Motor Rehabilitation
Before dealing with rehabilitation, we must clearly realize that its activities should be carried out in parallel with the prevention of a second stroke.If the cause of the illness is not eliminated, then a second stroke can reverse all efforts to restore the lost functions. Only comprehensive and competent treatment of the disease that led to a stroke can give reason to believe that time and effort will not be wasted.
One of my patients suffered a first stroke at the age of 64 years. The disease was manifested by speech impairment and weakness in the right limbs. Against the backdrop of treatment and rehabilitation, he quickly recovered, literally three weeks after the debut of the disease, he felt so good that he returned to work. The activity of the limbs was restored completely, and speech had hardly noticeable defects.
The patient without hesitation agreed to taking medications that normalize blood pressure and slow the heart rate (he suffered from hypertension and a constant form of atrial fibrillation). However, after 10 days of taking medications diluting the blood, flatly refused to continue taking them.After reading the instructions, he saw that the administration of drugs of this group can be accompanied by severe side effects, and decided to confine himself to the cardiomagnet . The first months passed calmly, but then the patient had a second stroke, as a result of which he completely lost his speech and the ability to move.
Relatives made heroic efforts to rehabilitate the patient, as a result of which he partially restored the ability to move and even goes outside.Nevertheless, working capacity is completely lost, he can not speak and hardly understands the speech addressed to him. The use of warfarin , a drug that reduces blood clotting, was resumed from the first day of a second stroke and continues to this day. For the past since 3,5 years of side effects and has not come, the recurrence of the stroke was also not. We must admit that in order to ensure the safety and effectiveness of the necessary treatment, the patient paid too high a price.
Restoration of motor functions after a stroke goes through the same stages as the early development of an infant, and the process of gaining control over the trunk proceeds in the same sequence as the growth of the child. First comes the control of the head after the overturning, then the balance is sitting, then standing, then walking with gradually increasing speed and stability is possible. Any attempt to train more complex movements, bypassing the previous stage of rehabilitation, is harmful, not beneficial. American scientist G. Doman , a prominent specialist in the field of rehabilitation, wrote: “The road of development for which any person goes is very clearly defined, and there are no detours, intersections and intersections on it.” Therefore, rehabilitation activities should be carried out in the sequence outlined below.
For the prevention of pressure sores and diseases of the respiratory system, and just to maintain the strength of the body after a stroke, it is necessary to lie on both a healthy and paralyzed side. Lie on a healthy side in such a way that the weight of the body was correctly distributed. For this, a healthy leg should be almost straightened, and the patient needs to be slightly moved forward, slightly bent and laid on a pillow or roller.Put a pillow under a sick hand.
Lying on the sore side is also helpful, it can help restore sensitivity and touch.
Correctly lying on the paralyzed side should be like this:
• Under the patient’s back, lay a pillow to relax the muscles and stability, so that he does not roll off the bed.
• The paralyzed hand must be moved forward; straighten your hand and put your palm up. Long lie on the paralyzed side can not be!
• straighten the paralyzed leg so that it is aligned with the trunk, bend the knee slightly, push the shin slightly back.
• A healthy leg bend in the joints and put on the pillow in front of the sore leg.
Long lying on the back is not very desirable, since it strengthens the muscle tension of the limbs. Nevertheless, some time can be spent in this position, for example, during the setting of a dropper. To properly lie on your back, with the help of a healthy hand, you should lay the patient so that her upper and shoulder joints lie on the pillow, and the spatula is outside the pillow. Sick hand turns outward, palm up. Under the painful leg, another pillow is put in such a way that the knee is slightly bent. This will serve as a support for the sick thigh, and the leg will not roll down. If lying on the back is uncomfortable, it is usually due to the fact that under the head too many pillows and the spine are bent, and the sore arm is clamped in the body or, slipping off the cushion, turned out or bent. In this case, someone has to help the patient put paralyzed limbs.
With ischemic stroke a patient can lie with a raised head for 15-30 minutes 3 times a day, starting from the first day of the disease.
The position of the body in bed is desirable to change as often as possible. Remember that during sleep we often move, on average it happens every 40 minutes. Too strong sleep in the same position, when they say “sleeps like a dead man,” is not something normal for a person. The patient who has suffered a stroke, too, should not lie without moving. Prolonged squeezing of the same areas of the skin can lead to the formation of pressure sores. Fight this with the help of an anti- decubitus mattress. This device is an inflatable rubber container divided into compartments.The applied motor alternately inflates different compartments, due to which the load on different parts of the body alternates, which has a beneficial effect on the condition of the skin and subcutaneous tissue.
Nevertheless, changing the position in bed is also necessary, including to improve the drainage function of the bronchi. The thing is that the bronchial system is therefore called figuratively bronchial tree, that large and small bronchi form a figure resembling the crown of a tree, and therefore they are directed in all directions. If a person is constantly in the same position, then sputum from certain bronchi under the influence of gravity flows into the trachea and clears throat, and from other bronchi, on the contrary, does not flow out. As you know, stagnation in any hollow organ leads to its inflammation. Bronchias and lungs are not an exception – even in the absence of dangerous microorganisms, microbes begin to multiply in the hearth of stagnation (and they are always present), which ultimately leads to pneumonia, which is difficult to cure for a weakened patient. Frequent turns in bed can avoid this problem.
