I. Overview
Stroke (commonly known as stroke) is a general term for a group of acute cerebrovascular diseases, including ischemic cerebral thrombosis, cerebral embolism, lacunar cerebral infarction and hemorrhagic cerebral hemorrhage and subarachnoid hemorrhage. Its common causes are hypertension, atherosclerosis, heart disease, blood disorders, congenital vascular disease, etc. Stroke is characterized by high morbidity, high mortality and high disability. There are about 2 million new stroke patients in China every year, and 70%-80% of them are unable to live independently because of their disabilities.
Evidence-based medicine confirms that stroke rehabilitation is the most effective way to reduce the disability rate and is an integral part of the organized stroke management model. Modern rehabilitation theory and practice have demonstrated that effective rehabilitation can reduce functional disability, improve patient satisfaction, accelerate the stroke rehabilitation process, reduce potential care costs, and save social resources. For this reason, it is important to carry out stroke rehabilitation to improve the functional disability of patients, enhance their ability to take care of themselves, and maximize their return to society.
II. Principles of stroke rehabilitation
Stroke rehabilitation uses the principles of plasticity and functional reorganization of the nervous system to promote superior central control of movement, inhibit abnormal, primitive reflex activity, improve movement patterns, counteract spasticity formation, rebuild normal movement patterns, and enhance muscle strength at the same time.
After neurological damage in stroke patients, the central nervous system has the ability to compensate and functionally reorganize, i.e., “brain plasticity”, and other brain cells will regenerate through axonal regeneration, dendritic “sprouting”, and changes in synaptic threshold as a result of “brain plasticity”. The physiological, biochemical and morphological changes that underlie “brain plasticity” require special functional exercises and repeated practice activities.
After central nervous damage in stroke patients, the cerebral spinal cord has some plasticity and the brain still has regional functional reorganization properties, especially when the paralyzed limb performs purposeful activities, the blood flow in its corresponding innervated functional brain area increases significantly, which cannot be achieved by drug therapy and cannot be replaced by any drug.
Possible mechanisms of recovery after brain injury include.
1, regenerative germination of nerve cell axons ;
2, functional reorganization;
3, synaptic changes;
4.Functional replacement;
5.Cortical excitability changes;
6.Special skills learning.
III. Objectives of stroke rehabilitation
To use all effective measures to prevent disabilities and complications that may occur after stroke (e.g. pressure sores, crushing or aspiration pneumonia, urinary tract infection, deep vein thrombosis, etc.), to improve impaired functions (e.g. sensory, motor, language, cognitive and psychological), and to improve the patient’s ability to perform activities of daily living and adapt to social life, i.e. to improve the quality of life of stroke patients.
IV. Timing of stroke rehabilitation
The timing of stroke rehabilitation is not clearly defined internationally. In the past, the timing of rehabilitation was generally considered to be within six months of the onset of stroke, but it is too late for the regeneration and repair of central nervous system damage. Currently, many rehabilitation experts believe that the earlier the intervention time for rehabilitation, the better. Early rehabilitation can not only improve neurological function and increase ADL capacity, but also eliminate or reduce the occurrence of disuse syndrome.
Rehabilitation experts advocate that rehabilitation can be started as soon as the patient is clear, the vital signs are stable, the neurological signs are no longer progressing for 48h, and the GCS score is >8. In general, rehabilitation can be started one week after the onset of ischemic stroke and two weeks after the onset of hemorrhagic stroke. Especially for motor function, the earlier the start of rehabilitation, the better. It is important to note the importance of good limb positioning and passive movement of the affected limb in the acute phase.
However, for patients with serious comorbidities or 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, etc., treatment of the original disease should be actively treated along with the comorbidities or complications, and rehabilitation should be carried out gradually only after the patient’s condition has stabilized for 48h.
V. Rehabilitation principles of stroke
1. Choose the right time for early rehabilitation. According to the conclusion of the national “Ninth Five-Year Plan” research project “early rehabilitation of acute stroke”, “in ischemic stroke, as long as the patient is conscious, the vital signs are stable, and the condition no longer progresses 48 hours later, rehabilitation can be carried out. Rehabilitation” is safe, reliable, effective and feasible. In contrast, rehabilitation for patients with hypertension and substantial cerebral hemorrhage is generally recommended 10 to 14 days after illness.
2. The rehabilitation treatment plan must be based on the rehabilitation assessment, developed jointly by the rehabilitation team, and gradually revised and improved during the implementation of the treatment plan to achieve individualized treatment.
3, rehabilitation treatment throughout the whole process of stroke treatment, to achieve a gradual progression.
