The subluxed shoulder is a common problem post stroke and often treated only with a sling, that really does not offer much support. I think we need to change the way we treat the subluxed shoulder. Historically, weight bearing through the paretic arm has mostly resulted in a painful shoulder. Often the paretic hand is bound / tied to the handle bar of machine that does reciprocal pedaling/rowing/etc. This is really not good for the subluxed shoulder. Every revolution of the handle bar is essentially pulling the arm out of the shoulder joint again.
In my book “Highs, Lows, and Plateaus: a path to recovery from stroke” I talk about the stages of recovery following a stroke. Not everyone goes through these precise stages but it provides a framework. Early on the arm is often flaccid and the shoulder joint becomes subluxed, i.e. the upper arm bone literally slips out of the shoulder socket. A few DO and DO NOT lessons that I have learned:
- Use a sling to keep the arm safe when walking
- Electrical stimulation to the muscles of the shoulder joint is helpful when used daily on a set protocol.
- All exercises for the arm should be done while lying on your back. This provides stability to the shoulder blade and also allows the upper arm to gently glide back into the joint.
- The first exercise is to bring the weak arm gently over head (with help from your strong arm) so that with your hands together, both arms are vertical to the body (90 flexion) and the elbows are straight. Then make TINY little circles with the hands allowing a gentle motion of the shoulder joint. This allows the joint to gently settle into the socket and stimulate the sensory receptors that then excite the muscles around the joint.
- DO NOT Use any type of reciprocal exercise machine for the weak arm!
- DO NOT Put weight through the weak arm – not until the shoulder joint is no longer subluxed out of the socket
- DO NOT Overstretch the arm by having any motion that brings the arm overhead or out to the side. If an overhead motion is made, then the shoulder blade MUST also be rotated to prevent the arm bone from pinching into the front of the shoulder socket
As you do the first exercise the muscles around the shoulder joint will begin to activate again. As the subluxation resolves, the exercises are advanced.
I see so many clients post-stroke who have poor standing balance yet have already begun to “walk”. They don’t actually walk, they “hobble”. Thing is that I have also noticed a lot of people who have never had a stroke also “hobble”, due to back pain.
I think that we have been ignoring the amazing features of the human brain and physiology that allow us to walk upright on two very small bases of support. It is really kind of crazy that two little feet can keep us upright! Well, we have more going for us than our feet…
Balance and upright posture is controlled by sensory interactions within our brains. We do not “think” about balance, we simply balance. This requires that our brain be able to continuously compare input from our EYES, our INNER EAR, and SENSORY RECEPTORS in our MUSCLES. After a stroke…or even an injury to the back… this sensory comparison is all out of whack! It is imperative to recalibrate the brain and the sensory signals it is utilizing.
A simple daily exercise will make a huge difference:
Stand against a wall with your heels touching the baseboard, hips touching the wall, shoulders touching the wall, head touching the wall. Close your eyes. Hold this position for 2 minutes with your eyes closed! It will feel strange. Perhaps difficult and occasionally it may not seem possible. Stick with it. After 2 minutes, open your eyes and then slowly turn your head to the left and then to the right, three times. Returning the head to midline each time.
Do this exercise 3 times per day every day for 2 weeks.
Once this is easy, the do the same exercise while standing in the corner of the kitchen. You will no longer be touching the wall, but instead free-standing as if you were against a wall.
*Always have supervision when doing any kind of balance training* Never try the exercise alone the first time*
When I was actively lecturing on the warning signs of stroke and the need for immediate medical attention, I would get letters from people. Lots of letters. Letters that said thank you for teaching the warning signs of stroke. It is so important to know when to call 911 – because everyday heroes are the ones that can change the outcome for a person having a stroke.
