I. Good limb (posture) position
For post-stroke hemiplegic patients, good limb position in bed, also known as good posture and good limb position, has a certain role in preventing and reducing the typical spasm of upper limb flexors and lower limb extensors, shoulder subluxation, shoulder pain, shoulder-hand syndrome, posterior pelvic tilt, hip abduction and external rotation, and early induction of separation movement. Family members and accompanying persons must assist and cooperate, and please ask the medical personnel in time if you are not sure, so as to avoid operating errors and adverse effects on functional recovery. The following 3 kinds of good positions are commonly used.
The patient’s head is slightly bent forward, the trunk is tilted back, the back is firmly supported by pillows, and the body is relaxed. Upper limb on the affected side: the affected shoulder is stretched forward, the affected upper limb and trunk are at an angle of 80-90°, the elbow is straight, the forearm is rotated back, the wrist is dorsally extended, the palm of the hand is up, and the fingers are stretched out. Lower extremity on the affected side: hip extension, knee slightly flexed, ankle dorsiflexed as much as possible, keeping 90b. Upper extremity on the healthy side: placed naturally on the body or pillow; lower extremity on the healthy side: kept in stepping position, placed on a pillow in front of the body; knee and ankle slightly flexed naturally. To avoid compression by the healthy leg, a soft pillow should be placed between the healthy and affected legs. It is important to keep the affected shoulder in forward extension in this position.
Evaluation: It is a suitable position for stroke, which can increase the sensory input to the affected side and make the whole affected side be elongated, thus reducing spasm, and the healthy hand can move freely.
2.Healthy side lying position (hemiplegic side on top) Head on pillow, torso front perpendicular to the bed surface. The upper limb on the affected side is padded with a pillow, the shoulder joint is flexed forward about 100°, the upper limb is straightened as much as possible, and the fingers are extended. Lower extremity on the affected side: padded with pillow, maintain hip flexion and knee flexion position, foot also padded on the pillow, ankle joint dorsiflexed as much as possible, maintain 90b, not hanging on the edge of the pillow. The healthy side of the limb: adopt a comfortable position on it, with mild hip extension and knee flexion.
Evaluation: It can improve the blood circulation of the affected side, reduce the spasm of the affected limb, and prevent swelling of the affected limb.
3.Supine position: head on pillow, head on or to the affected side, trunk spreading. Upper limb on the affected side: place a pillow under the scapula on the affected side to lift the affected shoulder and extend the shoulder joint forward as much as possible to prevent shoulder joint subluxation; abduct and externally rotate the shoulder joint; place a towel roll between the upper arm and the torso to prevent shoulder joint inversion and internal rotation; keep the elbow joint in the extended position to prevent upper limb flexor tension; slightly dorsiflex the wrist joint and spread the fingers with the palm upward or hold the towel roll to prevent finger flexion. Lower extremity on the affected side: Place a bolster from the hip to the lower outer thigh on the affected side to prevent external rotation of the affected hip. With the affected lower extremity extended, a small pillow can be placed under the knee joint to make the knee joint slightly flexed. The affected ankle should be kept in a neutral position with the toe pointing upward. For patients with significant plantarflexion or inversion, a foot brace can be placed to keep the ankle in a neutral position.
Evaluation: The supine position should be used as little as possible because of the influence of the tense neck reflex and the tense vagus reflex, which cause abnormal posture and are prone to decubitus ulcers and external rotation of the affected lower limb.
The good posture is a temporary position designed from the therapeutic point of view. To avoid complications such as pressure sores and contractures, the position should be changed regularly (1 change/1 to 2 h). In particular, the patient should not maintain the supine position for a long time, and should be helped to learn to alternate the supine position with the healthy side or the affected side. Generally speaking, the affected side position is better than the healthy side position, and the healthy side position is better than the supine position, that is, the affected side position〉healthy side position〉supine position. At the same time, because the supine position strengthens the extensor advantage, the healthy side position strengthens the flexor advantage on the affected side, and the affected side position strengthens the extensor advantage on the affected side, therefore, the position should be correctly selected according to the patient’s condition and under the guidance of the doctor.
II. Passive exercise
From the day of onset, if the patient has been in coma for a long time or for other reasons (serious comorbidities), the patient cannot move actively in bed, he/she should do passive movement of the limb joints, which can prevent the limitation of joint movement (contracture) and also promote blood circulation and increase sensory input to the limbs. This rehabilitation treatment should be performed simultaneously with body position placement.
