The Shoulder: Positioning and Handling Considerations PostStroke

1
The Shoulder Positioning and Handling
Considerations Post-Stroke

• 11 December 2008
• Sonja Findlater
• Occupational Therapist
• sfindlater_at_dthr.ab.ca

2
Learning Goals

• Upon completion of the session, the participants
  will be able to
• Provide a rationale for encouraging the client to
  participate in moving the more-affected limb.
• Make some basic alignment adaptations to
  encourage use of the hemiparetic arm.
• Describe a common cause of hemiparetic shoulder
  pain.
• List some strategies to prevent/minimize shoulder
  pain.
• Position and support the hemiparetic arm.

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Fill in the Blanks

• HANDLING CONSIDERATIONS
• 1) _______________________________________________
  ____
• 2) _______________________________________________
  ____
• 3) _______________________________________________
  ____
• 4) _______________________________________________
  ____
• POSITIONING CONSIDERATIONS
• 1) _______________________________________________
  ____
• 2) ______________________________________________
  _____
• 3) ______________________________________________
  _____

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Background

• Incidence of Shoulder Pain Post CVA
• Effects Increased LOS, Decreased Quality of
  Life, Decreased Independence with ADLs
• Preventable?
• It takes a village

5
Key Concept Body Schema

• Through the integration of proprioceptive,
  tactile, and pressure input, the body scheme
  becomes the neural foundation for perception of
  body position and the relationship of the body
  and its parts.
• (van Deusen in Zoltan, 2007)
• Handling Consideration Tactile and
  proprioceptive information to the more-affected
  limb contributes to body schema!

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Key Concept Alignment

• Falling
• Neurologically, falling occurs when our COM
  (centre of mass) goes beyond our stability
  limits. Therefore, our system may feel that we
  are falling even if we are in bed, a chair etc.
• The vestibular system receives afferent
  information from the semicircular canals, the
  visual system, the cerebellum and spinal cord.
  Activation of this system results in antigravity
  muscle activity. (Latash, 2008)
• TASK what does vestibular activity look like??
• POSITIONING CONSIDERATION Position to prevent
  excessive vestibular activity
• Optimal Alignment
• The cerebellum notes change in alignment - this
  input updates our body schema. Potentiation of
  activity.
• HANDLING CONSIDERATION Align a limb so that it
  MAY be able to move

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Key Concept Postural Control

• Postural Control
• Proximal stability to enhance distal mobility
• Good and bad sides after a stroke - not so
  black and white! (Gillen, 2004) (Kandell, 2000)
• Anticipatory Postural Adjustments
• APAs prepare the body for the expected
  pertebation of a voluntary movement.
• APAs are FEEDFORWARD, not feedback
• APAs are learned
• HANDLING CONSIDERATIONS Encourage the person to
  HELP you move their limb/let them KNOW that you
  are going to move their limb!!

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A Little Anatomy...
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Resting Position of the Scapula
Gillen, 2004 pg. 205
10
Levangie, 2005 Pg. 243
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Scapular Motions
Elevation/Depression (Lippert)
Abd/Adduction (Lippert)
Up/Downward Rotation (Lippert)
Movements Not Pictured Int/External Rotation
Ant/Posterior Tipping
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Scapulohumeral Rhythm

• ref Neumann, 2002 pg 126 115

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Ref Neumann, 2002 pg. 109
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Shoulder Pain Prevention

• Maintain glenohumeral external rotation
• Maintain scapular mobility on the thorax
• Avoid passive or active shoulder movements beyond
  90 degrees unless the scapula is gliding toward
  upward rotation and sufficient external rotation
  is available.
• Educate!!!!
• Positioning - ax shoulder positions in bed,
  wheelchair and during upright function
• Avoid activities that may cause impingement such
  as pulleys.
• (Gillen, 2004 pg. 204)
• Handling Consideration As the humerus approaches
  90 degrees of flexion or abduction, it needs to
  externally rotate and the scapula needs to
  upwardly rotate

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Positioning

• Bed
• Head/Neck symmetrical
• Affected UL protracted scapula, supported UL,
  wrist fingers extended
• Trunk aligned
• Affected LL flexed and supported.
• Positioning Consideration Scapular protraction
  Supported humerus

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Positioning

• Wheelchair
• Head/Neck symmetrical
• Affected UL protracted scapula, supported UL,
  wrist fingers extended
• Trunk aligned
• Affected LL supported... FOOTRESTS!!!!
• Eating

