Hemiplegia and the shoulder

Shoulder dysfunction is a common post CVA complication. In the acute phase the hemiplegic upper limb is often flaccid, and unless properly positioned and handled during this crucial period, subluxation and joint malalignment can occur (Roy, Sands, & Hill, 1994).
Neurological recovery is most often very rapid in the first three months but continues throughout the first year and beyond. Because of its rapid pace, acute assessment and intervention is very important in predicting future outcomes with recovery.

Relevance to Occupational Therapy
 A patient is referred to occupational therapy because of deficits in the performance areas of activities of daily living (ADL's), work and leisure. The assessment and evaluation process identifies the underlying components (sensorimotor, cognitive, phychosocial) and contextual factos that limit functional performance (Van Dyck, 1999). In the case of the hemiplegic shoulder, only neuromuscular skeletal aspects are looked at in the acute phase. Upperlimb (shoulders, arms & hands) mobility has an important focus to the occupational therapist as it is essential for the basic completion of ADL's. While physiotherapists typically focus on the same performance components but usually in relation to the lower limbs and improving the patient/client's general energy levels. This is why occupational therapists and physiotherapists share such a close working relationship. Walking and improving one's physical endurance after a CVA as well as regaining functional skills are placed in high regard by the patients/client's as well as the health professional. When people ask me for a basic comparison of skill definition between the two groups that is what I usually give. I know that it is generally a stereotypical casting of two professions but it is based on my student experiences. I personally view physiotherapy as like a sibling to OT in the world of allied health.

As stated before, hemiplegia is a common side effect of a CVA. So is unilateral neglect. I will mention this briefly and how it affects recovery in the upper limb after a stroke. Unilateral neglect is a neuropsychological condition which occurs when damage (eg by a stroke) is done to the right cerebral hemisphere side of the brain. This causes a visual perceptual deficit where the person becomes unaware of that side of their body (Menon-Nair, Korner-Bitensky, Wood-Dauphinee & Robertson, 2006). To a client the left side of their body will not exist to them. For example they will bump into things, shave one side of their face (even if their looking in a mirror), or when asked to draw a clock may draw a circle then put all the numbers on one side. Add this side affect to hemiplegia and you've got a recipe where the most robust joint in the body (shoulder) is weak, or heavy or worse ignored due to impaired perception. Add in gravity which naturally pulls us towards the ground. If the shoulder joint is not protected or used during the acute period then deconditioning, pain, immobilization, contractures and subluxation occurs. Contactures are when the muscles and skin around the ground shorten, making full range of motion painful and near impossible. Subluxation is where the muscles and tendons protecting the shoulder girdle weaken against gravity and the humerus bone slowly and painfully dislocates. I saw this once on a client where their clavicle was raised and their arm was just hanging there. There was also this reasonably sized dent in their shoulder that was big enough to stick my finger in (though of course I didnt).

Heres an exemplar picture of a subluxed shoulder: 









So what does an OT do?

• (Re)Education: This starts the minute the client/patient is medically stable and carries through all the way to community services. Eg Involving the impaired side in tasks, educating and reinforcing medical staff on preventative positioning, slow upper body rolling, positioning of shoulder/arm while sitting, indorsing symmetrical standing. 

For a definition on the service of occupational therapy please click here


References


Menon-Nair, A., Korner-Bitensky, N., Wood-Dauphinee, S., & Robertson, E. (2006). Assessment of unilateral spatial neglect post stroke in Canadian acute care hospitals: are we neglecting neglect? Clinical Rehabilitation, 20, 623-634.

Roy, C., Sands, M. R., & Hill, L. D. (1994). Shoulder pain in acutely admitted hemiplegic's. Clinical Rehabilitation, 8(4), 334-40.

Van Dyck, W. R. (1999). Integrating treatment of the hemiplegic shoulder with self care. OT Practice, 31(1), 32-37. 


Picture of cat. Retrieved from http://thenonist.com/index.php/annex/permalink/hemispatial_neglect/ on 04/09/10. Site last updated on 04/09/10.