(I) Acute phase
The acute phase is defined as within two weeks of onset.
1. Rehabilitation assessment
The scales of choice include the Glasgow Coma Scale for assessment of state of consciousness and the National Institutes of Health Stroke Scale (NIHSS). If depression and deficits in motor, sensory, cognitive, communication and swallowing functions were found, they were assessed by the appropriate physician from the rehabilitation team.
2. Rehabilitation program
Once the patient’s vital signs are stabilized, the patient is ready for rehabilitation. Rehabilitation training such as positioning of good limbs in bed, passive movement, early bed activities (including turning, bed mobility, sitting up at the edge of the bed, and bridge movement) will be carried out. Avoid infusion of fluids to the affected limb. The use of drugs does not exclude the advantages of traditional rehabilitation methods at the same time, and treatment such as acupuncture, pointer and nasal herbal medicine can be performed under cardiac supervision.
(II) Soft paralysis period
1. Rehabilitation assessment
Brunnstrom evaluation method and Fugl-Meyer scale are preferred for motor function assessment, and Barthel index scale is preferred for daily living activity assessment. In addition, the assessment content should be selected according to the patient’s dysfunction, such as the assessment of cognitive function, including anosognosia and dysfunction assessment, etc. In the rehabilitation training, the patient’s cardiopulmonary function should also be understood to avoid excessive fatigue, and cardiopulmonary function assessment can be conducted when necessary. During this period, muscle strength assessment can be conducted, but attention must be paid to prevent the posture and method of assessment from causing spasticity.
2. Rehabilitation program
This stage is equivalent to Brunnstrom’s hemiplegia functional classification grade I-II. It is characterized by loss of control of the limbs, loss of random movements, low muscle tone and weakened or absent tendon reflexes. The principle of treatment in the soft palsy stage is to use various methods to improve limb muscle strength and tone, induce active movement of the limb, and conduct active activity training in bed as early as possible. At the same time, attention should be paid to the prevention of complications such as swelling, muscle atrophy, and limitation of joint movement.
(1) Giant prick method
In this period, the traditional rehabilitation treatment prefers the giant acupuncture method, i.e., the method of acupuncture points on the healthy side, which uses the meridian qi on the healthy side to mobilize the remaining true qi in the meridians on the affected side under the stimulation of acupuncture, and jointly expel the evil qi of the same meridian, so that the damaged function on the paralyzed side can be restored and the potential motor ability can be brought into play. This method of stimulating the healthy side actually utilizes the joint response of the early low central control of post-stroke hemiplegia, and the joint movement increases the muscle tone of the affected side by forceful contraction of the healthy side.
(2) Traditional techniques
The preferred method is percussion or patting on the affected side. When percussion or patting, the palm should be put as soft as possible, slow patting and quick lifting, the order is from bottom to top, the frequency is about 100 times/minute, to the extent that the skin is hot and flushed. If there is swelling on the affected upper limb, the rolling method can be used to treat it in the order from bottom to top.
Note: The joints, especially the shoulder and wrist joints, should not use the pulling and stretching method, wrenching method or shaking method to avoid ligament and muscle damage, or even cause joint dislocation.
(3) Functional training
①Maintain the correct position in bed: actively maintain the correct position in bed during the period of flaccid paralysis. At the same time, attention should be paid to supporting the upper limb of the hemiplegic side when sitting or standing, and avoid pulling the shoulder joint as much as possible.
②Passive activities: If the patient is unable to do active activities, passive activities of each joint should be trained as soon as possible. When training, the training should be performed within the pain-free range. For patients who already have joint pain, pain relief treatment such as hot compresses can be applied before training. Pay attention to protect the shoulder joint and hip joint.
(3) Bed training: As long as the patient is conscious and the vital signs are stable, the patient should be instructed to conduct active bed training as soon as possible, including turning, bed mobility, bedside sitting, bridge movement, etc.
(4) Physical factor therapy: Apply Chinese medicine treatment equipment intelligent Tongluo treatment instrument, meridian guide leveling treatment instrument for neuromuscular electrical stimulation and functional electrical stimulation, myoelectric biofeedback and other physical therapy to improve muscle tone, 20 minutes/time, 1 time/day.
