The Study Of The Effect Of Early Comprehensive Rehabilitation Treatment To Upper Limb Dyfunction And Shoulder-hand Syndrome Afer Cerebral Infarction

1. Research backgroundCerebral infarction is caused by the reduction or shutoff of the blood flow in the supply artery, which would lead to brain tissue ischemia, hypoxia and tissue necrosis, softening of the blood supply area, followed by the corresponding parts of the clinical impairment such as hemiplegia, aphasia and other neurological deficit signs and symptoms. Cerebral infarction is harm to people’s lives and health seriously, and a huge heavy mental, physical and economic burden to patients, families and the society. As the medicine continues to grow and develop in China in recent years, the etiology, pathology of cerebral infarction has been more in-depth research. Also, drug, intervention, etc., and the level of rescue critically ill patients has greatly improved, while mortality is significantly reduced. But most of the surviving patients had cerebral motor, sensory, speech and cognitive dysfunction with varying degrees, It caused great psychological burden of patients, and led to a serious decline even or lost in the ability to work in patients, and affected the quality of life seriously. With the aging of our population and lifestyle changing, smoking, obesity, alcoholism, diabetes, hypertension, hyperlipidemia, hyperhomocysteinemia and other cerebrovascular accidents caused by the growing risk factors, increases the incidence of cerebral infarction significantly. Faceing with high morbidity caused by cerebral infarction, medical workers should find solutions to reduce the motor dysfunction due to the disease at an early stage to improve the quality of life of patients, so that there is the opportunity to return home or reintegration and reduce the burden on families and society. How to prevent and treat a variety of dysfunction after cerebral infarction is an important issue for the majority of rehabilitation workers currently. There have been reported in the literature, rehabilitation training can promote the establishment of the cerebral collateral circulation, improve brain cell compensatory function, promote functional recombinant tissue around the lesion, to play a "brain plasticity", most scholars agree that the theory about plasticity and function recombination of the nervous system is the theoretical basis of the central nervous system rehabilitation after injury neurological. Brain plasticity refers to the brain can reorganize and modify the structure and function, in order to adapt to physiological changes after injury. Brain function has the ability of plasticity, which wouid be a solid theoretical basis that the treatment of various rehabilitation can be used for dysfunction after cerebral infarction. With the rapidly development of rehabilitation medicine and technology, stroke rehabilitation has become the focus of the majority of workers in rehabilitation medicine research.Rehabilitation should proceed as soon as cerebral infarction occurred,which is approved by most of scholars.But due to many physicians lack of emphasis on as well as worried rehabilitation may affect heart and lung function of patients,the early rehabilitation treatment is scarce.This phenomenon is particularly serious in the primary hospital. The recovery of upper limb function is the emphasis and difficulties in rehabilitation work.But often the upper limb functional recovery is much more difficult than the lower limb, many patients rehabilitation effect are not ideal。And one of the reasons for these results may be linked to upper limb of less training than lower limb and trunk. Upper extremity paralysis after cerebral infarction is often complicated by shoulder-hand syndrome, with pain and edema of upper extremity which would eventually increase the difficulty of recover upper limb functional. Discussing early and effective rehabilitation to improve upper extremity function and reduce treatment shoulder-hand syndrome is significant. At present, early intervention comprehensive rehabilitation treatment of acute cerebral infarction is still in its infancy, rehabilitation intervention time and rehabilitation programs need continue to explore the clinical rehabilitation in order to find the best method.The present study is to investigate the effect of upper limb function in patients with cerebral infarction and the incidence of shoulder-hand syndrome of acute cerebral infarction in a stable condition within 48 hours (onset within one week) carried out by the comprehensive rehabilitation, and explore its therapeutic effect and safety.2.ObjectiveUpper limb functional recovery after cerebral infarction is far more difficult than lower limb, this study was designed to investigate the effects of early intervention c omprehensive rehabilitation to improve the of hemiplegic upper limb function and the incidence of shoulder-hand syndrome by the clinical randomized controlied study, which explored the acute brain infarction patients with hemiplegia rehabilitation therapy intervention time and the effectiveness and safety of rehabilitation programs, expecting for the future rehabilitation of hemiplegic patients.3. Subjects and Methods3.1 SubjectsChoose between October 2012 to October 2014 before the onset of the 89 patients with acute anterior circulation cerebral infarction, the cases were from Neurology and Rehabilitation medicine department of Southern Medical University Affiliated Shunde First People’s Hospital of acute cerebral infarction incidence of hospitalized patients, aged 40 to 78 years old. Using a random number sequence grouping approach,selected patients were divided into early rehabilitation group and early control group.Early rehabilitation group of 45 patients, including 25 males and 20 females; aged 42 to 77 years, mean (63.2 ± 8.3) years; onset to start the recovery time (the set time)= 3 d 27 cases,4～5 d 18 patients; type infarction:25 cases of cerebral thrombosis,14 cases of lacunar cerebral infarction,6 cases of cerebral embolism; area of infarction:5 cases of frontal lobe,4 cases of parietal lobe,27 cases of basal ganglia,9 cases of thalamus; hemiplegia side:26 cases of left hemiplegia,17 cases of right hemiparesis; Strength:13 cases of grade 0 to 1,32 cases of grade 2-3. Early control group 44 cases, including 23 males and 21 females, aged 43 to 76 years, mean (62.4 ± 8.8) years; the set time≦ 3 d 25 cases,4～5 d 19 patients; type