Upper Extremity Physiotherapy for Post-CVA Pain Management

1. Upper extremity Physiotherapy Approaches to minimize pain and maximize function in persons post CVA

2. Acknowledgements • Canadian Stroke Strategy: Best Practice Recommendations and Performance Measures • Evidence-Based Review of Stroke Rehabilitation • Stroke Canada Optimization of Rehabilitation through Evidence (SCORE)

3. Upper limb post CVA • Flaccid • No muscle reaction to passive movement and no voluntary movement and no reflexive reaction • High tone • Velocity dependant increase in resistance to passive stretch accompanied by hyperactive stretch reflexes

4. Causes of Shoulder Pain • Muscle Imbalance • Fracture • Tendonitis • Glenohumeral Subluxation • Bursitis • Adhesive Capsulitis • Neuropathic (RSD)

5. Muscle Imbalance • Disorganized muscle activation • Flexor tone predominates in the hemiplegic upper extremity and results in scapular retraction and depression as well as internal rotation and adduction of the shoulder • Current research suggests relation between spasticity and shoulder pain • Also relation between CVA, frozen shoulder and pain

6. Shoulder subluxation • Occurs in a large percentage of persons post stroke with flaccid upper extremity (29-82%) • Possibly a reason for development of pain but inconclusive

7. Injury • Rotator cuff injury is a possibility however no studies showing conclusive evidence of a tear causing pain • Also tears found may not be premorbid • Questionable cause of pain

8. Shoulder pain post CVA:Management • Prevention is the NUMBER 1 action for health care providers • There is no one specific treatment for the reduction and elimination of shoulder pain post stroke currently

9. Pain Prevention • Positioning

12. Pain prevention • Passive range of motion • Recommended to avoid shoulder ranging past 90 degrees of flexion and abduction. • Emphasis on external rotation as tolerated • Slings and straps • Perhaps some benefit to prevent shoulder subluxation however little evidence for pain reduction or prevention

13. Slings

14. Slings • http://shop.ebay.ca/items/_W0QQ_nkwZarmQ20slingsQQ_armrsZ1QQ_dmdZ2QQ_fromZ • http://www.lifesolutionsplus.com/harris-hemi-arm-sling-p-301.html • http://www.sammonspreston.ca/app.aspx?cmd=get_product&id=76118 • http://www.sammonspreston.ca/app.aspx?cmd=get_product&id=97428

15. Pain treatment • Active treatment • Overhead pulleys shown to create pain • Moderate evidence showing gentle exercises are preferred approach • Limited evidence that nonsteroidal anti-inflamatory medication improves pain, ROM and function • Sustained stretch may be as equally harmful as immobile position • decreasing range and increasing pain

16. Pain Treatment • Modalities • Functional electrical stimulation • Conflicting evidence http://www.google.ca/search?hl=en&q=functional+electrical+stimulation+shoulder+pictures&meta=

17. Conclusions of shoulder pain • Protection • Position properly • Use devices consistently • Patient and family education • Passive ranging • Light movement no further than 90 degrees of shoulder flexion and abduction • Emphasis on maintaining external rotation and abduction

18. CIMT • CIMT-Constraint induced movement therapy • Introduced by Edward Taub in the 1960s after working with deafferented monkeys • Phrasing learned non-use • Monkeys unaffected arms were restrained in slings and affected arms regained movement

19. Video • http://www.youtube.com/watch?v=MMTh2hWvB2g

20. EXCITE Trial • 222 participants, 3-9 month period • Multi-site, single blinded randomized • Inclusion: • 20 degrees wrist extension, 10 degrees MCP and IP extension (high function) • 10 degrees wrist extension, 10 degrees thumb abduction, and 10 degrees extension of at least 2 digits (low function)

21. EXCITE Trial • Glove on for 90% of waking hours to less-impaired arm • Task practice in lab 6 hours per day, for 2 work weeks (10 days) • Conclusion: • Improved function shown to be retained 24 months after 2 week program in SIS strength, ADLs, and social participation

22. Modified CIMT: Page et al. 2008 • Stroke was 12 + months prior • 20 degrees wrist, 10 degrees MCP and IP extension • Restraint for 5 hours per day, with 30 minute one-on-one sessions 3 times per week for 10 weeks

23. Modified CIMT: Page et al. 2008 • Conclusion: • Improvement in function and quality of arm movement • May be more practical program than previous studies

24. More local input • Ploughman et al. 2008 • Case study from the Miller Rehabilitation Centre in Newfoundland • Same parameters as EXCITE trial • Demonstrated remarkable increase in function for a hockey loving adolescent male

25. Feasibility in NB hospital • Inpatient rehab • Glove is cheap and easy to create • Could be used on appropriate patients with consent • Dressing, feeding, toileting would all take more time • therefore need health care team, patient and family buy in

26. Feasibility in NB • Outpatient CIMT • Labour intensive but there is suggested long term effect • Modified CIMT may be beneficial • Possibility for group therapy sessions • Possible treatment at chronic stage

27. Questions?