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Neuro Test Notes

Acquired Brain Injury (ABI)
Traumatic Brain Injury (TBI)
Medically based or drug related (Stroke, Brain Tumours, Substance Abuse,
Hypoxic Brain Injury e.g. near drowning)
Develop an understanding of the Ax process in
an acute inpatient setting
Start with gathering information: team, family, medical notes, consider what to expect before seeing
the client.
what is appropriate Ax process for the condition?
What is priority?
Medical stability
Results of scans and medical assessments
Emotional distress of client and family members/significant others
Priorities for immediate Ax and Rx – as part of diagnostic team, client comfort,
prevention, getting client sitting out of bed if at all possible
Early action to take:
Starting to plan discharge on admission
Will client need rehabilitation? Are they suitable/ready for rehab?
Does client need inpatient rehabilitation? e.g. Neuro specific (State Rehabilitation
Service at FSH) or general rehabilitation
Where to for rehab? Consider age e.g. only State rehab if younger than 65yr;
restorative units if older than 65yr, direct discharge home or to nursing home
Can they go home with rehab? e.g. RITH, Homelink
If the person did not come in through intensive care unit and was not acutely very unwell, need to
already consider:
Is the client’s home suitable for discharge? Arrange functional home visit
Will client need support services? Social work – determine eligibility of support
services; liaise with social worker
What planning needs to take place for after discharge from hospital? e.g. ongoing
rehab needs, referrals for return to work/driving, State Head Injury Unit (SHIU) for
case coordination services, private OT services
Better to start with
Positioning: (1st question to start your
reasoning)what position to do occupation?
Address immediate needs
Positioning: liaise with physio and make sure that you all communicate the positioning needs to the
Complete the Motor Assessment Scale: this will determine the positioning of the shoulder if at risk
Ax – some immediate options
Initial Neurological Screen = Neuro-physical assessment (see example on next slide)
Visual screen e.g. NPAx or start of OT-APST (Labs Week 4)
UL screen e.g. NPAx
Client post TBI: GCS, RLA levels, Westmead PTA, R-PTA
Client post Stroke and post TBI if not in PTA:
o Cognitive screen e.g. Cognistat (Labs Week 3)
o Perceptual screen e.g. OT-APST (Labs Week 4)
o Observe and document functional capacity
o Progress to more formal Ax
Knowledge of assessments specific to clients
post Traumatic Brain Injury (TBI)
Glasgow Coma Scale (GCS)
Ranchos Los Amigos (RLA) Cognitive Function Scale
Don’t use for Stroke
Most common for OT:
RLA Level IV:
o Be very confused and frightened;
o Not understand what he feels or what is happening around him;
o Overreact to what he sees, hears, or feels by hitting, screaming, using abusive
language, or thrashing about. This is because of the confusion.
o Be restrained so he does not hurt himself or pull on tubes;
o Be highly focused on his basic needs e.g. eating, relieving pain, going back to bed,
going to the bathroom, or going home;
o May not understand that people are trying to help him;
o Not pay attention or be able to concentrate for a few seconds;
o Have difficulty following directions;
o Recognise family/friends some of the time with help, be able to do simple routine
activities such as feeding himself, dressing or talking
Westmead Post Traumatic Amnesia Scale (PTA)
 best predictor of cognitive-behavioural-social dysfunction
Closed Head Injury (not Stroke)GCS
 PTA= On emerging from a loss of consciousness, client’s orientation and memory for
ongoing events is poor
Why PTA is important?
o Client care - the behaviours associated with PTA include agitation, irritability and
restlessness, therefore measuring PTA monitors the client's mental state during this
acute recovery stage
o Rehabilitation - as new learning ability is impaired during PTA, conventional forms
of therapy which require the client to retain information over time are not viable
o Neuropsychological testing - the neuropsychological testing of clients in PTA will
have little validity
o Index of severity - the duration of PTA is used as an index of severity for
prognosis, medico-legal and scientific purposes
Duration of PTA
<5 minutes
5-60 minutes
1-24 hours
1-7 days
1-4 weeks
>4 weeks
>6 months
Very Mild
Very Severe
Chronic Amnesia
Revised Westmead Post Traumatic Amnesia Scale (R-PTA)
same as Westmead PTA but administered hourly until client achieve 3 consecutive 12 points.