The patient’s family or therapist usually performs passive joint exercises for the patient twice a day. The limb should be relaxed so that the joints are fully active; start with the major joints first, then move to the minor joints in sequence, doing more shoulder abduction, external rotation, forearm rotation, ankle dorsiflexion and finger joint extension. Be careful to prevent damage to the shoulder joint due to excessive activity. Shoulder abduction and flexion should not exceed 90b, which is 50% of the normal range of motion. If the patient has a painful expression, stop the activity. Repeat the activity for each joint at least 5-7 times each time.
III. Active movement
Since passive exercise can only prevent decubitus ulcers, pneumonia and joint contractures, but not other sequelae such as disuse muscle atrophy, and it does not significantly promote functional recovery, patients should also start the next phase of active training as early as possible, not only to prevent the occurrence of spasticity, but more importantly, to let patients know that they “can move” and increase their confidence in recovery. This will not only prevent the occurrence of spasticity, but more importantly, let the patient know that he or she “can move” and increase confidence in recovery. When the patient is conscious and the vital signs are stable for 48 hours, active rehabilitation training can be started in bed whenever possible.
Turning over: This is one of the most basic trunk function training, because the trunk is governed by bilateral cone bundles and paralysis is generally incomplete, recovery is faster. The supine position is the strongest position to cause spasm of the extensor muscles and also aggravate the posterior protrusion of the scapulae, so the patient should not always stay in the supine position, but should learn to turn over to both sides as soon as possible.
(1) Assisted turning to the affected side Make the patient lift the healthy leg to the affected side, the healthy upper limb also swings forward, the assistants put one hand on the affected knee to assist the affected leg to externally rotate, the other hand can assist the affected upper limb in the forward position.
(2) Independent turning to the affected side Supine position with hands crossed, the upper limb of the healthy side drives the affected upper limb to straighten, the lower limb of the healthy side is flexed, and the affected upper limb is placed in the outer booth with the healthy side to prevent pressure after turning.
(3) Assisted turning to the healthy side The supine position is held with both hands crossed, and the assistive person flexes the patient’s lower limbs and places both hands on the patient’s buttocks and feet to assist in turning to the healthy side and placing the limbs.
(4) Independent turning to the healthy side The patient is supine, the healthy leg is inserted under the affected leg, the hands are crossed, the upper limb is stretched upward, swinging from side to side, increasing the amplitude, when swinging to the healthy side, turning to the healthy side in a homeopathic manner, while using the healthy leg to drive the affected leg to turn over.
2, bridge exercise: in bed for turning training at the same time, must rift handsome affected side of the hip extension exercises.
(1)Bilateral bridge exercise Therapist help the patient to flex both legs, feet under the hip flat on the bed, let the patient extend the hip to lift the hip off the bed, such as the affected hip external rotation and abduction can not support, therapist help to stabilize the affected knee.
(2) Unilateral bridging movement When the patient completes the bilateral bridging movement, the patient can straighten the healthy leg and the affected leg completes the movement of knee flexion, hip extension and hip lift.
(3) Dynamic bridging exercise In order to obtain the ability to control the lower extremity inward and outward, the patient lies supine with the knees flexed, the feet on the bed, the knees parallel and together, the healthy leg remains motionless, the affected leg makes alternate inward and outward movements of smaller amplitude, and learns to control the amplitude and speed of the movements. Then the affected leg is kept in a neutral position, and the healthy leg is used for inversion and abduction exercises, and combined with double bridge exercises.
3, sitting training: sitting training can be carried out 5 days after cerebrovascular disease, first take 30b to 40b position, increase 10b every 2 to 3 days, last 5 to 10 minutes a day, reach the ability to maintain 90b, last 30 minutes can be trained sitting endurance, light patients can be exempted from endurance training; before and after training pay attention to observe the patient’s reaction, side pulse, observe blood pressure if necessary, to prevent accidents; training semi-sitting position When training semi-sitting position, it is advisable to protect the shoulder joint from dislocation due to upper limb flaccidity, and hang the forearm of the affected limb from the neck with a triangular scarf; in sitting position, both upper limbs are placed on the platform or moving table in front of the bed, and then enter the sitting balance training later, that is, after sitting steadily, the patient is pushed by both sides or front and back alternately to train to adjust the balance and not to fall down, which means having the ability of trunk balance at this time.
4.Sitting training: Sitting from supine position can be divided into four steps, the leg on the healthy side is stretched under the affected leg, the affected leg is brought to the side of the bed, the patient turns to the lateral position and supports the trunk with the forearm on the healthy side, lifts the head to the upright position, uses the upper limb on the healthy side to push the support to make the trunk upright and sits on the side of the bed.
