朱姝,楊禮慶
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自身肌力標(biāo)準(zhǔn)指導(dǎo)功能訓(xùn)練在全膝關(guān)節(jié)置換術(shù)后早期康復(fù)中的應(yīng)用
朱姝,楊禮慶
[摘要]目的觀察自身肌力標(biāo)準(zhǔn)指導(dǎo)功能訓(xùn)練在全膝關(guān)節(jié)置換術(shù)(TKA)后早期臨床康復(fù)訓(xùn)練中的效果。方法2014年9月~2015年9月在本科室進(jìn)行單側(cè)TKA后患者62例,隨機(jī)分為實(shí)驗(yàn)組(n=31)和對(duì)照組(n=31)。對(duì)照組給予臨床常規(guī)的康復(fù)綜合訓(xùn)練,實(shí)驗(yàn)組給予自身肌力標(biāo)準(zhǔn)指導(dǎo)下的康復(fù)綜合訓(xùn)練。比較術(shù)后7d膝關(guān)節(jié)腫脹、疼痛程度,術(shù)后7d、15d肌力情況,術(shù)后15d膝關(guān)節(jié)活動(dòng)度、美國膝關(guān)節(jié)協(xié)會(huì)評(píng)分(KSS)以及術(shù)后住院時(shí)間。結(jié)果兩組術(shù)前各項(xiàng)評(píng)分均無顯著性差異(t<0.960,P>0.05),術(shù)后均明顯提高(t>3.470,P<0.01)。術(shù)后7d,兩組視覺模擬評(píng)分無顯著性差異(t=1.800,P=0.077),患膝髕骨中點(diǎn)和腓腸肌最粗點(diǎn)的周徑差無顯著性差異(t=0.840,P=0.404)。術(shù)后7d、15d,實(shí)驗(yàn)組股四頭肌肌力評(píng)分均高于對(duì)照組(t>2.280,P<0.05)。術(shù)后15d,兩組膝關(guān)節(jié)活動(dòng)度、KSS膝評(píng)分均無顯著性差異(t>0.850,P>0.05);實(shí)驗(yàn)組KSS功能評(píng)分顯著高于對(duì)照組(t=5.870,P<0.001)。實(shí)驗(yàn)組術(shù)后住院時(shí)間明顯短于對(duì)照組(t=7.65,P<0.01)。結(jié)論自身肌力標(biāo)準(zhǔn)指導(dǎo)的功能訓(xùn)練能增加TKA后下肢肌力和膝關(guān)節(jié)功能,縮短住院天數(shù)。
[關(guān)鍵詞]全膝關(guān)節(jié)置換術(shù);肌力標(biāo)準(zhǔn);功能訓(xùn)練;術(shù)后康復(fù)
[本文著錄格式]朱姝,楊禮慶.自身肌力標(biāo)準(zhǔn)指導(dǎo)功能訓(xùn)練在全膝關(guān)節(jié)置換術(shù)后早期康復(fù)中的應(yīng)用[J].中國康復(fù)理論與實(shí)踐,2016,22(6):709-714.
CITED AS:Zhu S,Yang LQ.Functional exercise guided by self muscle strength standard for early rehabilitation after total knee arthroplasty[J].Zhongguo Kangfu Lilun Yu Shijian,2016,22(6):709-714.
