HEMIPLEGIC SHOULDER

1. HEMIPLEGIC SHOULDER Lisa Taipalus Physiotherapist 1

2. 2 OUTLINE Function Anatomy Biomechanics Effects of Stroke Risk for Injury Management

3. 3 KEY ASPECTS OF THE SHOULDER Function affects transfers, balance, ADLs and hand function Large range of motion which contributes to speed, power, coordination and fine motor control Sacrifice for this increased range of motion is decreased stability

4. Anatomy Key components: Glenohumeral (GH) joint: joint between the rounded humeral head and shallow saucer like surface of the glenoid fossa 4

5. Scapulothoracic joint: scapula rotates against the ribcage and contributes to normal movement of the GH joint 5 Reproduced from: Orthopedic Physical Assessment by David J Magee

6. Capsule: tissue that envelops the head of humerus like a sleeve and reinforces the GH joint Ligaments: support and reinforce the glenohumeral joint. 6

7. Bursa: fluid filled sac that sits between ligaments and muscles to prevent friction during movement 7

8. Rotator cuff muscles: are attached to and act on the head of the humerus 8

9. 9 BIOMECHANICS OF SHOULDER Primary movement occurs at the glenohumeral joint The scapula also contributes to movement of the arm. It helps to complete full shoulder range of motion

10. 10 Rotator cuff muscles guide the humeral head through rolls and glides to allow normal movement of the shoulder through all of its range of motion

11. STABILITY OF GLENOHUMERAL JOINT Depends on normal muscle tone and length of rotator cuff muscles and flexibility of the capsule Rotator cuff muscles provide dynamic stability and the capsule provides static stability 11

12. ALIGNMENT OF HUMERAL HEAD Correct angulation of the glenoid fossa Normal activity of scapular, rotator cuff , trunk mm to maintain alignment of the scapula and humerus 12

13. 13 Proper Shoulder Movement is Dependent on: Integrity of the muscles, ligaments and capsule Proper alignment of bones, joints and muscles Stability of the joints Correct biomechanics

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15. 15 How is the Arm Affected in Stroke? Changes in muscle tone Weakness Change in posture Loss of sensation Loss of awareness

16. 16 CHANGES IN MUSCLE TONE Tone is the resting state of the muscle A decrease in tone leads to a flaccid or floppy state An increase in tone leads to a spastic or excited state

17. 17 LOW TONE The arm will feel heavy and has little or no muscle activity Affects the trunk muscles and alters the position of the scapula, resulting in downward rotation of the glenoid fossa (change in alignment)

18. Low Tone Head of the humerus then also moves downward due to weight of arm (change in biomechanics) 18

19. 19 SPASTICITY Over time the tone can begin to change and increase Mild spasticity will present with mild resistance to movement

20. 20 Spasticity Severe spasticity will present with difficulty to move the joint through its range The spasticity leads to progressive tightening of muscles of scapula and humerus

21. 21 Spasticity Affects humeral head position and prevents normal movement (alignment and biomechanics affected)

22. The space between the acromial arch and humeral head is reduced with the tightened muscles. Muscles and ligaments attached to the humeral head as well as the bursa, can become pinched, irritated and inflamed with forced movement 22

23. Spasticity can also create abnormal arm postures Reproduced from: Neurological Rehabilitation edited by Darcy Ann Umphred 23

24. 24 Potential for Injury Due to Tone A low tone arm is susceptible to injury with the weight of the arm stretching tissues In a spastic arm, injury and pain can occur with muscle contractures, impingement of tissues

25. WEAKNESS Shoulder and scapular muscles can be weakened to varying degrees, with no active muscle activity present, to almost full movement Weakened muscles are not able to provide normal mobility or stability 25

26. Muscles Provide Stability and Proper Alignment 26

27. CHANGE IN POSTURE Trunk muscles can also be weakened affecting posture. 27

28. Change in Posture Change in trunk alignment affects the position of the scapula and glenoid fossa (change in alignment and biomechanics) 28 Reproduced from: A Motor Relearning Programme for Stroke, Janet H Carr and Roberta B Shepherd

29. 29 Weakness Lack of muscle activity or muscle pump can lead to edema in the arm or hand This edema contributes to stiffness of the joints and pain with movement

30. 30 Potential for Injury with Weakness Lack of stability and loss of protection of the joint Change in alignment in shoulder girdle affecting movement patterns can cause tissues to be pinched Weight of the arm can lead to tissues being stretched, torn, inflamed

31. 31 Once these tissues are stretched they do not recover and remain in a lengthened state Torn or inflamed tissues are painful and can lead to chronic conditions

32. 32 LOSS OF SENSATION There can be a loss of the ability to feel touch, pressure, temperature or position sense of the arm and hand Potential for injury as they cannot feel what is happening to the arm to protect it

33. 33 LOSS OF AWARENESS This is called inattention or neglect whereby the person is not aware of the affected side of the body or environment on that side of the body They may not see things placed on their affected side, know that their arm is hanging off the side of chair

