0 Introduction
Walking dysfunction is one of the main problems encountered in the rehabilitation of stroke patients, and whether walking can be restored is the main indicator to evaluate the motor function of hemiplegic patients. Therefore, one of the basic tasks of rehabilitation medical treatment for hemiplegia is walking training. Since 1990, our department has adopted neuromuscular retraining therapy based on the facilitation technique for walking training, and the patients’ walking ability and walking quality have been significantly improved, which is reported as follows: Zhang Tingfeng, Rehabilitation Center, The First Affiliated Hospital of Henan College of Traditional Chinese Medicine
1 Clinical data
All 87 cases were stroke patients diagnosed by clinical cranial CT and MRI. There were 50 cases in the rehabilitation treatment group, including 34 males and 16 females, aged 38-75 years, with an average of (60.4±6.2) years. There were 18 cases of cerebral infarction, 26 cases of cerebral hemorrhage, and 6 cases of embolism combined with hematoma. In the control group, there were 34 cases, including 23 males and 11 females, aged from 39 to 75 years, with an average of (53.35±13.46) years. There were 20 cases of cerebral infarction, 11 cases of cerebral hemorrhage, and 3 cases of embolism combined with hematoma. Both groups of patients had lower limb involvement, and both groups of cases did not include those with transient ischemic attack (TIA) and reversible ischemic neurological dysfunction (RIND), and the duration of the disease was within 1 month.
2 Treatment methods
2.1 Standing phase ① hip extensor group control training, such as bedside bridge exercise, bedside bridge exercise, forward and backward step of the healthy leg and step up of the healthy leg, etc.; ② knee extensor group control training, such as active flexion and extension exercises of the affected knee at 0-15 degrees and step up and down of the healthy leg, etc.; ③ pelvis horizontal lateral shift, practice left and right weight shift, practice side walk; ④ dorsiflexion retraction of the ankle joint and (3) horizontal lateral shift of the pelvis, practice left and right weight shift and lateral walk; (4) dorsiflexion and posterior extension of the ankle joint; (5) hip extension on the affected side in the kneeling position and hip flexion on the healthy side off the bed.
2.2 Swing phase ① control ability training of hip flexor group, such as lower limb centripetal movement in supine position; ② control ability training of knee flexor group, such as prone position, small range of knee flexion and extension activities (bending knee <90°); ③ anterior and posterior swing exercises of lower limb on the affected side in standing position, followed by up and down steps or forward and backward steps with the affected leg; ④ control ability of knee extensor group and foot Dorsiflexion exercises, such as standing with the healthy leg to shift the weight to the affected leg, maintaining knee extension and foot dorsiflexion.
2.3 Comprehensive gait exercises: (1) walking exercises in kneeling position; (2) dynamic walking exercises; (3) walking exercises on a 10 cm thick sponge mat.
Among the 50 cases in the treatment group, 26 cases were treated for 1 month, 15 cases were treated for 1 to 2 months, and 13 cases were treated for more than 2 months.
2.4 Precautions All of the above were performed in the exercise therapy room under the guidance of an exercise therapist (PT), and the training of each movement should be programmed. Before training, cardiopulmonary function was measured in order to understand the patients’ cardiopulmonary function.
3 Efficacy assessment
3.1 Evaluation method ① The lower limb motor function was evaluated by the Brunnstrom 6-stage evaluation method [1]. ② Gait function can be assessed according to the following methods: Grade 0: completely unable to stand; Grade 1: completely supported by others; Grade 2: supported by walkers and others; Grade 3: walking independently under the guidance and protection of a bystander; Grade 4: walking steadily on a flat surface; Grade 5: able to walk up and down stairs. The assessment of walking ability was based on the method currently used by the China Rehabilitation Center: Level 1: independent and normal walking; Level 2: walking with guidance; Level 3: walking with assistance; Level 4: unable to walk.
3.2 Statistical treatment The assessment results were statistically processed by the χ2 test.
4 Results
The gait changes, lower limb function improvement and walking ability of the 50 patients before and after training are shown in Tables 1 to 4, respectively.
Table 1 The gait function before and after training in the treatment group
Table 1 The gait function changes of pre-training
and post-training in therapy group
Grade
0
1
2
3
4
5
Pre-training
30
7
2
6
5
0
Post-training
0
4
4
11
12
19
Table 2 The function of the lower limb of the two groups 〈Brunnstrom classification〉
Table 2 The function changes of lower limb of 2 groups
Grade
Ⅰ
Ⅱ
Ⅲ
Ⅳ
V
VI
Therapeutic group
Pre-training
15
2
13
6
14
0
Post-training
0
0
2
16
14
18
Control group
Pre-observing
9
12
7
5
1
0
Post-observing
0
2
21
6
4
1
Table 3 The walking ability of pre-training and post-training in the treatment group
Table 3 The walking ability of pre-training
and post-training in therapy group
Grade
4
3
2
1
Pre-training
37
2
6
5
Post-training
0
4
15
31
Table 4 Comparison of the recovered function of lower limb in 2 groups
Table 4 The recoverent function of lower limb in 2 groups
Walking ability
Brunnstrom grade
Independent
walking
Dependent
walking
Revival
ratio
Ⅰ～Ⅲ
IV-VI
Therapeutic
group
31
19
62%
2
48
Control
Control group
5
29
14.71%
23
11
P<0.05
From Table 1, it can be seen that the gait condition of the patients improved significantly after training, and the number of patients with excellent gait (grade 3-5) increased significantly from 11 to 42 cases, an increase of 62% (from 22% to 84%); however, there were still 15 cases with hemiplegic gait and 4 cases with severe gait, accounting for 38% of the total number of both cases. In contrast, there were 45 cases (90%) of both before training and 52% reduction after training. This indicates that walking training is beneficial to the improvement of gait function.
