eke ‘The hand is the focal point for movement of the upper limb. Moving and placing the hand is brought about by the functional apparatus ofthe upper limb, which comprises the controlled and complex activation of many muscles, plus mechanical interactions between the glenobumetal (GH) joint. the scapula moving on the thoracic wall and at the clavicle. Muscle attachments between the spine. pelvis, thoracic cage, scapula and humerus add tothe complexity. ‘Afiera stroke that results in severely reduced muscle activa tion, loss of motor control and subsequent immobiliza tion ofthe limb, the potential for development of pain in the shoulder area and wrist, swelling of the hand and sub- Iuyation of the GH joint is considerable in those people ‘whose activity limitations are the most severe. Ealy rha- bilitation should focus primarily on task-oriented training targeting controlled movement of the GH joint, and using clectrical stimulation and mechanical arm trainers when muscles are very weak. These may be the best methods for facilitating optimal recovery of upper limb function and preventing secondary complications (see Kumar & Swin: keels 2009), GLENOHUMERAL JOINT ‘SUBLUXATION Adapiive changes to the soft tissues around the GH jaint ‘may occur in individuals with severe muscle weakness and an immobilized arm, particularly ifthe arm is dependent ff in the same position for long periods (see Fig. 6.88) “The weight of the limb appeats to cause an overstfetching of paretic muscles and other soft tissues that normally would stabilize the GH joint when the arm is dependent (Fig. 114) and displacement of the head of the humerus may occur. Moderate 10 severe weakness of muscles of the rotator cuff leaves joint integrity dependent on passive structures ~ joint capsule, ligaments and inactive muscles. Enrly lengthening of the joint capsule was shown in an arthrographic study reported many decades ago (Migieta etal 1959) Downward rotation of the scapula caused by the weight ‘of the patetc limb has been considered a contributing mechanical cause of subluxation by repositioning the glenoid fossa more vertically (Cailiet 1991). However, a radiological report of a group of people after stroke found no relationship between scapulohumeral orientation and subluxation (Culham et al 1995), and it has been shown, ina recent study of healthy individuals, using a new meas uring device. thatthe scapula is normaly ited downward, (Price et al 2001). There is teally no evidence that altered scapulohumeral position plays a role in subluxation, and extreme muscle weakness or paralysis, adaptive soft tissue 270 “Sonn, He ) She| Newto gical mekor jose a Foe of he lator eral caps secures us Figure 11.4 Mechanism for stabilization of the dependent arm. Wath the atm relaxed by the side, the dovrwtord pl of ‘tat opposed by pasive tension inthe rotator interval ‘Capsule (superior capsule and GH ligament, coracohumera ligament). The resutart of these opposing forces stabilizes the humeral head on the glenoid Tossa. Frm Lexan Pk & Norn CC 2005) le Suc & Function. A Comprehensive Arabs, dtc 9 255 Fa Davis Paci by person) changes flexed thoracic spine plus absence of active am ‘movement remain the probable major contributors to GH rmalaligament (Linn et al 1999). Indeed, there is a ten: dency for subluxation 10 decrease as range of active shou der abduction increases and as significant motor recovery ‘occurs (Zorowite 2001), ‘Whether GH subluxation isa contributing factor in the development of pain in the shoulder region is not clear and remains controversial (Joynt 1992: Lo et al 2003) Some studies have reponed a statistical relationship between subluxation and pain (van Cuwenvaller etal 1986; Roy et al 1995), however several studies report patients with subluxation and no pain, even when sub- luxation was moderate to severe (Ika et al 1998; Zorowitz 2001). Subluxation is fiequently present in patients with pain, severe muscle weakness and activity limitations ~ but ‘Causation cannot be assumed. One possible cause of brief episodes of pain atthe sub. used joint during movement is pinching of soft tissue (suerched capsular and rotator cuff tissue) during active (or passive) movement. Sharp pain on movement at a particular point during movernent (often berween 60° and 120” of abduction}, which may be due to impinge: ‘ment of the humerus on acromion, can be relieved by gentle distraction atthe joint dusing waining, When GH abductor and flexor muscles. ate very weak, reaching actions in flexion and abduction should be practized with Relrladikdion : )pdoncy og om C2 2) we dition . Chur dll Lowiny hmeof the nat the limb supported on a table so that movement of the shoulder can be achieved without impingement (see Fig {6.13}, An elevated position changes the