Handling Hemiplegic UE

Report
UE Management Post-Stroke
Joy Boyce BSc.O.T.
&
Lindsay Edwards BSc.O.T.
Objectives
To review early management of the upper
extremity post-stroke
 To review the impact of spasticity, shoulder pain
and subluxation on the upper extremity poststroke
 To review common goals and treatment options
for upper extremity management post-stroke.

Shoulder After A Stroke
Initial period of flaccid (floppy) paralysis in >90% of
individuals
Continued flaccid paralysis:
• Weakness of shoulder muscles & gravitational pull
tend to result in inferior subluxation.
• Weakness in arm lateral rotators while lifting the arm
up may result in muscles getting caught between
bones.
• Weight of unsupported arm may cause traction on
various nerves.
Shoulder After a Stroke cont’d
Spasticity
 Is defined as an increase in muscle tone due
to hyperexcitability of the stretch reflex and
is characterized by a velocity-dependent
increase in tonic stretch reflexes.
 Very common: 20% to 70% incidence post
stroke or brain injury
 Ranges from very mild to quite severe:
Commonly measured by Modified Ashworth
Scale or Tardue
Shoulder After a Stroke cont’d
Spasticity Cont’d
 As spasticity develops, scapular rotation may
be stopped by tone in the latissimus dorsi,
levator scapulae and rhomboid muscles.
 Increased activity in medial rotators may
pull humerus into medial rotation,
contributing to muscle pinching on Active
and Passive Range of Motion.
 Humeral head may be displaced forward.
Complications of Spasticity

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Pain
Contractures – lose joint flexibility
Interferes with function
Slow rehabilitation efforts
Interferes with hygiene
Lead to skin breakdown – pressure sores
Interferes with positioning
Interferes with sleep
Interferes with degree of recovery of
movement
Spasticity and Shoulder Pain
FLEXOR SYNERGY PATTERN
Where the arm is held tight
and close to the chest
 Pain with attempted
movement or stretching
 Secondary complications of
frozen shoulder, permanent
loss of range of motion,
difficulty with hygiene,
dressing, balance

Possible Causes For Fluctuations in
Spasticity






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Infections, e.g. bladder, lungs, etc.
Constipation
Ingrown toenails
Pressure sores
Fatigue
Poor fit of brace or wheelchair
Stress
Satkunam, CMAJ 2003;169(11):1173-9
Treatment Options

Physical Modalities
◦
◦
◦
◦
◦
◦
Stretching/ROM/Positioning
Serial Casting
Splinting/Orthoses
NMES
Heat/Ice
Motor recovery techniques/interventions
Treatment Options

Oral Medication
◦ e.g., tizanidine, gabapentin, lyrica,
dantrolene

Chemodenervation – Botulinum Toxin
◦ Best treatment for focal spasticity
◦
E.g., clenched fist, thumb in palm deformity,
equinovarus deformity

Surgery: tendon transfer or release

Intrathecal Baclofen Pump
Shoulder Pain Indicators
Poor Prognostic Indicators
 UE in low stage of recovery (Stage 3 or
lower on the Chedoke McMaster Ax)
 Scapular malalignment
 Passive Range Of Motion abduction <900,
lateral rot < 600
 Neglect
 Sensory loss
Prevalence

The incidence of shoulder pain varies
between studies; estimates range from
48% to 84%

Shoulder pain post stroke or brain injury
is a symptom not a diagnosis – must
first determine the exact cause of the
pain which will then direct treatment
Potential Causes of Shoulder Pain
Anatomical
Site
Muscle
Bone
Mechanism
Rotator Cuff, Muscle Imbalance, Subscapularis
Spasticity, Pectoralis Spasticity
Humeral Fracture
Glenohumeral Subluxation
Joint
Bursa
Bursitis
Tendon
Tendonitis
Joint Capsule Frozen or Contracted Shoulder
(Adhensive Capsulitis)
Other
Complex Regional Pain Syndrome
Table 11.2 EBRSR Painful Hemiplegic
Shoulder module
(www.strokebestpractices.ca)
Shoulder Pain Management
Canadian Stroke Strategy Best Practice Guidelines 2013
Joint protection strategies should be used during the early
or flaccid stage of recovery to prevent or minimize shoulder
pain. These include:
• Positioning and supporting the arm during rest
[Evidence Level B].
• Protecting and supporting the arm during functional
mobility [Evidence Level C].
• Protecting and supporting the arm during wheelchair
use by using a hemi-tray or arm trough [Evidence
Level C].
During the flaccid stage slings can be used to prevent
injury; however, beyond the flaccid stage the use of slings
remains controversial [Evidence Level C].
Shoulder Pain Management
Canadian Stroke Strategy Best Practice Guidelines 2013



Overhead pulleys should not be used [Evidence Level
A].
The arm should not be moved beyond 90 degrees of
shoulder flexion or abduction, unless the scapula is
upwardly rotated and the humerus is laterally rotated
[Evidence Level A].
Patients and staff should be educated to correctly
handle the involved arm [Evidence Level A]. For
example, excessive traction should be avoided during
assisted movements such as transfers [Evidence level
C].
Management of Shoulder Pain

Management can be difficult and response
may be unsatisfactory – so
PREVENTION is Key!

