Painful Shoulder and Hemiplegia

Painful Shoulder Interventions

• To decrease pain, start with an indirect approach by focusing away from the pain.
• Progress to a direct approach to address the pain.
• Use pain-free areas to influence painful areas, and use combining movements along with total pattern of movements.

Indirect Approach

• Complete scapular mobilization to indirectly influence a painful glenohumeral (GH) joint.
• Perform exercises using active-assisted range of motion (AAROM) with the contralateral extremity.
  • Focus attention on the contralateral extremity and then progress to the painful extremity.

Direct Approach

• Move the painful shoulder as able, focusing on client control of the motion.
• Try closed-chain activities to simulate support.
  • Complete reaching with support from the contralateral upper extremity (UE) to ‘close the pain loop’ & allow the patient to feel in control of the painful UE.

Pain-Free Influence On Painful Areas

• Use resisted bridging to treat a painful shoulder.
• Apply resisted lower trunk rotation to treat a painful neck.
• Use irradiation from a neighboring body part.
  • Straight leg raise with abdominal ‘crunch’ uses strength of abs to ‘irradiate' into the painful quad mm post THA to promote lower extremity (LE) management during bed mobility.
  • Scapular retraction can additionally irradiate shoulder ER rotation to promote function.

Combining Movements

• Chops and lifts can close the sensory loop.
  • Can help to create/restore the feeling of having a sense of control
• Using bimanual tasks can decrease focus on the painful UE moving independently.

Total Pattern of Movements

• Utilize prone on elbows, modified plantigrade, quadruped, or rolling exercises.

Interventions

• Use manual contacts gently, away from the painful area.
• Provide rhythmical, calming verbal cues.
• Stretch with caution to avoid pain.
• Avoid pain when applying maximal resistance.

Training Modalities

• Use breathing and external cues to promote relaxation.
• Avoid training a painful agonist muscle, as it could lead to muscle imbalance.
• Train the antagonist first before targeting the agonist.
• If completing scapular depression/retraction increases anterior shoulder pain, attempt to train scapular elevation/protraction before retrying the once painful scapular depression/retraction.

Client Feedback

• Obtain consistent feedback from the patient on tolerance during a treatment session, as well as post-treatment session.
• Use severity and irritability scales as reference points.

Client Education

• Instruct patient on nighttime positioning needs to reduce pain.
• Introduce modalities to address pain and reduce irritation.
• The less a body part experiences pain, the less inflammation may occur.

Constraint-Induced Movement Therapy (CIMT)

• CIMT was originally meant to address learned non-use, particularly due to hemiplegia; hypothesized causes include early emphasis on adaptive strategies and frustration incurred due to hemiplegia negative reinforcement.
• Key principles: forced use of the impaired UE with a mitt on the unaffected limb, approximately 90% of waking hours.
• Massed practice (6-8 hours per day) of impaired UE through shaping.
• Implement small steps, increasing in difficulty that lead to the overall objective.

CIMT Protocols

• Modified protocols address barriers to participation.
  • Reduced mitt wear time ranges from 5-9 hours per day.
• Reduced practice time options include:
  • 3 hours per day for 20 days.
  • 2 hours per weekday for 3 weeks.
  • 30 minutes, 3 days/week for 10 weeks.
• Studies show 6 hours of training/restraint per week is most effective.

CIMT Requirements

• Minimal requirements in the original protocol.

Includes:

• 10° active wrist extension.
• 10° active thumb extension/abduction.
• 10°active extension of at least 2 additional digits.
• Adequate balance while wearing restraint.
• Ability to stand >2 minutes with or without UE support.
• MMSE score must be >24.

CIMT Applications

• Shown to create changes in the cortical representation of affected UE.
• Both CIMT and modified CIMT (mCIMT) reduce UE impairments and increase motor skill.
  • This may not necessarily translate to functional performance.
• More recently, shown to also be effective for those with MS & Parinkinson's Disease (PD).

Cognitive Strategies

• Can be effective when used in combination with Task-Oriented Training (TOT).
• Beneficial for self-directed practice or those with extremely limited motor control.
• Include mental practice, mirror therapy, or action observation

Mental Practice (Motor Imagery)

• Mental practice improves motor imagery due to patient mentally rehearsing a physical action without physical movement.
• Evidence shows this activates similar brain regions as actual movement occurs.
• It can act as a neuro-primer.
• Can provide taped scripts for patients to listen to.
• Evidence supports its use in stroke.
• Includes:
  • A four-week rhythmic, cued mental practice, and improves walking distance, speed, and cognitive fatigue in Multiple Sclerosis (MS).
  • A 12-week mental practice/physical practice (MP/PP) program in those with PD and showed faster motor sequence performance and improved cognitive test performance.

