1. science
2. medicine
3. surgery

Focus on Function: Occupational Therapy
Management of Shoulder Conditions
Anatomy
Christine Griffin, MS, OTR/L, BCPR
Mary Nester, MHS, OTR/L, CHT
Bones
Joints
 4 joints in Shoulder
 Glenohumeral Joint
 Acromioclavicular Joint
 Sternoclavicular Joint
 Scapulothoracic Joint
 False joint as no bone-bone
contact
Copyright Medical Multimedia Group 2001
Copyright Medical Multimedia Group 2003
Glenohumeral Joint
Posterior View Scapula
 Humeral Head much bigger than Glenoid
 Golf Ball on Tee
 Enhances Mobility but compromises Stability
Adapted from Interactive Shoulder, Primal Pictures 2001
Adapted from Interactive Shoulder, Primal Pictures 2001
1
Anterior/Lateral Scapula
Adapted from Interactive Shoulder, Primal Pictures 2001
Posterior Joint Capsule
Adapted from Interactive Shoulder, Primal Pictures 2001
Anterior Joint Capsule
Rotator Cuff Muscles
Posterior View
Adapted from Interactive Shoulder, Primal Pictures 2001
Lateral View
Adapted from Interactive Shoulder, Primal Pictures 2001
Rotator Cuff Muscles
Musculature as it Relates to Function
 Scapula has 16 muscles which attach to it
 Free scapular motion is imperative for free glenohumeral
motion
Anterior View
Cross Section
Adapted from Interactive Shoulder, Primal Pictures 2001
2
Scapula Protractors and Retractors
Shoulder Depressors
Adapted from Rehab of the Hand 5th Ed, 2005
Shoulder Elevators
Adapted from Rehab of the Hand 5th Ed, 2005
Scapula Rotators
Upward Rotators
Adapted from Rehab of the Hand 5th Ed, 2005
Shoulder Flexor and Extensors
Adapted from Rehab of the Hand 5th Ed, 2005
Downward Rotators
Adapted from Rehab of the Hand 5th Ed, 2005
Shoulder Abductors
Adapted from Rehab of the Hand 5th Ed, 2005
3
Shoulder Adductors
Adapted from Rehab of the Hand 5th Ed, 2005
Internal Rotators
Adapted from Rehab of the Hand 5th Ed, 2005
External Rotators
Scapulohumeral Rhythm
The ‘Dance’ between the scapula and humerus during shoulder elevation
•First 30 degrees is
abduction at the
glenohumeral joint
•Remaining arc of
motion occurs
simultaneously as 2
degrees glenohumeral
abduction for every 1
degree scapular upward
rotation.
Adapted from Rehab of the Hand 5th Ed, 2005
Foundation of Shoulder
Biomechanics:Trunk Control
 Alignment of the trunk
Biomechanics
 Foundation of all head, neck, and limb
movement
 Optimal alignment
 Anterior pelvic tilt
 Lumbar extension
 Thoracic extension
 Co-Contraction of Muscles
 Anterior abdominals & Lumbar Extensors→ lumbar
& thoracic extension
 Right & Left Lateral abdominals
(Bohman, 2003)
4
Trunk Malalignment vs. Alignment
Effect of pelvis on upper extremity
 Posterior pelvic tilt→ lumbar flexion→ thoracic
flexion→ scapular abduction→ humerus internal
rotation
 Anterior pelvic tilt→ lumbar extension→ thoracic
extension→ scapular adduction→ humerus
external rotation
Photo from personal collection of Christine Griffin. Used with permission.
Stretch for thoracic/ lumbar ext
 Wedge stretch
 Supine on large wedge
 Two towel rolls in “T” position
 One in lumbar region
 One along spine in thoracic region
Photo from personal collection
of Christine Griffin.
Used with permission.
Wedge stretch
Photo from personal collection of Christine Griffin. Used with permission.
Dynamic Trunk Control
Photo from personal collection of Christine Griffin. Used with permission.
