Purpose of treatment
Occupational therapy is an important part of the whole rehabilitation treatment. Its purpose is: ① to train patients to transfer their positions safely; ② On the premise of protecting the artificial joint, improve the safety and independence of ADL; ③ Design and make necessary auxiliary tools for patients; ④ Nursing and safety education for artificial joints; ⑤ Improve the ability of functional work activities, so as to improve the coordination of patients' muscle strength and joint range of motion.
(2) Treatment method
1. Occupational therapy after artificial hip replacement
(1)ADL exercise: ADL exercise is related to the fracture site and its severity, the stress state of the fixation device or artificial joint in the surgical method, the patient's weight and cognition.
1) The therapist should select and teach the patient to use a walker or crutch according to the allowable weight percentage of the lower limb on the surgical side (Table 1 1-5-3).
Table 1 1-5-3 Flow chart of hip surgery.
2) Therapists should teach patients to carry out ADL activities safely, and should comply with the doctor's advice and the allowable weight after operation. In order to save energy and ensure the safety of activities, patients should complete some ADL while sitting. When patients are in the stage of partial load-bearing, they can safely perform personal hygiene actions in a standing position. For patients with risk factors of artificial joint dislocation, ADL activities need help from others, such as wearing pants to take a bath in lower limbs.
3) Close communication among members of rehabilitation group can provide patients with the best treatment plan. The focus of occupational therapy for patients before discharge is to evaluate the safety and independence of BADL and IADL, as well as the assistive devices or help from others.
4) For those patients who can't bear or touch the load, from the perspective of energy saving and safety, it is best to perform ADL in a sitting position. Once the patient can bear part of the load, the patient can stand and wash safely. For some patients, the above activities can be started in the first week after operation; For other patients, it may be postponed to the third or fourth week; Some patients need to be put off until the sixth week. Due to these restrictions, the patient's body cannot be excessively bent or his feet are close to his hands. Therefore, assistive devices are needed to solve the problems of bathing and dressing, functional activities and housework (Table 1 1-5-4).
Table 1 1-5-4 Auxiliary Equipment for Artificial Hip Replacement
Patients must remember that hip flexion should not exceed 90 after operation; Can't rotate hip joint; The lower limb on the operation side cannot cross the healthy lower limb, or the hip joint on the operation side cannot bend actively or passively, or the lower limb adduction exceeds the midline (table 1 1-5-5).
Provide patients with long-handled dressing tables and self-help tools for decoration. Therapists teach patients to use self-help tools to bathe and dress on the surgical side of the body to avoid excessive flexion of the hip joint or excessive adduction of the lower limbs. If patients are allowed to take a shower, some patients can take a shower standing up. For safety reasons, handrails and anti-skid mats should be installed in the bathroom. For safety reasons, some patients must take a bath in a sitting position. The height of the bathing chair should be appropriate, the hip flexion should not exceed 80 ~ 90, and handrails and anti-skid should be installed.
Table 1 1-5-5 Mobility limitation after hip surgery
5) Safe use of toilet: In order to reduce the hip joint flexion when patients sit down and stand up, patients should be educated to use raised toilet cushions, mattresses and chair cushions, and patients should be taught not to excessively bend the operating side hip joint when they stand up. If the patient is sitting in a chair with armrests, the patient will move his body to the front edge of the chair, keep the hip joint at the operation side straight, support the armrests with both hands, and do not bend forward. If you sit in a chair without armrests, the patient will move to the edge of the chair. Make the thigh of the operation side exceed the edge of the chair, put the foot on the midline of the chair, keep the hip joint of the operation side straight, make the foot close to the center of gravity of the body, and make the patient stand up instantly without excessive flexion. The hips, knees and ankles on the healthy side of the hip joint should be placed in proper positions to bear the weight.
Six weeks after operation, almost all patients can walk with crutches, and most patients can resume driving, swimming and working. When wearing shoes and socks, the patient should be restrained from bending, sleep on the surgical side, and continue to use the raised pad until 8~ 12 weeks after operation.
(2) Preventive education 1) Use of crutches: The crutches, especially the crutches on the opposite side, can reduce the abductor muscle strength of the hip joint on the surgical side, and the estimated reduction rate is about 40%, so the joint load is also greatly reduced. Only when crutches are used without pain or limp can they be abandoned. It is best to use a single crutch for life to reduce the wear of the hip joint on the surgical side, especially when traveling or walking for a long distance.
2) Weight control: Losing weight is the most effective way to reduce joint load. If the weight is reduced 1kg, the stress on the hip joint will be reduced by about 3kg.
3) Prevention and control of infection: Any operation or treatment measures that may cause infection, such as tooth extraction, tonsillectomy and intubation, should be prevented in time to prevent intra-articular infection caused by blood circulation.
