LOSS OF AWARENESS

 Thisis called inattention or neglect

whereby the person is not aware of
the affected side of the body or
environment on that side of the body

 They may not see things placed on

their affected side, know that their
arm is hanging off the side of chair
33
Loss of Awareness

34
 Potential for Injury with Loss of
Sensation and Awareness

The arm and hand can be left in

positions where:

circulation is compromised
tissues are put on prolonged stretch
skin can be burned, caught
between objects or injured in other
ways
35
 These changes can lead to

 Subluxation

 Muscle injury

 Pain

36
 SUBLUXATION

 Subluxationis the dropping of the head of

the humerus down the glenoid fossa

 Ifyou feel your own shoulder, go over the

top of the shoulder and down, press in,
you can feel the head of your humerus
there and there is no gap

37
 Subluxation

 Ina subluxed shoulder you can

feel a shelf that could be as much
as 2 finger widths

38


Photo provided by Lori Blue and

Tuula Jodoin Occupational
Therapists at Sault Ste Marie
Hospital 39
 Reproduced from A Motor
Relearning Programme for
Stroke:Janet H Carr and Roberta
B Shepherd 40
 Contributing Factors to
Subluxation
 Change in posture affecting alignment

 Change in muscle tone reducing

stability

 Muscle weakness and weight of arm

stretching soft tissues
41
 SHOULDER PAIN

 Shoulder pain is a significant issue in

hemiplegia

 Itcan start as early as 2 weeks post

stroke to 2-3 months later

42
 PAIN

 Can occur with

 Subluxation

 Contractures

 Injury to soft tissue – rotator cuff

muscles, ligaments, capsule
43
 Shoulder Pain Arises

 With or without subluxation where the

weight of the arm compromises the
soft tissues by stretching them

 Contractures can lead to stiff joints

that are painful to move

44
 Injury to soft tissue with:

 weight of the arm pulling down

 poor handling and pulling on the arm
 poor positioning of the arm
 pinching of tissue with poor exercise
technique

45
46
 OUR RESPONSIBILITY

As primary caregivers we can:

 Prevent tissue damage

 Prevent pain

 Maintain good joint alignment

and muscle length
47
 PREVENTION IS KEY

 Stretchedcapsular tissue, ligaments

and muscles are not correctable
conditions. These tissues remain in a
lengthened state

 Subluxation is not correctable.

 Pain is difficult to treat and leads to

further loss of movement and
potential functional recovery 48
 TECHNIQUES

 Good handling

 Good positioning

 Useof appropriate aids and

equipment

49
 GOOD HANDLING
TECHNIQUES
☺Prepare
the person for transitional
movements or handling of the arm

☺Tellthem what you are going to do to

promote awareness of the arm

☺Involve them in protecting the arm to

bring their attention to the arm and
activity
50
Good Handling Techniques
☺ Support the arm at both the upper
arm and wrist.

☺ Never lift the arm by the hand, it

does not take any weight off of the
shoulder joint and will cause
stretching of soft tissues

51
 Good Handling Techniques

☺The arms are not handles

☺Never lift through the axilla or pull on

the arm. You are asking an
unprotected joint to support body
weight which will cause injury

52
 Good Handling Techniques
 During bathing and dressing support
the arm and move the joints gently.
The body will respond to how you
handle it.
 Quick movements will increase tone
and can cause pain.
 Keeping movements slow and gentle
can reduce tone and stimulate
activity. 53
 Good Handling Techniques
 Range of motion exercises should not
be done unless you have been
instructed by a therapist on proper
technique.

 Due to the changes in biomechanics

and alignment you can do more harm
than good.
54
 AIDS AND EQUIPMENT

Use a sling when transferring or

standing a person, to support the
weight of the arm

55
Apply the sling correctly

56
 POSITIONING
☺Proper seating assists with achieving
good trunk alignment and position of
the shoulder and arm

☺This helps maintain muscle length,

limit changes in tone and reduce
contractures in the shoulder and arm

57
When the person is sitting, support the
arm on a lap tray, arm trough, pillow or
table

Ensure that the arm is supported and

that the supporting surface is not too
high or too low

58
Elevate the hand to reduce edema

This can be achieved in supine or

sitting

59
 CARE OF THE HAND
 Good hygiene for the hand is
important.

 Often the fisted hand perspires, the

skin peels and there is an odour due
to the lack of exposure to air.

 Fingernails can cut into the skin.

60
 Care of the Hand

 Gentle opening of the hand and

fingers to clean the hand and
between fingers for good skin care
and it provides essential sensory
input to the hand.

 The client themselves can cleanse

the hand if pain is an issue.
61
 Care of the Hand

 Donot put objects in the client’s hand

unless directed by a therapist.

 Oftenthis can increase the tone in the

hand and arm leading to further
problems with hygiene, contractures
and pain.

 Pleaseconsult a therapist if you have

concerns.
62
 PREVENTION IS KEY

 Stretchedcapsular tissue, ligaments

and muscles are not correctable
conditions. These tissues remain in a
lengthened state

 Subluxation is not correctable.

 Painis difficult to treat and leads to

further loss of movement and
potential functional recovery
63
The shoulder girdle is a complex
system but being aware of potential
complications and utilizing good
positioning and careful handling
techniques, can minimize problems
too often seen with the hemiplegic
shoulder.

64
 Thank you !

???Questions???

65
 References
Physical Therapy of the Shoulder. Ed. Robert
Donatelli, Churchill Livingstone 1987.

Soft Tissue Pain and Disability Edition 2. Rene Cailliet,

F.A. Davis Co. Philadelphia, 1988.

Teasell R. et al. Evidence Based Review of Stroke

Rehabilitation 2004.

66