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Neurology 1 > Hemiplegic shoulder > Flashcards

Hemiplegic shoulder Flashcards

1
Q

mvmts of shoulder complex

A

Gross movements:
Elevation - predomin. at shoulder girdle.
Depression - predomin. at shoulder girdle.
Protraction - predomin. at shoulder girdle.
Retraction - predomin. at shoulder girdle.
Flexion - predomin. at glenohumeral joint.
Extension - predomin. at glenohumeral joint.
Abduction - predomin. at glenohumeral joint.
Adduction - predomin. at glenohumeral joint.
Medial/Internal Rotation - predomin. at glenohumeral joint.
Lateral/External Rotation - predomin. at glenohumeral joint.
Circumduction – combination of shoulder girdle and glenohumeral

Other movements:
Gliding – all joints and articulations.
Rolling – all joints and articulations.

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2
Q

mvmt at S/C jt

mvmt at A/C jt

A

SC/ Joint
S/C Joint is limited motion in nearly every direction – superior, inferior, anterior and posterior.

S/C joint motion that is clavicular motion carries the scapula in a gliding motion on the outer surface of the chest.

S/C joint forms the centre from which all movements of the supporting arch of the shoulder originate, and is the only point of articulation of the shoulder girdle with the trunk.

AC Joint
The movements of the A/C Joint are of two forms:
A gliding motion of the articular end of the clavicle on the acromion.
Rotation of the scapula forward and backward upon the clavicle.

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3
Q

mvmt at shoulder girdle

A

Shoulder Girdle: S/C joint, A/C joint, Scapulothoracic Articulation (small contribution from G/H joint).

Elevation: moves the shoulders towards the ears in a cranial/superior/upward direction.

Depression: moves the shoulders towards the waist in a caudal/inferior/downward direction.

Protraction or scapular abduction: pulling forward of the scapulae or shoulder girdle.

Retraction or scapular adduction: pulling scapulae horizontally towards the vertebral column.

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4
Q

mvmt at G/H jt

A

Flexion (0 - 180º, firm end-feel, scapulothoracic involvement).
Extension (0 – 60º, firm end-feel, scapulothoracic involvement).
Abduction (0 - 180º, firm end-feel, scapulothoracic involvement).
Adduction
Medial Rotation (0 - 70º, firm end-feel).
Lateral Rotation (0 - 70º, firm end-feel).
Circumduction

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5
Q

muscles for elevation

A

trapezius

levator scapulae

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6
Q

muscles for depression

A

trapezius

latissimus dorsi

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7
Q

muscles for protraction

A

pectoralis minor

serratus anterior

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8
Q

muscles for retraction

A

rhomboid major
rhomboid minor
Trapezius (middle fibres)

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9
Q

muscles for flexion

A

Pectoralis major (clavicular component)

Deltoid (anterior fibres)

Biceps brachii (long head)

Coracobrachialis

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10
Q

muscles for extension

A

Latissimus dorsi

Teres major

Pectoralis major (sternocostal fibres)

Deltoid (posterior fibres)

Triceps (long head)

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11
Q

muscles for abduction

A

supraspinatus

deltoid

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12
Q

muscles for adduction

A

coracobrachialis
pec major
lat dorsi
teres major

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13
Q

muscles for medial/ internal rotation

A

Subscapularis

Teres major

Latissimus dorsi

Pectoralis major

Deltoid (anterior fibres)

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14
Q

muscles for lateral/external rotation

A

teres minor
infraspinatus
deltoid
serratus anterior

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15
Q

rotator cuff muscles

A

Supraspinatus: Shoulder abduction
Infraspinatus: External rotation of the shoulder
Teres Minor: External rotation of the shoulder
Subscapularis: Internal rotation of the shoulder

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16
Q

RC function

A

The combined action of the rotator cuff muscles is to stabilise the head of the humerus in the glenoid cavity.

Although the muscles perform a combined function certain muscles within the group have an increased role in maintaining stability integrity in particular directions.