The position of the bed in the room should also be correctly selected. It is recommended to put it so that the patient observes life through the sick side. For example, if he suffers from left paralysis, then to the right of the bed there should be a wall, and to the left – free space. Having the opportunity to see the constantly changing situation, the patient includes the affected areas of the brain, thereby speeding up the recovery.
It is very important for a patient to learn to turn in bed. This is the first step to recovery, with successful implementation of which the psychological state of patients noticeably improves. However, before starting to act independently, this procedure is performed with an assistant.
To turn on the paralyzed side from the supine position, the assistant stands up on the patient’s side and helps him turn around, taking him by a healthy shoulder, knee or thigh.
For turning without assistance, the patient must independently bend both knees. Then the patient’s hand is moved away from the trunk with the help of a healthy hand, starting the movement of the sore arm from the shoulder joint. After this, the patient turns his head, then pushes back with a healthy leg and turns his knees and shoulders to the sore side.
Possible causes of failure:
• the patient does not repel the patient with a strong foot;
• The patient’s hand is pressed against the body. Before turning, make sure that the arm is straightened and set aside;
• when turning, the head was not turned;
• The mattress is too soft – in this case, a shield must be placed under it.
The next step is to learn how to sit properly in bed. Sitting should be straight, as close as possible to the back of the bed, which should be wide enough to not fall, gradually sliding to the side. It is even better to use a sofa as a support for the back. In the sitting position, the weight should be distributed to both buttocks evenly. A sore hand should be placed on the pillow, straightening it and straightening the brush. Keep your head straight, not bending it to one side.
Possible reasons why it is not convenient to sit:
• the position of the patient’s spine is hunched;
• There are too many pillows under the back;
• The weight of the body is transferred to the sick side. This happens when the weight is unevenly distributed on both buttocks. This can be corrected by lifting a sore thigh with help;
• the patient slides to the sore side, which may be due to lack of support when the balance is poorly maintained. It is necessary to put a pillow along the affected side;
• The hand slid off the pillow and, bent, with a fist clenched in a fist, lies between the body and the pillow. You can fix this by placing a pillow under the upper arm (shoulder) – the blade will move forward. Another pillow should be placed under the forearm, while the arm should slightly bend at the elbow. The brush should be placed so that the fingers are straightened, and the palm is turned down.
For 3-5 days from the onset of the disease, you can sit down with your feet down. The length of stay in this position is from 15 minutes for the first time to 30-60 minutes with good tolerability. The sitting position should be used to eat or practice with a speech therapist.
Getting up is an important point in the rehabilitation of patients. The vertical position of the body contributes to improving breathing and cardiac activity, equalizing the pressure inside the thoracic and abdominal cavities, restoring deep sensitivity, preventing the development of pneumonia, decubitus, joint stiffness , and increasing tolerance to stress.
Ideally, verticalization is carried out in the intensive care unit, where there should be vertical tables . Unfortunately, they are not in all intensive care units, and usually the process of self-standing, which was preceded by turns in the bed and sitting, is the first opportunity for the patient to take a vertical position.
The rising is made from the sitting position. For this, the patient himself shifts to the edge of the seat. Steps should be placed on one line on the width of the shoulders and push to the legs of the chair or chair. Then the patient leans forward so that his shoulders are above the knees and feet, while the weight of the body is transferred to both feet. Hands rest on the armrest or hang down. Then the patient straightens, keeping his balance, and stands up, straightening his legs.
To do this, you need to do the following:
• stand with your back as close as possible to the seat, put your feet on one line and push them to the legs of the chair;
• Take the armrests with both hands. If this is difficult, then you need to hold a healthy hand, slightly leaning in a healthy direction; To sink to the seat, bend forward, bend your legs and then sit down. It’s not necessary to do this drastically, because you can overturn, losing balance. It is important to follow the patient hand so as not to sit on it and do not pinch the side of the chair;
• try to sit down in an armchair as deep as possible.
Remember that if you sit too hastily or if the chair is far away and you do not feel the edge of the seat, you can fall. If it is not enough to lean forward, it can also lead to a fall.
This maneuver must be mastered as early as possible in order to be able to independently use the bathroom and toilet. Transplantation occurs in three steps – get up from the chair, turn your back to another chair and sit in it. It is advisable to perform this action, relying on a healthy leg, as shown in the figure.
If you change with the help of an assistant, you need to wrap it around your neck and not around your neck. The assistant guides the patient’s movements, supporting him by the waist or hips.
The doctor will allow the doctor to get up (usually on the 7th day of the disease), you need to do this gradually, starting from 2 minutes and bringing the duration of the training to 20-30 minutes. Forced immobility, caused by an acute period of stroke, of course, leads to a weakening of the muscles, so the first training will not be easy. Take it easy, gradually the forces will return.
When a person is standing, muscles of the back and legs are straining, the body weight is distributed evenly from the top down, which is usual for the body. Try to stand in such a way – the paralyzed leg should work too. Incorrect weight distribution can lead to a curvature of the spine, and in the future – to muscle atrophy of the diseased side. When standing up, any stable object is used as a support – the table, the back of the bed. It is better if the support is not on the side, but on the contrary. On the surface it should be supported by the palms and the weight of the body is transferred evenly to both hands. You need to get up as straight as possible, spreading the weight of the body on both legs, straightening them in the joints and picking up the buttocks. With palms resting on the table or other stable support that should be at the waist level, you should keep the balance and stand, starting from 2-3 minutes and gradually increasing the time.