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Shoulder Supports

• Red Flag
• Shoulder Supports
• Slings
• Trays
• ... if the goal of treatment is to provide
  glenohumeral joint stability, then the device
  must support the scapula on the ribcage with the
  glenoid fossa facing upward, forward, and outward
  and must compensate for a lack of support by the
  rotator cuff and possibly the superior capsule.
  (Gillen, 2004 pg. 209)

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• Annotated Bibliography Etc....
• Neurology Texts
• Latash, ML. Neurophysiological Basis of Movement.
  2nd ed. Champagne, IL Human Kinetics, 2008.
• Kandel ER, Schwartz JH, Jessell TM. Principles of
  Neural Science 4th ed., 2000, McGraw-Hill.
• Websites
• Evidence Based Review of Stroke Rehabilitation
  www.ebrsr.com
• APSS www.strokstrategy.ab.ca
• Stroke Engine www.medicine.mcgill.ca
• Anticipatory Postural Adjustments
• APAs were reduced in individuals with
  hemiparesis. The results suggest that the ability
  of individuals with hemiparesis to prepare for a
  self-initiated predictable perturbation is
  reduced and that they may use alternative
  strategies of stabilization. (Slijer, 2002)
• Reduced APA activity was found in the studied
  trunk muscles (lat dorsi, ext oblique, rectus
  abdominis) on the paretic side of the body.
  Erector Spinae were the least affected of the
  monitored muscles. (Dickstein, 2004)
• Trunk Muscle Activity Post Stroke
• Bilateral Trunk Rotation Weakness Post Stroke.
  In stroke subjects rotated just as well to each
  side, despite side of hemiparesis. HOWEVER, this
  muscle performance was decreased to both sides
  when compared to healthy subjects. The author
  hypothesized that this finding may be due to
  descending bilateral innervation of the trunk
  muscles. (Tanaka, 1997)
• Differential Activation in Symmetrical versus
  Asymmetrical Tasks. Similar Rectus Abdominis
  activation on affected and non-affected sides
  during symmetrical activity, lower output of RA
  in asymmetrical activity (shoe donning)
  (Winzeler-Mercay, 2002)
• Horak study hemiplegic subjects demonstrated
  same sequence of muscle activation as subjects
  without hemiplegia, although activity was
  delayed. Also, the hemiplegic subjects were
  unable to make rapid movements with the
  unimpaired arm (Gillen, 2004)

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References

• Dickstein R, Shefi S, Marcovitz E, Villa Y.
  Anticipatory postural adjustments in selected
  trunk muscles in poststroke hemiparetic patients.
  Archives of Physical Medicine and Rehabilitation
  85(2004) 261-267.
• Gillen G, Burkhardt A. Stroke Rehabilitation, A
  Function Based Approach 2nd ed., St. Louis, 2004,
  Mosby.
• Kandel ER, Schwartz JH, Jessell TM. Principles of
  Neural Science 4th ed., 2000, McGraw-Hill.
• Latash, ML. Neurophysiological Basis of Movement.
  2nd ed. Champagne, IL Human Kinetics, 2008.
• Levangie PK, Norkin CC. Joint Structure and
  Function A Comprehensive Analysis. Philadelphia,
  2005, F.A. Davis Company.
• Lippert L. Clinical Kinesiology for Physical
  Therapist Assistants, Philadelphia, 1994, F.A.
  Davis Company.
• Neumann DA. Kinesiology of the Musculoskeletal
  System, Foundations for Physical Rehabilitation.
  St. Louis, 2002, Mosby.
• Slijer H, Latash ML, Rao N, Aruin A. Task
  specific modulation of anticipatory postural
  adjustments in individuals with hemiparesis.
  Clinical Neurophysiology 113 (2002) 642-655.
• Tanaka S, Hachisuka K, Ogata H. Trunk rotary
  muscle performance in post-stroke hemiplegic
  patients, Am J Phys Med Rehabil 1997 76(5)
  366-369.
• Winzeler-Mercay U, Mudie H. The nature of the
  effects of stroke on trunk flexor and extensor
  muscles during work and at rest. Disability and
  Rehabilitation. 200224(17) 875-886.
• Zoltan B. Vision, Perception, and Cognition, A
  manual for the evaluation and treatment of the
  adult with acquired brain injury. 4th ed. New
  Jersey 2007, Slack Inc.