How to deal with the common complications of stroke?

Some complications are easy to occur after stroke, among which shoulder subluxation and shoulder-hand syndrome are more common.

1. Bile bleeding is one of the most common complications of cerebrovascular diseases, with an incidence of 60%~70%. Subluxation usually occurs in the hypotonia stage of Bronnstrumⅰ-ⅱ, which does not cause shoulder pain, but it is easy to cause shoulder injury and then pain, so it should be paid attention to in treatment.

(1) Etiology and pathogenesis The shoulder joint is a ball-and-socket joint composed of the glenoid of the scapula and the humeral head. The humeral head is large, the glenoid is small and shallow, and two-thirds of the humeral head is located outside the glenoid. Although this is beneficial to the large-scale movement of the shoulder joint in all directions, it will reduce the stability of the shoulder joint. Strong muscles around the shoulder joint can partially compensate for the lack of stability. Under normal circumstances, the glenoid of the scapula is forward and outward. This upward inclined glenoid structure plays an important role in preventing downward dislocation, because when the humeral head is displaced downward, it must first move outward. When the upper limb is in the retracted position, the upper part of the joint capsule and the coracoclavicular ligament are tense, which passively prevents the lateral movement of the humeral head, thus preventing downward dislocation. It is called "locking mechanism of shoulder joint". When the upper limb is loaded, the supraspinatus muscle strengthens the horizontal tension of the joint capsule. When the upper limb is abducted, the locking mechanism no longer works. Because the upper part of the joint capsule will become slack when the upper limb is abducted or stretched forward, the stability of the shoulder joint must be ensured by muscle contraction, and the stability of the joint depends almost entirely on the rotator cuff muscles.

The causes of shoulder subluxation in hemiplegic patients are not clear, and the following aspects are currently considered:

1) Loss of shoulder locking mechanism: During cerebral palsy, due to the decrease of muscle tension of the serratus and trapezius, the scapula moves downward and rotates downward under the gravity of the upper limb, resulting in the humerus being in the outer booth relative to the changing scapula, destroying the "shoulder locking mechanism" provided by the normal upward inclination of the glenoid, and making the humeral head.

2) Low function of fixed muscles around the shoulder: Paralysis of muscles around the shoulder, mainly deltoid muscle, especially supraspinatus muscle, is considered as an important cause of shoulder subluxation. These muscles can produce shoulder subluxation under the traction of upper limb weight after paralysis.

3) Improper nursing: Patients with flaccid paralysis often fail to give proper protection to the shoulder joint during the process of turning over, sitting up and transferring, and even pull the affected upper limb when helping, which is often an important cause of shoulder subluxation.

(2) The clinical manifestations of shoulder subluxation do not appear immediately after hemiplegia, but only after the patient begins to sit and stand, and the patient may not feel discomfort in the early stage. Some patients may feel uncomfortable or painful when the affected upper limb hangs sideways for a long time. When the upper limb is supported or lifted, this pain can be relieved or disappeared. Physical examination showed that the supraspinatus deltoid muscle was obviously muscular atrophy, the joint capsule was slack, and the humeral head was displaced downward, showing a square shoulder deformity. The glenoid is empty, and an obvious depression can be felt between the acromion and the humeral head. Seen from the back, the scapula moves downward along the chest wall, rotates downward, and is close to the spine. The lower angle of the scapula is obviously adducted, and the inner edge of the scapula is pulled away from the chest wall lower than the other side, becoming a "wing-like" scapula.

(3) inspection method

1) Palpation examination: The patient takes an upright position, the trunk remains stable, and the upper limbs naturally hang down to the sides of the body. The therapist touches the depression between the acromion and the upper part of the humeral head with the index finger, and judges with the width of the transverse finger as the unit, and records it as half transverse finger, transverse finger and transverse finger.

2)x-ray inspection:

① Check posture: The patient takes a sitting position, with the upper limbs naturally drooping and the palms facing the body.

② Projection method: The center height of X-ray tube is consistent with the lateral upper edge of clavicle, and the midline is consistent with the midline of humeral head. The inclination distance of the ball to the foot is 15, and the distance is1m. Under the same conditions, the bilateral upper limbs were projected, and the gap between acromion and humeral head was measured and compared bilaterally.

⑷ Diagnostic criteria

① The depression can be touched under the acromion; ② The gap between the diseased acromion and humeral head on the bilateral shoulder joint radiograph is larger than 14mm, or the gap between the diseased acromion and humeral head is larger than 10mm or more compared with the healthy side.

⑤ Treatment

1) therapeutic purpose:

① Correct the position of scapula and restore the original locking mechanism of shoulder joint.

② Stimulate the activity and tension of the muscles around the shoulders that play a stabilizing role.

③ Keep the painless passive range of motion of the shoulder joint without damaging the joint and its surrounding structures.

④ Protect the fragile shoulder joint during the treatment and nursing.

