THIS is what should never have to be done. All you should ever have to do is look up what you need in that public database of all stroke research and protocols. I know this is Kazakhstan but that is all the more reason that this should never have to occur.
EARLY REHABILITATION OF PATIENTS AFTER A STROKE
Kozhagul Gulzat Residents of the 1th year, “Neurology: including children’s neurology” Kazakh Medical University of Continuing Education, Almaty, Kazakhstan
Parakhatov Mansur Residents of the 1th year, “Neurology: including children’s neurology” Kazakh Medical University of Continuing Education, Almaty, Kazakhstan
Karimbekova Uldana Residents of the 1th year, “Neurology: including children’s neurology” Kazakh Medical University of Continuing Education, Almaty, Kazakhstan
Parakhatov Mansur Residents of the 1th year, “Neurology: including children’s neurology” Kazakh Medical University of Continuing Education, Almaty, Kazakhstan
Karimbekova Uldana Residents of the 1th year, “Neurology: including children’s neurology” Kazakh Medical University of Continuing Education, Almaty, Kazakhstan
Abstract.
This article discusses the principles and methods of early rehabilitation of stroke patients. The authors describe the basic methods and principle of early rehabilitation of cognitive, motor and speech impairment after a stroke. The authors apply the method of collecting quantitative data contained in scientific articles with clinical studies of the early rehabilitation of patients after a stroke. In this review, we highlight recent trials of early mobilization, aphasia, dysphagia and upper limb treatment Keywords: stroke, early rehabilitation, motor disorders, speech impairment, cognitive impairment.
Introduction Stroke is an urgent problem of modern medicine. Mortality after ischemic stroke reaches 20% during the first month and about 25% during the first year. More than half of the surviving patients have a second stroke over the next 5 years, with most cases occurring in the first year [1]. In connection with the increase in the number of stroke patients, along with the development of methods for the prevention of diseases of the cardiovascular system and standards for the treatment of
stroke, it is necessary to improve methods for the rehabilitation of patients in the post-stroke period. High rates of morbidity and disability confirm the need to maintain and improve the practice of early sanatorium aftercare at the expense of social insurance funds. Considering the large number of combined cardiac pathologies, there is an urgent need to develop tactics for the early rehabilitation of post-stroke patients in conjunction with cardiologists. The stage of early rehabilitation in post-stroke patients should be carried out in a specialized department of the sanatorium. To date, ongoing research has focused mainly on the study of the results of individual rehabilitation methods after a stroke. The problem of the research is that there are very few studies evaluating the effectiveness of early rehabilitation of patients who have suffered a stroke against a background of cardiac neurology and there are no clear guidelines for comprehensive rehabilitation of patients after a stroke in a cardiac neurological sanatorium. The purpose of the research is to analyze the methods of early rehabilitation of patients after a stroke. The main neurological symptoms of stroke, which require rehabilitation, are motor impairment and walking disorders, speech impairment and cognitive impairment. Currently, the post-stroke period is divided into 4 periods: 1. Acute period (first 3-4 weeks); 2. Early recovery period (first 6 months); 3. Late recovery period (from 6 months to 1 year); 4. Residual period (more than 1 year). In the early recovery period, in turn, two time intervals can be distinguished: up to 3 months, when the range of movements and strength in the paretic limbs is mainly restored and post-stroke cyst formation ends, and from 3 to 6 months, when the restoration of lost motor skills. Speech recovery, social and mental preadaptation take a longer time. The basis of rehabilitation is neuroplasticity, the property of the brain to change its functional and structural reorganization, the ability of its various structures to be involved in different forms of activity. According to the Fisher M. and Ginsberg M. the early reorganization is based on such factors as multifunctionality of a neuron and neuronal pool and hierarchical structure of the brain and sprouting (germination and further anastomosis of nerve fibers) [2]. Early rehabilitation prevents the development of complications of the acute period of stroke caused by hypokinesia and hypodynamia (thrombophlebitis of the lower extremities followed by pulmonary embolism, congestive pneumonia, pressure sores, etc.), the development and progression of secondary pathological conditions, the development of social and mental maladaptation, depressive conditions. Functional magnetic resonance imaging data indicate that the sooner rehabilitation is started the more active is the functional restructuring of the central nervous system and the earlier intact parts of the brain are involved in the