The effectiveness and importance of rehabilitation for the overall treatment of cerebrovascular disease has been internationally recognized. According to the information published by the World Health Organization in 1989, after rehabilitation, about 60% of stroke patients can take care of their daily activities at the end of the first year, 20% need some help, 15% need more help, and only 5% need all help; and 30% of patients of working age can return to work at the end of one year after the disease.
In countries with advanced rehabilitation medicine in Europe and the United States, especially the United States and Canada, the rehabilitation process for cerebrovascular disease is: early rehabilitation of cerebrovascular disease in the acute phase is implemented in the cerebrovascular disease wards within general hospitals to assist clinical treatment and prevent secondary comorbidities. Implement early training of sitting ability and feeding ability to lay the foundation for leaving the cerebrovascular disease ward for the next step of rehabilitation. This period is usually about 7 days. The patient is then transferred to the rehabilitation unit for further rehabilitation. This phase is dominated by rehabilitation treatment and supplemented by clinical treatment. The task of rehabilitation treatment is to improve the patient’s limb movement function and daily living ability, such as standing balance training, transfer training, walking ability training and self-feeding, toileting, bathing, grooming and washing, and communication ability training. This period is usually about 20 days. The vast majority of patients can take care of themselves and return to their families after this period of training, and 80% of them are referred to community health care for further rehabilitation training. The task of community rehabilitation is to consolidate the achieved rehabilitation effect and further improve motor function|communication function and daily living ability. About 20% of the patients who are not yet able to achieve full self-care in daily life are directly transferred to a specialized cerebrovascular disease rehabilitation center for rehabilitation treatment. The task is to enable the patients to achieve a majority of self-care in daily life. This usually takes about 2 months. This is known as the acute cerebrovascular disease tertiary rehabilitation system.
As a result of the implementation of the network of tertiary rehabilitation system for cerebrovascular disease, the disability rate of cerebrovascular disease in these countries has been greatly reduced, with 90% being able to fully take care of themselves in daily life and health expenditure decreasing . This has been implemented not only in developed countries in Europe and the United States, but also in Hong Kong, Taiwan and other regions. Tertiary rehabilitation of cerebrovascular disease has become an important part of the treatment system of cerebrovascular disease, and it is the right to rehabilitation that patients with cerebrovascular disease should enjoy, which is confirmed by the laws of social insurance and health administration.
Although the rehabilitation of acute cerebrovascular disease in China has made great progress in recent years, especially through the “Ninth Five-Year Plan” and “Tenth Five-Year Plan” two national rehabilitation research work, more and more neurologists are aware of the importance of rehabilitation. However, compared with developed countries, there is still a big gap. However, compared with developed countries, there is still a big gap, which is mainly in the following two aspects.
(1) Insufficient awareness of the importance of rehabilitation of acute cerebrovascular disease
(1) Insufficient awareness of the importance of rehabilitation for acute cerebrovascular disease, which is more common in China than in other countries. This situation is at least 20 years behind compared with developed countries abroad. If this misconception is not corrected, it will have a great negative effect on the overall treatment level of acute cerebrovascular diseases in China.
(2) Low overall level of rehabilitation of cerebrovascular disease
At present, the overall level of rehabilitation of acute cerebrovascular disease in China is still relatively low, although some hospitals in some large and medium-sized cities in China have carried out cerebrovascular disease rehabilitation one after another, but there are not many really high-quality, some units put up the sign of “stroke unit”, also seems to have rehabilitation intervention, but ” The phenomenon of “formalization” is more prominent. This is mainly due to
(1) Lack of professional rehabilitation staff.
(2) Lack of standardized protocols for acute cerebrovascular disease.
Section I. Basic conditions of stroke rehabilitation
I. Composition of rehabilitation professionals and rehabilitation wards
(a) Professional staff
Rehabilitation physicians, rehabilitation nurses, therapists (including physiotherapists, occupational therapists, speech therapists, psychotherapists, social workers) and other professionals.
