Download The Hemiplegic Arm - Toronto Stroke Networks Virtual Community of

North & East GTA
Ontario Region Stroke Network
The Hemiplegic Arm
Henza Miller B.H.Sc. (PT)
Physiotherapist, Regional Stroke Team
May 2013
Introduction
v Today’s session will assist you in
managing the care of the stroke
survivor’s upper extremity.
Objectives
1.  To understand how a stroke affects
movement.
2.  To understand how a stroke can affect
the upper extremity.
The Nervous System
Divided into 2 parts:
1.  The Central Nervous System- consists
of the brain and spinal cord
2.  The Peripheral Nervous Systemconsists of spinal and peripheral
nerves
•  Voluntary (biceps) vs. Involuntary (heart)
•  Receptors and Effectors
How Does Normal Movement
Happen?
•  Information from the body and/or
environment comes into the sensory
region of the cerebral cortex (located in
the parietal lobe)
•  The motor cortex (located in the frontal
lobe) decides if movement should
happen
How Does Normal Movement
Happen?
•  The strength and intensity of the muscle
contraction is monitored by the
cerebellum so that the movement is
smooth
•  Normal tone present in the muscle
ensures that the movement is
coordinated and isolated
What is Muscle Tone?
•  All normal muscles have tone.
•  This tone is slight tension in the muscle
that indicates the readiness of the
muscle to contract
•  Normal tone allows body to resist the
effects of gravity but also allows
freedom of movement.
•  Tone is rated on a scale from low
(hypotonic) to high (hypertonic)
Low Muscle Tone
•  Also known as hypotonicity or flaccidity.
•  The affected limb appears heavy and limp and
there is no movement in the limb.
•  This lack of movement in the affected limb, can
cause ligaments around the joint to stretch
causing instability and dislocations at the joint.
•  It can also cause a shortening or contracture of
the involved muscles thereby restricting
movement available at the joint.
High Muscle Tone
•  Also known as hypertonicity
•  High tone in a limb over a long period of
time can reduce the movement of that
limb because the muscles stay in a
shortened or contracted position
leading to contractures.
How Does a Stroke Affect
Movement?
•  The injury is in the brain therefore the
message required for movement is altered.
•  How the message is altered depends on the
location and size of the injury.
•  Since one hemisphere generally controls the
functions on the opposite side of the body, a
stroke on the right side of the brain affects the
left side of the body and vice versa.
Physical Recovery From a
Stroke
•  After the stroke, there is initially a state of low
tone (flaccidity) on the affected side
•  The length of this state varies from one
person to the next
•  After this state of low tone, there is a period of
returning muscle function and fluctuation
between high and low tone on the affected
side
Physical Recovery From a
Stroke
•  Typically, muscle function returns in the trunk,
shoulders and hips first and then moves into
the limbs
•  The rate of return of these patterns of muscle
function is variable and is influenced by the
location of the lesion, the severity of the
lesion and by rehabilitation
Other Typical Abnormal
Movement After a Stroke
•  Apraxia: Inability to perform a voluntary
movement although there is adequate mobility,
strength and coordination
•  Ataxia: Voluntary movement is possible but the
movement is uncoordinated
•  Synergies: Movement of the affected limb in a
pattern of flexion or extension. The flexion
pattern is dominant in the arm and the extension
pattern is dominant in the leg
Other Typical Abnormal
Movement After a Stroke
•  Associated Reactions: automatic responses
of the limbs as a result of action occurring in
some other part of the body
•  Compensatory techniques: using other
muscles to complete a certain task (eg. Trunk
to swing leg or move arm)
The Hemiplegic Shoulder and
Hand
•  The upper limb (arm) requires special
concern after a stroke as the shoulder
and hand are very vulnerable when
motor function has been affected.
•  Generally, after a stroke, the shoulder
will either be low-tone or high-tone.
Normal Shoulder Anatomy
•  The shoulder joint is a ball and socket
joint that moves in many directions.
•  It is largely held in place by muscles
surrounding the joint
instead of ligaments.
Survivor with a Low-Tone
Shoulder
•  When there is low-tone in the upper
extremity, the muscles are no longer
able to support the shoulder joint, they
feel heavy
•  the ligaments get stretched and the
shoulder may partially dislocate
(subluxation)
Shoulder Pain
•  The excessive stretching of both muscles
and ligaments increases the risk of pain.
