1 / 27

Upper extremity Physiotherapy

Upper extremity Physiotherapy. Approaches to minimize pain and maximize function in persons post CVA. Acknowledgements. Canadian Stroke Strategy: Best Practice Recommendations and Performance Measures Evidence-Based Review of Stroke Rehabilitation

george
Download Presentation

Upper extremity Physiotherapy

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Upper extremity Physiotherapy Approaches to minimize pain and maximize function in persons post CVA

  2. Acknowledgements • Canadian Stroke Strategy: Best Practice Recommendations and Performance Measures • Evidence-Based Review of Stroke Rehabilitation • Stroke Canada Optimization of Rehabilitation through Evidence (SCORE)

  3. Upper limb post CVA • Flaccid • No muscle reaction to passive movement and no voluntary movement and no reflexive reaction • High tone • Velocity dependant increase in resistance to passive stretch accompanied by hyperactive stretch reflexes

  4. Causes of Shoulder Pain • Muscle Imbalance • Fracture • Tendonitis • Glenohumeral Subluxation • Bursitis • Adhesive Capsulitis • Neuropathic (RSD)

  5. Muscle Imbalance • Disorganized muscle activation • Flexor tone predominates in the hemiplegic upper extremity and results in scapular retraction and depression as well as internal rotation and adduction of the shoulder • Current research suggests relation between spasticity and shoulder pain • Also relation between CVA, frozen shoulder and pain

  6. Shoulder subluxation • Occurs in a large percentage of persons post stroke with flaccid upper extremity (29-82%) • Possibly a reason for development of pain but inconclusive

  7. Injury • Rotator cuff injury is a possibility however no studies showing conclusive evidence of a tear causing pain • Also tears found may not be premorbid • Questionable cause of pain

  8. Shoulder pain post CVA:Management • Prevention is the NUMBER 1 action for health care providers • There is no one specific treatment for the reduction and elimination of shoulder pain post stroke currently

  9. Pain Prevention • Positioning

  10. Pain prevention • Passive range of motion • Recommended to avoid shoulder ranging past 90 degrees of flexion and abduction. • Emphasis on external rotation as tolerated • Slings and straps • Perhaps some benefit to prevent shoulder subluxation however little evidence for pain reduction or prevention

  11. Slings

  12. Slings • http://shop.ebay.ca/items/_W0QQ_nkwZarmQ20slingsQQ_armrsZ1QQ_dmdZ2QQ_fromZ • http://www.lifesolutionsplus.com/harris-hemi-arm-sling-p-301.html • http://www.sammonspreston.ca/app.aspx?cmd=get_product&id=76118 • http://www.sammonspreston.ca/app.aspx?cmd=get_product&id=97428

  13. Pain treatment • Active treatment • Overhead pulleys shown to create pain • Moderate evidence showing gentle exercises are preferred approach • Limited evidence that nonsteroidal anti-inflamatory medication improves pain, ROM and function • Sustained stretch may be as equally harmful as immobile position • decreasing range and increasing pain

  14. Pain Treatment • Modalities • Functional electrical stimulation • Conflicting evidence http://www.google.ca/search?hl=en&q=functional+electrical+stimulation+shoulder+pictures&meta=

  15. Conclusions of shoulder pain • Protection • Position properly • Use devices consistently • Patient and family education • Passive ranging • Light movement no further than 90 degrees of shoulder flexion and abduction • Emphasis on maintaining external rotation and abduction

  16. CIMT • CIMT-Constraint induced movement therapy • Introduced by Edward Taub in the 1960s after working with deafferented monkeys • Phrasing learned non-use • Monkeys unaffected arms were restrained in slings and affected arms regained movement

  17. Video • http://www.youtube.com/watch?v=MMTh2hWvB2g

  18. EXCITE Trial • 222 participants, 3-9 month period • Multi-site, single blinded randomized • Inclusion: • 20 degrees wrist extension, 10 degrees MCP and IP extension (high function) • 10 degrees wrist extension, 10 degrees thumb abduction, and 10 degrees extension of at least 2 digits (low function)

  19. EXCITE Trial • Glove on for 90% of waking hours to less-impaired arm • Task practice in lab 6 hours per day, for 2 work weeks (10 days) • Conclusion: • Improved function shown to be retained 24 months after 2 week program in SIS strength, ADLs, and social participation

  20. Modified CIMT: Page et al. 2008 • Stroke was 12 + months prior • 20 degrees wrist, 10 degrees MCP and IP extension • Restraint for 5 hours per day, with 30 minute one-on-one sessions 3 times per week for 10 weeks

  21. Modified CIMT: Page et al. 2008 • Conclusion: • Improvement in function and quality of arm movement • May be more practical program than previous studies

  22. More local input • Ploughman et al. 2008 • Case study from the Miller Rehabilitation Centre in Newfoundland • Same parameters as EXCITE trial • Demonstrated remarkable increase in function for a hockey loving adolescent male

  23. Feasibility in NB hospital • Inpatient rehab • Glove is cheap and easy to create • Could be used on appropriate patients with consent • Dressing, feeding, toileting would all take more time • therefore need health care team, patient and family buy in

  24. Feasibility in NB • Outpatient CIMT • Labour intensive but there is suggested long term effect • Modified CIMT may be beneficial • Possibility for group therapy sessions • Possible treatment at chronic stage

  25. Questions?

More Related