3. Understanding of motor control and different components of
motor control to consider in an inpatient acute setting
1. Normal muscle tone
o Effective stabilisation at axial & proximal joints
o Ability to move against gravity & resistance
o Ability to maintain position of limb if placed passively by the examiner &
then released
o Balanced tone between agonist & antagonistic muscles
o Ability to shift from stability to mobility & reverse as needed
o Ability to use muscles in groups or selectively with normal timing &
o Slight resistance in response to passive movement
2. Normal postural tone
o Lowest tone to allow an individual to be up against gravity whilst allowing
selective movement.
o Low enough to take up base of support (BOS)
o High enough to maintain posture
o Automatic changes in postural tone in response to displacement or voluntary
o Proprioceptive awareness of BOS
o Varies between individuals
Postural mechanisms
Automatic movements
Provides an appropriate level of stability & mobility
Provides orientation of the body
Provides balance
 Normal postural tone & control
 Integration of primitive reflexes
 Mass movement patterns
 Righting reactions
 Equilibrium & protective reactions
 Selective movement
Balance = maintaining COG over BOS
o Centre of gravity (COG): the point where the mass of the body can be
considered to be located - is a constant downward force
o Base of support (BOS): the supporting surface and the body part in contact
with it and the relationship between the two
o Vision, vestibular system and proprioception = all crucial for balance
Selective movement
Ability to grade postural tone to move from one BOS to another
Coordinated grading of concentric and eccentric activity to provide a dynamic
stability throughout movement
Enables change and choice at any point during movement in response to demand
Requires background postural stability as a basis for selective skilled movement
Selective movement after stroke often difficult due to synergies
Patterns of movement – synergies
Initiation of a movement of one joint - all muscles linked in synergy with that
movement automatically contract causing a stereotyped movement pattern
Upper limb:
Flexion synergy: (strongest component of flexion synergy = elbow flexion)
Scapula retraction & elevation, shoulder abduction & external rotation, elbow
flexion, forearm supination. Hand & finger position is variable, generally flexed
Extensor synergy: (strongest component of extensor synergy = shoulder adduction
& internal rotation)
Scapula protraction, shoulder adduction & internal rotation, elbow extension,
Stage I
Flaccidity: no voluntary movement,
muscle tone, or reflexive responses
Stage II
Synergies can be elicited reflexively;
Spasticity is developing
Stage III
Beginning voluntary movement but only in synergy; spasticity may
be significant
Stage IV
Spasticity begins to decrease; ability to voluntarily perform
movements that deviate slightly from synergy patterns
Stage V
Increased control of isolated voluntary movements, independent of
synergy patterns
Stage VI
Isolated motor control; spasticity is minimal
Stage VII
Normal speed and coordination of motor function
6. Sensory & proprioceptive controls
o Remember to consider the impact of sensory and proprioceptive controls on motor
function which will be covered in more detail later in the semester
o Think of examples of how sensory & proprioceptive deficits will influence motor
7. Coordination
o Ability to produce accurate, controlled movement
o Characteristics include:
o smoothness
o rhythm
o appropriate speed
o refinement to the minimum number of muscle groups needed & appropriate muscle
tension, tone & equilibrium
o Consider influence of cognition e.g. alertness, attention, initiation, planning,
problem solving
o Consider influence of perception e.g. spatial relations, unilateral neglect, ideomotor
apraxia or ideational apraxia
4. Observations linked to motor control: knowing what to look for
Observations in sitting
Alignment: Symmetry of trunk? Position of head?