人工全膝關(guān)節(jié)置換術(shù)(total knee arthroplasty,TKA)是用于治療嚴(yán)重膝關(guān)節(jié)疾病的有效方法,其術(shù)后療效與康復(fù)治療工作密不可分[1-2]。術(shù)后早期康復(fù)訓(xùn)練包括肌力訓(xùn)練、關(guān)節(jié)活動(dòng)度訓(xùn)練及站立、行走等運(yùn)動(dòng)[3-4]。肌力是各種康復(fù)運(yùn)動(dòng)訓(xùn)練的基礎(chǔ),因個(gè)體日常運(yùn)動(dòng)量和負(fù)荷相差較大,下肢肌力的個(gè)體化差異明顯,在多種康復(fù)訓(xùn)練中無法確定合理的肌力運(yùn)動(dòng)標(biāo)準(zhǔn)[3-7]。目前關(guān)于肌力訓(xùn)練領(lǐng)域的研究仍主要是如何促進(jìn)肌力快速恢復(fù)到自身健肢水平,如神經(jīng)電刺激療法、水療法、等速肌力訓(xùn)練等[8-11],而肌力定性、半定量和定量評(píng)估也多用于疾病嚴(yán)重程度和康復(fù)效果的評(píng)價(jià)[12-13]。在臨床康復(fù)工作中,鮮有以定量的肌力運(yùn)動(dòng)標(biāo)準(zhǔn)來指導(dǎo)功能訓(xùn)練的研究報(bào)道。
我們根據(jù)人體正常行走時(shí)對(duì)稱負(fù)重的要求,結(jié)合康復(fù)訓(xùn)練形式[3-5],以健肢肌力為多種康復(fù)訓(xùn)練中患肢的肌力標(biāo)準(zhǔn),開展自身肌力標(biāo)準(zhǔn)指導(dǎo)功能訓(xùn)練的臨床實(shí)用性研究。
1.1一般資料
2014年9月~2015年9月在本科室進(jìn)行單側(cè)TKA患者62例,按照隨機(jī)數(shù)字表法分成兩組,每組31例。全部患者術(shù)前均有一定的生活自理能力。兩組患者在性別、年齡、病程、側(cè)別、病因、生活自理情況等方面無顯著性差異(P>0.05)。見表1。
1.2方法
1.2.1術(shù)前處理
術(shù)前所有患者均予康復(fù)指導(dǎo)及短期訓(xùn)練。
實(shí)驗(yàn)組患者每天訓(xùn)練前口服鎮(zhèn)痛藥物,并按以下程序進(jìn)行股四頭肌和腘繩肌肌力測(cè)定。
①健肢測(cè)量值確定為患肢完全康復(fù)(S完全)的肌力標(biāo)準(zhǔn);患肢測(cè)量值確定為患肢可扶拐站立并逐步負(fù)重訓(xùn)練(S站立)的肌力標(biāo)準(zhǔn)。
表1 一般資料比較
②患者以日常習(xí)慣姿態(tài)站立于改裝的單肢稱重測(cè)量臺(tái)上,分別測(cè)定健側(cè)、患側(cè)下肢的承重量,計(jì)算“下肢負(fù)重比”。健康人群下肢負(fù)重比的標(biāo)準(zhǔn)接近0.5:0.5。
③患者拄雙腋拐或使用助力器,進(jìn)行患肢抬起、健肢獨(dú)立負(fù)重的行走訓(xùn)練,記錄30min內(nèi)雙上肢勞累無力支持的時(shí)間,確定為初始拄拐訓(xùn)練的最長(zhǎng)安全時(shí)間(T初次)。
④而后患者去雙拐,繼續(xù)保持患肢抬起、健肢獨(dú)立負(fù)重姿勢(shì)站立,至健肢勞累乏力時(shí)測(cè)量健肢肌力,確定為患肢可開始去拐、完全負(fù)重行走(S去拐)的肌力標(biāo)準(zhǔn)。
⑤休息3~5min后,患者再次拄雙腋拐,保持患肢抬起、健肢獨(dú)立負(fù)重姿勢(shì)站立,至全身勞累乏力時(shí)測(cè)量健肢肌力,確定為患肢可開始扶拐行走并逐步完全負(fù)重訓(xùn)練(S行走)的肌力標(biāo)準(zhǔn)。
⑥肌力測(cè)定:患者平臥位,參照術(shù)后下肢肌力抗阻訓(xùn)練方式,測(cè)量膝關(guān)節(jié)屈曲45°時(shí)等長(zhǎng)伸、曲膝的最大肌力,以穩(wěn)定10s為準(zhǔn);每次測(cè)量10遍取平均值,分別代表股四頭肌和腘繩肌肌力。
⑦取每日測(cè)量值的平均值作為肌力標(biāo)準(zhǔn),代表術(shù)后站立、負(fù)重、行走訓(xùn)練時(shí)患肢所需先達(dá)到的肌力,以保障運(yùn)動(dòng)安全。針對(duì)每個(gè)患者的肌力測(cè)定情況,預(yù)估其各種肌力訓(xùn)練所需要的時(shí)間和強(qiáng)度,進(jìn)行臨床路徑表格式管理。運(yùn)動(dòng)訓(xùn)練指導(dǎo)時(shí)以股四頭肌肌力為主,并保證同期的患肢腘繩肌肌力滿足屈/伸肌(H/Q)在50%~80%。