4, rehabilitation must be the patient’s active participation 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 methods.
VI. Stroke rehabilitation assessment
A series of examinations must be done before stroke rehabilitation, including: examination of all organs of the body; examination of mental and neurological disorders; examination of daily living ability. These examinations are important for the determination of rehabilitation suitability, the design of rehabilitation procedures, the formulation of goals, the management of comorbidities and complications, the assessment of functional impairment, the estimation of prognosis, and the safety in rehabilitation.
The Fugl-Meyer (FMA) scale is commonly used to assess the efficacy of stroke rehabilitation, and the Fugl-Meyer Movement Score (FMA) can be used to assess the degree of disability before and after rehabilitation of hemiplegic patients, to develop a rehabilitation program, and to predict rehabilitation goals.
The ultimate goal of stroke rehabilitation is to restore and improve the functional impairment caused by central nerve cell injury so that the patient can live independently to the maximum extent possible, i.e., to improve the ability to perform daily living. Therefore, it is necessary to examine and evaluate the patient’s ability to perform daily living.
1. The purpose is to.
(1) To understand the effect of central nerve cell damage on the ability to perform daily living, and to consider methods of treatment and training.
(2) To determine the adaptability of rehabilitation according to the ability of daily living, to make prognosis assessment, and to set treatment goals.
(3) To understand the effect of training and treatment according to the development of daily living ability, and to study the effectiveness of training programs.
(4) To provide patients and family members with life guidance and future improvement of daily living environment according to the evaluation of daily living ability.
2. Assessment of muscle spasm.
Modified Ashworth method
Grade 0 no increased muscle tone.
Grade Ⅰ mildly increased muscle tone, end of ROM.
Grade Ⅰ+ mildly increased muscle tone, 50% after ROM and always with some resistance.
Grade II with markedly increased muscle tone, mostly ROM, but still easy to move.
Grade III severely increased muscle tone with difficulty in passive movement.
Grade IV stiffness in flexion or extension position.
3.Sensory function assessment.
It mainly includes: pain, touch, temperature, motion, position, solidity, and graphic sensation.
4.Other functional assessments.
For example, language function assessment and psychological assessment are also aspects of stroke dysfunction assessment.
VII. Functional impairment of stroke
1.Motor impairment.
Early in the stroke, the upper and lower limbs of the paralysis are often immobile, and other people will feel that the limbs are flaccid when helping the patient to move. Over time, the paralyzed limbs can move slightly, but they often become increasingly stiff (medically called spasticity), so they are also called rigid or spastic paralysis. Even if the person is able to walk later, he or she often has a specific “hemiplegic circling” gait. The motor impairment of the upper limbs, especially the motor function of the hands, is more difficult to recover.
2. Sensory impairment.
It is often manifested as pain and numbness of the hemiplegic limbs. Some patients lose all sensation of pain and hot and cold, and have no sensation even when the hot water bag burns the skin. Therefore, the water temperature should not be too high when washing the patient’s feet with hot water, and the hot water bag should be wrapped in a towel when warming to avoid burns.
3. Language impairment.
Some hemiplegic patients, especially those with right hemiplegia, often have one or more of the following situations when speaking or talking
(1) The patient does not speak clearly, which is called slurred speech. This is medically known as dysarthria.
(2) The patient is unable to speak, or intermittently speaks a few single words as if typing a telegram.
(3) The patient does not understand what the relative says, such as “open your mouth to drink”, but the patient does not open his or her mouth until the cup of tea is brought to his or her mouth.
(4) The patient sometimes cannot speak or understand what others say.
(5) The patient has difficulty writing or cannot write, and cannot even write his or her own name.
(6) The patient cannot read when looking at words.
(7) The patient cannot name objects, such as holding a teacup in front of him and asking him, “What is this?” He will often say: “This is for drinking water”, but just can’t name the “tea cup”.
4. Swallowing disorder.
The performance of drooling, feeding food often stays in the mouth, drinking water choking cough. Patients who encounter swallowing disorders, drink water to tilt their heads to the normal side of the limbs, food processing into paste, which can generally reduce swallowing difficulties.
5. Emotional disorders.
Stroke patients cannot take care of themselves completely because of hemiplegia, aphasia and other sequelae, and many patients will have different manifestations of psychological disorders such as pessimism, irritability, irritability or depression and anxiety. In this case, we should actively carry out psychological guidance, stabilize the patient’s mind and emotion, and establish the patient’s confidence in recovery and release the psychological barriers through various psychotherapy methods such as communication, reasoning, education, suggestion, psychoanalysis, music, exercise, relaxation and silence.