I. Shoulder joint subluxation.
Shoulder subluxation occurs mostly in the early stage of stroke, especially when the whole upper limb is in flaccid paralysis, when it starts to stand or sit, often due to the effect of gravity. Once subluxation of the shoulder joint occurs, the following methods should be used to correct it.
1. The normal range of motion of the shoulder joint should be maintained. These activities not only include passive movement of the scapula and upper extremity, but also involve movement in bed, or transfer to a chair and postural placement in the prone and sitting positions.
2. The activity and tone of the stabilizing muscles around the shoulder joint should be strengthened.
This can be done through weight-bearing activities of the affected arm, which reflexively stimulate muscle activity by squeezing the joint. If the patient takes a sitting position, the elbow joint of the affected upper limb is straightened, the wrist joint is dorsiflexed, the affected hand is placed slightly lateral to the hip level, and then the torso is allowed to tilt to the affected side, using the patient’s weight to put pressure and weight on the joints of the affected limb. The therapist must help with the hand to ensure the correct position of the scapula during lengthening on the affected side.
In addition, the activity of the muscles involved can be induced more directly by careful graded stimulation. The therapist supports the affected arm with one hand by extending it forward, while the other hand gently taps the humeral head upward. The pulling reflex of the elbow increases the tone and mobility of the deltoid and supraspinatus muscles.
The affected arm is kept extended anteriorly and the therapist makes rapid, repeated squeezes through the palm of the affected hand in the direction of the shoulder to keep the patient’s hand extended anteriorly and prevent the shoulder from retracting. The therapist uses the hand to make rapid rubs over the infraspinatus, deltoid and triceps muscles, from proximal to distal. Ice may be used for rapid rubbing, which may stimulate the activity of the relevant muscles.
3. Correct the posture of the scapula.
The therapist may use those activities that move the proximal end of the trunk to release the spastic state of the distal scapula. For example, the hemiplegic side is turned over, the upper extremity of the affected side is weighted, the weight is shifted to both sides, and the scapula is moved. When moving the scapulae to full supination and forward extension, the therapist needs to move the patient’s shoulders forward at the same time, otherwise the healthy side shoulder is backward and the affected side shoulder forward extension is only an appearance.
Good postural placement is important both during the day and at night, and the patient should be encouraged to frequently use the healthy hand to help the affected upper extremity to do full supination. It is important to note that there should be no pain in the shoulder joint and its surrounding structures during the activity. If there is pain, it indicates that certain structures are involved and the treatment approach must be changed. It is well documented that shoulder slings do not reduce subluxation, but rather interfere with posture, braking the upper extremity, increasing flexor tone, and impeding normal gait, so they are generally not recommended. For stroke patients, early and correct management can prevent shoulder subluxation.
II. Shoulder-hand syndrome.
The causes of shoulder-hand syndrome are complex and cannot simply be attributed entirely to loss of motor function or passive arm position. Some of the more recognized causes are
1, the wrist flexion position for a long time pressure, affect the venous return, the hand most of the venous lymphatic return are in the back of the hand, so the early shoulder hand syndrome, hand edema also has the back of the hand mainly.
2. Excessive strain on the hand joints may trigger inflammatory reactions, resulting in edema and pain.
3. Fluid leaks into the tissues of the back of the hand during infusion. Repeated infusions often require the use of hand veins, and medical personnel are generally reluctant to use the healthy hand because that will affect the patient’s self-care in bed, and if the fluid leaks out, it will cause significant edema.
4. Small accidental injuries to the hand.
In the early stages of the syndrome, the best results are achieved when treatment is given as soon as edema, pain, and limited motion appear. Even after several months, if there is an inflammatory reaction, acute pain and edema, treatment is still effective. Once the actual change has occurred and the size and color of the hand has returned to normal, it will be difficult to change the contracture of the hand.
The main goal of treatment is to reduce edema as soon as possible, followed by pain and stiffness. The condition of the hand must be treated as an emergency.
1.Positioning
No matter what position the patient is in, attention should be paid to the placement of the good limb position to avoid prolonged hand droop. In the sitting position, the upper limb should be placed on the table in front. To help with lifting and comfort, a pillow can be placed under the arm. When the patient is moving around the hospital in a wheelchair, a table plate should be placed on the wheelchair or to ensure that the patient’s hand does not dangle on one side.
2.Avoid wrist flexion
To improve venous return and prevent persistent extension of the metacarpophalangeal joint, it is important to keep the wrist in dorsiflexion 24 hours a day. If the patient has significant swelling of the affected hand, a supination splint can be used to keep the wrist in dorsiflexion for 24 hours to facilitate venous return.
3. Compression centripetal winding
For swollen fingers, centripetal compression wrapping can be used, usually by wrapping the finger from distal to proximal end with a 1-2mm diameter cord, starting at the nail and making a small loop, and then wrapping quickly and forcefully until the heel of the finger cannot be wrapped, after which the therapist immediately pulls the wrapped cord away from the loop at the end of the finger. Starting with the thumb, each finger is wrapped once, and finally the palm of the hand is wrapped. This method is easy and safe.
4.Ice therapy
Ice and water are mixed 2:1 and placed in a container. The patient’s hand is immersed 3 times with a short interval between immersions and the therapist’s hand is immersed together to determine the tolerance time of the immersion.
5. Active exercise
The patient should be allowed to do as many active exercises as possible during treatment, even if the hand is completely paralyzed, in combination with muscles that have active function. For example, having the patient lie supine with the upper extremity kept elevated often stimulates elbow extensor muscle activity. Muscle contraction provides a good pumping action to reduce edema. Any activity that stimulates the return of function in the affected limb, especially grasping activities, can be applied, such as wringing a towel with the help of a therapist and grasping a wooden stick and then relaxing it.
Do not do weight-bearing exercises with elbow extension until the pain and edema have resolved; these activities can promote the development of the syndrome. Any activity and position that can induce pain should be avoided.
6. Passive exercises
Careful passive movements of the shoulder joint can prevent the development of shoulder pain. Passive movements of the hand and fingers should also be very lightly rubbed and should not cause pain. In the case of hand edema, the amount of treatment should be appropriately controlled and the therapist should perform the activity with the patient in a supine position with the upper extremity elevated to facilitate venous return. Mobility of the portal joint will return quickly after the edema has decreased and the pain has been relieved.
If necessary. Oral prednisone may be administered.