•  High incidence of pain following a stroke –
72% report at least one episode in first yr
( Duncan Stroke 2005)
•  Can delay rehab and recovery
•  Mask improvement of function
•  Inhibit patient participation
•  Preventing sh. pain may affect quality of life
How you can help a Stroke
Survivor?
According to the WHO, Inter professional
education occurs when 2 or more
professions learn about information which
enables effective collaboration and
improves health outcomes (WHO2008)
How you can help a Survivor
with a Low Tone Shoulder
•  When the survivor is sitting, support the
affected arm at all times, using a lap
tray or arm rest.
•  Always be careful when handling the
arm
•  Never pull on the arm when transferring
or assisting the survivor to move in bed.
How you can help a Survivor with
Stage 2 CMSA or Low Toned
Shoulder ?
•  The tissues around the joint are vulnerable to
being pinched or injured because the joint is
subluxed
•  Frequently with reduced tone there is reduced
sensation and proprioception
•  Passive ROM
•  Touch, rub, weight bearing, supportive
positioning to increase sensory awareness
Supported Positioning
Helps reduce pain
Helps muscle imbalance
Prevents the development of
contractures
Shoulder Hand Pain
•  Braus and coworkers (Ann Neurol
1994) found that careful handling in
the early phases post stroke, reduced
the incidence of shoulder pain from
27% to 8%
•  In subacute patients with shoulder pain,
one randomized controlled trial (n = 28)
demonstrated that shoulder positioning
compared with treatment also showed a
trend toward improvement in active
range-of-motion abduction (Ottawa
Panel Top Stroke Rehabil 2006)
•  Teasell and collaborators stated that
“careful positioning of the shoulder
serves to minimize subluxation and later
contractures
as well as possibly promote
recovery” (Teasell, Evidence –based
review of stroke rehabilitation 2007)
•  Poor positioning may adversely affect
symmetry, balance and body
•  McKenna noted that the “recommended
position for the upper limb is towards
abduction, external rotation and flexion
of the shoulder” (Disabil rehabil 2001)
•  However the shoulder should not be
passively moved beyond 90 flexion and
abduction unless the scapula is
upwardly rotated and the humerus is
laterally rotated
•  Pulleys should not be used as they do
not adequately support the shoulder
•  Use of supportive slings and support
evaluated in context of improving shoulder
alignment with those with shoulder
subluxation
•  Use of devices reduce subluxation but
neither presence nor resolution of pain was
assessed.
•  Early electrical stimulation on shoulder
helps prevent development of hemi
shoulder while later treatments helps to
reduce pain
Therapeutic Taping
can help Support the Shoulder
Post Subluxation
Therapeutic Taping
can help Support the Shoulder
Post Subluxation
•  Tape can offer proprioceptive benefits and
mechanical corrections.
•  Tape with joint in flexed and muscle in
shortened position.
•  muscle contraction are supported and
assisted and prevents muscle overstretching
•  Trim edges of tape
•  Proximal to distal facilitates
Survivor with a High-Tone
Shoulder
•  In some survivors, the balance of muscle
activity around the shoulder joint is abnormal
due to high tone and/or spasticity.
•  It is as if the muscles involuntarily “seize up”
without being able to stop
•  Can affect a single or
multiple group of muscles
Spasticity
•  In the upper extremity it can affect shoulder,
elbow, forearm, wrist and hands.
•  It can interfere with the ability for self care
and/or posture. Generally, this high tone pulls
arm in towards the chest, making
active movement difficult
and painful.
Spasticity – cont.
•  Ranges from mild to severe
•  In Mild it can cause manageable effects
•  In Severe it can be painful, the muscles
stiffen up and remain permanently contracted
or shortened
•  A long- term condition of which symptoms
can change over time
•  Needs to be reassessed on a regular basis
Does the Survivor Need
Treatment?
If it interferes with:
•  Basic activities such as eating or dressing
(getting a sleeve on), hygiene ( washing
under the arm)
•  Reduces mobility
•  Causes pain
How you can assist the survivor
with a high tone shoulder
•  If the high tone is not reduced, it can impact on the
survivor’s ability to move.
Controlling this tone is complex and requires your
guidance
•  If the high tone is interfering with ADLs or causing
severe pain, the survivor may need to be assessed by a
Physiatrist/Neurologist at the Spasticity Clinic.