Ability to change own position?
Ability to sit unsupported: do they need to use arms for support when sitting? Is
weight bearing symmetrical? Position of pelvis?
Can the person shift weight laterally? And correct themselves after weight shift?
Muscle tone? Any obvious changes in muscle tone?
Position of LLs? Position of ULs?
Signs of pain?
Observations in standing
Alignment: Symmetry of trunk? Position of head?
Ability to change own position?
Ability to stand unsupported: do they need to use arms for support when standing?
Is weight bearing symmetrical? Position of pelvis?
Can the person shift weight laterally? And correct themselves after weight shift?
Muscle tone? Any obvious changes in muscle tone?
o Position of LLs? Position of ULs?
o Signs of pain?
Observations motor control during functional task
o Did the person position self appropriately for task?
o Endurance - over length of task? Did posture, tone, balance, change over length of
o Effort to complete task?
o Did tone change as posture changed?
o Did you observe any movement synergies e.g. flexor synergy (during elbow
flexion) and/or extensor synergy (during shoulder adduction & internal rotation)?
o Bilateral hand use?
o Preferred hand? Is it the dominant hand?
Observations of complications impacting on motor control
o Pain (how can you observe for pain?)
o Incidence as high as 84%
o Pain significantly limits patient’s mobility, mood and motivation
o Causes unclear and multifactorial therefore Rx not straightforward and must
incorporate several strategies
o Literature suggests little correlation with age, spasticity & subluxation
o Oedema – observe swelling of the affected limb (Ax by measurement)
o Occurs in approximately 16% of cases
o Impingement from postural change
o Decreased activity of vascular muscular pump due to weakness, immobility and
lack of normal activity or blood clot/trauma
5. Knowledge of assessment of motor control: posture, tone, balance, PROM
Ax of posture
Ax through observation
Liaise with physiotherapist
Important to look for symmetry
Influenced by postural tone and postural mechanisms (see Lecture outlining
characteristics of postural tone and postural mechanisms)
Ax of tone
NPAx Task 4.2 – 4.5 (will practice in Lab this week)
Ax  tone with Modified Ashworth Scale
Observe scapulohumeral rhythm
Importance of also assessing postural tone
Can have low tone in trunk and increased tone in upper limb
Ax of external rotation is very important
Ax of balance
Posterior pelvic tilt
UL support to increase BOS
Furniture walking
Wide BOS, decreased single limb support time
Reduced function due to fear of falling
NPAx Task 8.1 – 8.5
o Berg Balance Scale (usually completed by physiotherapist but important to know
how we can use the Ax results)
o Functional Reach (usually completed by physiotherapist)
o Timed Up and Go (usually completed by physiotherapist)
Ax of PROM
o NPAx Task 4.2 – 4.5 (Week 2 Labs)
o Typical muscle groups at risk of loss of flexibility & muscle shortening in affected
o Scapula – loss of shoulder ROM
o Shoulder internal rotators – loss of external rotation particularly pecs
o Shoulder adductors – loss of shoulder abduction
o Elbow flexors – loss of elbow extension (biceps & brachialis)
o Forearm pronators – loss of supination
o Wrist & finger flexors – loss of wrist & finger extension
o Thumb adductors & intrinsics – loss of thumb abduction
PTA (Post Traumatic Amnesia)
Challenging behaviours that are typically associated with PTA, such as agitation,
aggression and wandering resolved in the early stages of PTA and incidence rates of
these behaviours were less than 20%.
Independence in self-care and bowel and bladder continence emerged later during
resolution of PTA.
New learning in functional situations was demonstrated by clients in PTA.
Concusions and recommendations from this study:
It is feasible to begin active rehabilitation focused on functional skills-based learning
with clients in the later stages of PTA.
Formal Ax of typically observed behaviours during PTA may complement memorybased PTA assessments in determining emergence from PTA.