performance of impaired functions. Rehabilitation of patients with motor disorders After a stroke, many patients have problems with motor functions. Rehabilitation of motor functions is one of the important aspects and includes treatment with posture (antispastic laying of limbs), passive exercises and selective massage. Heron H., Durieu I., Godefroy O. et al. note that early rehabilitation of motor impairment (in the first 14 days after a stroke) helps to reduce disability, reduce mortality in the first 3 months from a stroke, reduce dependence on others, reduce the frequency and severity of complications and side effects, improving the quality of life of patients by the end of the 1st year after a stroke [3]. According to many clinical researches, therapeutic gymnastics is one of the most effective rehabilitation methods for impaired motor function. Apply therapeutic gymnastics to restore movement in paralyzed limbs, electrical stimulation of the neuromuscular apparatus. Along with the restoration of movements, the tasks of medical gymnastics include training in walking and the elements of self-care. D.L. McLellan and B. Wilson in clinical trials used computerized robotic orthoses, which initially provide passive movements in the lower extremities, simulating a step. As the movements recover, the patient’s active participation in
locomotion increases [4]. The biocontrol method according to the electromyogram is widely used. In order to suppress synkinesias, in addition to their conscious suppression, orthopedic fixation (longs, orthopedic shoes, etc.) and special anti-friendly passive and passive-active movements are widely used [5]. To improve the walking function, the patient is taught to walk along the Swedish wall first, then with a four-leg support, an ordinary stick, then without support (if possible). To increase the stability of the vertical posture, various types of balance therapy are used (step training, special therapeutic and gymnastic exercises, functional bio-control with feedback on the stabilokinesiogram, virtual reality, etc.). In general, early rehabilitation is more focused on the motor sphere, this is determined not only by its effect on plasticity, but also by the fact that: 1) Motor disorders are observed in more than 85% of stroke patients; 2) They are more likely to interfere with self-care; 3) Motor function is the most mobile it is quickly disrupted with a decrease in cerebral blood flow and can also be restored quickly; 4) Uneven recovery of individual muscles leads to the development of pathological motor patterns, which determines the need to control the process of restoration of movements; 5) Motility can be affected from the periphery through the interneurons of the spinal cord both by kinesiotherapy methods and by sensory stimuli; 6) The impact on the motor sphere will contribute to the normalization of other functions, since the same transmitters are involved in the transmission of information in the motor, sensory, cognitive systems. Rehabilitation of patients with speech impairment The main method of correction of speech disorders are classes in the restoration of speech, reading and writing, which are carried out by speech therapistsaphasiologists or neuropsychologists. At an early stage, special “disinhibition” and stimulation methods of restorative training are used [6]. Restoring understanding of speech at the first stage of individual words and situational speech, at the next stage outside of situational phrases. In parallel, the patient learns to understand written language. Stimulation of understanding of speech occurs not only in the classroom, but also during normal household contact. Speech rehabilitation is carried out against the background of medicine therapy, which has an activating effect on the integrative functions of the brain (nootropics, cerebrolysin, choline alfoscerate, memantine). Rehabilitation of patients with cognitive impairment after a stroke Cognitive impairment often occurs after a stroke and is manifested by impaired memory, attention, gnosis, praxis, and decreased intelligence. According to a study by Roman G.C., memory impairments developing after acute cerebrovascular accident are reported to be observed in 23–70% of patients in the first 3 months after a stroke [7]. By the end of the 1st year, the number of patients with impaired memory decreases to 11–31%. The frequency of dementia in patients after a stroke is 26%, and with age, it tends to increase. In patients older than 60 years, the risk of dementia in the first 3 months after a stroke is 9 times higher than in people without a stroke [7]. The cause of severe cognitive impairment and even dementia can be: massive hemorrhage and extensive cerebral infarction; multiple heart attacks; single, relatively small heart attacks, located in functionally significant areas (the anteromedial sections of the optic tubercle and related areas, frontal lobes, parietal, temporal and occipital regions of the brain). Cognitive impairment or dementia due to heart attacks in functionally significant areas does not increase with time, but even decrease. So, according to Yakhno N.N., Damulin I.V., Zakharov