5
Taping
Postural Training
 Kinesio Tape
 McConnell Tape
 Light flexible tape
/Leukotape
 Supports Muscle
 Very rigid, needs 2 layers
of tape to protect skin
 Removes congestion
(edema)
 Corrects joints
 Activates analgesic system
(pain relief)
(Gillen, 2004)
 Stabilizes
 Re-aligns
 Reduce Pain
(Gillen, 2004)
Video from personal collection of Christine Griffin. Used with permission.
Biomechanics of the Scapula
Alignment/ Approximation
• Key landmarks for the shoulder
• Scapula
– Scapula: Acromion, root of the spine, inferior angle
– Humerus: Humeral head
• Scapula has a concave/ convex relationship with the rib cage
• Scapula is a curved surface that easily tilts and moves
• High mobility, Low articulation
– Joint relies on muscle strength for stability
– Post neurological event stability is lost with muscle
– Acromion process is higher that the root of the
spine
– Inferior angle is the against the rib cage
– Sits in neutral plane of elev./ dep., abd./ add.
• Humerus
– Humeral head approximated into the glenoid fossa
(Runyon, 2003)
decreased function
• Reason why upper limb more effected than lower limb
(Runyon, 2003)
Alignment/ Approximation
Shoulder subluxation
 Therapist sitting lateral to
 Malfunction of the rotator cuff muscles
pt.
 Front hand: Approximation of
humeral head into glenoid
fossa
 Back hand: Approximation of
scapula with inferior angle in
forward direction
 “Rotate the globe”
(Runyon, 2003)
 Rotator cuff seats the head of the humerus into the
glenoid fossa
 Remember Anatomy when considering treatment
methods
 Rotator cuff (Internal muscle layer)
 Deltoid (external muscle layer)
 Focus on positioning of scapula first
Photo from personal collection of Christine Griffin. Used with permission.
6
Subluxation Patterns
Prevention of Pain & Complications
 Biomechanics of Scapulohumeral
 Inferior
Rhythm
 In a normal shoulder has 2:1 ratio
 Anterior
 2 parts humeral movement to 1 part
scapular movement
 Superior
(Clarkson & Gilewich, 1989)
(Ryerson & Levit, 1998)
Photos from personal collection of Christine Griffin. Used with permission.
Abnormal scapulohumeral rhythm
Subacromial Trauma
 Scapulohumeral Rhythm with hemiplegia
 DO NOT perform
 over head arm raises
 PROM greater than 60° shld flex or abd
Kumar, et al (1990)
 Will cause subacromial trauma
 Impingement of supraspinatus under coricoacromial
arch
 Increased pressure on subdeltoid bursa
 Impingement of brachial plexus
 Impingement Arterial and venous supply
 Stretching of glenohumeral capsule
(Griffin, 1968; Peat, 1968)
 At most effected state neither portion actively
moves
 With a Non moving scapula & Passively moving
humerus
 Subacromial trauma occurs at 90° shoulder flexion
Kumar, et al (1990)
Superimposed Orthopedic Injures
Brauss, Krauss, & Strobel, 1994
 Lesions of the Rotator Cuff
 Suggests that pain from SHS/ CRPS I is initiated
 Lesions of the Biceps tendon
 Adhesive Capsulitis
 Brachial Plexus Traction Injury
 Impingement Syndromes
(Gillen, 2004)
by a peripheral lesion (tissue or nerve)
 Autopsy data
 Confirmed micro-bleeding of the suprahumeral joint
of the affected side.
 Subacromial trauma
 If cause is peripheral, than prevention program
would be effective
7
Braus, et al, 1994
 Implemented Prevention Protocol:
 Education to prevent peripheral injury
 No PROM before scapula mobilization
 No pain during exercise/ activity
 No infusions into affected hands
 Incidence of pain from SHS decreased from 27%
to 8%
Prevention of Pain & Complications:
Subacromial trauma is preventable!!
