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.

 

 

 

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Cross-Brain Exercises

I was giving a talk over the weekend to a group of stroke survivors when a woman in the audience reminded me to talk about “cross-brain exercises.”  She had used these types of exercises to help her own post-stroke recovery.

There are lots of websites, You Tube videos, and books about exercises that encourage the two halves of your brain to communicate with each other. This is especially important when one half has been injured!   Historically, these exercises have been used for children to aid in neuromuscular development, but they are great for any brain ~ young, old, or injured.

Just a few ideas:

1. Reach for bean bags, balls, stuffed animals, or other objects across midline, then throw them at a target. You can use your sound or affected hand to do this exercise.  You can also use your feet to kick rather than throw across midline.

2. Draw large Figure Eights (the infinity sign or an 8 turned on its side) on paper or in the air with a finger. While drawing the Figure Eight follow the path closely with your eyes, but do not allow your head to move.  Then try it again, keeping your eyes quiet while allowing your head to move as you follow the Figure Eight.

3. Strength and coordination training of the sound hand or leg has been shown to be beneficial for affected / weak side. Practice lifting a weight with one hand and then placing it on the opposite side of the body without switching hands. Or lift a weight on your ankle and cross your leg over to the other side.

4. Touch the opposite elbow and to knee. You can begin by touching your elbow the the strong side to the knee of your weak side, and then vice versa.

5. Cross one foot over while sitting, then alternate.  To make this more difficult, cross one foot over the other while standing against the wall, or if you are doing really well over the other while walking sideways.

6. Windmills-Stand with feet spread apart and arms extended out to the sides. Bend over at waist and tap right hand to left foot or knee. Stand back up and then bend and tap left hand to right foot or knee.

Those are a few ideas.  You can also do cognitive exercises such as:

  1. Working puzzles.  Start with a 32 piece puzzle and work your way up to a 500 piece puzzle as you get better at it.
  2. Work on “hidden word puzzles”
  3. Play card games

The basic idea is to use your brain daily. If movement is limited, do the best you can to cross body, cross brain. Be creative!!

Options for ankle bracing

Why is the ankle so difficult to recover function after a stroke?  There are a lot of reasons that circle around the neurological control of the ankle, the complexity of the ankle joint, and problems with sensory awareness after stroke.  If you think about it, it is pretty cool that a foot and skinny little ankle can support our entire body all day long!

So, I really do not like the plastic molded ankle joints that so many people are sent home with!  They make NO sense to me.  They are rigid, have no energy storage, block sensory signals from the foot, block the natural motion of the foot bones and they are just plain ugly.  I think it is time we all start demanding that stroke survivors be fit with dynamic, energy storing ankle braces.

There are a lot available, but here are the four I have worked with just this week and have been very pleased with how well they work in not only providing support to the ankle, but providing for a dynamic, energy-storing system that actually helps one learn to walk again.

 

 
 

 

Please note that this information is provided for educational purposes and does NOT provide endorsement of any particular device.

Get rid of the rigid AFO

The rigid AFO serves a purpose early in rehabilitation following stroke.  It provides stability to the weak leg, allowing people to safely stand and transfer.  This rigid AFO, however, is NOT the ankle brace that should be used when one is learning how to walk again.  It is time to start demanding that ankle orthosis be made so that a hinged ankle and some form of dorsiflexion assistance can be added once the survivor is ready to learn to walk.  Using a rigid ankle brace almost demands that the person learn to walk with a stiff leg, that is thrown forward with hip hike and circumduction.  One cannot bend the knee for walking if the ankle is fixed!  Simple biomechanics.   So, how do we change the way Therapists, Physicians, and Orthotists approach the ankle??

Making new speech areas in the brain?

I am not a speech therapist and have no real training in speech therapy… and yet I think about speech rehab all the time.  I see clients who post one year have not yet regained their speech following a stroke and I wonder if maybe the wrong approach is being taken.  Instead of trying to “regain” speech, maybe they need to learn speech again.  Like learning a foreign language!  Building new speech centers in the brain!  I have had several clients tell me that they benefited from foreign language tapes and from programs like Rosetta Stone.  The language they “learned” was English.  Yep, just as if it was a foreign language.

I would love to hear what others have done for their speech therapy and recovery.  The more we share with each other, the more empowered all stroke survivors will be.

Getting the fingers working again!

So, I have decided that getting the fingers to work again after a stroke is one of the greatest challenges.  I would love to hear from people about what worked for you.   Fine control and dexterity are so uniquely human!  I have recently been studying the literature about how babies and young infants gain control of their finger function. Truly amazing how the brain and body interface goes from shoving a fisted hand into the mouth, to tying shoes, playing the piano, typing, and having unlimited motion and control at our fingertips.  Tell me your story so that we can then share it with other stroke survivors!