All students to assume the seated position of readiness for function (Gillen, Box 18-3, p. 384)
Pelvis is in neutral to anterior tilt
Equal weight-bearing on both ischial tuberosities
Trunk erect and midline with appropriate spinal curves
Shoulders symmetrical and over the hips
Head/neck neutral
Hips slightly above the level of the knees
Knees in line with the hips
Feet equally weight-bearing and underneath the knees
Positioning in bed:
Supine (this is the least preferred position – can you see why?)
Side lying on affected side (this is the most preferred lying position – can you see why?)
Side lying on un-affected side (will this be a good position if a person has no function in
the affected upper limb at all?)
Long legged sitting (why would you not want the person to sit like this for a long time?)
Side Lying on Unaffected Side
Head/neck in neutral/symmetrical
Affected leg supported by one or two pillows (affected leg may be either flexed in front or
positioned behind unaffected leg-see diagrams).
Gap maintained between the legs.
Affected arm supported on a pillow or C Cushion. Scapula protraction of affected upper limb.
Side Lying on Affected Side
Flat pillow under head
Lie on affected side with affected shoulder well forward and flexed to 90 degrees
Palm of hand should be in supination with entire arm supported
Affected leg straight with knee slightly flexed
Pillow under unaffected leg with knee flexed
Visual perception
Stroke: Affected Side: LL: Extension
UP: Flexiontry to help them to extend
As an OT: try to get clients out of bedThe pic just for resting and not apply for all the clients
Ensure client is positioned so that he can access his bedside table and the lamp.
Positioning in Supine
Flat pillow under head, with head in alignment
Body in alignment (straight) in bed
Pillow under affected scapula
Affected arm supported by pillow to side of body
Pillow under affected hip
Small towel roll under affected knee
Long legged sitting in bed (short periods only)
Sit in bed as upright as possible with head and body in alignment, pillows behind back
Weight evenly distributed between both buttocks-no leaning
Affected arm supported at side by pillows with some elbow flexion
Affected scapula supported from behind by pillow
Affected hand should be supported on pillow in supination
Small towel can be placed under the affected knee
Ensure client is positioned with bedside table over bed so that she can eat her breakfast.
try to help the legs to flexion try to tell opposite what the brain tell you.
Use of C Cushion
Large part of cushion supports affected forearm and hand
Affected arm should have minimal elbow flexion
Affected hand positioned in supination on cushion with fingers as straight as possible
Minimal stuffing in narrow section of cushion, placed behind affected scapula
Ensure affected shoulder is forward and supported
Ensure client is positioned in the high backed chair with a magazine or activity of interest
Use of lap tray/arm trough-chair/wheelchair
Sit back in chair, hips and knees at right angles.
Feet on floor or supported by foot plates
Head and body in alignment, weight distributed evenly between buttocks
Affected arm supported by lap tray or arm trough
Affected shoulder slightly forward, wrist and hand supported
Arm in central mid-position, avoid internal rotation
Correctly position client in wheelchair with lap tray and an appropriate activity. Use unaffected arm
as a stabiliser if no movement possible.
Vital Sign Response
S: Increase, Decrease by 20
D: Decrease by 10
Just to consider: take client out of bed ActivityBack to bed
1. The physio will assist you to get the client out of bed to walk to the sink and brush her
hair. What increase in heart rate is expected and will be considered normal?
2. Once the client is up and started walking, you make sure to monitor the client’s blood
pressure. What would be considered an abnormal response?
The physio will assist you to get the client out of bed to walk to the
sink and brush her hair. When you get to the client the monitor
looks like this.
