A. Basic knowledge (a) Definition of stroke: In Chinese medicine, acute cerebrovascular disease is called stroke or strokes.
Most strokes occur in middle-aged and elderly people, and they constitute the three leading causes of death, along with heart disease and malignant tumors. Although a large number of patients survive, 80% of them are often left with varying degrees of disability and require family care or long-term hospitalization, which places a great burden on families and society. Therefore, in addition to active preventive measures and timely treatment, early intervention of rehabilitation is equally important. Zhao Dongqi, Department of Tui-Na Massage, Songyuan City Hospital of Traditional Chinese Medicine (II) Definition of hemiplegia.
Hemiplegia is a syndrome caused by cerebrovascular disease, traumatic brain injury, brain tumor, encephalitis, meningitis and other intracerebral lesions, with incomplete or complete loss of ipsilateral upper and lower limb random movements as the main clinical manifestation.
Hemiplegia is not an independent disease, but mainly manifests as motor paralysis of the upper and lower extremities on one side, which may be accompanied by hemianesthesia and alteration of key reflexes, and depending on the site of brain injury, aphasia and visual field loss may occur. Therefore, hemiplegia is only one of the syndromes of stroke.
(iii) Causes of hemiplegia.
(i) Intracerebral lesions; cerebrovascular lesions: divided into ischemic cerebrovascular diseases (cerebral thrombosis, cerebral embolism, lacunar infarction), hemorrhagic cerebrovascular diseases (cerebral hemorrhage, subarachnoid hemorrhage) (ii) Traumatic brain injury (iv) Common functional disorders of hemiplegia.
(i) Motor disorders.
1. Flaccid phase: muscle relaxation, hypotonia, and inability to perform voluntary movements.
2. Spastic phase: abnormal postural reflexes, spasticity, and hyperactive tendon reflexes occur, resulting in abnormal movement patterns.
(1) Spasticity pattern: The common spasticity pattern is characterized by hyperflexia of the upper limbs and hyperactivity of the extensor muscles of the lower limbs, as shown by
Head: affected flexion, face turned to the key side Trunk: affected flexion, posterior rotation Scapular girdle: posterior withdrawal, subsidence Pelvis: elevation, posterior rotation Shoulder: adduction, internal rotation Hip: extension, adduction, internal rotation Elbow: flexion Knee: extension Forearm: rotation anterior Ankle: plantar flexion, internal rotation Wrist: palmar flexion, ulnar deviation Toe: flexion, internal rotation (2) Reflex inhibition antispastic position (RIP) Upper extremity RIP. Abduction, external rotation, elbow extension, forearm rotation posteriorly, wrist finger extension, thumb abduction Lower limb RIP: mild flexion of hip and knee; inversion and internal rotation of lower limb; dorsiflexion of ankle and toe 3. Recovery period: spasticity is reduced and separate movements of limbs appear.
(B) Sensory impairment: mainly manifested as pain, temperature, touch, pressure, proprioception and visual impairment.
(C) Language disorders: aphasia: including motor aphasia, sensory aphasia, complete aphasia, naming aphasia, dyslexia, dysgraphia, dysgraphia (d) Cognitive disorders: including orientation, attention, memory, thinking and other dysfunctions, and perceptual disorders such as aphasia and dyscalculia.
(E) Complications of hemiplegia; (I) Hemiplegic shoulder pain; (1) Shoulder joint subluxation: Mostly seen in the early stage of stroke patients, the incidence is as high as 60-70%, especially when the whole upper limb is in a sluggish state, and occurs naturally due to gravity when starting to sit or stand. The activity and tension of the stabilizing muscles around the shoulder should be strengthened.
2. Shoulder-hand syndrome: It is a syndrome characterized by shoulder joint pain, restricted movement and hand swelling and pain after traumatic brain injury or cerebrovascular disease. It is usually seen within 1-3 months after stroke. This phenomenon is often caused by prolonged flexion and pressure on the wrist joint, inappropriate overstretching of the hand joint and accidental injury. For this reason, shoulder~hand syndrome should be detected early and treated promptly, once it enters the late stage, it will be difficult to change the contracture and loss of function of the hand. Specific measures: maintain a good sitting and lying position to avoid prolonged hand drop; strengthen the passive and active activities of the affected limb to prevent joint contracture; for swollen fingers, centripetal compression winding method can be used, in addition, ice water therapy can also be used, and if necessary, oral Prednisone can be given orally if necessary.
