I. Rehabilitation Medicine
It is a discipline of study on the prevention, diagnosis, assessment, functional repair, treatment and management of disabilities and functional disorders. Its purpose is to reduce or eliminate functional disorders, to help the injured, sick and disabled to recover their physical, psychological, occupational and social life functions to the maximum extent possible according to their actual needs and physical potential, to improve their ability to live, learn, and work independently, and to improve their quality of life.
Neurorehabilitation is a discipline that specializes in the prevention of rehabilitation and rehabilitation treatment of disorders caused by neurological diseases. It has changed the disconnect between neurology and rehabilitation, and enabled the diagnosis and treatment of neurological and muscular diseases to reach a new overall level.
II. Why rehabilitation treatment for neurological diseases
Neurological diseases, especially cerebrovascular diseases, are characterized by high morbidity and high disability rate. Neurorehabilitation is the most effective method proven by evidence-based medicine for reducing the disability rate, and is an indispensable key link in the organized management of neurological diseases.
(1) In the acute phase of the disease: rehabilitation should be started as early as possible, which can prevent related complications. For example, to prevent shoulder pain, shoulder dislocation and joint contracture after hemiplegia; disuse muscle and joint atrophy, disuse lung function decline and vascular embolism after bed rest.
(2) In the recovery period of the disease: Adopt comprehensive rehabilitation treatment measures to help patients give full play to their own potential, carry out functional enhancement and compensatory training for disease disability, avoid complications or secondary disabilities caused by reduced movement, shorten the duration of hospitalization, change the non-functional life state, reduce the degree of disability, reduce blind ineffective medication, and reduce the economic and labor burden of society and families.
(3) At the later stage of the disease: Develop family community rehabilitation plans and programs with hospital rehabilitation as a backstop, provide necessary rehabilitation education to patients and their families, and carry out corresponding home and community rehabilitation to improve patients’ social adaptability. Conduct relevant vocational rehabilitation training, so that patients can truly return to society.
Advanced international rehabilitation concept
The basic concept of rehabilitation medicine is the ICF (International Classification of Functioning, Disability and Health) signed by the World Health Organization, and the concept of early, active and comprehensive rehabilitation is used throughout the treatment.
In Europe, the advanced rehabilitation concept is deeply rooted in people’s hearts through systematic education of patients. This is very useful in promoting the progress of rehabilitation medicine.
”Early” means that rehabilitation starts at a later stage of the disease, and then it starts after the patient’s acute and dangerous period.
”Active” is a shift from passive training in the past to emphasizing the patient’s initiative and motivation, encouraging the patient to take the initiative in training, and enhancing the patient’s self-confidence to return to society.
”Comprehensive” means that rehabilitation should be carried out from the very beginning of the injury or illness and should be carried out throughout. From the perspective of overall rehabilitation, this process includes not only medical rehabilitation, but also educational, vocational and social rehabilitation.
The basic principles of stroke rehabilitation treatment
1. Choose the right time for rehabilitation
A large number of clinical rehabilitation practices have shown that early rehabilitation can help improve the damaged functions of stroke patients, reduce the degree of disability, and improve their quality of life. It is usually advocated to start rehabilitation after 48 hours of stabilization of vital signs and no aggravation or improvement of the primary neurological disorder (cerebral hemorrhage patients with relatively heavy cerebral edema are generally advocated to start rehabilitation 1-2 weeks after the onset of stroke and after the condition is stabilized).
For patients with serious complications, such as high blood pressure, severe mental disorder, severe infection, acute myocardial infarction or cardiac insufficiency, severe liver and kidney impairment or diabetic ketoacidosis, rehabilitation treatment should be carried out gradually only after 48 hours of stabilization, while treating the original disease and actively treating the complications.
2. Rehabilitation assessment
It is used throughout the treatment of stroke, including the acute phase, early recovery phase (subacute phase), middle and late recovery phase and sequelae phase.
Rehabilitation assessment is not about finding the cause and diagnosis of the disease, but about objectively and accurately assessing the nature, location, extent, severity, development trend, prognosis and regression of functional impairment. It is similar to the diagnostic process in clinical medicine, but not identical. It can be understood as follows: rehabilitation assessment is the process of objectively and accurately examining and judging the nature, location, scope and degree of functional impairment; determining the remaining compensatory capacity; estimating the development, regression and prognosis of functional impairment; identifying rehabilitation goals; formulating rehabilitation measures; determining the rehabilitation effect; and deciding the patient’s destination.
Tasks of rehabilitation assessment
Initial: The first assessment before starting treatment, aiming to understand the functional status and degree of impairment, causes of disability, rehabilitation potential, and estimate the prognosis of rehabilitation, as a basis for formulating rehabilitation goals and making rehabilitation plans.
