Stroke is divided into hemorrhagic stroke (cerebral hemorrhage) and ischemic stroke (cerebral thrombosis). With the improvement of people’s living standards and the aging of the population, the incidence of stroke is increasing year by year, which brings a heavy burden to patients and their families. How to enable more stroke patients to take care of themselves and return to society, rehabilitation medicine solves this problem.
Rehabilitation is a process to achieve the following goals, aiming to eliminate or reduce the physical, mental and social dysfunction of the sick, injured or disabled person through the integrated and coordinated application of various measures, to achieve and maintain the optimal level of physical, sensory, intellectual-spiritual and/or social functions, so that they can change their lives and enhance their self-sufficiency with the help of some means, and enable the sick, injured or disabled person to return to society and improve their quality of life. Although there are pathological changes that cannot be eliminated, it is still possible to achieve the best state of survival for the individual through rehabilitation. Gao Ming, Department of Rehabilitation, Songwon Chinese Medicine Hospital
Rehabilitation medicine is the use of a variety of medically based means to try to restore the patient’s restricted or lost functions and abilities to the maximum possible extent so that they can return to society and lead a near normal or relatively normal life. This is done through a variety of methods such as physical therapy, occupational therapy, speech therapy, psychotherapy and rehabilitation engineering, supplemented by the necessary medication and surgery.
Movement is a sign of life, manifested not only by physical displacement of objects, but also by dynamic changes in the internal structure of the organism.
The effect of braking on the organism
Braking can take the form of immobilization, bed rest and paralysis. Long-term braking can cause braking or disuse syndrome, and long-term bed rest or braking can increase new dysfunctions and aggravate disability, sometimes with more serious consequences than the effects of the original disease and trauma, and even involving the functions of multiple systems.
Effects of braking on the cardiovascular system.
In strictly bedridden individuals, the basal heart rate increases. The basal heart rate is extremely important for maintaining a certain level of coronary blood flow, because the perfusion of the coronary arteries lies in the diastolic phase of the heartbeat. A faster basal heart rate and shorter diastolic phase will reduce coronary perfusion, so even light physical activity can lead to tachycardia in those who are bedridden for long periods of time. Platelet aggregation, reduced arterial blood flow, increased resistance to blood flow in the lower extremities, and increased viscosity of blood increase the risk of venous thrombosis in those who are bedridden for long periods of time. Prolonged bedridden patients are prone to postural hypotension, which is manifested by pallor, sweating, dizziness, decreased systolic blood pressure, accelerated heart rate, decreased pulse pressure, and in severe cases, syncope.
Effects of braking on the respiratory system.
After several weeks of bed rest, the patient’s whole body muscle strength decreases, and the respiratory muscle strength also decreases. In addition, the external resistance of the thorax increases when lying down, the elastic resistance increases, which is not conducive to chest expansion, the compliance of the lungs becomes smaller, and the lung capacity decreases significantly. In addition, the movement of the diaphragm is partially blocked in the recumbent position, which reduces the respiratory movement. Bed rest makes the function of tracheal cilia decrease, secretions adhere to the bronchial wall, making discharge difficult, and secretions deposited in the lower bronchi are likely to induce respiratory tract infection. Pulmonary embolism is a complication of venous thrombosis of the lower extremities.
Effects of braking on the muscular system.
Prolonged bed rest causes muscle ischemia and hypoxia due to the decrease in local blood flow and oxygen transport capacity of muscles, which directly affects the process of glucose metabolism. After 4 weeks of immobilization of the elbow joint in healthy individuals, the circumference of the forearm decreases by 5%, and the decrease in muscle weight is most pronounced after 5-7 days of immobilization.
