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2. OUTLINE. FunctionAnatomyBiomechanicsEffects of StrokeRisk for InjuryManagement. 3. KEY ASPECTS OF THE SHOULDER. Function affects transfers, balance, ADLs and hand functionLarge range of motion which contributes to speed, power, coordination and fine motor control Sacrifice for this increased range of motion is decreased stability.
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1. HEMIPLEGIC SHOULDER Lisa Taipalus
Physiotherapist
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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
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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.
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7. Bursa: fluid filled sac that sits between ligaments and muscles to prevent friction during movement
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8. Rotator cuff muscles: are attached to and act on the head of the humerus
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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
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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
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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
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26. Muscles Provide Stability and Proper Alignment 26
27. CHANGE IN POSTURE Trunk muscles can also be weakened affecting posture.
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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.
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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
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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.
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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.