Rehabilitation therapy is one of the important contents of rehabilitation medicine, and is an important means to rehabilitate the sick, injured or disabled person, and is often carried out in combination with clinical treatment such as drug therapy and surgical therapy. Rehabilitation treatment should be carried out before the rehabilitation assessment of the sick, injured or disabled person, and then a rehabilitation treatment plan should be formulated and set, which should be implemented by a rehabilitation treatment team composed of rehabilitation physicians, rehabilitation therapists and clinical medicine related personnel, and continuously summarized, assessed and adjusted during the implementation process until the end of the treatment.
This chapter focuses on physical therapy, occupational therapy, speech therapy, psychotherapy, rehabilitation engineering and traditional Chinese medical therapy in the traditional field of rehabilitation medicine.
I. Classification, role and clinical application of exercise therapy
(I) Classification
Exercise therapy is very rich in content, and there are many ways to classify it. For example, it is customarily divided into traditional exercise therapy and neurophysiological exercise therapy; according to whether to use equipment in treatment is divided into unarmed exercise therapy and equipment exercise therapy; for the treatment of functional disorders is divided into joint exercise therapy, muscle exercise therapy, balance exercise therapy, etc.; according to the organizational form is divided into individual exercise therapy and group exercise therapy.
(II) Therapeutic effects
The main aspects are as follows.
1. maintain and improve the form and function of the locomotor organs, exercise therapy can promote blood circulation, maintain and improve the range of motion of joints, and increase and enhance the strength and endurance of muscles.
2. Promote the formation and development of compensatory functions to compensate for the lost functions.
3. Promote metabolism of organs and enhance cardiopulmonary function.
4. Improve the regulation ability of the nervous system, through exercise training can maintain and improve the excitability, flexibility and coordination of the nervous system.
5. Enhance the metabolic function of the endocrine system, such as promoting glucose metabolism and increasing the absorption of minerals by bone tissue.
(C) Clinical application
Exercise therapy has a wide range of adaptations, and the clinical efficacy is more satisfactory for neurological diseases, such as cerebrovascular accident, traumatic brain injury, cerebral palsy, peripheral nerve injury; motor organ diseases, such as limb fracture, dislocation, spinal fracture, post-operative joint surgery, neck, shoulder, lumbar and leg pain, arthritis, post-burn scar formation, osteoporosis, etc.; visceral organ diseases, such as coronary heart disease, hypertension, chronic bronchitis, emphysema, visceral prolapse, peptic ulcer; metabolic disorders, such as diabetes mellitus, hyperlipidemia, etc.
The implementation time of exercise therapy should be aimed at the early intervention of the disease, that is, 48 h after the stabilization of vital signs can be implemented, even comatose patients can do some small-scale local passive limb movement, but to master the treatment items and intensity.
Second, common equipment and treatment prescriptions for exercise therapy
(A) equipment
In addition to hands-on treatment, most of the exercise therapy can not be separated from the equipment, and there are many kinds. In recent years, with the application of computer technology, many multi-functional computer-controlled exercise therapy equipment has been applied in the field of rehabilitation medicine.
Commonly used simple exercise therapy equipment include shoulder exercises, shoulder ladders, pulley rings, ribbed logs, wall tensioners, forearm rotational flexion and extension exercises, suspension traction frames, electric standing beds, standing frames, quadriceps exercises, balance bars, seated steppers, etc.
Multifunctional computer-controlled exercise therapy equipment such as balance function training detection system, weight loss gait trainer with computerized running table, computerized cervical and lumbar spine traction apparatus, multifunctional exercise training combination system, etc.
(II) Prescription
After the rehabilitation physician has assessed the function of the patient, the rehabilitation physician and the teacher will select the treatment program, design the amount of exercise and the exercise time for the patient. The exercise treatment prescription should include the exercise treatment program, the amount of exercise treatment and the precautions of exercise treatment.
1.The overall exercise therapy program can be divided into endurance program, strength program, relaxation program and corrective program according to the purpose of exercise therapy; specifically for patients, it can be divided into joint mobility exercise training, restoration of walking ability training and other treatment programs; further refinement, such as joint mobility exercise training, can be detailed to passive or active exercise training of shoulder, elbow, wrist, hand, hip, knee, ankle and other joints and other small The project. In addition, it can also include whether to apply equipment and so on.
