Functional Training: UE Management in Hemiplegia

Hemiplegic UE Conditions

  • shoulder subluxation

  • hypertonia

  • hypotonia

  • spasticity

  • subacromial trauma

  • adhesive capsulitis

  • bursitis

  • shoulder-hand syndrome (CRPS)

  • contracture/adaptive shortening - shoulder in IR, Add, elbow flexion, wrist flexion

Hemiplegic UE Considerations

  • promote upright mobilization, movement, and motor control of involved side ASAP

  • prevent learned non-use

  • prevent shoulder pain

  • minimize shoulder complications

    • More passive

      • taping

      • slings

      • handling techniques

      • PROM

      • AAROM

    • More active

      • NMES, Biofeedback

      • UE supported therapies - aquatics, mobile arm support

      • brain computer interface , VR

      • bilateral or contralateral strengthening

      • forced use

      • constraint induced

Tests and Outcome Measures for UE

  • Box and Blocks Test

  • Nine Hole Peg Test

  • Pinch Grip

  • Fugl-Meyer for UE

  • Handedness Inventory

  • Stroke Impact Scale

  • AROM and PROM

UE Positioning in Bed

  • Non involved side on top

    • Spine straight, head on 2 pillows and scapula protracted

    • when moving, can pull scap forward to make sure not resting on GHJ

  • Involved side on top

    • Support more involved UE on pillow and 2 pillows under LE

    • make sure to look at the alignment of the spine in both cases

UE Positioning in a Wheelchair

  • Clear tray are better so they can see their whole body and involved parts

    • also good for preventing learned non-use

    • easier to cue visually for UE

Mental Practice - Imagery

  • rehearsing task or series of tasks mentally

  • activates musculature in the same pattern that correlates w/ imagined movements - measurable on EMG

  • activates cortical representation in the same pattern that correlates w/ imagined movements - measurable on fMRI

  • improves learning and performance

  • neuroplasticity happens and can use at any stage of recovery

  • supplement

NMES after CVA

  • Cyclic NMES: contracts muscles on a preset schedule, doesn’t require active participation

  • Electro Myograph Generated (EMG): Triggered; must actively move to reach established threshold to “trigger” NMES to activate

    • pt has to reach level of contraction for stim to activate

  • Functional Electrical Stimulation (FES): engage in functional activity; used during therapy for retraining; supplemental to treatment or combined with other interventions

UE Slings

  • originally thought to use to decrease subluxation, but they do not reduce subluxation

  • slings are likely not beneficial for shoulder hemiplegia following stroke

Splinting/ Orthoses

  • resting hand splint, botox, serial casting, air cast to assist w/ positioning (elbow ext)

Opening Hand: Principles to keep in mind

  • note postural alignment

  • utilize gravity to help UE relax

  • open the thumb first

  • spread the metacarpals, stay OUT of palm of hand

  • Do not overextend the fingers and wrist

  • place heel of hand on surface and slide hand out