肘关节骨折术后四阶段康复程序-AROMAAROM or PROM

利用这个长假在丁香园陆续整理完成了一文“肘关节骨折术后四阶段康复程序-AROM/AAROM or PROM？”   现将之整理成文发布在博客里。 ------------------------------------------------------------------------------------------------------ 早在一年前我曾组织我们的团队集体学习过专著《treatment & rehabilitation of fractures》.详情点此进入。这本书给我们最大的冲击在于，全书对于任何一个部位的骨折康复中均未提及PROM练习。通篇强调AROM/AAROM。而这对我们一贯接受的观念“早期PROM，中期/AAROM,晚期抗阻训练”发起了挑战。著者这样的观点值得我们去思考。而对于肘关节的骨折，由于会发生异位骨化（Heterotopic Ossification, HO）这一严重影响关节ROM的问，更是很多学者建议要避免PROM。他们这样建议的理由是认为PROM导致和加速HO的发生。我清楚的记得几年前我在阅读谭维溢主译编《康复医学专业复习试题集》里美国康复医师的考题（2003出版，755题）中有一道关于HO的题目，在它的题解中p132写道“一旦诊断为HO，早期治疗应包括持续的关节活动范围练习、支具。冷敷科作为辅助治疗。没有资料明早期的活动范围联系会加重炎症与骨的生成。” 近期我学习了美国骨科创伤学会OTA的肱骨远端骨折处理的资料，发现作者同样是强调避免PROM，主张AROM/AAROM 在我们的部门对于肘关节骨折患者内固定牢靠的情况下我们会早期使用肘关节CPM治疗，我们这样的做法是否科学？到底术后的康复程序是否可以使用PROM，另外患者若出现HO，我们是否需要停止PROM，康复程序需要做什么样的调整？带着这一系列的问题和困惑，我查阅了关于肘关节HO的一些文献。在众多文献中Heterotopic Ossification about the Elbow: A Therapist’s Guide to Evaluation and Management. J HAND THER. 2006;19:255–67.给了我很多启示。我比较认同笔者的观点。相关读书笔记： http://orthorehab.blog.sohu.com/132974547.html 1.Acute and Edematous Phase (First Two Weeks following Injury/Surgery) 1.急性肿胀期（损伤/手术后2周） 这个阶段最重要的是控制肿胀、减轻炎症反应。 小插曲：记得3年前在一次骨科康复学习班上，一位教授在授课时说，“肿胀是引起关节僵硬的罪魁祸首”。这句话深深的印在我脑海里，也是我参加那次学习班的最大收获。当时她推荐有条件的购买cryocuff-冷敷加压袖套（含各个关节和肢体的袖套）。我回到上海，第一件事就购买了这套设备。 引自：http://www.htherapy.co.za/ 损伤和/或手术后急性期出血会造成组织明显的肿胀。而肿胀会造成瘢痕形成、粘连。所以我们要重视急性期的冷敷、加压包扎。平时我们的做法是患者术后2天内我们给予cryocuff处理。对于消除肿胀，当然还包括最基本的抬高患肢。其它有效的措施，大家可以给出你们的做法或者意见。 另外疼痛的处理也很重要。它可以让患者最大程度的参与治疗程序。药物、TENS? 根据内固定的稳定程度，只要手术医师许可，应该尽早开始ROM治疗，强调规律的训练和AROM练习。 --------------------------------------------------------------------------------------------------------------------------------------- During this initial phase, it is important to apply proper edema control measures to reduce postinjury and/or postsurgery inflammation. Bleeding occurring from the initial injury and/or surgical intervention can cause significant swelling of the tissues. This edema leads to the development of scar, and minimizing edema with an effective compressive dressing will minimize scar formation. In addition, pain management is essential to allow for maximum participation in the therapy program. ROM exercises should be initiated to the elbow and forearm within the parameters of the physician as determined by the stability of the injury, with particular emphasis on regular exercise and active ROM as muscles quickly lose strength after an injury and a period of non-use. 2.Inflammatory Phase (Two to Six Weeks following Injury/Surgery) 2.炎症期（损伤/术后2-6周） 这个阶段的主要特征是出现大量增生的同时又无序排列的瘢痕组织。这种增生比较活跃同时瘢痕组织也具有很好的延展性，我们要好好利用这个阶段瘢痕的延展性，用我们的治疗措施进行干预以获得可能的最大关节活动度。 如果允许进行全关节活动度的被动运动，治疗的重点是“自我被动牵伸”，配合使用重量牵引、动态/静态进展支具。这个阶段支具的使用是最有效的获得ROM的手段。 引自：http://www.lantzmedical.com/ 非常遗憾的是，能够用上专业的动态或静态进展牵伸的支具的患者太少了。其原因除了进口支具的昂贵，国产支具的匮乏之外，还有骨科医师和康复工作者这方面的理念和知识的缺乏。这也是我个人觉得为什么我们的肱骨远端术后患者最后的结果与美国OTA报道（75%的优良率，优良率的标准是15°-140°）的有那么大的差距。我们的差距最大的方面就是在支具这一块。缺少了支具，我们每天屈指可数的治疗时间换得的效果无法维持。因为对于ROM训练，最通俗的一句话就是"用时间换取空间" 对于肘关节ROM的训练，基本上大家公认的一个事实是，屈曲比较容易恢复，一般在术后2-3月，而伸的恢复比较慢，通常需要4-6月甚至更长时间。