Mirror Therapy

• Mirror placed in mid-sagittal plane with affected limb placed behind mirror and the reflection from the unimpaired limb.
• Patient asked to perform simple movements/functional tasks while concentrating on the image in mirror.
• The affected limb should rest or attempt to mimic movements of the unaffected limb.

Action Observation

• The patient observes a health person performing a task (in person or on video).
• The patient attempts to then recreate task.
• May be set by # of attempts or length of time.
• The use of shaping in creating tasks for patients may activate mirror neuron network and reorganizes neural pathways.

Technology

• Works best for those with cognitive strategies as an add-on to task-oriented training.
• Includes virtual reality and robotics.

Virtual Reality

• Computer-based, interactive, simulated environment to practice functional tasks.
• Virtual Reality advantages include:
  • Enriched environment leads to increased motivation, increases the number of practice repetitions and training adherence, offers unsupervised practice, and presents trialing tasks that might be unsafe in the real world.

VR Immersion

• Various degrees of immersion
• High: user represented in visual environment.
• Low: single-screen projection.

Robotics

• Machines that support the movement of the shoulder, the elbow and or help to move the hand.
• Provide passive, resisted or assisted movement at 1+ joints.
• Often linked to VR training.

Biofeedback

• Electromyogram biofeedback amplifies and converts electromyogram signals into simplified format that the patient can understand, (visual or auditory signals).
• Helpful in training patients to recruit desired muscles.

NMES

• Neuromuscular electrical stimulation or electrostimulation
• Provides electrical stimulation to elicit muscle contraction; beneficial while doing task training.

Orthotics

• Consider use of external support devices to increase functionality of limb during TOT.
  • SaeboFlex, SaeboReach, Saebo Glove.
• Mobile Arm Support: Beneficial when working with proximal muscle weakness of the arm.

Strengthening & ROM

• Evidence suggests safe to engage hemiparetic limb in strengthening without risk of increasing tone.
  • Focus efforts on weak muscles.
• Utilize PROM to maintain joint ROM and prevent contractures.
• Do not forget to incorporate trunk as proximal stability affords distal mobility.
  • Consider modifying environment or checking position of arm/scapula.
• Place and hold can be used as a starting point for significant weakness.
• Use AAROM to facilitate limb engagement during TOT, allow patient to complete movement before providing assistance.
• Consider in which plane the patient is moving their limb.
• Cue the patient to watch movements of hemiparetic limb.

Weight-Bearing Positions

• Provides proprioceptive input.
• Induces co-contraction of musculature surrounding a joint.
• Can be done in multiple positions.

Includes:

• Lateral leaning in seated.
• Bilateral pushing into arms in standing.
• Quadruped.
• Bridging.
• Standing.

Bilateral Arm Training

• Patient performs simultaneous arm movement; the unaffected limb use positively affects recovery of affected limb via hemispheric coupling through communication in corpus callosum.
• Use of bilateral upper extremity (BUE) in a functional task is more attainable for patient (than exclusive use of the hemiparetic limb).
• Arms can be completed in identical movement, opposite movement, or as a manipulator/stabilizer.
• Incorporate hemiparetic limb first as a stabilizer.
• Eventually can progress to unilateral limb usage.

Edema Due to Hemiparesis

• Retrograde massage utilizes lubricant, moves fluid distal to proximal with light pressure (not deep tissue massage).
• Positioning and active movement of the limb, especially tasks to activate the lumbricals, works well.
• Can be combatted via compression.

Contraindications

• Not utilized in retrograde massage in the following cases:
• DVT.
• Lymphedema.
• Heart conditions.

Positioning Considerations

• If hemiparetic side is unsupported then risk of subluxation begins.
• The patient may be unaware of their limb.
• Use of pulleys to increase shoulder range of motion in cases of hemiplegia is not indicated.
• Caregiver training to minimize risks of complications to the upper extremity is needed.
• Early positioning is needed to minimize later risks.
• Risks include pain, subluxation or contractures.