Rehabilitation of stroke
Objective: To prevent complications, reduce sequelae, promote functional rehabilitation, and give full play to residual functions so that patients can take care of themselves and return to society.
Rehabilitation treatment in the acute phase
Prevention of complications: bedsores, respiratory tract infections, urinary tract infections, deep phlebitis
Prevention of joint contracture and deformation Massage, passive movement, posture therapy Zhuang Health, Department of Rehabilitation Medicine, Henan Provincial People’s Hospital
Acute phase
1. Rehabilitation goals
The acute phase of stroke usually lasts for 2-4 weeks, and rehabilitation can be carried out simultaneously with clinical consultation and treatment after the condition has stabilized for 48-72 hours.
The aim of rehabilitation is to prevent pressure sores, respiratory and urinary tract infections, deep phlebitis and joint contracture and deformation, and to prepare for functional training during the recovery period.
Rehabilitation measures
Correct position in bed
In the early rehabilitation of hemiplegia, correct positioning can prevent and reduce the emergence and development of flexor or extensor spasticity patterns typical of hemiplegia, such as upper limb flexion with scapular band retraction and lower limb extension with hip external rotation. Therefore, it is advisable to place the limb in an antispastic position in bed
① When lying on the affected side, the affected shoulder is stretched forward and pulled out to avoid pressure and retraction, the elbow is straightened, the forearm is externally rotated, the finger joints are extended, the affected hip is extended, the knee is slightly flexed, and the healthy leg is flexed forward on the support pillow in front of the body. This position can increase the sensory input of the affected side, pull the whole hemiplegic side of the limb, and help prevent spasticity
(ii) The healthy-side position is the most comfortable position for the patient, with the affected shoulder extended forward, elbow, wrist and finger joints extended and placed on the pillow in front of the chest, the upper limb raised about 1000 towards the head, the affected leg flexed forward on another support pillow in front of the body, the hip joint naturally flexed, and the foot not turned inward.
③Supine position
Because of the influence of the cervical tension reflex and vagal reflex, the abnormal reflex activity is stronger, and it is also easy to cause pressure sores in the sacrococcygeal region, the lateral heel or the external ankle, therefore, stroke patients should mainly lie in the lateral position. When supine position is necessary, the affected arm should be placed on a pillow next to the body, the shoulder joint should be extended forward, the elbow should be kept extended, the wrist should be dorsally extended, the fingers should be extended, a support pillow should be placed under the hip and thigh on the affected side, the pelvis should be extended forward to prevent external rotation of the affected leg, a small pillow should be placed under the knee to make the knee joint slightly flexed, and the sole of the foot should avoid touching any support to avoid stimulation of the plantar receptors and aggravation of foot drop by positive support reflex.
The semi-recumbent position should be avoided because the trunk flexion and lower limb extension in this position directly reinforces the spasticity pattern.
Muscle massage
Massage is a motor-sensory stimulus to the affected limb and promotes blood and lymphatic return. For the prevention of disuse or trophic muscle atrophy, deep vein thrombosis has a role. Massage movements should be gentle, slow and regular.
Passive joint movement
For comatose or completely hemiplegic patients, the passive activities of the joints of the affected limbs should be made, in order to help prevent joint contractures and deformations. The order of movement should be from proximal to distal joints, and the range of movement should be from small to full range, twice a day, until active movement is restored. Avoid soft tissue damage due to roughness, and do more activities in anti-spastic mode, such as shoulder abduction and external rotation, forearm rotation and posterior rotation, wrist dorsiflexion, finger extension, hip extension, knee flexion, ankle dorsiflexion, etc.
Bed activities
Early bed activity is one of the important elements of stroke rehabilitation. It is important that patients start from passive activities as soon as possible and transition to active rehabilitation program through self-help activities. Acute active training is done in bed.
The purpose is to enable the patient to independently complete the transition from supine to bedside sitting position after completing various early training in bed
①Passive movements of upper limb self-help.
②Bridge exercise: supine position, both legs flexed, legs flat on the bed, hip extension and lifting the hips off the bed.
