全膝关节置换术后的康复干预_英文_

中国临床康复 第10卷 第28期 2006-07-25出版 ChineseJournalofClinicalRehabilitation,July252006Vol.10No.28 LiXue-ping,ChengKai,YuJun-long ·REVIEW· RehabilitationMedicalDepartment, NanjingFirstHospitalAffiliatedto NanjingMedicalUniversity,Nanjing 210006,JiangsuProvince,China LiXue-ping★,Master,Associatechiefphysician,RehabilitationMedical Department,NanjingFirstHospitalAffiliatedtoNanjingMedicalUniver- sity,Nanjing 210006,JiangsuProvince,China Received:2006-01-03 Accepted:2006-01-18 (05-50-8-6422/Y) Abstract BACKGROUND:Withtheimprovementofartificialjointmaterials,con- tinuousconsummationofprothesisdesignandthematurityoftotalkneere- placement(TKR),excellenteffectshasbeenachievedintreatmentofseri- ousrheumatoidarthritis(RA)andosteoarthritiswithTKR.Atpresent,itis generallythoughtinChinaandabroadthatstagedrehabilitativetreatment ofstepbystepshouldbeconductedasearlyaspossibleafterTKR,which canpromotetherecoveryofpatient’skneejointfunction,andenablepa- tientstofreelycarethemselvessoastoenhancetheirqualitiesoflife. OBJECTIVE:ToexplaintherehabilitativetreatmentafterTKRandrele- vantresearches. DATASOURCES:AcomputerbasedsearchofMedlinedatabaseforrel- evantarticlesfromJanuary1998toAugust2005wereconductedwiththe keywordsof“totalkneereplacement,rehabilitation,therapy”andthelan- guagewaslimitedtoEnglish. Meanwhile, Chinesejournalfull-text databaseandWanfangdatabasewereretrievedforrelevantChinesepapers fromJanuary1990toDecember2004withthekeywordsof“totalkneere- placement,rehabilitation,therapy”. STUDYSELECTION:Datawerecheckedinthefirsttrial,accepting criteria:①Items,procedures,processandannouncementsintherehabilita- tivetreatmentafterTKR. ② Retrospectiveinvestigationsaboutspecific cases.Exclusivecriteria:repetitiveresearches. DATAEXTRACTION:Atotalof37literaturesinaccordancewithabove requirementswereretrievedand22repetitiveresearcheswereexcluded. Fifteenarticleswereinaccordancewiththeinclusivecriteria:3werere- viewsaboutTKRandrelevantrehabilitativetreatment,8wereclinicalre- searchesrelatedtorehabilitativetreatmentafterTKR,4wereanalyzingre- searchesonrelevantfactorsofrehabilitativetreatmentafterTKR.Besides, therewere3otherrelevantmonographs. DATASYNTHESIS:Rehabilitativetreatmentwasextremelyimportantto theclinicaleffectsofTKR,whichwasthekeyreasonwhyanticipatedef- fectscouldbeachievedafterTKR.Exerciseforpower,trainingofmotion ofjoint,proprioceptivesensationtrainingandgaittrainingwerethemost importantcontentsofpostoperativerehabilitationtreatment.Comprehensive rehabilitativetrainingwasessentialtomaximumrecoveryofkneejoint functionincludingvariousagonisticmuscletrainingplusextendingand flexingpowerofkneejoint_ continuouspassivetrainingofmotionofknee jointinearlyperiodplusmotionofjoint_ proprioceptivesensationtrainingin ameliorationofmotorcontrollability,posturalrectificationandbalance-keep capabilityandgaittrainingincorrectionofabnormalgait. CONCLUSION:StagedrehabilitativetreatmentofstepbystepafterTKR shouldbeconductedasearlyaspossible,whichisabsolutelyimportantto exerciseforpower,trainingofmotionofjoint,proprioceptivesensation training,gaittrainingandpromotionoffunctionalrecoveryofkneejointsin patients. LiXP, ChengK, YuJL.Rehabilitativeinterventionaftertotalkneereplacement. ZhongguoLinchuangKangfu2006C10(28):190-2(China) [www.zglckf.com] INTRODUCTION Recently, artificialkneejointreplacementisconsideredasthe therapeuticmethodwithexcellenteffects,theachievementratioof