1.2.2手術(shù)及術(shù)后處理
62例患者由同一手術(shù)組行TKA,植入非限制性全髁型假體,未行髕骨置換。術(shù)中被動(dòng)行膝關(guān)節(jié)活動(dòng)度為0°~90°??祻?fù)訓(xùn)練期間予口服塞來昔布止痛。
1.2.3術(shù)后早期康復(fù)管理
全麻清醒后即開始康復(fù)訓(xùn)練。術(shù)后第1天復(fù)查X線片顯示膝關(guān)節(jié)對(duì)位對(duì)線良好,均嘗試下床扶拐站立活動(dòng),并隨著體力、肌力改善,增加運(yùn)動(dòng)訓(xùn)練的方式和強(qiáng)度。關(guān)節(jié)活動(dòng)度訓(xùn)練均進(jìn)行主被動(dòng)屈伸膝關(guān)節(jié)、不同體位直腿抬高訓(xùn)練、抗阻力屈伸膝訓(xùn)練、深蹲和抱膝訓(xùn)練等,以改善膝關(guān)節(jié)活動(dòng)功能。肌力訓(xùn)練包括主動(dòng)屈伸踝關(guān)節(jié)運(yùn)動(dòng)和股四頭肌、腘繩肌的定位收縮訓(xùn)練,直腿抬高訓(xùn)練、各種抗阻訓(xùn)練和多角度等長(zhǎng)與等張收縮交替運(yùn)動(dòng)、站立負(fù)重、輔助步行及上下樓梯等,以提高肌力達(dá)到恢復(fù)站立、行走等目的。兩組患者康復(fù)訓(xùn)練方式相同,在肌力訓(xùn)練中的評(píng)估和指導(dǎo)方法方面有如下區(qū)別。
對(duì)照組肌力訓(xùn)練的強(qiáng)度遵循由小到大,循序漸進(jìn)的原則,根據(jù)患者主觀意愿調(diào)整,出現(xiàn)頭暈、勞累和患膝脹痛時(shí)立即停止。
實(shí)驗(yàn)組訓(xùn)練要求如下。①每天測(cè)量患肢股四頭肌和腘繩肌肌力,合理安排訓(xùn)練形式。②早期肌力訓(xùn)練以慢速抗阻訓(xùn)練為主,訓(xùn)練時(shí)強(qiáng)調(diào)中高等強(qiáng)度;參照S站立或S行走標(biāo)準(zhǔn),結(jié)合本次抗阻訓(xùn)練完成的難易度,設(shè)定下次訓(xùn)練負(fù)荷,以期快速達(dá)標(biāo)后站立、行走運(yùn)動(dòng)。③在T初次時(shí)間內(nèi)進(jìn)行輔助站立、行走訓(xùn)練;以肌力測(cè)定情況來決定負(fù)重程度,保證訓(xùn)練順利、安全。④肌力測(cè)定達(dá)標(biāo)后,可明顯增加站立、行走訓(xùn)練的時(shí)間和強(qiáng)度。⑤若患肢功能良好,術(shù)前測(cè)定的S站立可大于S行走標(biāo)準(zhǔn),術(shù)后肌力滿足S行走標(biāo)準(zhǔn),即可同時(shí)進(jìn)行負(fù)重的站立和行走訓(xùn)練。
1.3療效評(píng)判標(biāo)準(zhǔn)
觀察指標(biāo)包括術(shù)后7d患膝靜息時(shí)疼痛、患膝腫脹情況,術(shù)后7d和15d的股四頭肌肌力,術(shù)后15d的膝關(guān)節(jié)活動(dòng)度、膝評(píng)分、功能評(píng)分,以及術(shù)后住院天數(shù)。疼痛采用視覺模擬評(píng)分(Visual Analogue Score,VAS)[14];根據(jù)美國膝關(guān)節(jié)協(xié)會(huì)評(píng)分[15](Keen Society Score,KSS)標(biāo)準(zhǔn)進(jìn)行患膝關(guān)節(jié)的膝評(píng)分和功能評(píng)分;兩組肌力評(píng)定對(duì)比采用徒手肌力檢查(Manual Muscle Test,MMT)分級(jí)標(biāo)準(zhǔn)之Kendall百分比法完成[3];患膝術(shù)后腫脹情況采用皮尺測(cè)量髕骨中點(diǎn)、腓腸肌最粗點(diǎn)的周徑,計(jì)算周徑差;測(cè)量患膝關(guān)節(jié)主動(dòng)活動(dòng)范圍[16]。評(píng)定采用盲法,均由同一康復(fù)評(píng)定醫(yī)師完成。
實(shí)驗(yàn)組記錄6項(xiàng)指標(biāo):患肢S站立、S行走、S去拐以及S完全的肌力標(biāo)準(zhǔn);T初次時(shí)間;雙側(cè)“下肢負(fù)重比”。