An excerpt from my book “Highs, Lows, and Plateaus: a path to recovery from stroke”
“It is very important for everyone to recognize the signs of stroke, because stroke strikes anywhere, anytime, across age, ethnicity, and socio-economic groups. I have never known anyone who planned on having a stroke. But, I know a lot of people who survived with minimal deficit because someone else recognized the signs and sought help. Unfortunately, in my field of work, I also know a lot of people whose symptoms of stroke went unrecognized. Remember, according to our national statistics, fewer that 7 percent of stroke victims get to the hospital in time for emergency intervention.
The odd thing about a stroke is that the person having a stroke often does not fully realize that anything is wrong. When asked if they are o.k. the person having the stroke quite often says they are fine or makes up a reason to explain their behavior. Remember, it is the brain that is under attack – and this is the same brain that is supposed to be identifying that something is wrong! A brain under attack is going to have to rely on someone else to identify the problem and seek help.”
I had the pleasure of attending Stroke Camp last week in La Jolla California.
I went as a volunteer and also to promote my new book, “Highs, Lows, and Plateaus: a path to recovery from stroke.”
I can honestly say that I gained so much more than I gave! It was a weekend of laughter and camaraderie ~ a weekend of sharing and supporting ~ a weekend of gaining strength from each other. I met some amazing people and have so much respect for the stroke survivors and their loved ones who live each day with the struggles of stroke, and yet they turn those struggles into moments of inspiration and strength.
As anyone there can attest, I cry very easily. Sometimes I tell people that I have “dry eye” and that the lubricating tears are just a side effect of the disorder. Not true. I just cry easily. My daughter says it is because my heart sometimes brims over as tears. At stroke camp, I did not cry tears of sadness. Instead they were tears of release, of celebration for the strength of the human spirit.
Every day we hear about the pain and suffering and cruelty of our world. What I experienced was only love and respect. That is what we need to be shouting from the mountain tops. Not our differences, but our similarities ~ as people. From that we gain strength. Cheers to the Entire Team from “Stroke Camp”. You are everyday heroes !
2014 was a good year… now cheers to 2015!
I wanted to highlight a few successes that some of my clients had in 2014:
K. received a new dynamic ankle brace and is now walking more than ever. He reports that he can feel the muscles in his weak leg getting stronger, and he can walk over uneven ground, up /down stairs easily and finally can say that he enjoys walking again.
C. is using her fingers again! Not quite two years post stroke and she is able to use her hand to help her with all kinds of daily activities. She has returned to work full-time and has also gotten back in the routine of being “mom” in her family now. It was hard having her daughter and husband take care of the baby, but she is back. This year, is dedicated to fine motor control in those fingers!
E. became independent in transferring into the shower, is driving his own van, and is learning to walk again. Not bad for someone who is not even three years post injury to his cervical spinal cord. No need for an electric chair because he can push himself in his new lightweight chair and feels he is getting stronger (below the level of lesion) every day.
S. returned to work full time, is using her right hand for typing and is talking up a storm! She and her family have fought hard. Still a ways to go until this young woman feels satisfied with her recovery, but I have no doubt she will get there.
M. barely survived his stroke, but he is getting better every day. He can stand independently, transfer for showers and walk short distances. Mostly delayed now by distorted vision that makes it hard to move, but he is having a surgical procedure this week that hopes to improve his vision.
Just a few successes. Would love to hear from others about the Highs, Lows, and Plateaus of recovery.
Cheers to 2015!
Rehab gyms across the country, such as SciFit and ProjectWalk are changing the scope of recovery following spinal cord injury and stroke. Rather than focusing on the deficits and problems left by the injury, their focus is on the potential for neuroplasticity and learning within the human central nervous system. Movement recovery depends on a demand for use. Rehab professionals should embrace a change from speaking of the negative “incomplete” and focusing on the positive “partially complete”. This is the only way we can change the dialogue around recovery.
I would love to hear from survivors who have continued to improve and reach their goals despite a negative prediction set by many health care providers.
