Neurologically Impaired UE Flashcards
1
Q
What needs to be considered regarding biomechanical alignment after a CVA?
A
- Following CVA there is usually a loss in the ability to posturally adjust and maintain postural alignment
- Interdependence of trunk and limb alignment decreases (as a result of the acromioclavicular joint)
- Scapular alignment is affected (distance between inferior and angle and vertebral column should be greater than distance between medial border of scapula and vertebral column)
2
Q
What happens to posture if someone has an inferior subluxation?
A
Trunk: lateral flexion to weak side
Scapula Alignment: downwardly rotated
Humeral Alignment: relative abduction and internal rotation; humeral head below inferior lip of fossa
Distal Extremity Alignment: elbow extension and pronation
Movement Available: scapula elevation and internal rotation
3
Q
What happens to posture if someone has an anterior subluxation?
A
Trunk: increased extension, lateral flaring, or rotation of ribcage
Scapula Alignment: downwardly rotated and elevated, winging
Humeral Alignment: hyperextension and internal rotation; humeral head inferior and forward relative to fossa
Distal Extremity Alignment: elbow flexion and pronation or supination
Movement Available: shoulder elevation, humeral internal rotation and hyperextension and elbow flexion
4
Q
How do you measure and treat subluxation?
A
Measuring (finger measurement)
- Palpate subacromial space and superior aspect of humeral head
- Use index and middle finger
- Pt should be seated with UE unsupported
- Pt should be in neutral rotation
- Score by finger: 0, 1, 2
Taping
Slings - cannot be prescribed to reduce subluxation as they do not realign the scapula to the ribcage. Lap board or arm board is a better option.
5
Q
What are two causes of shoulder pain?
A
- Impingement: result of trauma, improper handling or poor sitting position. Most common during “mixed tone” phase of recovery
- Immobility: caused from not doing anything or from soft tissue tightness and loss of ROM. If scapula cannot move then the humerus is blocked from moving and the arm cannot rotate - results in swelling of supraspinatus
6
Q
How should the hemiplegic shoulder be protected?
A
- Never pull on hemiplegic arm
- Avoid repositioning in WC by placing arms under pts arms
- Avoid using slings
- Avoid arm troughs
- Don’t force painful ROM
- Don’t raise arm in flexion or abduction without external rotation of humerus
- Do not raise arm in flexion or abduction past 90 degrees if scapula is not gliding (raising above 90 degrees starts to engage scapula)
- Never use reciprocal overhead pulleys with patients who have had a stroke
7
Q
How can shoulder pain be prevented?
A
- Maintain/increase passive GH joint external rotation
- Maintain scapula mobility on thorax
- Avoid P/AROM beyond 90 degrees - unless scapula is gliding toward upward rotation and external rotation is available
- Educate pt, family, staff on safe movement/positioning during ADLs
- Educate pt on different types of pain
- Provide positioning to prevent UE from dangling
8
Q
When should proper handling of the hemiplegic shoulder be considered?
A
- Bed positioning
- WC positioning
- Arm on lap tray
- Transfers (keep flaccid arm protracted and internally rotated during transfers)
- Sit to stand
9
Q
How should therapist handle the scapula during scapular elevation?
A
- Cup hand and place over head of humerus. Apply pressure to medial pectoralis and humeral head with heel of hand.
- Place other hand along medial and inferior border of scapula and use heel of hand to cradle inferior border
- Bring elbows in towards side
- Apply pressure through heels of hand and bring entire shoulder girdle into elevation
- Bring to end range
*Can do side-lying on uninvolved side or in supine
10
Q
How should therapist handle scapula during scapular protraction?
A
- Stand in front of client
- Gently take arm and bring into forward flexion, no more than 90 degrees
- Support arm at elbow and tuck it along side to prevent internal rotation
- With other hand, find medial border and give pressure along medial border
- Glide scapula forward into protraction
- Hold for one or two seconds
11
Q
How should therapist handle upward rotation of the scapula?