After the patient has successfully completed the above-mentioned active exercises and achieved results, the patient can enter functional rehabilitation training, such as standing, transferring, walking, speech and cognitive rehabilitation. The training cannot be interrupted, so that the patient can recover early and return to family and society.
IV. Acupuncture therapy
The efficacy of acupuncture in the treatment of stroke has been confirmed by numerous clinical practices, with an effective rate of 98% and a basic cure rate of about 65%. Acupuncture treatment differs according to the internal organs and meridians.
The main symptoms of the middle meridians are hemiplegia, strong tongue and speech, and boiling of the corners of the mouth V畏ㄎ消纭 (12) 衅钛允重室 knitted together with striders (3) 亍 (4) 纵纵弧 ⑶咴蟆 (10) 械妊ǎ莶煌ば脱∮貌煌呐溲ǎ绺窝舯┛杭犹犹 (8) 环缣底末缂臃崧 瞎龋惶等雀導忧亍 涓谕ァ賤崧。 Cheese striders! (13)! (19) Yin deficiency and wind movement plus Taixi, Fengchi; mouth angle? (13) The oblique plus cheek car, the ground hamlet; upper limb incompetence plus shoulder k, hand three li, hegu; lower limb incompetence plus ring jump, yanglingquan, hanging bell, taichong; dizziness plus Fengchi, complete bone, tianzhu; foot inversion plus Qiu Hui through zhaohai; constipation plus Shuidao, Guilai, Fenglong, branch gou; diplopia plus Fengchi, tianzhu, eye-minded, after the ball; urinary incontinence, urinary retention plus Zhongji, Qu bone, Guan Yuan. Operate according to the method of deficiency supplementation and actual diarrhea.
The main symptoms of the middle organs are trance, confusion, drowsiness, or lethargy, or even coma and hemiplegia. The treatment is to awaken the brain and open the orifice, to open and close the body, with the Hand Conjunctive Yin meridian and the Governor’s meridian as the main points. The main acupuncture points are Neiguan and Shuigou, and the supporting acupuncture points are Twelve Wells, Taichong and Hegu for the closed evidence; Guan Yuan, Qihai and Shen Que for the detached evidence. Acupuncture operation: the twelve well points are punctured with trigeminal needles for bleeding; Taichong and Hegu are used for laxative method and strong stimulation; Guan Yuan and Qi Hai are used for moxibustion with large moxa cones, and Shen Que is used for moxibustion with salt interval until the extremities turn warm.
Head acupuncture, electric acupuncture, skin acupuncture, eye acupuncture, ear acupuncture and other acupuncture methods can be used together clinically.
It is worth noting that meridian acupuncture points have the phenomenon of “meridian fatigue” or “acupuncture point adaptability”, that is, when acupuncture points are initially effective, but as the number of acupuncture points increases, the effect gradually weakens, affecting the therapeutic effect. Because of the long duration of stroke treatment, it is easy to produce “meridian fatigue” or “acupuncture point adaptation phenomenon” if care is not taken. How to avoid this phenomenon has been discussed in detail in the article “Analysis of the problems of acupuncture in the treatment of stroke hemiplegia” in this column, which can be consulted.
V. Tuina Therapy
According to Chinese medicine, most stroke diseases are caused by blockage of meridians, stagnation of qi and blood, which leads to paralysis. From the modern medical point of view, Tui Na therapy is a series of different movements that produce different forces for the body, stimulate skin receptors and peripheral nerves, and reflexively act on the central nervous system to eliminate and alleviate various obstacles. Modern research shows that Tui Na therapy is useful for stroke disease in terms of motor dysfunction.
After thousands of years of development, Tui Na has more than a hundred kinds of techniques. Clinically, the techniques are generally divided into 6 categories: oscillation: such as one-finger meditation pushing, kneading, etc.; friction: such as mo, rubbing, pushing, rubbing, wiping, etc.; pressure: such as pressing, pointing, pinching, holding, twisting, stepping, etc.; percussion: such as patting, striking, playing, etc.; vibration: such as shaking, vibrating, etc.; movement: such as shaking, wrenching, pulling and stretching, etc.
When applying these techniques, the doctor will choose different techniques and operate on different meridians and acupuncture points according to the cause, severity, duration, age and physical condition of the patient. It is worth noting that since the affected side is paralyzed and the muscle tone is lowered, when using movement-type techniques, it is necessary to proceed gradually and not to pull the joints forcibly, so as to prevent the joints from being damaged.