Effects of braking on the osteoarticular system:
Bone metabolism is mainly dependent on daily compression and distraction. The weight in the standing position compresses the bone and the tendon acts on distraction, and the above two forces directly affect the bone morphology and density. Studies related to space flight have demonstrated that the reduction of pressure along the longitudinal axis of the long bones is the main cause of osteoporosis. With prolonged braking, several changes will occur in the bone: bone resorption is accelerated at the beginning, especially in the trabeculae, and cortical resorption is also significant. Later on, the resorption slows down, but lasts for a long time. Prolonged braking can produce severe joint degeneration. The stiffness of the periarticular ligaments decreases, strength decreases, energy absorption decreases, elastic modulus decreases, tendon attachment points become weak, and ligaments are prone to rupture. The joint capsule becomes painful due to vascular and synovial hyperplasia and adhesions between the fibrous connective tissue and cartilage surfaces. Subsequently, the joint capsule contracts, the joint contractures, the range of motion is reduced, and the joint is fixed within a certain range.
Effects of braking on the central nervous system.
After prolonged braking, sensory abnormalities and decreased pain thresholds can occur due to reduced sensory input. Isolation from society, reduced sensory input, combined with the pain of the primary disease, produces anxiety, depression, emotional instability and neuroticism, or emotional indifference, withdrawal, irritability, aggressive behavior, and in severe cases, unusual touch, kinesthesia, hallucinations and hallucinations.
Effects of braking on the digestive system.
The mental and emotional effects of prolonged bed rest and illness can reduce the secretion of gastric juice, slow down the emptying of food in the stomach and decrease appetite, resulting in reduced absorption of protein and carbohydrates, producing a certain degree of hypoproteinemia. Gastrointestinal peristalsis is weakened, food residues stay in the intestine for too long, water is absorbed and becomes dry, resulting in constipation.
Effects of braking on the urinary system:
The secretion of antidiuretic hormone decreases when bedridden, urination increases, and potassium, sodium and nitrogen excreted with urine increase. As calcium is released from bone tissue into the blood, hypercalcemia is produced, and excess calcium in the blood is excreted through the kidneys, producing hypercalciuria. Increased urinary excretion of calcium and phosphorus, urinary retention, and urinary tract infection are the three major factors in the formation of urolithiasis.
Effects of braking on the skin system.
Poor skin hygiene leads to bacterial and fungal infections, and braking can cause atrophy and decubitus ulcers on the skin and its attachments.
Effects of braking on metabolism and endocrine.
1. negative nitrogen balance The secretion of antidiuretic hormone decreases during braking, producing polyuria and a significant increase in urinary nitrogen excretion, which begins on the 4th-5th day of braking, reaches a peak during the second week and continues.
2. Endocrine changes Antidiuretic hormone secretion starts to decrease on the 2nd-3rd day of bed rest, adrenocorticotropic hormone secretion increases, and androgen level decreases.
3, water-electrolyte changes Hypercalcemia is a common and easily neglected water-electrolyte abnormality after braking, and the incidence of hypercalcemia can reach 50% in children who are bedridden for a long time due to fracture fixation or traction.
Post-stroke is an alteration of motor nature, and the rehabilitation process is divided into six phases: flaccid phase, spastic phase, joint band movement phase, partial dissociative movement phase, dissociative movement phase and normal phase.
Phase I: characteristics of the bradykinetic phase
1. The patient loses control of the limbs and the random movements disappear, 2. the muscle tone is low, and 3. the tendon reflexes are weakened or disappear.
The second stage: characteristics of the spastic stage
After the course of the disease varies from several days or weeks, the limb function can be determined to enter the spastic stage if the patient shows one of the following characteristics
1. hyperactive tendon reflexes, 2. increased muscle tone, and 3. the appearance of joint reaction.
Spasticity is the main factor affecting the patient’s casual movement. In rehabilitation treatment, prevention and reduction of spasticity is the key to selecting and designing treatment plans and promoting early recovery.
Stage 3: Characteristics of the joint band movement stage
Divided flexor spasticity pattern and extensor spasticity pattern.
Stage 4: Characteristics of the partial dissociative movement stage
Upper extremity: When the patient can complete any one of the following three movements, it proves that his function has entered the partial dissociative movement stage.