A
- While the scapula is in protraction, slide one hand to elbow and hold onto epicondyles
- Slide other hand to client’s hand (as if to shake hands)
- Give slight amount of external rotation and gently bring arm up overhead
12
Q
What impairments should be considered when treating someone who has had a CVA?
A
Impaired postural control and spasticity
13
Q
Impaired Postural Control
A
- Proximal stability is compromised
- Research has demonstrated UE function originates from the trunk
- Activity analysis should be used to determine missing trunk control components
14
Q
What is spasticity?
A
- An exaggeration of the stretch reflex
- Motor disorder that is velocity dependent
Spasticity is normal in CVA recovery. Flaccidity is usually seen within the first 48 hours, followed by an increase in tendon reflexes and resistance to PROM. Most pronounced in the flexor muscles of UE and extensor muscles of LE
15
Q
What are three different types of spasticity?
A
- Clasp knife syndrome
- Clonus
- Cogwheel rigidity
16
Q
What is clasp knife syndrome?
A
- Severe rigidity
- Sustained stretch will relax muscle group and give way (similar to when you return a blade on a pocket knife)
17
Q
What is clonus?
A
- Uncontrolled oscillations in spastic muscle groups
- Repetitive contractions in the antagonistic muscles in response to rapid stretch
- Weight bearing is a way to actively stop clonus
18
Q
What is cogwheel rigidity?
A
- Jerky resistance
19
Q
What are common responses seen in stroke rehab?
A
- Hyperactive stretch reflexes
- Increased resistance to passive movement
- Posturing of extremities
- Excessive cocontraction - agonist and antagonist contract at the same time
- Stereotypical movement synergies
- Other presentations of spasticity exist. Ex: wrist flexion with finger extension
20
Q
What is the traditional way to evaluate spasticity?
A
- Move limb quickly and feel for resistance
- Grade using the Ashworth Scale (only use if someone presents with tone)
21
Q
How can spasticity be treated?
A
- Cannot be treated uniformly by surgical, physical, or pharmacological procedures
- One study found sustained stretch of 10 minutes can lead to decreased spasticity of the elbow, hand, and fingers
- Nerve blocks or Botox have to be given by neurologist or physician. Usually takes about two weeks to take effect
- Prevent pain syndromes
- Guide appropriate use of available motor control
- Maintain soft tissue length
- Avoid using excessive effort during movement such as substitution patterns that you do not want
- Encourage slow and controlled movements
- Teach specific functional synergies during tasks to fight the synergy that is present
- Avoid use of repetitive compensatory movement patterns
- Teach specific functional synergies during tasks
- Keep spastic muscles on stretch via positioning or orthotics to prevent contracture
- Teach the client or caretaker specific stretching techniques targeted at spastic muscles
- Use activities to enhance agonist/antagonist relationship
- Refer for pharmacologic or surgical interventions when appropriate (seen more with contractures and burns)
22
Q
How can spasticity be managed?
A
- ROM and positioning
- Alleviate tone for transient periods to increase pt comfort and function:
1) Prolonged stretch through serial casting and positioning
2) Electrical stimulation to antagonist muscle
3) EMG Biofeedback (requires shock to nerve)
4) Pool therapy/whirlpool in warm water
5) Use of splints - Increase awareness of exacerbating factors so pt can avoid or take advantage
- Neurorehabilitatitve techniques
23
Q
How can spasticity be increased?
A
- Short tissue shortening
- Increased stretch reflexes
- Secondary problems to include:
1) Deformity of limbs - elbow and digits
2) Impaired upright function - plantar flexion
3) Tissue maceration of palm
4) Pain syndromes - loss of jt kinematics
5) Inability to manage basic ADLs
6) Loss of reciprocal arm swing during gait
7) Fall risk
24
Q
How do you know if someone with tone needs an orthotic?
A
- Spasticity limits ADLs
- ROM limitations are present
- Potential for contractures
25
What are different types of orthotics for tone?
- Antispasticity splint
- Functional position splint
- Serial casting - only if spasticity overwhelms splint material. Worn until functional ROM returns
26
What are the pros and cons of a serial cast?