A referral can be made by the resident physician to the
clinic (referral forms?)
How you can assist the survivor
with a high tone shoulder and
hand
•  Passive ROM can cause severe pain
and damage the tissue around
the shoulder joint
•  Positioning is important
•  Hand splinting
i.e. Saebo dynamic
The Hand
•  After a stroke, the hand is prone to swelling
and positioning problems due to lack of
sensation and/or movement.
•  A hand with low tone often swells as the fluid
pools.
•  Swelling and disuse may
result in pain and skin problems
•  grade 1-2 accessory mobs, cold water/
contrast
How you can help protect
the Survivor’s Hand
•  Always be considerate of the affected hand. The hand must
always be supported when sitting.
•  Use foam wedges and arm supports placed on
the tray to elevate the hand and reduce swelling.
•  Taping may be used to reduce swelling.
•  Encourage the survivor to use the unaffected hand to gently
bend and open the fingers, and to place the hand on the
supporting surface.
•  Pillows can also be used to support the arm & hand in the
supine position.
•  Ultrasound/ functional stimulation can reduce swelling
Taping the Swollen Hand
Conclusions of 3 Different Approaches
In Reduction Of Hand Edema
•  2 small uncontrolled trials suggest neither passive ROM or
neuromuscular stim help reduce hand edema
•  2 hours of intermittent pneumatic compression for 1 month
no more effective than standard physio
•  No definitive therapeutic intervention for complex regional
pain syndrome. Some evidence that oral corticosteroids
are more effective than nsaids or placebo
Ultrasound
•  Can be used to reduce swelling
•  Check client’s sensation as the output
can be adjusted to reduce the
thermal affects.
Functional Electrical Stimulation
H200 can be used to
reduce swelling and
increase activity
Stimulation can be used
to assist in functional
tasks
FES and
Task Oriented Training
>6 months FES plus conventional therapy is more
effective than conventional therapy alone for improving
hand function, dexterity and ROM
Task oriented training with strengthening is superior to
NDT
Task- oriented training involves practicing real life tasks
to acquire a skill (challenging and adapted progressively,
active participation)
FES can be used for pain free lateral rotation
How you can help protect the
Survivor’s Hand
•  Contrary to popular belief, squeezing
soft balls should be discouraged as it
promotes closure of the hand and
tightness of the fingers.
•  Follow any instructions prescribed by a
therapist to mobilize the hand and treat
pain and swelling.
Physiotherapy Treatment
•  Is often used in conjunction with antispasticity
drugs
•  Treatment often includes stretching the
muscles and tendons
•  Range of motion exercises so as to keep the
joints from being stiff
•  Activation of the opposite muscle group
through active movement or stimulation
Physiotherapy Treatment
- cont’d
•  Motor imagery has shown to improve arm
function as compared to traditional alone
•  Biofeedback does not improve upper limb
outcomes over conventional therapy and is
not recommended.
•  Cochrane Review suggests that bilateral
upper limb training is not more effective for
improving arm function than interventions
focused only on the more affected limb.
Important Facts about Muscle
Contractions and Training
•  Manual muscle testing is isometric action but
ADL rarely involves isometric alone
•  Faster eccentric contractions develop more force
than slow eccentric contractions
•  Eccentric contractions > isometric> concentric.
Eccentric gain strength in rehab with less energy
cost
•  Strength and speed of mvt can be trained in
people after CVA in 6 wk exercise program
Muscle Contractions and
training cont.
•  A shorter m fibre has fewer sarcomeres in
series and generates less force and moves
throughout smaller range of motion, also
disadvantage for rehab so prevent atrophy
and maintain length
•  Reorganization of motor units occurs as
early as 9 days post stroke and the number
and size of mu are stabilized after 3 months.
