients with cortical disorder for motor control. Researchers also suggest the use of mental imagery, tactile, verbal, visual, tapping, weight bearing, and movement-oriented cues for the better results.[7]

Proprioceptive neuromuscular facilitation (PNF) is an approach to therapeutic exercise that combines functionally based diagonal patterns of movement with techniques of neuromuscular facilitation to evoke motor responses and improve neuromuscular control and function.[8] The main intention for performing the PNF exercises in specific diagonal patterns is to enhance the functional movement through facilitation, inhibition, strengthening, and relaxation of muscle groups.[9] Principal components of this approach to therapeutic exercise are the use of diagonal patterns and the application of sensory cues, specifically proprioceptive, cutaneous, visual, and auditory stimuli, to elicit or augment motor response.[8]

The scapular patterns targeting the various groups of scapular muscles can be administered in two diagonals: Anterior elevation – posterior depression and posterior elevation – anterior depression. The exercises can be performed with the patient lying on the treatment table, on mat, sitting, or standing.[9] Scapular PNF techniques incorporate functional or diagonal patterns for performing the exercises, and these techniques can also be used to stretch or strengthen the muscles selectively. These techniques also help the muscles to relearn the spatial and temporal aspects of recruitment (amount and timing of activation) that gets impaired following cerebrovascular damage and can lead to the restoration of balance between different groups of muscles.

One of the techniques utilized in PNF is hold-relax technique. It is an effective, simple, and pain-free technique which has potential to induce relaxation, improve flexibility, and reduce pain. The authors hypothesized that there will be an effect of scapular hold-relax technique on PSSP in patients with hemiplegia. However, there is paucity of literature relating to the effect of scapular PNF hold-relax technique on shoulder pain; hence, the need arises to study the presence of any influence of scapular hold relax technique in PSSP.

  Methods Top

Study design

This study used a randomized controlled design to study the effect of scapular PNF on poststroke shoulder pain. Approval of the project was obtained from the Ethical Committee of Institute. Institutionally approved written consent was obtained before the study participation. Participants after their enrollment were randomly allocated into either (1) Experimental group, receiving scapular hold relax technique and conventional treatment or (2) Control group, receiving only conventional treatment.


Participants of either sex with hemiplegia were recruited from secondary and tertiary health-care centers. Participants were included if they were suitable according to the following criteria (1) age group: 40–80 years; (2) diagnosis of first-ever stroke; (3) having shoulder pain; (4) cooperative and willing to participate. Participants were excluded if they had (1) any other diagnosed cause of shoulder pathology (fracture etc.) not associated with stroke; (2) acute stroke (flaccid stage); (3) shoulder subluxation; (4) inability to follow the commands; and (5) other neurological disorders.

Outcome measure

Shoulder pain was assessed at baseline and after the completion of 12 session protocol using VAS.


The participants in the experimental group received scapular hold-relax plus conventional treatment. The session began with 30 min of conventional treatment including passive range of motion exercises, passive stretching, and TENS (100 Hz; painful area method) followed by hold relax technique (3 sets of 10 repetitions) in the diagonal pattern of anterior elevation and posterior depression. The control participants received conventional treatment measures. Both the groups underwent the same protocol of 12 sessions (4 sessions per week). The outcome measures were assessed once again 12 sessions.

Data analysis

Statistical analysis of the data obtained was done using Statistical Package for the Social Sciences (SPSS) version 20 (SPSS, IBM, Bengaluru, Karnataka, India). Kolmogorov–Smirnov test was used to test the normality of pre- and post-intervention values. Paired and unpaired t-tests were used to assess within the group and between-group differences, respectively. P < 0.05 were considered statistically significant and P < 0.001 were considered highly significant.

  Results Top

We screened 51 individuals with hemiplegia and enrolled thirty participants in our study; all the participants completed the study. No significant harms or unintended effects were found during the study. The flow of participants through the trial is summarized in [Figure 1]. All the demographic characteristics were nonsignificant on between-group comparison implying the homogenous distribution of the participants in both the groups. The baseline values recorded for shoulder pain were compared between groups which elicited nonsignificant results stating that the severity and status of the patients in both the groups were distributed homogeneously (P > 0.05). The demographic characteristics of each group are summarized in [Table 1].
Figure 1: Consort diagram illustrating the fl ow of participants through the trial

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Table 1: Demographic and baseline characteristics of patients (n=30)

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[Table 2] presents baseline and post-intervention values of the PSSP scores on VAS. The pain as per VAS score reduced significantly in both the groups but between-group comparison demonstrated no significance.
Table 2: Within and between group comparison for the outcome measure

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  Discussion Top

The current study aimed to evaluate the effect of scapular PNF-hold-relax technique on shoulder pain, range of motion, scapular position, and upper extremity function in participants with hemiplegia. The gender distribution observed in this study (percentage of male patients: 60%) matched with that presented in a 2013 report of global burden of stroke which showed that 57.79% of stroke patients were male.[10] The mean age of all the participants was 56.06 years, 55.73 years for experimental group, and 56.40 for control group.

A group of researchers have expressed the scepticism toward the validity of VAS in stroke patients.[11] They exhibited the inefficiency of the stroke patients to complete the scales with correct pattern and accuracy. However, in this study, VAS was used confidently because any issues regarding its validity were ruled out by excluding the patients with cognitive impairment.