The next stage of rehabilitation – the development of climbing and descending the stairs. If the strength in the legs is restored, you can independently go down and climb the stairs in the usual way, that is, alternately putting one foot on each step. If the sick leg is not strong enough, then you need to climb the stairs, leaning on a healthy leg and putting the patient to her. The socks of the feet must be directed forward, the feet are put on the step completely. It is necessary to descend, leaning on a sick leg and putting to it healthy. It is possible to facilitate descent on the stairs, moving backwards with support on the sick side.
If there is no handrail, a cane is used for the support. Hold it with a healthy hand and put it on the step before you put a sick leg.
Before moving on the stairs, you need to make sure that the railing is firmly fixed, the lighting is sufficient, the steps are not covered by loose carpet paths.
In any training, try to use the paralyzed side as much as possible. It is quite natural that a sick leg moves after a stroke worse than before it. For recovery, daily training is necessary, no matter how hard they are given. There is simply no other way!
For the convenience of training, the room should be well lit. Choose shoes with low heels, avoid slippery soles! With insufficient balance, canes, including three- and four-pegs , can be of great help , they are highly resistant. You can use the walkers, be sure to adjust them in height, to avoid a violation of posture. Correctly selected walkers and walking-sticks should reach the wrist level of the patient standing with his hands down.
Do not forget to change the rubber tips of the canes in time to avoid slipping.
Quite often after a stroke, there is such a phenomenon as ” flapping ” of the foot, – because of the weakness of the muscles, it sags when walking.In such cases, boots with high bootlegs that fix the ankle joint will help.
It has long been known that the simultaneous execution of identical exercises with two hands – healthy and paralyzed – more effectively restores the functions lost by the stroke than the work of the paraplegic limb. In the early 90-ies of the XX century, the method of mirror training was proposed.
For their conduct on the table in front of the patient, a mirror is installed in such a way that its reflecting surface is directed to the healthy side.The affected hand remains invisible to him. The patient does exercises with a healthy hand and sees the movements he performs in mirror reflection. This creates the illusion that the affected arm moves in the same volume as the healthy limb. The mechanism of action of this illusion has not yet been fully studied, but it is noted that mirror training much more quickly restores the functions of a paralyzed hand than training in standard techniques, when patients could see how the affected hand operates.
Usually, mirror training is performed in case of impaired hand function – paralysis or weakness. A good effect is achieved with a sensitivity disorder and even with pain in the hand, which also often complicates the stroke.
The technique is used in patients who have undergone a relatively easy or moderate severity of stroke, which has isolated one upper limb, and patients with paralysis of the arm recover more easily than those suffering spasticity , although in such cases the results can be impressive.
Training is conducted in a quiet room. It is also important that there are no pictures or other distracting objects in it, the mirror should not reflect the windows. On the healthy hand reflected in the mirror there should be no clocks and rings.
Experience shows that the optimal size of the mirror for training is 50 × 50 cm.
Depending on the degree of injury to the hand, three types of training are possible.
1. The patient independently tries to carry out the patient with the hand the same movements that he makes healthy.
2. In case of severe impairment of the functions of the paralyzed hand, the assistant helps the patient move it by analogy with the movements made by a healthy hand. This option is especially suitable for patients who experience pain when walking or feel a missing limb.
3. A paralyzed hand behind the mirror does not perform any movements. This is not devoid of meaning and can be used in the initial stages of classes.
Controlling the success of training can be done by measuring the angle of self-bending of the arm in the shoulder, elbow and wrist joints. It is enough to carry out control measurements once a week.
Exercises performed during training can be very diverse. You can bend and unbend the joints of the hands and fingers, do rotational movements, take your hands various objects, such as children’s cubes or chopsticks. The function of brush compression into a fist is practiced by tightening a soft ball.
The duration of training can be 30 minutes 1-3 times a day, you can often.
Of course, mirror training should be combined with other rehabilitation measures, and not replace them.
As a rule, all patients who have suffered a stroke with motor impairments are examined by a physiotherapist and prescribes a set of exercises for the speedy restoration of paralyzed limb functions. If, for some reason, there is no possibility to exercise under the supervision of a doctor, it is possible to perform daily exercises according to this scheme.
1. The starting position – sitting on a chair. Breathe in by the nose – belly inflate, exhale with the mouth – pull the stomach.
2. Sitting on a chair, put your hands on your knees. Raise the brushes and feet simultaneously and lower them 5-6 times.
3. Hands along the trunk. Brushes expand inward, then outward, execute 5-6 times.
4. Hands on the knees. Roll the foot from the heel to the toe 5-6 times.
5. Hands along the trunk. Circular motion shoulders back and forth 5 times in each direction.
6. Hands on the knees. To walk sitting on a place 5 times with each foot.
7. Bend arms in the elbows, press the wrists to the shoulders. Circular movements of the hands forward and back 5 times.
8. Sitting on a chair, slide feet on the floor, like on skis, 5 times each.
9. Brushes to connect in the lock. Circular motion forward and backward 5 times.
10. Circular motion with one foot, sliding on the floor of the foot in one and the other side. 5 times each leg.
11. Brushes in the castle. Circular motion with straightened hands in one and the other side for 5 times.
12. Feet on the width of the shoulders. Knees to spread apart. Tilt one knee inward, return to its original position. 5 times each leg.
