RU2147857C1 - Method for applying recovery treatment of patients undergone to surgical intervention on the occasion of bone fracture - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves distinguishing four stages of recovery treatment as follows: from 1 to 14 days, from 15 days to 8 weeks, from 8 weeks to 12 weeks and from 12 weeks to 6 months. Active physical training exercises in supine position and turns in bed at the first stage beginning from the second or the third day after operation are carried out. Next to it, the patient assumes sitting position in bed supporting the body with rest on hands. The patient gets up out of bed using a support. Physiotherapy with diadynamic currents are applied. Physical training exercises are added in standing position near a support at the second stage. Mark time marching is included without using support and walking with support on crutches. Magnetotherapy or ultrasonic therapy course is applied to lumbosacral region. Massage course is applied to lower extremities. Exercises of the third stage are carried out with greater effort and in larger volume. Back and lower extremity muscles electrostimulation is carried out. Lumbar, gluteal regions and lower extremities are subjected to massage after taking off external fixation apparatus. Exercises are added that are aimed at walking stereotype restoration. Mechanical treatment and/or training in swimming pool are administered at the fourth stage. Treatment course is carried out in hospital at the first and the second stage in cases of isolated trauma of the pelvic ring, the third and the fourth stages are carried out outdoors. EFFECT: accelerated treatment course; full functional repair of locomotor system. 3 cl, 3 tbl

Description

 The invention relates to medicine, namely to traumatology, and can be used in the rehabilitation treatment of patients with severe multiple injuries of the pelvic bones after transosseous osteosynthesis.

 As you know, with injuries and diseases of the musculoskeletal system, the patient’s body is in particularly unfavorable conditions, not only due to impaired limb function, but also due to a decrease in overall motor activity, which leads to the development of hypokinetic disease. A prolonged restriction of motor activity leads to the development of muscle atrophy, a decrease in proprioception, i.e. lower trophic levels of all organs and body systems, which accordingly leads to its slow recovery.

 Exercise, improving peripheral blood circulation, blood oxygenation, extracardiac hemodynamics and respiratory function, increasing the flow of proprioceptive impulses from the periphery, helps restore normal relationships in the activities of all parts of the blood circulation, respiration and movement. A known method of rehabilitation treatment for pelvic fractures after immobilization of the pelvic ring using a roller, including physiotherapeutic procedures and physiotherapy exercises with exercises to strengthen the pelvic girdle (AF Kaptelin. Restorative treatment for injuries and deformations of the musculoskeletal system. M.: Medicine , 1969, p. 151-154).

 Along with breathing exercises, passive and active exercises are carried out in the supine position, starting from 4-5 days for 3-4 weeks before the patient rises. At the first stage, exercises involving the muscles of the upper extremities, shoulder girdle, trunk and pelvic girdle, supported by a roller, are performed for 10-14 days. From 15 days to 4 weeks, these exercises are carried out more energetically and without relying on the roller, connecting exercises in a supine position. With the patient rising to an upright position (after 3-4 weeks), the third period of treatment begins. Exercises are carried out in a standing position, do squats and begin to teach the patient how to walk.

 However, a prolonged restriction of motor activity leads to disruption of the activity of many organs and systems of both a functional and morphological nature. Bed rest for 3-4 weeks reduces the amount of muscle activity, and the exercises are ineffective for the prevention of trophic disorders of the tissues of the body and atrophy of the muscles of the lower extremities and pelvic girdle. The patient is raised to an upright position and trained to walk in the later stages of treatment, as a result of which the patient does not fully restore the functional relationships of the movement system. Often the patient sways with his body while walking, limps. With conservative treatment of bone fractures, repeated bone displacements are not uncommon, complications of a different nature are possible in the early and late stages of the post-traumatic period.

 There is a method of rehabilitation treatment of patients with injuries of the pelvic bones after surgical treatment (Yumashev G.S., Epifanov V.A. Surgical traumatology and rehabilitation of patients with damage to the musculoskeletal system. M: Medicine, 1983, p. 357-359), including massage, physiotherapy and therapeutic exercises.

 After surgery, the patient is laid on his back, a roller is placed under his knees or the patient’s pelvic area is placed in a hammock for 4 weeks. The recovery period is divided into two stages. The first period lasts 4 weeks. In the first 7-10 days, breathing exercises (static and dynamic) are carried out, gradually connecting special exercises performed in lightened conditions while lying on the back, for example, active movements in the ankle joints, alternating flexion and extension of the legs in the knee joints without detaching from the roller. Starting from day 10, exercises with alternating abduction and bringing legs (connecting hips along the roller) are connected. On day 14, the roller is removed and includes exercises with raising legs and static limb retention, exercises for the upper limbs and shoulder girdle. From 21 days they perform exercises with active movements of the lower extremities without resting on the bed plane, turning the patient on his stomach. In the first period, a lower limb massage, ultraviolet irradiation of the chest, electrophoresis are performed. 4 weeks after surgery (from the moment the patient is raised), the second period of rehabilitation treatment begins. Exercises of the first period are carried out with a large number of repetitions of each movement, connect exercises with resistance, resistance, standing at the gymnastic wall.