Pros:
- Provides constant prolonged stretch
- Provides intimate fit
- Can help to maintain biomechanical alignment
- Ensures compliance
Cons:
- May interfer with ADLs and mobility
- Does not allow access to a joint or extremity to monitor skin and provide other therapy
27
What are the pros and cons of a bivalve cast?
Pros:
- Allows access to jt and extremity to monitor skin
- Allows access to jt and extremity for other interventions
- Allows removal of cast for ADLs and mobility
- May be used as a night or resting splint
- Allows quick removal of cast in emergencies
Cons:
- Impossible for cast to fit exactly together again once it is cut
- Can be difficult to maintain a wearing schedule
- Provides an intermittent stretch
- Has potential to pinch or cause soft tissue trauma
28
What are the pros and cons of a drop out cast?
Pros:
- Gravity aids in stretching
- Allows enhanced active or passive movement in the desired direction while preventing further contracture
- Allows access to joint for mobilization, stretching, and soft tissue mobilization
- Allows active ROM in desired range that may strengthen weak muscles opposing contracture
- Allows active movement that may increase patient's perception of movement via kinesthetic responses/stimulation if neglect is present
Cons:
- If cast is not precisely made and cut, then there is potential for movement within the cast and subsequent skin breakdown and/or patient removal
29
What should be considered when someone has a brachial plexus injury?
- Positioning, PROM, and AROM
- It is not recommended that one sleep on affected side
- Avoid traction and compression
- Position pillow so that elbow is in 45 degrees of external rotation, 90 degrees of elbow flexion, and in forearm neutral
- No self ROM above the head
30
What is Shoulder-Hand Syndrome?
- Severe pain which progresses to stiffness in shoulder, pain throughout extremity, moderate swelling of wrist/hand, vasomotor changes, and atrophy
- If left untreated, it can lead to frozen shoulder and permanent deformity in the hand
- Due to damage to sympathetic nervous system
31
What are the different stages of Shoulder-Hand Syndrome?
Stage 1:
The pt complains of shoulder and hand pain, tenderness, and vasomotor changes (with symptoms of discolorization and temperature changes). Chances of reversal are high at this stage
Stage 2:
The pt has early dystrophic limb changes, muscle and skin atrophy, vasospasm, hyperhidrosis (increased sweating), and radiographic signs of osteoporosis. At this stage, shoulder-hand syndrome becomes increasingly difficult to treat
Stage 3:
Pts rarely have pain and vasomotor changes, but they do have soft tissue dystrophy, contracture (including frozen shoulder and clawed hand), and severe osteoporosis. At this stage, shoulder-hand syndrome is irreversible
32
How should UE function be preserved during transfers?
- Perform level transfers when possible
- Avoid positions of impingement - internal rotation, forward flexion, and abduction
- Avoid placing hand on flat surface when grip is possible
- Vary technique and arm that leads when walking
- Vary weight shifting
- Consider use of transfer-assist device (slide board)
33
How should UE function be preserved during exercise?
- Incorporate flexibility into exercise program
- Incorporate resistance training:
1) Start with one set of 8-10 exercises with 8-12 repetitions of the major muscle groups - 2 to 3 times per week
2) Pay particular attention to shoulder depressors (infraspinatus, subscapularis, pectoralis major, latissimus dorsi) and scapular stabilizers (trapezius and rhomboids)
3) Avoid internal rotation when exercised above level of shoulder
34
What is the role of weakness in function?
- Major role in UE dysfunction
| - There is debate about which type of muscle contractions are most effective (eccentric, concentric, or isometric)
35
How can ROM be graded?
Passive ROM > Active assistive ROM > Active ROM > Graded activities with overhead pulleys, deltoid slings, self ROM
36
How can endurance be improved?
- Increase number of repetitions
- Increase time out of bed
- Increase time in treatment
37
How can coordination and motor control be improved?
- Activities should use several muscle groups simultaneously
- Encourage both gross motor and fine motor coordination
- Facilitate UE movement patterns:
1) Hand to table
2) Hand to lap
3) Hand to mouth
4) Touch top of head
5) Reach knee/foot
6) Reach behind neck