Recovery period (1~3 months, 3~6 months, 6 months~2 years)
Rehabilitation goals: (Long-term goals)
include improvement of gait and restoration of walking ability.
Enhancement of limb coordination and fine motor movements.
Improving and restoring the ability to perform activities of daily living.
Appropriate application of assistive devices to compensate for the function of the affected limb; emphasis on psychological, social and family environment transformation to enable patients to return to society.
Rehabilitation assessment during the recovery period
Fugl-Myer Somatic Function Scale.
Fugl-Myer Joint Mobility Scale
Fugl-Myer Balance Scale
Fugl-Myer Sensory Function Scale
Quality of Life Index Scale
Rehabilitation measures
Neurodevelopmental treatment (NDT)
Bobath technique
Brunnstrom technique
Rood technique
Facilitation techniques such as proprioceptive neuromuscular facilitation (PNF) have been widely used in stroke rehabilitation.
Bobath technique
Bobath technique is one of the most widely accepted and effective methods for treating neurological disorders.
It is a flexible application of motor developmental control theory that emphasizes motor sensory learning through the learning and mastery of basic posture and movement patterns, which are then gradually transformed into complex functional and skillful movements in daily life.
Brunnstrom Movement Therapy makes full use of all methods to elicit the motor response of the limb and uses various motor patterns, such as co-movement and joint response, and then directs and isolates the normal motor components from the abnormal patterns. The process of recovery gradually progresses toward normal, complex motor patterns, leading to the reassembly of the central nervous system
Rood technique
A variety of sensory stimuli are used to stimulate the generation of movement, such as taking stronger stimuli such as rapid brushing, rapid icing and vibration to induce movement in sluggishly paralyzed muscles, or lighter stimuli such as light brushing and slow pulling to inhibit abnormal movement in spastic paralyzed muscles.
The technique often uses special sensory stimuli such as music, light, and color to facilitate or inhibit the muscles.
Neuromuscular proprioceptive facilitation (PNF) technique
With normal movement patterns and motor development as the basic technique, it is characterized by spiral and diagonal movements of the limbs and trunk, emphasizing overall movement rather than single muscle activity. The treatment emphasizes utilizing the patient’s abilities and tapping into the body’s potential.
Carr-Shepheerd’s motor relearning program
Emphasis on specific functional training programs
Motor training should be carried out in a developmental sequence and at different levels of postural reflexes.
From rolling over → sitting → sitting balance → double knee standing balance → single knee standing balance → sitting to standing → standing balance → walking
①Sitting balance training.
Sit-up training should be conducted as early as possible, from supine position to bedside sitting, from the patient being able to sit unsupported on a chair to achieve the first level of sitting balance, to the second level of balance that allows the affected limbs to do the swinging activities of the trunk with different spokes in each direction, and finally to complete the “other dynamic” that can resist the external force of others. “The third level of balance
②Standing balance training.
First stand up on the standing bed.
Then gradually enter the support stand, parallel bar stand, so that the patient is gradually removed from the support, the center of gravity shifted to the affected side, training the patient’s ability to hold weight, can stand unassisted, and then implement the standing balance training, and finally achieve the three-stage balance in the standing position
③Walking training.
Restoring walking is one of the basic goals of rehabilitation treatment. Support walking or walking inside the parallel bar, then unassisted walking, training to improve gait, focusing on correcting the circle gait.
Targeted training should be implemented for the patient. For example, in the standing phase, the affected leg has poor weight-bearing ability and lacks the ability to respond to balance in the process of weight transition, so the focus should be on training the weight-bearing ability of the affected leg, such as in the swing phase, the affected leg cannot flex well, so the independent movement of the affected knee with alternating flexion and extension of smaller amplitude should be practiced, and the affected knee can complete flexion and step forward in the swing phase.
Activities of daily living (ADL) training
ADL includes bed and chair transfer, dressing, eating, toileting, bathing, walking, going up and down stairs, personal hygiene, etc. Through occupational therapy, patients can achieve self-care as much as possible.