1. Can you do this activity with the client today?
2. If not, why not?
ICU videos
Introduction to ICU equipment:
1. Before came in the room, need to assessment, do I have enough space to transfer the
2. Before transferring, disconnected temporary medical equipment (but with permission
of nurses and therapists)move along off the way
3. Drain Cerebral fluid from a clientfluid change with body positionrecommend bed
need to be flatted if they are runningask the nurse to close the knob
4. EKG (cardiac)on their chest. Check Blood pressure when sitting them up
5. Temperature devices- connected to the urinary catheter.
6. Check the O2 Saturation -check the nurse. If doctor write keep it >92%. OT keep it
increase. If decreaseddiscontinue treatmentlay them back down
7. Get client out of bed, clear and prepare everything. Prepare chair, put a flat sheet on
the chair (if the client may not get out), blanket instead of pillow (make client sit
taller). Consider location of chair- the lines. And then move the chair after
Coma Recovery Scale – Revised
Orientation Log (O-Log)
Westmead PTA Scale
How might you expect someone to present in the first 48 hours of admission
What changes might you expect (pain, confused, fatigue, disorientation,
fear, consciousness…..)
Consider the setting they are in – where will you see them? (noises,
orientation, bed not comfortable, cannot talk, gastric tube,….)
Team members: Nurses, Doctors.
On the wheelchair bc his LLs are now extended need to make him flex his kneecan
adjust the chair.
Talk to the clients about the chair and more….
Educate family members + get 1 page profile from the family
Lecture 2
Ax and Rx process used at
Brightwater Oats Street
2. 3 Ax used at Oat street:
Rehabilitation Goal Tree
 Attached to Goal Attainment Scale (GAS) to complete the feedback loop
 Need to read up on the GAS as it is often used as an outcome measure in settings
 Measuring outcomes on a 5 point scale
0 = expected outcome
+1 = more than expected outcome
+2 = much more than expected outcome
-1 = less than expected outcome
-2 = much less than expected outcome
The higher the score the better
7 = best
1 = Total Assist
 Outside of circle is independent
 To check the level of independent
Mayo-Portland Adaptability Inventory
Completed by using a team consensus
The lower the score is the better
0 = no problem
4 = severe problem
 Purple: score
 Grey: progress
3. Rx - how to facilitate positive behaviours:
Common barriers:
For the client:
 Intrinsic factors – pain, discomfort, fatigue, physical limitations
 Extrinsic factors – new environment, strangers, loss of control
For the family:
Family understanding – implications of disability, expectations
Family emotional reactions – depression, grief, anxiety, fear
**2 non-verbal pain scales:
1. Checklist of non-verbal pain indicators (CNPI) = see Resources folder: Pain
2. Mobid-2 Pain Scale
Make sure you know how to observe for pain as the person will not always clearly verbalise
that but may have behaviours that indicate pain.
Commonly encountered barriers
1. Loss of self- control
1.1 Lack of cooperation
1.2 Agitation
1.3 Physical and verbal aggression
1.4 Low frustration tolerance
1.5 Sexually oriented disinhibited behaviour
1.6 Impulsivity
2. Physical impairment
3. Mood and thought disorders
3.1 Anxiety
3.2 Depression and grief
3.3 Labile mood
3.4 Social withdrawal
4. Cognitive & perceptual impairment
1.1. Lack of cooperation
What could it look like?
 Unwillingness to follow through instructions, requests, rules
 Depression, lack of initiation, problem solving deficits, pain, anxiety, memory
dysfunction, low endurance, fatigue
 Consider what they are being asked to do - are they being made to do something? Is
what we’re asking inappropriate?
 Evaluate client’s capacities before setting tasks
 Consider premorbid personality
 Don’t mistake for problems with initiation and motivation
 Encourage patient to participate
During Rx:
 Give choices - in controlled manner
 Set environment to facilitate client’s performance
 Be prepared so task can start immediately
 Use positive relationships to encourage participation
1.2 Agitation
What could it look like?