13. Brushes in the castle. Straight arms – up, lowered by the head, then lifted up and lowered to your knees 5 times.
14. Brushes on the knees. Take the right hand and right leg to the right, then return to its original position. 5 times each hand and foot.
15. Hands bend in the elbows, brush to the shoulders. Elbows to take back, to bend – inhale. Elbows forward, connect, tilt-exhale.
16. One leg to unbend in the knee, pull the toe on yourself, return to the starting position. The same with the other leg. 5 times.
17. Hands bend at the elbows, lift up – inhale, lower down through the sides – exhale.
18. Bike with one foot forward and back, then the other foot. 5 times.
19. Brushes in the castle. Turn out the palms outward. Pull your hands forward – exhale. Hands rest on the chest – inhale.
20. Legs unbend in the knees, heels on the floor. Alternate flexion and extension of the feet.
21. Feet to unbend at the knees. Hands bend in the elbows. Circular movements of brushes and feet in one and the other side for 5 times.
1. The mouth is open. Lips are stretched in a smile. Keep the tongue wide and relaxed in the mouth at the expense of up to 5-10. Ensure that the tongue does not taper, and its tip touches the lower teeth.
2. The mouth is open. Lips are stretched in a smile. Put tongue out of your mouth with a shovel – give it a flat, wide shape, so that it touches the corners of the mouth with the side edges. In a relaxed relaxed state, hold the position under the count to 5-10. To make sure that the lower lip does not turn, the wide tip of the tongue lay on the lip, the tongue did not protrude far. If for a long time it is not possible to give the desired form to the language, then it is possible: a) to pronounce with a languid language ” five-five-five , b -bja-bja “; b) on the tongue stretched between the lips, blow out (breathe out) the air and sing in a singsong sound of the “i-and-and”.
3. Lips in a smile. To relax the tongue, bite it all over the surface, gradually popping out and drawing again. Biting should be easy.
4. Wide tongue with force to squeeze between teeth outwards so that the upper incisors scrape on the back of the tongue. Lips in a smile.
5. The mouth is open. Teeth grin. Pushing out the tongue outward with a “needle” – the tongue is given the most sharpened form. Ensure that the tip of the tongue does not bend. If this movement does not work for a long time, then it is possible: a) to squeeze the tongue between the teeth or lips, squeezing it with the lips from the sides; b) reach for the finger or pencil that is moved away from it; c) Extremely stretch the tongue forward, to the right, to the left, and when in the corner of the mouth it narrows, gently pull it to the middle line of the mouth and fix it in this position.
6. The mouth is open. Lips in a smile. Alternately put out a wide and narrow tongue “shovel”, “sting”, “needle.” Ensure that the lips and lower jaw are immovable.
7. The mouth is open. Lips in a smile. Stick out the tongue alternately with a wide spread, “shovel” and narrow – “sting”, “needle”. Make sure that your lips are still.
8. Do the same movements with the tongue, but inside the mouth, the tip of the tongue rests against the upper and lower teeth. The mouth is open. Lips in a smile, watch them stay still.
9. Mouth wide open, teeth grin. To raise a wide tongue as far as possible from the mouth, and then draw it as deep as possible into the mouth to form only a muscular lump, the tip of the tongue becomes invisible. Ensure that the jaw does not move, the lips do not stretch on the teeth.
The mouth is open. Lips in a smile. Turn the tongue, strongly sticked out of the mouth, to the right and to the left so that the tip of the tongue touches the corners of the mouth. Ensure that the lower jaw and lips do not move, the tongue does not slip on the lower lip and teeth.
11. The mouth is open. Lips in a smile. The tip of the tongue lick the upper lip from one corner of the mouth to the other, trying to bring the tip to the upper outer edge of the lip. Ensure that the lips are not stretched on the tongue, the tongue reaches the corners of the mouth, the movement was smooth, without jumps, the lower jaw did not move.
12. The mouth is open. Lips in a smile. The tip of the tongue lick the lower lip from side to side. Tip the tongue to the outside edge of the lip. Ensure that the lips are not stretched on the tongue, the tongue reaches the corners of the mouth, the movement was smooth, without jumps, the jaw did not move.
13. The mouth is open. Lips in a smile. The tip of the tongue is to lick your lips, making movements in a circle. Ensure that the lips are not stretched on the tongue, the tongue reaches the corners of the mouth, the movement was smooth, without jumps, the lower jaw did not move.
14. The mouth is closed. Lick your teeth under the upper lip from side to side, gradually bending the tip of the tongue more and more. Ensure that the lower jaw does not move, the lips do not move apart.
15. The mouth is closed. Lick your teeth under your lower lip from side to side, gradually bending the tip of the tongue more and more. Ensure that the lower jaw does not move, the lips do not move apart.
16. The mouth is closed. Lick your teeth under your lips in a circle, bending the tip of the tongue as much as possible. Ensure that the lower jaw does not move, the lips do not move apart.
17. The mouth is open. Lick your teeth under the upper lip, the tip of the tongue wrapping as much as possible. Ensure that the mouth does not close, the lower jaw does not move.
18. The mouth is open. Lick the lower teeth under the lip, wrapping the tip of the tongue as much as possible. Ensure that the mouth does not close, the lower jaw does not move.
