Neurological disorders are characterized by the coexistence of disease and impairment, so rehabilitative training and care should be carried out simultaneously with resuscitation. The first principle of rehabilitative care for neurological diseases is that no matter how serious the disease or disability is, it must be considered from the first day of its onset that one day it may return to its normal and satisfactory lifestyle; the second principle is that rehabilitative care must be implemented as early as possible in order to help the patient recover to the most satisfactory state.
I. Correct placement and maintenance of good limb position
The abnormal posture produced by spasticity affects the quality of life of patients. Therefore, patients should start to pay attention to the placement and maintenance of good limb positions as soon as they are admitted to the hospital, and adopt positions that inhibit abnormal movement patterns and anti-spasticity patterns o
1, the placement of good limb position lower limb flexion hip and knee, upper limb scapula forward elbow and wrist.
(1) Supine position: put a thin pad behind the scapula, correct the internal rotation of the scapula inward, slightly externally rotate the shoulder, extend the elbow and wrist, extend the fingers to prevent finger flexion spasm; lower limbs present knee and hip natural flexion; keep the ankle joint dorsiflexed.
(2) Health side lying position: the affected shoulder is flexed forward about 90°, the hand is placed flat on the pillow, the elbow is extended, the knee and hip on the affected side of the lower limb are flexed and placed on the support pillow to make the hip slightly internally rotated.
(3) Affected side lying position: Affected shoulder forward, elbow extended, forearm rotated, wrist and fingers extended, lower limb on affected side slightly posteriorly extended, knee flexed, lower limb on the healthy side placed in front of the affected limb, pillow under it, note that the affected shoulder should not be pressed to prevent shoulder joint injury.
It is not possible to maintain a complete antispastic position 24 hours a day, but some antispastic positions must be maintained. Consider the shoulder and hip joints first. A pillow should be placed outside the knee in the flexed position to prevent the sudden external rotation of the hip in the flexed knee position from causing strain on the femoral adductor muscle, and do not place the affected hand on the chest to prevent spasm of the upper limb flexors.
2, the good limb position with objects ordinary buckwheat bark pillow 1-2, under the foot with a board 1-2, cushion pillow 2. Patients with neurological disorders to maintain a good limb position with the pillow, with a height of about 1, 70-1, 75 meters, weighing about 70-75 kg of male patients as a model.
(1) head with an ordinary buckwheat leather pillow is appropriate, the angle between the head and the bed ≥ about 15 °.
Purpose: to keep the airway open.
(2) Reclining position: the same pillow to maintain the posture of the ordinary buckwheat bark pillow is appropriate, the angle between the body and the bed is about 100-120 °.
Purpose: to maintain the position and prevent pressure sores.
Second, bed training
1.Elbow extension training Take the supine position. The therapist places one hand on the distal humerus for support and keeps the shoulder flexed forward at 90°, while giving instructions to extend the elbow, so that the patient makes efforts to straighten the elbow joint. The patient can further extend the elbow actively and then make him do the training of extending the elbow and touching the opposite shoulder repeatedly. Assistance should be given when the shoulder cannot be controlled in forward flexion position.
2. Double upper limb supination Supine position, in a good lower limb position with palms touching each other and fingers crossed, with the affected thumb on top (called Bobath grip), use the healthy arm to straighten the elbow and do the full range of shoulder forward flexion movement. The palm of the hand is turned over at the end of the forward flexion, so that the affected forearm is rotated back and the shoulder is externally rotated. The affected shoulder is gradually increased from passive to active degree. The palms touching each other can maintain a certain degree of shoulder external rotation. This training is important for maintaining joint mobility, experiencing shoulder joint spatial position and kinesthesia, and enhancing the awareness of the affected limb.
The therapist helps to keep the patient’s elbow joint straight with one hand and helps to drive the affected upper extremity up. The initial independent activity can be trained in the 90° position of supination for stable control, bring the upper limb to this position, encourage the patient to extend the elbow and shoulder upward, and use the hand to give a touch to the target guide. After the control ability is improved, small range of controlled activities will be carried out until the full range of activities and can be controlled at any angle.
