1. Correct the posture of scapula
Good limb position placement: in the supine position, the affected scapula is padded with a pillow under the scapula, so that it is in the forward extension position, with the elbow joint extended, forearm rotated back, wrist joint and fingers extended; in the affected side lying position, the affected shoulder is extended forward, flexed forward, elbow extended, forearm rotated back; in the healthy side lying position, the affected shoulder and upper limb are fully extended forward, with the elbow joint extended. In the sitting position, a flat table is placed in front of the affected limb to hold it up. When standing or walking, the therapist should fully protect the affected limb to avoid natural drooping.
Bobath-type handshake: extend both upper extremities and lift them up fully, repeatedly, both in the prone and seated positions.
Turning to the affected side: resist scapular retraction to the back.
Active scapular girdle: The patient is in a sitting position with both upper limbs on the side of the body and actively shrugs the shoulders. The therapist stands behind the patient with one hand under the armpit and gives appropriate assistance during the shrug. When the action is completed, the therapist can add resistance to the affected shoulder to make it complete the shrugging action.
2. Stimulate the activity and tension of the stabilizing muscles around the shoulder
Pull reflex: The therapist supports the affected arm with one hand and extends it forward, while the other hand gently taps the humeral head upward. The pull reflex of the elbow increases the tone and activity of the deltoid and supraspinatus muscles. Rapid stimulation: Do rapid and fast friction or stimulation with ice on supraspinatus, deltoid and triceps from near to far.
Weight bearing on the affected side: The patient is seated with the head turned to the affected side, the healthy hand assists in the control to extend the elbow joint on the affected side, the wrist joint is dorsiflexed, and the affected hand is placed slightly lateral to the level of the sitting hip, allowing the torso to tilt to the affected side.
Joint compression: The patient is placed in a lateral position with the affected side above, the affected shoulder joint is flexed, the elbow joint is extended, the forearm is rotated back, the wrist joint is dorsiflexed, the therapist places one hand at the elbow joint, the other hand holds the affected hand with the common hand, the palms touch and apply pressure to the shoulder joint along the longitudinal axis of the upper limb, the patient is confronted, allowing the patient to experience the sensation in the process and gradually learn to resist the therapist’s hand.
3. Protect the full range of painless passive mobility of the shoulder joint
Scapulothoracic joint movement
The therapist fixes the proximal humerus with one hand and the inferior scapular angle with the other hand, and passively completes movements in all directions.
Shoulder flexion and abduction movements
The therapist supports the scapula with one hand, fixes the upper limb with the other hand, and moves the shoulder-humeral joint and the scapulothoracic joint in the ratio of 2:1 motion forward and upward, squeezing the humeral head toward the joint fossa during the shoulder joint motion.
The causes of shoulder subluxation are currently considered in four main areas.
a. Decreased function of the muscles surrounding the shoulder joint, mainly the supraspinatus.
b, laxity of the shoulder capsule itself, destruction and prolongation of long-term strain.
c, paralysis of the muscles around the scapula, spasticity and subscapular rotation due to the influence of the upright spine.
d. Significant atrophy of both the infraspinatus and posterior deltoid muscles and inability to tense the flaccid joint capsule, for which we take a variety of rehabilitation measures to address the causative factors.
Good limb position
The formation and strengthening of abnormal muscle tone is avoided, and the shoulder capsule and ligaments are protected from continued laxity and secondary injury. Whenever possible, the sling is not used in sitting and standing positions or when walking. The sling hinders the movement of the affected limb, increases flexor tone, is not conducive to supporting posture, and hinders normal gait.
Correction of scapular position
Correct the position of the scapula to normalize the position of the articular glenoid to restore the original locking mechanism of the shoulder, such as turning over to the affected side, correcting and controlling the imbalance of the muscles around the shoulder caused by scapular drop, retraction and downward rotation. Passive correction of “winged” scapula. Crossing the arms to raise the scapula; promoting forward extension of the scapula and increasing the tone and activity of the deltoid and supraspinatus muscles through the pulling reflex. Active shoulder shrugging increases the tone and activity of the suprascapularis, relieving the subscapularis spasm and thus counteracting the downward rotation of the shoulder joint.
Stimulation of the activity of the periapical muscles
We applied nerve facilitation and upper extremity proprioceptive strengthening training. Rapid stimulation, which enhances the input of sensory information, excites the peri-shoulder muscles, thereby inducing muscle activity. Through the pull reflex, normal muscle force production is induced, which improves the strength contrast of the muscles around the shoulder, resulting in inhibition of spastic muscles, improvement of paralyzed muscles, and increased stability of the shoulder joint. Joint compression, which causes the patient’s shoulder, elbow and wrist joints to receive proprioceptive stimulation, inhibits abnormal motor pattern elicitation and promotes the establishment of normal motor patterns. It also induces a muscle response, with strong squeezing promoting contraction of the periarticular muscle association and light squeezing inhibiting spastic muscles, resulting in relief of flexor muscle spasm.
Passive activities of the shoulder joint
Passive movement of the shoulder joint should be performed without damaging the shoulder joint and its surrounding tissues. When moving the shoulder joint passively, the range of passive movement of the shoulder joint during the flaccid phase should be controlled at 50% of the normal mobility, and as the muscle strength increases, the mobility of the joint increases. This may cause shoulder pain and increase the difficulty of treatment.
The cure rate of shoulder subluxation in hemiplegic patients who adopt early rehabilitation treatment is significantly higher because early rehabilitation treatment fully protects the normal limb position of the hemiplegic shoulder joint, so that the rehabilitation of the hemiplegic upper limb does not follow the general pattern, i.e. “flaccid – spastic – detached”, but rather “flaccid – spastic – detached”. –The rehabilitation of the hemiplegic upper limb does not follow the usual pattern, i.e. “flaccid – spastic”, but rather the “flaccid – detached” movement pattern. This shortens the rehabilitation time, improves the motor function of the upper limb, and reduces the incidence of misuse and disuse syndrome.