whichhasbeenover90%[1]formanyyears.Itisthoughtatpre- sentthatrehabilitativetreatmentshouldbeconductedstepbystep asearlyaspossibleaftertotalkneereplacement(TKR), which playsanunnegligibleroleinfunctionalrecoveryofkneejoint.Gao etal[2] consideredthatalthoughitincreasedthemedicalcostin settingupspecialrehabilitationpersonnel,consummatingmethods ofrehabilitationtrainingandenhancingpatient’strainingdegree, patient’spostoperativemotionofjointwasaugmented, function wasameliorated,qualityoflifeandconfidenceinoperationwere enhanced.Bynow,mainmethodsofrehabilitativetreatmentin- clude:exerciseforpower,exerciseformotionofjoint,propriocep- tivesensationtrainingandgaittraining(GT)etc.Inthisarticle,18 articleswereretrievedincomputer-basedsearchingofrelevantar- ticlesinMedlinedatabasefromJanuary1998toAugust2005,Chi- nesejournalfull-textdatabaseandWanfangdatabasefromJanuary 1990toDecember2004,soastoexplaintherehabilitativetreat- mentafterTKRandrelevantresearches. EXERCISEFORPOWER Thereweremuscularatrophyandmuscleweaknessinmusculus quadricepsfexorisandhamstringmusclestodifferentdegreein patientsbeforeTKR, whichwereinducedbypaininaffected knees,dropsyandlimitationofjointmotion.Strengthofmuscles aroundkneejointwasweakenedandstabilityofjointwasruined bytheimbalanceofpowerbetweenmusculusquadricepsfexoris andhamstringmusclestogetherwithperipheralinjuredtissuesof kneejointscausedbyoperation.Therefore,scholarsbelievedthat exerciseforpowerwastheprocedurethatmostimportantinpost- operativerehabilitation[3],moreover,earlierexerciseforpowernot onlyrecoveredtheperipheralpowerofkneesinpatientsbutalso promotedthebloodcirculationoflowerlimbsandreducedthe thrombosesindeepveins. Trainingmethodsofpowerweremultiform,whilebynowitisac- knowledgedbymostofauthorsthatexerciseforpowershouldbe performedwithoutpain,anddifferenttrainingmethodsshouldbe adoptedaccordingtotherecuperativestatusofpatientsindifferent stages.Generallyspeaking,isometriccontractionexerciseofmus- culusquadricepsfexoriandactivemovementoffemoralarticula- tion,talocruralarticulationandlowerlimbsofuninjuredsideshould beconductedat1-2daysafteroperation.Musclepowershouldbe reinforcedwithoutpainanddropsyincreasing,andstraightlegrais- ingexercisesindorsalposition,pronepositionandstandingposi- tion,progressiveresistanceexerciseshouldbeperformedat3-14 daysafteroperation.At15-21daysafteroperation:itaimsatob- tainingsatisfactorymotionofjoint,musclepower,stayingpowerand balance-keepcapacity.Besidesvariousexercisesinearlierstages, extendingexerciseofendkneescanalsobeconducted. Zhou[4] thoughtthattheratioofpowerbetweenmusculusquadri- cepsfexorisandhamstringmusclesplayedasignificantroleinsta- bilityofkneejoints,whichwasnormalin50%-80%.Theratio decreasedafterTKR. Inpostoperativerehabilitation, besides strengthtrainingofmusculusquadricepsfexoris,strengthofham- stringmusclesshallalsobereinforced,soastoenhancetheEVQ ratioandraisethestabilityofkneejoints.Yanetal[5]considered thatfibersdistributinginobliquepositionofthemedialvastus muscleswereimportantinmaintainingpatellofemoralalignments. Rehabilitativeinterventionaftertotalkneereplacement★ 190 Furthermore,theelectricactivitiesoffibersdistributinginoblique positioninmedialvastusmusclesweresignificantlyhigherthan thoseinlateralmusclesduringmarrowadducting.Thus,straight- legraisingexerciseinmarrowadductingofaffectedlimbsinaffect- edlateralpositionhadremarkabletherapeuticeffectinalternative- lyreinforcingthemusclepoweroffibersdistributinginoblique