(2) Rehabilitation ward
It is ideal to accommodate 4 persons. Facilities in the ward should be convenient for hemiplegic patients, such as pressure-type hot water bottles, sitting toilets, door handles and faucet switches that are easy to hold, etc. The patient’s gown should be loose and fat, simple and easy to wear, and the design of buckle and trouser belt should be easy to use.
II. Preparation work before rehabilitation
(I) Assessment
1. General status: such as the patient’s general status, age, comorbidities, past history, functional status of major organs, etc.
2. Neurological status: including consciousness, intelligence, speech impairment and degree of physical disability, etc.
3.Psychological status: including depression, anxiety, anxiety, patient personality, etc.
4.Personal quality and family conditions: such as the patient’s hobbies, occupation, education, economic conditions, family environment, the patient’s relationship with family members, etc.
5. Natural recovery of lost functions: make predictions.
(ii) Determination of rehabilitation goals
Individualized goals are set according to the condition, which can be divided into immediate and long-term goals. The former is the goal required to be achieved at 1 month of treatment. The latter is the rehabilitation goal that should be achieved after 3 months of treatment and is also the final goal (e.g., independent living, partial independence, partial assistance, return to society, return to family, etc.).
The rehabilitation goals are set by a rehabilitation team. Its composition includes personnel from the medical, nursing, physical therapy, exercise therapy, occupational therapy, speech therapy, clinical psychology and social rehabilitation departments. Rehabilitation goals are developed based on each patient’s specific functional impairment, disability, and social disadvantage. A collaborative evaluation meeting is held under the leadership of the clinical rehabilitation physician to set specific rehabilitation goals, and the goals are broken down into specific implementation departments.
After a period of time, the patient’s condition should be revised, because there is a distance between the initial goal and the actual goal, so an evaluation meeting should be held every 2-4 weeks for each patient to evaluate whether the goal has been achieved.
C. Assessment of functional impairment in stroke
Functional impairment after stroke: hemiparesis, bilateral paresis, speech impairment, cognitive dysfunction and emotional impairment should be assessed by the international common scale.
There are three levels of functional impairment after stroke: impairement, where the physiology, anatomical structure and motor function are missing or abnormal; disability, where the individual’s ability is limited, missing or unable to perform a task normally; and handicap, where the individual is unable to participate fully in social activities, i.e., the basic rights of the person are affected.
Fourth, the principles of stroke rehabilitation
(a) Rehabilitation should be carried out as early as possible
Patients with cerebral ischemia can be rehabilitated after 48 hours as long as they are clear, their vital signs are stable, and their condition is no longer developing, and the amount of rehabilitation starts from small to large and progresses gradually. Most cerebral hemorrhage rehabilitation can be started 10 to 14 days after the disease.
(2) Mobilize patients’ enthusiasm
The essence of rehabilitation is “learning, exercising, exercising again and learning again”, which requires patients’ understanding and active participation. In the acute stage, the main purpose of rehabilitation is to suppress abnormal primitive reflexes and rebuild normal movement patterns, followed by strengthening muscle strength training.
(3) Rehabilitation should go hand in hand with treatment
Stroke is characterized by the coexistence of impairment and disease, so it is important to adopt an individualized program and progress step by step. In addition to motor rehabilitation, attention should be paid to speech, cognitive, psychological, occupational and social rehabilitation. Some medications, such as bromocriptine, have been shown to be effective in restoring limb movement and speech, and baclofen is effective in suppressing spasticity, starting with small doses. Colistin, prazosin, phenytoin sodium, valium, phenobarbital, and haloperidol have adverse effects on movement in the acute phase, so they should be used sparingly or not.
(iv) Emphasize that rehabilitation is a continuous process
Observe stroke patients closely for depression and anxiety, which can seriously affect the conduct and efficacy of rehabilitation. (iv) Emphasize the importance of community and family rehabilitation
Section II. Rehabilitation of major neurological disorders
I. Rehabilitation of motor function
(a) Acute phase (early bed rest) rehabilitation
Maintain good body position, perform passive movement, bed exercise training and start ADL training. Training should be gradual and the basic procedures are as follows.
