CVA - 4a Stroke Rehab UE Flashcards
what are primary vs second post-stroke UE impairments (5)
PRIMARY
motor control/activation
altered ms tone
loss of sensation
coordination problems
unilateral neglect
SECONDARY
weakness, atrophy
ms length, ROM
edema
subluxation
pain
what are 4 interventions/foci of the hemiplegic UE
positioning
shoulder joint integ
pain management
UE functioning
what are the goals of positioning for a hemiplegic UE
protect joints
limit edema
dec pain
visualize limb
function
what are the goals of preserving shoulder joint integrity of hemiplegic UE
prevent subluxation
prevent shoulder-hand syndrome (CRPS)
how can pts experience pain related to the shoulder joint integrity of a hemiplegic UE
not having structures to hold humerus and joint capsule appropriately
what is a standardized outcome measure to use for a hemiplegic UE
Fugl Meyer
what is the most common sequelae secondary to a hemiplegic UE
inferior shoulder subluxation
- ant and superior possible, but inferior most common
why are inferior shoulder subluxations so common in hemiplegic UE
weakness, hypotonicity surrounding GH joint and gravity of limb’s wt -> downward rotation of scap and glenoid fossa -> traction of humerus -> soft tissue surrounding GH joint and joint capsule stretches and lengthens -> ms length-tension relationship changes
what could result from improper management of a hemiplegic UE post stroke
soft tissue damage causing shoulder and UE pain
what is pain of subluxed hemiplegic shoulder associated with
subluxation itself
loss of ROM
nerve impingement (GH rhythm off)
overstretching and/or rupture of ligaments, tendons, and ms of shoulder
how is a shoulder subluxation dx
radiographs (reliable, valid)
calipers or tape measure
palpation**
- 1-2 finger gap from acromion/clavicle to HOH
- also see asymmetry
when is it esp important to properly handle pt’s hemiplegic UE and why
positioning
bed mobility
transfers
dec risk of developing pain syndromes and improve functional outcomes
what is the goal of the collaborative care of the interdisciplinary team of a pt hemiplegic UE
protect from risk of secondary complications
what are 3 causes of hemiplegia shoulder pain
malalignment of joints can lead to soft tissue involvement
impingement syndrome
complex regional pain syndrome (CRPS; shoulder-hand syndrome)
how can malalignment of joints cause hemiplegia shoulder pain and what can it lead to
can lead to soft tissue involvement:
- tendon tear
- tendinitis
- bursitis
this can cause shoulder pain and dec function, adhesive capsulitis
how can impingement syndrome result from a hemiplegic UE
GH rhythm off -> humerus pulled down and not in proper alignment -> GH friction-compression if go into flex or ABD -> risk for impingement
how can CRPS cause hemiplegia shoulder pain
ANS changes -> vasomotor changes, discoloration and temp changes (pink and cool with hyperalgesia
how can CRPS in a hemiplegic UE be prevented
support and position UE
mobilize scap and UE
- esp w PROM >90deg for shoulder flex and ABD, need to ensure scap is gliding into upward rotation on thoracic wall
promote active movement and WB-ing
what is important education to give to caregivers to prevent CRPS in a hemiplegic UE
never pull on hemiplegic UE to roll pt or during transfers
what are 6 PT interventions for hemiplegic UE management
ROM
positioning to prevent progression
supportive devices
NMES
taping
promote recovery of motor function
how does trunk control play impact an hemiplegic UE
poor trunk control -> abnormal postures -> will affect how they move and scap orientation -> altered scap orientation -> change orientation of glenoid fossa
how does altered ms tone impact an hemiplegic UE
spasticity in pec major and lats downwardly rotates scap
- changes glenoid orientation
what does a scap that isn’t moving w ROM put the pt at risk for
inc risk for sublux and impingement
how can spasticity present in hemiplegic UE that inc risk of what secondary complication
abnormal ms synergy of excessive ADD and IR
- worsens sublux pathomechanics
at what ROM is ensured scapular gliding and approximation of humeral head into glenoid fossa especially important
flex and ABD >90deg
what ROM is contraindicated in a hemiplegic UE
overhead pulleys for self ROM
- can’t confirm scap is moving w arm
best positioning practice for hemiplegic UE while supine in bed and why
ext elbow and elevate hand, forearm supinated
pts at risk for flexion contractures & inc IR tone
how, what, and to who should education be provided on positioning for hemiplegic UE
signage
use of supports: pillows, arm troughs, trays
healthcare providers, pt, fam
what type of stroke might a wc tray be esp good in and why
R side
impulsive, poor safety awareness, reminder not to get up
what are pros to the use of a traditional sling