Mid-term: The purpose is to understand the changes in function after a period of rehabilitation treatment and to analyze the causes, which is used as an argument for adjusting the rehabilitation treatment plan.
Closure: To assess the total functional status at the end of the rehabilitation treatment, so as to evaluate the effect of the rehabilitation treatment and make recommendations for future social reintegration or further rehabilitation treatment.
3. Rehabilitation treatment plan
It is based on the rehabilitation assessment and is jointly developed by the rehabilitation team, and is gradually revised and improved during the implementation of the treatment plan.
4.Rehab treatment
The rehabilitation treatment should be gradual, with the active participation of the stroke patient and the cooperation of his family, and combined with daily life and health education.
5.Use comprehensive rehabilitation therapy
Include physical therapy, occupational therapy, speech therapy, psychotherapy, traditional rehabilitation therapy and rehabilitation engineering.
6.Conventional drug treatment and necessary surgery.
V. Rehabilitation goals of stroke
To use all effective measures to prevent disabilities and complications that may occur after stroke (e.g. pressure sores, aspiration pneumonia, urinary tract infections, deep vein thrombosis, etc.), to improve impaired functions (e.g. sensory, motor, language, cognitive and psychological), and to improve the patient’s ability to perform activities of daily living and to adapt to social life. That is, to improve the quality of life of patients with stroke.
VI. Stroke rehabilitation outcome
The rehabilitation outcome of stroke is related to the type, size and location of the lesion, the timing, method and duration of neurological and rehabilitation treatment, and the desire or initiative for rehabilitation. spatial neglect, visual deficit, shoulder-hand syndrome, shoulder pain, shoulder subluxation, loss of use syndrome, misuse syndrome, heterotopic ossification, and deep vein thrombosis of the lower extremities.
The earlier the rehabilitation treatment is carried out, the better the outcome. It is generally said that neurological recovery is fastest within 3 months, still after 6 months, and becomes slower after 1 year, but rehabilitation therapy is still beneficial. Late initiation of rehabilitation treatment results in poor rehabilitation outcome and more complications.
The more standardized and systematic the rehabilitation treatment is, the better the outcome is. We should do comprehensive, standardized and systematic rehabilitation treatment.
The more adequate the course of rehabilitation treatment, the better the outcome. However, clinically, for various reasons, many patients stop rehabilitation treatment just after they see results, and often their disease rebound and have poor outcomes. Of course, there are also many patients or their families who do not recognize the significance and characteristics of rehabilitation. According to the national “Tenth Five-Year Plan” key research project “Stroke three-level rehabilitation program research”, systematic rehabilitation should be carried out at least within 6 months.
The higher the initiative of rehabilitation, the better the outcome. Stroke patients are often pessimistic and anxious because of the sudden shock. Loss of confidence in survival and rehabilitation, non-acceptance of rehabilitation treatment, or passive acceptance of rehabilitation treatment, make the rehabilitation outcome suffer. Active participation of patients in rehabilitation treatment will greatly enhance the effect of rehabilitation treatment.
The better the complications of stroke are prevented and managed, the better the outcome. A very important factor affecting the rehabilitation outcome is the lack of timely rehabilitation after stroke, with shoulder-hand syndrome, shoulder subluxation, shoulder pain, loss of use syndrome, misuse syndrome, heterotopic ossification, contracture, fracture, and pain. Preventive rehabilitation treatment and systematic rehabilitation in the acute phase can significantly reduce these conditions, which is one of the greatest benefits of early rehabilitation and has a great impact on the outcome of stroke rehabilitation.
1. Improvement of motor-sensory function
In the vast majority of patients, recovery of motor function occurs in the first 1-3 months after the disease, and recovery is still faster from 3-6 months, and in some patients recovery can last 1-2 years. In general, recovery is faster in patients with milder paralysis and later in those with more severe paralysis.
Approximately 70% of patients have upper limb dysfunction after stroke, and 30% are non-functional at 6 months after onset, with 10% of patients with initial upper limb non-function recovering well. Those who are generally unable to move their fingers within 4-6 months are likely to end up with a disabling hand.
The order of recovery from paralysis is generally lower extremity before upper extremity, proximal before distal. The shoulder function recovers earlier than the hand, and the thumb function recovers the slowest.
Half of the patients have sensory impairment after stroke, with more recovering a few weeks after onset.
Most patients recover their activities of daily living (ADLs) 3-6 months after onset. In some patients, ADL gradually deteriorates after discharge from hospital, mainly because of complications or reduced rehabilitation. A small number of severely ill patients are eventually unable to walk independently or even bedridden for a long time despite long-term rehabilitation.