angle/line of pul fof abductor and flexor muscles and simplifies the mechan- ies of the movement, enabling pain-free limb movement even shen muscles are very weak. Active retraining of ‘muscles around the shoulder with smallrange reaching, movements into abduction, external rotation and flexion, with a major focus on controlling muscle activity around the joint, may help in avoiding the negative effects of disuse and misuse, and enable the individual to develop better control of the limbs (Figs 6.13 & 6.14). There is no evidence that supporive devices developed so far are effective in. preventing subluxation (Ada et al 20056, 2008). PAIN Some patients develop pain in the shoulder following stroke, porting pain either over a specifi site or an ache radiating down the arm, The major causes appear related to weakness/paralysis of muscles around the joint, poor coordination of shoulder movement and immobility of the limb for long periods of the day with resultant adap. tive changes in soft tissues. Causative factors include pre ‘existing degenerative or trauma.induced changes in the GH joint area, and trauma occurring to the unprotected shoulder post-strake caused when the person is assisted 10 sit up and stand, Some patients develop pain as part of complex regional pain syndrome (CRPS), reflex sympathetic dystrophy (RSD) br shoulder-hand syndrome. This condition is character ized by pain, stifiess, swelling and discolouration of the involved limb. Repors citing frequency of this syndrome are variable and its cause is unknown, although immobil ity and GH joint inflammation appear to contribute Shoulder pain is most evident in those whose motor Impairment and activity limitations are severe (Chae et al 2007: Sackley et al 2008). Recent studies have found that shoulder pain may occur in about 30-40% of survivors, with the likelihood of increasing overtime inthe 6 months following stroke (Gamble et al 2000; Ratnasabapathy etal 2003; Lindgren et al 2007; Rajarainam et al 2007) Pain can be a factor in poor recovery of upper limb function following stroke - a significant degree of pain can use inhibition of muscle action at the shoulder and discourage participation in upper limb training. Broader effects of pain include diminished quality of life, depres- sion and poor sleep (Chae et al 2007). Localized tender ness over supraspinatus or biceps brachii may be present. Pain may be present at rest or only when the arm is moved Passively or during attempts at active movernent Wide variations in reports of pain incidence may reflect, wre of the investigations carried out (eg svoke SITES +7) methodology, heterogeneity of the populations studied). ‘They may also reflect multifactorial causations, diversity in rehabilitation methods and whether or not early and active motor taining is provided with a mandated cave of shoulder programme. When there is muscle weakness and imbalance around the shoulder, early training should ‘emphasize active shoulder movement. Therapy methods should place emphasis on encouraging controlled contrac. tions of GH external rotator, abductor and flexor muscles and associated shoulder girdle movements within a task specific exercise and raining programme. Surprisingly, focus may still be on the effects of spasticity and its reduc tion (Turner-Stokes & Jackson 2002; Ryerson 2007) instead ‘of on muscle weakness and imbalance, preventing/mit mizing soft tissue stiffness and contracture, training lim movement and, where possible, promoting or ‘driving active functional use ofthe limb. Complexity of shoulder movement. Normally, when. the upper limb isin active use, effective function isbrought about by complex mechanical interactions between sic tures that comprise the shoulder complex ~ humerus, acromion, clavicle, thoracic wall and sternutn, In ofder 10 understand the potential for injury after stroke it is useful to reflect on the complex nature of the shoulder region. ‘Anatomy and biomechanics reflect the complex mobility of the limb. Ginn and colleagues (1997) have pointed out that the mobile base of the GH joint, the scapula, is sus pended feom the skeleton via the acromicelasicular joint and coracocavicular ligament. At the GH joint, the passive structures that provide stability at other joints are designed also 10 facilitate mobility. The articular surfaces of the hhumeral head and the glenoid fossa of the scapula lack congrity, and the joint capsule itself is thin and lax allowing 2-3 cm of distraction between the anicular sur faces. The ligaments are few and provide stability ony in limited ranges of motion, The shoulder region depends fon muscles and their synchronized activity to provide stability Raising the arm may seem a simple action but i is not. For example, during abduction of the arm