4.Bridge exercise Upper limbs straight put on the side of the body, both lower limbs (standing knee position) bend knees, hips, feet flat on the bed, force down to lift the hips and control, lower limbs to maintain stability, as far as possible to achieve full hip extension, hold 2-3 seconds, do not hold your breath. It is usually necessary to help the patient to place the lower limb well at the beginning of the training and to give downward pressure at the knee, even to help lift the hip. Because of the increased tension of the extensor muscles when the affected lower limb is strained, it is necessary to help fix the knee and ankle to maintain a stable position. Gradually transition to independent completion of the bridging movement and appropriate resistance can be given after full completion. After this movement becomes easy to complete, you can lift the lower extremity on the healthy side after the hip lift, keeping the single foot support, that is, the single bridge movement. The bridge position is a good anti-spasticity position and is the first step in self-care training. If you can not do a good job of strong and controlled bridge movement, it is difficult to achieve full hip extension, and this will certainly affect the normal walking, in addition to bridge movement also lays a good foundation for sitting and standing activities, etc.
5.Bobath turning method from supine to side lying position. Both hips and knees flexed, both upper limbs Bobath grip elbows, shoulders up about 90 °, head turned to the side, the healthy side of the upper limbs drive the affected limbs straight elb forward to send, to turn the trunk side hard, while swinging the knee to the same side, complete the common swing of the scapular belt, pelvic belt, to reach the side. The therapist should stand on the side of turning during this process to relieve the patient’s fear of falling down. Initially, appropriate assistance can be given by the therapist using the hand as a target to guide the patient’s upper limb to drive or help swing the knee to one side. Turning to the affected side is easier than to the healthy side, but care should be taken not to damage the affected shoulder.
6.Sit up training Start from the side lying position, push the affected foot with the healthy foot and move the lower leg outside the edge of the bed. When sitting up on the affected side, insert the palm of the healthy side in the axilla of the affected side for support and push the trunk hard, withdrawing the palm of the hand while pushing, and at the same time flexing the trunk sideways to sit up. If there is difficulty, the therapist can push on the knee and calf or push upward from the neck to help sit up. When sitting up on the healthy side, the trunk is pushed up with the support of the healthy elbow, but this action tends to aggravate the condition of trunk muscle spasm on the affected side, so it is generally not necessary to retrain after it is completed.
7.Squeeze the shoulder joint In the supine position, the upper limb on the affected side is fully extended with the elbow raised. The therapist holds the affected hand with one hand, the palm of the hand is dorsally extended relative to the wrist, and the other hand is placed on the elbow, keeping the elbow straight and pushing the humerus into the joint socket. At the same time, the patient is helped to do forward flexion and abduction. The patient needs to pay attention to the sensation of this process. The patient can take the initiative to send the shoulder to push the hand of the therapist to move the scapula, at which time the therapist can push to give resistance. This activity can also be performed in the healthy side lying position.
8.Stretching the trunk muscles Supine position, the lower limb of the affected side of the knee flexion, hip internal rotation, the therapist one hand down the affected knee at the same time the role of the other hand on the affected shoulder, so that the affected side of the trunk muscles are subject to slow and continuous pull, so that the spastic muscles relax, control the key point of the thumb to reduce the spasm of the hand flexors, you can train finger extension in this position.
9, elbow joint rotation front, rotation back activities due to the rotation front muscle tension caused by the rotation back difficulties, by using continuous pulling of the rotation front muscle after the rapid pulling of the rotation back muscle, and immediately after the patient to do the palm of the hand turned upward forearm rotation back action, the therapist can give appropriate assistance in the trend.
10.Pelvic girdle swing The recovery of motor function starts from the trunk and proceeds sequentially from the proximal to the distal end. Hip swing is an important training for early hip control ability. Lie in supine standing knee position and swing both knees together from one side to the other. The process of swinging from external to internal rotation of the hip on the affected side is the difficult part of this activity, and appropriate help can be given at the beginning.