protect from overstretching supraspinatus and joint capsule
free up therapist hands
what are cons to the use of a traditional sling (5)
- don’t dec sublux
- don’t encourage functional use of limb
- encourage secondary adaptive shortening and contractures
- IR, ADD, elbow flex, finger flex - encourage learned nonuse and exacerbate neglect
- contribute to balance deficit
- COM shift ant, inc postural instability
what is the GivMohr sling
places pt affected extremity in anatomically correct position in standing
- support at hand/wrist and elbow to approximate shoulder joint
what are the pros of the GivMohr sling (3)
- prevent/dec loss of ROM and contractures - UE rests at side and not flex/IR
- prevent/dec pain
- prevent/dec hand edema
what is a con of the GivMohr sling
no improvement seen in shoulder subluxation when sling removed
- see benefits if sling is on
- can’t prevent if sling is off
who is NMES appropriate for
reducing subluxation & prevent further joint separation in acute and subacute stroke (<6mo)
what/who did NMES have no effect on
chronic stroke
arm function
shoulder pain
why is NMES ineffective in chronic stroke
ligamentous structures already overstretched, could provide temporary joint support during stim time
- but no carryover once stim is off
what does the evidence say about the use of NMES for strengthening in post-stroke
most effective if in conjunction w active practice of task
- no evidence that use alone will lead to return of ms function
what does evidence say about the use of taping or strapping of shoulders post-stroke
low levels of evidence
may delay pain onset
doesn’t reduce sublux or improve function
not great research available, mostly anecdotal
what are interventions included in task-oriented retraining (contemporary approach) - 3
CIMT
bimanual therapy
progressive resistance exercise
what is key in promoting neuromotor recovery
repetition!!!!!
what are tools of technology that can be used in promoting neuromotor recovery and how
EMG biofeedback
- facilitate movement
NMES
- while doing task for strengthening
robotic assist
VR
- w impaired UE
what does evidence say about PNF and neuromotor recovery
none to support use for return of function
- some support for improvement in ROM
who is appropriate for CIMT
min cog and sensory deficits
min 20deg active wrist ext
min 10deg active finger ext
what are characteristics of CIMT
- restraint
- repetitive task practice
- shaping - memory and motor learning for task
what is a modified version of CIMT and when is this used
dec duration of therapy
less time using mitt
more home-based therapy
why does bimanual therapy work
helps w crossover when intact brain is doing to mobilize to cross over to impaired side
what is the full name for bimanual therapy
hand-arm bimanual intensive training (HABIT)
who was bimanual therapy studied in
children w CP
what populations are and aren’t appropriate for bimanual therapy and why
appropriate - children
- children should practice functional tasks as most functional activities are bimanual
not - adults w stroke
- have already acquired bimanual skills so focus is on impaired UE
what are examples of augmented sensory input and feedback
WBing
joint compression
tapping
brushing
stroking
air sleeves
vibration
visual input
what is the key quality of interventions to getting motion back in impaired UE
practice functional, not passive tasks
what are examples of simultaneous bimanual activities
UBE
rolling pin
weighted wand
open jar
dial phone
typing
writing
why should simultaneous bimanual activities be promoted
activity and proprioception in less affected UE can help improve activation and control of affected limb
why do we bother doing any strength training if functional activities are more effective
prevent atrophy and secondary weakness
what does evidence say about strength training
inc strength
improve activity
doesn’t inc/worsen spasticity
how should strength training be implemented in a POC
as a complement to functional training
- don’t want to just do strength training w/o task oriented approach
what are examples of strength training interventions
grip strength - putty, foam, etc
theraband
hand-held wt cuff
medicine balls
UBE
pushing, pulling, grasp/release w progressively heavier objects
what is PT’s role with tone management
we can’t directly treat tone but we can prepare limb to tolerate ROM easier and be more functional
what is the primary management of tone
pharmacological
how can PT help to manage tone in a hypotonic limb (5)
positioning
protection
resting splints
WB-ing w good alignment
tapping
how can PT help to manage tone in a hypertonic limb (6)
positioning
- ER, ABD, ext elbow/fingers, neutral hand positioning
splinting (dynamic)
serial casting
prolonged stretch
deep pressure on tendons
- esp for pts w clonus
neutral warmth