(b) Disuse syndrome: disuse muscular atrophy, joint contracture deformity, upright hypotension (a) Assessment of motor dysfunction: assessment of upper limb, trunk, lower limb function and assessment of muscle spasm.
(b) Assessment of balance function.
V: able to stand on one leg Ⅳ: able to kneel on one knee Ⅲ: able to shift the body weight from the back leg to the front leg when standing on one leg in front and one leg in back Ⅱ-3: able to stand on both feet Ⅱ-2: able to kneel on both knees Ⅱ-1: able to stand on hands and knees Ⅰ: able to sit with the lower limb extended О: unable to sit when extending the lower limb (iii) Assessment of the practical ability of hand function: you need to prepare an umbrella, a wallet, a number of coins, a 10 cm size nail clipper, and an ordinary shirt.
Practical hand A: all 5 movements can be completed Practical hand B: 5 movements can be completed 4 auxiliary hands A: 5 movements can be completed 3 auxiliary hands B: 5 movements can be completed 2 auxiliary hands C: 5 movements can be completed 1 disuse hand: 5 movements cannot be completed (d) Assessment of other functional disorders: assessment of daily living ability, assessment of mental and emotional disorders, assessment of language dysfunction III. Rehabilitation goals and plans Recovery phase Training goals Training plan Delayed period Prevention of spasticity Good posture maintenance Prevention of joint reactions Postural transfer training Prevention of complications and secondary damage Auxiliary passive movement Induction of normal movement patterns Active movement Spasticity period Suppression of spasticity and abnormal movement patterns Suppression of spasticity training Promoting the emergence of dissociative movements Weight-bearing training of limbs Completion of basic movements with normal movement patterns Trunk control training Bilateral limb coordination training Normal limb movement pattern training Recovery period The emergence of more adequate separate movement Movement coordination training Movement pattern close to normal Increased motor speed training Fine motor training Walking training Fourth, the method of rehabilitation training (a) physical therapy: (PT) is the application of force, electricity, light, sound, magnetism and kinetics and other physical factors to treat patients. Exercise therapy is the main part of physical methods. It applies various exercises to treat limb dysfunction and correct abnormal movement posture, which is an important means of rehabilitation.
(A) Physical therapy exercise training should pay attention to the following matters.
1.Training is not excessive, and there is no fatigue on the next day of training.
2.During the training process, closely observe the patient’s reaction, such as dizziness, blurred vision, palpitations, shortness of breath, etc., should suspend training.
3, before, during and after training, the patient’s pulse is faster than usual by more than 30%; pulse > 120 beats/min; arrhythmia > 10 beats/min, if any of the above, the patient should stop training.
4, the training should be gentle movements, to prevent severe pain. Prevent damage to the skin and prevent decubitus ulcers. Limb movement training should be accurate and gentle to prevent pathological fractures and other complications.
5.Standing and walking training should be protected to prevent falls.
6.The training should be combined with psychological communication to obtain the cooperation of the patient.
(B) Traditional exercise therapy; 1. Maintenance of joint mobility training: To maintain and expand the range of motion of the joints, joint mobility training is provided to the patient.
Several methods are commonly used.
① Passive movement: the patient himself has no active muscle contraction ability, under the action of external force, to complete the full range of motion of the joint, in order to maintain the range of motion of the joint to prevent contracture.
② Active-assisted movement: It is through the action of external force as an auxiliary force, and the auxiliary force includes human and mechanical, so at this time the patient’s active muscle strength is insufficient, and needs help to complete the joint movement.
(③) Active motion: The patient actively contracts the muscles to perform joint activities. Generally, the patient’s joint range of motion is not limited by these exercises.
④Drawing exercise: mainly used to draw the shortened soft tissue to enhance the range of motion of the joint.
Precautions: Make a good explanation and obtain the cooperation of the patient.
The intensity of training should be appropriate to the patient’s level of function.
The patient should be placed in a comfortable position and the immobilized part should be firm, comfortable and stable.
Be familiar with the anatomical structure of the joint.
The muscles around the joint being exercised should be fully relaxed.
Movement should be done slowly and smoothly through the maximum existing joint mobility.
The pulling force should be maintained as much as possible.
The number of times each exercise is performed, generally 3-5 times of activity, and 2 times a day.
