 Shoulder Pain in Hemiplegia AAPM&R CONFERENCE November 2014 Kris Gellert, OTR/L, C/NDT Cone Health System Comprehensive Inpatient Rehabilitation Greensboro, NC

Shoulder Assessment in the Neurological Patient  Alignment: Head, neck, trunk, pelvis, shoulders  AROM  PROM, includes understanding of mobility at each joint  Muscle tone : Modified Ashworth Scale  Strength: testing conditions  Sensation  Pain  “Quality” of movement; e.g. speed, accuracy, timing, force exerted / effort, ability to recruit or sustain activity, etc

Shoulder Complex  Only one bony attachment to body  Ball and socket joint, but unlike hip  Reliant on muscular and ligamentous attachments for strength / stability

Structure  Bones:  Scapula  Clavicle  Humerus  Joints:  Sternoclavicular,  Acromioclavicular,  Glenohumeral,  Scapulothoracic  Muscles (three groupings)  Scapula to trunk  Scapula to humerus  Trunk to humerus  Tendons / ligaments  Bursa

Function of Shoulder Girdle / Upper Extremity  Tremendous mobility yet lacks stability  Combinations of movements and muscles to position hand for function in any plane (overhead, behind back, in front of body…)  Patients motivated to get UE moving for function. Compensatory strategies are patients’ best attempts for function and movement

What goes wrong?  Head/Neck/Trunk poor alignment  Gravitational forces / weight of arm distracts joint  Muscle inactivity  Muscle imbalance  Muscle over-activity (increased co-activation / spasticity)  Tightness / limited motion

How do we fix it?  Mobilize early (and often)  Activate proximal muscle activity / postural control early  Position for support and protection in bed, sitting, during activity  Work for muscle balance  Maintain joint mobility  Manage edema  Manage skin integrity  Educate patient and caregivers

Strategies  Estim / Standard vs. Interferential current  Taping  Positioning splinting / slings  Edema management  Soft tissue mobilization

Questions?