Flaccid-stage exercise therapy

1. Flaccid Stage

1. Duration: days, weeks, or even longer.
2. Main Symptoms: Muscle relaxation, low muscle tone, inability to perform voluntary movements, and the affected limb not being able to resist gravity.
3. Rehabilitation Goal: The primary goal is to prevent secondary (additional) damage and prepare for active functional training.

2. Key Problems in Patients in the Flaccid Stage

1. Muscle relaxation.
2. Low muscle tone.
3. Lack of voluntary movement.

3. Training Goals for Flaccid-Stage Patients

1. Prevent the onset of muscle spasms.
2. Prevent the development of joint contracture deformities.
3. Prevent complications and strengthen the prevention of secondary damage.
4. Induce normal movement patterns and control capabilities in the affected limb.

4. Training Plan for Flaccid Stage Patients

A. Proper Limb Positioning

In the acute stage, patients spend most of their time in bed, making proper bed positioning crucial. Poor positioning can exacerbate spasms and cause severe joint contractures. Proper bed positioning during the acute stage is vital for successful rehabilitation.

Proper Positioning Methods:

1. Supine Position: The correct supine position is similar to the flaccid stage position (see Figure 4-1-14). Avoid placing objects under the patient’s feet to prevent unnecessary extensor tension. The supine position is prone to strong abnormal reflexes, leading to extensor spasms and increasing the risk of bedsores at the sacral, heel, and outer ankle areas. Therefore, prolonged use of this position is not recommended. Patients should learn to rest in a side-lying position as soon as possible.

1. Healthy Side-Lying Position: This involves lying on the healthy side. The affected upper limb should be extended forward, with the elbow joint supported by a soft pillow placed in front of the chest. The affected lower limb should be naturally semi-flexed and placed on a pillow. To prevent the patient from rolling back due to poor trunk stability, place a soft pillow behind the patient to help maintain the side-lying position.

1. Affected Side-Lying Position: This is the most suitable position for hemiplegic patients, increasing sensory input to the affected trunk, providing slow stretching of the trunk muscles, and relieving spasms. The healthy upper limb can move freely. While initially uncomfortable, this position helps prevent limb spasms.

1. Sitting Position in Bed: Avoid semi-reclined sitting, which increases unnecessary trunk flexion with lower limb extension. Instead, choose the optimal sitting position (Figure 4-1-18), with the hips flexed nearly at a right angle, the spine extended, and the back supported by enough pillows to achieve an upright sitting position. The head should be unsupported to encourage active head control, with a table in front for the patient to rest their crossed arms on, countering trunk flexion. Prolonged sitting should be avoided to prevent sliding into a semi-reclined position, which can increase extensor tension.

B. Bed Position Transfer Training

Prolonged maintenance of any position can lead to secondary injuries, such as joint contractures and pressure sores. Therefore, changing positions regularly is essential to prevent joint contractures and pressure sores.

1. Passive Turning to the Healthy Side: Rotate the upper torso first, followed by the lower torso. Place one hand under the neck and the other around the affected shoulder blade, turning the head and upper torso into a side-lying position. Then place one hand on the affected pelvis and the other behind the affected knee, rotating and positioning the affected lower limb naturally semi-flexed.
2. Passive Turning to the Affected Side: Position the affected upper limb in 90° abduction, then have the patient turn towards the affected side. If the patient is comatose or weak, assist with a method similar to turning to the healthy side.

C. Active Position Transfers

1. Cross-Arm Lift Training: The patient lies on their back with fingers interlaced, ensuring the thumb of the affected hand is over the thumb of the healthy hand. The healthy arm leads the affected arm in an elbow extension lift across the chest, returning to rest on the abdomen. This process is repeated, ensuring scapular protraction and elbow extension and allowing the arms to lift overhead.
2. Cross-Arm Swing Training: Building on the previous exercise, this involves lifting the arms and then swinging them to the left and right. The swinging motion should be moderate in speed but gradually increase in range, incorporating trunk movement.
3. Leg Lift Assistance Using the Healthy Limb: The patient lies on their back, inserting the healthy foot under the affected knee, extending along the affected leg, and placing the affected foot on top of the healthy foot. The patient uses the healthy limb to lift the affected leg as high as possible without bending it, then slowly lowers it back to the bed. This is repeated multiple times.
4. “Bridge” Exercise: The patient lies on their back with arms extended at their sides, hips and knees flexed, and feet flat on the bed. The patient is instructed to lift the pelvis, maintain a horizontal position, and hold before slowly lowering (double bridge exercise). Initially, the therapist can stimulate the affected gluteal muscles with light taps to aid in hip extension. As control improves, the difficulty can be increased by lifting the healthy leg off the bed or placing it on the affected leg, performing the bridge exercise with the affected leg alone (single bridge exercise).

D. Passive Movements

Passive joint movements are essential for patients who are comatose or unable to perform active movements. They help prevent joint contractures and deformities, provide early correct movement sensation, and maintain the cortical “memory” of movement.

Key Points for Passive Limb Movements:

1. Perform passive movements within the normal range of joint motion; avoid forcing movements if the patient experiences pain.
2. Fully stabilize the proximal joint of the moving joint to prevent compensatory movements.
3. Movements should be slow, gentle, and rhythmic to avoid soft tissue injuries from rough handling.
4.  Pay special attention to joints prone to or already deformed.
5. Movement should proceed from proximal to distal joints, with each joint moving in all directions. Perform 10–15 repetitions of each movement twice daily.
6.  Perform exercises on both sides, starting with the healthy side, then the affected side.

 E. Neuromuscular Facilitation Techniques

Active movements or resistance exercises of the healthy limb can induce a central facilitation response, leading to cooperative movements and muscle contractions in the affected side. Excitatory facilitation techniques can also be used to increase the tone of flaccid muscle groups, promoting contractions in weak muscles.

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