1, correct lying position: affected side lying, healthy side lying, supine position (transitional, time should not be too long)
2.Sitting position in bed: first of all, the patient’s trunk should be kept upright, for which a large pillow can be used behind the body, hip flexion 90°, both upper limbs placed on a small mobile table to prevent the trunk from being thrown back, and a pillow under the elbow and forearm to prevent pressure on the elbow.
3, maintain joint mobility training: should be started early, the acute phase can be implemented in the ward. Generally do it twice a day for 10-20 minutes each time. Do exercises for each joint and each direction 2 to 3 times.
4. Correct sitting position in chair and wheelchair: Compared with bed rest, sitting position is conducive to trunk extension and can achieve the effect of promoting the improvement of the whole body and mental status. Therefore, as soon as physical conditions allow, you should leave the bed and take a sitting position. However, the sitting position can only serve the purpose of treatment and training if the correct sitting posture is maintained. The therapist should always observe the sitting posture of the patient, find the bad sitting posture and correct it in time.
5.Transfer movement training: It can be divided into bed transfer (lateral movement and turning in supine position), bed sitting, transfer from bed to wheelchair, standing up, etc.
6.Self-assisted training of the upper limbs: The mobility of the shoulder and shoulder joint largely affects the recovery of the upper limb motor function, so measures must be taken from the early stage to both protect the easily damaged shoulder joint and to maintain its mobility. The main application of the Bobath grip method for practice.
7.Activate the scapula: The activity of the scapula can be done in the supine and healthy side lying or sitting position.
(II) Recovery period rehabilitation
1.Upper limb functional training: In this stage, the motor functions involved in exercise therapy should be fully applied to daily life through a combination of exercise therapy and occupational therapy, and continuously trained and strengthened so that the patient’s recovered functions can be consolidated. Therefore, the exercise therapist and the occupational therapist should work closely together during this period to identify the key problems that exist in the patient and fully understand the main purpose of the training content and program.
2. Lower limb functional training: Lower limb functional training during the recovery period is mainly focused on improving gait. Specific training methods include: selective dorsiflexion and plantarflexion of the ankle joint, walking-like movement of both lower limbs, forward movement of the affected lower limb in a self-standing position, weight-bearing and balance ability of the affected lower limb, stepping to the rear, pelvic and scapular belt rotation.
Rehabilitation of sensory disorders
Many patients with hemiplegia have sensory disorders along with motor disorders, and there are loss of sensation, dullness and hypersensitivity, which can seriously affect the motor function. Therefore, if the sensory training and motor training are separated, it will be ineffective, and the concept of integration of sensory-motor training must be established.
In the early stage of hemiplegia recovery, the focus of training and recovery is often on motor function, which is a misconception, and therapists should pay equal attention to motor and sensory disorders and train them.
(i) Training of motor sensory function of upper limbs
Often use the wooden nail plate, such as the wooden nail plate on the wooden nail slightly modified, such as the outside of the nail with a variety of materials wrapped, such as sandpaper, cotton, woolen fabric, rubber skin, iron, etc., in the patient grasp the wooden nail, through a variety of materials on the sensory stimulation of the patient’s limb endings, improve the perceptual ability of its central nerve, you can make motor function and sensory function at the same time to get training.
(2) Weight-bearing training of the affected upper limb
It is one of the training methods to improve the motor function of the upper limb. This kind of exercise is not only beneficial to motor function, but also has obvious improvement effect on sensory function.
Rehabilitation of spasticity
The treatment and rehabilitation of spasticity is comprehensive and requires a variety of measures.
(A) Drug treatment
The main treatment of spasticity is the use of anti-spasticity drugs that have the effect of reducing spasticity. Anti-spasticity drugs are divided into central anti-spasticity drugs and peripheral anti-spasticity drugs according to the different action sites, the former has Diazepam, Tizanidine, sirdalnd, Baclofen; the latter has nitrobenzofuranhine (Dantrolene)
(ii) Exercise therapy
Retraction method, reflexology to inhibit muscle tone, postural reflex method.