1. Shoulder joint extension, elbow joint flexion, and hand touching the spine <5cm from the spine
2. The elbow joint is extended while the shoulder joint is flexed.
Shoulder joint flexion shall not be <60°, inversion and abduction shall not be >10°, elbow joint flexion shall not be >20°.
3. Elbow joint flexion, forearm rotation forward, upper arm must not leave the trunk, elbow joint flexion 90°±10°, rotation forward >50°.
Lower extremity: When the patient can complete any one of the following three movements, it is proved that the function has entered the stage of partial separation movement.
1.Supine position, hip abduction, abduction >20°, heel must not leave the bed, knee extension, flexion must not be >20°, 2.Supine position, knee extension, hip flexion, knee flexion <20°, hip flexion >30°. 3.Sitting position, knee extension, hip 60°-90° position, knee flexion <20°
Stage 5:Characteristics of the separation movement stage
Upper extremity: the function of the upper extremity can be judged to have reached the stage of separate movement if it can complete one of the following three movements.
1.Elbow extension, shoulder abduction, elbow flexion <20°, shoulder abduction >60°.
2.Elbow extension, upper limb elevation, elbow flexion <20°, shoulder flexion >130°.
3.Elbow extension, shoulder flexion, forearm rotation forward, elbow flexion <20°, shoulder flexion >60°, forearm rotation forward >50°.
Lower limbs: Those who can complete one of the following three movements are judged to have reached the stage of detached movement.
1.Sitting position, knee extension, ankle dorsiflexion, hip flexion 60°-90°, knee flexion <20°, ankle dorsiflexion >5°.
2.Sitting position, hip internal rotation, hip flexion 60°-90° knee flexion 90°±10°, hip internal rotation >20°.
3.Standing position, ankle dorsiflexion, hip and knee flexion <20°, ankle dorsiflexion >5°.
Stage 6: Normal.
The rehabilitation treatment advocates early intervention, and the design of good limb position in the acute stage is extremely important for the rehabilitation of hemiplegic patients. The good limb position is divided into three positions: affected side lying, healthy side lying and supine position.
1. Affected side lying position: It is the most important position among all lying positions, which can give good stimulation to the affected side and is conducive to the rehabilitation of the affected limb. The head should be well supported, the trunk should be slightly rotated to the back, and the back should be firmly supported by soft pillows. The upper limb on the affected side should be extended forward, with the angle of the trunk not less than 90°, the forearm rotated backward, the wrist passively extended dorsally, the auxiliary personnel make the patient’s scapula extend forward, the upper limb on the healthy side can be placed on the body or on the pillow behind, the lower limb is in the striding position, the hip and knee on the healthy side are flexed and supported with a pillow underneath, while the affected leg is kept in the extended hip and slightly flexed knee position with a pillow.
2.Healthy side lying position: the head is still well supported by pillows to ensure the patient’s comfort, the trunk is at a right angle to the bed, the hemiplegic upper limb is supported by pillows in front of the patient and lifted up about 100°, the healthy side upper limb can be placed in any comfortable position, the affected side lower limb is bent forward at the hip and knee and fully supported by pillows, the foot cannot be inwardly turned and hung on the edge of the pillow. The lower limb on the healthy side is placed flat on the bed, mildly extending the hip and slightly flexing the knee.
3, supine position: supine position should be minimized, because this position is affected by the cervical tension reflex and vagus reflex, the strongest abnormal reflex activity, this position also makes the risk of decubitus ulcers in the sacrococcygeal region, the heel and the outer ankle greatly increased. The head is well supported by pillows, taking care not to flex the thoracic vertebrae. A soft pillow is placed under the scapula on the affected side to make it stretch forward, and a pillow is placed under the hip and thigh on the affected side to make the pelvis move forward and prevent the affected leg from external rotation.
Positioning considerations.
1, the bed should be flat, the head of the bed should not be raised, and semi-recumbent position should be avoided as much as possible.