2. The amount of exercise therapy is related to the intensity, time and frequency of exercise therapy. In the exercise therapy prescription, these three aspects should be indicated. Exercise intensity is the most important, to determine the indicators are heart rate, body oxygen consumption, metabolic equivalent and subjective feeling, heart rate should be marked with the highest heart rate allowed to reach and appropriate heart rate. Treatment time refers to the total time of an exercise treatment, which can be divided into three parts: preparation, practice and conclusion. Frequency refers to the number of exercise therapy sessions per week and per day.
3, exercise therapy considerations first to master the indications, different diseases choose different exercise therapy to ensure the efficacy; second is to pay attention to the gradual progress, from less to more content, the degree from easy to difficult, the amount of exercise from small to large; third is persistent, exercise therapy most items need to be effective after a period of time, only persistent treatment to accumulate therapeutic effect; fourth is the implementation of exercise therapy process Fourth, the implementation of sports therapy should be regularly evaluated, timely adjustment of the treatment plan, and then continue to implement, re-evaluation, re-implementation, until the end of the program, to achieve the intended goal.
Third, maintenance and improvement of joint mobility training techniques
The training techniques for maintaining and improving joint mobility are divided into active, active-assisted and passive exercises according to whether or not external force is used.
(A) Active movement
Various kinds of freehand gymnastics are commonly used. According to the direction and degree of the patient’s restricted joint movement, some targeted and targeted movements are designed. Active exercises can promote blood circulation, have a mild pulling effect, can loosen the adhesions, pulling contractures
Tissue, help to maintain and increase the range of motion of the joint.
(B) Active-assisted exercise
It is also called assisted active exercise, mainly used for patients with muscle strength level l. 2, who cannot move their joints on their own or whose range of motion does not reach the normal value.
1.Suspension exercise is the use of rope (adjustable length), buckle or “S” hook and sling combination, the proposed training activities to suspend the limb, so that the premise of removing the gravity of the limb active pendulum-like training activities.
2.Self-assisted exercise is a training method to help the opposite limb with the healthy limb, which is suitable for patients with limited joint movement due to pain. Pulleys and ropes are commonly used to train shoulder joint abduction and adduction, as well as forward flexion and backward extension (Figure 3-4). The method of lower extremity training is shown in Figure 3-5.
3.Apparatus exercise is to use the principle of leverage, using the apparatus as a helper to drive the restricted joint for training activities. Such as shoulder exercises, elbow exercises, ankle exercises and gymnastic bars, etc..
When performing active exercises, attention should be paid to explaining to the patient the main points and directions of the movements, and the direction of the assistance should be consistent with the direction of contraction of the trained muscles to avoid compensatory movements.
(C) Passive exercise
It is a training method to maintain the normal or existing joint range of motion and prevent contracture and deformation, without the active contraction of the muscle to participate in the movement, but with the help of others, equipment or self-limb assistance to complete the training method. It is usually used for patients with generalized or localized muscle paralysis or muscle weakness, such as paraplegia and hemiplegia. According to the source of power, there are two kinds of passive movements, one is the movement within the movable range of joints and joint loosening technique, which is done by therapists or specially trained personnel; the other is the passive movement done by the patient himself with the help of external force, such as joint traction, continuous passive activity, etc.
1.Passive movement of joint range of motion The therapist completes the movement of the joint in all directions according to kinematic principles.
2.Joint mobilization technique (ioint mobilization) is a highly targeted manipulation technique that the therapist performs within the range of motion of the joint. It uses the physiological movement of the joints and ancillary movements to passively move the patient’s joints, maintain or improve the range of motion of the joints and relieve pain, similar to the manipulative therapy of traditional medicine in China, but there are major differences in the theoretical system, manipulation and clinical application, commonly used ‘, manipulation includes joint traction, sliding, rolling, squeezing, rotation, etc.
3.Continuous passive motion (CPM) is the use of mechanical or mechanical manipulation.
CPM is the use of mechanical or motorized mobility devices, so that the limb to carry out continuous passive movement within the range of no pain. It can relieve pain, improve joint range of motion, prevent adhesions and joint stiffness, and eliminate complications caused by surgery and braking. Specialized continuous passive motion devices for each joint are commonly used.
During the training of passive joint activities, attention should be paid to one joint at a time, and the maximum existing range of motion of the joint should be completed slowly and smoothly, with a short stop at the end, generally 3 to 5 times in each direction of motion, once a day in the morning and once in the evening, but the number of times should be increased for those joints with a tendency of restricted range of motion.
