Effects,of,Personalized,Ultra-early,Limb,Function,Rehabilitation,on,Neurological,Impairment,and,Satisfaction,of,Inpatients,with,Hemiplegia,after,Ischemic,Stroke

Jing ZENG, Yan LI, Congfen GONG, Xiaodong LIU, Haidong SUN, Li ZHANG

1. Hubei University of Medicine, Shiyan 442000, China; 2. Center of Health Administration and Development Studies, Hubei University of Medicine, Shiyan 442000, China; 3. Department of Neurology, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China; 4. Rehabilitation Forward Department, Taihe Hospital of Hubei University of Medicine, Shiyan 442000, China

Abstract [Objectives] To investigate the effects of personalized ultra-early limb function rehabilitation on neurological impairment and satisfaction of inpatients with hemiplegia after ischemic stroke. [Methods] From November 2020 to November 2021, 66 ischemic stroke patients with hemiplegia in the Neurology Department of a Grade A hospital were randomly divided into experimental group and control group, with 33 cases in each group. The experimental group received personalized ultra-early limb function rehabilitation, and the control group adopted routine rehabilitation nursing. The neurological function defect and nursing service satisfaction of inpatients were compared between the two groups at discharge. [Results] After intervention, the neurological impairment in the experimental group was lighter than that in the control group (P<0.05), and the nursing service satisfaction of the inpatients in the experimental group was higher than that in the control group (P<0.05). [Conclusions] Personalized ultra-early limb function rehabilitation can improve the neurological deficit of inpatients with hemiplegia after ischemic stroke and improve the satisfaction of inpatients.

Key words Stroke, Ultra-early rehabilitation, Neurological, Function, Satisfaction

Cerebral stroke is a disease caused by cerebral vascular obstruction or rupture of blood circulation disorders in the brain and brain tissue function and structure damage[1]. The incidence of ischemic stroke is higher than that of hemorrhagic stroke, accounting for about 80% of the total number of strokes[2]. Patients with ischemic stroke are often left with sequelae of varying degrees after treatment, mainly manifested as limb dysfunction, resulting in reduced quality of life[3]. Very-early mobilization (VEM), first proposed by Bernhardt[4], refers to the occurrence of a certain frequency of bed-free activities (bed-free sitting, standing, walking, bed-chair transfer,etc.) within 24 h after stroke to promote the recovery of patients’ neurological function and improve their prognosis. Scientific and reasonable ultra-early rehabilitation training can significantly promote the recovery of patients’ neurological function, limb motor function and daily living ability, effectively improve the prognosis of the disease and improve the satisfaction of inpatients[5-10]. In this study, personalized ultra-early limb function rehabilitation was carried out for patients with hemiplegia after ischemic stroke, and the implementation effect was tested.

2.1 SamplingA total of 66 patients with ischemic stroke and hemiplegia who were admitted to the Neurology Department of a Grade A hospital from November 2020 to November 2021 were selected as the research subjects.

2.2 Inclusion criteria and exclusion criteriaInclusion criteria: (i) age: 45-80 years old; (ii) the patient is conscious and can communicate normally; (iii) patients with first-episode ischemic stroke who met the clinical diagnostic criteria stipulated inChineseGuidelinesfortheDiagnosisandTreatmentofAcuteIschemicStroke2018[11]and were confirmed by head CT or MRI; (iv) NIHSS (American National Institutes of Health Stroke Scale) score ≤16; (v) patients’ systolic blood pressure was 90-180 mmHg, heart rate was 50-120 beats/min, and blood oxygen saturation was ≥95%; (vi) the patient had limb dysfunction at admission, and the muscle strength of at least one limb was ≤ grade 4.

Exclusion criteria: (i) patients with very mild or rapidly improving neurological dysfunction; (ii) patients receiving thrombolytic therapy after admission; (iii) patients transferred from other hospitals; (iv) patients admitted to hospital within 24 h of non-onset; (v) before the onset of paralysis or disability; (vi) patients with other serious systemic diseases, such as severe respiratory failure, heart failure, malignant tumor,etc.