2, nothing should be placed in the hands, the correct position is to make the patient’s hands open, and not to let the hands in the anti-gravity position.
3. many patients have difficulty posing their bodies in relation to adjacent objects, and it is best to keep the patient’s body parallel to the side of the bed while he or she is recumbent
4. preparing multiple pillows of different sizes and shapes to support different body positions
5. Nothing should be placed on the bottom of the foot, and attempts to avoid plantarflexion deformity in this way are undesirable.
We apply Bobash technique and motor relearning therapy to treat stroke patients, which mainly includes joint mobility maintenance, promotion of muscle strength production, spasticity inhibition, and early emergence of casual movement, and can be divided into three stages: passive movement, assisted active movement, and active movement.
After the necrosis of brain tissue cells, they cannot be regenerated and can only compensate for their functions through the plasticity of the brain, which is the theoretical basis of rehabilitation medicine.
Seated endurance training standards.
I. Criteria for the beginning of seated endurance training.
1.No further development of impairment of consciousness, motor impairment, and impairment of activities of daily living.
2. Stable general condition.
Second, the implementation of training standards: 1.
1. Blood pressure and heart rate were measured before training and 5, 15 and 30 minutes after the start of training.
2, 30 °, 45 °, 60 ° and the highest 80 ° four stages, must be able to maintain a certain stage for 30 minutes before the next stage of training.
3.Twice a day at the beginning, training at breakfast and lunch, and three times a day after stabilization.
After maintaining the 80° position for more than 30 minutes, start practicing wheelchair training.
III. Criteria for termination of training.
1.When the blood pressure exceeds 10mmHg or more, judging by the recovery level after 5 minutes and the conscious symptoms, if it exceeds 30mmHg, the training should be terminated.
2.Pulse increases by more than 30% or more than 120 beats/minute than before the start.
3.People with symptoms of postural hypotension.
Training to maintain joint mobility
The normal flexion and extension or (and) rotation of each joint have a certain range, and this range is the mobility of the joint.
Neck: forward flexion 0-60° back extension 0-50°
Left rotation 0-70° Right rotation 0-70°
Left flexion 0-50° Right flexion 0-50°
Thoracolumbar spine: anterior flexion 0-45° posterior extension 0-30°
Left rotation 0-40° Right rotation 0-40°
Left flexion 0-50° Right flexion 0-50°
Upper extremity: shoulder joint: flexion 0°-180° extension 0°-50
Abduction 0°-180° Internal rotation 180°-0° External rotation 0°-90° Internal rotation 0°-90°
Elbow joint: flexion 0-145° extension 0° hyperextension 0°-5°
Forearm: anterior rotation 0°-90° posterior rotation 0°-90°
Wrist: dorsiflexion 0°-70° palmar flexion 0°-90°
ulnar deviation 0°-55° radial deviation 0°-25°
Lower extremity: hip: knee flexion and hip flexion 125° knee extension and hip flexion 90°
Extension 0°-15°
abduction 0°-45° internal retraction 0°-20°
Internal and external rotation 0°-45°
Knee: knee extension 0° knee flexion 0°-130°
Calf: internal rotation 0°-10° external rotation 0°-20
Ankle: dorsiflexion 0°-20° flexion 0°-45°
Balance ability: When the body’s center of gravity deviates from the stable base, it should be able to immediately return the center of gravity to the stable base through active or reflexive activities, this ability is called balance ability.
A truly practical function of walking must be
1. Safe
2. Relatively effortless
3. Natural in appearance
4. As far as possible without a cane
5. Can walk automatically
Walking cycle: When a person walks, the time from when one foot follows the ground to when the heel of that side hits the ground again is called a walking cycle. In a walking cycle, each side of the lower limbs to experience a ground contact and weight-bearing standing phase, and off the ground to move forward in the stride phase, the normal human standing phase accounts for about 60%-65% of the entire walking cycle, the stride phase accounts for about 35%-40%.