(5) Occupational therapy: The main purpose of occupational therapy in this period is to improve the muscle strength and muscle tone of the patient’s trunk and limbs with other means such as exercise therapy and physical factor therapy, so that the patient can transition from the bed-resting period to the bed-leaving period as soon as possible, and can independently perform part of the activities of daily living such as dressing and undressing, putting on and taking off socks, etc., and restore a certain degree of self-care ability, so as to build and enhance the confidence of returning to the family and society.
(III) Spasticity period
1. Rehabilitation assessment
The patients’ improvement in muscle tone, limb motor function and activities of daily living were evaluated by using the modified Ashworth scale, Brunnstrom evaluation method, Fugl-Meyer scale and Barthel Index scale respectively.
2. Rehabilitation program
This stage is equivalent to the stage III-IV of Brunnstrom’s hemiplegia functional evaluation. The functional characteristics of this stage are increased muscle tone, hyperactive tendon reflexes, and the appearance of co-movement during random movements. Treatment focuses on controlling muscle spasm and promoting the emergence of dissociative movements.
(1) The basic principle of acupuncture is “antagonistic muscle acupuncture”.
(2) Traditional manipulation: Different manipulations for different muscle groups can regulate the muscle and nerve functions of the affected limb, induce the establishment of normal movement patterns, promote the completion of active and detached movements, and improve the overall functional recovery.
(3) Chinese herbal medicine external treatment: blood activation and stretching application for external use
(4) Functional training: Inhibit synergistic movement patterns, train random movements, improve coordination and flexibility of each joint, and help patients gradually recover detachment movements.
(1) Anti-spasticity manipulation: the content includes the placement of good limb position, anti-spasticity pattern (RIP) training, maintenance of joint mobility and static stretching of spastic muscles. For spasticity, pulling, squeezing and rapid rubbing can be used to reduce the muscle tone of the patient’s upper limbs.
②Sensory stimulation: According to the Rood technique, spasticity can be inhibited by various sensory stimuli, such as gentle compression of the joint, pressure on the tendon attachment points, pushing and moistening the skin surface of the posterior branch innervation (skin surface of the paraspinal muscles) with firm light pressure, continuous stretching, slowly turning the patient from the supine or prone position to the lateral position, medium-temperature stimulation, local warm baths without sensory heat, and hot wet compresses.
③Therapeutic training: balance training in sitting position, balance training in standing position, walking training, up and down stairs training, etc.
OT: Reduce the muscle spasm of the affected upper limb using weight-bearing exercises or work activities in the weight-bearing state. Perform exercises such as ball-holding and bat-holding to target synergistic movements. In addition, anti-spasticity supports are available, including finger splints and inflatable pressure splints for finger flexion and wrist and palm flexion spasticity.
PT: Spasticity machine therapy for the affected limb: once a day; lymphatic circulation therapy for the affected limb: once a day.
(5) Physical factor treatment: application of TCM treatment equipment magnetic vibration heat therapy instrument to relieve muscle spasm and promote detachment movement, 20 minutes/time, 1 time/day.
(4) Relative recovery period
1. Rehabilitation assessment
The focus of assessment in this period is the ability of daily living activities, which can be assessed by applying Barthel index. Fugl-Meyer scale can be used to assess the motor function of patients. The Fugl-Meyer scale can be used to assess the motor function of the patient, so as to understand the obstacles of the patient, adjust the rehabilitation plan and method, and prepare the patient to return to the family and community. The assessment of psychological and cognitive functions can be applied according to the patient’s condition.
2. Rehabilitation program
The relative recovery period of this period is equivalent to stages V-VI of Brunnstrom’s hemiplegic functional evaluation. The functional characteristics of this period are that the muscle spasm is mild or even completely disappeared, and the patient can perform free movement out of the synergistic mode, or even coordinated single joint movement. Treatment should be based on continuing to train the patient’s muscle strength and muscle endurance, strengthening the training of physical coordination and the cultivation of the ability to perform activities of daily living, and encouraging active participation in social activities by means of group training. If the functional exercise is abandoned or reduced, the existing function is highly susceptible to degeneration.
(1) Functional training: On the basis of continuing to train the patient’s muscle strength and muscle endurance, the main principle is to improve the body’s coordination and the ability to perform activities of daily living. The training includes occupational therapy to improve coordination and speed and exercise therapy to enhance muscle strength and muscle endurance.
(2) In addition to functional training, traditional rehabilitation methods such as acupuncture and tui-na can be used to improve muscle strength and relieve muscle fatigue after functional training. According to the theory of “treating impotence by taking only Yangming”, acupuncture points should be selected and needled.