ue management post-stroke joy boyce bsc.o.t. & lindsay edwards bsc.o.t
TRANSCRIPT
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UE Management Post-Stroke
Joy Boyce BSc.O.T.&Lindsay Edwards BSc.O.T.
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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.
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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.
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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
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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.
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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
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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
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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
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Treatment OptionsPhysical Modalities
◦Stretching/ROM/Positioning◦Serial Casting◦Splinting/Orthoses◦NMES◦Heat/Ice◦Motor recovery
techniques/interventions
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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
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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
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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
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Potential Causes of Shoulder Pain
Anatomical Site
Mechanism
Muscle Rotator Cuff, Muscle Imbalance, Subscapularis Spasticity, Pectoralis Spasticity
Bone Humeral Fracture
Joint Glenohumeral Subluxation
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
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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)
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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].
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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)
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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
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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)
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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!!
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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)
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Shoulder SubluxationShoulder 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
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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
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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
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24 Hour Arm Supports cont’d
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Bed Positioning
LYING ON THE AFFECTED SIDE
LYING ON THE UNAFFECTED SIDE
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Bed Positioning
LYING ON THE BACK SITTING UP IN BED
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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)
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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
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Common Mechanical Lifts
Sit-stand Lift Hoyer Lift
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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
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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
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Splinting options
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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
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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
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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
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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/