Rehabilitation treatment during the recovery period
Walking training: an important link in the struggle for self-care Preparation for walking – support the affected leg to swing back and forth in the standing position, step and bend the knee, hip extension, practice alternate back and forth steps and weight transfer Walking with support or walking inside the parallel bars Improve gait training, focus on correcting the circle gait Up and down steps training, start “the healthy leg goes up first, the sick leg goes down first” – let it be natural
Recovery rehabilitation
Occupational therapy
ADL motor training – eating, personal hygiene, dressing, bathing, writing, craft therapy – weaving, embroidery, painting, ceramics, clay sculpture, training two-handed operation; typing, knotting, building blocks, screwing, picking up small objects, playing the piano, training the fine motor skills of the hands Self-care aids – long handles Household chores, outdoor activities
Post-acute period (after 1 year)
Rehabilitation assessment
Assessment of continued recovery period
Evaluation after returning to life and family
Ability to perform activities of daily living
Functional independence
Rehabilitation goals
Learning and using compensatory technology
Cane
Walkers
Wheelchairs
Braces
Strive for maximum functional independence
Spasticity, muscle weakness, contracture deformity
Continue to train and utilize residual functions, prevent functional degeneration, improve the environment to adapt to the disability, strive for maximum self-care Maintenance rehabilitation training Non-recoverable on the affected side, give full play to the compensatory role of the healthy side, environmental modification Emphasis on occupational, social and psychological rehabilitation
Other rehabilitation treatment
Hydrotherapy
Physical therapy
Traditional medicine
Other rehabilitation treatment methods
Physiotherapy
Small doses of direct current or ultrashort wave therapy can promote the regeneration of peripheral nerves
Traditional rehabilitation therapy
Traditional medicine treatments currently used in stroke rehabilitation
Massage
Acupuncture therapy
Acupuncture can improve the perfusion of brain tissue and the nutrition of local limb cells, which is useful in promoting the recovery of the affected limb. Studies on electrophysiology have shown that acupuncture can increase the amplitude of myoelectricity, reduce the appearance of abnormal brain waves and improve cortical activity. There are body acupuncture, auricular acupuncture and head acupuncture methods, among which body acupuncture is the most widely used.
Depression after stroke
Poststroke depression (PSD)
Depression is a common concomitant symptom after stroke. The incidence of depression is mostly reported to be 40% to 50% abroad, and the incidence of poststroke depression in China is 34.2%, of which 20.2% is mild, 10.4% is moderate and 3.7% is severe. Depression is also one of the most important factors in predicting quality of life in stroke.
Risk factors for PSD
2 to 12 months post-stroke.
Female.
Sites of lesions such as left frontal and left basal ganglia injuries; severe neurological deficits such as aphasia or impairment of cognition.
Presence of comorbidities.
A previous history of depression.
Social impairment and other factors are associated with post-stroke depression.
Assessment of PSD
The Zung self-rating depression scale (ZSDS) was used to screen patients for depression, with a cut-off score of 30 on the ZSDS and a further score of 30 on the ZSDS.
The Hamilton depression scale (HAMD) was used to assess the severity of depression.
HAMD <8 as no depression.
>20 as mild or moderate depression.
>35 is severe depression.
The Geriatric Depression Scale (GDS) is commonly used to assess depression in the elderly, with a total score of 15
A score of 0-5 is considered normal.
A score of >5 indicates depression.
Rehabilitation of PSD
Early and aggressive rehabilitation of stroke patients to minimize neurological deficits and functional dependence is the key to reducing the incidence of post-stroke depression, and treatment of PSD includes psychotherapy and antidepressants. Psychotherapy such as Beck’s cognitive-behavioral psychotherapy has significant benefits for PSD. For patients who cannot receive psychotherapy, antidepressants should be used.
The currently advocated medications for PSD are 5-hydroxytryptamine selective reuptake inhibitors (selective serotonin reuptake inhibitors, SSRIs)
such as fluoxetine hydrochloride (Eucerin or Benadryl), 10 to 20 mg once daily.