between O° and 30", most of the movement takes place at the GH joint. After 30° the ratio of GH-1o-seapulothoracic movement is about 5:4, meaning that the humerus moves 5* on the glenoid fossa while the scapula moves 4* on the thorax (Poppen & Walker 1976; Donatelli 2004; Greenfield etal 2004), Even a simple movement at the shoulder isbrought about by the controlled action of many muscles that link humerus 10 scapula, and humerus and scapula to thorax and pelvis (Fig 1.5). Some muscles are stabilizers, others prime movers. Deltaid (middle fibres) and supraspinatus are major abductors of the GH joint (Fig. 11.6) but many. muscles contribute to this action by ensuring the joint movernent is controlled appropriately for the tsk being, carried out. Since delioid is attached to the scapula, muscles linking the scapula to the spine (such as trapezius 21{31 Sarat ane (opps) oper eras | te owes) | Figure 11.5 Muscles ofthe shoulder girdle and major forces acting onthe shoulder gid. gam Fest 1986, with psmisson) ‘Surana ner GH capsule Figure 11.6 Position of deltoid and sunrapinatus with the ‘aim at rest by the side. Inthe position the superior capsule 's taut and the inferior capsule i lack. (rom tevagie Pk Norn CC 2005) ot Structure & Function. & Compehersive [arly ath ep 248, A Das Pade, by peso serratus anterior) act to stabilize and control scapular movement. The pull of the deltoid muscle t0 abduet the aim tends wo displace the humeral head upwards in the ‘lenotd fossa and itis counteracted normally by the mus cclotendinous (rotator) cuff, formed by the blending of i four muscles with the capsule (teres minor, infaspinatus, supraspinatus and subscapularis) (Levangie & Norlin 2005). The rotator cuff stabilizes the humeral head into, the fossa. Attachment of these muscles and of biceps brachii close to the GH joint enhances their role as 272 body function and structure, limitations in activities and participatio stabilizers. Other muscles around the GH joint also con. Usibute to stability of the joint. The application of these combined stabilizing muscle forces at the CH joint, together with the action of deltoid on the humeral hhead, provides the counterforce necessary to abduct the humerus, Effects of weakness, loss of coordination and adap- tive soft tissue changes. The brain lesion impacts the mechanism of the shoulder complex when there is a reduction in descending inputs ta spinal motor neurons and disturbance of motor control mechanisms. When the resulting muscle weakness is severe and the limb is not used, this provokes adaptive changes in soft tissues including increased passive intrinsic muscle stiffness and contracture of the muscles, that are held at a shortened length (see Fig, 6.88), ‘The mechanisms of scapulohurheral coordination and control of the limb are grossly disturbed by muscle weak ness and length-associated muscle and capsular changes. 1 muscles have variable levels of innervation or if there is pain due to impingement or inflammatory processes. an imbalance of muscle forces is evident on any attempt at active movement (Rohannon & Smith 1987). Poor motor control of muscles of the shoulder complex results in altered joint mechanics when the patient attempis 10 ‘move the limb. Changed intersegmental mechanics may bbe a major cause of impingement trauma, and training, needs 10 be carefully caried out to avoid repetitive injury ‘Mechanical derangements can lead to inflammation of the supraspinatus where it crosses the head of the humerus below the actomion, ofthe tendon of biceps brachii in the humeral groove, and bursitis, Inability 10 externally rotate the GH joint actively through range and to abduct the arm seem particularly critical facto in the development of a siff shoulder and pain. Several studies point to significant relationships between weakness of GH external rotators and abductors, diminished range of external rotation (due to increased siffness or contracture of internal rotatars and adductors) and pain (Bohannon et al 1986; Bohannon 1988; Zorow: izeval 1995; Wanklyn etal 1996; Rajaratnam et al 2007). An objective in early habitation is the preservation of ‘musculoskeletal integrity as a means of helping the indi vidual regain optimal functional hand recovery (Shepherd & Care 1998). A major focus of early motor taining. should be on encouraging activation of these muscles, with specific exercises involving external ration with the arm by the sie and elbow flexed and withthe arm straight and resting on a table (see Fig. 6.15). (See Ch. 6 for seiails.) Changes in response to muscle weakness, immobility and disuse are becoming better understood and are described in detail in Chapters 6 and 8, Changes in ‘muscles immobilized in a shortened position include con nective tissue remodelling