I. Major functional impairment in stroke
1.Motor dysfunction
Assessment of muscle strength, joint mobility, muscle tone, spasticity, gait analysis, balance function assessment method Brunnstrom motor grade 6 stage, Fugl-Meyer motor leveling scale, modified Ashworth spasticity scale
2.Sensory dysfunction
3.Speech dysfunction, aphasia, dysarthria
4.Swallowing disorder
5.Cognitive disorders
6.Psychological disorders
Second, rehabilitation goals and timing selection and withdrawal
1.The goal of stroke rehabilitation
To use all effective measures to prevent disability and complications that may occur after stroke (such as pressure sores, aspiration pneumonia, urinary tract infection, deep vein thrombosis, etc.), to improve impaired functions (such as sensory, motor, language, cognitive and psychological), and to improve the patient’s ability to perform activities of daily living and to adapt to social life. That is, to improve the quality of life of patients with stroke.
2. Timing of rehabilitation
A large number of clinical rehabilitation practices have shown that early rehabilitation can help improve the damaged functions of stroke patients, reduce the degree of disability and improve their quality of life. It is usually advocated to start rehabilitation after 48 hours of stabilization of vital signs and no aggravation or improvement of the primary neurological disorder (brain edema is relatively heavy in patients with cerebral hemorrhage, and it is generally advocated to start rehabilitation 1-2 weeks after onset and stabilization of the disease).
For patients with serious complications, such as high blood pressure, severe mental disorder, severe infection, acute myocardial infarction or cardiac insufficiency, severe liver and kidney impairment or diabetic ketoacidosis, rehabilitation therapy should be started gradually only after 48 hours of stabilization and active treatment of the complications along with treatment of the primary disease.
3. Basic principles of rehabilitation treatment
1. Choose the right time for rehabilitation
2, rehabilitation assessment throughout the whole stroke treatment, including the acute phase, early recovery (subacute phase), middle and late recovery and sequelae period.
3.The rehabilitation treatment plan is based on the rehabilitation assessment, which is jointly developed by the rehabilitation team, and gradually revised and improved during the implementation of the treatment plan.
4. Rehabilitation treatment should be gradual, with the active participation of stroke patients and the cooperation of their families, and combined with daily life and health education.
5, the use of comprehensive rehabilitation treatment including physical therapy, occupational therapy, speech therapy, psychotherapy, traditional rehabilitation therapy and rehabilitation engineering.
6.Conventional drug treatment and necessary surgery.
IV. Rehabilitation outcome of stroke
The rehabilitation outcome of stroke is related to the type, size and location of the lesion, the timing, method and duration of neurological and rehabilitation treatment, the desire or initiative of rehabilitation, etc. In addition, it is also affected by the patient’s age, systemic condition (such as heart, liver, lung and kidney disorders, hypertension, cancer, serious infection, etc.), cognitive impairment, psychological impairment, speech impairment, swallowing impairment, balance impairment, sensory impairment, spatial disorders, visual impairment, and the rehabilitation of stroke. spatial neglect, visual deficit, shoulder-hand syndrome, shoulder pain, shoulder subluxation, loss of use syndrome, misuse syndrome, heterotopic ossification, and deep vein thrombosis of the lower extremities.
The earlier the rehabilitation treatment is carried out, the better the outcome. It is generally said that neurological recovery is fastest within 3 months, still after 6 months, and becomes slower after 1 year, but rehabilitation therapy is still beneficial. Late initiation of rehabilitation treatment results in poor rehabilitation outcome and more complications.
The more standardized and systematic the rehabilitation treatment is, the better the outcome is. We should do comprehensive, standardized and systematic rehabilitation treatment.
The more adequate the course of rehabilitation treatment, the better the outcome. However, clinically, for various reasons, many patients stop rehabilitation treatment just after they have seen results, and often their condition rebounded with poor outcomes. Of course, there are also many patients or their families who do not recognize the meaning and characteristics of rehabilitation. According to the national “Tenth Five-Year Plan” key research project “Stroke three-level rehabilitation program research”, systematic rehabilitation should be carried out at least within 6 months.
The higher the initiative of rehabilitation, the better the outcome. Stroke patients are often pessimistic and anxious because of the sudden shock. Loss of confidence in survival and rehabilitation, non-acceptance of rehabilitation treatment, or passive acceptance of rehabilitation treatment make the rehabilitation outcome suffer. Active participation of patients in rehabilitation treatment will greatly enhance the effect of rehabilitation treatment.
The better the complications of stroke are prevented and managed, the better the outcome. A very important factor affecting the rehabilitation outcome is the lack of timely rehabilitation after stroke, with shoulder-hand syndrome, shoulder subluxation, shoulder pain, loss of use syndrome, misuse syndrome, heterotopic ossification, contracture, fracture, and pain. Preventive rehabilitation treatment and systematic rehabilitation in the acute phase can significantly reduce these conditions, which is one of the greatest benefits of early rehabilitation and has a great impact on the outcome of stroke rehabilitation.
1. Improvement of motor-sensory function
In the vast majority of patients, recovery of motor function occurs in the first 1-3 months after the disease, and recovery is still faster from 3-6 months, and in some patients recovery can last 1-2 years. In general, recovery is faster in patients with milder paralysis and later in those with more severe paralysis.
