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.