CVA IV: Upper Extremity in Hemiplegia

Question 1

An inability to fractionate appears to be from damage from what part of the brain?

Answer 1

primary cortex and it’s tracts.

Question 2

Is the percentage of recovery for the LE and UE different or proportional

Answer 2

proportional, but the UE appears to be slower because of the more complex tasks it does.

Question 3

What 3 things must you consider with loss of trunk control with UE dysfunction/pain?

Answer 3

1. Whether pt utilizes feedforward postural control.
2. How use of the UE within the environment affects trunk function.
3. Biomechanical considerations (alignment of trunk & scapula).

Question 4

What is the primary type of postural control that we use, feedback or feedforward (therefore affecting type of treatment that we use)?

Answer 4

feedforward

Question 5

What are 4 common problems of trunk alignment?

Answer 5

1. Posterior pelvic tilt
2. Kyphosis (goes along with #1)
3. Lateral flexion
4. Rotation of ribcage

Question 6

What 4 impairments could cause posterior pelvic tilt?

Answer 6

1. Weak trunk extensors
2. Weak abdominals
3. Loss of lumbar/thoracic spine ROM into extension.
4. Short hamstrings

Question 7

What 2 additional impairments (besides posterior pelvic tilt) could cause kyphosis?

Answer 7

1. Compression fractures of the spine

2. Scoliosis

Question 8

What 3 impairments could cause lateral flexion trunk alignment?

Answer 8

1. Overactivity (spasticity) on one side.
2. Paresis that allows spine to collapse toward one side.
3. Perceptual (midline) issues.

Question 9

What 2 impairments could cause rotation of the ribcage?

Answer 9

1. Paresis of the obliques

2. Overactivity of the obliques.

Question 10

Function between trunk and scapula is dependent on which muscles?

Answer 10

scapula stabilizers (traps, serratus ant. rhomboids, pec minor, levator scap)

Question 11

Function between the humerus and trunk dependent on which muscles?

Answer 11

prime movers (pec major, lats, delts, triceps, biceps)

Question 12

Function between scapula and humerus dependent on which muscles?

Answer 12

rotator cuff (you know these)

Question 13

What joint or joints connect the UE to the axial skeleton?

Answer 13

SC joint only.

Question 14

The spine of the scapula is normally at what level of the spine? The inferior angle?

Answer 14

T2-T3, T7

Question 15

The normal distance of the medial border of spine of the scapula to the spine? from the inferior angle?

Answer 15

3-4 fingerbreadths. 4-5 FBs.

Question 16

The glenoid fossa points in what direction at how many degrees normally?

Answer 16

forward and upwards 30-40 degrees.

Question 17

A scapula that has undergone inferior rotation may result in what 5 impairments?

Answer 17

1. Inferior subluxation?
2. Abnormal scapulohumeral rhythm.
3. Impingement and pain.
4. Possible Shoulder-Hand Syndrome (CRPS)
5. Decreased function of UE

Question 18

What are three possible causes of inferior rotation of the scapula?

Answer 18

1. Weakness of scapular stabilizers (serratus ant. and lower traps especially).
2. Muscular imbalance of scapular stabilizers (spasticity of rhomboids, levator scap, lats).
3. Trunk malalignment (leaning to side).
4. Weight of flaccid arm.

Question 19

What 3 conditions are needed to maintain static stability of the scapula to prevent shoulder subluxation?

Answer 19

1. Tight joint capsule
2. Supraspinatous activity
3. Upward/outward facing of glenoid fossa

Question 20

What is the most common type of subluxation and when does it occur?

Answer 20

inferior, in the flaccid stage

Question 21

What are 2 possible causes of inferior subluxation?

Answer 21

1. Upright position with unsupported flaccid arm.

2. Pulling on the arm.

Question 22

What type of subluxation is high tone? What type of subluxation is low tone?

Answer 22

High tone: Anterior, superior. Low tone: inferior

Question 23

What type of subluxation is correlated with pain? without pain (initially)?

Answer 23

pain: anterior, superior. no pain: inferior.

Question 24

How do you prevent anterior subluxation?

Answer 24

1. put a block on arm of affected side that prevents hyperextension when doing one-armed W/C propulsion.
2. put a pillow under humerus while in supine.

Question 25

What are 4 things that you need to do to reduce a subluxed shoulder (in general)?

Answer 25

1. Correct trunk alignment 2. Correct scapular alignment manually (with mobs) 3. Externally rotate humerus 4. Replace humeral in glenoid from its subluxed position.

Question 26

What are 4 arguments against using slings for pts with subluxation?

Answer 26

1. Arm is held in position of internal rotation and elbow flexion (contributing to contracture formation). 2. Encourage abnormal flexor synergies. 3. Inhibit arm swing in gait. 4. Decrease body image.

Question 27

What are some of the 9 conditions that shoulder pain in hemiplegics is associated with?

Answer 27

1. Lack of GH joint ext. rotation. 2. Subacromial trauma. 3. Shoulder-Hand Syndrome (CRPS). 4. Biomechanical malalignment? 5. Neglect?? (not clear) 6. Inappropriate treatment choice (overhead stuff). 7. Iatrogenic causes (stupid caregiver pulling arm). 8. Flaccidity?? (not clear) 9. Spasticity?? (not clear)

Question 28

What does the research say about FES in treating shoulder pts?

Answer 28

Significant improvement in a couple studies, but more studies show no significant improvements. Plus, experimental conditions were long (6 hrs/day, 6 days/wk for 6 wks.)

Question 29

What should you NOT do with pts with hemiplegic shoulder?

Answer 29

1. Pull on the arm 2. Let it go unsupported during transfers. 3. Teach self ROM to pt. 4. Use an overhead trapeze. 5. put weight directly on the point of the shoulder when lying on the involved side.

Question 30

What is the evidence of using steroid injections for hemiplegic shoulder pts?

Answer 30

Not much there to support its use.

Question 31

Evidence for use of slings in subluxation?

Answer 31

1. No evidence it can prevent or reduce subluxation. | 2. May help prevent pain and further injury. GiveMohr sling is better than traditional probably.

Question 32

What is an important consideration for treatment of hemiplegic shoulders (and in most neuro rehab in general)?

Answer 32

Make it FUNCTIONAL.

Question 33

All done.

Answer 33

Go study for research class or ortho quiz... ugh...