The functional recovery of stroke patients mainly occurs within 6 months after the disease, especially within the first 3 months. It has been proved that stroke is the best period for limb function recovery within 6 months after the onset of stroke, which should not be neglected, and reasonable rehabilitation treatment should be emphasized and carried out as early as possible. Rehabilitation of stroke should be done as early as possible according to the condition. In general, patients with ischemic stroke can be rehabilitated after 48 hours as long as they are clear, their vital signs are stable and their condition is no longer developing, while patients with cerebral hemorrhage are relatively late (2-3 weeks after the disease). Rehabilitation is most effective in the first 3 months after stroke onset. Without early rehabilitation, the movement of the limbs may show abnormal walking patterns, i.e. the formation of misuse syndrome or disuse syndrome, and rehabilitation after discharge is often half-hearted and fails to achieve the desired goal, while early rehabilitation of stroke can minimize the impact of disability on normal life.
The objectives of stroke rehabilitation are: to prevent disuse syndrome, prevent pressure sores, shoulder hand syndrome, joint contracture, disuse muscle atrophy, shoulder dislocation and other common complications; to promote functional recovery; to give full play to residual functions; to create conditions for active training; to strive for self-care, return to family, society and work. Wang Bo, Department of Rehabilitation, Songwon Hospital of Traditional Chinese Medicine
Stroke rehabilitation treatment includes three levels:
The first level of rehabilitation is within one month after the onset of the disease, and the main contents include correct body position, passive joint mobility training, and the start of active bed training and self-care activities in bed.
The second level of rehabilitation is usually from the beginning of the second month to the end of the third month after the onset of the disease. In this period, the patient’s active movement starts to recover, but the movement cannot be well coordinated at will due to the presence of joint reaction, co-movement and spasm of anti-gravity muscles, and fine and rapid movements cannot be completed. The purpose of rehabilitation in this period is to reduce muscle tone to relieve spasticity, break the co-movement movement pattern, train the muscle joints to move independently at will as much as possible, and improve the coordination of each joint. The content mainly includes standing training, standing balance, single-leg standing, walking training and stair walking training to solve the patient’s walking problem.
The third level of rehabilitation is the late recovery and sequelae period. Patients mostly return to the community or home for rehabilitation. The main purpose of rehabilitation in this period is how to make patients more comfortable using the affected side, how to better master various family daily living abilities through training, improve speed on the basis of ensuring the quality of movement, maximize the quality of life, and enable patients to return to their families, society and work.
Many patients and their families do not know how they should carry out stroke rehabilitation treatment. In fact, active training can be started after the onset of stroke through postural placement and passive movements to prevent or reduce the occurrence of limb spasms and sequelae, and after the condition has stabilized. Since turning and passive joint exercises can only prevent bed sores, pneumonia and joint contractures, and cannot prevent other sequelae such as disuse muscle atrophy, and have no significant effect on functional recovery, patients should also start the next phase of active training as early as possible.
In order to achieve better results, stroke patients should pay attention to the following issues in the rehabilitation process.
① Pay attention to the normal limb placement. It is important to place the body in a good position and pay attention to the protection of the affected limb. Do not let the affected limb stay in one position for a long time, which may lead to joint stiffness and prolonged compression of the affected limb and obstruct the blood circulation of the affected limb. From the day of onset, if the patient’s vital signs are stable, the patient should try to move the affected limb as much as possible, such as lifting the hand and stretching the leg. If the patient is unable to exercise, family members should help the patient to do passive activities of the limb joints in bed to prevent joint contracture and muscle atrophy. When moving the affected limb, the movement must be gentle to avoid excessive stretching of the limb leading to joint dislocation or injury. The mattress should be reasonably chosen. A bed that is too hard is prone to pressure sores, while a bed that is too soft makes it difficult for the body to sink and change position. Should turn over every 2 hours. Each practice a movement, be sure to achieve the correct posture, focus on. For each muscle exercise, the muscle should be stimulated with a certain intensity several times in a row to complete a certain amount of work load, and gradually increase. In the acute stage, rehabilitation exercises are mainly to suppress the abnormal primitive reflex activity and rebuild the normal movement pattern, followed by the training to strengthen the muscle strength.
② Once the patient’s condition is stabilized, the training of transferring from the prone position to the sitting position can be carried out. Sitting training should be carried out when the trunk has the ability to balance. As the patient is bedridden for many days to have an adaptation process, sitting training can be carried out by first elevating the head of the bed 30° and sitting for 10 minutes without dizziness and panic, and then gradually increasing from 45° to 9 0° for 30 minutes to 1 hour to prevent the occurrence of upright hypotension. If the patient can sit smoothly on the bed, then feet down and further practice sitting on the bedside, a chair can be placed on the bedside and the patient is required to sit on the chair at least 3 times a day to avoid the debilitation brought by long-term bed rest.
After the patient is able to sit independently, he/she can start to train to stand. The rehabilitation training method from sitting to standing is: support the bed with the healthy hand, transfer to the bedside with the feet in the right position, cross the fingers of both hands (the thumb of the affected limb is at the top) and bend the waist, lean the body forward, use the forward shift of the center of gravity, lift the hips and make the body upright.