positionofmedialvastusmuscles.Extendingexerciseofendknees wastheextendingexerciseagainstgravityofgenuflexwithin30°, anditstheoreticalbasiswasthatresearchofelectromyogram (EMG)suggestedthatinthelast30°ofextendingexercise,activi- tiesoffibersdistributinginobliquepositionofmedialvastusmus- cleswereveryactive.Yueetal[6]consideredthatexerciseforpower shallbeperformedbeforeoperation, andtherecoveryofmuscle strengthatthesametimeofpost-operationwasmoresignificant. Inrecentyears,ithasbeenreportedthattherearerehabilitative treatmentwiththeapplicationofisokinetictraininginTKR.Wu[7] thoughtthatinisokinetictraining,speedofmotionwasconstant andresistanceinthemotionmatchedwiththerealstrengthof muscle.Accordinglymusclesborethemaximumresistancealla- longthewholerangeofmotionandproducedthemaximum strengthofmuscle,whichwaseffectiveandsafeinrehabilitative treatmentafterTKR.Xu[8]believedthattherewereimportantsig- nificancesinconductingisokineticmusclestrengthtestbefore TKR.SurfaceEMGandtrainingsystemcouldmacroscopiclyquan- tizatetheelectricactivityofmusclesandevaluatethefunctional statusofmusculationsuchassymmetry, concordant, timeand tiredness,therebyinstructtrainingofmusclesandfunctionalreha- bilitation[9]. TRAININGOFMOTIONOFJOINT Continuouspassivemotionwasthemajortrainingmethod.Mostof theauthorsthoughtthatitshallbeconductedasearlyaspossible suchasonthedayofoperationorthedaynexttoit.Exerciseshall beperformedfromsmallrangewithanincreasingof5°-10°per day,whichenabledthepatient'smotionofkneejointtoreach90° assoonaspossible,andwasbeneficialtothetreatmentofthenext stage.Zhang[10]observed22patients(24knees),whoconducted thecontinuouspassiveexercisefromthe48thhourofpost-operation withaninitiatingangleof0°-30°twiceadayrespectivelyinthe morningandafternoon.Therewasanincreasingof10°eachday withthespeedaccelerating,towhichpatientscouldadapt.Allpa- tientsfunctionallyrecoveredafterTKR,autonomousflexingmotion ofwhichallreached90°-100°, patientscouldstraightento0° withoutjointswellingoraching.Therewerenoonesufferedfrom abnormalknocking,painorabnormalactivitiesinjointsduringthe followupafteroperation.Heetal[11] observed19patients,who conductedfunctionalexercisewithlower-limbjointmotionmeterat thebasisofcommonexercisingonthedayofoperation.Compared withsimpleexercisingtreatment, itwasfoundthatthegenuflex angleof6monthsafteroperationwassuperiortothatinthecon- trolgroup(P<0.01).Therefore,itwasthoughtthattherewerere- markableeffectsofearliercontinuouspassiveexerciseafterTKR onextendingandflexingfunctionsofkneejoint. Atpresent, itisbelievedthattherearenewcollagentissues appearedonthe2nddayofTKR,andthegrowthpeakisonthe 5th-7thdayofpost-operation,whichfinallyformintofibroblastsif therearenointerventions,andwillthuslimitjointmotion.Earlier postoperativeexercisecanreducethelimitationoffibroustissue (FT),reduceadherencesinsidethejointandisbeneficialtothe functionalrecoveryofkneejoint.Moreover,thisexerciseisgoodto thebackstreamingofveinandlymphoidinlimbs,andcanreduce theswellingoflimbs,reinforcethemetabolismofpartialmuscula- ture(PM),amelioratemicrocirculation(MC)oftissueinoperative regionandpromotethehealingofincision. Therearealsore- searchessuggestthateffortofmachinecanregulatethedeposited orientatingofnewly-borncollagenfibers,andkneejointmovement canmakethecollagenfibersdepositalongwiththeorientationof stress[12].Therefore,jointmovementshouldbeperformedimmedi- atelyafteroperationsoastoreducethelimitationofjointrangeof