Approximately 70% of patients have upper limb dysfunction after stroke, and 30% are non-functional at 6 months after onset, with 10% of patients with initial upper limb non-function recovering well. Those who are generally unable to move their fingers within 4-6 months are likely to end up with a disabling hand.
The order of recovery from paralysis is generally lower extremity before upper extremity, proximal before distal. Shoulder function recovers earlier than hand, and thumb function recovers the slowest.
Half of the patients have sensory impairment after stroke, with more recovering a few weeks after onset.
Most patients recover their activities of daily living (ADLs) 3-6 months after onset. In some patients, ADL gradually deteriorates after discharge from hospital, mainly because of complications or reduced rehabilitation. A small number of severely ill patients are eventually unable to walk independently or even bedridden for a long time despite long-term rehabilitation.
2. Improvement of language function
Post-stroke aphasia accounts for 22% – 32% of stroke patients. Speech dysfunction affects doctor-patient communication and directly influences the recovery of motor function and other rehabilitation treatments. With appropriate rehabilitation, the majority of patients, within a few weeks, can regain some ability to express themselves orally.
Patients with dysarthria have difficulty in expressing themselves orally, which can be greatly improved through rehabilitation treatment.
3.Improvement of swallowing function
The incidence of swallowing disorder after stroke is 20% – 40%. It is mostly seen in patients with severe, pseudobulbar palsy; patients with long-term nasal feeding or intravenous nutrition are prone to misaspiration, resulting in aspiration pneumonia, refractory lung infection or malnutrition. Remove the cause, after regular rehabilitation treatment, most patients can remove the gastric tube or intravenous nutrition tube and eat through the mouth.
4.Improvement of cognitive function
Cognitive impairment, vascular dementia, the degree of rehabilitation treatment can reduce and prevent its continued aggravation.
5.Improvement of psychological disorders
Psychological disorders are mostly depression, after psychological rehabilitation and drug treatment, combined with PTOTST and other therapeutic effects, often evoke hope for recovery, and most patients with psychological disorders are relieved with the improvement of their condition.
V. Health education for stroke
Prevention of disability and handicap in individuals who have had a stroke.
1.Primary prevention
Primary prevention refers to the prevention of disease occurrence, which is the ultimate goal of reducing the incidence of disease by intervening in high-risk causative factors. For stroke, primary prevention focuses on monitoring the hypertensive population and changing the unhealthy behaviors and lifestyles of the population.
1.1 Surveillance and management of the hypertensive population.
① All hypertensive patients should insist on blood pressure measurement and standardize the use of antihypertensive drugs to keep their blood pressure under the ideal level (140/90 mmHg or less);
②For patients with grade 2 hypertension, increase monitoring efforts to achieve a weekly follow-up visit and adjust the treatment plan at any time.
③For patients with grade 3 hypertension who cannot be well controlled even after regular medication, try to hospitalize them and bring their blood pressure up to the standard through personalized treatment measures.
④People over 35 years of age should have their blood pressure measured at the first visit, and if new hypertensive patients are found, they should be included in the target of monitoring and management.
1.2 Establish a healthy and supportive environment: Change the work model that emphasizes solely on health education and make the creation of a healthy and supportive environment and conditions one of the main goals of the intervention. This is done mainly through long-term promotion and education by medical personnel who go to all streets, schools and enterprises, especially for some patients with chronic diseases such as cardiovascular and cerebrovascular diseases for a long time, it is recommended to.
① Control total caloric intake and maintain normal weight;
②Control blood sugar and blood lipid;
③ Quit smoking
④regularize life and prevent mood swings;
⑤ Strive to avoid severe coughing, prevent constipation, and abstain from sexual activity;
⑥Balanced diet;
(7) Maintain a certain amount of exercise.
2.Secondary prevention
It refers to the active clinical treatment after the occurrence of the disease, as well as early and recovery rehabilitation, in order to prevent the aggravation of the disease and prevent the disability and dysfunction of organs or systems due to injury or disease.
The sequelae of cerebrovascular disease seriously affect the quality of life of patients. Among them, hemiplegia is the most common and the most harmful. According to the World Health Organization, in economically developed countries, patients with hemiplegia have significantly improved their ability to perform daily life after formal rehabilitation, and a high percentage of working-age patients can return to work. Community-based rehabilitation is an important approach to stroke rehabilitation, and the critical period for functional rehabilitation is within 6 months after stroke onset. Interventions include control of high-risk factors, guidance on rehabilitation treatment and rehabilitation training, health promotion and psychological guidance. At the same time, the family members of stroke patients should closely cooperate with the counseling and supervise the patients to perform functional training at least three times a week for at least 30-45 minutes each time.
3.Tertiary prevention
It means that functional rehabilitation should be actively carried out for the disability caused after the disease, while avoiding the recurrence of the original disease. Rehabilitation training is a combination of modern rehabilitation techniques and our traditional rehabilitation techniques (acupuncture, acupressure) for patients with disabilities caused by post-stroke. It includes rehabilitation medical treatment, training guidance, psychological guidance, knowledge dissemination, supplies and appliances, consultation and education to restore or compensate for the patient’s deficient functions and enhance his or her ability to participate in social life as much as possible.
Strengthening the tertiary prevention of stroke can further improve the level of prevention and treatment of chronic diseases such as stroke, especially for high-risk patients, and establish a social and physical environment conducive to stroke prevention and treatment, gradually reduce the level of major risk factors in the community, reduce the number of stroke incidence, disease, disability and death, and improve the quality of life and quality of life of the community.