 However, the patient after surgical treatment for a long period (up to 4 weeks), and with severe damage to the pelvic bones and more than 4 weeks, is on bed rest. Massage, physiotherapy and exercises used in the rehabilitation of patients during this period do not prevent muscle atrophy. Restoring the functional state of visceral organs is too slow. The stereotype of support and walking is not fully restored, since walking training occurs in the late postoperative period.

 The task is to fully restore the musculoskeletal system - the "stereotype of support and walking", restore physical performance and ability to work, reduce treatment time by maintaining motor stereotypes of support and walking from the first days of the postoperative period.

 The problem is solved as follows. The entire period of rehabilitation treatment for pelvic fractures after surgery (after transosseous osteosynthesis with external fixation devices), including physiotherapy, massage and a complex of therapeutic exercises with phased respiratory, passive and active exercises, according to the invention, are divided into four stages from 1 to 14 days , from 15 days to 8 weeks, from 8 weeks to 12 weeks and from 12 weeks to 6 months, and from 2-3 days after surgery, they begin to carry out active exercises, first in the supine position by pulling on the bedside frame, performing circular and flexion movements in the joints of the upper and lower extremities, performing turns in bed, and then from 3-4 days they sit in bed with emphasis on the hands, and from 4-5 days they lift the patient with support, while doing daily physiotherapy with diadynamic currents, in the second stage after exercises in the supine position, they perform exercises while standing at the support, by tilting the body, alternately moving straight legs forward and to the sides, alternately bending the legs in the knee and of the hip joints, with the load on the muscular system of the trunk, hip belt and lower extremities increasing gradually, the complex includes walking in place without additional support and walking with support on crutches, first on a horizontal plane, and then on the stairs, and conduct a course of magnetotherapy or ultrasound, acting on the lumbosacral region, conduct a massage course of the lower extremities, at the third stage the exercises of the first and second stages are carried out with great effort and in a larger volume, with the transition from smaller loads to large ones, from a small amplitude of movements in the joints to a larger one and they perform electrical stimulation of the muscles of the back and lower extremities, and after removal of the external fixation device, massage of the lumbar, gluteal regions, lower extremities is connected and exercises are carried out aimed at restoring the stereotype of walking in a standing position without support kneeling and standing on all fours, in the fourth stage, mechanotherapy and / or exercises in the swimming pool are connected, and at the 1-2 or 1-2-3 stages of treatment, exercises with isometric training weakened muscles with the maximum possible tension and subsequent relaxation and periodically, at least two times per lesson, monitor the general condition of the patient by determining the number of heart contractions by peripheral pulse. With an isolated pelvic ring injury, the first and second stages of therapeutic exercises are carried out in a hospital, and the third and fourth stages of rehabilitation treatment are recommended to be performed on an outpatient basis.

 Restorative treatment after transosseous osteosynthesis with external fixation devices is divided into four stages according to the phases of the traumatic disease. A strict step-by-step sequence for including therapeutic physical exercises, physiotherapy and massage during the period of rehabilitation treatment allows you to restore and strengthen the structural basis of the patient’s functional system of movement after a severe injury to the pelvic bones.

 The early activation of patients begins immediately at the first stage of treatment from 2-3 days with the development of movements in the joints of the upper and lower extremities, with the patient sitting on the bed for 3-4 days, lifting with support (on the back of the bed, on crutches) from 4 -5 days, which helps prevent the development of complications such as fat embolism and thrombosis, the occurrence of pressure sores, eliminate muscle atrophy and joint stiffness, maintain motor-visceral reflexes of the body as a whole, while exercising support function. Physiotherapy - diadynamic currents, at this stage has a painkiller effect, stimulates trophic processes.

 Connecting at the second stage of exercises in a standing position at a support, as well as the inclusion of walking in place without support and with support on a horizontal plane and on a ladder, allows you to increase mobility in the joints of the lower extremities, increase the strength and endurance of the muscles of the shoulder girdle, gluteal muscles, muscles of the lower extremities , improve blood and lymph circulation in the pelvic area, which has a beneficial effect on bone regeneration and maintaining the stereotype of support and walking. Physiotherapy - magnetotherapy or ultrasound, at this stage they have analgesic, vasodilating, anti-inflammatory and trophic effects. Massage of the lower extremities reduces tissue swelling, accelerates the resorption of subcutaneous hematomas, improves reparative processes in the tissues. The more intensive execution of the first two stages at the third stage of exercises - with the transition from smaller loads to larger ones, from a small amplitude of movements in the joints to a larger one, strengthens muscles, improves muscle performance, and exercises performed with the external fixation apparatus removed when standing without support , kneeling and on all fours, can increase the load on the lower limbs and strengthen the patient's support ability. Electrical stimulation of the muscles of the back and lower extremities, as well as massage of the lumbosacral regions and lower extremities, strengthens the muscle corset, improves metabolic processes. At this stage, the function of support and movement is fully restored.