Fourth, the training techniques to enhance muscle strength and muscle endurance
Muscle strength is the ability of the muscle in the contraction, to muscle maximum excitement when the weight can be loaded to express. There are many ways to enhance muscle strength, according to the way the muscle contraction can be divided into isometric and isotonic exercise; according to whether to apply resistance is divided into non-resistance exercise and resistance exercise. Non-resistance sports include active sports and active assistance sports; resistance sports include isotonic, isometric, isometric resistance sports, etc.
(A) non-resistance exercise
When the muscle strength is l, 2, mostly use active-assisted exercise by the therapist to help the patient exercise, or use a simple device to suspend the affected limb on the horizontal surface for exercise training, the assistance from the therapist to apply unassisted or other heavy objects. And when the muscle strength level 3 or above, the patient can be allowed to put the limb to be trained in the position of resistance to gravity and perform active exercises.
(II) Resistance exercise
It is an active training method to overcome the applied assistance and is mostly used for patients with muscle strength of grade 3 and above. According to the type of contraction is subdivided into resistance to isotonic resistance exercise, resistance to isometric resistance exercise and isokinetic exercise.
1, resistance to isotonic resistance exercise is also known as power exercise. When a muscle contracts against resistance, the length is shortened or elongated and the joint moves. Commonly used unarmed to their own body weight as a load, like push-ups, squat stands, sit-ups and other exercises; or with equipment such as sandbags, dumbbells, wall tensioners or special muscle strength exercise machines. These methods are commonly used for plyometric training at level 4 or above. Its training weight, the number of repetitions is small, favorable to the development of muscle strength; and medium weight, the number of repetitions is favorable to the development of muscle endurance.
2, resistance to progressive resistance exercise is also known as progressive resistance exercise. First measure the maximum load that the muscle to be trained can withstand for 10 consecutive tension contractions, called IORM (IO repetition maximum). Each training to do 3 groups of 10 exercises, the master group asked rest 1 min, the first, 2, 3 groups of training resistance load used in order to l/2, 3/4, and a 10RM. weekly re-test 10RM value, according to the actual amount of training load, so that it increases with the growth of muscle strength.
3, resistance to isometric resistance exercise is also called static exercise. When the muscle is contracted against excessive resistance for jointless movement, the muscle is not significantly shortened, but its internal tension is great, which can generate strength. Exercise training pay attention to the joints placed in different angular positions, each time resistance to maintain 5 to 10 s is appropriate, then relax, repeat 5. l0 times. 4. isometric exercise (also known as adjustable resistance exercise, constant speed exercise) is the use of equipment to provide variable compliance resistance, the antagonist muscle simultaneously round-trip exercise training, so that its balanced development.
The operating system of the isokinetic exercise test system can provide the limb to perform muscle strength test at predetermined speed, while its computer system can record a series of data of joint and muscle activities, which is suitable for strength testing and training of spine and limb muscles, auxiliary diagnosis of sports system injury one and prevention, and efficacy assessment of rehabilitation training.
Muscle exercise training is to train muscle groups, so choose the appropriate training method, master the amount of exercise, pay attention to the patient’s systemic condition (especially the condition of the cardiovascular system) and local conditions, timely adjustment of resistance. Training 1 to 2 times a day, each time about 30 min. You can practice in groups, with a break of l. 2 min in between.
V. Training techniques to restore balance
This is the training of static and dynamic balance ability in various postures, so that the patient can automatically adjust to maintain the posture. (I) Basic principles
The basic principle of balance training is to gradually transition from the most stable posture to the most unstable posture through training; to transition from static balance to dynamic balance in order to gradually increase the difficulty. In other words, gradually reduce the body support area, gradually improve the body’s center of gravity, and improve from open-eye training to closed-eye training. Static balance is the basis, mainly relying on muscle isometric contraction and muscle contraction on both sides of the joint to complete.
(B) Training methods
1.Sitting balance training
(1) Transversal: The patient sits, the therapist sits on the patient’s side and induces the trunk to tilt to one side.
(2) Longitudinal: the patient sits, the therapist sits in front of the patient, and induces the patient to gradually move the center of gravity back and forth to eliminate the psychology of fear of falling when the body moves forward. Sitting balance training mainly improves the balance control ability of the head and trunk.
