Stroke shoulder Flashcards
Initial flaccid stage; What are the structural factors that cause of an Inferior subluxation?
Can be caused by:
Improper positioning/lack of support in supine/sidelying and in sitting, pulling on the arm during transfers, improper ROM
- Hypotonic/flaccid supraspinatus and deltoid muscles
- Downward pull of gravity and weight of arm
- Overstretching of capsule
- Weak serratus anterior and upper trapezius result in depression and downward rotation of scapula
- need to make sure shoulder is in ER when doing ROM to prevent RTC rubbing against acromion
Do patients with shoulder subluxation have pain with it?
Patients with shoulder subluxation do not necessarily experience pain and not all cases of hemiplegic shoulder pain suffer from subluxation
- It is uncertain whether shoulder subluxation causes hemiplegic shoulder pain
What two muscles are most often spastic and implicated in hemiplegic shoulder pain?
- Subscapularis
2. pectoralis major
What often causes pain in the shoulder following stroke?
Combo of spasticity and frozen contracted shoulder
- stuck in scapular depression, retraction and downward rotation (usually)
- limits scapular/ GH movement
What are the two spastic positions fo the shoulder?
- Scapular depression, retraction, downward rotation
2. Shoulder internal rotation and adduction
What are the potential soft tissue lesions that result in hemiplegic shoulder pain
- Muscle* - RTC, m imbalance, subs cap spasticity, pec spasticity
- joint* - GH subluxation
- bursa - bursitis
- tendon - tendonitis/tear
- joint capsule* - frozen or contracted shoulder
- other - CRPS (1+ of the above sites)
When does hemiplegic shoulder pain usually onset?
usually 2-3 months post stroke
- can occur as early as 2 weeks
What is hempiplegic shoulder pain associated with?
- reduced motor function
- increased stroke severity
- poorer functional outcomes
What are the different management strategies of hemiplegic shoulder pain?
- Positioning - Prevent develop of spasticity and discourage inefficient patterns; UE towards abd, ER, and flexion; Evidence suggests it may not work
- Slings - Limited evidence that they influence clinical outcomes (don’t use this anymore)
- Strapping - Used to prevent or reduce severity of subluxation and provide sensory input; Bandage or tape; Evidence shows strapping doesn’t appear to improve UE function but may reduce pain
- Range of Motion - Gentler ROM is better than aggressive
Are slings good to use for hemiplegic shoulder pain?
NO
- Does NOT prevent subluxation
- Interferes with body image
- Immobilizes the arm (IR and add) and encourages nonuse of the extremity
- Reinforces flexor tone
- May lead to elbow contracture
- May affect balance
What are the shoulder ROM major concepts?
- Sidelying or seated position - seated = see scap movement, assist for balance
- Don’t range into painful area
- Always mobilize scapula first
- Keep the scapula protracted during PROM (then go into abd and fl)
- ER of humerus if above 90 degrees of abduction or flexion - always make sure scap is moving with motion
- Teach patient to do ROM or family how to assist
- Bilateral arm elevation - can do AAROM with strong side
- Exercises with ball in front of patient
- Positioning in sitting, supine, and sidelying
- ALL MUST BE DONE WITH THE CORRECT SCAPULOHUMERAL RHYTHM - no pulleys
What are additional treatments that can be used for treating hemiplegic shoulder pain?
- E-stim
- Surgical muscle resection
- Botox injections
- Steroid injections
- Massage therapy
- Nerve block
Diffuse onset of PNS and CNS changes; Continuous burning pain; Edema; Changes in skin color; Hypersensitive to touch (Can’t tolerate pressure on hand); Joint stiffness/decreased ROM; Passive flexion of wrist, MCP, and PIP joints is painful and limited
Complex Regional Pain syndrome
- Type I is more common and associated with hemiplegia
- Incidence is 12-48% following a stroke (about 1 in 4)
- recovery is generally spontaneous; if it doesn’t resolve in 6 months, it will be a chronic problem
What can you use for treatment of CRPS?
- Compression wrapping
- Gentle PROM
- Encourage active ROM if possible
- Oral corticosteroids
- Mirror therapy
What are ways to incorporate a non-functional UE into treatment?
- Weightbearing/ stabilizing - Encourages use of involved side, facilitates WB, improves awareness
- Guiding - Promotes normal sensory input and patterns of movement
- Bilateral movement - Incorporates involved side without assistance promotes symmetry, facilitates dynamic trunk control