4) Avoid sexual life within 6~8 weeks after operation. During sexual life, prevent extreme abduction of the lower limbs on the surgical side and avoid oppression.
5) Avoid heavy physical activity and sports events that require vigorous hip joint activity, so as to reduce postoperative joint dislocation, fracture, prosthesis loosening and other problems.
6) Avoid placing the hip joint in a position prone to dislocation: excessive flexion and adduction of the hip joint, flexion and extension and adduction and external rotation of the hip joint on the surgical side.
7) Avoid walking on uneven or flat roads to avoid falling.
8) The affected limb should be kept in abduction or neutral position, and the flexion of hip joint should not exceed 90 degrees within 6~8 weeks after operation.
9) If the abnormal hip joint on the operation side is found, you should contact the surgeon in time.
(3) Other rehabilitation treatment methods:
1) 1~ 7 days after operation A. On the day of operation: supine position, put a cushion with appropriate thickness under the outer limb of the operation side to make the hip and knee joint slightly bend, and the patient wears anti-rotation shoes (T-shoes) to avoid external rotation of the lower limbs and relieve pain.
B. The first day after operation: Take out the cushion, and straighten the lower limbs on the surgical side as far as possible to prevent hip flexion deformity. According to the drainage volume, the drainage tube was removed within 24~48 hours after operation, and the foot vein pump was used to promote the blood circulation of lower limbs after bacteria culture and drug sensitivity test. Sedative painkillers can be taken appropriately to reduce pain stimulation and ensure patients rest.
C. 3 days before operation: deep breathing exercises; Active ankle flexion and extension exercises; 1~2 days after isometric contraction of hamstring muscle and gluteus maximus muscle, the drainage tube was removed and X-ray was taken to determine the position of the prosthesis. If there are no special questions, you can start the following exercise.
D 4-7 days after operation: the flexion and extension of hip and knee joint can't leave the bed surface. You can sit up in bed until the hip flexion is less than 45 degrees, then gradually change from passive motion to assistance, and then fully actively practice transitional hip straightening exercises. In supine position, you can flex and straighten the healthy hip and knee joint, actively straighten the surgical hip joint, fully stretch the hip flexor and the front of the joint capsule, and exercise the muscle strength of the upper limbs.
E. Note: ① Avoid putting the hip joint on the operating side in supination and extension position. In order to prevent the patient from turning over to the opposite side, the bedside table should be placed on the operating side. (2) Keep the limb abduction on the operation side or put a triangular pad between the legs, but prevent the lower limb from supination. ③ If the hip joint on the operating side has moderate buckling instability, avoid tilting the upper body to the operating side when practicing sitting hip joint. ④ Postoperative approach to avoid excessive flexion, adduction and pronation of the affected lower limb, especially the combined action of flexion, adduction and pronation.
2) 2~6 weeks after operation: Patients who use bone cement to fix prosthesis can do the following exercises, but they must do it under the direct guidance of doctor PT.
A. bed exercise: hip flexion muscle exercise: active or active hip flexion exercise should pay attention to:
It is not advisable to take the initiative to raise the straight leg in the early postoperative period, because it is of little significance to the hip flexion movement, which often puts the acetabulum under excessive pressure, which is not conducive to the bone tissue growth of the acetabular prosthesis fixed with bone cement and the pain in the wound area, and affects the patient's movement. Therefore, it is not recommended to do this kind of exercise early after operation. If there are no special circumstances, patients can be allowed to turn over. The correct turning posture is: straighten the hip joint on the surgical side, maintain rotational neutrality, straighten the upper limb on the same side, and put the palm behind the greater trochanter to prevent it.
B. Sitting exercise: within 6-8 weeks after operation, patients mainly lie and walk, and the sitting time should be as short as possible, 4-6 times a day, 30 minutes each time, because sitting is the most prone to dislocation and subluxation of hip joint. If the patient's joint stability is not good during the operation, it is not suitable for sitting. Practice the contents of sitting exercise: hip extension, hip flexion and hip rotation.
C standing exercises: hip joint stretching, pelvic swinging from side to side, correction of coxa varus deformity, hip joint flexion exercises, and hip joint rotation.
D. Walking exercise: The first hip replacement used bone cement prosthesis, and there was no bone graft fracture during the operation. The patient could walk on the third day after the operation. If you use a bone cement prosthesis, you can start walking exercise at least six weeks after the operation. According to the X-ray film, walking exercise should be postponed to at least two months after the operation for patients with femoral fracture during femoral trochanter osteotomy. When the center of gravity is stable, the lower limbs on the operating side should bear at least the weight.