2. Kneeling balance training is performed with the patient kneeling on both knees and the therapist standing on his or her back side, with hands on both sides of the pelvis, to train the patient to maintain balance or induce the body to move its weight laterally. Kneeling balance training increases the center of gravity and reduces the support surface compared to sitting balance training, increasing the balance control ability of the trunk and pelvis. If the patient maintains a stable balance on both knees, dynamic balance training can be carried out on one knee, that is, the other lower limb is raised up and down.
3.Standing balance training can be divided into standing static and dynamic balance training, bipedal or unipedal balance training, etc. The therapist protects and induces the emergence of weight-holding response and trains the patient to shift the body weight laterally or vertically. The patient can also be placed on a balance board or balance training tester to train the transfer of body weight in all directions, and gradually transition to unipedal standing balance training.
VI. Training techniques to restore walking ability
Walking is a process of maintaining dynamic balance posture in standing position, which requires coordinated movement of all parts of the body to achieve the purpose from losing balance to regaining balance.
(A) Training in the parallel bar
First, use the parallel bar for standing training, then practice weight transfer, and gradually transition to walking training within the bar. In-bar walking training mainly includes four-point walking (Figure 3-13), two-point walking (Figure 3-14), dragging step training, swinging to step (Figure 3-111-15), swinging over step (Figure 3-16) and other methods.
(B) crutch-assisted walking training
Commonly used crutches are axillary crutches, elbow crutches, canes (four-legged cane, three-legged cane) and so on. Walking training using crutches, to have good balance and upper limb support ability, generally after the basic movement training within the parallel bar before proceeding, common crutch-assisted walking training with crutches over step training.
Seven, easy technology
Ease of use technology is based on the normal physiological development process of human nerves, that is, from head to foot, from proximal to distal development process, the use of induction and inhibition methods, so that patients gradually learn how to complete the normal way to daily life movements of a class of rehabilitation treatment techniques, so also known as neurodevelopmental therapy. It is mainly used for the treatment of limb movement disorders after brain injury, and its typical representatives are Bobath technique, Brunnstrom technique, Rood technique and PNF technique.
(I) Bobath therapy is a training method created by British therapist Bexta Bobath, mainly used to treat hemiplegic patients and children with cerebral palsy. The basic idea is to induce the patient to gradually learn the sensory and motor patterns of normal movement, to learn how to control posture and maintain balance, and to train the emergence of the rollover response, balance response and other protective responses based on the normal developmental process of the human body. Bobath’s training method is to suppress the pathological reflexes and motor patterns that appear during training.
After the proximal joints have acquired a certain level of movement and control, then the distal joints (e.g. elbow, wrist, ankle, etc.) can be trained. The main techniques of Bobath therapy are as follows: 1. The key point of control is that the therapist changes the patient’s abnormal movement pattern, inhibits spasticity, and guides the patient to perform active movement when manipulating the patient’s key areas. At the proximal end are the neck, spine, shoulder, pelvis, sternal stalk, scapula, etc.; at the distal end are the fingers, toes, wrist, ankle, etc.
It is a treatment method proposed by American therapist Signe Brunnstrom, mainly for hemiplegic patients. Its uniqueness lies in its belief that the emergence of basic limb synergistic movements, primitive postural reflexes and co-movements that occur in patients after hemiplegia are normally present in the early stages of motor development. Patients with hemiplegia must also pass through these stages in the process of regaining their limb motor function. Brunnstrom therefore advocates emphasizing the movability of the affected limb during the initial stages of motor function recovery, that is, inducing the patient to use and control these abnormal patterns in order to obtain some motor response.
Brunnstrom divided the recovery process of hemiplegic motor function into 6 stages, namely, stage I flaccid phase, in which the affected upper and lower limbs are flaccidly paralyzed; stage Il about The spasticity and co-movement appear about 2 weeks after the onset of the disease; stage IIl, the co-movement reaches its peak and the spasticity increases; stage IV, some movements out of the co-movement appear and the spasticity starts to decrease; stage v, the separated movement is dominant and the spasticity decreases significantly; stage Vl, the coordinated movement is approximately normal.
(See rehabilitation of cerebrovascular disease for details). According to the above theory, the training principle of Brunnstrom therapy stages l-IIl is to use tension reflex, joint response, proprioceptive stimulation and peripheral stimulation to enhance the muscle tone of the affected limb; stages IV and V, are to induce a gradual transition to more difficult movements of the affected limb.