Infraspinatus & Teres minor - Posterior stability
Subscapularis - Anterior stability

17
Q

scapulohumeral dynamics/ rhythm

A

The Scapulothoracic articulation contributes to both flexion and abduction of the humerus by upwardly rotating the glenoid fossa 60° from its resting position.

The G/H joint contributes 120º of flexion and anywhere from 90 -120º of abduction.
Ratio of G/H to scapulothoracic movement is 2:1
2 degrees of GH movement for every 1 degree of scapular movement.
Early phase of motion is mainly G/H joint motion.

18
Q

Causative factors

A 
Paralysis / Loss of movement post stroke
Muscle weakness
Muscle imbalance
Abnormal tone 
Sensory loss
Altered alignment / biomechanics
Perceptual deficits 
Dependent limb
Poor handling 
Trauma
Forced ROM
Immobility
Prolonged positioning
Secondary changes
Degeneration
19
Q

secondary impairments

A 
immobility 
weakness 
abnormal tone 
adaptive soft tissue changes 
degenerative changes 
restricted joint ROM and stiffness
20
Q

impact of shoulder disability

A

Function of the UL:
Co-ordinated movements, fine motor control, grasp & manipulation, ? weight bearing, communication / expression, self care, ADL.

Consequences of UL dysfunction
Pain (distraction)
Recovery & outcome of rehabilitation
Interferes with rehabilitation
Interferes with transfers
ADL and Independent function 
Depression 
Sleep disturbance
21
Q

3 types of stroke dysfunction

A
  1. Hemiplegic shoulder pain (HSP) - 72%
  2. Subluxation - 34%
  3. Shoulder Hand Syndrome (SHS) - 57%
22
Q

Hemiplegic shoulder pain

A
  • common post stroke
  • may present early/ late
  • presence of abnormal tone+/- subluxation
  • sharp pain at end of ROM
  • night pain/ diffuse
23
Q
  1. Hemiplegic shoulder pain - causes

Exam
Mgmt

A 
Loss of co-ordinated joint motion
Abnormal scapulo-humeral rhythm
Inadequate external rotation
Lack of downward glide
Muscle imbalance, abnormal tone
Forced passive ROM
Incorrect handling / trauma

Shoulder position
Depressed & retracted
Lower level
Medial rotation humerus

mgmt 
pain mgmt 
positioning Mobilise scapula
Normalise tone
Facilitate muscle activity
Proximal stability
External rotation
Shoulder supports
24
Q
  1. subluxation
A

Mechanism
Scapula depressed or retracted

Impaired locking mechanism
Orientation of scapula & glenoid fossa – up, forward, lateral
Slope of fossa - prevents downward subluxation
Reinforced by supraspinatus
‘Locking mechanism’

Subluxation

Causative factors
Paralysis rotator cuff
Mal-alignment
Abnormal tone
Loss of locking mechanism
Gravity 
Weight of limb
subluxation Presentation
\+ / - painful 
Classification of subluxation***
Inferior subluxation 
Superior subluxation
Anterior subluxation

Mal-alignment shoulder & displaced humeral head

Subjective ‘dragging’

Relieved by passive elevation

diagnosis - palpable dip

Patient in sitting
Palpate from the SC joint along the clavicle to the AC joint
Check for a gap between the lateral acromial border and the head of the humerus
A gap of 1-2 fingers indicates subluxation is present

25
Q

subluxation
assessment
management

A 
Shoulder level lower
Low tone
Scapula retracted
Inferior angle adducted
Winging of scapula
\+/- Tight pectorals
\+/- Medial rotation

Correct position of scapula
Facilitate muscle activity
Minimise trauma
Care in handling

26
Q

shoulder hand syndrome

A 
Stage 1
Tender swollen hand 
Diffuse aching pain
Sensitivity
Discoloration
Warm / moist
Loss of movement