1.4統(tǒng)計(jì)學(xué)分析
采用SPSS 13.0軟件進(jìn)行統(tǒng)計(jì)學(xué)分析。計(jì)量資料采用(±s)表示,兩組間均值比較采用獨(dú)立樣本t檢驗(yàn),兩兩比較使用配對(duì)t檢驗(yàn)。顯著性水平α=0.05。
兩組患者術(shù)后均沒有出現(xiàn)關(guān)節(jié)腔積血、切口裂開、下肢深靜脈血栓形成等嚴(yán)重并發(fā)癥。術(shù)后7d,大多數(shù)患者能輔助站立行走。兩組術(shù)后住院天數(shù)實(shí)驗(yàn)組(11.89±1.97)d,對(duì)照組(16.21±2.45)d(t=7.65,P<0.01)。
2.1實(shí)驗(yàn)組6項(xiàng)指標(biāo)
患者自身的健患下肢負(fù)重比大部分在0.52/0.48~0.67/0.33之間,少部分病程較長(zhǎng)患者可達(dá)0.75/0.25。肌力測(cè)序結(jié)果中62%患者的患肢S站立<S行走<S去拐<S完全標(biāo)準(zhǔn),38%患者患肢S行走<S站立<S去拐<S完全標(biāo)準(zhǔn),極少數(shù)患者患肢S行走<S去拐<S站立<S完全標(biāo)準(zhǔn);T初次時(shí)間在85~930s,大部分可超過3min。
2.2疼痛
兩組術(shù)前患膝靜息VAS評(píng)分無顯著性差異(P>0.05)。兩組在術(shù)后7d時(shí),患膝靜息VAS評(píng)分顯著低于術(shù)前(P<0.001),但兩組間比較無顯著性差異(P>0.05)。見表2。
2.3腫脹情況
兩組術(shù)前、術(shù)后7d患膝髕骨中點(diǎn)和腓腸肌最粗點(diǎn)的周徑差無顯著性差異(P<0.05)。見表3。
2.4股四頭肌肌力
兩組術(shù)前股四頭肌肌力評(píng)分無顯著性差異(P>0.05),術(shù)后各組均提高,術(shù)后15d最為顯著(P<0.001),且術(shù)后7d、15d實(shí)驗(yàn)組均高于對(duì)照組(P<0.05)。見表4。
2.5膝關(guān)節(jié)活動(dòng)度
兩組術(shù)前膝關(guān)節(jié)活動(dòng)度無顯著性差異(P>0.05)。術(shù)后15d兩組均顯著增大(P<0.001),但兩組間無顯著性差異(P>0.05)。見表5。
2.6膝評(píng)分
兩組術(shù)前膝評(píng)分無顯著性差異(P>0.05)。術(shù)后15d兩組均顯著增大(P<0.001),但兩組間無顯著性差異(P>0.05)。見表6。
2.7功能評(píng)分
兩組術(shù)前功能評(píng)分無顯著性差異(P>0.05)。術(shù)后15d兩組均顯著增大(P<0.001),實(shí)驗(yàn)組顯著高于對(duì)照組(P<0.05)。見表7。
表2 兩組術(shù)前、術(shù)后7d患膝靜息VAS評(píng)分
表3 兩組術(shù)前、術(shù)后7d膝關(guān)節(jié)周徑差(cm)
表4 兩組MMT分級(jí)標(biāo)準(zhǔn)之患肢股四頭肌Kendall肌力評(píng)分
表5 兩組術(shù)前、術(shù)后15d膝關(guān)節(jié)活動(dòng)度(°)
表6 兩組術(shù)前、術(shù)后15d膝評(píng)分
表7 兩組術(shù)前、術(shù)后15d功能評(píng)分
科學(xué)規(guī)范的康復(fù)訓(xùn)練對(duì)患者TKA的預(yù)后具有重要作用[17-19]。肌力訓(xùn)練和關(guān)節(jié)活動(dòng)度訓(xùn)練是早期康復(fù)訓(xùn)練的重點(diǎn)和其他訓(xùn)練的基礎(chǔ),而站立、行走運(yùn)動(dòng)是康復(fù)訓(xùn)練的目標(biāo),也是肌力和關(guān)節(jié)活動(dòng)度的一種綜合訓(xùn)練形式[3,19-20]。準(zhǔn)確的效果評(píng)估和合理的訓(xùn)練指導(dǎo)安排則是良好康復(fù)效果的保證[5,19-20]。在關(guān)節(jié)活動(dòng)訓(xùn)練中,根據(jù)長(zhǎng)期有效活動(dòng)度和并發(fā)癥的評(píng)價(jià)[21],目前持續(xù)被動(dòng)運(yùn)動(dòng)(continuous passive motion,CPM)僅使用于患肢無力至生活自理受限的患者,本研究采用被廣泛推薦的主動(dòng)關(guān)節(jié)運(yùn)動(dòng)訓(xùn)練模式[19-21]。