V.V. сognitive improvement is clearly observed in 1/3 of patients by the end of the acute period of stroke [8]. The degree of regression is different and depends on the location of the heart attack, its location in the dominant or subdominant hemisphere, single or bilateral lesions, the presence of a previous brain lesion, which was asymptomatic before the stroke. Cognitive impairment that is detected in connection with a stroke can occur at different periods: immediately after a stroke (acute cognitive impairment) and in a more delayed period (delayed post-stroke cognitive impairment), the latter, as a rule, are caused by a parallel neurodegenerative process that is activated in connection with increasing ischemia and hypoxia. Post-stroke cognitive impairment worsens the prognosis, increases mortality and the risk of repeated stroke by 3 times, and also increases the severity of functional disorders after a stroke, and significantly complicates rehabilitation [9]. To correct cognitive impairment after a stroke, metabolic and neuroprotective agents, medicine acting on neurotransmitter systems, corrective cognitive, emotional-volitional and other mental disorders are widely used. Medicine treatment as part of the early rehabilitation of stroke patients, it is difficult to distinguish between rehabilitation and therapeutic methods. The use of medicine in the acute period of stroke is explained by the need to correct systemic hemodynamics, brain perfusion, symptoms of cerebral edema, conduct of pathogenetic therapy (antihypoxic, antioxidant, neuroprotective, neurotrophic), adequate provision of the motor system, orthostasis state. The principles of medicine therapy also include the treatment of background, concomitant diseases and the activation of regenerative and reparative processes of the brain through plasticity mechanisms. The specified multilateral approach to treatment determines the feasibility of using medicine of combined action. Covington forte belongs to such medicine a vasoactive medicine that acts mainly on the microvasculature, reduces the aggregation of red blood cells and platelets, increases the number of capillaries, reduces their permeability, improves venous outflow, and eliminates vasospasm without affecting systemic blood pressure. Conclusion There is clinical evidence that post-stroke rehabilitation, which began in the first two weeks after an acute cerebrovascular accident, significantly reduces mortality and disability, and reduces the frequency and severity of thromboembolic complications and congestive pneumonia. By the end of the first year, such patients have an improvement in vital signs and the need for help from those around them decreases. For the prevention of venous thrombosis of the lower extremities, compression stockings or elastic bandage are used. In addition, there are auxiliary devices - verticalizers that help the patient's body to take a vertical position. In parallel, passive physiotherapy exercises, neuromuscular electrical stimulation, and self-care training
are prescribed to restore motor functions. In a number of rehabilitation centers, poststroke patients who are allowed activity, but because of muscle weakness are not able to take an independent vertical position, use computerized robotic devices and passive movement of the limbs orthoses. Unfortunately, due to the relatively high cost of these devices, their use is very limited.
Introduction Stroke is an urgent problem of modern medicine. Mortality after ischemic stroke reaches 20% during the first month and about 25% during the first year. More than half of the surviving patients have a second stroke over the next 5 years, with most cases occurring in the first year [1]. In connection with the increase in the number of stroke patients, along with the development of methods for the prevention of diseases of the cardiovascular system and standards for the treatment of
stroke, it is necessary to improve methods for the rehabilitation of patients in the post-stroke period. High rates of morbidity and disability confirm the need to maintain and improve the practice of early sanatorium aftercare at the expense of social insurance funds. Considering the large number of combined cardiac pathologies, there is an urgent need to develop tactics for the early rehabilitation of post-stroke patients in conjunction with cardiologists. The stage of early rehabilitation in post-stroke patients should be carried out in a specialized department of the sanatorium. To date, ongoing research has focused mainly on the study of the results of individual rehabilitation methods after a stroke. The problem of the research is that there are very few studies evaluating the effectiveness of early rehabilitation of patients who have suffered a stroke against a background of cardiac neurology and there are no clear guidelines for comprehensive rehabilitation of patients after a stroke in a cardiac neurological sanatorium. The purpose of the research is to analyze the methods of early rehabilitation of patients after a stroke. The main neurological symptoms of stroke, which require rehabilitation, are motor impairment and walking disorders, speech