and reduction in sarcomere‘number, and, if positioning persists and there is minimal regaining of active movement, contracture becomes estab Tished. Changes in muscle morphology and mechanics lead to a marked increase in muscle stiffness and changes in muscle spindle sensitivity can occur. Spastcity has been considered a cause of pain, with the assumption that spastic muscles hold the limb immobi- lized by ‘spastic contracture’ of muscles such as scapula reuractors and GH joint adductors and internal rotators (Bobath 1990; Tumer-Stokes & Jackson 2002). There is no evidentiary suppos for this assumption and a more likely explanation is that resistance to passive movernent is the result of adaptive viscoslastic changes in muscles held short in response to prolonged immobility (see Fig. 6.9 and Ch. 8), Muscles that become shorter and stiffer restrict bboth passive and active joint movement. For example, contracture of GH adductor and internal rotator ‘muscles anchors the humerus tothe scapula and prevents the coordinated scapulohumeral movement that nocmally ‘occurs during movements of the arm, Muscle contracture, reduced range of motion and repeated trauma including Impingement have been shown to be associated with Joint changes typical of adhesive capsuliis in the able- bodied population as well as after stroke (Bruckner & Nye 1981; Rizk et al 1984; Lo et al 2003; Ludewig & Reynolds 2009). A recent study using MRI scans of 89 individuals with poststroke shoulder pain and paresis found that paral rotator cuff teats (particulary age dependent tears of supraspinatus) and tendinopathies (mostly ofsupraspinatus,infraspinatus and subscapularis) were highly prevalent (Shah et al 2008). These findings point 10 the need for a focus on training of rotator Cuff muscles with exercises to improve shoulder dynamics and reduce the potential for wear and tear (Blennerhassett 2009) Pre-existing degenerative changes. Older people may have sustained injuries to the shoulder at some time ot may have developed anbritic and general ‘wear-and tear ‘changes to the GH joint (Ratnasabapathy et al 2003), Degenerative changes in perianicular soft tissues occurring With increasing age include thickening and shredding of biceps brachii tendon; calcific deposits in rotator cull tendons; and thinning and ftaying of supraspinatus muscle (Hakuno etal 1984; Shah et al 2008), Any increase in the angle of thoracic kyphosis with decreased thoracic extension is associated with decreased range of unilateral ‘but particularly of bilateral, arm elevation (Crawford & Jull 1993). In_people with severe thoracic kyphosis, ‘decteased capacity to lift the arms high above the head can influence the performance of both unimanval and biman- tual actions. These findings point to the need 10 take pat ticular cate with the shoulder fiom the time a person, particularly an elderly individual, is admitted 10 acute care following stroke. A gentle stretch ofthe thoracic spine into extension can be applied by a rolled-up towel along the spine (see Fig, 13.5) and may be helpful where the spine is sift Trauma to the unprotected arm. The shoulder without muscle control is virtwally defenseless. Trauma to the Unprotected tim has been implicated inthe cause cof shoulder pain (Cailliet 1980; Wanklyn et al 1996; Turner Stokes & lackson 2002) and capsulitis is known to follow on from even relatively minor trauma in the non- stroke population. In the presence of extreme weakness following stroke, when the limb is moved passively by its ‘own weight as in turning over in bed, or when moved by another person, there is potential for injury due to the absence of normally occurring, protective mechanisms, ‘The altered mechanics caused in part by the limitations fon movement imposed by the altered length of tissue, together with thoracic stiffness, can also subject bone and fof tissue to stresses that cause inflammation, soft tissue damage and pain, Pre-existing tendinopathies or inflam- matory states such as capsultis, tendinitis and bursitis may be aggravated. Potential causes of injury in the hos pital environment inclade: ‘assisting the person to shift position by pulling on for holding the arm poor self-care, for example inattention, so-called ‘negh passive range of movement and pulley exercises. a person with Tete have been few investigations of the environmen tal factors leading to injury. In one study, the authors reported that lifting patients by palling on the arm was a Tathet common occurrence, even when staff had been advised not to (Wanklyn et al 1996). They found that those who most needed help with getting in and out of bed. standing up and siting down on a chair were most likely to suffer shoulder pain, suggesting that assisting by hholding the arm can be a causative