肌力訓(xùn)練主要采用直腿抬高、多角度抗阻訓(xùn)練等運(yùn)動(dòng)療法,而評(píng)價(jià)其訓(xùn)練效果的臨床肌力評(píng)估主要是定性或半定量的MMT,檢查結(jié)果較為籠統(tǒng),對(duì)康復(fù)訓(xùn)練的指導(dǎo)意義不強(qiáng)[3-7,12-13]。良好的肌力是關(guān)節(jié)穩(wěn)定、功能恢復(fù)、行走正常的保證[22-23]。因此,國內(nèi)外一直在廣泛開展以促進(jìn)肌力快速康復(fù)為目標(biāo)的基礎(chǔ)或臨床研究,如系統(tǒng)康復(fù)運(yùn)動(dòng)訓(xùn)練、物理因子療法等,尤其是近年來發(fā)展了等速技術(shù)[24-26],后者可進(jìn)行實(shí)時(shí)的定量肌力訓(xùn)練和效果評(píng)估。但由于患肢長(zhǎng)期廢用性萎縮而缺乏參考性,這些康復(fù)方法均以肌力恢復(fù)至健肢水平為標(biāo)準(zhǔn),對(duì)輔助站立、行走等運(yùn)動(dòng)訓(xùn)練仍未能給出有效的肌力參考標(biāo)準(zhǔn),而且康復(fù)設(shè)備昂貴,操作復(fù)雜,臨床普及較為困難[12-13,27]。
患者TKA術(shù)后肌力恢復(fù)情況各不相同,康復(fù)訓(xùn)練效果的個(gè)體化差異明顯[6-7,12-13,20,23,28-30]。康復(fù)訓(xùn)練中合理的肌力運(yùn)動(dòng)參考標(biāo)準(zhǔn),有助于對(duì)多種訓(xùn)練方式和訓(xùn)練負(fù)荷進(jìn)行明確的指導(dǎo),既獲得快速康復(fù)的效果,又能避免運(yùn)動(dòng)性損傷和長(zhǎng)期緩慢訓(xùn)練的無效性。
我們根據(jù)對(duì)稱負(fù)重行走的康復(fù)訓(xùn)練基本要求和主觀康復(fù)運(yùn)動(dòng)強(qiáng)度(Rating of Perceived Exertion,RPE)法則[3-5,31],進(jìn)行健肢的康復(fù)模擬訓(xùn)練,測(cè)量其下肢具有代表意義的股四頭肌和腘繩肌[32-33]健側(cè)肌力,確定為患肢各種運(yùn)動(dòng)時(shí)所需要的肌力標(biāo)準(zhǔn),開展了自身肌力標(biāo)準(zhǔn)指導(dǎo)的功能訓(xùn)練在TKA術(shù)后康復(fù)中的臨床實(shí)用性研究。
正常站立和行走需要雙下肢具有對(duì)稱的支撐負(fù)重和運(yùn)動(dòng)功能,健肢的狀況也代表了個(gè)體化運(yùn)動(dòng)時(shí)單側(cè)下肢所需具備的肌力條件(S完全)。當(dāng)健肢活動(dòng)至疲勞乏力、僅能維持站立時(shí),所測(cè)肌力也是患肢經(jīng)康復(fù)訓(xùn)練達(dá)到正常站立、負(fù)重、行走的最低肌力標(biāo)準(zhǔn)(S去拐)。而助行器和雙拐的使用可以減輕下肢的負(fù)重,在早期康復(fù)過程中,我們可以測(cè)量這種輔助狀態(tài)下健肢疲勞站立所需的肌力,作為輔助站立、行走的肌力標(biāo)準(zhǔn)(S行走)。當(dāng)然這種運(yùn)動(dòng)狀態(tài)模擬還需要考慮體力情況和疲勞程度,我們參照RPE法則[31],在“患者主觀感覺很費(fèi)力”時(shí)所測(cè)量的肌力確定為滿足運(yùn)動(dòng)要求的最低肌力標(biāo)準(zhǔn),也同時(shí)確定了初始拄拐訓(xùn)練的最長(zhǎng)安全時(shí)間,以保證康復(fù)訓(xùn)練的有效性和安全性?;贾男g(shù)前肌力測(cè)定,既代表患肢術(shù)前的肌力狀況,也確定了無助力條件下患肢安全站立的肌力標(biāo)準(zhǔn)(S站立),并可通過與其他肌力標(biāo)準(zhǔn)對(duì)比,預(yù)估術(shù)后患肢恢復(fù)過程中站立、負(fù)重和輔助行走的時(shí)程。下肢負(fù)重比主要是為了判斷患者術(shù)前的患肢承重強(qiáng)度及肌力狀態(tài),預(yù)估術(shù)后訓(xùn)練恢復(fù)的難易度。我們將術(shù)后康復(fù)各時(shí)段的患肢肌力狀況,與術(shù)前個(gè)人下肢負(fù)重比、患肢站立和健肢運(yùn)動(dòng)所確立的各個(gè)肌力標(biāo)準(zhǔn)進(jìn)行對(duì)比,作為參考,綜合判定患肢的恢復(fù)狀態(tài)和下一步主動(dòng)訓(xùn)練時(shí)抗阻和負(fù)重的訓(xùn)練強(qiáng)度。