impairment and cognitive impairment. Currently, the post-stroke period is divided into 4 periods: 1. Acute period (first 3-4 weeks); 2. Early recovery period (first 6 months); 3. Late recovery period (from 6 months to 1 year); 4. Residual period (more than 1 year). In the early recovery period, in turn, two time intervals can be distinguished: up to 3 months, when the range of movements and strength in the paretic limbs is mainly restored and post-stroke cyst formation ends, and from 3 to 6 months, when the restoration of lost motor skills. Speech recovery, social and mental preadaptation take a longer time. The basis of rehabilitation is neuroplasticity, the property of the brain to change its functional and structural reorganization, the ability of its various structures to be involved in different forms of activity. According to the Fisher M. and Ginsberg M. the early reorganization is based on such factors as multifunctionality of a neuron and neuronal pool and hierarchical structure of the brain and sprouting (germination and further anastomosis of nerve fibers) [2]. Early rehabilitation prevents the development of complications of the acute period of stroke caused by hypokinesia and hypodynamia (thrombophlebitis of the lower extremities followed by pulmonary embolism, congestive pneumonia, pressure sores, etc.), the development and progression of secondary pathological conditions, the development of social and mental maladaptation, depressive conditions. Functional magnetic resonance imaging data indicate that the sooner rehabilitation is started the more active is the functional restructuring of the central nervous system and the earlier intact parts of the brain are involved in the performance of impaired functions. Rehabilitation of patients with motor disorders After a stroke, many patients have problems with motor functions. Rehabilitation of motor functions is one of the important aspects and includes treatment with posture (antispastic laying of limbs), passive exercises and selective massage. Heron H., Durieu I., Godefroy O. et al. note that early rehabilitation of motor impairment (in the first 14 days after a stroke) helps to reduce disability, reduce mortality in the first 3 months from a stroke, reduce dependence on others, reduce the frequency and severity of complications and side effects, improving the quality of life of patients by the end of the 1st year after a stroke [3]. According to many clinical researches, therapeutic gymnastics is one of the most effective rehabilitation methods for impaired motor function. Apply therapeutic gymnastics to restore movement in paralyzed limbs, electrical stimulation of the neuromuscular apparatus. Along with the restoration of movements, the tasks of medical gymnastics include training in walking and the elements of self-care. D.L. McLellan and B. Wilson in clinical trials used computerized robotic orthoses, which initially provide passive movements in the lower extremities, simulating a step. As the movements recover, the patient’s active participation in
locomotion increases [4]. The biocontrol method according to the electromyogram is widely used. In order to suppress synkinesias, in addition to their conscious suppression, orthopedic fixation (longs, orthopedic shoes, etc.) and special anti-friendly passive and passive-active movements are widely used [5]. To improve the walking function, the patient is taught to walk along the Swedish wall first, then with a four-leg support, an ordinary stick, then without support (if possible). To increase the stability of the vertical posture, various types of balance therapy are used (step training, special therapeutic and gymnastic exercises, functional bio-control with feedback on the stabilokinesiogram, virtual reality, etc.). In general, early rehabilitation is more focused on the motor sphere, this is determined not only by its effect on plasticity, but also by the fact that: 1) Motor disorders are observed in more than 85% of stroke patients; 2) They are more likely to interfere with self-care; 3) Motor function is the most mobile it is quickly disrupted with a decrease in cerebral blood flow and can also be restored quickly; 4) Uneven recovery of individual muscles leads to the development of pathological motor patterns, which determines the need to control the process of restoration of movements; 5) Motility can be affected from the periphery through the interneurons of the spinal cord both by kinesiotherapy methods and by sensory stimuli; 6) The impact on the motor sphere will contribute to the normalization of other functions, since the same transmitters are involved in the transmission of information in the motor, sensory, cognitive systems. Rehabilitation of patients with speech impairment The main method of correction of speech disorders are classes in the restoration of speech, reading and writing, which are carried out by speech therapistsaphasiologists or neuropsychologists. At an early stage, special “disinhibition” and stimulation methods of restorative training are used [6]. Restoring understanding of speech at the first stage of individual words and situational speech, at the next stage outside