2. Strong muscle strength and endurance training.
(1) auxiliary active exercise: unassisted active exercise, apparatus-assisted active exercise (2) active exercise: applicable muscle strength at level 3 or higher (3) resistance exercise: in the process of muscle contraction, in addition to resistance to gravity, but also need to overcome the applied resistance, and can complete the full range of joint activities.
Contraindications and training precautions: cardiovascular patients unstable period, continuous fatigue, excessive training volume, muscle soreness, during inflammation such as joint inflammation and swelling, do not do resistance training, in the resistance training caused by pain should be prohibited training.
3, restore balance training a) static balance training: prone forearm support training, kneeling forearm support training, four-point kneeling support training on hands and knees, kneeling training on both knees, sitting training, standing training.
b) Dynamic balance training: prone balance training, kneeling balance training, sitting balance training, standing balance training.
c) Walking ability training.
①Standing training: standing with both feet together, balance training standing with both feet together, left and right weight transfer training standing with one leg in front of the other, weight transfer training forward and backward with one leg supporting standing and the other leg doing stride forward and backward training.
② walking training: support period training: with the change of walking position, support the body weight shift.
Foot following the ground training; palm landing training; support training; heel off the ground training; toe stirrups training.
③Walking training: a straight line forward walking training straight line backward walking training lateral walking training lateral cross walking training cross straight line forward walking training cross straight line backward walking training (b) occupational therapy (OT); is based on the patient’s dysfunction, from the physical and mental activities of daily life, from the work production labor or leisure activities in a targeted manner to select a number of operational activities, the patient training It is a rehabilitation method to restore the patient’s independent living ability. It includes three major categories: activities of daily living, productive activities, and recreational activities.
(1) functional training in occupational therapy; 1. muscle strength training: including two parts of the muscles on the healthy side and the affected side of the muscle group muscle strength training should follow the principles of.
① muscle strength level 0-1 passive exercise ② muscle strength level 2 assisted active exercise or the use of brace-assisted exercise ③ muscle strength level 3 or more fully active exercise ④ muscle strength level 4-5 in addition to active exercise, but also provide resistance exercise according to the situation 2, maintenance and expansion of joint mobility training 3, to improve coordination and dexterity training 4, balance training Transfer training: transfer from wheelchair to bed, transfer from wheelchair to toilet 2. feeding training 3. grooming training 4. dressing training: dressing and undressing training 5. toilet and bathroom training 5. rehabilitation training for hemiplegia (a) rehabilitation training for the relaxation period 1. 1. Head and upper limbs: head bent sideways towards the affected side, pillow under the scapula to prevent retraction, place the extended upper limbs on the pillow.
2. pelvis and lower limbs: pillow under the affected pelvis, pillow on the outside of the affected limb to prevent abduction and external rotation, towel roll under the knee to avoid extensor spasm, and foot brace to keep the ankle joint dorsiflexed and externally turned.
The lower limbs have a tendency to flex: take the supine position with the foot inversion extensor muscle tension; take the healthy side or the affected side of the position (2) supine position to turn to the side of the position 1, the preparatory actions before turning: hands palm to palm, cross fingers, the affected side of the thumb on the top, elbow extension, hands up, above the head, and then back to the original position.
2. Rotation movement of the upper part of the body: hands up, shoulders fully extended forward, elbow and wrist joints remain extended and swing to the left and right.
(3) Preparing to sit up and stand up 1. Training of lower limb flexion: the therapist keeps the affected foot in dorsiflexion and valgus position with one hand, with the palm of the foot on the bed, and holds the affected knee joint with the other hand to maintain the hip joint inward and complete the hip and knee flexion movement.
2. Training to extend the lower limb in preparation for weight-bearing: the affected lower limb is extended, the foot is dorsiflexed and externally turned, and the top is placed on the front of the therapist’s thigh. The therapist applies pressure along the long axis of the patient’s lower limb and instructs the patient to do a small range of knee extension and flexion movements.
(D) Preparation for walking without paddle movement 1. Knee flexion movements in hip extension position: supine, with the affected limb draped over the side of the bed from the knee and the hip extended, the therapist keeps the ankle dorsiflexed and externally turned and instructs the patient to do extension and flexion movements.
2. Anterior pelvic tilt training: lie on your back, stand up the affected knee, let the patient take the initiative to internalize the hip and drive the pelvis forward, then let the affected foot cross the midline, reach for the opposite wall and move up and down.
