Brief introduction of rehabilitation diseases of shoulder subluxation

Glenohumeral subluxation (GHS), also known as shoulder malalignment, is very common in hemiplegic patients. It shows that the humeral head slips in the glenoid and the acromion appears obvious depression between the humeral heads. GHS may be related to shoulder pain in hemiplegic patients, and may be related to brachial plexus injury, which is a sign of poor prognosis of upper limbs. The reported incidence of GHS varies greatly (0-80%), mostly between 30% and 50%. The etiology of shoulder subluxation in patients with stroke is not very clear, and the main considerations are as follows:

(1) The muscles around the shoulder joint, mainly the supraspinatus and the posterior part of the deltoid, have low function. The muscle paralysis and hypotonia of the deltoid, especially the supraspinatus, are considered as the most important reasons for the subluxation of the shoulder joint.

(2) Relaxation of the shoulder joint capsule and ligament, which is caused by long-term traction at the destruction level.

(3) Due to the paralysis and spasm of the muscles around the scapula and the influence of erector spinae, the scapula rotates downward. Shoulder subluxation does not appear immediately after hemiplegia, but is discovered after sitting and other activities in the first few weeks after illness. In the early stage, patients may not feel any discomfort. Some patients will feel uncomfortable or painful when the affected upper limb hangs on one side for a long time. When the upper limb is supported or lifted, the above symptoms can be alleviated or disappeared. As time goes on, severe shoulder pain can occur, and there are more people with limited shoulder joints than those without subluxation.

Physical examination shows that:

The deltoid muscle of the shoulder collapsed, the joint capsule relaxed, and the humeral head shifted downward and forward, showing mild square shoulder deformity. The joint is hollow, and there is an obvious depression between acromion and humeral head, which can accommodate 1-2 transverse fingers. With the increase of muscle tension and motor function, the above signs can be gradually reduced or even disappeared. Most patients only show temporary relief and disappearance when lifting their upper limbs or when they are nervous, active and exerting strength, and they still show obvious subluxation when they are sitting and sagging without support.

The scapula moves down along the chest wall and rotates downward, and the scapula is inclined downward. With the increase of muscle tension, we can see that the scapula is retracted and the inner edge is raised, which is closer to the spine, especially the lower angle, which is lower than the contralateral lower angle. Holding the lower end of scapula and pulling it outwards and upwards can improve subluxation.

Early passive movement of scapula and shoulder joint can not feel obvious resistance. After spasm, passive exercise can increase resistance, and some patients have shoulder pain and shoulder joint limitation. Due to the loss of muscle protection, excessive stretching will damage the brachial plexus during treatment. Some patients may have scoliosis. There is no recognized diagnostic standard and method for shoulder subluxation, and the clinical method-level radiology method adopted has little guiding significance for rehabilitation and prognosis, and can only reflect the degree of humeral head displacement.

(1) Clinical methods

① Palpation: The patient takes a sitting position, and the upper limbs naturally droop to the side. The examiner palpated the distance between the acromion process and the humeral head of the affected side with the index finger, and indicated the degree of dislocation with the adjusted transverse index.

② anthropometry: measure the distance from acromion process on both sides to lateral epicondyle of humerus with a graduated bipedal gauge.

(2) Radiological method: The patient takes a sitting position, and the upper limbs naturally droop to the side. X-rays of bilateral shoulder joints are taken at an oblique projection angle of 45 degrees, and the vertical distance between the horizontal extension line of the center of humeral head and the horizontal extension line of the center of glenoid is measured, or the distance between acromion and humeral head exceeds 14mm or the difference between the two sides is greater than10 mm. ..

(3) Others: grading Smith method, Van langenberghe method, Poppen method, measuring the descending rate of humeral head, scapular supination angle, etc. In supine position, pad the scapula of the affected side so that it is in the forward extension position, elbow joint is straight, forearm is supinated, wrist joint and fingers are straight; When the patient lies on his side, the affected shoulder stretches forward, bends forward, stretches his elbow, and pronates his forearm; When lying on the healthy side, the affected shoulder and upper limbs are fully extended forward and the elbow joint is extended.

When sitting, put a flat plate in front of the affected limb to lift the affected limb to avoid natural sagging. 1. Load on the affected side: The patient takes a sitting position, turns his head to the affected side, and the healthy hand helps to control the elbow joint extension and wrist flexion. When sitting, the affected hand is placed slightly outside the hip level, so that the body leans to the affected side. Upper limb weight training can stimulate muscle activity by squeezing upper limb joints. The therapist must ensure the correct position of scapula, trunk and shoulder joint by hand.