 Poor self-awareness/insight
 Impulsivity
 Drooling/spitting
 Pain
 Sleep disturbance
 Verbal expression difficulties
Environmental changes:
 Altering the physical setting - calm, confident, quiet but appropriate stimulation,
familiar items, visitor limitations, monitor comfort level
 Reducing irritants - e.g. physical needs: pain, full bladder, hunger
 Structured physical activity, walk, exert physical energy
 Changing staff behaviour
Consistent strategies for staff:
 Verbal interactions
 Working as a team
 Physical interactions
 Redirection
 Time-out
 Positive feedback and tangible rewards
 Relaxation
During Rx:
 Voice-reassuring, firm but gentle
 Avoid “over keen”/irritating manner
 Social cues- may miss tone of voice, gesture or expressions that would help monitor
 Directions - give clear picture of expectations, prepare, avoid surprises, don’t touch
without warning, use non-threatening postures
 Personal space - warn, no sudden reactions
Your self-management:
 Recognise own agitation
 Do something about it
Areas of caution:
 Monitor warning signs
 Confronting patient
 Setting unrealistic expectations
 Failure to consider environmental influences
 Abandoning strategies too soon
1.3 Physical and verbal aggression
What could it look like?
 Physical aggression - deliberate direct effort to hurt or to restrict someone’s
freedom of movement
 Sometimes harmful without harmful intent - disoriented, confused, frightened
 Verbal - many forms: depends on vocabulary, personal experience and
disinhibition, shouting, screaming, swearing, insults, sarcasm
General strategies:
 Warning signs - increased talkativeness, pacing, rapid eye movements, abusive
verbal behaviour, extreme confusion, disorganised behaviour
 Avoid panic reactions - contingency plan
 Manage agitation and disinhibited behaviour - so doesn’t progress
 Keep attentive and don’t divide attention
 Consider physical distance
 Don’t give inconsistent messages – yourself and other people
 Don’t ignore the behaviour and just take it - resolve it as a team
 Don’t take the behaviour personally and/or that it has the intent of being hurtful
 Don’t correct behaviour too harshly
 Find out how the behaviour has changed since the injury
During Rx:
 Environmental management
 De-escalation:
o soothing voice
o agree
o redirect attention slowly
o time out
 Strong verbal ‘reprimand’ if hurting someone
1.4 Low frustration tolerance
What could it look like?
 Severe often rapid behavioural reaction precipitated by:
o being placed under pressure
o trying to do something when environment not conducive
o exerting effort without result
o being criticised
 Often mistaken as anger- combination of irritability, aggressiveness, swearing,
throwing things, refusing to continue tasks
 One of the most common following brain injury
General strategies:
 Don’t wait too long to address the behaviour
 Just because it is not wilful doesn’t mean delaying addressing it
 Early implementation of feedback, setting limits, time-out
 Give positive feedback based on effort not success otherwise motivation decreases
During Rx:
 Environmental management
 avoid overstimulation
 moderate challenge level of task
 remember different clients have different ideas about the level of challenge
 Positive feedback - praise efforts
 Set limits for exertion - you know when enough is enough, patient may not
 Teach self-monitoring - teach to monitor and modify their behaviour to meet their
 Programs to reduce stress, be assertive, manage anger
1.5 Sexually oriented disinhibited behaviour
What could it look like?
 Making lewd remarks
 Attempts to touch, hug unwilling others
 Attempts to remove clothing
 Revealing breasts or genitals
 Masturbating in public
 Sexual behaviour with consenting other in public
 Sexually suggestive gestures
General strategies:
 Take action rather than ignore
 Ignoring this behaviour is major reason behaviours persist
 Maintain a professional manner
 Don’t laugh at the behaviour
 Don’t violate confidentiality
 Discuss and prepare others - including family about how to act/react and how to
redirect patient
During Rx:
 Act immediately – as time between behaviour and appropriate response ↑ the
chance of the feedback being effective ↓
 Successful ignoring is difficult - if eventually respond can reinforce it
 Strong verbal reprimand
 If no longer aware of social norms - negative feedback often then not effective
 Time out can be effective
1.6 Impulsivity
What could it look like?