 Education is key
 Patient, therapist, staff, family
 Proper Handling
 During ADL’s and transfers
 Avoid inappropriate treatment choice
 Let Active ROM determine a patient’s
Passive ROM limitation
 Positioning in wheelchair and bed
 Safe ROM
(Davis, 1990) (Gillen, 2004)
The Role of OT in Shoulder Treatment
Diagnosis and Treatment of
Orthopedic Shoulder Conditions
“The occupational therapist’s approach to
rehabilitation is a HOLISTIC one that goes
beyond an isolated upper-extremity injury to
include the entire person and each individual’s
functional needs and roles. The ultimate goal is
the client’s return to PARTICIPATION in his or
her daily activities.”
Am J Occup Ther. 2011 Jan-Feb;65(1):16-23
The Role of OT in Shoulder Treatment
 As part of the evaluation process, occupational therapists
identify psychosocial, environmental, and other factors that
may influence rehabilitation outcomes.
CONTEXT IS KEY!!
Common Orthopedic Shoulder
Conditions Treated by OTs
 Acute/Injury
 Humeral Fractures
 Rotator Cuff Tears (10% of time)
 Chronic
 Impingement
 Frozen Shoulder/Adhesive Capsulitis
 Bursitis
 Tendonitis
 Arthritis
 Pain
 Rotator Cuff Tears (90% of time)
8
Continuum of Chronic Shoulder
Conditions
From a treatment standpoint diagnosis does NOT matter,
symptoms are the KEY!!
 Pain with full Range of Motion
 Impingement, Bursitis, Tendonitis
 Pain with Limited Range of Motion
 Adhesive Capsulitis, Frozen Shoulder, Small RC Tear
 No Pain with Limited Range of Motion
 Massive RC Tear
Mechanics of Impingement
 It’s a ‘real estate’ issue
Where to Start??
 Thorough Evaluation
 Distance from Acromion
 Posture
to Humeral Head 1.5 cm
 Abnormal
Scapulohumeral Rhythm
 Range of Motion/Scapular
Mobility
 Strength
 Pain Producing Activities
 Client Centered Goals
Key to Treatment Starts with Postural
Control—Forward Head Posture
 Scapula assumes
abducted, elevated,
anteriorly tilted
position
 Decreases lengthtension ratios of
Rotator Cuff Muscles
which leads to
decreased strength.
Conservative Treatment for Chronic
Shoulder Conditions
 Rest
 Avoid pain
 May lead to further disuse/weakness
 Activity Modification
 Avoid overhead reaching, shoulder flexion > 90 =
impingement
 Pain Management (NSAID vs. Injection)
Photos adapted from Interactive Shoulder, Primal Pictures 2001
9
Conservative Treatment-Evidence
Based Practice
Conservative Treatment for Chronic
Shoulder Conditions
 2010 Systematic Review by Blanchard
 Stretching/ROM
 “The results of this review suggest that corticosteroid injections
 Focus on Posterior Stretching
have greater effect in the short term compared with
physiotherapeutic interventions. This decreased over time, with
only a small effect in favour of injections in the longer term.”
 Small sample sizes in included studies and different treatment
approaches so results must be interpreted with caution
 Avoid Abduction
 Eliminate gravity, work in supine
 Strengthening
 When pain decreases
Blanchard V, Barr S, Cerisola FL. (2010). The effectiveness of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitis:
a systematic review. Physiotherapy. 96(2):95-107.
Conservative Treatment-Evidence
Based Practice
 2009 Systematic Review by Kuhn:
 Synthesized data from 11 randomized trials to determine most
effective treatment for impingement.