E. Treadmill exercise: Generally, the start time is after the patient walks. Generally, it can be adjusted in 2 ~ 3 weeks after operation according to the patient's specific situation, and the start-up time can be slightly adjusted, and the speed can be kept at about 25m/h, and it will gradually accelerate in 6 ~ 8 weeks after operation. After stepping on 10~ 15 minutes, it is advisable to step on the pedal with both feet, raise the car seat cushion as much as possible, and reduce the degree of hip flexion.
3) Week 7 after operation: The affected lower limb can bear all the weight, and you can sit in an ordinary chair, but you can't squat.
The first follow-up was performed 6-8 weeks after operation. According to the results of X-ray and physical examination of hip joint, the next rehabilitation plan is put forward. The focus of rehabilitation at this stage is to improve the overall strength of muscles and guide patients to resume their daily activities. For those whose hip joint activity is still limited, targeted functional exercise should be strengthened.
The second follow-up time was 4 months after operation. The contents are as follows: ① Whether muscle strength returns to normal; Whether you can walk independently (without braces) and walk a long distance; ③ Whether the range of joint motion can meet the needs of daily life; If there is no pain and limping, you can give up. The focus of rehabilitation at this stage is to improve muscle endurance, and the methods include resisting straight leg lifting exercise, lateral hip abduction and prone hip extension exercise.
(4) Precautions for patients after artificial hip replacement (1) Only when there is no pain and limp can crutches be used. It is best to use a single crutch for life to reduce the wear of the hip joint on the surgical side, especially when traveling or walking for a long distance.
2) Prevention and control of infection: Any operation or treatment measures that may cause infection, such as tooth extraction, tonsillectomy and intubation, should be prevented in time to prevent intra-articular infection caused by blood circulation.
3) Avoid sexual life within 6~8 weeks after operation. During sexual life, prevent extreme abduction of the lower limbs on the surgical side and avoid oppression.
4) Avoid heavy physical activity and sports events that require vigorous hip joint activity, so as to reduce postoperative joint dislocation, fracture, prosthesis loosening and other problems.
5) Avoid placing the hip joint in a position prone to dislocation: excessive flexion and adduction of the hip joint, flexion and extension and adduction and external rotation of the hip joint on the surgical side.
6) Avoid walking on uneven or flat roads to avoid falling.
7) The affected limb should be kept in abduction or neutral position, and the flexion of hip joint should not exceed 90 degrees within 6~8 weeks after operation.
8) If the abnormal hip joint on the operation side is found, you should contact the surgeon in time.
9) The third review is 65,438+0 years after operation, and it will be reviewed once a year thereafter, including the functional score of artificial hip joint in the positive and lateral X-ray films.
2. Methods such as occupational therapy after artificial knee replacement (1) Before operation: The focus of rehabilitation at this stage is to let patients know the general procedures of postoperative rehabilitation, recover their physical strength, strengthen the muscle strength of quadriceps femoris and hamstring muscles as much as possible, and enhance the range of joint activity.
(2) From the day of operation to the third day after operation:
1) Pay attention to whether the patient has symptoms such as abnormal cardiopulmonary function and excessive bleeding from shock wounds. , and functional training began only after the patient's general and local conditions were stable.
2) Deep breathing exercises
3) isometric contraction training of lower limb muscles on the operation side; Straighten the knee joint, active or passive ankle flexion and extension
4) Active activity training of both upper limbs
5) Pull out the drainage tube on the 2nd to 3rd day after operation, conduct bacterial culture and drug sensitivity test on the end of the drainage tube and blood clots in the tube, and take X-rays on the right side of the knee joint and the patella axis with knee flexion of 45 degrees.
(3) The first day of 4 ~2 weeks after operation: The main goal of rehabilitation training is to gradually restore ROM of knee joint and at least restore quadriceps muscle strength at 0 ~ 90. The intensity of each training should be within the patient's tolerance range, and the original limb pain and swelling should not be aggravated after training.
1)CPM exercise, starting from the range of 20 ~ 70.
2) Active knee movement (training after removing CPM equipment)
3) quadriceps hamstring training
4) Those who generally use bone cement should practice standing and walking with the help of medical staff on the 4th day after operation.
If the joint is unstable, knee brace can be used for those with severe knee flexion deformity before operation. In the meantime, they still need to be supported and fixed in the knee extension position with plaster at night, which should generally last for 4~6 weeks.
5)CPM activity range is 0 ~ 1 10.
(4) 2~6 weeks after operation:
1) Continue joint mobility and muscle strength training.
2) Daily living ability training, occupational therapy and physical therapy.
3) X-ray film of positive lateral position of knee joint
(5) 6~ 12 weeks after operation: ROM 0 ~ 125 of knee joint, balance training of lower limbs on the operating side of jogging and swimming with bicycle trampoline.
(6) postoperative 12~20 weeks: walking agility training, obstacle-crossing training and lateral movement training.