2.3 Sampling methodThe simple random sampling method was used for sampling, and the patients who met the inclusion criteria were numbered according to the order of admission. The random number was generated by computer. The single number was the observation group (experimental group), and the double number was the control group.

The estimation method of sample content adopted table lookup. In this study, the mean numbers of two samples were compared. According to the unilateralα=0.05,β=0.20,δ/σ=0.5, and the attached table of medical statistics,n=51 was obtained. Assuming 20% of the samples were lost, the sample size wasn=51/80%=63.75, so the total number of samples was at least 64. A total of 66 cases were included in this study, including 33 cases in the experimental group and 33 cases in the control group. There was no statistical difference among all major factors (P>0.05), as shown in Table 1 and Table 2.Therefore, the comparison between patients in the data group is relatively comparable.

Table 1 Comparison of baseline data between the two groups (%, n=33)

Table 2 Comparison of NIHSS score between the two groups at admission (n=33)

This study has been approved by the Medical Ethics Committee of Taihe Hospital of Hubei University of Medicine (Approval No.2021KS01), and informed consent of patients and their families has been obtained.

3.1 Multidisciplinary collaborative teamTeam members: 4 attending physicians in neurology department, 2 rehabilitation technicians, 2 stroke health managers, 1 nursing graduate student. The responsibilities are as follows: (i) Attending physician: after the patient is admitted to hospital, conduct professional evaluation in a timely manner, improve relevant examinations, treat the patient according to the symptoms of the disease, and jointly negotiate the rehabilitation activity plan with the team members. (ii) Rehabilitation technicians: evaluate patients, arrange rehabilitation activities according to the specific conditions, and carry out rehabilitation activities for patients with stroke health managers. (iii) Stroke health managers (nurses who have been trained and qualified by the National Brain Prevention Commission for Stroke Health Managers): carry out rehabilitation activities for patients with rehabilitation technicians, strengthen the observation of patients’ conditions in the rehabilitation process, understand patients’ feelings and experience of rehabilitation activities, do a good job of team communication and coordination, do a good job of bridge between patients and the team, in order to ensure the safety of patients at the same time, ensure the smooth development of personalized ultra-early rehabilitation activities. (iv) Nursing graduate students: assist stroke health managers to carry out rehabilitation activities, collect, sort out, summarize and analyze relevant data, and participate in team coordination and communication.

Team communication methods: a team Wechat group was established, and stroke health managers sent the patient’s rehabilitation content, duration and frequency of the day, as well as the patient’s subjective experience and feelings to the group after the patient’s last rehabilitation each day to communicate with the attending physician and rehabilitation technician: whether to adjust or increase the content, duration and frequency of rehabilitation the next day. If the attending physician and rehabilitation technician did not respond in time, the stroke health manager would contact and communicate face to face the next morning to formulate the rehabilitation content of the next day. If the patient has discomfort or changes in his/her condition during rehabilitation, he/she should immediately suspend rehabilitation, communicate with team members, and adjust the rehabilitation content, duration and frequency of each rehabilitation. Personalized rehabilitation nursing for patients with ischemic stroke can be realized through effective team communication.

3.2 Building personalized ultra-early limb function rehabilitation contentTheoretical basis: guided by the full compensation system theory of nursing system theory in Orem self-care mode, the specific content of rehabilitation, the duration of each rehabilitation and the frequency of rehabilitation are determined according to patients’ conditions and feelings.

Rehabilitation principle: under the joint guidance of rehabilitation technician and stroke health management division, personalized rehabilitation is reflected, step by step, from simple to difficult, and patients can tolerate it. Methods to evaluate tolerance of patients[12]: movement before and after 3 min rest, each measuring a vital signs, patient tolerance performance for sports 3 min after the end of the pulse back to close before exercise, and exercise before the pulse frequency differs 6 times/min or less, patients present intolerance for sports oximetry after 3 min failed to restore to close before exercise level, differ with oximetry before exercise > 7 times/min.

Content of limb function rehabilitation: Appropriate rehabilitation content should be selected according to the muscle strength of hemiplegic limbs (Table 3). (i) Move in bed: good limb placement, body massage, passive and active movement, decubitus conversion, sitting training. (ii) Move out of bed: standing training, static station balance training, stepping training, walking training, up and down stairs training.