(C) physical therapy
Including warm therapy, cold therapy, vibration therapy, electrical stimulation, etc.
(D) Biofeedback therapy
Clinically, it is often used to promote the treatment of palmar flexion and dorsiflexion of hand joints, and the treatment of anterior tibial and peroneal muscles for ankle inversion of the pointed foot.
(E) Spastic muscle nerve trunk block method
Phenolic agents are injected percutaneously into the peripheral nerve trunk of the spastic limb or the motor point of the spastic muscle to block conduction.
(F) Brace therapy
One of the commonly used braces is the finger splitting plate for finger flexion and carpal palmar flexion spasm.
(vii) Surgical treatment
The purpose is to correct the joint contracture and deformation caused by long-term spasticity and improve the motor function. It is often used to correct acromioclavicular foot and to correct toe flexion contracture.
(H) Botulinum toxin local injection method
The injection sites can be determined according to the anatomical positioning of the muscles with increased muscle tone, and 3 to 4 injection sites can be selected for large muscles.
IV. Rehabilitation of aphasia
There can be many types of aphasia after stroke. Each type has its specific manifestations, such as receptive or expressive impairments, and rehabilitation is carried out by designing programs based on these symptoms. There are also a variety of rehabilitation methods for aphasia. For example, to learn the word “apple,” write out the word apple, read out the word apple, present the word apple, and finally, taste the word apple, with multi-sensory stimulation, repetitive stimulation, and adequate auditory stimulation. If necessary, the elicited responses can be corrected, encouraged, and praised so that they are reinforced. The patient should be trained in four aspects: listening, speaking, reading and writing, from simple to complex, from easy to difficult, from words and phrases, short sentences to long sentences, in a gradual manner. If the patient has dysarthria, difficulty in finding words, difficulty in expressing utterances, difficulty in listening comprehension, difficulty in reading or writing, etc. You can also train from these aspects.
V. Rehabilitation of dysarthria
(i) Substitute techniques
Comprehension is present and compensatory techniques are available. Cue the patient to speak slowly, and supplemented with respiratory support therapy can often be effective.
(ii) Communication board communication therapy
Designed for severe patients.
(iii) Electronic communication board therapy
Through the role of the computer, there is a digital language or on the key printed on the common needs of life language, just press the key to have speech, express needs.
(iv) Surgery
Soft palate paralysis at the time of stroke and nasal speech, can be treated by surgery such as soft palate repair.
VI. Rehabilitation of swallowing disorder
Swallowing disorders secondary to cerebrovascular disease have been paid more and more attention because swallowing disorders have a great impact on the maintenance of nutrition, the recovery of the disease and the quality of life of patients.
Although more than 85% of swallowing disorders in acute cerebrovascular disease can be recovered or reduced by treatment, untimely treatment and loss of the best time for recovery can lead to lifelong nasal feeding. Therefore, patients with swallowing disorders in acute cerebrovascular disease should be evacuated from nasal feeding and trained for swallowing function as early as possible. Oral phase disorders include voluntary and passive movements around the oral cavity, tongue muscle movements, ice massaging the skin, ice massaging the throat, etc. or moist heat stimulation vocal training; pharyngeal phase paralysis includes lateral swallowing, swallowing while lowering the head, air or saliva swallowing training, small mouth breathing, coughing, humming, etc.
Whether indirect or direct swallowing disorder training, patient position is particularly important. Because the forward flexion of the neck is easy to cause swallowing reflex, while the backward tilt of the trunk can prevent mis-swallowing and also promote the recovery of swallowing function.
VII. Rehabilitation of urinary dysfunction
Anyone with bladder dysfunction should measure the residual urine volume; residual urine <50ml, urinary incontinence, regular urination procedure; residual urine >50ml, normal forceps or high reflex, regular urination procedure, monitoring residual urine volume; residual urine >50ml, low reflex forceps, intermittent catheterization; residual urine >50ml, urethral outlet obstruction, urological treatment.