19. The mouth is open. Lick your teeth under your lips, moving around in circles, bending your tongue as much as possible. Ensure that the mouth does not close, the lower jaw does not move.
20. The mouth is closed. A tense tongue rests against one cheek and then the other. Ensure that the lower jaw does not move.
21. The mouth is open. Lips in a smile. A strained tongue rests against one cheek and then the other. Ensure that the jaw and lips do not move.
22. The mouth is closed. The tip of the tongue rests against the cheek and makes the movements up and down. Ensure that the lower jaw does not move.
23. The mouth is open. Lips in a smile. Smoothly guide the tongue over the upper teeth, touching each tooth from the extreme root on one side to the extreme root on the other. Ensure that the lower jaw does not move, the lips do not stretch on the teeth.
24. The mouth is open. Lips in a smile. Smoothly carry the tongue over the lower teeth, touching each tooth, from the extreme root on one side to the extreme root on the other side. Ensure that the lower jaw does not move, the lips do not stretch on the teeth.
25. To turn in the mouth cubes from dry bread crusts, peas, etc.
Bedsores are damage to the skin and subcutaneous tissue that result from the compression of the tissues with a hard surface (bed, chair, orthopedic appliances).
Most often they are formed in people who are obese or, conversely, depleted. Diabetes mellitus, severe heart failure, strokes, craniocerebral trauma are also typical risk factors.
It is known that the nutrition of the tissues of our body is carried out by blood, which comes through vessels and capillaries. Skin compression leads to poor nutrition. Each of us can easily carry out a simple experiment: take a transparent glass and tightly squeeze it with your fingers.Through the glass you will see that the tips of your fingers are white – this is due to their bleeding, because it is the blood that gives the skin a physiological pink color. If the squeezing continues for a long time, necrosis (necrosis) of the tissues can occur. The terms for the formation of bedsores are individual and largely depend on the general state of the organism. It is not uncommon for a bed patient, whose skin has been healthy for many months and even years, was covered with multiple bedsores in 1-2 days. Usually this is due to the attachment of some disease or the deterioration of the current already available.
In January 2015, a 46-year-old patient suffering from myasthenia gravis was brought to the intensive care unit, a serious illness characterized by gradually growing muscle weakness. For several years she practically did not get out of bed, but thanks to good skin care she had no bedsores. As a result of the progression of the disease, a weakness of the respiratory muscles appeared, which led to shortness of breath, which was the reason for hospitalization. Literally on the first day of her stay in the intensive care unit, despite proper skin care, she had deep sores on the rump with the size of two palms. Apparently, the cause of them was hypoxia – an insufficient saturation of the blood with oxygen, which, combined with inactivity, led to a disturbance in the nutrition of the skin and subcutaneous tissue. Against the background of complex treatment, the patient’s condition improved, while the bedsores were gradually cured. Stay in the intensive care unit lasted more than six months, but as a result, the patient was discharged home, now she uses a home apparatus for ventilation.
Excessive squeezing of the skin is the main, but not the only cause of pressure sores. Some contribution can make so-called shear forces . In order to understand what it is, do the following experiment. Place a bare arm on the table so that the forearm lies on the table, and the elbow hangs a few centimeters. Firmly pressing your forearm against the surface of the table, pull your hand toward you. The skin, adhering to the table, remains immobile, and the elbow will move slightly. This is possible due to the elasticity of the skin and subcutaneous tissues. Stretching the tissues between the bone and the skin causes a worsening of the blood supply, as a result of which bedsores can form in deep tissues with intact skin.
When a sedentary patient tries to move, there may be a situation where the skin remains pressed against the bed, and the bones move slightly.This leads to compression or even rupture of blood vessels, which disrupts the nutrition of deep tissues, causing the appearance of subcutaneous decubitus. The same happens when the patients slide from the bed, pulling the sheets out from under them, and in other similar situations.
By the way, abrasions, provoked by stretching from under the sick bed sheet or bed-board, are easily infected, which ultimately accelerates the development of pressure sores.
All bedridden patients should be examined daily, revealing bedsores at the earliest stages. First of all, assess the condition of the skin above the bony protuberances – in the nape of the neck, scapulas, sacrum, heels. If the patient lies on his side, bedsores can form in the region of pelvic bones, trochanter of the femur, on the knees.
The first stage of development of pressure ulcers is the reddening of the area of the skin, which does not go away when you press a finger on it.Then there are bubbles, reminiscent of those that occur with burns of the second degree. After this, if you do not take the necessary measures, an ulcer opens, which deepens to the bone, gradually destroying them. It is clear that the further the process went, the less chance of recovery, so prevention is very important. Let us dwell on it in detail.
• The main and most simple preventive measure is the use of an anti- decubitus mattress. Details about him are written in the chapter devoted to motor rehabilitation. Its cost is 3-4 thousand rubles (September 2016). By paying this amount, you can avoid large spending on treatment, and most importantly – significantly relieve the patient’s life. To some extent, the mattress can be replaced with rubber underlays under the sacrum and heels, however these devices are much less reliable and quite inconvenient.
• Change the patient’s position as often as possible. The methods of turning in bed are described in detail in the chapter on motor rehabilitation.Ideally, the turn needs to be done every two hours.
