The Arm – No Movement Yet

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. 

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Fact or Fiction: Understanding recovery of movement after stroke

Last week, I presented a talk for stroke survivors affiliated with The Pacific Stroke Association.  Several attendees asked me to post my slides.  I am doing so, but some of the slides may not be entirely self explanatory.

Feel free to contact me with questions.

PSA 3-17

The Subluxed Shoulder – stage one

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:

DO

  • 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

  • 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.