The recommendations are graded by their level (I, II) and strength (A, B, C+, C, D, D+, D-) of evidence. Definitions for the level and strength of the recommendations are presented at the end of the "Major Recommendations" field.
Clinical Practice Guidelines for Shoulder Subluxation
Functional electrical stimulation (FES) versus control, level I (randomized controlled trial [RCT]): Grade C+ for shoulder lateral range of motion (SLROM), motor function, and decrease in shoulder subluxation at end of treatment, 4 weeks, and pain relief at end of treatment, 4 weeks, and follow-up, 8 weeks (clinically important benefit demonstrated without statistical significance); grade C for SLROM and decrease in shoulder subluxation at follow-up, 8 weeks, and muscle bulk at end of treatment, 4 weeks, and follow-up, 8 weeks (no benefit demonstrated); grade D for motor function at follow-up, 8 weeks (no benefit demonstrated, but favoring control). Patients with acute stroke.
FES versus control, level I (RCT) and level II (controlled clinical trial [CCT]):
Grade A for SLROM, motor function (upper extremity [UE] function), decrease in shoulder subluxation (v-value* difference), and improvement of muscle tone on affected upper extremity at end of treatment, 6 weeks, and follow-up, 6 weeks, and decrease in shoulder subluxation**(mm) at end of treatment, 12 and 18 weeks (clinically important benefit demonstrated); grade B for pain relief at end of treatment 3, 6, 12, and 24 months, and motor function (% of patients with recovery of motor function) and decrease in shoulder subluxation (% of decreased shoulder subluxation) at end of treatment, 6, 12, and 24 months (clinically important benefit demonstrated). Patients with subacute stroke.
*v-value is calculated by using a radiological technique, where the v = vertical component of the glenohumeral alignment is determined by measuring the vertical distance between the acromial point and the central point of the humeral head in millimeters.
**The degree of subluxation was determined on the x-ray by measuring the shortest perpendicular distance (in mm) between tangents drawn through the inferior border of the acromion and the most superior aspect of the head of the humerus of the affected upper extremity. The method was generally accepted and used for finding all "decrease in shoulder subluxation."
FES versus control, level I (RCT): Grade C for decrease in shoulder subluxation at end of treatment, 12 and 18 weeks (no benefit demonstrated). Patients with chronic stroke.
FES of the supraspinatus versus FES of the middle deltoid, level I (CCT): Grade C+ for muscle force at end of treatment, 6 weeks (clinically important benefit demonstrated without statistical significance); grade C for decrease in shoulder subluxation at end of treatment, 6 weeks (no benefit demonstrated). Patients with chronic stroke.
FES of the supraspinatus versus no treatment, level I (CCT): Grade C+ for muscle force and decrease in shoulder subluxation at end of treatment, 6 weeks (clinically important benefit demonstrated without statistical significance). Patients with chronic stroke.
FES of the middle deltoid of chronic versus no treatment, level II (CCT): Grade C+ for muscle force and decrease in shoulder subluxation at end of treatment, 6 weeks. Patients with chronic stroke.
Support methods – Bobath versus Henderson, level II (CCT): Grade C for decrease in shoulder subluxation at end of treatment, 1 day. Patients with post-acute stroke.
Support methods – Henderson shoulder ring versus no support, level II (CCT): Grade B for decrease in shoulder subluxation at end of treatment, 1 day (clinically important benefit demonstrated). Patients with post-acute stroke.
Support methods – Bobath shoulder roll versus no support, level II (CCT): Grade B for decrease in shoulder subluxation at end of treatment, 1 day (clinically important benefit demonstrated). Patients with post-acute stroke.
Strapping versus no strapping, level I (RCT): Grade C+ for pain relief at end of treatment, 6 weeks, and follow-up, 2 months (clinically important benefit demonstrated without statistical significance). Patients with subacute stroke.
Shoulder positioning versus no treatment, level I (RCT): Grade C+ for ROM (active abduction [ABD]) at end of treatment, 6 weeks (clinically important benefit demonstrated without statistical significance); grade C for ROM (passive external rotation) and pain relief at end of treatment, 6 weeks (no benefit demonstrated). Patients with subacute stroke.
Definitions:
Level of Evidence
Level I: Randomized controlled trials
Level II: Nonrandomized studies
Grade of Recommendation
Grade A: Evidence from one or more randomized controlled trials (RCTs) of a statistically significant, clinically important benefit (>15%)
Grade B: Statistically significant, clinically important benefit (>15%), if the evidence was from observational studies or controlled clinical trials (CCTs)
Grade C+: Evidence of clinical importance (>15%) but not statistical significance
Grade C: Interventions where an appropriate outcome was measured in a study that met the inclusion criteria, but no clinically important difference and no statistical significance were shown
Grade D: Evidence from one or more randomized controlled trials of a statistically significant benefit favoring the control group (<0%: favors controls)
Grade D+: Evidence of clinical importance (<-15% for controls) without statistical significance
Grade D-: Evidence from one or more randomized controlled trials of a clinically important benefit (<-15% for controls) that was statistically significant, where the number of participants in the study is equal to or higher than 100