 Acting quickly and without consideration of consequences or purpose
 May compromise own or others’ behaviour
 May be perceived by others as insensitive, offensive
General strategies:
 Reduce safety risks in environment
 Use opportunities to give reminders before behaviour occurs
 Teach effective alternative behaviours
 Use reminders and reasoning vs negative feedback
During Rx:
 Remove potential danger and clutter
 Remind to:
 slow down
 attend to instructions
 to think then respond
 Engrain these behaviours with supervision
 Reminder phrases - slow, listen carefully, think then do, check
 Anticipate impulsive behaviour
 help patient identify the behaviour
 know when it is likely to occur and encourage not to do
 give reminders with repetitive instructions
2. Physical impairment
3.1 Anxiety
3.2 Depression and grief
3.3 Labile mood
3.4 Social withdrawal
4. Cognitive & perceptual impairment
Typical position of stroke:
Lateral flexion towards the involved side with rotation away from the involved extremity
Upper extremity (involved side)
Scapula: Depression, retraction; Shoulder: Adduction, internal rotation, flexion; Elbow:
Flexion; Forearm: Pronation; Wrist: Flexion, ulnar deviation;
Fingers: Flexed, adducted; Thumb: Adducted; Trunk: Lateral flexion towards the
involved side (trunk shortening)
Lower extremity (involved side)
Pelvis: Posterior pelvic tilt; Hip: Internal rotation; Knee: Extension; Ankle:
Plantar flexion, inversion; Toes: Flexion
Short discussion on how this typical posture will impact and guide positioning.
Initially see no tone but eventually see tone increasing
The chances of movement are low when there is prolonged low tone in stroke patients
“We do not know how much you will progress, but we can work together to see how
you can improve”
1. Upward & downward rotation = lateral & medial rotation
2. Protraction & retraction = abduction & adduction
3. Elevation & depression = anterior & posterior tilt
**Important: Know what scale is used for measuring tone: Modified Ashworth Scale (measures
INCREASED muscle tone, NOT decreased muscle tone)
Can measure an increase in tone but not a decrease in tone
Sling post stroke:
Protects client from injury during transfers
Allows therapist to focus on providing assistance to trunk and lower limb during
initial transfer or gait practice
Assist in protecting soft tissues around shoulder from stretching
Prevent upper limb from dangling
May relieve pressure on neurovascular aspects of shoulder (brachial plexus/brachial
Supports weight of the upper limb
Can assist with shoulder pain management
Can contribute to body schema and neglect problems
Encourages learned non use
Holds upper limb in shoulder internal rotation, adduction and elbow flexion–
facilitating shortening
Does not reduce subluxation as alignment of scapula and trunk are not affected
Prevents reciprocal arm swing while ambulating
Blocks sensory input
Prevents use of available upper limb movement and places no motor demands on the
upper limb
Prevents balance reactions of the upper limb
 When will you use a sling?
- When transferring the person
- May not necessarily use when client is in pain as using a sling may result in pain as we do not
want the shoulder in internal rotation, we want it in a natural position
 C-cushion
- Used with high back chair
- Small bit is behind scapula
- Big bit is on the lap, put arm parallel to leg (not in internal rotation)
Shoulder Pain Post Stroke
The shoulder is an essential component of any use of the upper limb; it is a very mobile joint with limited
anatomical protection. The shoulder tends to be neglected in acute management of the stroke patient,
due to the need to attend to medical issues and the patient’s usual initial goal of regaining mobility.
Shoulder pain is one of the common complications following stroke.
Incidence of shoulder pain is reported as high as 84%. A systematic review (2010) on the subject quoted
as many as 72% of hemiplegic patients experience shoulder pain at least once during rehabilitation,
approximately for half of the patients, pain recurred.
Pain can be localised or can radiate down the arm. It may be present at rest or only on PROM or
attempted active movement.