Occupational Therapy
•  May include new strategies for dressing and
grooming
•  Splinting in conjunction with botox to
maintain/ increase range (you may be asked
to don the splint nightly for maintained/ or
increased range of motion)
•  Special equipment- larger handles so
function can be incorporated into ADLs
Occupational Therapy- cont’d
•  Graded Repetitive Arm Supplementary
Program (GRASP) 1 hr/ 6 days/wk
•  Should included strengthening, range,
gross, fine motor, repetitive goal and
task oriented activities
Strategies on How you can Help a
Survivor with a Low Tone Shoulder
•  Adequate range of motion
•  Proper alignment of muscles/ joint prior to
facilitation
•  Facilitation through sensory/proprioception
•  Activation (tapping, vibration)
Practical
• 
• 
• 
• 
• 
Scapula
Shoulder
Elbow
Hand
Fingers
Other Treatment Options for Spasticity
often used in conjunction with PT/OT
•  Drug Therapy
•  Botox
Drug Therapy
These help relax the muscle contractions and
may be given orally
Diazepam - Used as sedative and to treat anxiety disorders
Can cause drowsiness, dependence
Baclofen - Acts on central nervous system
Usually used with spasticity from MS, spinal cord/CP
Can cause drowsiness, muscle weakness
Tizanidine - Short acting drug
Reduces muscle tone without reducing strength
Used with MS, and spinal cord injury
Those with low or variable blood pressure need to be careful
Studies have shown it to be more affective than baclofen
BOTOX
(botulinum toxin type A)
•  Acts as neuromuscular blocker
when injected into muscle
•  It works at the nerve endings
and binds with them to
block the signal so
it filters the brain signal
muscle weaker
reducing muscle hyperactivity
BOTOX (botulinum toxin type A)
•  Usually works within 2 wks after the injection
•  It lasts 3-4 months but degree of relief and
duration effect varies
•  Strong evidence that botox reduces focal
spasticity in finger, wrist and elbow
•  Botox into subscapulari and pectoralis muscles
is beneficial in reducing shoulder pain
•  Spasticity is not a contraindication to strength
training
XEOMIN
New botulinum neurotoxin
type A
Produced by Merz Canada
•  More purified form of the toxin
•  Doesn’t need to be refrigerated
Other Treatments used by PT/OT
Constraint Induced Movement
Therapy (CIMT)
•  Technique to increase function and use
of the paretic arm
•  Labor intensive
Constraint Induced Movement
Therapy (CIMT)
•  Method to improve motor function in the
upper extremity following stroke & head
injury
•  2 components:
– Restraining the unaffected side (oven mitt)
– Increasing the use of the affected extremity
by repetitive practiced training
Post CVA disuse of extremity
CIMT- Restrain dominant arm,
forced use of affected limb
Increased motivation
Positive
reinforcement
Brain changes
Increased
use in ADLs
Schematic Model for Overcoming
Learned Non Use (Wolf et al 2002)
Learned
Nonuse
Masked
Recovery
of limb
Increased
Motivation
accesses
function
Affected
Limb
used
Positive
Reinforcement
Limb used in
life situation
permanent
Use dependant
Cortical
reorganization
Further practice
& more reinforcement
CIMT
•  Most studies inclusion criteria:
–  Ability to extend wrist, finger and thumb 10 degrees
–  6 months post stroke
–  Sufficient stability to walk when the healthy arm is
immobilized
–  Ability to follow simple commands
•  Motor Activity Log – participants rate frequency they use
paretic arm in 30 common activities (0-5) and quality of
movement (0-5)
•  Varied Training: 6hrs during 10 weekdays for 2 weeks
– 
Shaping Exercises
•  Therapist structured tasks which are
individualized to the patient to practice
•  List of 10 activities each day
•  Each activity is performed 10x- can be timed
or amount of reps
•  Help required initially and less help as
improvement seen
•  Ex. Brush teeth, open fridge
Conclusion
Studies show that CIMT :
•  Induces plasticity in the motor cx of the
affected hemisphere and increases excitability
of the neuronal network
•  Formerly shrunken cortical representation of
the affected limb was reversed
•  CIMT should be avoided 1st month post CVA
•  Subacute post stroke, modified CIMT
improves motor function over traditional
therapy
CIMT – cont’d
•  Use of mCIMT late after stroke is more
effective than traditional for improving
UE motor function.
Hemiplegic Arm
Low Tone
Moderate Tone
High Tone
Avoid Pain
Proper positioning/
handling
Proper positioning/handling
Supportive
positioning/handling
Taping/ Bioness/FES
Facilitate movement
Sensory Stimulation
CIMT
Maintain ROM
Bioness/ FES
Drug Therapy/ Botox
Facilitate mvt /
Strengthening
Sensory Stimulation
CIMT
Stretching /Splinting
Sensory Stimulation
Facilitate movement/CIMT
Bioness/FES