The post-stroke shoulder - Schoudernetwerk · PDF fileThe post-stroke shoulder ... Trunk control test Item 3 < 25 No balance in sitting position 30s Lying JSU-diagram for rehabilitaton

The post-stroke shoulderLiesbet De Baets

What is a stroke?

Acute verstoring bloedcirculatie in de hersenen

met neurologische uitvalverschijnselen

- Ischemisch (80%) of hemorragisch (20%)

- Meest voorkomende ernstige neurologische aandoening

- 1/3de zeer ernstige beperkingen

- Restverschijnselen:

Motorische stoornissen (verlamming, spasme, …)

Sensorische stoornissen

Pijn

Affectieve stoornissen

Cognitieve stoornissen

Fatische stoornissen

Diplopie / Hemi-anopsie

…

Patients’ priorities for rehabilitation immediately after stroke are on

regaining gait self-care in general

Patients’ priorities for rehabilitation ~ 3 mths after stroke are on

Regaining arm function

88% of the variance in hand function post-stroke is explained

by changes in active range of shoulder motion

Beebe and Lang, 2008

Regain upper extremity FUNCTION

Prevent shoulder PAIN

UE related treatment goals after stroke

Initial after stroke:

often flaccid paralysis

importance of correct handling/positioning

Spontaneous ‘recovery’:

Proximal to distal UE ‘recovery’

synergies that produce one movement pattern

evolution towards selective movement control

importance of correct exercise therapy


Gillen 2011; Kim, 2012, Gould and Barnes, 2013


flaccid paralysis in >90%









Correct handling of the paretic shoulder/upper limb

Attention for transfers

Attention: Dof risk for learned non-use

Slings?

Correct handling of the paretic shoulder/upper limb

Prevent post-stroke shoulder pain

Correct positioning/handling of the hemiplegic shoulder:

Prevention of inferior subluxation due to gravitational pull

Prevention of traction on various nerves

Decrease the risk for shoulder-hand syndrome (CRPS)


often flaccid paralysis










Start on as early as possible with upper extremity rehab

to maximize neuroplasticity

to avoid learned non-use

to prevent development of shoulder pain

=

Day 1


Michielsen et al., Int J Phys Med Rehabil 2015

Trunk control test

Item 3 < 25No balance in

sitting position 30s

Item 3 = 25

BFM – stage 2 < 11no movement out of flexion pattern

BFM – stage 2,3,4 > 17 movement out of

pattern

Lying Supine Pronesit/stand

SupineLat.pos.

Supine/a/

Lat.pos./ap/, /a/

Sit/ap/to

/a/

Stand/ap/to

/a/

Scapula setting Selectiverecruitment

Core in lying, related toreaching

SitStand

JSU-diagram for rehabilitaton of the upper limb after stroke

Eccentric movement of internal rotators – pectoralis majorActivation of biceps and triceps (concentric and eccentric)

During a meaningful activity

Side lying on affected side


Trunk control test

Item 3 < 25No balance in sitting

position 30s

Lying


trunk, scapula and upper arm are passively stabilized, to enable movement outside synergy

eccentric and concentric activity of serratus anterior (scapula protraction/scapula setting)

eccentric and concentric control of triceps

Lying in supine position


Trunk control test


position 30s

Lying


Trunk and scapula are passively stabilized, more DoF for GH joint and influence of Fz

eccentric activity of pectoralis and anterior deltoid (horizontal abduction)

concentric / eccentric activity of shoulder flexors


Trunk control test


position 30s

Lying


Lying in supine position

Trunk and scapula are passively stabilized, more DoF for GH joint and influence of Fz

scapula setting

scapulothoracic protraction (serratus anterior)

concentric/eccentric control external rotators and

posterior deltoideus

concentric/eccentric activity of triceps brachii.

Side lying non-affected side


Trunk control test


position 30s

Lying


To address relation between core stability and scapula setting

A task is chosen in which grasping is included



Trunk control test



Item 3 = 25



pattern


SupineLat.pos.