2. The therapist supports the affected arm to stretch forward with one hand, and taps the humeral head upward with the other hand. Elbow traction reflex increases the tension activity of deltoid muscle and supraspinatus muscle

3. Joint compression: The patient lies on his side, with the affected side above, the affected shoulder flexed, the elbow joint straightened, the forearm supinated and the wrist joint straightened. The therapist puts one hand on the elbow joint, the other hand holds the patient's hand, and the palms touch each other, so that the shoulder joint is pressed along the longitudinal axis of the upper limb, and the patient resists, so that the patient can experience the feelings in this process and gradually learn to resist the therapist's hand.

Rapid stimulation: The therapist straightens his fingers, and makes rapid rubbing or ice compress stimulation on supraspinatus, deltoid and triceps brachii from near to far. It should be done without damaging the shoulder joint and its surrounding tissues. When passively moving the shoulder joint, the passive range of motion of the shoulder joint should be controlled at 50% of the normal range of motion when relaxing. With the increase of muscle strength, the range of motion of joints will increase. Whether in treatment or in the process of daily life transfer, therapists and psychologists should always remember to strengthen the protection of the affected shoulder, and never pull the affected upper limb to avoid aggravating dislocation, causing shoulder pain and increasing the difficulty of treatment.

1, passive exercise training of shoulder-thoracic joint: the patient takes a sitting position, and the therapist supports the proximal end of the affected upper limb with one hand and drags the lower foot of the scapula with the other hand to assist the patient to complete the counterclockwise movement of the scapula. Then move in the opposite direction according to the patient's condition. With the emergence of patients' active exercise, passive exercise gradually changes to auxiliary active exercise and active exercise. Put the patient's healthy hand on the affected shoulder, and tell the patient to complete the movement of the shoulder joint in the direction of his nose, so that the scapula can be extended forward and the abnormal posture of the scapula can be corrected.

2. Shoulder flexion abduction: The therapist supports the scapula with one hand and fixes the upper limb with the other hand, and moves forward and upward according to the motion ratio of the acromioclavicular joint and the scapulohumeral joint of 2: 1. When the shoulder joint moves, the humeral head should be squeezed into the articular fossa. When passively moving the affected arm, the therapist should ensure the correct position of the humeral head in the glenohumeral joint during the whole movement. Promote the control ability of the proximal end of the upper limb and inhibit the distal spasm.

1. The patient is seated in the treatment table, and the patient's hand is placed on the ball for control. The therapist helps to adjust the posture, so that the scapula is as abduction as possible, the upper limbs are stretched forward, and the shoulders on both sides are horizontal.

2. Therapists can talk to patients during maintenance training to distract their attention. For patients with control difficulties, they can help patients keep their wrists stretched and fixed at the distal end. Different exercise modes can be designed according to different functional levels of patients, which increases the difficulty of training.

3. For muscle groups with loose proximal end, such as deltoid muscle, supraspinatus muscle, rhomboid muscle and other middle and rear fibers. Before punching, you can adjust the position of upper limbs in spasticity suppression mode (elbow joint straight, wrist joint extended backward, fingers straight, flat on the treatment table). The therapist presses the affected hand with the thigh to maintain the fixation and stability of the distal end and prevent the impact of percussion on the spastic state. The rhythm of the hitting technique should be fast and the strength should be even.

4, upper limb ball training

5, shoulder strap weight training

1) The patient faces the treatment table and supports his hands on the treatment table. In order to relieve the upper limb spasm, the therapist assists the affected limb in elbow joint extension, wrist joint extension and finger extension, so that the patient's body center of gravity moves forward, the upper limb supports the weight, and then the center of gravity shifts left and right alternately, and the pelvis tilts back and forth to exercise all-round control of the shoulder joint.

2) The patient's back is turned to the treatment bed, and the upper limbs are straightened and supinated, the wrist joints are extended backwards, the fingers are straightened, and they are supported on the treatment bed, and the hip joints and knee joints are straightened, so that the hips leave the treatment bed and the upper limbs are loaded. Move the pelvis back and forth to adjust the weight of the shoulder joint.

3) The patient takes knee and hand position, and the therapist assists the elbow joint of the affected limb to stretch, and adjusts the load by moving the body center of gravity according to the load level of the patient's upper limb. The therapist can apply external force to the scapula, or swing vertically downward, or gently swing back and forth, left and right, so as to fix the distal end of the upper limb, move the proximal end, and relieve the upper limb spasm. Hemiplegic patients will have shoulder subluxation if the muscle tension of the affected side is reduced, but the shoulder muscles can't support the weight of the arm.

1, fitting time: to induce the active movement of the shoulder;

2. The purpose of the patch is to promote the supraspinatus and deltoid muscles and support the arm;

3, posture: the arm is placed on the plane of the scapula and abduction is 45 degrees;

4. Patch shape: I-type spiral patch;

5. Sticking method: the base of the patch is fixed on the back of the scapula, and the rest of the patch is stuck around the upper arm, which is naturally tightened.