 Ultrasound NOT effective
 Heat/Cold effectiveness could not be established
 Manual Therapy combined with exercise most effective
 Developed ‘gold standard’ treatment protocol based on
evidence
Kuhn’s ‘Gold Standard’ Treatment
 Start with Postural Exercises, Shoulder Shrugs, Scapular
Retraction
Kuhn JE. (2009). Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidencebased rehabilitation protocol. J Shoulder Elbow Surg. 2009 Jan-Feb;18(1):138-60
Kuhn JE. (2009). Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized
evidence-based rehabilitation protocol. J Shoulder Elbow Surg. 2009 Jan-Feb;18(1):138-60
Kuhn’s ‘Gold Standard’ Treatment
 Progress to Pendulum Exercises
Kuhn’s ‘Gold Standard’ Treatment
 Progress to Active-Assist ROM then AROM then PROM if
needed
 Assistive ROM can be done with cane, pulleys, other arm
 Try to Eliminate Gravity when Possible
 Manual Therapy Augments Exercise
 Scapular Mobilization
Kuhn JE. (2009). Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized
evidence-based rehabilitation protocol. J Shoulder Elbow Surg. 2009 Jan-Feb;18(1):138-60
Kuhn JE. (2009). Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized
evidence-based rehabilitation protocol. J Shoulder Elbow Surg. 2009 Jan-Feb;18(1):138-60
10
Kuhn’s ‘Gold Standard’ Treatment
Kuhn’s ‘Gold Standard’ Treatment
 Progress to Anterior/Posterior Shoulder Stretching
 Progress to Strengthening
 Theraband, Weights, Push-Ups
Kuhn JE. (2009). Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidencebased rehabilitation protocol. J Shoulder Elbow Surg. 2009 Jan-Feb;18(1):138-60
Rotator Cuff Strengthening
 Takes at least 6
weeks
 Symptom relief
should begin in 4-6
weeks, if no change
by that time consider
longer rest period or
rotator cuff tear
Photo adapted from AAOS Monograph Series
Kuhn JE. (2009). Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidencebased rehabilitation protocol. J Shoulder Elbow Surg. 2009 Jan-Feb;18(1):138-60
Impingement and Night Pain
 Most people sleep on unaffected side, leaving affected shoulder
in adduction.
 Rotator Cuff Vasculature severely compromised in adduction.
 Better position on back with 45 degrees abduction or on side
propped into slight abduction with pillows.
Stock Photos from Krames Patient Education Resource
An Ounce of Prevention
Impingement Surgical Treatment
 Activity Modification
 Failed Conservative Treatment
 Have clients work to identify what triggers pain and problem
solve a workable solution
 Avoid repeated overhead reaching
 Unrelated Injuries often lead to Shoulder Problems
 Disuse
Weakness
 Monitor ALL clients to catch signs early
 Natural History of Impingement
 Acromion Type
 Age, Severity, Duration
 Better results if full ROM
pre-op
 Therapy depends on what type of surgery performed, if
deltoid cut through needs to be protected
11
Rotator Cuff Tears
Therapy Post Op Rotator Cuff Repair
 Supraspinatus most common
 Purpose of Surgery to decrease PAIN
 90% chronic/insidious onset
 Protect repair
 Uncommon in < 40 years old
 Different techniques (open, mini-open, arthroscopic) have different
protocols
 Most occur in tendons that have
been weakened by combination
of:




Age related changes
Minor Trauma
Impingement
Injections
Therapy Protocol Post Op RC
Repair
 1-3 days post op
 Pendulum Exercises, Scapular ROM
 3-5 days post op
 Advance based on strength of repair!!
 Communication with Surgeon!!
Knowing what NOT to do is more
important than knowing what to
do!!
Therapy Protocol Post Op RC Repair
 Avoid Combined Extension and Internal Rotation
 Avoid Combined Adduction and External Rotation
 PROM in all planes except extension (deltoid repair)
ANATOMY IS THE KEY!!
 2-5 weeks post op
 Add gentle PROM shoulder extension
 5-8 weeks post op
 Add AROM, Isometric Strengthening
 8-12 weeks post op
 Add R-C strengthening
Taken from Indiana Hand Center Diagnosis and Treatment Manual (2004)
Humeral Fractures
 Most often in the proximal 1/3 of the Humerus
 Most often result from fall on outstretched hand with a twisting injury
 Radial Nerve Palsy occurs 1/3 of time in Shaft Fractures
Conservative Treatment Proximal
Humeral Fractures
 Immobilize 3-4 weeks
 Sling or Swathe and Sling
 3-4 weeks begin AROM
 4-5 weeks AAROM
 6 weeks PROM
 8 weeks Strengthening
Most patients do well with emphasis on HEP
12
Conservative Treatment Humeral Shaft
Fractures
 0-2 weeks
 Immobilize with Swathe and
Sling
 2-3 weeks
 Humeral Fracture Brace
 Custom vs. Pre-Fabricated
 Address Distal Edema/ROM
Conservative Treatment Humeral Shaft
Fractures
 3-4 weeks
 AROM when fracture stable
 6 weeks
 PROM
 8 weeks
 Strength
These are GUIDELINES, many factor affect healing!
Photos from the personal collection of Chris Bochenek, used with permission
Complications post Humeral Fracture
 Radial Nerve Palsy
 Non-Union
 Is Surgery an Option??
Diagnosis and Treatment of
Neurological Shoulder Conditions
 Stiffness/Weakness
 Impingement
AOTA Guidelines: Intervention for
Hemiplegic Shoulder Complex
 Prevent secondary impairments
 Prevention of postural deformities
 Prevention of pain and other complications associated
with immobility or abnormal joint alignment
 Prevention of learned nonuse
 Restore performance skills
 Structured practice opportunities to maximize emerging
skills
 OT practitioner assess patient’s ongoing changes and
understand kinesiology of effective movement patterns
 Challenge emerging movement without promoting
secondary impairments that limits function
Biomechanicaly safe PROM
 Completed by therapist or caregiver after training
 Range scapula with aproximation of scapular
humeral joint (Runyon, 2003)
 Can be completed by patient
(Sabari, 2008)
13
Range scapula with aproximation of
scapular humeral joint
Range scapula with aproximation of
scapular humeral joint
 Elevation
 Approximate scapula and
humerus
 Perform scapular elevation
with inferior angle between
therapist’s thenar and
hypothenar eminence of
hand
 Have pt. move into posterior
pelvic tilt
 Depression
 Approximate scapula and
humerus
 Therapist places finger
tips on pt’s spine of
scapula
 Have pt move head in
lateral direction away from
you. Ear on non-involved
side to shoulder on noninvolved side
 “Roll your belly back” “Hide
your belly button” “Slouch
and touch your chin to your
chest”
(Runyon, 2003)
(Runyon, 2003)
Photo from personal collection of Christine Griffin. Used with permission.
Photo from personal collection of Christine Griffin. Used with permission.
Range scapula with aproximation of
scapular humeral joint
Range scapula with aproximation of
scapular humeral joint
 Adduction
 Approximate scapula and
 Abduction
 Approximate scapula and
humerus
 Therapist places PIP’s
onto pt’s medial border
 Perform Abduction and
maintain
 Ask pt. to slowly turn head
toward therapist and
reach for therapist’s
shoulder




humerus
Therapist has pt’s axillary in
web space
Perform adduction and
maintain hold
Ask pt. to slowly turn head in
opposite direction
For additional stretch ask pt
to place opposite hand on
opposite hip with thumb
pointing down
(Runyon, 2003)
(Runyon, 2003)
Photos from personal collection of Christine Griffin. Used with permission.
Photo from personal collection of Christine Griffin. Used with permission.
Scapulothoracic Mobilization: Upward
Rotation
Clinical Use of Scapular Mobilization
 Pt in side lying on
 Assess current position of both scapulae
unaffected side
 Use only scapular stretches necessary to achieve
 Approximate scapula
and humerus and
support upper limb
 Therapist places PIP’s
on medial border by
inferior angle
 Perform upward rotation
and maintain
approximation and symmetry of Hemiplegic side
scapula with Non-Hemiplegic side scapula
 (Dale, 2005)
Photo from personal collection of Christine Griffin. Used with permission.
14
Biomechanicaly safe PROM completed
by patient
 “Rock the baby” Cradle arm with trunk rotation to 60°
shoulder abd.
(Gillen, 2004)
Photos from personal collection of Christine Griffin. Used with permission.
Biomechanically safe PROM completed
by patient
Photos from personal collection of Christine Griffin. Used with permission.
Active Scapular Stability
 Lack of G-H joint external
rotation is associated with
pain
 Stretch for External
Rotation
 Lay supine with 45°shoulder
abduction
 Gently rotate to ext. rotation
 Lay forearm on pillow for
prolonged stretch
(Gillen, 2004)
Photo from personal collection of Christine Griffin. Used with permission.
Prevention of Secondary Impairment
of Immobility:Edema
Prevention of Secondary Impairment
of Immobility: Slings
 Combination of mobilization and garments
 Manual edema mobilization techniques
 No difference found in shoulder ROM, pain, or
 Manual lymph drainage, massage
 Garments
 Jobst ®, Isotoner ® gloves, Coban ®, Lymphadema
wrapping
 Elevation alone can lead to guarding and
disuse (Harden et al, 2006; Swan, 2004)
subluxation for pt’s with or without slings (Hurd,
1974)
 “No absolute evidence that supports prevent or
reduce long term shoulder subluxation” “or that a
support will present complications of the shoulder
subluxation” (Zorowitz, 1995)
 Active Motion in conjunction with elevation is
more effective (Barreca, 2003)
15
Prevention of Secondary Impairment
of Immobility: Slings
 Minimize use!!
 Immediate removal
 Pt. becomes dependent
 Avoid slings that position G-H joint in Internal
Rotation
 Investigate alternate means of support
 Lap trays, positioning in bed
(Gillen, 2004)
Postural Training
Taping & Hemiplegic Shoulder
 Conflicting evidence that taping reduces pain
 Ancliffe, 1992
 Hanger et al, 2000
 Griffin & Bernhardt, 2006
 “Moderate evidence that Strapping (taping) does not
improve upper limb function or ROM” with a
subluxation
 Teasell, 2009
 Assist with approximation of joint during AROM
 Need to have muscle activity around joint you are
taping to be affective
 Once taping is applied, complete scapular
stability exercises and gravity eliminated
AAROM exercises
Anterior Hyperlaxity & Inferior Hyperlaxity
Pictures from personal collection of Christine Griffin. Used with permission.
Anterior Hyperlaxity & Inferior
Hyperlaxity
Gravity Eliminated AAROM
 Stability of scapula on
thoracic wall with
emphasis on upward
rotation (Gillen, 2004)
 Improves shoulder
function and
subluxation
Photos from personal collection of Christine Griffin. Used with permission.
Video from personal collection of Christine Griffin. Used with permission.
16
Active Motion - Closed Chain
AAROM with PVC pole
Prevention of Learned Nonuse
 Learned nonuse creates a negative spiral
 Decrease is muscle/ motor activity → decrease
in function → frustration → avoidance of activity
 Use every opportunity to teach patient to
be aware of and use hemiplegic upper limb
in current available motor function
 Continually assess motor potential in
muscle groups
 Gravity eliminated plane
(Sabari, 2008)
Photos from personal collection of Christine Griffin. Used with permission.
Restore Performance Skills
Neuroplasticity
Restore Performance Skills:
Neuroplasticity & Repetitive Practice
• Neuroplasticity  Changing the brain
 High Intensity/ High Repetition → Cortical Changes
 Motivational Strategies for Patient
• Areas of the brain assume functions that were once the
•
•
•
•
responsibility of a damaged area of the brain
Areas of the brain lay dormant until needed to assume
functioning for damaged regions
The ability of neurons to change their function,
neurotransmitter characteristics, and structure.