As can be seen from Table 2, the lower limb function of patients in the treatment group improved significantly after training, and the lower limb Brunnstrom grade IV-VI (detachment movement ~ normal) increased from 20 cases to 48 cases. Grade Ⅰ to Ⅲ (flaccid ~ coordinated movement) decreased from 30 cases to 2 cases. The lower limb function of the control group also showed some improvement: the Brunnstrom grade I-III of the lower limb decreased from 28 to 23 cases, and the grade IV-VI increased from 6 to 11 cases, with a recovery rate of 14.7%, but not as high as that of the treatment group (56%).
As can be seen from Table 3, the number of people who could walk (grade 1-2) increased significantly after training, from 11 cases to 46 cases, and the walking increased to 92% (originally 22%), an increase of 70%, while the number of people who could not walk was 0. There were 4 cases who needed help to walk, accounting for 8%, which was 70% less than the 78% before training, indicating that walking training helped the recovery of walking ability.
As can be seen from Table 4, 62% of the treated group could walk independently after training, while the natural recovery rate in the control group was 14.71%, with a significant difference between the two (P<0.05). In the same two groups of Brunnstrom's classification, there were 2 cases in the treatment group and 23 cases in the control group for grades I-III, while there were 48 cases in the treatment group and 11 cases in the control group for grades IV-VI, with significant differences (P<0.05), indicating that walking training is beneficial to the recovery of walking ability.
5 Discussion
The human body walks mainly by the continuous change of hip, knee and ankle joint angles, so that the left and right legs swing alternately and realize. Each of these movements cannot be accomplished by a single muscle group or group of muscles; they must be under the control of the nervous system. After stroke, due to the damage of upper motor neurons, the movement loses the regulation of higher centers and the intercontrol and coordination between muscles or muscles are lost. It has been reported that 80% of hemiplegic patients can regain walking ability after stroke, but most of them walk in a hemiplegic pattern. Analysis of the abnormal gait of patients revealed two main problems with hemiplegic gait [2]: (i) in the standing phase, the affected leg lacks the ability to balance during weight transfer because of its poor weight-bearing capacity; (ii) in the swing phase, the affected side produces hip lifting upward and causes the lower limb to “paddle” in external rotation and abduction because of inadequate knee flexion. In this way, the patient can only use the toes or the front lateral part of the foot to land first in the support phase, instead of landing by the heel first, and then smoothly move the center of gravity to the front, reducing the fluctuation of the center of gravity up and down. In addition, in the swing phase, the affected foot always drags the ground, which is also associated with trunk muscle spasm. Therefore, walking training for stroke is mainly about muscle control ability training in functional position (such as hip, knee and ankle joint control ability training), weight-bearing training of the affected leg and standing balance training to prepare the necessary conditions for walking. However, walking is a very complex activity, including not only the function of the lower limb muscles, bones and joints, but also the degree of coordination of the overall function of the lower limb [7, 9]. Therefore, when we design exercise programs and conduct exercise training, we also give patients appropriate coordination training.
In the practice of walking rehabilitation, irregular rehabilitation exercises and premature weight-bearing and step walking and strengthening training can temporarily or to some extent promote the recovery of walking function and reduce the dependence on others in stroke patients with hemiplegia, but this improvement is only temporary and limited. In one of the eight patients with severe hemiplegic gait, the failure to follow the treatment protocol, the inadequate preparation for walking, and the lack of balance, resulted in a significant reduction in the number of patients with hemiplegia. One of the eight patients with severe hemiplegic gait did not follow the treatment plan, and the preparation before walking was not fully completed, and the balance had not yet reached level 2 or higher. As a result, the extensor muscles of the lower limbs, which were already in a spastic state, were strengthened, resulting in a hemiplegic gait. Therefore, before we instructed the patient to walk, we put some effort on joint muscle training, i.e., trunk muscle exercise, lower limb joint movement, and balance training. As for the heart and lung function measurement, it is mainly to understand the heart and lung function of the patients, so as to formulate and arrange the training contents, master the training intensity and training quantity, and avoid blind training and sports accidents. There are many patients with low cardiac and pulmonary function, which affects the recovery of the body’s motor function, and then limited walking ability.
Xie Xuxiao and Shen Shu [4] reported that the recovery of lower limb walking function in hemiplegia rehabilitation treatment was 81.2%. The recovery of walking in our group of 50 cases was 92%, which is basically consistent with the literature. This indicates that training has a significant effect on improving walking ability. Four people still did not achieve independent walking after training. The reasons for this may be: ① older age (one patient was 75 years old): older age, cerebral arteriosclerosis, poor cerebral blood flow circulation, decreased cerebral metabolic function, slow absorption of hematoma and poor establishment of collateral circulation [5]. ② Larger and longer duration of bleeding. Many studies have shown that the best time to recover from acute cerebral hemorrhage hemiplegic lower limb walking should be the first 3 months after the onset. The larger the bleeding volume and the longer the duration, the worse the walking ability [6]. One of the patients could be the cause of this aspect. The presence of impaired consciousness and complications, such as depression, cerebral edema, post-infarction hemorrhage, epilepsy? etc. affect the correct functioning of psychological defense mechanisms and functional reorganization of the brain, which could be the cause in two of these patients.
Currently, there are many methods to assess motor dysfunction after stroke, such as Fugle-Meyer score, Linkmark score, Brunnstrom staging assessment method, and Ueda Min method. From Tables 1, 2, 3 and 4, we can find that using the lower limb functional assessment method combined with gait, which reflects both walking ability and walking quality, and the method is simple and easy to use, is an effective evaluation method.
References.
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