infarction:24 cases of cerebral thrombosis,13 cases of lacunar cerebral infarction,7 cases of cerebral embolism; area of infarction:6 cases of frontal lobe,5 cases of parietal lobe,25 cases of basal ganglia,8 cases of thalamus; hemiplegia side:24 cases of left hemiplegia,20 cases of right hemiparesis; Strength:15 cases of grade 0 to 1,29 cases of grade 2-3. Differences between the two groups in terms of sex, age, infarction, type, location, hemiplegia side, stroke risk factors and the severity of illness at admission were not statistically significant, the two groups are comparable (P> 0.05). Inclusion criteria:patients were in accordance with the diagnostic criteria made from the 4th National Conference on cerebrovascular in 1995; and by brain CT or MRI scan to confirm the clinical diagnosis of cerebral infarction; and in accordance with:1, the internal carotid artery infarction onset patients, without affecting the functional recovery of nerve merger or musculoskeletal disorders; 2, vital signs of patients were stable, with no serious cardiopulmonary dysfunction; 3, patients aged 46-80 years old; 4, there is a side of the limb dysfunction, no aphasia and severe mental retardation; 5, after the onset of no thrombolytic therapy; 6, patients with conscious, no language barrier; 7, patients without mental illness or deaf or quadriplegic; 8, patients were willing to sign informed consent; 9,patients with course of disease≦ 5d, stable condition; 10,hemiplegic limb muscle strength≦ 3 grade (manual muscle assay). Exclusion criteria:1,patients with shoulder pain caused by periarthritis of shoulder and neck disease and thalamic lesion,ect;2,patients with local trauma and infection and hand skin diseases,etc;3, patients with clotting mechanism obstacle and peripheral vascular disease;4, patients with dysfunction of important organs,such as heart,liver and kidney;5, patients with dementia,severe aphasia,disuse obstacles,mental disorders;7, patients with subarachnoid hemorrhage, cerebral hemorrhage;8, patients with brainstem and cerebellar infarction; 9, patients with bilateral hemispheres lesions; 10, patients with severe pulmonary complications and fever wihich may significantly affect the prognosis; 11, patients with duration> 7 d and light condition and hemiplegic upper limb muscle strength> 3grade;12, patients from other place.3.2 Treatment PlanEarly rehabilitation group and early control group were given antiplatelet aggregation or anticoagulant, neurotrophic, dehydration and other medical therapy in accordance with the condition and given traditional Chinese acupuncture treatment. On this basis,early rehabilitation group group were given early comprehensive rehabilitation within 48 hours in a stable condition. Comprehensive rehabilitation treatment include:①patients and caregivers comleted putting proper body position and training muscle contraction and breath control several times a day,meanwhile, healthy hands do daily life activities in patients’ power; ②Therapist synthesize the application of the therapy technology on patients,, every time 45 minutes,6 days a week;③Therapists complete functional electrical stimulation therapy, every time 20 minutes,6 days a week;④Therapist use auxiliary appliance properly and proceed speech training and psychotherapy properly. In the treatment process, it emphasized that rehabilitation is a comprehensive, early, step by step continuous and comprehensive process.At the same time,the the patients family members and caregivers should be targeted on clinical training and guidance of rehabilitation knowledge, and they should participate in the entire rehabilitation therapy. Early control group were not given comprehensive rehabilitation treatment developed by this study.3.3 Assessment MethodsThe efficacy of the upper limb function was assessed by the scales of Fugl-Meyer Assessment (FMA) (upper part) and Barthel Index。Shoulder-hand syndrome diagnosis comply with the clinical diagnosis standard. The two groups of patients are assessed before treatment and after 30 days treatment., and observed on the occurrence of two groups of shoulder hand syndrome.3.4 Statistical AnalysisSPSS 17.0 statistical analysis were applied. (FMA) (upper part) and Barthel index were compared using the t test. Count data describing use frequency (%),and the incidence between groups were compared with chi-square test. P<0.05 was considered statistically significant.4.ResultsFMA(upper part) score before treatment of the early rehabilitation group was 16.55±7.38, and of the early control group was 15.97±7.37. After 30 days treatment,FMA score of the early rehabilitation group was 25.91±12.12 分, and of the early control group was 21.20±9.25. Within each group, FMA score after the treatment are better than that before the treatment, and the difference was statistically significant (P< 0.05). Between the two groups, FMA score was not statistically significant before treatment (P>0.05). And the score of the early rehabilitation group was better than that of the early control group after treatment,and the difference was statistically significant (t P<0.05).Barthel index before treatment of the early rehabilitation group was 19.22±10.86, and of the early control group was 22.27± 10.64. After 30 days treatment, Barthel index of the early rehabilitation group was 43.66±18.53, and of the early control group was 33.97±11.84. Between the two groups, Barthel index was not statistically significant before treatment(P>0.05). Between the two groups, Barthel index was not statistically significant (P>0.05). Barthel index of the early rehabilitation group was better than that of the early control group after treatment,and the difference was statistically significant (P<0.05).1 case of shoulder-hand syndrome occurred in the early rehabilitation group,and the rate was 2.22%.6 cases occurred in the early control group, and the rate was 13.63%. The incidence of shoulder-hand syndrome of the early rehabilitation was significantly lower than the early control group, the difference was significant (P <0.05). Shoulder hand syndrome occurred in the two groups were in phase Ⅰ (eraly phase).5.ConclusionEarly comprehensive rehabilitation is proved to improve upper extremity function in patients with cerebral infarction and promote patient quality of life safely and effectively, meanwile, reduce the incidence of shoulder-hand syndrome, and optimisticly lay the foundation for the subsequent rehabilitation.