34. 34 Loss of Awareness

35. 35 Potential for Injury with Loss of Sensation and Awareness

36. 36 These changes can lead to Subluxation Muscle injury Pain

37. 37 SUBLUXATION Subluxation is the dropping of the head of the humerus down the glenoid fossa If you feel your own shoulder, go over the top of the shoulder and down, press in, you can feel the head of your humerus there and there is no gap

38. 38 Subluxation In a subluxed shoulder you can feel a shelf that could be as much as 2 finger widths

39. 39  Photo provided by Lori Blue and Tuula Jodoin Occupational Therapists at Sault Ste Marie Hospital

40. 40 Reproduced from A Motor Relearning Programme for Stroke:Janet H Carr and Roberta B Shepherd

41. 41 Contributing Factors toSubluxation Change in posture affecting alignment Change in muscle tone reducing stability Muscle weakness and weight of arm stretching soft tissues

42. 42 SHOULDER PAIN Shoulder pain is a significant issue in hemiplegia It can start as early as 2 weeks post stroke to 2-3 months later

43. 43 PAIN Can occur with Subluxation Contractures Injury to soft tissue – rotator cuff muscles, ligaments, capsule

44. 44 Shoulder Pain Arises With or without subluxation where the weight of the arm compromises the soft tissues by stretching them Contractures can lead to stiff joints that are painful to move

45. 45 Injury to soft tissue with: weight of the arm pulling down poor handling and pulling on the arm poor positioning of the arm pinching of tissue with poor exercise technique

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47. 47 OUR RESPONSIBILITY As primary caregivers we can: Prevent tissue damage Prevent pain Maintain good joint alignment and muscle length

48. 48 PREVENTION IS KEY Stretched capsular tissue, ligaments and muscles are not correctable conditions. These tissues remain in a lengthened state Subluxation is not correctable. Pain is difficult to treat and leads to further loss of movement and potential functional recovery

49. 49 TECHNIQUES Good handling Good positioning Use of appropriate aids and equipment

50. 50 GOOD HANDLING TECHNIQUES Prepare the person for transitional movements or handling of the arm Tell them what you are going to do to promote awareness of the arm Involve them in protecting the arm to bring their attention to the arm and activity

51. 51 Good Handling Techniques Support the arm at both the upper arm and wrist. Never lift the arm by the hand, it does not take any weight off of the shoulder joint and will cause stretching of soft tissues

52. 52 Good Handling Techniques The arms are not handles Never lift through the axilla or pull on the arm. You are asking an unprotected joint to support body weight which will cause injury

53. 53 Good Handling Techniques During bathing and dressing support the arm and move the joints gently. The body will respond to how you handle it. Quick movements will increase tone and can cause pain. Keeping movements slow and gentle can reduce tone and stimulate activity.

54. 54 Good Handling Techniques Range of motion exercises should not be done unless you have been instructed by a therapist on proper technique. Due to the changes in biomechanics and alignment you can do more harm than good.

55. AIDS AND EQUIPMENTUse a sling when transferring or standing a person, to support the weight of the arm  55

56. Apply the sling correctly 56

57. 57 POSITIONING Proper seating assists with achieving good trunk alignment and position of the shoulder and arm This helps maintain muscle length, limit changes in tone and reduce contractures in the shoulder and arm

58. When the person is sitting, support the arm on a lap tray, arm trough, pillow or table Ensure that the arm is supported and that the supporting surface is not too high or too low 58

59. Elevate the hand to reduce edemaThis can be achieved in supine or sitting  59

60. 60 CARE OF THE HAND Good hygiene for the hand is important. Often the fisted hand perspires, the skin peels and there is an odour due to the lack of exposure to air. Fingernails can cut into the skin.

61. Care of the Hand Gentle opening of the hand and fingers to clean the hand and between fingers for good skin care and it provides essential sensory input to the hand. The client themselves can cleanse the hand if pain is an issue. 61

62. 62 Care of the Hand Do not put objects in the client’s hand unless directed by a therapist. Often this can increase the tone in the hand and arm leading to further problems with hygiene, contractures and pain. Please consult a therapist if you have concerns.

63. 63 PREVENTION IS KEY Stretched capsular tissue, ligaments and muscles are not correctable conditions. These tissues remain in a lengthened state Subluxation is not correctable. Pain is difficult to treat and leads to further loss of movement and potential functional recovery

64. The shoulder girdle is a complex system but being aware of potential complications and utilizing good positioning and careful handling techniques, can minimize problems too often seen with the hemiplegic shoulder. 64

65. 65 Thank you ! ???Questions???

66. 66 References Physical Therapy of the Shoulder. Ed. Robert Donatelli, Churchill Livingstone 1987. Soft Tissue Pain and Disability Edition 2. Rene Cailliet, F.A. Davis Co. Philadelphia, 1988. Teasell R. et al. Evidence Based Review of Stroke Rehabilitation 2004.