Eight, disuse syndrome (disuse syndrome)
Disuse syndrome is a secondary disorder due to the inactive state of the body.
(a) Local disuse syndrome
1, disuse muscle weakness and myasthenia: do a few minutes of exercise every day, the muscle strength used should be 20% to 30% of the body’s maximum muscle strength, and the use of neuromuscular electrical stimulation may also prevent or reduce muscle weakness and myasthenia.
2, joint contracture: the main measures for prevention and control are.
(1) change position regularly.
(2) Maintain good limb position.
(3) Passive joint movement.
(4) voluntary or passive joint activities.
(5) Mechanical correction training.
(6) Inhibit spasticity treatment (such as Bobath method, PNF method).
(3) Disuse osteoporosis: prevention and treatment methods: weight-bearing standing, strength, endurance and coordination training, muscle isometric and isotonic contraction, etc.
(B) Symptoms and treatment caused by systemic disuse
1, positional hypotension (upright hypotension): prevention and treatment methods include regular changes of position; lower limbs, abdomen with elastic bandages to promote increased blood return; healthy limbs, trunk, head resistance exercise to increase the amount of heart beat; sleep, the upper body is slightly higher than the lower body; lying down with the head higher than the feet, etc.. The most important thing is to avoid long-term bed rest as much as possible, and start sitting training as early as possible.
2, venous thrombosis: prevention and control measures are to move the limbs early, elevate the lower limbs, use elastic bandages to promote venous return, and also use massage to assist venous return, and in severe cases, use anticoagulants such as Warfarin, Heparin and Aspirin. If necessary, surgical treatment may be performed.
3. Mental, emotional and cognitive changes: The prevention and treatment method is to encourage patients to have more contact with medical staff, other patients and family members, to complete psychosocial and social activities, and to have some recreational treatment.
4. Other: changes in the heart, gastrointestinal tract, endocrine, water-electrolyte, metabolism and nutrition, etc., which should be treated symptomatically according to the situation.
Shoulder dislocation
When the patient’s upper limb is in flaccid paralysis, maintaining the correct position of the scapula is an important measure for early prevention of shoulder subluxation. Treatment includes.
(1) Correct the correct position of the scapula of the shoulder joint and the position of the humeral head in the shoulder joint cavity according to the correct position of the scapula to restore the fixation mechanism of the shoulder.
(2) Direct promotion of the muscle groups associated with shoulder joint fixation through progressive incremental intensity stimulation.
(3) Perform passive painless total joint movement without damaging the shoulder joint and surrounding tissues.
X. Shoulder-hand syndrome
The principle is early detection and early treatment. Once chronic, there is no effective treatment, especially within 3 months of onset is the best time for treatment. The methods are.
(1) Prevention of palmar flexion of the wrist joint.
(2) Compression of the fingers by centripetal winding.
(3) Ice water immersion method.
(4) Alternating cold and warm water immersion.
(5) Active and passive exercises.
Recommendations.
(1) Emphasize early rehabilitation: Early rehabilitation is very important to prevent complications and improve function, especially early bedside rehabilitation such as protection of the affected limb and passive movement, etc. These methods are simple and practical, easy to master and very effective.
(2) Emphasis on continuous rehabilitation: It should be noted that some functional disorders are left for a long time, even for life. Therefore, it is recommended that a system of continuous rehabilitation from the acute stage in general hospitals to community medicine can be established, similar to the current international rehabilitation programs for cerebrovascular diseases, so that patients can enjoy complete rehabilitation.
(3) Pay attention to psychological rehabilitation: The psychological disorders of patients with cerebrovascular disease are very prominent but often neglected. Psychological disorders are very detrimental to the functional recovery of patients and must be highly valued and actively treated.
(4) Pay attention to the participation of family members: Patients eventually have to return to their families, so family members play a very important role in the recovery of patients. Family members should be allowed to fully understand the situation of patients, including functional impairment and psychological problems, so that they can adapt to each other, and they should also master certain rehabilitation tools and conduct necessary rehabilitation training for patients.