motioncausedbyscarstotheminimum.Continuouspassivemo- tionofkneejointstimulatesthehemangiectasiaofmusculartis- sues,promotestheinfiltrationanddiffusionofsynovialfluid,and isbeneficialtopartialhistotrophicintakingandtheexpulsionof metabolicproducts,acceleratestheregenerationandrecoveryof cartilagecells.Besides,jointmotioncanstimulatetheundifferenti- atedmesenchymocytesincartilagetissuetodifferentiatetowards cartilage,therebyacceleratesthetransformationandrecoveryofcar- tilagecells. PROPRIOCEPTIVESENSATIONTRAINING ProprioceptivesensationwasinjuredafterTKR, proprioceptive sensationsofperiarticularmuscles, tendonsandligamentswere reducedbypostoperativefixation,whichmaycausethedescend- ingofcontrollabilityinjointmotion, posturalrectificationand balance-maintainingcapability.Koralewiczetal[13]reportedthat sensingcapabilitiesofjointpositioninpatientswhoneededTKR obviouslyweakened,whichhadnothingtodowiththechanging degreeofretrogressioninmedicalimageology.Wangetal[14]found throughtheobservationthatpathwayandareaofswingcenterof gravityofpatientswitheyesclosedweremarkedlyenhancedthan thoseinpatientswitheyesopen.Twoweeksafteroperation,de- spitepassiveexercisewasperformed, enhancementoffeedback controllabilityofproprioceptivesensationwasnotrapid. Even thoughpostoperativeexerciseforpowerofjointwasbeneficialto therecoveryofproprioceptivesensation,itstilldependedonspe- cialtraining.Accordingtopatient’scondition,balancingexercise wasproperlyincreased,statusofpatientsturnedbetterinthe4th weekofpost-operation,whileitwasstillinferiortopatientswith eyesopen,whichindicatedthatthereconstructionofpropriocep- tivesensationfeedbackinpatientsneededlongertime.Ifpossible, exerciseforproprioceptivesensationfeedbackshouldbeperformed beforeoperationsoastoenablepatientstoachievesatisfactory balancingcapacity.Zhou[4]thoughtthatproprioceptiveneuromus- cularfacilitation(PNF)couldpromoteneuromuscularexercise,pro- prioceptivesensoryfunctionsofmuscles,tendonsandligamentum. TheyhadalsoappliedtheRAPSproprioceptivesensorytraining meterwithasemiglobatebottomintrainingtheproprioceptivesen- sationofjoint,withwhichexcellenteffectshasbeenachieved. GAITTRAINING GTwasanimportantmethodofpostoperativetrainingofjointin lowerlimbs.Compensatedabnormalgaitoftenformedinthemor- bidityofpatients,whichmustbecorrected.Contentsoftraining weredifferentaccordingtodifferentsubjects,whilethebasicprin- ciplewaisfundamentallysame,whichweresummarizedasthefol- lowing:GTcouldbeconductedwhenpatientscouldstandontheir affectedlimbswithweightloading.Atthebeginning,patientssup- portedbytwopeoplecouldwalkslowlyintheroom,whileafter ISSN1671-5926 CN21-1470/R www.zglckf.com kf23385083@sina.com 李雪萍,等.全膝关节置换术后的康复干预 191 ISSN1671-5926 CN21-1470/R www.zglckf.com 中国临床康复 2006年7月25日 第10卷 第28期 accommodation,patientscouldwalkonhimselfwithtwocrutches. Afterthemusclestrengthinaffectedlimbsrecovered, loading weightwasgraduallyincreased,patient’sdependenceoncrutches wasreducedstepbystep,andpatientscouldwalkindependently withoutcrutches.DuringGTonwalkingdeviceorslightslope,pa- tientsshalllookforwardwithchinupandchestoutandwithout haunchcockedup,andinitiativelybentthekneejointsotospur theshank.Unaffectedlegwasthefirstingoinguptheslopeand affectedlegwasthefirstingoingdowntheslope. OTHERS Liuetal[15]thoughtthatpreoperativerehabilitationeducationwas necessary,theaimofwhichwastoletpatientsknowoperativepro- cess,effectsofoperationonkneejointfunctionandpostoperative