Cerebrovascular disease, also known as stroke or strokes, is a common and frequent disease with high mortality, disability and recurrence rates. About 70% to 80% of stroke survivors have varying degrees of functional impairment. Improper post-stroke management can lead to disuse syndrome and misuse syndrome. The goals of stroke rehabilitation are to restore or reconstruct function, bring into play residual functional complications, reduce sequelae, adjust psychology, learn to use mobility tools and assistive devices, prepare for returning to family and society, and improve quality of life.
1.Psychological guidance
(1) First of all, it should be clearly explained to the family and the patient that rehabilitation is not equivalent to discharge guidance and is not synonymous with good food, good clothing and good rest after illness. In order to maximize the patient’s residual function, rehabilitation should be carried out throughout.
(2) When carrying out rehabilitation training, especially walking training, patients should not be overconfident and should not get up or move their bodies on their own unaccompanied or unattended to avoid accidents such as falls.
(3) Patients with language disorders, in order to improve the patient’s training enthusiasm, reduce interference, and facilitate the patient’s concentration, the training process prohibits the participation of outsiders, the nurse and family members should follow the requirements of the rehabilitation doctor when reinforcing the training, supervision is the main focus, when the patient still has the desire to train after the language training reaches the requirements of the rehabilitation doctor, the training content can be extended according to their requirements.
(4) When the patient becomes emotionally irritable during training and refuses to train, the patient and family should be consulted in a timely manner. For example, lack of self-confidence or shyness, pressure from family or society, etc.
(5) Rehabilitation training should be evaluated regularly to understand the patient’s rehabilitation progress and modify the training plan in a timely manner. Tell the patient not to be irritated by certain repetitive examinations and to do his best to cooperate.
2.Positioning
Keep the muscles and soft tissues prone to contracture in an elongated position to prevent muscle shortening and stiffness, and do a full range of passive activities on each joint of the affected limb every day to improve blood circulation in the limb and prevent joint stiffness and contracture.
3.Passive movement
After the patient’s condition has stabilized, in addition to paying attention to the placement of the good limb position, both clear-minded and comatose patients should carry out passive exercises early.
(1) Shoulder joint flexion, extension, abduction, rotation inward, rotation outward, etc., to the extent that the patient can tolerate, comatose patients can reach the maximum functional position, not too much force, the amplitude from small to large, a total of 2 to 3min is appropriate to prevent shoulder joint dislocation.
(2) Elbow flexion and extension, internal rotation, external rotation, etc., the force is appropriate, the frequency should not be too fast, a total of 2 to 3 min.
(3) Wrist dorsiflexion, dorsiextension, encirclement, etc. 3 to 4 times in each direction, do not use excessive force to avoid fracture.
(4) Flexion and extension activities of the joints of the fingers, thumb abduction, encirclement and the remaining 4 fingers, each activity should last for about 5 min.
(5) Hip joint abduction, internal rotation and internal rotation, as tolerated by the patient, 15°~30° of abduction, 5° of internal rotation and external rotation for comatose patients, no excessive force, moderate speed, 2~3 min of activity, 2~3 times of activity in each direction is appropriate.
(6) Knee flexion, extension, internal rotation, external rotation, etc., a total of 2 to 3 min of activity.
(7) Plantarflexion, plantarflexion and extension of the ankle joint, and encircling position, for a total of 3 min, without excessive force to prevent sprain.
(8) Flexion, extension and encirclement of the toe joints for 4 to 5 min.
Passive exercise can be carried out 2 to 3 times a day, and massage the heart of the foot (Yongquan point), the heart of the hand (Laogong point), Hegu point, Quchi point, etc., to help the patient massage the muscles of the whole body, to prevent muscle atrophy and joint contracture.
4.Active movement
When the patient is clear and the vital signs are stable, active training of key activities should be carried out, and the patient should wear clothes suitable for training, including appropriate shoes. Treatment should include practice of active control of sitting and standing and active movement. Practice work should be performed while sitting, standing (especially reaching objects beyond the length of the upper extremity), standing up and sitting down, walking and maneuvering.
(1) Turning to the healthy side and sitting up from the side of the bed is critical to establishing independence.
(2) Increased plyometric training restores more motor units, increases the frequency of motor unit discharge, and increases the synchronization of motor units. Specific lower extremity plyometric training is performed in conjunction with walking exercises and attention is paid to the training of daily life movements: batting, knitting wool, picking up beans, etc.
(3) Walking training consists of weight-bearing on the affected limb, resistance exercises on an isometric trainer, and walking on a running platform with sling support.
(4) Walking on a running platform with sling support (weight reduction) is an effective gait training method. Patients start walking on the running platform for 15 min at a time, increasing to 30 min after 5 days. after 25 sessions of running platform training, endurance, walking speed, stride frequency, and stride distance all increase. The running table provides the patient with the opportunity to practice the full walking cycle.
(5) The use of orthoses and assistive devices, many types of devices are helpful in helping stroke patients improve their level of self-care. For example, appliances used in daily life to help with eating, bathing, dressing, grooming, walking, and wheelchairs.
5.Language training
(1) Oral exercises: teach patients to pout, puff their cheeks, show their teeth, knock their teeth, and flick their tongues, etc. Do each movement 5 to 10 times.
(2) Tongue exercise: open the mouth wide, do the tongue outward and backward movement, stick the tip of the tongue out of the mouth as far as possible, lick the upper and lower lips, left and right corners of the mouth, and do the tongue around the lips of the mouth around the movement, tongue licking the palate movement. Repeat each exercise 5 times, 2 to 3 times a day.
(3) Teach the patient to learn to pronounce [pa, ta, ka], first single coherent repetition, when the patient can pronounce accurately, 3 sounds together and repeat [pa, ta, ka], repeat the training several times a day until the patient is well trained.
(4) Respiratory training: When the patient has uneven breathing, the patient should be trained to breathe first: touch the patient’s two thoracic ribs with both hands, ask the patient to inhale, ask the patient to pause at the end of inspiration, ask the patient to lightly press down with both hands, ask the patient to exhale evenly, and so on. You can also teach the patient to inhale through the mouth first, and then exhale through the nose, in order to adjust the respiratory airflow and improve language function.
(5) Use pictures, word cards, objects, etc. to strengthen the patient’s memory. Early on, you can also use copying, spontaneous writing, mimeography, etc. to strengthen the patient’s language memory function, and ask the patient to read more and read out loud to stimulate memory.
6.Guidance on swallowing disorder training
(1) Diet should be light, less crumbly and soft, bread and buns can be wrapped in juice for consumption. When choking is obvious, drink as little water as possible and replace it with soup or juice.
(2) Raise the head of the bed 30°~45° when eating.
(3) Ice water gargle or ice cotton swab can be used to stimulate the throat before eating to facilitate the passage of food and water.
7.Application of Chinese traditional medicine
Acupuncture and massage have a good effect on the patient’s functional recovery.
8.Training for caregivers
Caregivers are taught to ensure the patient’s safety, nutrition and water supply and some basic training techniques such as bed exercises, transfers, hygiene and dressing, etc. and home training programs.
9. Psychosocial aspects of rehabilitation
The main factor that affects the level of participation in treatment and the outcome of treatment is the patient’s motivation. Several techniques can be used to increase motivation to participate in treatment, such as explanation, positive reinforcement, behavior modification and patient handling. The degree of family support also affects the outcome of treatment.