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Hemiplegic ShoulderPower Point for staff education sessions

Presented by Cathy McBay and Candace Coe

HHS Stroke Annual Review

March 7 and 7, 2018

Overview

• Structure of the Shoulder Complex

• Low Tone Upper Limb

• Hemi Arm protocol

• High Tone Upper Limb

• Hemiplegic Shoulder Pain

Hemi Sling Application

Structure

GLENOHUMERAL JOINT

• Ball and socket joint.

• Stability sacrificed for mobility.

MUSCULAR CONTROL

• Rotator Cuff muscles

• Scapular and trunk muscles

Biomechanics: Arm Elevation

• 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

o Rotate up

o Glide along rib cage

Low Tone Shoulder

• 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 Tone Shoulder

• 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

Shoulder Subluxation

• 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.

Shoulder Subluxation

Management of Low Tone Shoulder

• Positioning

• Support low tone arm at all times:

o Use pillows, slings, lap trays

o Slings should be worn during transfers or ambulation

only. They should be removed during sitting or in bed.

o In sitting, position shoulder in slight flexion, abduction

and external rotation; forearm in pronation and hand

in open weightbearing position.

o Pay attention to position of pelvis and trunk

alignment when sitting.

Sitting In Wheelchair

Sitting In Bed

Rolling to Hemiplegic Side

Lying On Hemiplegic Side

Rolling to Unaffected Side

Lying on Unaffected Side

Management of the Low Tone Shoulder• Handling…Be Gentle!!

o Avoid lifting through underarm or pulling on arm to move patient. Instead grasp upper trunk near scapula to move the person.

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

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

o Support both the humerus and hand when moving the affected limb to position or dress patient.

o Do not move arm beyond 90 degrees elevation.

o Dressing Rule for hemiplegia: “First on; last off”.

• NOTE: Shoulder pain occurs more frequently

in patients who are dependent for transfers.

The Hemiplegic Arm Protocol

Hemiplegic Shoulder Best Practice Positioning And

Handling Protocol

Objective

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.

Inclusion Criteria

• Hemiplegic arm is flaccid.

• And/or patient is unable to lift arm off bed to 90°.

• And/or the arm is painful.

Procedure

• 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

High Tone Upper Limb

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

High Tone Upper Limb

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

High Tone Upper Limb

• “Flexor Pattern”

Management of the High Tone

Upper Limb

• 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.

Hemiplegic Shoulder Pain

• 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?