of situational phrases. In parallel, the patient learns to understand written language. Stimulation of understanding of speech occurs not only in the classroom, but also during normal household contact. Speech rehabilitation is carried out against the background of medicine therapy, which has an activating effect on the integrative functions of the brain (nootropics, cerebrolysin, choline alfoscerate, memantine). Rehabilitation of patients with cognitive impairment after a stroke Cognitive impairment often occurs after a stroke and is manifested by impaired memory, attention, gnosis, praxis, and decreased intelligence. According to a study by Roman G.C., memory impairments developing after acute cerebrovascular accident are reported to be observed in 23–70% of patients in the first 3 months after a stroke [7]. By the end of the 1st year, the number of patients with impaired memory decreases to 11–31%. The frequency of dementia in patients after a stroke is 26%, and with age, it tends to increase. In patients older than 60 years, the risk of dementia in the first 3 months after a stroke is 9 times higher than in people without a stroke [7]. The cause of severe cognitive impairment and even dementia can be: massive hemorrhage and extensive cerebral infarction; multiple heart attacks; single, relatively small heart attacks, located in functionally significant areas (the anteromedial sections of the optic tubercle and related areas, frontal lobes, parietal, temporal and occipital regions of the brain). Cognitive impairment or dementia due to heart attacks in functionally significant areas does not increase with time, but even decrease. So, according to Yakhno N.N., Damulin I.V., Zakharov V.V. сognitive improvement is clearly observed in 1/3 of patients by the end of the acute period of stroke [8]. The degree of regression is different and depends on the location of the heart attack, its location in the dominant or subdominant hemisphere, single or bilateral lesions, the presence of a previous brain lesion, which was asymptomatic before the stroke. Cognitive impairment that is detected in connection with a stroke can occur at different periods: immediately after a stroke (acute cognitive impairment) and in a more delayed period (delayed post-stroke cognitive impairment), the latter, as a rule, are caused by a parallel neurodegenerative process that is activated in connection with increasing ischemia and hypoxia. Post-stroke cognitive impairment worsens the prognosis, increases mortality and the risk of repeated stroke by 3 times, and also increases the severity of functional disorders after a stroke, and significantly complicates rehabilitation [9]. To correct cognitive impairment after a stroke, metabolic and neuroprotective agents, medicine acting on neurotransmitter systems, corrective cognitive, emotional-volitional and other mental disorders are widely used. Medicine treatment as part of the early rehabilitation of stroke patients, it is difficult to distinguish between rehabilitation and therapeutic methods. The use of medicine in the acute period of stroke is explained by the need to correct systemic hemodynamics, brain perfusion, symptoms of cerebral edema, conduct of pathogenetic therapy (antihypoxic, antioxidant, neuroprotective, neurotrophic), adequate provision of the motor system, orthostasis state. The principles of medicine therapy also include the treatment of background, concomitant diseases and the activation of regenerative and reparative processes of the brain through plasticity mechanisms. The specified multilateral approach to treatment determines the feasibility of using medicine of combined action. Covington forte belongs to such medicine a vasoactive medicine that acts mainly on the microvasculature, reduces the aggregation of red blood cells and platelets, increases the number of capillaries, reduces their permeability, improves venous outflow, and eliminates vasospasm without affecting systemic blood pressure. Conclusion There is clinical evidence that post-stroke rehabilitation, which began in the first two weeks after an acute cerebrovascular accident, significantly reduces mortality and disability, and reduces the frequency and severity of thromboembolic complications and congestive pneumonia. By the end of the first year, such patients have an improvement in vital signs and the need for help from those around them decreases. For the prevention of venous thrombosis of the lower extremities, compression stockings or elastic bandage are used. In addition, there are auxiliary devices - verticalizers that help the patient's body to take a vertical position. In parallel, passive physiotherapy exercises, neuromuscular electrical stimulation, and self-care training
are prescribed to restore motor functions. In a number of rehabilitation centers, poststroke patients who are allowed activity, but because of muscle weakness are not able to take an independent vertical position, use computerized robotic devices and passive movement of the limbs orthoses. Unfortunately, due to the relatively high cost of these devices, their use is very limited.
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