Hemiplegic shoulder Flashcards
mvmts of shoulder complex
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.
mvmt at S/C jt
mvmt at A/C jt
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.
mvmt at shoulder girdle
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.
mvmt at G/H jt
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
muscles for elevation
trapezius
levator scapulae
muscles for depression
trapezius
latissimus dorsi
muscles for protraction
pectoralis minor
serratus anterior
muscles for retraction
rhomboid major
rhomboid minor
Trapezius (middle fibres)
muscles for flexion
Pectoralis major (clavicular component)
Deltoid (anterior fibres)
Biceps brachii (long head)
Coracobrachialis
muscles for extension
Latissimus dorsi
Teres major
Pectoralis major (sternocostal fibres)
Deltoid (posterior fibres)
Triceps (long head)
muscles for abduction
supraspinatus
deltoid
muscles for adduction
coracobrachialis
pec major
lat dorsi
teres major
muscles for medial/ internal rotation
Subscapularis
Teres major
Latissimus dorsi
Pectoralis major
Deltoid (anterior fibres)
muscles for lateral/external rotation
teres minor
infraspinatus
deltoid
serratus anterior
rotator cuff muscles
Supraspinatus: Shoulder abduction
Infraspinatus: External rotation of the shoulder
Teres Minor: External rotation of the shoulder
Subscapularis: Internal rotation of the shoulder
RC function
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
scapulohumeral dynamics/ rhythm
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.
Causative factors
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
secondary impairments
immobility weakness abnormal tone adaptive soft tissue changes degenerative changes restricted joint ROM and stiffness
impact of shoulder disability
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
3 types of stroke dysfunction
- Hemiplegic shoulder pain (HSP) - 72%
- Subluxation - 34%
- Shoulder Hand Syndrome (SHS) - 57%
Hemiplegic shoulder pain
- common post stroke
- may present early/ late
- presence of abnormal tone+/- subluxation
- sharp pain at end of ROM
- night pain/ diffuse
- Hemiplegic shoulder pain - causes
Exam
Mgmt
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
- subluxation
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
subluxation
assessment
management
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
shoulder hand syndrome
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
shoulder hand syndrome - management
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
overall mgmt of hemi shoulder dysfunction
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
UL stroke posture
depressed and protracted shoulder
arm adducted and IR
elbow flexed and pronated
wrist and finger flexion - clenched fist with thumb in palm deformity
care of hemiplegis UL - positioning
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
TReatment approaches
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
mirror therapy
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.
strapping/ taping
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
shoulder supports
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
positioning when sitting out, adapted wheelchair arm rest
liaise with occupational therapist
provides support to hemiplegic forearm/ hand
FES/ NMES
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
Constrain induced movement therapy
- learned non-use theory
- forced-use principle of CIMT
stroke UL rehab and robotics
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.
Hemiplegic UL and recovery
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
