Hemip Hem iplegic legic Sh Shou oulder lder Power Point for - - PowerPoint PPT Presentation

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Power Point for staff education sessions Presented by Cathy McBay and Candace Coe HHS Stroke ke Annual al Review ew March h 7 and 7, 2018

Overv verview iew

• Structure of the Shoulder Complex
• Low Tone Upper Limb
• Hemi Arm protocol
• High Tone Upper Limb
• Hemiplegic Shoulder Pain

He Hemi mi Sli ling ng App pplicat lication ion

Str tructure ucture

GLENOHUMERAL JOINT

• Ball and socket joint.
• Stability sacrificed for mobility.

MUSCULAR CONTROL

• Rotator Cuff muscles
• Scapular and trunk muscles

Bio iomech mechanics: anics: Arm rm El Elevation evation

• 0-90 degrees
• Primarily arm (ie:humerus) movement
• Little movement in shoulder blade (scapula)
• Above 90 degrees
• To allow normal movement and prevent impingement of rotator cuff

tendons the shoulder blade MUST

• Rotate up
• Glide along rib cage

Low To Tone ne Sho houlder ulder

• Most common in initial stages following stroke.
• Results from damage to the motor pathways innervating

the upper limb muscles.

• Low tone shoulders are highly susceptible to damage of the

structures surrounding the shoulder (muscles, tendons, ligaments).

• Preventing subluxation is crucial in the early stages of

stroke recovery- critical role for all team members

Low To Tone ne Sho houlder ulder

• Pathoanatomy of Subluxed Shoulder
• Flaccid or low tone muscles at shoulder and trunk lead

to altered alignment of scapula and humerus.

• Stabilizing muscles not present
• Muscles overstretch due to weight of arm in dependent

position.

• Inferior subluxation is most common

Sho houlder ulder Sub ubluxat luxation ion

• Consequences of shoulder subluxation:
• Irreversible stretching of ligaments, tendons and capsule

leading to instability at the joint.

• Structural changes hamper recovery of muscle activity in

shoulder complex.

• Injury to brachial plexus.
• Chronic shoulder pain.

Sho houlder ulder Sub ubluxat luxation ion

Managemen nagement t of Low w Tone e Shoulder ulder

• Positioning
• Support low tone arm at all times:
• Use pillows, slings, lap trays
• Slings should be worn during transfers or ambulation
• nly. They should be removed during sitting or in bed.
• In sitting, position shoulder in slight flexion, abduction

and external rotation; forearm in pronation and hand in open weightbearing position.

• Pay attention to position of pelvis and trunk

alignment when sitting.

Sit itting ting In Wheel heelchair chair

Sit itting ting In n Bed ed

Ro Rolli lling ng to to He Hemi miplegic plegic Sid ide

Lyi ying ng On n He Hemi miplegic plegic Sid ide

Ro Rolli lling ng to to Un Unaffected affected Sid ide

Lyi ying ng on Unaf n Unaffect fected ed Sid ide

Managemen nagement t of th the Lo e Low w Tone ne Shoulder ulder

• Handling…Be Gentle!!
• Avoid lifting through underarm or pulling on arm to move patient.

Instead grasp upper trunk near scapula to move the person.

• Bed mobility: Hemi-arm out of way when rolling onto affected side.

No pulling on hemi-arm when rolling onto unaffected side.

• Support both the humerus and hand when moving the affected limb to

position or dress patient.

• Do not move arm beyond 90 degrees elevation.
• Dressing

sing Rule e for hemiplegia: “First on; last off”.

• NOTE: Shoulder pain occurs more frequently

in patients who are dependent for transfers.

Th The e He Hemi miplegic plegic Arm rm Pr Protocol

• tocol

Hemiplegic Shoulder Best Practice Positioning And Handling Protocol

Objective bjective

The hemiplegic upper extremity will be protected from injury by being properly handled during mobility and transfers and properly positioned in bed or wheelchair, according to the positioning protocol diagrams for all patients meeting the criteria for the protocol.

Incl nclusion usion Criteria riteria

• Hemiplegic arm is flaccid.
• And/or patient is unable to lift arm off bed to 90°.
• And/or the arm is painful.

Pr Procedure

• cedure
• OT/PT assesses patients for protocol inclusion

criteria

• All disciplines adhere to implementation of the

protocol

• Patients meeting criteria will receive:
• A hemi sling at bedside
• Hemi sling application directions posted at bedside

Hi High gh To Tone ne Up Upper per Lim imb

Frequently occurs later post stroke. Natural recovery may include high tone as a temporary phase or a permanent

• consequence. Good early management of possible severe

long term consequences is important. High muscle tone or spasticity:

• increased state of excitability of muscle stretch reflexes.
• Speed and position dependent.
• Stiffness, spasms

Hi High gh To Tone ne Up Upper per Lim imb

Consequences of high tone:

• Impaired skin care (axilla and hand)
• Impaired ADLs (dressing)
• Impaired range of motion: permanent contracture
• Shoulder pain

Hi High gh To Tone ne Up Upper per Lim imb

• “Flexor Pattern”

Managemen nagement t of th the Hi e High gh Tone e Upp pper er Limb mb

• Positioning
• Promote position that is opposite to flexor pattern
• Position for extended periods of time (up to 1 hour or

more) to promote lengthening of the tight muscles

• Use pillows, airsplints, thermoplastic splints or casting

as required

• Consider a referral to the Spasticity Management Clinic:

a team of a Physiatrist, RN, and OT/PT can facilitate pharmaceutical (BOTOX) treatment, splinting etc.

He Hemiplegic miplegic Sho houlder ulder Pa Pain in

• Incidence of Shoulder Pain
• Up to 1/3 of adult stroke patients within the first year
• Signs and Symptoms
• Pain located in shoulder, may radiate down arm.
• Pain worse with movement especially external rotation,

abduction and flexion of GH joint.

• Pain may be present constantly and interfere

with sleep.

Questions? uestions?