• Try to keep the skin clean. Daily 1-2 times treat it with camphor alcohol. It should not be too wet or dry.
• Make sure that there are no wrinkles, crumbs from food and other foreign objects on the sheet.
• Do not pull the sheets and the vessel out of the patients, but take them slowly and carefully.
• Do not allow patients to slip from the bed and a prolonged forced position in bed.
• Do not place heating devices (reflectors, oil heaters) near the patient’s bed. He can get burned because of the inability to change the position of the body.
• Do not use oilcloth to place under the patient’s body. If the patient does not control urination, it is better to put diapers on him, and a moisture -absorbing disposable sheet ( under the body) should be placed under the body . Adhesives cause excessive moisturizing of the skin, which in the future can worsen its protective properties and lead to the development of pressure sores.
• Use special skin care products instead of soap. They do not cause skin irritation, since they have a neutral, not an alkaline reaction.
At the first stage of development of decubitus, when there is no skin defect, it is enough just to ease pressure on the skin, for which the above-mentioned anti- bedsore mattresses and rubber circles are used. Turning in bed once every two hours is already mandatory, not desirable.Slapping the palm over reddened places can also speed recovery.
When a skin defect occurs, a solution of hydrogen peroxide is used – it allows you to clean the wound thoroughly, removing dirt and infected contents from it. Then, the same ointments that are usually prescribed for the treatment of open wounds are selected. Argosulfan is well proven – it contains an antibiotic and silver ions. Ointment allows you to quickly cope with the infection, has an analgesic effect and, as a rule, is well tolerated. Argosulfan is applied abundantly on the wound 2-3 times a day, the course of treatment depends on the speed of healing and can be up to two months. Levomekol and levosin are also shown . These ointments contain an antibiotic and a wound healing component, and levosin is also a local anesthetic trimomein , so the use of this ointment is preferred in cases of severe pain syndrome. The complex effect is sprayed with olazole , which contains sea buckthorn oil, an antibiotic, a topical anesthetic, and boric acid.
Solcoseryl or actovegin may be added to the treatment in the form of ointments, however, their intravenous administration is more effective, which strengthens the defenses of the body and prevents the emergence of new pressure sores.
Severe deep bedsores are an occasion to seek help from a surgeon. The operation consists in removing necrotic tissues, after which ointments are applied, which have already been discussed in this section.
On sale there are plastic bottles, when pressed on which a jet of hydrogen peroxide ishes all pathological contents from the decubitus. If you bought hydrogen peroxide in a glass container, you can pour it into a 20-ml syringe, attaching a needle to it from an insulin syringe. The needle should be fixed as best as possible, with adhesive tape or tape. When you press the piston, the jet will be thin, but very powerful, with its help you can separate the purulent masses from healthy tissues. After drying, apply ointment.
Yes. Instead of an ointment, the use of such drugs is acceptable. Usually, the bottom of the bed is smeared with potassium permanganate, and the green spot is around it. Treatment should be carried out often, 3-6 times a day. At night, when the patient is sleeping, you can apply a bandage with a spray of olazole or panthenol (apply a very thick layer, to a centimeter thick) and cover with a wide gauze bandage, strengthening its edges with adhesive tape . In the morning remove the bandage, rinse the wound with hydrogen peroxide and continue drying.
Correct speech can be restored only by a speech therapist. The task of relatives – as soon as possible to turn to such a specialist and not try to do something yourself. Inept attempts to teach the patient to speak bring more harm than good. For example, if you ask the patient to repeat the name of an item for you, you may be able to do it. True, the consequences will become unexpected for you: a so-called echolalia can form – a person will continue to repeat certain words, but he himself can still say nothing.
If a patient is able to pronounce a word and you encourage him to often reproduce this success, a verbal embolus may arise – the patient without any sense and reason will repeat the word, but to teach him to speak other words will be much more difficult. If the patient can repeat after you the name of an object, do not rush to rejoice. Often it happens that he will use these words in his original form, without declension. Such a speech disorder is called agrammatism .
Only an experienced speech therapist will be able to draw up the correct program for restoring speech and combating the violation of her perception.
As a rule, the exercises selected by the speech therapist at the beginning of the recovery cycle are of a non-verbal nature. This is the folding ofpuzzles , drawing, the construction of figures using cubes. You can offer games in cards, dominoes, lotto. In the next stages, patients are given jobs to combine the picture and the signature to it. The restoration of writing skills is carried out by recording dictation of words and numbers.
It should be remembered that classes with a speech therapist should be conducted in silence. Extraneous noises, a working TV or radio interfere with a patient with impaired speech much more than a healthy person. Moreover, it is impossible to talk to two people at the same time with something to the patient – such a flow of information is difficult for him to understand.
There are several more rules for communicating with a patient with a speech disorder.
• Talk more in his presence. He must participate in general conversations, it speeds up recovery and improves the emotional background.
• Classes with a speech therapist should be conducted as early as possible after the discovery of a speech defect. The first three weeks from the moment of the disease are most productive. Then the compensatory capacities of the body gradually decrease. It is conditionally considered that after two years from the beginning of the disease recovery is impossible.
• Try to refer to the patient with short and clear phrases.
• When talking with a patient, speak slowly, pronouncing words well.
• Do not raise your voice when talking to a patient and do not lisp. Aphasia (a violation of understanding and formulating speech) – this is not deafness and not dementia!