我們認(rèn)為站立、行走、負(fù)重活動(dòng)在術(shù)后膝關(guān)節(jié)功能康復(fù)中極為重要。依據(jù)肌力標(biāo)準(zhǔn),肌力定量評(píng)估策略進(jìn)一步把部分負(fù)重概念劃分為站立時(shí)部分負(fù)重和行走時(shí)部分負(fù)重兩種形式,再細(xì)致劃分為數(shù)個(gè)階段:站立分為拄拐健肢站立、拄拐患肢部分負(fù)重、拄拐患肢安全站立、拄拐患肢完全負(fù)重,患肢去拐完全負(fù)重站立等階段;行走則分為拄拐健肢行走、拄拐患肢部分負(fù)重、拄拐患肢完全負(fù)重、患肢去拐負(fù)重安全行走、患肢完全負(fù)重行走等階段。這種運(yùn)動(dòng)階段細(xì)分,有利于安全、明確的肌力訓(xùn)練指導(dǎo),可以避免運(yùn)動(dòng)性損傷、促進(jìn)關(guān)節(jié)功能快速康復(fù),滿足了患者對(duì)站立和行走、運(yùn)動(dòng)的需求。
在本研究過程中,我們發(fā)現(xiàn)部分患者病程較長(zhǎng),患肢肌力差,下肢負(fù)重比失衡明顯,站立及行走能力的恢復(fù)緩慢,必要時(shí)可建議出院繼續(xù)康復(fù);由于該方法參考指標(biāo)明確,盡管該部分老年患者的術(shù)后早期恢復(fù)效果不明顯,但治療結(jié)果都可獲得患者及家屬的認(rèn)可,對(duì)出院康復(fù)的指導(dǎo)建議依從性很高,也減輕了非必需的醫(yī)療費(fèi)用。而有些患者日常行走運(yùn)動(dòng)較多,術(shù)前患肢站立肌力即S站立已大于S行走標(biāo)準(zhǔn),術(shù)后患肢肌力下降不明顯,進(jìn)行拄拐站立和行走訓(xùn)練的時(shí)間明顯提前,甚至極少數(shù)患者可以術(shù)后盡早盡可能地恢復(fù)負(fù)重。
本研究結(jié)果表明,TKA患者進(jìn)行自身肌力標(biāo)準(zhǔn)指導(dǎo)的功能訓(xùn)練,較常規(guī)康復(fù)訓(xùn)練組,在肌力和膝關(guān)節(jié)功能方面的康復(fù)效果有明顯提高,住院時(shí)間縮短(P<0.05),而沒有增加患膝疼痛、腫脹等副損傷。
我們體會(huì)到,在臨床工作中這種自身肌力標(biāo)準(zhǔn)指導(dǎo)功能訓(xùn)練的新策略具有易操作、安全性強(qiáng)及指導(dǎo)明確等特點(diǎn),而且經(jīng)濟(jì)實(shí)用,在臨床康復(fù)工作中具有推廣價(jià)值。但本研究仍有一定的局限性,如適宜于具有一定生活自理能力的患者,而無法指導(dǎo)雙膝關(guān)節(jié)置換或長(zhǎng)期臥床的患者,而且由于本次研究中病例數(shù)量尚少及研究時(shí)間較短,缺乏大樣本的長(zhǎng)期隨機(jī)對(duì)照實(shí)驗(yàn),對(duì)于該治療方法的優(yōu)缺點(diǎn),還需進(jìn)一步的研究觀察。
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Functional Exercise Guided by Self Muscle Strength Standard for Early Rehabilitation after Total Knee Arthroplasty
ZHU Shu,YANG Li-qing
Department of Spine and Joint,Shengjing Hospital of China Medical University,Shenyang,Liaoning 110004,China
Correspondence to YANG Li-qing.E-mail:yanglq@sj-hospital.org