methodsandproceduresofrehabilitativetraining,soastoobtain patient’scooperationandprovidebasisforrehabilitativetreatment. Mainpurposeofrehabilitativetraininginthisstagewastorein- forcethestatic-forcecontractionexerciseofmusculusquadriceps fexorisandhamstringmusclesinaffectedlegs. Theremarkable thingwasthatbecauseofsatisfactorytherapeuticeffects,patients usuallyforgotthestep-by-stepprincipleandblindlyincreasedthe doseandanticipatedtoactnormally,whilehastedosenotbring success.Tianetal[16] foundthattherewere6patientssuffered fromreactiveedemaorsofttissueinjuryforblindlyrehabilitative advancing,whichresultedinjointpainandforcedthetrainingbe stopped.Inthefollow-upofoneyearafteroperation,althoughpain wasrelieved,motionofjointsignificantlydecreasedthanthatin patientslefthospital.Therefore,itwasnecessarytoreinforcepro- pagandaandeducationaswellasinstructcorrectexerciseonpa- tientswhentheylefthospital.Yuanetal[17]observedthatconcern- ingpatientswhohadlongcourseofdisease,rehabilitationonpsy- chologicaldiseasesshallalsobepaidmoreattentionto.Thiskinds ofpatientsanticipatedmuchonoperationbutwerepoorinendur- ingpain,mostofthemalwayssufferedfrominsomnia,anxiety,de- pression,irritabilityandsoon.Inrehabilitativetreatment,patient's conditionshallbetoldpatientlyandcarefully,rehabilitativetrain- ingshallbeperformedgently.Medicalpersonnelshallobservepa- tient’sresponseinanytime,praiseandencouragethemfrequent- ly,letpatientscommunicatewiththosewhohadachievedbetter therapeuticeffectssoastoreinforcetheirconfidence.Moreover,as tospecialcasessuchasrheumatoidarthritispatientswhoreceived revisionofjointreplacementandtakenendocrineforlong-termaf- terartificialjointreplacement,routinerehabilitativeprojectfollow- ingartificialprostheticreplacementisnotsuitable,rehabilitative projectshouldbedesignedaccordingtospecificcasessoasto preventunexpectanceintherehabilitationtraining[18]. Tosumup,overallreasonableprojectofrehabilitativetreatmentplays animportantroleintherecoveryofkneejointfunctionafterTKR. REFERENCES 全膝关节置换术后的康复干预★ 李雪萍,程 凯,于俊龙 南京医科大学附属南京第一医院康复医学科,江苏省南京市 210006 李雪萍★,女,1965年生,江苏省靖江市人,汉族,1998年解放军第四军 医大学毕业,硕士,副主任医师,主要从事骨与关节、心脑血管疾病等临 床康复研究。 摘要 背景:随着人工关节材料的改进和假体设计的不断完善、全膝关节置换 技术的不断成熟,以全膝关节置换术治疗严重类风湿性关节炎和骨性 关节炎已能取得良好的结果。目前国内外普遍认为全膝关节置换术后 尽早进行分阶段的循序渐进的康复治疗可促进患者膝关节功能恢复, 达到生活自理,从而提高生活质量。 目的:阐述全膝关节置换术后的康复治疗及其相关研究。 资料来源:应用计算机检索Medline数据库1998-01/2005-08的相关文 章,检索词“totalkneereplacement,Rehabilitation,therapy”,限定文章语 言种类为英文。同时计算机检索中国期刊全文数据库、万方数据库 1990-01/2004-12的相关文章,检索词“全膝关节置换术;康复;治疗”, 限定文章语言种类为中文。 资料选择:对资料进行初审,纳入标准:①关于全膝关节置换术后康复 治疗的项目、步骤、过程及注意事项。②对具体病例的回顾调查研究。排 除标准:排除重复性研究。 资料提炼:共收集到符合上述要求的文献37篇,排除22篇重复性研 究。15篇符合纳入标准:其中3篇关于全膝关节置换术及有关康复治疗 的综述,8篇关于全膝关节置换术后康复治疗的临床研究,4篇关于全膝 关节置换术后康复治疗相关因素的分析研究。另参阅了有关专著3本。 资料综合:康复治疗对人工膝关节置换术后的临床效果至关重要,是术 后膝关节功能能够达到预期效果的重要原因。肌力训练、关节活动度训 练、本体觉训练及行走步态训练是术后康复治疗最重要的内容。为最大 限度的恢复膝关节功能,综合的康复训练必不可少:包括各种主动肌力 训练增加膝关节伸、屈肌力;早期持续被动的膝关节活动度训练增加关 节活动度;本体感觉训练改善膝关节的运动控制能力、姿势校正及平衡 维持能力;行走步态训练矫正异常行走步态。 结论:全膝关节置换术后尽早进行分阶段的循序渐进的康复治疗,即对 患者进行肌力训练、关节活动度训练、本体觉训练及行走步态训练,对 提高手术疗效、促进患者膝关节功能恢复有着重要的作用。 主题词:关节成形术,置换,膝;康复;治疗学 中图分类号:R687.4 文献标识码:B 文章编号:1671-5926(2006)28-0190-03 李雪萍,程凯,于俊龙.全膝关节置换术后的康复干预[J].中国临床康复,2006,10(28): 190-2 [www.zglckf.com] (EditedbyLiHY/XuY/WangL) 1 2 3 4 5 6 DonaldsonTK.Techniquesinorthopaedics:totalkneerevision.OperTechOr- thop1998;8(3):146 GaoT,LuHS,GuanZP,etal.Costanalysisoftotalkneereplacementsurgery. 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