factor Passive range of motion exercises to a paralysed arm, including overhead pulley exercises, were implicated in injury oF reactivation of previous inflammatory states in several early studies (Cailliet 1980; Griffin 1986; Kumar et al 1990). Passive movements can cause impingement related pain or repeated minor trauma to muscle bres oF capsule: Impingement of the head of the humerus against the acromion occurs ifthe shoulder is passively or atively abducted without external humeral rotation (Hawkins & Mumaghan 1984) (Fig. 11.7). This can cause inflamma- tion and can put stress on ischaemic or damaged soft tissues. Poor control of muscles that link the scapula to the thorax and spine affect scapula movement, interfering ith rotation and protraction when the arm is moved into elevation. This effect is magnified if muscles. linking scapula to humerus are short and stiff (particularly adduc tor and internal rotator muscles) Difficulties with diagnosis. Despite the fact that shoul: der pain can be a common complication reported after 273 Weed |! Eastroke the cause may not be subject to a careful diagnostic evaluation (eg, X-ray, ultrasound, clinical evaluation) as it would be in a non-stroke population, Similarly, the site and type of pain are rarely presented in published studies, although this may be citcal information, although the causes of shoulder pain are multifactorial and, in indi vidual patients, may not be at all clear, evaluation is required to enable taining to be planned. preliminary study attempting to identify pain-produc: ing structures found that those in the subscromial area appeared to be common sites of pain, perhaps related to inflammation or tauma. or impingement of the head of the humerus against the acromion process due 10 dis turbed shoulder mechanics (Joynt 1992) (Fig. 11.8). Recent studies have reported adhesive capsulitis as a potential cause of pain (Iki et al 1998; Lo et al 2003). Patients with capsultis had restticted passive shoulder extemal rotation and abduction, and a higher incidence of shoulder-hand syndrome, A study of 67 individuals found that the amount of shoulder pain was related mast 10 loss of movement at the shoulder, Amount of pain was unrelated to subluxation, spasticity, muscle stength oF sensation (Joynt 1992). Causes of pain have been sum Figure 11.7 Scopuiar-humeal anatomical relationships: tinal rotation of the humerus during abduction ensures thatthe greater tuberosity of the humerus rotates out of the vray of the acroman process 274 PRET 2) 2025 con st sce aos nace an peicpaon marized as rotator cuff tears, adhesive capsulits, osteoar Uritis,bicipital or supraspinatus tendinitis, bursitis, and as part of complex regional pain syndrome (Zotowitz 2001; Ratnasabapathy et al 2003), Since there are few studies that have examined the cause of shoulder pain in individual subjects poststroke, the best methods of prevention and intervention remain unclear (National Stroke Foundation 2005). Nevertheless, specific subgroups of patients probably require specific interventions (Price etal 2001) and a clinical evaluation is necessary to develop a plan for intervention. Its likely that developments in imaging techniques. and foture investigations will enable a better understanding of shoul der dysfunction In summary, the factors predisposing to the develop: ‘ment of a painful sif shoulder are as follows Paralysis or severe weakness of muscles around the GH joint that results in persistent immobility ofthe Tim. Positioning for lengthy periods ofthe day with the (GH joint in internal rotation and adduction, Adaptive changes 10 soft tissues, for example increased muscle stiffness, and changed muscle fbre length and morphology in response to paresis and. inactivity, gravitational effects and limb position Muscle imbalance causing mechanical derangement during movernent and resulting in impingement of the humenis on the scapula, Compounding effects of, * prestroke degeneration of cartilage, bone and sof tissues around the GH joint Post stroke injury to the unprotected shoulder region of the paretic limb, exacerbating pre ‘existing degenerative changes and causing inflammation of sof tissues, ‘These factors can be responsive to intervention; some could probably be prevented by the newer training Figure 11.8 (A) Without downward siting of the humerat heads anicular surface asthe arm abducts, the head wl ll ‘up the glenoid fossa and impinge an the coracoacromial atc. (8) With downward siding of humeral head os the humerus abducts, a full ange of motion can occur without impingement. rom tevangie Pk Neskin CC (2005) Jont Suture & funcion. A Camprehansie Anais, 4h ed. pp 2 avis Phizseiona, by german!