This morning, my daughter asked me why animals begin walking shortly after they are born but it takes years for a baby to walk? The answer is not as simple as four versus two legs. If it were, then babies would begin crawling shortly after birth! Is it about size? That cannot be right since baby elephants, giraffes, and horses are far larger. Is it about survival? Perhaps. Is it about the complexity of the human nervous system? Most likely. The desire to walk it tantamount in recovery from injury! It is the driving force for much of physical rehabilitation. This complexity of the human nervous system also gives rise to the potential for neuroplasticity.
What are your thoughts on this topic? Would love to hear from you?
It seems that each week, I hear from someone who has been told by their doctor “not to expect any further recovery.” Most recently, I heard this from a young man who had an incomplete Spinal Cord Injury only a few months ago! Such a statement by a doctor is utter non-sense, so I ask myself “Why would someone say that?”. What I have decided is that health care professionals play it safe by not promoting any form of expectation from their patients. If someone is told they will never do anything again, and then they accomplish something they are pleasantly pleased… in fact, they feel that they have beat the odds.
I think we need to let people expect more. We need to instill hope through information and education and resources. No false promises, but rather the opportunity to believe in the power of neurorecovery and the strength and resilience of the human spirit.
Well two months after meeting that young man, he has already made tremendous gains and yet the words of his doctor still haunt him. It will take a long time to diffuse the negativity of comments that are destructive to the potential of hope, handwork and neuroplasticity.
Today is World Stroke Day. It is a day dedicated to increasing awareness about stroke and the warning signs of stroke. Stroke strikes anywhere, anytime, across age, ethnicity, and socio-economic groups. I have never known anyone who planned on having a stroke.
Stroke is the result of disrupted blood flow to the brain. The more technical term is Cerebral Vascular Accident (CVA): cerebral = brain, vascular = blood flow, accident = unexpected. The more attention-catching media term is Brain Attack – much like a Heart Attack. A heart attack occurs when blood flow to the heart is interrupted and the cells that are electrical in nature stop functioning. Likewise, a brain attack occurs when the blood flow to the brain is interrupted causing the cells that are electrical in nature to stop communicating. The symptoms of the brain attack (stroke) will depend on which pathway for blood flow is interrupted and thus the corresponding region of cells whose communication is compromised.
I graduated with my bachelors’ degree in Physical Therapy in 1985. At that time, there was not a lot that could be done in regards to the emergency treatment of stroke. By the time I earned my doctoral degree in Neuroscience and Physiology in 1995 progress was in the making. In February 1996, a clot-busting medication was approved, by the Federal Drug Administration, for the emergency treatment of stroke.
Advances in imaging and drug delivery have helped to lengthen the treatment window for using tPA. Clot-retrieval devices that mechanically reach into a blood vessel to remove the clot have recently come onto the treatment scene and have lengthened the treatment time window. Surgical advances have also been made in the treatment of hemorrhagic stroke.
In 2003, the Joint Commission, a nonprofit organization that accredits and certifies healthcare organizations, joined forces with the American Heart Association and American Stroke Association (AHA/ASA) to begin certification of Primary Stroke Centers (http://www.strokeassociation.org). These centers are certified to provide for emergency treatment of stroke. More than 900 hospitals nationwide have been certified. It may be worth knowing which hospitals in your area are certified.
In 2012 this accreditation process was expanded and the Joint Commission together with AHA/ASA began certification of comprehensive stroke centers. These centers are even more specialized having advanced treatment and surgical tools for the emergency management of stroke.
With more awareness, better treatment and improved follow-up rehabilitation, we can reduce the devastation caused by stroke.
I have been working in NeuroRehab for over 25 years now. Some days are sad days. My daughter says that I am a “Healer”. She says it is o.k. to feel sad sometimes. Helping people along the path of recovery can sometimes be emotionally draining, and I want to cry by the end of the day. Other times it can be so amazingly rewarding that I want to cry, not from sadness but from joy! I have learned to appreciate each day. To notice the little things. To try and be kind to everyone regardless of their race, ethnicity, religion, or socio-economic level. We are all just people. Doesn’t matter how impressive of a life one lives, if it can all be reduced to a common denominator by stroke!