(II) PNF therapy
PNF therapy is a treatment method that uses proprioceptive stimulation such as tension, joint compression and traction, and applied resistance to promote the recovery of motor function by applying spiral diagonal or motor patterns, which was first proposed by Kabat in the United States. In addition to the normal motor development process of the human body, PNrr therapy emphasizes the role of each joint of the body in the movement pattern, i.e., the mobility, stability, control ability of the joints and the skillfulness of completing compound movements. the theory of PNT considers that the human movement is characterized by two directions of movement that cross each joint of the head, trunk and limbs.
1.Basic techniques
(1) Manipulation contact: apply resistance to the correct direction, thus stimulating the receptors in the muscles, tendons and joints.
(2) Traction: In the starting position of PNT, the therapist applies the maximum range of traction to the main muscle groups involved in the movement.
(3) Traction: The joint is stretched to increase the joint space, activate joint receptors, and stimulate the muscles around the joint.
(4) Squeeze: Squeezing of the joint reduces the joint interval, again activating joint receptors and stimulating the muscles around the joint to contract at the same time.
(5) Muzzle: The therapist gives a muzzle at the right time to stimulate active movement and improve the quality of movement completion.
(6) Maximum resistance: given at a graded level according to the patient’s ability and needs, but not to prevent the patient from completing all joint movements.
(7) Timing: It refers to the sequence of muscle contraction from distal to proximal in the coordinated movement.
2.Special techniques of PNF
(1) Repetitive contraction: by repeatedly pulling the muscle, the isotonic contraction is enhanced.
(2) Rhythmic initiation: The whole activity process is first done passively by the therapist, then the patient is allowed to complete it with active assistance, and finally reaches active completion.
(3) Slow reversal: after retrograde maximum tension on the antagonist muscle, to promote the weaker active muscle to perform isotonic contraction.
(4) Slow reversal a jerk: similar to the slow reversal technique, except that the isometric contraction of the muscle is performed at one of the desired joint ranges of motion.
(5) Rhythmic stabilization: is an alternating isometric contraction of the active and antagonist muscles at any point in the joint range of motion to improve control of the limb.
(6) Fast reversal: It is a bilateral stretch stimulation of the active and antagonist muscles, which aims to promote the tension contraction of the active muscles by stimulating the tension contraction of the antagonist muscles in order to improve muscle responsiveness and control.
Eight, motor relearning therapy
Motor relearning program (MRP) is a kind of motor therapy proposed by Janet H. Cart, an Australian scholar. He regarded the training of motor function recovery after central nerve injury as a process of relearning or retraining. It is mainly based on the theories of neurophysiology, exercise science, biomechanics and behavioral science, and is oriented to homework or functional activities. Under the premise of emphasizing the importance of patient’s subjective participation and cognition, it is a method to re-educate patients according to scientific motor learning methods in order to restore their motor functions.
MRP believes that the main condition for achieving functional reorganization is the need for targeted exercise activities, and the more practice, the more effective the functional reorganization will be, especially early practice of the exercise in question. Lack of practice, on the other hand, may produce secondary neural atrophy or failure to form normal synapses. The role of feedback in motor control is fully utilized by advocating a variety of feedback, such as visual, auditory, skin, body position, and hand guidance to reinforce the training effect.
MRP consists of seven components that encompass the basic motor functions in daily life, namely upper limb function, El facial function, supine to bedside sitting up, sitting balance, standing and sitting down, standing balance and walking. The treatment begins with the selection of the most appropriate part of the training according to the patient’s functional impairment.
Each component is trained in 4 steps.
① Understanding the normal motor components and analyzing the missing basic components by observing the patient’s movements;
(2) Gradually restore the lost motor function through concise explanations and instructions, repeated exercises, and verbal and visual feedback and manual instruction for the missing motor components;
③ Combine the acquired motor components with normal movement, correct them continuously, and gradually normalize them;
④Training the acquired motor functions in real-life environment, so that they are continuously skilled.
There are also some training techniques in exercise therapy, such as training to restore cardiopulmonary function, training of functional transfer movements, etc., which are included in the rehabilitation treatment of various disabilities. Massage therapy, traction therapy, etc. are listed in the rehabilitation techniques of Chinese medicine.