bubble_chart Overview

Cerebral apoplexy—refers to a clinical syndrome characterized by rapidly developing, vascular-origin focal brain dysfunction lasting more than 24 hours, also known as cerebrovascular accident (CVA).

Due to advancements in the clinical diagnosis, emergency care, and treatment of this condition, the acute-phase mortality rate of cerebrovascular diseases has significantly decreased (domestically <30%). However, alongside this decline in acute-phase mortality, the overall prevalence and disability rates in the population have risen substantially.

After the acute phase of apoplexy (Stroke) (typically within 2–3 weeks), approximately two-thirds of patients retain certain brain dysfunctions, such as cognitive and perceptual disorders (cognitive disorders), communication and speech disorders (communication disorder), psychological or emotional disorders, etc. The most common remains motor (often accompanied by sensory) dysfunction—hemiplegia.

To date, neither biological nor medical research has provided evidence that highly differentiated nerve cells possess regenerative capabilities. However, both experimental animals and clinical medical phenomena reveal that lost brain functions (e.g., motor functions) after cerebral apoplexy can recover to some extent. This indicates that during the recovery process of brain injury, there exist mechanisms of recovery other than regeneration.

After decades of effort and based on extensive applied research, clinical medicine has developed a relatively comprehensive system for the modern evaluation and treatment of cerebral apoplexy. Following the clinical trials of neurophysiological approaches to hemiplegia treatment pioneered by B. Bobath and S. Brunstrom, the effectiveness and reliability of these methods have been conclusively proven, and the related theories have gained widespread recognition in the medical community.

Today, theories on functional reorganization and facilitation techniques have become the guiding principles for modern hemiplegia rehabilitation and are still evolving and improving. In developed countries, early rehabilitation for cerebral apoplexy has already become a routine part of clinical practice.

However, there remains a significant gap between hemiplegia rehabilitation in China and modern medicine. For instance, domestically, the increase in muscle strength (e.g., upper limb pulling force, lower limb straight-leg raising strength) is often used as the basis for evaluating motor function recovery in hemiplegia. In contrast, modern rehabilitation considers muscle strength highly unreliable for such evaluations and instead advocates using movement quality (limb movement patterns) and activities of daily living (ADL) as indicators for motor function recovery in hemiplegia.

Consequently, improper muscle strength training in domestic practices—such as focusing on increasing upper limb pulling and grip strength or prematurely assisting patients in "walking" to boost lower limb muscle strength—leads to misuse syndromes like hemiplegic gait "walking," which hinders the recovery of practical functions in patients.

bubble_chart Clinical Manifestations

1. Psychological and Emotional Disorders: Apoplexy patients, in addition to the general psychological changes seen in patients, also experience more severe psychological disturbances due to brain function injury, which directly affects the entire apoplexy process, including the recovery of limb motor function. These manifestations include:
   1. Denial: Early lack of understanding and denial of the illness. When patients exhibit somatosensory neglect or body image disorders, they may feel their limbs can move and completely deny hemiplegia, with this denial persisting for a certain period. The former is a general psychological reaction, while the latter is a unique psychological disorder resulting from cortical injury during stroke.
   2. Anger: "Why did this happen to me?" Paralysis, refusal to cooperate, refusal to eat—psychological support is needed.
   3. Over-optimism: Rapid early recovery leads patients to expect quick or even complete restoration.
   4. Depression: Anxiety, pessimism, or alternating cycles of over-optimism and disappointment are common and require psychological intervention.
   5. Acceptance: Coming to terms with the reality of hemiplegia.
   The psychological states at these different stages often severely hinder the recovery of motor function. Comparing two patients with similar conditions, the one with psychological or emotional disorders will recover limb motor function much more slowly than the one without such barriers.
2. Sensory Disorders
   1. Pain: Limits movement, reduces ROM, and exacerbates spasms. Thalamic and nearby vascular lesions can cause thalamic pain due to brain dysfunction, manifesting as widespread burning pain.
      Common shoulder joint pain often becomes a major obstacle to upper limb movement. Patients may avoid active use of the affected limb, reject treatment, and exhibit poor mood, all of which hinder functional recovery.
   2. Hemianopia: Causes visual field defects, where patients cannot see objects on the affected side or half of their vision, leading to abnormal body posture and gait.
   3. Loss of joint position sense and proprioception—subjective sensory ataxia, such as inaccurate movements, static and dynamic balance disorders, and abnormal posture, necessitating visual compensation.
3. Cognitive Disorders: Cognitive functions belong to the higher cortical activities of the brain, including sensation, perception, attention, memory, comprehension, and intelligence. Symptoms vary depending on the lesion site, with attention and memory being most affected.
   Patients with memory disorders find it extremely difficult to learn new things, including the relearning of limb motor functions.
4. Speech Disorders: The impact of speech disorders on movement primarily affects daily activity learning and limb motor function training. Due to difficulties in language comprehension and expression, occupational therapists often find it challenging to teach daily activities.
5. Ataxia: Ataxia refers to the impairment of coordinated limb movements and body balance during walking. The mechanism involves disruptions in the integration of afferent neural signals, leading to ataxic movement.

bubble_chart Treatment Measures

I. Goals and Training Principles

1. Goal: Through a combination primarily focused on exercise therapy, achieve the prevention and treatment of complications, reduce sequelae, adjust psychological states, promote functional recovery, and fully utilize residual functions to strive for self-care and reintegration into society.
2. Training Principles: Primarily suppress abnormal, primitive reflex activities, improve movement patterns, and rebuild normal movement patterns; secondarily, strengthen the training of weaker muscle groups.

