UE Management Post-Stroke

Joy Boyce BSc.O.T.&Lindsay Edwards BSc.O.T.

ObjectivesTo review early management of the

upper extremity post-strokeTo 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 StrokeInitial period of flaccid (floppy) paralysis in >90% of

individualsContinued 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’dSpasticity 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’dSpasticity 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 SpasticityPainContractures – lose joint flexibilityInterferes with functionSlow rehabilitation effortsInterferes with hygieneLead to skin breakdown – pressure

soresInterferes with positioning Interferes with sleepInterferes 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 OptionsPhysical Modalities

◦Stretching/ROM/Positioning◦Serial Casting◦Splinting/Orthoses◦NMES◦Heat/Ice◦Motor recovery

techniques/interventions

Treatment OptionsOral 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

PrevalenceThe 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

Mechanism

Muscle Rotator Cuff, Muscle Imbalance, Subscapularis Spasticity, Pectoralis Spasticity

Bone Humeral Fracture

Joint Glenohumeral Subluxation

Bursa BursitisTendon Tendonitis Joint Capsule Frozen or Contracted Shoulder

(Adhensive Capsulitis)

Other Complex Regional Pain Syndrome

Table 11.2 EBRSR Painful Hemiplegic Shoulder module

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 PainManagement 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

GoalsUE protection strategies

oPositioningoTransfersoCaregiver training

Pain-free passive functional ROMoCaregiveroSelf-ranging

To use the affected arm as a stabilizeroGrasp patterno 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 SubluxationShoulder subluxation is common - but

it is preventableThe 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 topHalf 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 SIDE LYING ON THE UNAFFECTED

SIDE

Bed Positioning

LYING ON THE BACK SITTING UP IN BED

Transfers Guidelines for protecting the

affected armNever 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 LiftsTransfer 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 LiftsSit-stand Lift Hoyer Lift

SplintingRoutine 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 considerTolerated 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 SwellingCold 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 TechniquesThe 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 YouQuestions?Useful links:Strokengine: http://strokengine.ca/ Canadian Best Practices

Recommendations for Stroke care: http://www.strokebestpractices.ca/

EBRSR: http://www.ebrsr.com/