Transcript The Shoulder: Positioning and Handling Considerations Post

The Shoulder: Positioning and Handling
Considerations Post-Stroke
11 December 2008
Sonja Findlater
Occupational Therapist
[email protected]
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.
Fill in the Blanks
• HANDLING CONSIDERATIONS:
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1) ___________________________________________________
2) ___________________________________________________
3) ___________________________________________________
4) ___________________________________________________
• POSITIONING CONSIDERATIONS:
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1) ___________________________________________________
2) ___________________________________________________
3) ___________________________________________________
Background
Incidence of Shoulder Pain Post CVA
Effects: Increased LOS, Decreased Quality of Life,
Decreased Independence with ADL’s
Preventable?
It takes a village…
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.”
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(van Deusen in Zoltan, 2007)
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Handling Consideration: Tactile and proprioceptive information to the moreaffected limb contributes to body schema!
Key Concept
Alignment
• Falling
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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
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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
Key Concept
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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
APA’s prepare the body for the expected pertebation of a voluntary movement.
APA’s are FEEDFORWARD, not feedback
APA’s are learned
HANDLING CONSIDERATIONS: Encourage the person to HELP you move their
limb/let them KNOW that you are going to move their limb!!
A Little Anatomy...
Resting Position of
the Scapula:
Gillen, 2004 pg. 205
Levangie, 2005 Pg. 243
Scapular Motions
Elevation/Depression (Lippert)
Abd/Adduction (Lippert)
Up/Downward Rotation (Lippert)
Movements Not Pictured: Int/External Rotation & Ant/Posterior
Tipping
Scapulohumeral
Rhythm
ref: Neumann, 2002 pg 126 & 115
Ref: Neumann, 2002 pg. 109
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
Positioning
Bed
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Head/Neck = symmetrical
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Trunk = aligned
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Positioning Consideration: Scapular protraction & Supported
humerus
Affected UL = protracted scapula, supported UL, wrist & fingers
extended
Affected LL = flexed and supported.
Positioning
Wheelchair
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Head/Neck = symmetrical
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Trunk = aligned
Affected UL = protracted scapula, supported UL, wrist & fingers
extended
Affected LL = supported... FOOTRESTS!!!!
Eating
Shoulder Supports
Red Flag
Shoulder Supports
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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)
Annotated Bibliography Etc....
Neurology Texts
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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
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Evidence Based Review of Stroke Rehabilitation www.ebrsr.com
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APSS www.strokstrategy.ab.ca
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Stroke Engine www.medicine.mcgill.ca
Anticipatory Postural Adjustments
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APA’s 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)
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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
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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)
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Differential Activation in Symmetrical versus Asymmetrical Tasks. Similar Rectus Abdominis activation on affected and nonaffected sides during symmetrical activity, lower output of RA in asymmetrical activity (shoe donning) (Winzeler-Mercay,
2002)
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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)
References
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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.
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Gillen G, Burkhardt A. Stroke Rehabilitation, A Function Based Approach 2nd ed., St. Louis, 2004, Mosby.
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Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science 4th ed., 2000, McGraw-Hill.
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Latash, ML. Neurophysiological Basis of Movement. 2nd ed. Champagne, IL: Human Kinetics, 2008.
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Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis. Philadelphia, 2005, F.A. Davis
Company.
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Lippert L. Clinical Kinesiology for Physical Therapist Assistants, Philadelphia, 1994, F.A. Davis Company.
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Neumann DA. Kinesiology of the Musculoskeletal System, Foundations for Physical Rehabilitation. St. Louis, 2002,
Mosby.
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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. 2002:24(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.