④ Practice walking. After the patient can stand alone, let the patient gradually shift the weight to the affected leg and train the weight-bearing ability of the affected leg. Walk training can be started only when the patient can stand independently and balance, and the affected leg can hold more than 75% of the body weight and can step forward. For most patients, it is not advisable to use a cane prematurely as it may interfere with the training of the affected side. Before walking training, practice alternate forward and backward steps and weight transfer of the legs, instruct and correct the incorrect posture and gait of the patient, and ask the patient to look forward with the head up to maintain body balance during walking training. In recent years, some hospitals have used some of the weight loss support devices to carry out early walking training, so that patients have received better results in terms of walking ability and walking speed recovery.
⑤ Conduct training for activities of daily living. Once the patient has a good recovery of limb strength, we should train the ability of daily living, such as the ability to eat and drink independently, how to dress and undress by themselves, how to carry out personal hygiene and cleanliness, self-reliance of bowel movements, bathing, doing housework, etc., so that the patient can try to achieve self-care, in order to reduce the burden of family and society, to recover self-esteem and return to society and family.
(6) In addition to motor rehabilitation, attention should be paid to speech, cognitive, psychological, occupational and social rehabilitation.
(7) Patients with stroke cannot take care of themselves due to hemiplegia and aphasia, and many of them may have different degrees of anxiety and depression, with mood swings, pessimism, irritability, irritability or depression, anxiety and other psychological disorders. Medical staff should actively carry out psychological guidance, stabilize the patient’s mind and emotion, and establish the patient’s confidence in recovery and release psychological barriers through communication, reasoning, education, suggestion, psychoanalysis, music, exercise, relaxation and silence, and other psychotherapy methods.
⑧ The essence of stroke rehabilitation is learning, exercising, exercising again, and learning again, which is to mobilize the remaining brain tissue functions to reorganize and strengthen the residual functions and enhance the compensatory capacity, requiring patients to understand and actively participate in order to achieve good rehabilitation results. Rehabilitation is an ongoing process and should be integrated into daily life.
It is best to conduct rehabilitation training under the guidance of a professional rehabilitation physician, develop a rehabilitation plan, conduct regular assessments, and instruct the patient’s family or caregivers to collaborate in training. The amount of exercise should be moderately controlled and the intensity of training should range from small to large. If the patient still feels fatigue after a day of training and a night of rest, the amount of exercise is too much and should be reduced as appropriate. Do not overexercise to avoid overexertion affecting the rehabilitation process. Exercise must be carried out according to the prescribed time, avoid favoring one part of the exercise and neglecting other parts. Avoid the phenomenon of “overprotection” and allow the patient to do and act independently within his or her ability. The frequency of training should be kept at least 2 to 3 days per week, 1 to 2 times per day, for about 30 to 40 minutes each time. The training should be integrated and combined with activities of daily living.
Patients should not be treated with rehabilitation if they have: (1) heart rate > 100 beats/min at quiet rest, diastolic blood pressure > 120 mmHg; systolic blood pressure > 195 mmHg, exertional angina, cardiac insufficiency above grade II, severe arrhythmia, combined with myocardial infarction; (2) upper gastrointestinal bleeding; (3) respiratory tract infection; (4) renal insufficiency; (5) body temperature above 38oC.
Stroke is characterized by the coexistence of impairment and disease, so rehabilitation should be carried out simultaneously with pharmacological treatment. The drug treatment of stroke should be different for different stages of the disease. Nowadays, the principle of combining Chinese and Western medicine is mostly advocated to have better treatment effect. When the disease is stable and entering the recovery period, western medicine mainly focuses on stabilizing blood pressure and promoting the recovery of brain metabolism and neurological function, using brain circulation promoter and brain metabolism activator drugs, such as nimodipine, ginkgo biloba drugs, cipro, brain activator, etc.. Many Chinese herbal medicines also have good effect. Chinese herbal treatment should be based on the principle of diagnosis and treatment in Chinese medicine, and different methods are used depending on the etiology and pathogenesis.
Stroke patients often show two major dysfunctions, mainly unfavorable language and hemiplegia, because the reorganization of cortical function in stroke patients is limited. To improve the degree of functional recovery and enable patients to recover language and motor functions, rehabilitation treatments such as acupuncture, massage and functional training are extremely important methods, which can significantly improve language and motor functions through acupuncture, massage and other treatments. Acupuncture therapy: Head and face acupuncture points such as Baihui, Shangxing, Yin Tang, Ying Xiang, Sun, Xia Guan, Di Cang, Ren Zhong, Feng Chi, etc., upper limb acupuncture points such as shoulder k, Qu Chi, Wai Guan, He Guan, lower limb acupuncture points such as Huan Yuan, Yang Ling Quan, Foot San Li, Kun Lun, Tai Chong, etc., each time for 20 min, once a day, 10 days as a course of treatment, after 3 days of rest, the second course of treatment can be performed.