• Ask at first such questions, to which you can answer “yes” or “no”.
• Try not to interrupt the patient – the way will express his thought to the end, even if it does not turn out as quickly as we would like.
Edema of the extremities is a natural complication of stroke. More often it occurs in people who do not use the affected limb – do not try to move it, do not perform restorative exercises. The cause of edema is the excessive tone of the flexor muscles, as a result of which the outflow on the veins clamped by these muscles suffers. Ways to combat swelling are as follows:
• Try to do exercises more often. The contractions of the muscles of the sick arm, alternating with relaxations, contribute to the improvement of venous outflow from the diseased limb, hence, reduce puffiness.
• If the hand does not move at all, try to at least passively change its position. Lie with arms outstretched (or put a pillow between your arm and body) is most effective for eliminating edema.
• During waking and walking, you can put a small cushion between the arm and the body so that the hand is not pressed.
• There is a therapeutic massage that helps to reduce swelling of paralyzed limbs.
• Medical treatment of edema is usually ineffective. Nevertheless, in conjunction with the above measures, taking medication can sometimes be helpful. As a rule, in such cases, prescribe detraleks and / or homeopathic drug lymphomyositis .
• If the hand swells very strongly, cyanotic staining of the affected limb appears, you can think of venous thrombosis. In this situation, ultrasound of the veins of the arm and consultation of the vascular surgeon are necessary.
You can use the recommendations above. In addition, you can use elastic bandages or, much more effectively, compression underwear – knee-highs, stockings, tights. To improve venous outflow it is useful to dilute legs to the sides during sleep and rest. For this purpose, a pillow can be placed between the knees.
Usually, laxatives are prescribed to solve this problem, for example dufalak . There are microclycers microlux , their application is very effective. If medications do not help, the enema should be staged. Normally, the chair should be 1 time per day, a delay for a longer period is always bad.
Do not forget about the increase in the amount of fiber in the patient’s diet – give him prunes, food bran, drug ryacen RD. This can increase intestinal motility and help achieve a regular stool.
In such cases, special nutritional mixtures are usually prescribed – Nutridrink / Nutrikomp or baby food (preferably meat, it has more nutrients).You can diversify the diet with jelly, yogurt.
For more than three years I have been watching a patient who is 92 years old at the moment. After a stroke, she practically does not move around the apartment and can not swallow solid food. About 90% of its diet is a nutrient mix ” Nutridrink “, sometimes it adds a little baby food or jelly. Despite the monotonous and relatively meager diet, the patient is alive and feels good, as far as possible in her condition. All the needs of the body in nutrients are covered by Nutridrink .
After feeding, you must sit for half an hour, if it is not possible, then at least raise the head end of the bed.
In such cases it is necessary to offer semi-liquid products – jelly, kefir, yoghurt. Sometimes you can try to give 1-2 sips of water, and then seize it with something hard, it will improve the swallowing of the liquid.
There is an exercise that sometimes helps to stimulate the restoration of a swallowing reflex. After each sip of something liquid, a soft, damp toothbrush without paste is needed to pat the lower wisdom teeth (or the gums in their place, if they are removed) on both sides. It is enough to perform several massage movements, but it should be done often.
Measures to eliminate muscle spasm are as follows:
• Change the patient’s position regularly;
• as often as possible, perform slow, passive movements in the joints of the affected hand with the help of an assistant or with a healthy hand;
• The hand should not be on weight – during rest, always place it on the pedestal, the position of the limb should be the middle between the extreme flexion and extension;
• prescribed by a doctor may use drugs or sirdalud Mydocalmum. They help to cope with spasm, but experience shows that their reception leads to muscle weakness, which makes rehabilitation difficult and worsens the quality of life.
This question is so important that I consider it necessary to dwell on it in more detail. Unfortunately, the prophylactic appointment of droppers to patients who have suffered a stroke is very common. In the offices of the day hospital, polyclinics are administered solutions containing euphyllin, piracetam , cavinton and other similar preparations. Patients stand in line, and droppers are prescribed from a certain date, which are prepared in advance, often for 2-3 months …
However, the effectiveness of such methods of therapy is low. The fact that the treatment with droppers should be prescribed only in case of worsening of the course of diseases! In particular, with a repeated stroke, exacerbation of cerebral circulatory insufficiency with clear symptoms (for example, increased dizziness) or in other similar situations. The prophylactic effect of a repeated stroke does not have a dropper. It is not uncommon for patients to have a stroke immediately after the completion of the dropper course. Not from droppers, of course, but as a result of the progression of a chronic disease. No droppers can prevent this.
Remember: the treatment of any disease has only two goals – improving the prognosis and improving the quality of life. No others. If a drug does not improve the prognosis and well-being, it is not needed. To the fullest extent, this refers to “preventive” droppers with caviton or pyracetam .
Yes, of course, for the prevention of stroke are used pills, which have already been discussed in this book. I think it will be useful to repeat their groups and names.
First, it is necessary to prevent the progression of atherosclerosis. For this purpose there statins ( Crestor , Lipitor and others), ezetrol as a possible addition to these, as well as fibrates ( traykor , lipantil ) as an alternative to statins in some cases. Drugs are prescribed for life, require blood test control – lipidograms , transaminases ALT and AST, creatine phosphokinase .
