Management of Secondary Impairments in Hemiplegic Arm

Secondary Adaptations

Loss of ROM due to

• secondary muscle length changes

• decreased joint ROM

Shoulder (GH) subluxation

Shoulder pain

Wrist and hand pain

Oedema

“Learned non-use”

• Adaptive motor behavior

Central post-stroke pain

Loss of ROM

Muscle length changes

• Adaptation to the muscles spindles 

Joint stiffness 

• Adaptation of the soft tissues structures across the joint 

Common areas affected within the upper limb 

• Shoulder ER

• Shoulder abduction 

• Elbow extension 

• Forearm supination 

• Wrist and finger extension

Joint end feel 

• Soft end feel 

• Boney end feel (contracture lost range) 

Prevention/ Management: Positioning

Used within clinical settings, positioning for 24h. Teach patient/carer good “flexibility” habits instead, that they can use for short durations

Prevention/ Management: Active ROM

Best way to maintain ROM is by the muscle actively moving through it’s available range

Prevention/ Management: Splinting

Stroke survivors must be receiving comprehensive and active therapy and/or have voluntary movement; then routine use of hand and wrist splints are not recommended. They are at risk of contracture, then serial casting

• Therefore prescribing splints must be done on a a case by case basis

Passive Ranging Potential Benefits

Increases lubrication of the joints, thereby nourishing the cartilage

Tendon gliding during movement will help to prevent adhesions

Active-assisted movements is obviously better

Important for patient to attend to the movement and attempt the movement, so that it is not a purely passive exercise

Passive Ranging: Points to Consider

Limited evidence that PROM exercises will maintain muscle length

Self-ranging exercises may have potential for self-harm

NEVER push into pain

Shoulder: optimal position of humeral head (scapulohumeral mvt)

What to work on for UL function retraining, decreased M/S and ROM 

Support 

Reach 

Grasp and release 

Sublaxation cause

Weakness of the rotator cuff muscles

Prevention/Management of Shoulder Subluxation

• Sling

• Table

  • ESTIM

ESTIM recommendations 

Early safter stroke (within 28h) 

For those patients with a score on the upper limb section of the Motor Assessment Scale (MAS) of less than 4 

Continue until the score on the upper limb section of the MAS equals 4

ESTIM Parameters for Sublux shoulder

• Less than 50 Hz (create tetanic contraction)

• Daily, beginning at 1hr/day, progressing to 6hrs/day

• Begin with on/off cycle gradually increase duration of on cycle and decreased duration of off on/off ratio of

• Timer 1:3 sec cycle. Until an 30:2 sec

  • Patient, carer or nursing education to monitor and re-set time

Evidence for ESTIM

Supports early use

Suggests effective up to 6 months after

Effective in augmenting task specific training/movement, and may inform some aspects of motor activity and function

Weak for preventing shoulder pain

Supportive Devices 

Applied with aim of maintaining normal joint alignment, soft tissue length and ‘de-weight= the arm 

Firm support is best: lap tray for sitting or sling for standing

Slings

Elbow flexion or extension slings

Harris sling, triangle sling, collar and cuff

Education and training- manual handling, positioning and don/doff- to patient, family, nursing staff

Sling Pros/Cons 

Benefits: Prevents subluxation 

Cons: Discourages use of muscle 

What to train for sublux shoulder 

Support

Reach 

Shoulder Pain Risk Factors

Pre-existing shoulder pain

Shoulder sublaxation (may cause pain)

Loss of GH ROM

Sensory changes

Severity of arm weakness or poor motor return

High tone or spasticity particularly of subscapularis and pectoralis major

Prevention of Shoulder Pain

Shoulder strapping may help

Estim on the shoulder

Avoid OH shoulder pulleys

Careful manual handling/ education of nursing staff and warsmen to avoid trauma

Promote active recovery/functional movement

Treatment of shoulder pain should include 

Promote active recovery / functional movement 

Realignment of the shoulder girdle 

Weight bearing through the upper limb 

Management of shoulder pain acute MSK pain 

Strapping and Estim or both 

Management of Shoulder Pain

Promote active movement

Strapping and ESTIM or both

Differential diagnosis- MSK skills

Immediate cessation the painful movement

Analgesia, shoulder injection and local pain-relieving techniques

Careful manual handling

Aims of Shoulder Strapping

Reduce shoulder pain

Facilitate appropriate GH and scapulothoracic alignment

Facilitate or inhibit muscle activity

Disadvantages of strapping 

May irritate the skin (Use fixomul) 

Needs to be applied by someone with experience or under supervision 

Needs to be applied regularly (try to only reapply once-twice a week to reduce skin irritation) 

What to do for UL Function Retraining for Shoulder Pain

Support

Reach

Wrist and hand pain

From immobility

Individual joints feel tight

Loss of ROM

Pain throughout range

Oedema

May have altered tone

Note the loss of creases, knuckles and skin colours

Prevention of Wrist and Hand Pain 

Active movement (all joints) 

Good flexibility habits 

Wrist and hand in contact with a surface 

Stimulating the wrist and hand with unaffected hand 

Management / Treatment of Hand and Wrist pain

Active movement (all joints)

ESTIM

Gentle range of movement

Mobilisation of each joint

Massage of soft tissues

Analgesia - timing of therapy

Wrist and Hand Oedema

Continuous oedema / pitting oedema

From immobility

Note the:

• Loss of creases, knuckles

• Changes to skin colours

Can have pain

Oedema Management 

Active movement 

Elevation 

Massage 

Bandaging 

Compression glove 

What to do for UL function retraining hand pain and oedema

Support

Manipulation

Grasp and reach

Learned non-use management 

active movement 

functional of movement 

education 

constraint induced movement therapy 

• check hospital policy 

What to do for UL function retraining for learn non-use

Support

Reach

Grasp and release

Manipulation

Overall treatments for immobility of the UL

Active, active assisted movement and passive movement with patient encouragement

Motor relearning

Bimanual practice or bilateral training

Constraint-induced movement therapy

Somatosensory re-training

Robotic and mechanically assisted therapies

Virtual reality- immersed and non immersed

Electrical stimulation

Strapping

Mirror box therapy

Central Post-Stroke Pain - Peripheral Changes 

Vasomotor tone pain, swelling, exquisite tenderness or hyperaesthesia, protective immobility, trophic skin changes

Central Post-Stroke Pian - Peripheral Changes

Disruption of sensory cortical processing, disinhibition of the motor cortex, disrupted body schema

What to do for UL function retraining for central post stroke pain

Reach

Grasp and release

Support

Manipulation