3, control training of hip adduction and abduction: lie on your back, bend both knees, put your foot on the bed, actively adduct and abduct the hip, and then let the pelvis leave the bed for this action.
(E) prone sit-up training 1, side lying position; therapist put one hand around the patient’s neck and one hand under the knee to lift him/her up.
2. Supine position: the therapist holds the patient’s shoulders, instructs the patient to insert the lower limb of the healthy side into the lower limb of the affected side and move to the side of the bed, and uses the healthy elbow to support the upper body to sit up.
(6) Sitting balance training 1. Center of gravity affected side movement training: the therapist is located on the affected side, the hands control the affected upper limb, so that it is in the anti-spastic position, and move to the affected side, and then back to the original position.
2. Forward and backward movement training: The therapist stands in front of the patient, uses the elbow to fix the affected upper limb, fixes it at his waist, and instructs the patient to tilt his trunk forward.
3. Weight-bearing training of the affected upper limb: put the affected upper limb in the antispastic position, place it on the side of the trunk, and instruct the patient to put the weight of the trunk on the affected upper limb.
4. Wheelchair-to-bed transfer: wheelchair and bed at 45 degrees, help the patient to stand up and then rotate the body with his or her healthy side as the axis, shift the weight forward and bend over to sit down.
(G) Upper limb training 1. Active scapular girdle: in supine or healthy side lying position, the therapist passively moves the scapula downward, upward and forward, and then instructs the patient to actively stretch the upper limb forward and upward.
2. Stretching the affected trunk: lying on the back, stretching the affected upper limb, holding it high above the head, with the therapist holding his hand in one hand and holding his shoulder in the other hand, let the patient do the turning movement, that is, from supine to lateral to prone position.
3. Elbow extension training: Let the patient use the extended upper limb to actively push the therapist’s hand to promote elbow extension.
(B) Rehabilitation training in the spastic phase (1) Sitting and preparation for standing up training 1. pelvic control and trunk rotation training: place three chairs side by side, with the patient’s arms crossed, stretching forward and downward, lifting the hips and taking turns to sit on the chairs.
2.Hip inversion and pelvic rotation training: instruct the patient to put the affected leg over the healthy leg.
3.Leg lift training: The therapist holds the affected foot and instructs the patient to lift the leg upward, then slowly lower it and practice control at each stage.
4.Knee flexion training; the patient’s knee is passively flexed greater than 90 degrees, and the patient is instructed to do knee extension and flexion movements in a small range.
(B) stand up and sit down training 1, stand up training ① patient’s hands to the front, while the trunk leaned forward, in this position slowly stand up.
② sit up on a high bed, the healthy side of the hip on the edge of the bed, the affected leg to the ground, the therapist holds the upper limb of the affected side of the anti-spastic position, instructing the patient to extend the hip to let the knee weight bearing.
2. Sitting training.
3, slowly lower the hip, when the hip is close to the chair and then lift, repeat several times, and then sit on the chair.
(C) Walking training 1.
(1) In the standing position, the therapist maintains the antispastic position of the upper extremity on the affected side and gradually moves the weight to the affected side.
(2) In the standing position, the affected leg is alternately extended and the knee joint is flexed under weight.
(3) The affected leg stands and the healthy leg steps forward and backward.
2. Step training of the lower limb on the affected side.
(1) Knee flexion training: prone position, knee flexion 90 degrees, therapist passively extends the lower limb and instructs the patient to control at all angles.
(2) Hip and knee flexion training: In the standing position, the patient’s pelvis is naturally relaxed, and the knee is flexed and stepped forward.
(3) Hip inversion and knee flexion training: In the standing position, with the affected lower limb slightly behind and the healthy lower limb bearing weight, instruct the patient to bring the affected knee closer to the healthy side and practice hip inversion and knee flexion.
(4) Pre-step training: The therapist lifts the patient’s leg off the ground by supporting the sole of the affected foot and instructs the patient to lift the lower leg.
(5) Low step training: The knee joint guides the low step forward and slowly lowers it when it hits the ground.
(6) Foot-following training: instruct the patient to flex the knee, dorsiflex the ankle, and move the lower leg forward, then slowly lower the heel.
(7) lateral walking training (4) upper limb motor control training 1, upper limb control training: the affected limb is passively moved to a certain position in space, and then let go, instructing the patient to control the limb in this position to keep still.