‘methods that ate now increasingly in use as clinical prac: tice evolves. Pain prevention Research has not yet identified the most effective methods ‘of prevention of pain and its weatment. In clinical practice, avoidance of a stiff painful shoulder after stroke depends ‘on awareness of the negative sequelae of muscle weakness. Inactivity and disuse, and of the susceptibility of the unprotected shoulder to injury. We know that a stiff Painful shoulder can occur in those whose stroke has resulted in moderate to severe muscle weakness; we under stand that causative mechanisms are multifactorial and that some could be prevented. The next steps are to inves tigate methods of eliciting potential muscle activi in the ‘+ Early task-oriented training of reaching in all dvections (modited and assisted f necessary) ~ regaining active aortinated movement at the shoulder 8 major jieterent tothe development ofa stiff shoulder. Carell attention is paid 10 GH alignment and to ‘external rotation of the humerus during abduction, Emphasis on actve pain-free exercise for GH external rotation, abduction, flesion and elevation (Figs 6.13 & 6.14). Avoid impingement of the head of the humerus fon the scapula. Fostioning for at least 30 minutes each day siting at Table, with the GH joint in external rotation and abduction (Fig. 119) (Ada et al 20080) plus Task Telated exercises in this position, Pay attention to thoracic spine posture ‘Aim positioning in a wheelcha an an arm trough, "ap board or other arm support Turton & Britton sttoke rehabilitation and recavery (2005) include these interventions, providing the levels of available evidence They stress that particular emphasis should be placed during the acute phase on prevention of shoulder pain and prevention of subluxation, s no clear evidence exists for effective reatments ance they occur Thete is some evidence that positioning during the day can be effective at preventing contracture of internal rotator and adductor muscles, but 10 be effective the Patient also needs active exercise and taining Forexample, a recent study showed that including 30 minutess with the limb positioned in maximum GH extemal rotation on a table plus 10 minutes of task-oriented shoulder exercises, significantly reduced development of internal rotator om tractures ina small group of people within 3 weeks of their stroke compared to a contol group (Ada etal 2005a), Bo Chapter | ‘moderately and severely compromised shoulder region, test the effects of an eatly start to task specific training in lunimanual and bimanual tasks, and test the effects of a programme of care aimed at preventing avoidable injury, pain caused by tauma and immobility. Outcome studies should include data on type of pain and severity, site of Pain, what triggers it, any pre-existing episodes of pain. ‘details of intervention and follow-up. ‘The following box shows an example of a preventive programme with guidelines for shoulder care and early active exercise that should involve all staff and startin the acute care facility. This programme is developed out of ‘current knowledge and, where it is available, from ‘evidence ‘The National Stroke Foundation’s clinical guidelines for acute stroke management (2007) and for £2005) in mid-pronationsupination and GH rotation ‘Avoid prolonged GH internal rotationfadducton, for ‘example in a sing. There is no reliable evidence that 3 sing prevents subluxation (Turton etal 2004), wearing 2 slg is asociated with decreased GH extemal rotation range (Ads etal 2008). a sing i used it shoud be worn for very short periods at time, and staff must be aware of negative consequences Functional electrical stimulation to deltoid and Supraspnatus muscles (Ada & Foomchomcheay 2002) to preventiminimize subluxation Avid damaging events - passive range of mation and self-asisted pulley exercises (Kumar et af 1980), puling on the arm when helping sivto-stand (Wankiyn e1 al 1996), hing on the affected limb Major aspects of training and exercise These ate as follows: ‘+ Therapists need skil in using methods of eliciting and taining muscle activity in muscles such as upper trapezius, serratus anterior, deltoid. supraspinatus, biceps ai triceps brachii, and external rotators of the GH joint, Exercise should slant early, with active concenttie and eccentric ‘exercises, and involve simple modified reaching and ‘manipulation tasks (Fig, 11-10; Figs 6.13-6.15) ‘When muscles are active, intensive taining is likely to inctease contractile strength, the timing and speed of force production, and coordinated action betwee 27513] Body function and structure, Figure 11.9 Examples of positioning to preserve length in shoulder muscles, () sitting ata table, (8) hing down. A Sandbag can be used 10 keep the amin postion a} in this Dosiion, exercises to improve grp strength (particulary of 4th and Sth fingers