II. Principles of Phased Treatment

(1) Acute Phase: Within days of onset, focus on emergency care and initiate rehabilitation as early as possible, primarily to prevent complications and secondary damage.

1. Prevent complications: Prevent bedsores, respiratory infections, deep vein thrombosis, etc.
2. Prevent joint contractures and deformities.
   1. Massage; prevent and reduce edema; sensory stimulation—for those with high muscle tone, use relaxation techniques; for those with low muscle tone, use stimulating techniques.
   2. Passive movement: Start with small joints → large joints.
   3. Positioning: When lying down, limbs should be placed in anti-spasticity positions.

(2) Treatment during the Stage of Convalescence (1–3 weeks)

1. Flaccid Paralysis Phase: Use various methods to restore and improve muscle tone, induce active limb movement, and encourage patients to engage in active movements in bed (rolling over → sitting with Grade I balance).
2. Spasticity Phase: Control muscle spasms and abnormal movement patterns, promote the emergence of isolated movements.
3. Stage of Convalescence: Promote better recovery of selective movements and speed movements while continuing to suppress muscle rigidity.

Exercise training follows the developmental laws of human movement, progressing from simple to complex, easy to difficult. Rolling over → sitting → sitting balance → double-leg standing balance → single-knee standing balance → sitting → standing balance → walking. Most patients can skip the knee-standing and crawling stages. III. Brief Methods:

1. Self-assisted activity with interlocked fingers: Interlock the fingers of both hands, with the affected thumb on top and slightly abducted. Since the healthy fingers abduct the affected fingers, the flexor spasm of the entire upper limb can be reduced. Advantages:
   1. During movement and transfer, the hemiplegic shoulder is protected.
   2. With hands interlocked at the midline, sensation and perception improve.
   3. Prevents scapular retraction and overall hemiplegic-side retraction.
   4. Prevents associated reactions.
2. Rolling over is the most meaningful activity, stimulating whole-body reactions and movements.
3. Inhibit lower limb extensor spasm: Reduces lower limb extensor spasm while promoting scapular protraction and inhibiting upper limb flexor spasm.
4. Full-range control of the lower limb—learn active control of the lower limb.
5. Inhibit knee extension while extending the hip: Place the affected limb outside the bed edge. The therapist fully dorsiflexes the foot → relaxes the knee into flexion → all movement resistance disappears → actively lift the foot back onto the bed. The ability to flex the knee while extending the hip is the foundation for the swing phase of walking; facilitates moving the leg off the bed when transitioning from lying to sitting at the edge.
6. Active hip control: Supine position, knees flexed, feet supported on the bed. Stabilize the affected knee and keep the affected limb stable while moving the healthy limb.
7. Bridge exercise (selective hip extension): Same position → lift the buttocks → keep the pelvis level. The therapist places one hand on the front of the thigh. While pressing the knee downward, pull the femoral condyles forward, and lightly tap the buttocks with the other hand → assist hip extension (double bridge). Then have the patient lift the healthy foot off the bed → all weight on the affected leg (single bridge). Isolated movement for knee extension: Supine → therapist fully dorsiflexes the foot → perform isometric knee contraction (tighten the thigh without pushing with the foot or toes). Initially, the knee may be slightly flexed. Advantage: No metatarsal flexion during treatment, inhibiting triceps surae spasm.
8. By selectively extending the lower limbs to bear weight with both feet flat on the ground → Cross hands on the stool in front → Elbows straight, head forward beyond the feet → Lift the hips → Knees forward.
9. Training activities for weight-bearing on the unaffected limb
   1. Improving hip extension in external rotation position.
   2. Standing with dorsiflexion facilitated by a rolled bandage.
   Balance function training
10. Lateral tilt to elbow support: The patient tilts sideways until the elbow touches the treatment bed → sits up. The therapist supports the patient's upper shoulder with their forearm to facilitate the movement, while the other hand guides the patient's hand and arm. Advantage: Promotes head-righting response.
11. Slight lateral shift of the center of gravity
    1. Toward the affected side—the trunk should be elongated, with the therapist's hand placed under the armpit and on the contralateral flexor muscles.
    2. Toward the unaffected side—shorten the affected-side trunk muscles, with one hand pressing the affected flexors at the purlicue and the other on the affected back. Shift the center of gravity to the affected trunk while externally rotating the unaffected hand.
12. Crossing the legs and shifting the center of gravity toward the lower leg—used for balance during putting on shoes and socks.
13. Reaching forward with both hands to touch the ground and pushing a ball forward with interlocked hands.
14. Bending the knees and shifting the center of gravity laterally—transferring weight from one side to the other while standing.
15. Balloon play activity.
16. Standing activities with weight-bearing on the affected leg.

    Upper limb training

17. Inhibiting arm muscle spasticity: Supine position: 1. Inhibit trunk muscle spasticity → inhibit arm spasticity. Sitting position: Support with the affected limb.
18. Inhibiting scapular retraction and depression.
19. Inhibiting forearm pronation.
20. Selective flexion with elbow external rotation.
21. Active movement.
22. Sitting and pushing a ball.
23. Standing activity, dribbling a ball.
24. Standing position, arm supporting on a table for weight-bearing to inhibit spasticity.