Measures should be taken immediately
following stroke/brain injury to minimize
the potential for the development of
shoulder pain (gentle shoulder ROM, and
supporting and protecting the shoulder)
Prevention of Shoulder Pain
BENEFICAL IMPACT: Preventing shoulder pain may impact
quality of life (mood, cognition, physical and social).
Research evidence shows that early awareness of potential
injuries to the shoulder joint structures reduced the
frequency of shoulder-hand syndrome/CRPS from 27% to
8%. The shoulder-hand syndrome usually involves joint
inflammation resulting from trauma, which coincides with
increased arterial blood flow.
Canadian Best Practice Recommendations for Stroke2010
Goals

UE protection strategies
o Positioning
o Transfers
o Caregiver training

Pain-free passive functional ROM
o Caregiver
o Self-ranging

To use the affected arm as a stabilizer
o Grasp pattern
o Initiation of active movement (flexion & extension)
Management of Shoulder Pain
Team Focused and dependent on cause!!

Positioning

Slings/supports/taping

ROM– gentle, no
pulleys!

Modalities – ultrasound,
electrical stimulation,
heat, cold

Medications –
NSAIDS, neuropathic
pain meds

Corticosteroid
injections – only if due
to muscles getting
caught between
shoulder joint bones

Botox – only if due to
spasticity
Research Says: Encourage Joint Protection &
Minimize Joint Trauma
 PROM and AAROM:
 Shoulder should not be passively moved beyond
90 degrees of flexion and abduction unless the
scapula is upwardly rotated and the humerus is
laterally rotated. (HSF-AH 1.1b Level A)
 Use of overhead pulleys is inappropriate
because they appear to contribute to shoulder
tissue injury. (HSF-AH 1.1c Level A, Ottawa
Panel 2.38 Level A)
Shoulder Subluxation

Shoulder subluxation is common - but it is
preventable

The relationship between shoulder subluxation
and pain is not a direct one

Not all subluxed shoulders are painful and not
all painful shoulders are subluxed

However care should be taken early to prevent
subluxation and thus any contribution it may
have to a painful shoulder
Management Strategies
During lower stages (Stage 3 or lower), the arm
must be adequately supported
 Improper positioning in bed, lack of support
when upright, and/or pulling on the hemiplegic
arm when transferring, all contribute to
subluxation.

24 Hour Arm Supports
Pillows in bed and sitting
 Car transfers: try soft lap top
 Half lap trays:

◦ Medial, lateral and posterior blocks
◦ Different options: there is no one clear leader
◦ Function needs to be considered!
 Transfers
 Doorway widths
 Wheelchair mobility
24 Hour Arm Supports cont’d
LYING ON THE
AFFECTED SIDE
LYING ON THE UNAFFECTED SIDE
Bed Positioning
LYING ON THE BACK
SITTING UP IN BED
Bed Positioning
Transfers
Guidelines for protecting the affected arm
 Never pull on the affected arm.
 Avoid lifting the person from under their arms.
 Do not force painful range of movements of the
affected arm.
 Use slings only when the patient moves
throughout the transfers.
 When the patient is seated, remove the sling
and support the affected arm on a solid surface
(e.g. lap tray, tabletop, pillow)
Mechanical Lifts
Transfer slings from lifts can pull up on the
affected arm and put it at risk for developing
pain.
 Make sure you are aware of the position of
their arm
 Things to try:

◦
◦
◦
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Tuck the affected arm inside the transfer sling
Wear an arm sling during the transfer if you have one
Hold the affected arm when in the lift
Consider another way to transfer if able
Common Mechanical Lifts
Sit-stand Lift
Hoyer Lift
Splinting
Routine use of splints is not recommended
(early – level A, Late –level B). No evidence to
support splinting for the purpose of improving
function or reducing spasticity.
 When to splint?

◦
◦
◦
◦
◦
Provide comfort,
Support joint alignment
Cosmesis.
Consistent ROM, prolonged stretch is more beneficial
Prevent skin breakdown
Splinting cont’d
Things to consider

Tolerated position at both wrist and fingers,
◦ i.e. may only be able to achieve neutral wrist if you
are wanting to maximize extension at the PIP and DIP
joints
Ensure webspace at the thumb and support
opposition while maintaining arches of the palm.
 Beneficial to splint with two person assist
 Material of choice – Sansplint (low stretch)
 Ensure strapping is optimized to support
position

Splinting options
Management of Swelling

Cold water immersion (ice
dips) or contrast baths

Retrograde massage

Gentle movement of hand
and fingers

Active finger movement
along with elevation of the
hand (shoulder not higher
than 90 degrees)

Pressure garments
It’s Your Arm!!
Be your own advocate. Speak up!
 Don’t let others lift under your affected
arm or lift it above 90˚.
 Use transfer belts
 Make sure you educate and tell others

◦
◦
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Caregivers
Family members
Friends
Health professionals
One-Handed Techniques

The use of one-handed techniques in daily
activities can help promote safe positing
of an affected arm.
◦ One-Handed in a Two-Handed World
 Author: Tommye K. Mayer
◦ Adaptive Equipment
Thank You
Questions?
Useful links:
 Strokengine: http://strokengine.ca/
 Canadian Best Practices
Recommendations for Stroke care:
http://www.strokebestpractices.ca/

EBRSR: http://www.ebrsr.com/

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