Stroke is one of the common diseases with three major characteristics: high morbidity, mortality and disability. In recent years, due to the development of medical science and progress in stroke diagnosis and treatment, the mortality rate of stroke has gradually decreased, but there are many sequelae of different degrees, which seriously affect the life and work of patients. About 70% of the surviving stroke patients have varying degrees of functional impairment, including limb paralysis, speech impairment, cognitive impairment, post-stroke depression, swallowing difficulties, and loss of daily living skills. This causes pain to the patient and a heavy economic burden to the family and society. Therefore, according to the “coexistence of disease and disorder”, “treatment and rehabilitation” should be emphasized. This paper suggests that early intervention in stroke patients can improve motor function, reduce neurological deficits, improve daily living ability, reduce the occurrence of comorbidities, and create conditions for patients to return to their families and society.
I. The recovery process of hemiplegia
1. Characteristics of central paresis
The recovery process of central paresis is a qualitative change, because it involves not one or several muscle paralysis, but a group of muscle groups or the whole limb paralysis. Central paresis is the result of the disruption of the central nervous system, the loss of brain control over the regulation of the lower centers, the release of primitive reflexes, and the disturbance of normal motor conduction. Flaccidity, spasticity, abnormal motor patterns, loss of normal postural responses and motor control exist in different stages of hemiplegic recovery. Therefore, the loss of non-muscular strength in central palsy should not be used to evaluate the motor function by the size of muscle strength.
2. Abnormal movements in the recovery process of hemiplegia
In post-stroke hemiplegia, the higher motor functions innervated by the cerebral cortex are inhibited, while the movements controlled by the spinal cord are released due to brain damage. As a result, abnormal movements such as joint reaction, common movement, and postural reflexes appear.
(1) Joint reaction
When there is no random movement of the affected limb, the movement of the healthy limb causes the muscle contraction of the affected limb, which is called joint response, is an involuntary movement, controlled by the spinal cord, and appears in the early recovery of paralysis. The joint reaction of the upper limb is a bilateral dyadic activity, while the joint reaction of the lower limb is a symmetrical activity of inversion and abduction and an opposite activity of flexion and extension.
(2) Co-movement
Also known as co-movement, is caused by the will can only follow a certain pattern of movement is called co-movement. It is a partial random movement with a non-random movement component, which is a primitive or low-level movement controlled by the spinal cord and appears in the middle of hemiplegic recovery.
(3) Postural reflex
The change of flexor and extensor muscle tension in the limbs according to a certain pattern due to the change of body position is called postural reflex, which is controlled by the brainstem and spinal cord level and is characteristic of central paresis.
3.The recovery process of central paresis
The recovery process of hemiplegia is divided into 6 stages, which is one of the main methods of motor function assessment of hemiplegia.
Ⅰ Flaccid phase: short time and no random movement.
II emergence of joint reaction: the proximal part of the limb may have a little random movement and mild spasticity.
Ⅲ co-movement: spasticity may reach a peak at this stage.
Ⅳ emergence of activity separate from joint movement: proximal large joints (shoulder, elbow, hip, knee, etc.) have more independent flexion and extension activity, and spasticity begins to reduce.
V Separate movements: activities independent of common movements appear, independent movements of the joints become more adequate, and spasticity is significantly reduced.
VI Near-normal coordination and skillful movement: It should be noted that no central paresis can return to the pre-onset functional state, but only a gradual decrease of common movements at the spinal cord level and a gradual increase of dissociated movements at the higher cortical level. If you fail to seize a good opportunity for rehabilitation or train in an inappropriate way, the common motor pattern may be reinforced back, aggravating the spasticity and difficult to correct.
II. Early rehabilitation of stroke
The spasticity of the paralyzed limb after stroke is inevitable in the process of functional recovery, and the abnormal posture produced by the spasticity of the limb is often called spastic hemiplegia.
1.Contents of early rehabilitation
The contents of early rehabilitation are
(1) Maintaining a good limb position
(2) Position change
(3) Passive movement of joints
(4) Prevention of aspiration pneumonia
(5) Bed mobility training
(6) Bed movement training
(7) Sitting up training
(8) Sitting balance training
(9) Daily living ability training
(10) Mobility training, etc.
2.Time to start early rehabilitation
It is generally believed that rehabilitation should begin 48 hours after the patient’s vital signs have stabilized and neurological symptoms have ceased to develop. It is believed that rehabilitation should begin in the acute phase, and the earlier rehabilitation starts, the greater the possibility of functional recovery and the better the prognosis, as long as it does not interfere with treatment. Immediately after stroke, as long as it does not interfere with resuscitation, rehabilitation is feasible to maintain good limb position, position change (turning) and appropriate passive limb activities, while active training should be started 48 hours after the patient is conscious, the vital signs are stable and the mental symptoms are no longer progressing.
3.The main rehabilitation treatment and training for each stage after hemiplegia
Phase I-II.
Maintain the correct lying position and posture. Induce joint response by applying resistance exercise to the head and healthy limbs. Maintain joint mobility training. Maintain the opposite palm of the hand using the limb appliance. Use the affected hand as much as possible.
Phase II-III.
Perform more exercises that promote the movement of the muscles separate from the joint movement. For example: internal extension of the shoulder joint; forearm rotation forward in elbow flexion; rotation backward in elbow extension. Promote supportive and extension movements of the shoulder and elbow joints.
Phase III-IV.
At this stage, the supportive nature of the proximal joints of the upper extremity has improved, however, the extension of the fingers is limited due to the flexion movement pattern. Therefore, while further strengthening the supportive ability of the upper extremity, efforts should be made to expand the extension of the fingers and to use the affected hand in daily life as much as possible.
In conclusion, the process of hemiplegia recovery is a gradual one. Encouragement and support from medical care, family and society are needed to help the patient recover to the maximum extent possible. During this process, we should not be too hasty and cause psychological pressure to the patient and create a daunting psychology. At the same time, whenever the patient achieves functional progress, new training programs should be designed according to the specific situation and the difficulty should be increased appropriately in order to obtain more progress.