Disuse – Paralysis resulting in muscle weakness and imbalance result in immobilization. Patients spend a
large part of the day sitting with affected upper limb by the side with hand in lap; this can result in
adaptive shortening of the GH adductors, internal rotators, elbow flexors, forearm pronators, wrist and
finger flexors, and thumb adductors.
Subluxation –Traction on rotator cuff musculature and superior capsule may cause pain due to pinching
of the lengthened capsule. Studies have shown patients who have moderate to severe subluxation but
no shoulder pain
Spasticity – Literature has suggested that there is greater occurrence of shoulder pain with patients also
experiencing spasticity versus patients who are flaccid. Other studies have shown evidence that the
mechanism underlying resistance to passive stretch may be a combination of increase in reflex muscle
contraction and a decrease in the compliance of soft tissues.
Central post stroke pain syndrome – Chronic pain following a lesion or dysfunction of the CNS. Cause of
pain is a primary process within the CNS. Highest incidence with spinal cord injuries, but also
significantly with MS and stroke in dorsal lateral area of thalamus.
Age related pathology – Pre-existing shoulder pathology can be aggravated by changes in GH joint
alignment. Decreased painless range of elevation has been reported with increased age, possibly due to
relatively few daily activities requiring full elevation of the arm. Other changes include calcific deposits
in rotator cuff tendons, thinning and fraying of supraspinatus.
Joint trauma during PROM – Capsulitis is known to follow from even relatively minor trauma. Other soft
tissue problems may be rotator cuff tears, biceps or supraspinatus tendonitis or sub acromial bursitis.
Pain and stiffness has been reported as early as two weeks following stroke.
Correlation between shoulder pain and shoulder range of movement, significantly decreased shoulder
abduction and external rotation.
Assessment of risk of developing shoulder pain.
Positioning the upper limb at rest not in GH internal rotation, but in mid-rotation.
Staff and family need to be educated, e.g. they are instructed not to lift or assist by pulling the affected
upper limb.
Encourage active movement, if passively moving the affected upper limb; do not force it to extremes of
To match the appropriate intervention to the patient, there is a need for assessment of pain.
How much?
Team approach needed.
Different approach for the “flaccid” shoulder and for the “spastic” shoulder.
Need to set goals for management of pain.
Aim to restore shoulder alignment, normalise tone, and regular ROM.
Specific handling:
Study by Tyson and Chissim (2002) demonstrated that using an axilla hold when moving the hemiplegic
upper limb allows a greater range of pain free shoulder flexion than a distal hold.
Passive, active or self-ranging with stabilisation, approximation and external rotation at the shoulder will
prevent impingement of structures while lengthening and shortening of muscles through movement.
Throughout the literature are general claims of the importance of upper limb positioning as part of
shoulder management post stroke, but no evidence of guidelines for positioning.
Expert opinion recommends positioning the shoulder in abduction and external rotation.
Upper limb supports are still today basic and do not provide the perfect support or position or joint
alignment for the hemiplegic shoulder. This is due to the complexity of the shoulder, its relationship to
the trunk and the dynamic nature of these during the patient’s day. The optimum is always aimed for
and as each patient is different and individual, trial and error is sometimes the way to go. In the acute
setting support, symmetrical positioning and awareness of the affected upper limb are the objectives in
shoulder care.
Exercises/ Activities:
Literature recommends exercise techniques used should not increase a patient’s pain or cause of pain.
Avoid overhead pulleys.
 What assessments could the OT also consider?
o No formal Ax can be done yet as his PTA score is not perfect
o Cannot be discharged either; “He still has post traumatic amnesia”
o Functional Ax can be conducted
o Ax that could be done after out of PTA (Cognitive assessment of Minnesota (CAM), MOCA,
Cognitive Ax:
Cognitive Assessment of Minnesota (CAM)
Westmead PTA Scale