Abstract:Objective To observe the effect of functional exercise guided by self muscle strength in early rehabilitation on patients after total knee arthroplasty(TKA).Methods From September,2014 to September,2015,62 patients after TKA were randomly divided into experimental group(n=31)and control group(n=31).The control group received conventional rehabilitation training,while the experimental group received rehabilitation training under the guidance of their own muscle strength standard.The degrees of swelling and pain seven days after TKA;the muscle strength seven and 15 days after TKA;the range of motion(ROM),the Keen Society Score(KSS)15 days after TKA;and the postoperative hospital stay were compared.Results There was no significant difference in all the indexes above between two groups before TKA(t<0.960,P>0.05),and all of them improved after TKA(t>3.470,P<0.01).There was no significant difference in the degrees of swelling(t=1.800,P=0.077)and pain(t=0.840,P=0.404)seven days after TKA.The score of quadriceps strength was higher in the experiment group than in the control group(t>2.280,P<0.05)seven and 15 days after TKA.There was no significant difference in the ROM of the knee and the score of knee between two groups(t>0.850,P>0.05),and the functional score was higher in the experiment group than in the control group(t=5.870,P<0.001)15 days after TKA.The postoperative hospital stay was shorter in the experiment group(t=7.65,P<0.01).Conclusion Functional exercise under the guidance of their own muscle strength standard could contribute to the improvement of postoperative muscle strength and knee joint function,and shorten the hospitalization stay.
Key words:total knee arthroplasty;muscle strength standard;functional exercise;postoperative rehabilitation
[中圖分類號(hào)]R687.4
[文獻(xiàn)標(biāo)識(shí)碼]A
[文章編號(hào)]1006-9771(2016)06-0709-06
DOI:10.3969/j.issn.1006-9771.2016.06.018
作者單位:中國醫(yī)科大學(xué)附屬盛京醫(yī)院骨科,遼寧沈陽市110004。
作者簡(jiǎn)介:朱姝(1990-),女,漢族,遼寧沈陽市人,碩士研究生,醫(yī)師,主要研究方向:膝、髖關(guān)節(jié)疾病手術(shù)治療及其規(guī)范化康復(fù)治療。通訊作者:楊禮慶(1970-),男,漢族,遼寧沈陽市人,博士,副教授,主要研究方向:人工關(guān)節(jié)外科的基礎(chǔ)和臨床。E-mail:yanglq@sj-hospital.org。
收稿日期:(2016-01-15修回日期:2016-03-28)