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 post- stroke 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 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 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 FLEXOR SYNERGY PATTERN
Possible Causes For Fluctuations in Spasticity 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 <90 0, lateral rot < 60 0 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
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]. (www.strokebestpractices.ca)
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 Stroke 2010
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 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 Team Focused and dependent on cause!!
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
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. Management Strategies
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
Bed Positioning LYING ON THE AFFECTED SIDELYING ON THE UNAFFECTED SIDE
Bed Positioning LYING ON THE BACKSITTING UP IN BED
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: ◦ 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 LiftHoyer 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
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 ◦ 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: Canadian Best Practices Recommendations for Stroke care: EBRSR: