Management of shoulder problems in hemiplegia

Therapy during the flaccid stage
In patients with hemiplegia, ROM of the shoulder is usually lost early, so that preventive treatments begin as soon as possible, usually within the first 1-2 days poststroke. Arm support and preservation of joint ROM is performed through early passive motion. Before active rehabilitation exercises of the extremities are started, suggests initiating trunk motions with side-to-side rolling. As the patient progresses from the supine to the prone position, attempt to maintain the patient in reflex-inhibiting positions. Gradually implement exercises to raise the arm overhead. Upon regaining the seated position, the patient begins gentle weight-bearing exercises through the impaired arm with the elbow and wrist extended, causing glenohumeral joint reduction and proprioceptive stimulation to the shoulder.
ROM should be evaluated often because of the almost daily progression or regression of the completed stroke.Full ROM does not need to be a therapeutic objective but a means for preventing contractures. Also, during passive exercises, the patient should try to assist with motions and hold positions in hopes of encouraging active control of the extremity. Sensory stimulation, as well as NMES, can be used to initiate sensory-motor reeducation. However, if functional gains plateau because of persistent weakness, then attention may need to focus on functional retraining of the unaffected limb or, through the use of assistive devices, on achieving independence with ADL.
Therapy during the spastic stage
A major goal of early stroke management is the prevention of muscle spasticity that could interfere with the patient's potential for regaining function. As muscle tone returns to the hemiplegic limb, spasticity may progressively increase. The use of reflex-inhibiting postures tend to discourage the development of spasticity, contractures, and other undesirable sequela. Even with proper positioning, spasticity may evolve, thus requiring frequent slow stretching, along with the use of splints, to help reduce tone. Overly aggressive stretching should be avoided since it can have a deleterious effect on the treated shoulder by inducing a worsened synergy.
Development of motor control
As hemiparetic limb movements evolve, they show a combination of hypertonicity and weakness, features typical of an upper motor neuron lesion. The recruitment patterns of individual motor units in these affected muscles are slow and inconsistent. The variable degrees of cocontraction of the agonist and antagonist muscle groups cause movements to be slow and clumsy. Because of the importance in coordinating these movements during recovery, multiple approaches have been developed in an attempt to improve functional outcome. More conventional rehabilitation methods involve reeducating weak muscles by strengthening and stretching. But because these methods have produced marginal results, other techniques that attempt to counter the evolution of normal pathological processes and encourage the use of sensory inputs to facilitate muscle activity have been developed.
Neurodevelopmental technique
by the Bobaths for the treatment of cerebral palsy, the neurodevelopmental technique (NDT) is probably the most widely accepted method used in the development of motor control in patients with hemiplegia .It promote normal muscle tone and diminish excessive spasticity through the use of reflex-inhibiting postures are performed and allow the patient to feel normal movements while preventing the use of compensatory motions. This facilitates higher-level reactions and patterns in order to attain normal automatic motor responses that eventually allow the performance of skilled voluntary movement. Reciprocal inhibition also be used to temporarily reduce tone in spastic antagonist muscles through the use of a vibratory stimulus.
Sensorimotor integration
Advocated by Rood, the sensory integration system, as described by Brandstater, involves superficial sensory stimulation and feedback to the affected extremity by means of brushing, stroking, tapping, icing, vibration, sudden or gentle stretching of the muscle, and even electrical stimulation to facilitate muscle activation.
Functional utilization of evolving synergies
Assuming normal stages of recovery following stroke, Brunnstrom encouraged reflex tensing in order to develop flexor and extensor synergies during early recovery. According to Reding, induced synergistic reflexes transition into voluntary activation through central facilitation when applied to physiotherapy. Functional utilization uses techniques such as tonic stretches and voice commands to elicit muscle contractions.
Motor relearning program
Motor relearning by practicing task-specific motor activities while sitting, standing, or walking. Therapists analyze each task, determine which components the patient cannot perform or has difficulty performing, trains the patient in those components of the task, and ensures carryover of this training during daily activities. Brennan has maintained that ultimately, treatment focuses on eliminating unnecessary muscle activity, subsequently expediting skilled motor activities.
Biofeedback
Biofeedback is based on muscular relaxation and/or reeducation by verbal, visual, sensory, or auditory responses. Biofeedback is used in an attempt to relax the antagonist muscles, subsequently allowing the opposed agonists to function more effectively.
Proprioceptive neuromuscular facilitation
Developed by Kabat, Knott, and Voss, proprioceptive neuromuscular facilitation (PNF) involves repeated muscle activation of the limbs by quick stretching, traction, approximation, and maximal manual resistance in functional directions (ie, spiral and diagonal patterns) to assist with motor relearning and increasing sensory input. Brennan asserts that it is based on the principles of normal human development (ie, mass movements precede individual movements, reflexive movements precede volitional movements, developments occur cephalically to caudally, control is gained proximally prior to distally, the timing of normal movements is distal to proximal).
In an attempt to relax spastic antagonist muscle groups, rhythmic stabilization can be used, which involves alternating voluntary contractions of agonist and antagonist muscles. However, Brandstater revealed PNF to be more effective when muscle weakness is not due to upper motor neuron lesions.

Active repetition
active repetition is necessory to maximize motor relearning. The following basic concepts be used during muscle reeducation:

• Patient should visualize (ie, mirror) specific movements.
• Verbally reinforce intended movements and encourage the feel of specific motions.
• Copy similar motions performed simultaneously by the contralateral arm.
• Position the UE to decrease scapular depression and retraction.
• Apply sensory stimulation simultaneously to movements.
• Use prone exercises to stimulate righting reflexes that tend to imitate primitive motor function.
• Start seated and standing stimulation exercises to help decrease subluxation and modify synergy patterns.
• Attempt to increase passive range of motion (PROM) with gentle slow motion, rhythmic stabilization, or voluntary contraction followed by relaxation or gentle stretching.
• Avoid vigorous traction on the arm when stretching connective tissue around the spastic joint.
• Use of electric stimulation can enhance muscle relaxation.
• Use the functional arm to simultaneously train the paretic arm to improve ROM and proprioceptive stimulation.
• Use modalities (eg, ice, transcutaneous electrical nerve stimulation [TENS], vibration) to diminish spasticity.