Table 3 Comparison of muscle strength and rehabilitation contents of hemiplegic limbs

Personalized rehabilitation activities are reflected in the specific content of daily rehabilitation, the duration and frequency of each rehabilitation. (i) On the day of admission, our team made the first rehabilitation activity plan for the patient. Before the activity, assess the patient’s condition (measure vital signs, observe pupils and state of consciousness) and ask the patient’s subjective feelings. If the patient’s condition and vital signs are stable and there is no subjective discomfort, the patient can start to recover. (ii) In the process of rehabilitation activities, closely observe the condition, often ask the patient’s feelings, if the patient’s condition changes or subjective discomfort, then suspend rehabilitation activities, immediately report to the team, communication and discussion to modify the rehabilitation activity plan (adjust the content of rehabilitation, shorten the length of each rehabilitation, reduce the frequency of rehabilitation); if there is no change in the patient’s condition or subjective discomfort during the rehabilitation, the rehabilitation activity will continue until the end of the rehabilitation activity. (iii) After each rehabilitation activity, assist the patient to rest in bed, observe the patient’s condition again, ask whether the patient has dizziness, chest tightness, fatigue, sweating,etc., measure vital signs. If the patient feels good, his/her condition is stable and can tolerate rehabilitation activities, then the stroke health manager will send the patient’s rehabilitation content, duration and frequency of the day, as well as the patient’s subjective experience and feeling to the group after the last rehabilitation activity of the patient every day, and communicate with the attending physician and rehabilitation technician: whether to adjust or increase the content, duration and frequency of rehabilitation the next day. If the physician and therapist do not respond in time, the stroke health manager would contact and communicate face to face again the next morning to formulate rehabilitation activities for the next day.

3.3 Research tools

3.3.1NIHSS. The NIHSS is used to systematically evaluate the severity of neurological deficits in Stroke patients. It was developed by the WHO National Institutes of Health and is universally unified. The intraclass correlation coefficient (ICG) was 0.93 and the Intraclass correlation coefficient (ICG) was 0.95. A total of 15 items were included, with the total score ranging from 0 to 42[13]. The lower the score, the better the condition of the patient, and the higher the score, the more serious the damage to the neural structure of the patient.

3.3.2Nursing service satisfaction questionnaire for inpatients. Compiled by Liu Hui[14], it contains 26 items in 7 dimensions. The Cronbach ’α coefficient of the questionnaire is 0.78, and the content validity index (CVI) of each item ranges from 0.81 to 0.93. Likert5-level scoring method was adopted in the questionnaire, with 5 points indicating "very satisfied", 4 points indicating "satisfied", 3 points indicating "general", 2 points indicating "dissatisfied" and 1 point indicating "very dissatisfied". The higher the score, the higher the satisfaction of patients with medical care services.

3.4 Preliminary experimentAccording to the inclusion and exclusion criteria of the subjects, 10% of the sample size (6 subjects) was selected for the preliminary test. According to the conditions of the preliminary test, the content of limb function rehabilitation was improved again to determine the final personalized ultra-early limb function rehabilitation content for patients with ischemic stroke.

3.5 Implementation methods

3.5.1Experimental group. Acute phase (ultra-early rehabilitation nursing-admission to hospital before stabilization). Rehabilitation is based on bed activities, methods are as follows. (i) The placement of good limb position: advocate lateral decubitus, inform the patient can be carried out at any time. (ii) Passive and active movement: including passive activities of the body, Bobath handshake, single bridge, double bridge movement,etc., each activity for 1 min, repeat 3 groups. (iii) Decubitus transformation: gradually raise the head of the bed, supine position to raise the head of the bed 15°-20°, and then to 45°-60°, each maintain 3-5 min, and then back to the supine position. (iv) Turn over training, turn over to the healthy side and the affected side, each maintain 3 to 5 min. Repeat for three times. (v) Sitting training three steps: the first step: shake the head of the bed to 30°, maintain 3 min, the second step: shake the head of the bed to 60°, maintain 3 min, the third step: then assist to the edge of the bed sitting feet on the ground, maintain 3-5 min. Repeat for three times.

