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Approaches to minimize pain and
maximize function in persons post
CVA
2
 


 Canadian Stroke Strategy: Best

Practice Recommendations and
Performance Measures
 Evidence--Based Review of Stroke
Evidence
Rehabilitation
 Stroke Canada Optimization of
Rehabilitation through Evidence
(SCORE)
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 ^laccid
ƛ No muscle reaction to passive movement
and no voluntary movement and no
reflexive reaction
 High tone
ƛ Velocity dependant increase in resistance
to passive stretch accompanied by
hyperactive stretch reflexes
 


 

 Muscle Imbalance
 ^racture
 Tendonitis
 Glenohumeral Subluxation
 Bursitis
 Adhesive Capsulitis
 Neuropathic (RSD)
¦
  

 Disorganized muscle activation
 ^lexor 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


 

 Occurs in a large percentage of

persons post stroke with flaccid upper
extremity (29-
(29-82%)
 Possibly a reason for development of
pain but inconclusive


 Rotator cuff injury is a possibility

however no studies showing
conclusive evidence of a tear causing
pain
 Also tears found may not be
premorbid
ƛ Questionable cause of pain


  
¦  


 Prevention is the NUMBER 1 action for
health care providers
ƛ There is no one specific treatment for the
reduction and elimination of shoulder
pain post stroke currently
  



 Positioning
  



 Passive range of motion

ƛ Recommended to avoid shoulder ranging
past 90 degrees of flexion and abduction.
ƛ Emphasis on external rotation as
tolerated
 Slings and straps
ƛ Perhaps some benefit to prevent shoulder
subluxation however little evidence for
pain reduction or prevention
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 Active treatment
ƛ Overhead pulleys shown to create pain
ƛ Moderate evidence showing gentle exercises are
preferred approach
ƛ Limited evidence that nonsteroidal anti-
anti-
inflamatory medication improves pain, ROM and
function
ƛ Sustained stretch may be as equally harmful as
immobile position
 decreasing range and increasing pain
 


 Modalities
ƛ ^unctional electrical stimulation
 Conflicting evidence

http://www.google.ca/search?hl=en&q=functional+electrical+s
timulation+shoulder+pictures&meta=


 

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

 CIMT-Constraint induced movement therapy

CIMT-
 Introduced by Edward Taub in the 1960s
after working with deafferented monkeys
 Phrasing learned non-
non-use
 Monkeys unaffected arms were restrained in
slings and affected arms regained
movement


 
 
 
½ ½ 

 222 participants, 3-3-9 month period

 Multi--site, single blinded randomized
Multi
 Inclusion:
ƛ 20 degrees wrist extension, 10 degrees
MCP and IP extension (high function)
ƛ 10 degrees wrist extension, 10 degrees
thumb abduction, and 10 degrees
extension of at least 2 digits (low
function)
½ ½ 

 Glove on for 90% of waking hours to

less--impaired arm
less
 Task practice in lab 6 hours per day,
for 2 work weeks (10 days)
 Conclusion:
ƛ Improved function shown to be retained
24 months after 2 week program in SIS
strength, ADLs, and social participation
¦
¦ 

 
!!"
 Stroke was 12 + months prior
 20 degrees wrist, 10 degrees MCP and IP
extension
 Restraint for 5 hours per day, with 30
minute one-
one-on-
on-one sessions 3 times per
week for 10 weeks
¦
¦ 

 
!!"
 Conclusion:
ƛ Improvement in function and quality of
arm movement
ƛ May be more practical program than
previous studies
¦  

 Ploughman et al. 2008

ƛ Case study from the Miller Rehabilitation
Centre in Newfoundland
ƛ Same parameters as EXCITE trial
ƛ Demonstrated remarkable increase in
function for a hockey loving adolescent
male
^



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

 Outpatient CIMT
ƛ Labour intensive but there is suggested
long term effect
ƛ Modified CIMT may be beneficial
ƛ Possibility for group therapy sessions
ƛ Possible treatment at chronic stage
Questions?