Stage 2
Marked pain and swelling
Progressive loss of movement
Oedema loss of skin elasticity

after stroke Swollen left hand and forearm

Stage 3 
Resolution of pain and oedema
Decreased ROM
Bone demineralisation
Muscle atrophy
Soft tissue changes
Joint contracture
Deformity (flexion)
Examination
Postural 
Alignment 
Mobility 
Pain
Subluxation
Tone
Movement pattern
27
Q

shoulder hand syndrome - management

A 
Early - prevention
Long-term
Facilitate normal motor control
Normalise tone
Normalise alignment
Facilitate muscle activity
Sensory re-education
Correct handling and positioning
Staff - education 
Deal with perceptual deficits
Bilateral activity
Prevent secondary soft tissue changes
Facilitate functional restoration
28
Q

overall mgmt of hemi shoulder dysfunction

A 
Positioning
Handling 
Normalise tone
Education
Normalise alignment
Posture
Facilitate muscle activity
Prevent ST shortening
Joint mobilisation
Restore function
Strapping / taping
Supports / slings
FES/NMES
Medication
Constraint induced movement
Robotics
29
Q

UL stroke posture

A

depressed and protracted shoulder
arm adducted and IR
elbow flexed and pronated
wrist and finger flexion - clenched fist with thumb in palm deformity

30
Q

care of hemiplegis UL - positioning

A 
arm supported 
in supine lying 
sitting out 
hemipleic UL supported in all postures 
sit up straight 
stroke shoulder slightly forward
stroke elbow away from body 
stroke forearm slightly forward 
palm down and fingers straight
use pillows to support affected arm while seated

slings should only be used for transfers and walking
when in bed/ chair sling should be removed and arm positioned appropriately

31
Q

TReatment approaches

A

GRASP
graded repetitive arm supplementary program
improves arm function during impatient stroke rehab
has 3 exercise levels to accommodate different levels of stroke severity
ROM exercises
strenghtening
weight bearing exercises
functional tasks
fine motor skills

32
Q

mirror therapy

A

used to improve motor function after stroke. During mirror therapy, a mirror is placed in the patient’s midsaggital plane, reflecting movements pf the non-paretic side as if it were the affected side.

33
Q

strapping/ taping

A 
Factors to consider
Sensation
Tissue viability
Skill required in application
Aim
Reduce pain
Counteract traction imposed on joint by weight of limb + gravity 
Stabilisation / align
Provide proprioceptive feedback
Promote awareness
34
Q

shoulder supports

A

Factors to consider
Pattern of subluxation
Skill required in application
Presence of sensory loss / neglect

Aim of support
Reduce pain
Counteract traction imposed on joint by weight of limb + gravity 
Prevent stretch to capsule +ST
Stabilisation / align
Provide proprioceptive feedback
Promote awareness
35
Q

positioning when sitting out, adapted wheelchair arm rest

A

liaise with occupational therapist

provides support to hemiplegic forearm/ hand

36
Q

FES/ NMES

A

Factors to consider
Sensation
Tissue viability
Skill required in application

Aim 
Aim
Reduce pain
Counteract traction imposed on joint by weight of limb + gravity 
Assist with muscle activation.
Reduce atrophy.
Reduce risk of subluxation.
Provide proprioceptive feedback
Promote awareness
Increase ROM
37
Q

Constrain induced movement therapy

A
  • learned non-use theory

- forced-use principle of CIMT

38
Q

stroke UL rehab and robotics

A

The success of robotic devices in rehabilitation is heavily based upon the evidence that intensity of practice and the task and context specificity are the main drivers that make practice effective.

39
Q

Hemiplegic UL and recovery

A

Time course 3 - 6 months

No movement in first 4/52 - poorer prognosis (Heller et al., 1987).

Patients with shoulder subluxation poorer outcome (Arsenault et al., 1991).

Shoulder shrug/hand movements in first 11/7 good prognosis (Katrak et al., 1998

Neurology 1 (10 decks)

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