Upper extremity
Physiotherapy
Approaches to minimize pain and
maximize function in persons post
CVA
Acknowledgements
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Canadian Stroke Strategy: Best
Practice Recommendations and
Performance Measures
Evidence-Based Review of Stroke
Rehabilitation
Stroke Canada Optimization of
Rehabilitation through Evidence
(SCORE)
Upper limb post CVA

Flaccid
– No muscle reaction to passive movement
and no voluntary movement and no
reflexive reaction
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High tone
– Velocity dependant increase in resistance
to passive stretch accompanied by
hyperactive stretch reflexes
Causes of Shoulder Pain
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Muscle Imbalance
Fracture
Tendonitis
Glenohumeral Subluxation
Bursitis
Adhesive Capsulitis
Neuropathic (RSD)
Muscle Imbalance
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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
Shoulder subluxation
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Occurs in a large percentage of
persons post stroke with flaccid upper
extremity (29-82%)
Possibly a reason for development of
pain but inconclusive
Injury
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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
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
Pain Prevention

Positioning
Pain prevention
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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
Slings
Slings
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
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http://shop.ebay.ca/items/_W0QQ_nkwZar
mQ20slingsQQ_armrsZ1QQ_dmdZ2QQ_from
Z
http://www.lifesolutionsplus.com/harrishemi-arm-sling-p-301.html
http://www.sammonspreston.ca/app.aspx?c
md=get_product&id=76118
http://www.sammonspreston.ca/app.aspx?c
md=get_product&id=97428
Pain treatment

Active treatment
– Overhead pulleys shown to create pain
– Moderate evidence showing gentle exercises are
preferred approach
– Limited evidence that nonsteroidal antiinflamatory medication improves pain, ROM and
function
– Sustained stretch may be as equally harmful as
immobile position

decreasing range and increasing pain
Pain Treatment

Modalities
– Functional electrical stimulation

Conflicting evidence
http://www.google.ca/search?hl=en&q=functional+electrical+s
timulation+shoulder+pictures&meta=
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
CIMT
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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
Video
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http://www.youtube.com/watch?v=MMTh2hWvB2g
EXCITE Trial
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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)
EXCITE Trial
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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
Modified CIMT: Page et
al. 2008
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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
Modified CIMT: Page et
al. 2008

Conclusion:
– Improvement in function and quality of
arm movement
– May be more practical program than
previous studies
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
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
Feasibility in NB
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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
Questions?