Conventional TENS has demonstrated the positive effects on spasticity, reflex hyperexcitability occurring after stroke.[12],[13] The probable mechanisms underlying this effect are activation of large diameter afferent nerve fibers, modulation of interneuron activities in several spinal segments, which then triggers the inhibition of the activities of presynaptic nerve; or alternatively, it can act through continuous somatosensory stimulation leading to the insensitivity to prolonged excitation accompanied by lower corticomotor neuron excitability.[12]

PNF has been proven to provide analgesic effects through gate control mechanism.[14] This mechanism comes into play whenever there occurs any competition between different sensory modalities; pain and pressure in our case. It is known that nociceptors transmit the pain stimulus either via small, unmyelinated C fibers or through small, myelinated A-delta fibers; and these pain and pressure stimuli relay onto the same region at spinal cord level. Pressure and proprioceptive inputs (produced by the PNF techniques) make it to the spinal level and inhibit the entry and transmission of pain carrying signals. However, in the current study, the comparison of VAS scores between the 2 groups was not statistically significant implying no benefit of addition of scapular PNF on poststroke shoulder pain. The results of a similar study done by Balc et al.[15] to examine the effectiveness of single session of scapular PNF in patients with adhesive capsulitis resembled very much to that of the current study. One possible explanation for this could be that the structures involved in most common shoulder pathologies poststroke, that is, adhesive capsulitis and rotator cuff muscle strain [4] were not specifically addressed by the scapular PNF techniques administered.

Few limitations that strived in this study were (1) shoulder muscle assessment was not performed, specifically; shoulder muscle pathology might have influenced the outcomes assessed in this study, and (2) the absence of follow-up eliminated the chance of examining whether any between-group differences appeared in a longer run. The effect of combination of scapular PNF and upper extremity PNF on shoulder complex function demands to be studied as it seeks to assess the effect of training upper extremity as a whole.

  Conclusion Top

The reduction in shoulder pain observed in both the groups signifies the effectiveness of conventional measures (i.e., passive range of motion exercises, stretching exercises, and TENS) in relieving the shoulder pain in hemiplegic patients. Clinically, it was seen that the experimental group exhibited better improvement around the shoulder. Hence, it can be stated that scapular PNF has a positive impact on PSSP and scapular PNF is a vital component of the poststroke shoulder pain rehabilitation protocol. However, it demands more vigorous future researches to prove the hypothesis correct statistically.


The authors of the study express their sincere thanks to the Principal of the Institute of Physiotherapy. They would also like to thank the tertiary care hospital for giving permission to carry out the study and also the participants for their willingness to participate.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Geyer JD, Gomez CR. Stroke: A Practical Approach. Vol. 15-16. USA: Lippincott Williams and Wilkins; 2008. p. 312-5.  Back to cited text no. 1
Vuagnat H, Chantraine A. Shoulder pain in hemiplegia revisited: Contribution of functional electrical stimulation and other therapies. J Rehabil Med 2003;35:49-54.  Back to cited text no. 2
Coskun Benlidayi I, Basaran S. Hemiplegic shoulder pain: A common clinical consequence of stroke. Pract Neurol 2014;14:88-91.  Back to cited text no. 3
Lo SF, Chen SY, Lin HC, Jim YF, Meng NH, Kao MJ, et al. Arthrographic and clinical findings in patients with hemiplegic shoulder pain. Arch Phys Med Rehabil 2003;84:1786-91.  Back to cited text no. 4
Walsh K. Management of shoulder pain in patients with stroke. Postgrad Med J 2001;77:645-9.  Back to cited text no. 5
Gould R, Caillet R. Shoulder Pain in Hemiplegia: Hemiplegic Shoulder Pain. Medscape. Drugs and Disease. Available from: http://www.emedicine.medscape.com/article/328793-overview. [Last accessed on 2017 Jan 21].  Back to cited text no. 6
Magarey ME, Jones MA. Dynamic evaluation and early management of altered motor control around the shoulder complex. Man Ther 2003;8:195-206.  Back to cited text no. 7
Kisner C, Colby LA. Therapeutic Exercise: Foundation and Techniques. 5th ed. USA: Jaypee, FA Davis; 2007. p. 195-203.  Back to cited text no. 8
Adler SS, Beckers D, Buck M. PNF in Practice: An Illustrated Guide. 2nd ed. India: Springer; 2003.  Back to cited text no. 9
Barker-Collo S, Bennett DA, Krishnamurthi RV, Parmar P, Feigin VL, Naghavi M, et al. Sex differences in stroke incidence, prevalence, mortality and disability-adjusted life years: Results from the global burden of disease study 2013. Neuroepidemiology 2015;45:203-14.  Back to cited text no. 10
Price CI, Curless RH, Rodgers H. Can stroke patients use visual analogue scales? Stroke 1999;30:1357-61.  Back to cited text no. 11
Martins FL, Carvalho LC, Silva CC, Brasileiro JS, Souza TO, Lindquist AR, et al. Immediate effects of TENS and cryotherapy in the reflex excitability and voluntary activity in hemiparetic subjects: A randomized crossover trial. Rev Bras Fisioter 2012;16:337-44.  Back to cited text no. 12
Schuhfried O, Crevenna R, Fialka-Moser V, Paternostro-Sluga T. Non-invasive neuromuscular electrical stimulation in patients with central nervous system lesions: An educational review. J Rehabil Med 2012;44:99-105.  Back to cited text no. 13
Hindle KB, Whitcomb TJ, Briggs WO, Hong J. Proprioceptive neuromuscular facilitation (PNF): Its mechanisms and effects on range of motion and muscular function. J Hum Kinet 2012;31:105-13.  Back to cited text no. 14
Balc NC, Yuruk ZO, Zeybek A, Gulsen M, Tekindal MA. Acute effect of scapular proprioceptive neuromuscular facilitation (PNF) techniques and classic exercises in adhesive capsulitis: A randomized controlled trial. J Phys Ther Sci 2016;28:1219-27.  Back to cited text no. 15


  [Figure 1]

  [Table 1], [Table 2]


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