In Stage One, the arm is flaccid. It is lifeless. This is the stage of cortical shock during which most cortical and brainstem neurons are in electrical silence.
The shoulder is generally subluxed and the arm has fallen out of the joint. I have an earlier blog post about some Dos and Don’ts. Most important is Do Not over stretch the shoulder joint! Motion of the shoulder and arm at this time should only be done with the stroke survivor is laying on their back AND the arm should never be brought past about 90* shoulder flexion (the arm is vertical to the body when someone is laying on their back). Over-stretching will damage the tendons and joint of the shoulder!
Often the hand is swollen and puffy looking. It can sometimes look plastic and can sometimes hurt. The most important thing here is routinely touching and massaging the hand. Someone else may need to help the stroke survivor with this.
SITTING OR LAYING ON YOUR BACK
Hand massage– massage the web between the thumb and index for 30 seconds, then gently straighten each finger individually by working down the length of the finger from the first knuckle to the tip of the finger. Continue the massage for a minimum of 2 minutes.
Rotation of the forearm– after massaging the hand, hold it open at the wrist and fingers then rotate between palm down (pronation) and palm up (supination) for a minimum of 2 minutes. End by bringing the wrist into a full extension stretch.
Elbow Flexion/Extension with Pronation Supination– holding the hand at wrist and thumb to maintain an open position, move the elbow into flexion with supination, then into extension with pronation. Continue for a minimum of 2 minutes.
LAYING ON YOUR BACK
It is very important that the stroke survivor is laying on their back for the following exercises. We want Gravity to assist in bringing the shoulder into the socket and stimulating the sensory receptors for the muscles of postural stability. The shoulder blade is stabilized by being in laid upon so shoulder flexion should not exceed 90* at this time.
Ceiling Reach with small circles– An assistant or therapist brings the paretic arm to a 90* flexion angle to the body. Hand-holds should be behind the elbow keeping it straight and at the wrist or fingertips bringing the hand into extension. Maintain this position for a minimum of 2 minutes while doing VERY small circles with the shoulder joint. Carefully lower the arm to the mat, rest and repeat.
Ceiling Reach with elbow flexion/extension– An assistant or therapist brings the paretic arm to a 90* flexion angle to the body. Hand-holds should be behind the elbow keeping it straight and at the wrist or fingertips bringing the hand into extension. Bend the elbow 15* asking the stroke survivor to assist you. Then Straighten the elbow asking the stroke survivor to assist you. Repeat this motion with the arm at 90* shoulder flexion for a minimum of two minutes. Carefully lower the arm to the mat, rest and repeat.
AFTER TIME and PRACTICE WITH THESE EXERCISES, THE ARM WILL BEGIN TO HAVE SOME RESISTANCE TO MOVEMENT (tone) AND EVEN SLIGHT MOVEMENT AT THE ELBOW AND SHOULDER. THAT IS EXCITING! THEN IS IS TIME TO MOVE TO STAGE 2 EXERCISES.