Stabilization (early recovery-condition stabilizes until discharge). Rehabilitation to get out of bed activities, methods: (i) standing training: bedside sitting position to standing position (get up with the sitting position training method of three steps), maintain 3-5 min, rest for 3 min. Repeat for three times. (ii) Static station balance training: in the station training, let the patient gradually transfer the body center of gravity from the healthy side to the paralyzed side, so that the body center of gravity in the hemiplegia side and the healthy side of the repeated alternating, the initial duration can start from 10 sec, gradually extend the standing time to 3-5 min/time, rest 3 min. Repeat for three times. Step training: step training, 3-5 min/time, rest for 3 min. Repeat for three times. (iv) Walking training: lower limb muscle strength ≥ grade 3, walk 20 to 30 m, rest for 3 min. Repeat for three times. If the patient feels tired while walking, rest at any time. (v) Up and down the stairs training: on the healthy side hand grasp the handrail, the healthy side lower limb first, the affected lower limb again; next: the healthy side hand grasp the handrail, the healthy side lower limb first, the affected side lower limb again. Step by step until the patient can climb up and down stairs independently.

The placement of good limbs can be carried out at any time, and other rehabilitation activities can be selected according to the patient’s condition and the muscle strength of hemiplegic side limbs. Adequate explanation and demonstration should be given before new rehabilitation activities to eliminate the patient’s fear. The first rehabilitation activity of the day was carried out jointly by the rehabilitation technician and the stroke health manager, and the rest was carried out by the stroke health manager.

3.5.2Control group. Routine early rehabilitation, rehabilitation content is the same as the experimental group. In 24 h after the condition is stable, start to recover, stroke manager to explain the method of early out of bed activities, according to the patient’s condition of sitting, standing and walking and other aspects of guidance, step by step, patient tolerance is appropriate, but do not emphasize the beginning of the patient out of bed activities and each out of bed activity time and frequency.

3.6 Observation indicatorsNIHSS scores were evaluated by stroke managers at discharge and inpatient nursing service satisfaction was completed.

3.7 Statistical methodsSPSS 23.0 software was used for data analysis. The measurement data (NIHSS score and nursing service satisfaction) fit skewness distribution, represented by median (upper quartile, lower quartile) M (P25, P75), and nonparametric test was used for rank sum test of group samples.P<0.05 was considered as statistically significant difference.

4.1 Comparison of scores of daily living between the two groupsAfter intervention, the neurological deficit of the experimental group was lighter than that of the control group, indicating that personalized ultra-early limb function rehabilitation promoted the neurological recovery of patients, as shown in Table 4.

Table 4 Comparison of BI index score between the two groups M (P25, P75)(min, n=33)

4.2 Comparison of nursing service satisfaction scores between the two groupsWhen patients were discharged, the nursing service satisfaction of the experimental group was higher than that of the control group, and the difference was statistically significant, indicating that personalized ultra-early limb function rehabilitation improved patients’ satisfaction with nursing services, as shown in Table 5.

Table 5 Comparison of nursing service satisfaction score between the two groups M (P25, P75) (points, n=33)

