1. Upper extremity Physiotherapy
Approaches to minimize pain and maximize function in persons post CVA

2. Acknowledgements
Canadian Stroke Strategy: Best Practice Recommendations and Performance Measures
Evidence-Based Review of Stroke Rehabilitation
Stroke Canada Optimization of Rehabilitation through Evidence (SCORE)

3. Upper limb post CVA Flaccid High tone
No muscle reaction to passive movement and no voluntary movement and no reflexive reaction
High tone
Velocity dependant increase in resistance to passive stretch accompanied by hyperactive stretch reflexes

4. Causes of Shoulder Pain
Muscle Imbalance
Fracture
Tendonitis
Glenohumeral Subluxation
Bursitis
Adhesive Capsulitis
Neuropathic (RSD)
Estimated to occur in 48-84% of patients post stroke. Many of these will resolve however Lindgren et al 2007 found 27% still had pain at 16 months.

5. Muscle Imbalance Disorganized muscle activation
Flexor tone predominates in the hemiplegic upper extremity and results in scapular retraction and depression as well as internal rotation and adduction of the shoulder
Current research suggests relation between spasticity and shoulder pain
Also relation between CVA, frozen shoulder and pain
Subscapularis and pectoralis major specifically tonically contracted

6. Shoulder subluxation
Occurs in a large percentage of persons post stroke with flaccid upper extremity (29-82%)
Possibly a reason for development of pain but inconclusive

7. Injury
Rotator cuff injury is a possibility however no studies showing conclusive evidence of a tear causing pain
Also tears found may not be premorbid
Questionable cause of pain

8. Shoulder pain post CVA: Management
Prevention is the NUMBER 1 action for health care providers
There is no one specific treatment for the reduction and elimination of shoulder pain post stroke currently
Once pain is present it is very difficult to treat.

9. Pain Prevention
Positioning

12. Pain prevention Passive range of motion Slings and straps
Recommended to avoid shoulder ranging past 90 degrees of flexion and abduction.
Emphasis on external rotation as tolerated
Slings and straps
Perhaps some benefit to prevent shoulder subluxation however little evidence for pain reduction or prevention
Sensation disturbance may not be evident therefore use good clinical judgment in movement and positioning

13. Slings

14. Slings

15. Pain treatment Active treatment Overhead pulleys shown to create pain
Moderate evidence showing gentle exercises are preferred approach
Limited evidence that nonsteroidal anti-inflamatory medication improves pain, ROM and function
Sustained stretch may be as equally harmful as immobile position
decreasing range and increasing pain

16. Pain Treatment Modalities Functional electrical stimulation
Conflicting evidence
Some evidence is showing that if started before pain occurs there is less incidence of pain.
No good studies showing effective pain treatment.

17. Conclusions of shoulder pain
Protection
Position properly
Use devices consistently
Patient and family education
Passive ranging
Light movement no further than 90 degrees of shoulder flexion and abduction
Emphasis on maintaining external rotation and abduction
Devices- wheelchair tray, splints, slings..etc

18. CIMT CIMT-Constraint induced movement therapy
Introduced by Edward Taub in the 1960s after working with deafferented monkeys
Phrasing learned non-use
Monkeys unaffected arms were restrained in slings and affected arms regained movement
Monkeys were surgically prevented from receiving sensory information
Learned non-use being the lack of movement in the affected arm secondary to removal environment stimulus

19. Video

20. EXCITE Trial 222 participants, 3-9 month period
Multi-site, single blinded randomized
Inclusion:
20 degrees wrist extension, 10 degrees MCP and IP extension (high function)
10 degrees wrist extension, 10 degrees thumb abduction, and 10 degrees extension of at least 2 digits (low function)

21. EXCITE Trial Glove on for 90% of waking hours to less-impaired arm
Task practice in lab 6 hours per day, for 2 work weeks (10 days)
Conclusion:
Improved function shown to be retained 24 months after 2 week program in SIS strength, ADLs, and social participation
SIS- stroke impact scale

22. Modified CIMT: Page et al. 2008
Stroke was 12 + months prior
20 degrees wrist, 10 degrees MCP and IP extension
Restraint for 5 hours per day, with 30 minute one-on-one sessions 3 times per week for 10 weeks
Outcome measures: action research arm test, fugl-meyer assessment of motor recovery, motor activity log.

23. Modified CIMT: Page et al. 2008
Conclusion:
Improvement in function and quality of arm movement
May be more practical program than previous studies

24. More local input Ploughman et al. 2008
Case study from the Miller Rehabilitation Centre in Newfoundland
Same parameters as EXCITE trial
Demonstrated remarkable increase in function for a hockey loving adolescent male

25. Feasibility in NB hospital
Inpatient rehab
Glove is cheap and easy to create
Could be used on appropriate patients with consent
Dressing, feeding, toileting would all take more time
therefore need health care team, patient and family buy in
Compliance is what will make or break this treatment.

26. Feasibility in NB Outpatient CIMT
Labour intensive but there is suggested long term effect
Modified CIMT may be beneficial
Possibility for group therapy sessions
Possible treatment at chronic stage

27. Questions?