Secondly, we must achieve a reduction in blood clotting – for this purpose, aspirin is used. The dose of 100 mg or more per day has a proven effect. Usually appoint thrombotic ACC 100 mg 1 time per day immediately before meals or cardiomagnesium 150 mg once a day, regardless of food. Stronger drugs are prescribed at the discretion of the attending physician, they require monitoring of blood coagulability and close observation.
Thirdly, it is necessary to lower blood pressure if the patient suffers from hypertension. Preparations are described in detail in the chapter devoted to this disease.
Fourthly, in the presence of atrial fibrillation or heart aneurysm, drugs from the group of anticoagulants must be taken. Usually it is warfarin , pradaxa , xarelto . Read more about this in the chapter, which deals with the treatment of the permanent form of atrial fibrillation.
No other drug groups can prevent stroke. They have either a symptomatic effect – ease the course of the disease, eliminating symptoms, or simply useless.
No. Possible benefits for a person who did not suffer from a heart attack and stroke are less than the harm that regular aspirin can cause. The most undesirable consequence of this is the formation of a stomach ulcer with a risk of bleeding. In patients who have suffered a stroke, this risk has to be tolerated – the benefits of aspirin are very high for them.
If the patient has become dangerous to others or for himself, it is impossible to do without the help of a psychiatrist. The psychiatrist is called to the house through the ambulance service 03. Hospitalization is possible , where patients will be prescribed medications that have a calming effect, usually sonapaks or any drugs of a group of neuroleptics.
The night from 1 to 2 February 2001 I remembered well not only because she was my last night as an ambulance doctor, but also because she could be the last in my life. I received a call to a patient whose relatives reported that the patient who had suffered a stroke “became ill.” Walking up to the fifth floor, I saw a 55-year-old strong man who was standing in the stairwell at the door of his apartment, hiding his hands behind his back, to which I did not pay attention at first. Instead of greeting, he uttered words that terrified me. He asked: “And who is this behind you and smiles so creepy?” I did not suspect any treachery, so I was frightened by this phrase, and slowly began to turn around. Behind my back, of course, there was no one, but with a sidelong glance I caught that the patient made a quick move in my direction.I dashed in the opposite direction and managed – his hand, with the sharpening in it, passed by. The relatives who had come to the rescue grabbed the patient from behind, and we were able to immobilize him and take away his weapons. The specialized psychiatric brigade that I summoned to help brought him to a psychiatric hospital. While we waited for the brigade, my relatives told me that after a stroke a few months ago in the frontal lobe of the brain, the patient completely recovered his motor functions, but the psyche changed seriously. From a relatively quiet (though abused alcohol) person, he turned into an aggressive psychopath – more than once threatened to kill his wife and children, once chased with an ax over a small grandson, frightening him to stutter. When I asked why they did not go to a psychiatrist, the answer was:”And we did not know how to get him out of the house to the psychoneurological dispensary, he did not want to go there.” The fact that an aggressive person should be called a psychiatrist at home, they for some reason did not think.
In such situations, too, need the help of a psychiatrist. There are psychotropic drugs, such as exelon , reminil , which in some cases help to cope with dementia (this is the name of the condition in question).
The 88-year-old patient, whom I observe about the constant form of atrial fibrillation, suffered a stroke, after which he ceased to recognize relatives, often “talked”, talked with non-existent interlocutors, for example, with a long-dead brother. Relatives have already lost hope for an improvement in his condition, but after consulting a psychiatrist and starting a remineral, it has improved significantly. He himself leaves the house, does shopping in the store, reads books and newspapers, watches TV, and can tell in detail what was going on.
Self-medication in this situation is unacceptable, since the drugs have serious side effects, psychiatrist consultation is mandatory.
There is a rule: you have to train before the pain and a little more. Therefore, to continue training is necessary, albeit less than before. You can spend a few short workouts instead of one long. You do not need to break precisely.
Because most of the load falls on it. When restoring the function of a paralyzed leg, this will pass.
In addition to those exercises, which have already been discussed in this book, there is a relatively simple restorative technique. It consists in the following. The patient is given baby cubes, which he must take with a sick hand and shift to another place. When this exercise starts to work out, they switch to smaller objects, for example, pencils, counting sticks, paper clips. At the final stage, 1 kg of buckwheat and 1 kg of rice are mixed, and the patient spreads these cereals in different containers. Usually the successful completion of the final stage brings great moral satisfaction.
In the literature on the problem of stroke, there are recommendations for providing first aid to the sick. I must say that our capabilities are not great. So, it is necessary:
• put the patient on the bed;
• Ensure the flow of fresh air by opening the window;
• Turn your head to one side when you start vomiting, so that the patient does not choke.
In general, a set of simple and obvious actions.
In my opinion, the main problem is to distinguish a patient with suspected stroke from a person suffering from another disease that has similar symptoms.
If the patient is conscious, then everything is simple. We perform the above actions, call an ambulance on the mobile 911 and calmly wait. If a person is conscious, then in the short run he is not in danger.
It is quite another matter if the patient is unconscious. Delay can cost him his life, even a timely call of an ambulance will not always allow him to save, although, of course, this is the best thing you can do. The dispatcher must be informed that the patient is unconscious, the brigade is sent to such patients first of all. If the dispatcher will ask additional questions, try to answer them clearly and without unnecessary details. Well, for now the team is on the road, you can try to help yourself.