跟国外学者的建议一致，我们常常建议患者睡前训练伸，然后夜间佩戴伸肘支具。次日上午进行屈曲活动度练习。当肿胀开始消褪，我们在ROM练习前或者佩戴支具前可以进行湿热疗法，我们用的最多的是hot pack，没有这个条件的使用蜡疗也行。 即使平片发现HO，我比较同意国外学者的意见，继续进行ROM练习。 我们的康复目标也就是肘关节功能ROM，100°（30°，130°），这个ROM可以让患者完成90%以上的日常动作。 不可忽略力量训练。这也是现在大家都强调的主动康复。力量训练不仅可以让肌肉恢复力量也可以最大限度的改善ROM。另外要鼓励患者多在ADL中使用患肢。 背景资料：众所皆知，关节挛缩和肌无力是骨科康复研究的两大基本问题。刚接触这个领域，我就检索过国际上在关节挛缩方面的新进展，发现了在支具方面上世纪 90年代一位美国医师提出了静态进展性牵伸SPS（static progressive stretch）概念，并成功的研制了sps支具。也就是文中所提及的static progressive splinting。很遗憾国内的支具行业同样与国外有着非常大的差距。我曾经尝试从香港购买，但器械商的进价一个肘关节sps支具价格就在人民币 8000元左右，显然不适合中国国情。好在我后来借用biodex等速测力计实现了sps的理论，并已成功的用于门诊大量关节挛缩患者。当然没有sps支具那么便捷，患者可自行在家使用，每天使用3次以上。关于dynamic/static progressive splinting的理论，我已做成ppt上传供大家参考。里面涉及的软组织粘弹性理论-“蠕变”和“应力松弛”，是非常重要的骨科康复的生物力学基础知识。 splint点击下载 ----------------------------------------------------------------------------------------------------------------------- Prolific unorganized scar tissue is present during this phase, which is very active yet malleable, and its formation can be influenced by therapeutic measures. The greatest potential for ROM gains exists during this phase as the scar is deformable and will respond to therapy modalities. If full PROM is permitted, self-passive stretching should be emphasized along with the use of weighted stretches and/or dynamic/static progressive splinting. It is during this phase that splinting to recapture ROM will be most effective. We stress the concept of a low-load progressive stretch and oftentimes use static progressive splinting as an adjunct to restore elbow ROM.We recommend that patients wear this splint (or a dynamic splint if more of a soft end feel is present) four to six times a day for 30–45 minutes at a time. If elbow extension is limited, a nighttime static splint is fabricated to the patient’s maximum extension and then serially adjusted to accommodate for gains in motion. When swelling has subsided, moist heat can be used prior to stretching exercises or the wearing of a splint to increase the elasticity of the tissues and maximize motion. Even if HO is revealed on plain radiographs, usually seen at four to six weeks, the patient should continue with his/her current therapy program to maximize ROM. Patients should continue to wear the dynamic or static progressive splints frequently throughout the day, as pain allows, emphasizing the most limited direction. It is important to keep in mind the goals of functional ROM. According to a study by Morrey and coworkers an arc of 100° of elbow motion, from 30° of extension to 130° of flexion, is required for a patient to perform 90% of his or her normal daily activities. The patient’s therapy program should also include a strengthening program, as advised by the treating physician. Resistive exercises will not only help the muscles regain strength, which is often quickly lost after an injury, but also maximize ROM gains. Improved muscle power can work through passive resistance to increase ROM. In addition, it is important to encourage functional use of the affected extremity to help restore elbow motion and strength. 