2. Improvement of language function
Post-stroke aphasia accounts for 22% – 32% of stroke patients. Speech dysfunction affects doctor-patient communication and directly influences the recovery of motor function and other rehabilitation treatments. With appropriate rehabilitation, the majority of patients, within a few weeks, can regain some ability to express themselves orally.
Patients with dysarthria have difficulty in expressing themselves orally, which can be greatly improved through rehabilitation treatment.
3.Improvement of swallowing function
The incidence of swallowing disorder after stroke is 20% – 40%. It is mostly seen in patients with severe, pseudobulbar palsy; patients with long-term nasal feeding or intravenous nutrition are prone to misaspiration, resulting in aspiration pneumonia, refractory lung infection or malnutrition. Remove the cause, after regular rehabilitation treatment, most patients can remove the gastric tube or intravenous nutrition tube and eat through the mouth.
4.Improvement of cognitive function
Cognitive impairment, vascular dementia, the degree of rehabilitation treatment can reduce and prevent its continued aggravation.
5.Improvement of psychological disorders
Psychological disorders are mostly depression, after psychological rehabilitation and drug treatment, combined with PTOTST and other therapeutic effects, can often evoke hope for recovery, and most patients with psychological disorders remit with the improvement of their condition.
Seven, the three levels of stroke prevention
1. Primary prevention
Primary prevention refers to the prevention of disease occurrence, which is the ultimate goal of reducing the incidence of disease through the intervention of high-risk causative factors. For stroke, primary prevention focuses on monitoring the hypertensive population and changing the unhealthy behaviors and lifestyles of the population.
1. 1 Surveillance and management of hypertensive populations.
① All hypertensive patients should insist on blood pressure measurement and standardize the use of antihypertensive drugs to keep their blood pressure under the ideal level (140/90 mmHg or less);
②For patients with grade 2 hypertension, increase monitoring efforts to achieve a weekly follow-up visit and adjust the treatment plan at any time.
③For patients with grade 3 hypertension who cannot be well controlled even after regular medication, try to hospitalize them and bring their blood pressure up to the standard through personalized treatment measures.
④People over 35 years of age should have their blood pressure measured at the first visit, and if new hypertensive patients are found, they should be included in the target of monitoring and management.
1. 2 Establishment of a healthy and supportive environment.
Changing the work model that emphasizes solely on health education and making the creation of a healthy supportive environment and conditions one of the main goals of the intervention. This is done mainly through long-term promotion and education by medical staff reaching out to various streets, schools and enterprises, especially for some patients with chronic diseases such as cardiovascular and cerebrovascular diseases, it is recommended to.
① Control total caloric intake and maintain normal weight;
②Control blood sugar and blood lipid;
③ Quit smoking;
④Regularize life and prevent mood swings;
⑤ Strive to avoid severe coughing, prevent constipation, and abstain from sexual activity;
⑥Balanced diet;
(7) Maintain a certain amount of exercise.
2.Secondary prevention
It refers to active clinical treatment after the occurrence of the disease, as well as early and recovery rehabilitation, in order to prevent the aggravation of the disease and prevent the disability and dysfunction of organs or systems due to injury or disease.
The sequelae of cerebrovascular disease seriously affect the quality of life of patients. Among them, hemiplegia is the most common and the most harmful. According to the World Health Organization, in economically developed countries, patients with hemiplegia have significantly improved their ability to perform daily life after formal rehabilitation, and a high percentage of working-age patients can return to work. Community-based rehabilitation is an important approach to stroke rehabilitation, and the critical period for functional rehabilitation is within 6 months after stroke onset. Interventions include control of high-risk factors, guidance on rehabilitation treatment and rehabilitation training, health promotion and psychological guidance. At the same time, the family members of stroke patients should closely cooperate with the counseling and supervise the patients to perform functional training at least three times a week for at least 30-45 minutes each time.
3.Tertiary prevention
It means that functional rehabilitation should be actively carried out for the disability caused after the disease, while avoiding the recurrence of the original disease. Rehabilitation training is a combination of modern rehabilitation techniques and our traditional rehabilitation techniques (acupuncture, acupressure) for patients with disabilities caused by post-stroke. It includes rehabilitation medical treatment, training guidance, psychological guidance, knowledge dissemination, supplies and appliances, consultation and education to restore or compensate for the patient’s deficient functions and enhance his or her ability to participate in social life as much as possible.
Strengthening the tertiary prevention of stroke can further improve the level of prevention and treatment of chronic diseases such as stroke, especially for high-risk patients, and establish a social and physical environment conducive to stroke prevention and treatment, gradually reduce the level of major risk factors in the community, reduce the number of stroke incidence, disease, disability and death, and improve the quality of life and quality of life of the community.