The brain responds to functional/ environmental demands
Occurs after Repetitive Practice
 Self control vs. External Control
 Patient education
 Importance of intensity of repetition
 Intensive HEP
 Positive Effects of Repetitive/ Task Specific Training






Belnnerhassett & Dite, 2004
Barker et al., 2008
Michaelson et al., 2006
Caraugh et al., 2006
Stinear et al., 2008
Theilman et al., 2004
(Lundy- Ekman, 2007, Gutman, 2008)
Restore Performance Skills
Task Based Practice Opportunities
Neurofacilitation Techniques
 Improved function of hemiplegic upper limb
 Proprioceptive Neuromuscular Facilitation,
when using functional objects and activities
vs. performing similar movement sequences
in he absence of task performance
Wu, Trombly, Lin, and Tickle-Degnen (1998)
Trombly and Wu (1999)
Wu, Trombly, Lin, and Tickle-Degnen (2000)
Fasoli, Trombly, Tickle-Degnen, and
Verfaellie(2002)
 Smedley et al (1986)
 Winstein et al (2004)




Rood, and Brunnstrom Approach
 Evidence “sparse and inconclusive” (Sabari, 2010)
 Based on outdated views of motor recovery and motor control
(Ma & Trombly, 2002; Pollock, Baer, Pomeroy, & Langhorne,
2007; Steultjens et al, 2003)
 Neurodevelopment Treatment
 No evidence of significantly better outcomes for NDT when
compared with other treatments to improve upper limb motor
function (Luke, Dodd, & Brock, 2004; Packi, 2003)
17
Restore Performance Skills:
Motor Recovery and
Electrical Stimulation after Stroke
Electro Myograph Generated (EMG) Triggered
 Must actively move to established threshold to “trigger”
NMES to activate
Client centered
Low
High
Task Specific
Low
High
Cyclic
E-stim
EMGTriggered
E-stim
Functional
E-stim
Stimulation for
Shoulder
Subluxation
• How does it work?
– Set stimulation intensity and EMG threshold
– Electrodes sense trace contraction/muscular attempt
– Device rewards patient with stimulation
 Outcome
 Increased function
 Decreased motor impairment
 Marked increase in reaction time
 Increase AROM
(Hill-Herman, 2010)
(Hill-Herman, 2010)
EMG – Triggered NMES
Functional Electrical Stimulation (FES)
 Cyclic NMES during functional movements and functional
activity
 FES purpose
•
•
•
Adaptive
 Similar to an adaptive device to be used in order to engage in
functional activity
Therapeutic
 Used during therapy in order to retrain brain and muscles how to
work and how to work together
Supplemental
 Can be used above and beyond what is done in treatment and can be
combined with other interventions
(Hill-Herman, 2010)
Photos from personal collection of Christine Griffin. Used with permission.
Functional Electrical Stimulation (FES)
Neuro-prosthesis for FES
 Traditional FES
 Applied to muscles to elicit limb movement in specific
sequence during functional tasks
 NMES units, splints, and other supports may be used
 Patient actively moves limb to engage in activity (task specific
and client centered)
 Neuro-prosthesis
 Orthosis with embedded electrodes
 Custom fit to individual
(Hill-Herman, 2010)
Photos from personal collection of Christine Griffin. Used with permission.
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Shoulder Subluxation/ Surface NMES
NMES – Neuro Muscular Electrical
Stimulation Evidence
 Prevents and reduces subluxation
 “There is strong (Level 1a) evidence that NMES
treatment improves upper extremity function in acute
and chronic stroke”
(Faghri et al., 1994, Chantraine et al., 1999)
 Empi Protocol
 Strongest studies were EMG triggered and FES
 Start at 3 30 min. sessions/ day and progress to a 6-8 hr.
(Teasell, 2009)
 NMES for shoulder subluxation
 “Conflicting evidence that (surface) NMES reduces pain,
improves function and reduces subluxation following stroke”
 “NMES may not help with recovery of the hemiplegic shoulder”
(Teasell, 2009)
session / day
 Rationale
 Re-education of glenohumeral joint
 Repositioning of humeral head
 Improved joint alignment can provide stable base for improved
functional use of upper limb
 Inner layer vs. outer layer
Questions??
References
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