3.Fibrotic Phase (Six to 12 Weeks following Injury/Surgery) 3.纤维化期（损伤/术后6-12周） 这个阶段，瘢痕组织完全形成并受运动和应力的影响进行纤维重组，因此这个阶段也是康复治疗的有效期。我常告诉我的患者术后3月是你的“蜜月期”。 这个阶段支具的应用可以适度增加强度，因为骨折已经愈合啦。依然强调长时间规律的佩戴支具以获得对软组织的最大量的牵伸。 同样不可忽视抗阻力量训练对增加ROM的作用。 众所周知，随着病程的延长，增加ROM会越来越难。所以我们要珍惜术后3月这段“蜜月期”，鼓励患者主动参与、配合治疗。积极开展围手术期康复。如果患者错过蜜月期的治疗造成了关节挛缩再来诉求康复治疗，那将是一件非常遗憾的事情。谁之过？ --------------------------------------------------------------------------------------------------------------- During this phase, the scar tissue is usually fully formed but is reorganizing and will continue to respond to motion and stress. If aggressive splinting has not already been initiated, it can be added to the therapy program as fractures are typically fully healed at this time. Of course, the treating physician dictates the intensity of the therapy program. It is important for the patient to wear splints regularly throughout the day to maximize the amount of prolonged stretching to the tissues. Having the patient perform resistive exercises following the wearing of a splint will help to maximize ROM gains. It is important to note that gains in ROM will become more difficult to achieve with an increasing passage of time. 4.Late Phase (Three to Six Months following Injury/Surgery) 4.晚期（损伤/术后3-6月） 无论是神经康复还是骨科康复，都有个时间窗的概念。前面已经提及骨折术后3个月为康复的“蜜月期”，而进入第四期，康复的疗效大打折扣，但依然有效， Only mild or modest gains。 对于术后6月甚至更久来门诊诉求康复治疗的患者，这类患者一般没有接受过早期康复治疗，所以他们的关节僵硬会比较严重，加之这个时期本来康复效果就不大。我们通常会告知患者，保守治疗效果不理想，要付出很多的时间、精力、财力，而收获甚微，建议患者先行手术松解，术后再结合我们的康复治疗，那样会事半功倍。 在膝关节挛缩方面，晚期患者行手术松解结合康复治疗，我们取得了不少成功的经验。而对于肘关节，手术医师根据以往经验都会觉得最终效果不尽人意。这方面我们仍在积累中。查阅了一些文献，最近几年报道切除挛缩的肘关节关节囊可获得不错的效果，这些报道增加了医师对肘关节僵硬行切开松解术的热情。附： Aldridge JM III, Atkins TA, Gunneson EE, Urbaniak JR. Anterior release of the elbow for extension loss. J Bone Joint Surg Am 2004;86:1955-60. Marti RK, Kerkhoffs GM, Maas M, Blankevoort L. Progressive surgical release of a posttraumatic stiff elbow. Technique and outcome after 2-18 years in 46 patients. Acta Orthop Scand 2002;73:144-50. 这个阶段只要ROM还可以增加，就继续使用支具。当ROM达到康复目标或ROM进入平台期，则中止使用支具。支具的中止使用需要慢慢减少佩戴时间，不能一下子完全停用。（好比我们停用激素，呵呵） 力量训练建议最少需要坚持半年。让患者坚持这么长的时间来医院接受康复治疗是不现实的，一方面我们可以制定家庭康复程序（HEP）,另一方面开展社区康复也是有力的保障，患者可以就近得到康复治疗。现在，上海的各个社区卫生服务中心的康复功能正在不断的健全中. ----------------------------------------------------------------------------------------------------------------- During this phase, the scar is organized and fibrous tissue is present. Only mild or modest gains will be achieved at this time. Splinting to recapture ROM can continue as long as gains are noted. Patients eventually discontinue splints when either ROM goals have been achieved or ROM has reached a plateau. Typically, patients will wean from splints as long as motion is maintained instead of discontinuing them all at once. It is recommended that patients continue on a home strengthening program for a minimum of six months postinjury or postsurgery to maintain ROM and build upper extremity strength. 我正在玩搜狐微博，快来“关注”我，了解我的最新动态吧。 http://orthorehab.t.sohu.com/