Paroxetine hydrochloride (Sertral), 10-20 mg, once daily.
Sertraline (sertraline), 50 mg, once daily.
In the treatment of PSD, a comprehensive understanding of the patient’s physiological, psychological and social adaptation status should be provided, with emphasis on both the application of depressive drugs and psychotherapy and social intervention.
Spasticity
Spasticity is caused by elevated excitability of the detrusor reflex following damage to upper motor neurons and is characterized by an increase in skeletal muscle tone with increasing detrusor velocity.
Spasticity will occur in almost 90% of patients within 3 weeks after a stroke. Although spasticity may help some patients to stand and transfer, and may increase venous return in some patients, thereby reducing edema, spasticity impedes functional recovery in most patients, causing difficulty in the ability to perform activities of daily living and leading to complications such as pain, contractures, and pressure sores.
Rehabilitation goals
Reduction of pain.
Prevention of complications such as pressure sores and contractures.
To improve the ability to perform motor and activities of daily living and to improve the quality of life of stroke patients.
Rehabilitation assessment of spasticity
Ashworth method
Revised Ashworth Scale
Rehabilitation treatment of spasticity
The first step is to eliminate clinical conditions that increase and aggravate spasticity, such as urinary tract infections, constipation, pressure sores, and to avoid exertion and stress.
① Oral medication: medication is the preferred method of treatment for spasticity because of its ease of use.
Chlorpheniramine (baclofen) is a muscle relaxant, 5mg per dose, gradually increasing to an effective dose from three times daily, up to 120mg per day.
Other drugs used to treat spasticity include tiletin, diazepan and dantrolene.
②Carbonate nerve block.
③Physical therapy: cold therapy can reduce spasticity because it can lower the temperature of the muscles and have a sedative effect on the muscle shuttle; alternating electrical stimulation of the antimuscarinic muscles, stretching the spastic muscles, and moving the joints passively can also relieve spasticity.
Shoulder-hand syndrome (SHS)
SHS is also known as reflex sympathetic dystrophy (RSD). The pathogenesis of SHS is not known, but the factors associated with its development include sympathetic dysfunction, shoulder subluxation, spasticity, excessive wrist strain or accidental injury to the hand.
Clinical manifestations
The clinical manifestations are sudden onset of
pain in the shoulder.
limitation of motion.
The hand may become swollen and painful, and in later stages, hand muscle atrophy and finger contracture deformity may occur until the movement of the affected hand is permanently lost.
Rehabilitation of SHS
Treatment of SHS includes
① Avoiding the causes of SHS: avoiding straining the tissues around the shoulder joint in the early stage of hemiplegia, paying attention to correcting the position of the scapula, increasing the tension of the muscles around the shoulder joint to prevent shoulder joint subluxation; avoiding injury, pain, excessive stretching and prolonged hanging of the upper limbs, especially the hand; avoiding intravenous infusion of fluids in the affected hand
Rehabilitation treatment of SHS
② Correct placement of the affected limb: the upper limb on the affected side should be carefully placed to ensure that the wrist is not in full palmar flexion or that the upper limb is not draped over the side of the wheelchair.
(b) Proper elevation of the affected upper limb in the prone position.
In the seated position, place the affected upper limb on a small table mounted on the wheelchair and use a splint to fix it to avoid palmar flexion of the wrist
③Passive and active movements: Passive movements of the affected upper limb can prevent and treat shoulder pain, maintain the mobility of each joint, and move gently and slowly so as not to produce pain.
Active scapular activities, three-dimensional activities of the shoulder joint with the upper limb raised, but weight-bearing activities of the upper limb on the affected side that make extension should not be practiced to avoid increasing swelling and pain
Rehabilitation treatment for SHS
④Cold therapy: This therapy can reduce swelling, relieve pain and relieve spasm. ⑤ Those with significant symptoms can be treated with regular doses of steroid preparations for 2 to 3 weeks, and most patients can get good results.