2. Upper limb positioning training: instruct the patient to move the fixed limb up or down from this position, and then return to the original position.
(E) training in prone and kneeling positions.
1, hands and knees training: keep the upper limb of the affected side in the antispastic position with sufficient weight, instruct the patient to rock the trunk forward and backward, left and right to obtain balance. Then lift the upper and lower extremities on the healthy side to make the affected side fully weight-bearing.
2. Knee-stand training: The therapist is located on the affected side, keeping the upper limb on the affected side extended and instructing the patient to shift the weight from side to side.
3. Single knee training: The patient stands on a stool with the affected knee flexed, fully extends it to make it weight-bearing, and instructs the patient to step forward and backward to the lower extremity of the healthy side.
(F) Elbow control training 1. Sitting position, raise both hands above the head and touch the top of the head, opposite shoulder and ear. Then straighten.
2. In the sitting position, cross the hands and instruct the patient to raise the hands to the mouth and then return.
3. In the supine position, abduct the affected upper extremity, extend the elbow, instruct the patient to bend the elbow and touch his or her mouth, and then return to the extended elbow position.
4. In the supine position, rotate the patient’s forearm back and instruct the patient to touch the ulnar side of the forearm to the ipsilateral shoulder.
(3) Rehabilitation training during the recovery period (1) Initial training to improve gait 1. Ankle dorsiflexion training: stand with the healthy foot in front and the affected foot behind in a big step, dorsiflex the affected ankle under the condition that the heel of the affected foot does not leave the ground, and transfer the weight to the healthy leg in front.
2, ready to step training: the same posture as above, the affected foot heel off the ground but toes on the ground, and then restore the foot to follow the ground.
3, small step training: the healthy foot standing, the affected foot forward, backward small steps.
4, skateboard training: the affected foot stands, the healthy foot on the skateboard, sliding in all directions, so that the affected foot is fully weighted.
(B) further training to improve gait 1, step training.
① Test stride: stand on the healthy leg, instruct the affected leg to stride, and lift immediately when the heel will hit the ground.
② Weight-bearing training of the affected leg: standing, the therapist maintains the anti-spastic position of the affected upper limb, shifts the weight to the affected side, the healthy leg can be abducted from the ground, so that the affected leg is fully weight-bearing.
③Cross gait training: stand with legs externally rotated, lean the affected leg slightly forward and rotate the pelvis to bring the healthy leg to the opposite side.
④Backward and forward stepping training: stand on the healthy leg, step forward on the affected leg, bend the affected knee and step backward.
2, walking training ① lateral guidance training: the therapist is located on the affected side of the patient, holding the affected upper limb anti-spastic position for control, helping the patient to move the center of gravity and step forward.
② Posterior guidance training: The patient extends both upper limbs posteriorly, and the therapist holds his hands for control.
③ Pelvic and scapular girdle rotation training: The therapist is located behind the patient and controls the patient’s shoulders with both hands, touching the right leg with the left hand when stepping on the right leg and touching the left leg with the right hand when stepping on the left leg.
④ Walking with support training.
1) Application of orthopedic appliances: ankle-foot orthosis, bandage orthosis 2) Application of walker ⑤ Straight line walking ⑥ Up and down stairs training 1) Up and down stairs training: The therapist is located behind the affected side, one hand controls the knee joint, the other hand supports the waist of the affected side, the weight is shifted to the affected side, the healthy side foot is instructed to go up the steps, the weight is shifted forward, and the therapist assists the affected foot to lift.
(2) Down stairs training: the therapist is located on the affected side, one hand is placed above the affected knee to assist in knee flexion and stepping movements; the other hand is placed on the waist of the healthy side to help the body move forward.
(C) motor control training 1, joint response inhibition: the affected hand on the table to keep still, instruct the healthy hand to rub the affected upper limb; or raise the hand over the head, touch the top of the head, touch the back of the head occipital, and then return to the front.
2. Weight-bearing and trunk rotation training of the affected upper extremity: sitting position, the affected upper extremity on the side of the body to maintain the anti-spasticity weight-bearing, instruct the healthy hand to cross the midline to take the object, and then return.
3. Elbow extension exercise: in sitting position, the patient crosses his hands to push the rolling pillow or solid ball placed on the table and pulls back and forth.