Supine/a/

Lat.pos./ap/, /a/

Sit/ap/to

/a/

Stand/ap/to

/a/



SitStand


Focus on reachingObl. ext. abd – serr ant

Functional tasks, in different starting positions



SupineProne

sit/stand

SupineLat.pos.

Supine/a/

Lat.pos./ap/, /a/

Sit/ap/to /a/

Stand/ap/to /a/


Core in lying, related to reaching



Trunk control test



Item 3 = 25



pattern


SupineLat.pos.

Supine/a/

Lat.pos./ap/, /a/

Sit/ap/to

/a/

Stand/ap/to

/a/



SitStand


Constraint induced movement therapy

To decreaseinterhemispheric competition

Timmermans et al, 2009, Brunner et al, 2014

Technology-supported rehabilitation

Virtual reality - Serious gamingRobot assisted movement - Hocoma Patient-specific training - Tagtrainer

Frequent movement repetition (overlearning)

Natural environmental context

Address function, activity and participation


PSSP prolongs rehabilitation of affected limb and hospital stay,

negatively influences neuroplasticity

negatively affects ADL and QoL and

is associated with withdraw from participation in rehab process

Griffin and Bernhardt, 2006Suriya-amarit et al, 2014

4th most common medical complication after stroke

?

Suriya-amarit et al, 2014


Knowledge on functional anatomy, kinesiology and

muscle function around shoulder complex is essentiel

Neumann, 2009


Factors associated with shoulder pain after stroke

• Decreased glenohumeral abduction ROM

• Decreased glenohumeral external rotation ROM

• Poor scapulothoracic position

• Poor scapulothoracic motion

• Spasticity - hypertonicity of elbow flexors

Similar to factors associated with shoulder pain in musculoskeletal rehabilitation

De Baets L, 2013, 2015, 2016 Lindgren I, 2007, 2012, 2014

Patients’ priorities for rehabilitation immediately after stroke are on

regaining gait self-care in generalFocus physical therapy Focus occupational therapy

KNGF richtlijn beroerte, 2014

Prognose arm-handvaardigheid zes maanden na het CVAExtensie van de vingers / abductie van de schouder op dag twee na het CVA.

Indien mogelijk op dag 2: 98% kans op enige arm-hand vaardigheid op 6 maandenOnmogelijk op dag 2: op dag 5 wel: 25% kans op enige arm-hand vaardigheid op 6 maanden

op dag 9 wel: 14% kans op enige arm-hand vaardigheid op 6 maanden

Risico van ‘slechte’ prognose UE rehab is no priority?Risico van ‘goede’ prognose UE rehab is no priority?

Initial after stroke: flaccid paralysis in >90%

Spontaneous recovery:

Proximal to distal UE recoverysynergies that produce one movement pattern


Three to six months after stroke: 55 to 75% of stroke patients UE dysfunction

Six months after stroke: 30-66% of stroke patients remain without voluntary function 5-20% demonstrates complete recovery



Increase function – prevent shoulder pain : summary

Start with upper extremity rehab as early as possible

to facilitate neuroplasticity

to avoid learned non-use

to prevent secondary impairment, e.g. MSK-like shoulder pain,

shoulder hand syndrome, …

The patient 'thinks’ activity, the therapist 'thinks' structure/function

External focus for motor learning

UE recovery is often limited. Keep balance between …

Allowing compensatorymovement to increasefunctionality/activity

Risk for injury due tocompensatory movement

Implementation of a musculoskeletal model in neurorehabilitation is not straightforward

Increase function – prevent shoulder pain : conclusion

Documents

The post-stroke shoulder - Schoudernetwerk · PDF fileThe post-stroke shoulder ... Trunk control test Item 3 < 25 No balance in sitting position 30s Lying JSU-diagram for rehabilitaton