which are weak). finger extension and pronationtsupination ean be practised the muscles involved, Exercises ae ‘maximum transfer to daily life ‘Task practice is modified 19 take account of muscle vweakness (Fig. 1.10), Pain from impingement may bbe avoided by controlling the limb through small pain-free arcs, gradually increasing this range. The patient is encouraged to practise shoulder shrugging during the day to overcome the dragging effec of heavy weak limb. $k related for Conditions are set up to enable the patient to practise fequenty throughout the day. Motivating strategies help the person fecus atention, concentrating on the task of eliciting and sustaining muscle force while practising tasks. Strapping applied to the shoulder (Fig. 1.11) may help focus the person's attention on contracting the muscles around the shoulder, and the suppom it gives may increase comfort. Strapping has, bbeen shown to limit the development of pain and to decrease pain in the shoulder (Hanger et al 2000 Griffin & Bernhardt 2006) Constraint of the non-paretic limb plus intensive exercise (several hours per day) for the affected limb 276 tations in activities and participation, Figure 11.10 (A) Post stroke: racic of raising the arm and lowering iin an elevated postion, The therapist guides the path ofthe limb and ercaurages her to Keep the arm close by her head as she moves the arm off the pillow and down again. The distance moved is increased as het muscle control raves. (8) Practice of eccentric and concentric activity of shoulder muscles (piinepally pectoral) as she thes to move the elbow to touch the therapist’ finger and to conte an eccentric contraction as she moves the elbow back tothe pilow has been tested extensively as part of the EXCITE trial (Wolf et al 2006, 2007, 2008) in which inclusion criteria required that participants could ‘extend the wrist (10) and fingers (20°). There have been some tests with individuals with moderately severe weakness but some ability to move the limb. Positive results were reported (see Bonifer et al 2005; Ploughman et al 2008) and also in early rehabilitation afer stroke (Dromerick et al 2000) Bilateral actions are also a focus of training (see Ch. 6 fer discussion). Neuromuscular stimulation, used with and without EMG uiggering early in rehabilitation, has the aim ofFigure 11.11 (2,8) Strapping to provide some suppor forthe upper limb. Fixomul stretch tape (BSNmedical) is used under he Sports Tape or Leukopt(2SKimes te. short distance down the scapula cross-pice. (Courtesy of J kAcConnet preserving muscle fbre contractility and stimulating Functional recovery of critical muscles such as supraspinatus and deltoid. Functional electrical stimulation (FES) 1o shoulder muscles may prevent the development of subluxation (Faghi et al 1994 Linn etal 1999) and may reduce existing subluxation (Baker & Parker 1986; Chantraine et al 1999, Kobayashi et al 1999), although evidence is weak so far. FES to posterior deltoid and supraspinatus significantly increased atm function, muscle activity and joint range in one study when compared to a control group (Faghti et al 1998). Patients in the experimental group received FES for 6 outs a day for 6 weeks. systematic review (Price & Pandyan 2001) found evidence of a positive effect in seducing severity of subluxation and in improving pain-free range of passive external rotation but no significant effect on motor recovery of the upper limb. & meta-analysis reported that early application of electrical stimulation that evoked a motor response in deltoid and supraspinatus vas effective to protect the skin. (A) Upper: The fist piece passes aver the front of the shoukler fr 2 pieces are piled upward over the shoulder and held in place by 3 lower jn preventing shoulder subluxation (Ada & Foongchomcheay 2002) Robotic and non-tabotic waining devices to drive or enable active movement in people with severe paresis ate being developed (see Ch. 6). successful such evices could increase independent practice time. The frst study to examine the effects ofa simple EMG: triggered non-robotic devicein taining reaching in patients with severe muscle weakness has shown, significant improvements inall impairment and activity measures tested (Barker et al 2008) (see Fig, 6.21), In conclusion, there is evidence that motor training vith an emphasis on motor learning, taining that includes the use of imagery, electrical stimulation with and without biofeedback and practice of repetitive tasks can be effective in decreasing motor impairment afer stroke, In addition, ‘ate with handling, taining movements in elevation, the Use of stapping and avoidance of overhead pulley exer: cises can decrease or prevent pain in the paretic limb (see Barreca et al 2003 for systematic review) 277