5.1 Personalized ultra-early limb function rehabilitation promotes neurological function recoveryTable 4 shows that at discharge, the NIHSS score of the experimental group was 2 (1, 3), and that of the control group was 3 (2, 6). The neurological deficit of the experimental group was lighter than that of the control group, indicating that the neurological recovery of the experimental group was better than that of the control group after personalized ultra-early limb function rehabilitation. The results show that personalized ultra-early limb function rehabilitation can promote the recovery of nerve function in stroke patients with hemiplegia. Rehabilitation training can quickly and effectively improve the focal brain tissue and keep the excitability of nerve cells in the system, make brain lesion and its surrounding brain tissue remnants of the synaptic reorganization of brain cells activated or compensatory, forming a series of new neural pathways, thereby significantly promote restoration of the ischemic stroke patients after recovery of neurological function, greatly improve the cerebrovascular disease sequelae[15]. Fan Jiulinetal.[16-17]believed that early rehabilitation therapy for stroke can effectively reduce the intracranial residual volume of cerebral infarction in patients with ischemic stroke, improve peripheral nerve function, and promote the clinical recovery of motor coordination function and cognitive memory function. The earlier the rehabilitation admission time, the longer the treatment intensity and duration, the better the functional prognosis of hemiplegic limbs, the lower the mortality and re-hospitalization rate, and the shorter the hospital stay. The prospective studies by domestic scholars Jin Huijuanetal.[18-19]also suggest that the ultra-early phase rehabilitation training method can obviously and effectively enhance the body functions of the body for cerebral apoplexy patients, significantly improve the patients quality of life, get a relatively good prognosis in patients with post stroke treatment has a very important significance, consistent with the results of this study. In ischemic stroke hemiplegia after 24 h for personalized and ultra-early limb function in patients with hemiplegia rehabilitation, is conducive to the whole brain blood perfusion of brain cortex in ischemia artery reconstruction and collateral circulation function of ischemic brain regions to establish, from clinical can help improve the damaged brain neural function in patients with ischemic cerebral apoplexy hemiplegia[20]. Multi-disciplinary team cooperation, timely and dynamic adjustment of rehabilitation program, from simple to difficult, step by step personalized rehabilitation care for patients, patients more easily accept and tolerate. Every time to participate in rehabilitation nursing activity patients must have a rehabilitation professionals take care of the side to give guidance and supervision, guarantee the realization of patients every activity effect of rehabilitation therapy effectiveness, patients should be able to perceive at any time the dynamic change of the various body functions themselves, enhance their rehabilitation nursing work confidence, promote patients recovery of body function, improve patients’ daily living ability, so that they can adapt to return to work and family and integrate into society more quickly and better[21-22].

5.2 Personalized ultra-early limb function rehabilitation can improve nursing service satisfaction of inpatientsTable 5 shows that the nursing service satisfaction of the experimental group is better than that of the control group, indicating that personalized ultra-early limb function rehabilitation improves the nursing service satisfaction of stroke patients with hemiplegia. In patients with personalized ultra-early limb function training and rehabilitation training before, in the process, after the end of training timely ask each patient’s body special feelings, in all, patients can fully tolerate the premise of professional and effective comprehensive functional rehabilitation and guidance, the patient’s performance is: negative mood reduction. Personalized ultra-early rehabilitation, patients are in the early stages of the disease, patients could not immersed in the disease of sadness, just in time to get the attention of the multidisciplinary collaborative team ultra-early rehabilitation of limb function, and patients have a lot of opportunities and time to talk to the team members, timely release the anxiety and trepidation; even if patients have negative emotions after the disease, they can also get timely guidance from the team to get rid of the negative emotions. Appropriate aerobic exercise can promote the secretion of dopamine and adrenaline, and personalized ultra-early rehabilitation can bring physiological pleasure to patients. The confidence of overcoming the disease is increased. In the process of personalized ultra-early limb function rehabilitation, patients have gained from each rehabilitation, and the limb function is gradually improved within the visible range; during the contact with the team, I got more guidance, encouragement and rehabilitation skills from the medical staff, established a good nurse-patient relationship, improved patients’ compliance[21]and enhanced patients’ confidence in overcoming the disease. In the process of daily rehabilitation guidance, most of the inpatients and nursing staff, medical staff keep actively communication, often thanks to the medical personnel, emotional state also gradually by worries about disease into rational face and positive face, not only improving the patients psychological status at the time of admission, it also greatly helps us to improve the harmonious relationship between clinical care and improve the satisfaction of the majority of patients with nursing services during hospitalization[23].

In conclusion, personalized ultra-early limb function rehabilitation can effectively promote the recovery of neurological function, improve the limb function and improve the daily activity ability of patients with hemiplegia after ischemic stroke. Personalized ultra-early limb function rehabilitation can also effectively improve the nursing service satisfaction of inpatients, so it has high application value and is worth promoting in clinical application.