The Hemiplegic Arm – To Sling or Not To Sling?

This is a question we get all the time, but the real question is, what is the stroke sling for?

There are many slings out there you can buy, and most of them are used for people with a fractured or dislocated shoulder, or with problems with their acromioclavicular joint following sporting injuries. This means that you have a range of slings that can be classified into two forms of functions: 1) the rest the shoulder in, or 2) to support the shoulder during extreme movement in sporting activities.

Both these reasons suit the person with an orthopaedic problem nicely, where time is needed for either the fracture, muscle strain or ligament sprain to heal. And eventually the stroke sling comes off.

But when we think about the arm that has been paralysed by a stroke, the two scenarios don’t apply.

So we come back to the question – what are we expecting the stroke sling to do?

Myth 1: The sling helps with pain.

In some cases, the hemiplegic arm goes through a period of increasing sensitivity to touch, especially in more severe cases where there is persistent lack of movement or feeling. The arm then can become painful to touch when normally that kind of touch is not painful (allodynia). Adding a sling won’t change the progression of this problem, and in fact is likely to make it worse over time as you shield the arm more and more from what it is meant to experience. This is because the sling doesn’t allow any other experience of feeling because it is kept in one position.

Myth 2: The sling helps with subluxation (joint gapping).

Often a hemiplegic arm is flaccid and referred to as low toned, or hypotonic, and it tends to sit lower and becomes smaller from muscle wasting. This can mean that there can be a larger gap in the shoulder joint. As able bodied people, we immediately associate this as being painful because we remember how painful it was when dislocating a finger as a child. We forget that this is actually due to high impact trauma, whereas in stroke there is no such high impact trauma and hence no actual tissue damage.

In fact, there is very little correlation between subluxation and pain in hemiplegic arms in stroke. In research literature, a better correlation exists actually between available shoulder range and shoulder pain. But careless and forceful ranging of the shoulder is not the key, because it is a delicate and complex joint that very much needs to consider the person’s torso, shoulder blade and collarbone position and the upper arm bone (humerus) to determine what the true range of movement is.

While the sling may seem to reduce subluxation, it actually makes the shoulder blade side of the joint tighter and tighter, and what you end up getting is often a joint that has sides that sits way too close to each other. Consequently you can lose range of movement in the forward and outward direction because there is not enough upper space for the joint to move, and then trying to move it out of this position becomes painful as you stretch stiffened tissue.

In addition, there is no mention of slings in the National Stroke Foundation Clinical Guidelines for managing the upper limb subluxation or pain, but it is recommended that supportive surfaces such as tables and supportive cushions are better for shoulders because:

1.     They stay in view of the person who owns it.
2.     It doesn’t get ignored by others.
3.     You can provide some support not to overstretch tissues.
4.     You provide some opportunities for the arm to sit in different positions
5.     The hand can be placed on a surface to give the person some orientation on that side.

The only time I may consider having a sling used is for temporary support if there is going to be a period where I cannot control it during walking. And even so this is rare.

Obviously the lifelong goal of the hemiplegic arm is to restore feeling and movement to its original glory. Because the sling does not generally fit in line with this goal, I choose to avoid using it as much as possible.

It is only then that we can create an opportunity for change.

Resources:

Resources:
_{National Stroke Foundation (2010): Clinical Guidelines for Stroke Management 2010. Available for access via http://strokefoundation.com.au/site/media/clinical_guidelines_stroke_managment_2010_interactive.pdf}