In the same position as above, both hips can do the repeated movement from external rotation to neutral position at the same time. Further, the affected leg can be divided and combined with activities o
12, supine knee flexion exercise The lower limb anti-gravity muscle spasm causes difficulty in knee flexion, so the knee flexion exercise should be carried out. In the supine position, the lower knee is flexed from the extended position without the heel leaving the bed. Initial difficulties can be started in a slightly flexed knee position, and the therapist can help control the heel not to leave the bed or give slight assistance.
13.Supine bedside knee flexion The hip joint is always kept in the extended position, the lower leg is placed outside the edge of the bed, and the therapist helps to keep the ankle dorsiflexed to avoid the influence of gravity. This action has been separated from the common movement.
14, prone position knee flexion The hip joint is extended in the prone position, hook the leg backward and flex the knee.
Third, sitting training
1.Sitting balance training Sitting balance can be divided into three levels. The first level of static balance, which is the earliest patient can perform relatively easy to complete the action. When training, let the patient sit on the chair or bedside with both feet flat on the floor and hands on the knees to maintain stability, and adjust the position with a little help if there are difficulties. At the beginning, the patient is prone to leaning to the affected side, and can first maintain sitting balance under the Bobath reflex inhibition limb position, which can stretch the spastic lateral flexors and also assist in sitting balance training. In addition, the affected lateral flexors can also be passively stretched. A mirror can be placed in front of the patient during the sitting balance training to compensate for the effect of position perception impairment, so that the patient can continuously adjust his or her position through visualization. After the completion of static balance, further secondary self-dynamic balance training is required, i.e., self trunk and lumbar activities. To train balance under dynamics, patients can be asked to pick up target objects or transfer objects of different directions and heights, increasing the degree of difficulty from near to far. The third level of his dynamic balance is that the therapist applies thrusts to the patient in different directions from the front, back, left and right under static balance to break the static balance and make the patient adjust to a new balance as soon as possible. While giving thrusts, attention should be paid to protecting the patient to prevent falls. Through balance training, the control ability of trunk muscles is continuously enhanced, and the level of balance response is improved to prepare for standing and walking. The protective postural reflex of the affected side should be induced in this training, which is also a kind of promotion.
2, sitting under the affected limb weight training Sitting feet flat on the ground, double upper limbs Bobath grip elbow, shoulder fully forward, torso forward, head up, forward, to the affected side of the direction to reach the target object. In this process, the heel downward force, the weight gradually moved to the affected lower limb. When training weight-bearing should pay attention to the heel can not leave the ground, can not appear forefoot force down stirrup phenomenon, not to try to make the healthy leg single excessive force, because very easy to cause ankle clonus.
3, sit – stand up training Patients sitting on the edge of the bed or chair, generally heel from the edge of about 125px, feet at the same level or slightly behind the affected foot, upper limbs like the above leaning forward weight training, torso leaning forward legs weight-bearing, the center of gravity forward to the forefoot palm, knee extension and hip extension, lift the hip out of the bed and chest upright. The therapist can assist in the affected knee and hip. After standing up, the therapist can continue to use the knee to hold the affected knee to prevent “limpness”, noting that this process should prevent the lower extremity on the side of the patient from standing up alone with weight at the moment of standing by shifting the healthy foot back. The therapist can use the foot to hold the patient behind the affected foot. The forward tilt of the trunk is the process of hip flexion, rather than bending the spine and head down.
4.Standing-sitting training From standing to stable sitting is the opposite of the above, but more difficult to accomplish. Because, this is mainly controlled by the eccentric contraction of the quadriceps, seeking a better coordinated action of the lower limb muscle groups. The person starting the treatment can help to flex the knees to lift the belt and control the speed of sitting down.
5.Seated knee flexion and ankle dorsiflexion This training requires the heel to not leave the ground during knee flexion. Ankle dorsiflexion can be performed in a sitting position with the knee in natural flexion and should prevent inversion.
6.Upper limb training in sitting position Shrugging movement and upper limb reflexes inhibit scapular activity in limb position. Upper limb training in the prone position, such as upper limb supination and independent active supination training of the affected limb, should also be continued in the seated position.