Treatment:

① Correcting the position of the scapula: The key to correcting the position of the scapula is to restrain the muscle tension of the muscles that make the scapula sink, retreat and rotate downward and increase the mobility of the scapula. Therapists can relieve scapular spasm by moving the scapula to the hemiplegic side and shifting the center of gravity to both sides by stretching the elbow. After correcting the position of the scapula, they should train the active movement of the scapula. Enhance the mobility of the scapula, for example: the patient takes the supine position, the shoulder joint bends 90 degrees, the elbow joint extends, and the upper limb reaches the ceiling upwards and returns to the original position downwards to complete the adduction and abduction movement of the scapula; Or the patient takes a sitting position, crosses his hands, hangs his upper limbs in front of him, and shrugs his shoulders on both sides to complete the lifting of the scapula.

② Stimulate the muscles around the shoulder joint: All methods to stimulate the recovery of upper limb motor function, such as roller movement and table cleaning movement, can be used to activate the muscles around the shoulder joint. It is a very effective method to stimulate muscle activity by squeezing the upper limb joints under the load of the affected upper limb. In addition, the therapist can use the method of squeezing joints to stimulate muscle activity around the shoulders. The specific method is: the patient sits, and the upper limbs naturally droop. The therapist holds the patient's upper arms with both hands, and at the same time, the shoulder joint rotates outward and then rotates back to the original position. After several repetitions, the humeral head may be pulled back to the glenoid.

③ Maintenance of painless full range passive range of motion of shoulder joint: Patients with shoulder subluxation are prone to shoulder pain and limited joint motion, so it is very important to maintain painless full range of motion of joint. Therapists should pay attention to that once pain occurs, they should immediately reduce the range of motion or change the support method, correct the position of the scapula and fully support the shoulder joint, which can usually solve the problem.

④ Protecting the shoulder joint that is easy to be injured: During the treatment and nursing, we should pay attention to protecting the shoulder joint, not only to avoid causing pain when passively moving the upper limb or carrying out other therapeutic activities, but also to protect the shoulder joint when helping the patient move in bed or transfer to a wheelchair, and give support to the affected upper limb when sitting. When sitting in a wheelchair, it is more controversial to suggest using a wheelchair table. Not only is the effectiveness of the sling questionable, but the use of the sling may also have many adverse effects, which can be summarized as follows.

A. Aggravate the patient's agnosia of the affected upper limb, so that the affected upper limb is functionally separated from the whole body movement.

B. The spasticity pattern of the affected upper limb is aggravated or strengthened.

C. When the body posture or balance is impaired, it will hinder the reaction ability of the affected upper limb.

D. When walking, the compensatory swing of the affected upper limb is hindered.

E. it hinders the input of normal senses.

F due to braking or oppression, it is not conducive to the circulation of blood and lymph.

2. Shoulder-hand syndrome (SHS) is also called "reflex sympathetic dystrophy".

(RSD) is a common complication after cerebrovascular disease, which is more common in 1~3 months after stroke, and the incidence rate is about 12.5%~32.0%. Its typical manifestations are hand edema and pain, skin temperature increase, hand muscle atrophy and even contracture deformity after swelling.

(1) Etiology and pathogenesis The pathogenesis of shoulder-hand syndrome is still unclear. At present, there are several possibilities:

1) Sympathetic nervous system dysfunction theory: Sympathetic nerves dominate the vascular motor system and skin glands. When stimulated by painful brain lesions and other emotional changes, the vascular movement system and skin glands will be dysfunctional, which will lead to local congestion and edema.

2) Shoulder-hand pump dysfunction theory: Moberg thinks that the blood return of shoulder and hand depends on shoulder pump and hand pump, and the power of shoulder pump and hand pump comes from muscle contraction. After paralysis, muscle activity is weakened or disappeared, and blood backflow lacks motivation, which leads to edema at the distal end of the upper limb.

3) Continuous flexion and compression of the wrist joint: When the patient is in bed or in a wheelchair, he may not notice that the wrist joint is in excessive palm flexion. Angiography proves that excessive wrist bending will hinder blood return. When the patient is sitting in a wheelchair, because his weight leans to the affected side, it will further compress the wrist joint and further hinder venous return.

4) Wrist hyperextension: During the treatment, the patient's wrist may inadvertently exceed the normal range of joint movement, thus damaging the joint and surrounding tissues.

5) Intravenous infusion: When intravenous infusion is needed in acute phase, many nurses like to use intravenous infusion on the back of patients' hands to free their healthy hands. If the fluid seeps into the surrounding tissues during infusion, obvious edema will occur.

6) Accidental injury of the injured hand: If the injured hand touches the overheated container and burns when it falls to the affected side, it may cause edema of the injured hand.