② massage therapy: the order can start with the head, with gentle focus, with the thumb to rub the patient’s head 5 times, with the hand to rub the patient’s upper limbs 5 times, and then use the fingers in the tendon area to do the finger method 1 to 2 times, while pressing the kneading and activity of the joints, lower limb flexion several times, and thumb kneading the back of the foot between the toes several times, each massage 30min, once a day, 15 days for a course of treatment, the length of massage and power The size of the massage time and power to vary from person to person.
Because rehabilitation medicine is a new discipline, the current knowledge of rehabilitation is not high, many patients, including a considerable part of the health care workers on the rehabilitation treatment there are still such and such misconceptions. This must be corrected through education.
Myth 1. Expecting a panacea
Many patients fantasize that there is a panacea that will help them get better once they eat, but unfortunately, there is no such medicine. Any idea of recovery by virtue of a “magic pill” is undesirable and impossible. In fact, after a stroke, an important task is to strengthen the rehabilitation exercise, including physical function, speech function, and self-care training. Only with hard training and perseverance can stroke patients recover and take care of themselves.
Myth 2. Acute bed rest should be resting and not moving
Acute stroke rehabilitation is an important part of stroke treatment, but is often neglected by clinicians and families, with emphasis on medication and sedation. In fact, even comatose patients with massive cerebral hemorrhage, severe cerebral infarction and hemiplegia combined with severe pulmonary infection can undergo rehabilitation such as correct positioning of hemiplegic limbs, passive position change and passive joint movement to prevent decubitus ulcers, avoid or reduce the occurrence of future spasms and eliminate the possibility of “disuse syndrome”. It can prevent decubitus ulcers, prevent or reduce the occurrence of spasticity in the future, eliminate the possibility of “disuse syndrome”, shorten hospitalization days and reduce treatment costs. This will lay a good foundation for comprehensive functional rehabilitation in the future.
Misconception 3: Rehabilitation is a late work and optional
Some doctors and patients do not know enough about rehabilitation and think that rehabilitation is a late work and optional. In fact, it is advisable to start rehabilitation of hemiplegia as early as possible. After the patient’s vital signs (such as respiration, blood pressure, pulse, pupil changes, etc.) are stable and neurological symptoms no longer develop for 48h, generally speaking, 2-3d after the onset of cerebral infarction, and cerebral hemorrhage can be slightly delayed to about 7-10d, early, scientific and reasonable bedside rehabilitation can and should be carried out for the patient in a gradual manner while the neurosurgical ward is being treated with drugs. The patient can and should be treated with early, scientific and reasonable bedside rehabilitation.
Myth 4. Over-reliance on doctors or family members, excessive passive treatment
Some patients become sensitive and fragile after the disease, showing excessive dependence on doctors and family members and lack of initiative in rehabilitation training, believing that doctors’ manipulation, acupuncture or family massage is the treatment and their own active training is useless. In fact, for stroke patients, active training is ten times stronger than passive treatment.
Misconception 5: Forced walking or stair climbing without focusing on basic movement training.
Some patients and family members are eager to start walking or climbing stairs with a few people holding and pulling the affected limbs. In fact, the patient’s mood is understandable, but the method is not desirable. If you don’t pay attention to the basic movements and ignore the stage of the patient’s movement pattern, forcing walking or stair climbing will easily damage the knee joint, cause pain, aggravate the solidification of the wrong pattern and lead to the stagnation of systematic training.
Myth 6. Rehabilitation is a matter for the doctor and has little to do with the family.
Many patients’ family members mistakenly believe that rehabilitation is the doctor’s business, and as long as the patient receives treatment in the hospital, everything will be fine, and it has little to do with them. In fact, in the rehabilitation process of hemiplegic patients, the family or family members play a very important role. On the one hand, the warmth of the family, the affection of the family and the supervision of the training are the most powerful support for the hemiplegic patient to overcome the disability; on the other hand, the training of the hemiplegic patient’s daily living ability, such as dressing, eating and toileting, is not only feasible but also very effective in the family. It can be said that whether a hemiplegic can return to his family and reintegrate into society depends largely on the quality of the family’s support for the continued rehabilitation of the hemiplegic.
Myth 7. Only the rehabilitation treatment in the hospital is important, but not the rehabilitation actions in daily life.
In fact, the time for rehabilitation in the hospital is limited, and the recovery process of dysfunction is slow and requires a long period of repeated training and stimulation before the function can be restored to a significant degree. This contradiction can only be solved if the patient carries out the rehabilitation training actions in daily life and forms habits, which can speed up and consolidate the rehabilitation effect.
Myth 8: There is no rule for the recovery of the affected limb
Generally speaking, the recovery of motor function of hemiplegic patients is relatively faster in the head, trunk and large joints, and the recovery of motor function of lower limbs is earlier than that of upper limbs. The recovery of motor function of the limbs occurs in the order of proximal and then distal. For example, the recovery of motor function of the upper extremity is usually preceded by the recovery of shoulder joint activity, and gradually the elbow and wrist joints recover, while the recovery of finger function is relatively slow, with the thumb recovering the slowest. Of course, sometimes the order of hemiplegic limb function recovery may change due to the specificity of hemiplegic lesions and other reasons.