(2) Clinical manifestations and stage ⅰ: The patient's hand suddenly swelled, and soon there was obvious activity limitation. The edema on the back of the hand is the most obvious, usually ending at the wrist joint near the end, and the skin wrinkles disappear, which makes him feel soft and swollen when touching the affected hand. The color of the hand turns orange or purple, especially when the affected arm hangs to one side; The skin temperature of the affected hand is higher than that of the healthy side, sometimes it feels wet and the nails become pale and opaque; The affected shoulder joint and wrist joint are painful, and the range of joint movement is limited, especially the flexion of metacarpophalangeal joint is obviously limited, the bony process at metacarpophalangeal joint is invisible, the abduction of fingers is seriously limited, the proximal interphalangeal joint is stiff and swollen, and it can hardly flex or fully extend, while the distal interphalangeal joint is extended, and passive movement can hardly or hardly flex, which is easy to cause severe pain. The first stage usually lasts three to six months.

Stage II: Shoulder pain and hand edema are relieved, the skin and muscles of the affected hand are obviously atrophied, and the palmar aponeurosis hypertrophy similar to palmar aponeurosis contracture often occurs, and the movement of finger joints is increasingly restricted. X-ray fluoroscopy showed osteoporotic changes in the affected hand, and the hard protrusion between the dorsal carpal bone and the metacarpal joint area was visible to the naked eye.

Stage III: Edema and pain can disappear completely, but the joint mobility is permanently lost and fixed in a typical deformation state, as follows:

① The wrist flexes in the palm and deviates to the ulnar side, and the dorsiflexion is limited, and the protrusion on the wrist bone is harder and more obvious.

② Forearm supination is severely limited.

③ The metacarpophalangeal joint can't flex, and the atrophy between thumb and forefinger is inelastic.

④ Proximal and distal interphalangeal joints were fixed in mild flexion position, even if they could be flexed, they were in a small range.

⑤ Palm is flat, thenar and thenar muscles atrophy obviously.

(3) At present, there is no unified and recognized diagnostic standard for shoulder-hand syndrome. Ueda believes that if stroke patients have shoulder pain and swelling of upper limbs and fingers, whether finger pain occurs or not, they can be diagnosed as shoulder-hand syndrome, but edema caused by local trauma and peripheral vascular diseases should be excluded.

(4) The key to prevent shoulder-hand syndrome is to avoid all causes of edema and pay attention to the correct placement of patients' upper limbs and hands; Extra care should be taken when carrying out weight-bearing training in elbow extension position on the affected upper limb to avoid excessive wrist flexion; Try to avoid intravenous infusion in the affected hand; Avoid injured upper limbs, especially hands.

(5) Treatment in the early stage of shoulder-hand syndrome, when edema, pain and limited range of motion appear, active treatment can achieve the best effect. Even after several months, if there is still inflammation, pain and edema, the treatment may be effective. Once contracture fixation occurs, all kinds of methods have little effect. The main purpose of treatment is to eliminate edema and relieve pain and stiffness as soon as possible.

1) Posture: Keep a good posture of lying and sitting. When lying flat, the upper limb of the affected side can be raised appropriately. When sitting, put the affected upper limb on the table in front of you. When the patient is sitting in a wheelchair, it is recommended to use a wheelchair table to avoid the upper limbs and hands of the affected side hanging from the outside of the body or even the wheelchair.

2) Avoid wrist flexion: In order to improve the venous return, you can wear a wrist upturned splint to support the wrist joint, so that the wrist joint can remain in a dorsiflexion state for 24 hours until the edema and pain disappear and the hand color is normal.

3) Active exercise: During the treatment, patients should be required to exercise as actively as possible, because muscle contraction can act as a pump, and promoting venous return to reduce edema can stimulate the activity of voluntary movement in the affected arm. However, before the pain and edema are eliminated, weight-bearing training during elbow extension should be avoided.

4) Passive motion Passive motion of the affected upper limb and fingers can play a positive role in the prevention and treatment of shoulder-hand syndrome.

These activities should be carried out very gently to avoid causing pain. In fact, any activity and posture that can cause pain should be avoided. All activities can be carried out when the patient's upper limbs are raised in supine position to promote venous return.

5) It is a simple, safe, economical and very effective treatment to wrap fingers with centripetal pressure (Figure 4-4-57).

Figure 4-4-57 centripetal pressure winding fingers

The therapist winds a long rope with a diameter of 1 mm ~ 2mm from the distal end of the finger to the proximal end, first winding the thumb, then winding other fingers, and finally winding the palm until the palm is above the wrist joint. When winding the rope, one end of the rope is folded into a small ring, and then it is quickly and forcefully wound from the distal end of the finger to the proximal end without any gap. Immediately after winding, pull the wound rope out of the ring at the end of the finger.

6) The ice therapist immerses the patient's hand in ice water with ice cubes. The ideal ratio of ice to water is one-third of water and two-thirds of ice. This temperature is even if the hand is immersed in water, and the continuous melting of ice keeps the water temperature cold.

Soak your hands three times, with a short interval between them. Therapists should soak hands with patients to determine the tolerance time of soaking.

7) oral corticosteroid therapy

8. Sympathetic nerve block