 The inclusion at the stages of treatment of exercises with isometric training of weakened muscles improves blood circulation in tensed muscles, eliminates the occurrence of atrophy, and contributes to the speedy restoration of their tone and trophism.

 Monitoring the condition of the patient’s cardiovascular system, at least two times, during physiotherapy exercises (measuring blood pressure and pulse rate) allows an individual approach to dosing loads.

 At the fourth stage of treatment, the fusion of fractures and ruptures of the pelvic ring completely ends. During this period, mechanotherapy and exercises in the swimming pool contribute to reinforcing the restored stereotype of support and help to adapt to the natural conditions of walking.

 According to the proposed method, the Ural Research Institute of Traumatology and Orthopedics treated 105 patients with unstable pelvic ring injuries after transosseous osteosynthesis with the application of spoke and rod external fixation devices. For an objective assessment of the anatomical and functional recovery of the musculoskeletal system of patients after rehabilitation treatment, clinical and radiological methods of examining all patients and a comprehensive biomechanical study of 54 patients were used, including determining the static load on the limbs, podography, support foot reactions, goniography, oscillography of the oscillations of the body segments and electromyography. In all patients at an earlier date, in comparison with the prototype, the function of the musculoskeletal system was fully restored, physical performance was returned.

 The method of rehabilitation treatment is as follows.

 After transosseous osteosynthesis with an external fixation device (RF patents N 1811386 and 2062612), the patient is put to bed and an analgesic drug therapy, psychotherapy, and hypothermia can be applied topically. Diadynamic currents (DDT) are immediately prescribed. DDT is assigned transversely to the focus with a change in polarity. Modulations: 2-cycle wave 3–5 min, short period 3–5 min, long period 2–4 min, daily, no more than 3 fields per procedure. The number of procedures is 10.

 Medical gymnastics classes are carried out in the absence of a patient with severe pain under the supervision of a methodologist. Exercises are carried out individually with a patient, without a large load, they are performed slowly, up to the threshold of pain, in order to avoid reflex muscle tension and possible blocking of joints.

 On day 1-2, breathing exercises and general strengthening (passive) for the upper and lower extremities and for the body are performed. From 2-3 days the patient is activated. He performs pull-ups on the bed frame in the supine position, turns on the side on the bed, performs active movements in the joints of the upper and lower extremities, for example, performs a set of exercises 1-6 from table 1. From 3-4 days, depending on how you feel , the patient begins to sit down in bed, get out of bed with emphasis on the hands, and then they help him move from a lying position to a sitting position with his legs hanging up and stand up with support on the back of the bed and with support on crutches. The standing time with crutches is gradually increased. The patient performs an isometric training of the quadriceps femoris and gluteus muscle group and includes exercises 7-13 in the complex of exercises (see table 1). Exercises are performed with the transition from lighter to exercises with the maximum possible load, reducing it by the end of the session. The load is checked by performing functional tests. For this, the number of heart contractions is determined by the peripheral pulse. The maximum load should not cause the pulse to increase by more than 50% of the initial value, and the time to return the pulse to its original value after exercise should not exceed 2 - 3 minutes. Physical activity is considered optimal with an increase in the number of heart contractions in the middle of a session within 20-25% of the initial one. Increasing or decreasing the load is achieved by changing the number of exercises, the repetition of each exercise, changing the starting positions and pace of the exercises. From 4-5 days after surgery, the patient begins to stand up and walk on his own with crutches.

 At the second stage of rehabilitation treatment, therapeutic gymnastics classes begin with exercises of the first stage, connecting exercises in a standing position with support and walking in place with support. The patient begins to sit with emphasis on the lower extremities until pain or discomfort in the pelvic area appears.

 Exercises of the first period are performed with greater amplitude, load and greater repeatability. The load is gradually increased due to the inclusion of new exercises in the complex with the capture of other muscle groups, perform exercises with isometric tension of the muscles of the thigh and lower leg (table 2).

 6 weeks after the operation, the patient performs exercises to strengthen the gluteal muscles: alternating abduction of straightened legs backward (exercise "swallow") to strengthen the gluteus maximus muscle, alternating abduction of the legs to the side and bringing them to their original position to train the middle and small gluteal muscles. Gradually increases the duration of the walk with the help of crutches on a horizontal plane and proceeds to walk up the stairs.

 To prevent tissue inflammation, reduce pain, improve blood and lymph circulation in the pelvic area, patients are prescribed magnetotherapy or ultrasound.

 Magnetotherapy is prescribed transversely to the focus in 1-3 fields (using devices: Pole-1, Pole-2, Alimp), induction 10 - 12 - 25 mT, exposure time of 15 - 20 min per field, daily , 15 - 20 procedures under the control of blood pressure.

Ultrasound is assigned to the focus in 1 to 3 fields (frequency - 880 kHz). The method is labile, the method is contact, the pulse mode is 2 ms. Power flux density - 0.2 - 0.4 - 0.7 W / cm, daily, 10 - 15 procedures, under the control of blood pressure and the reflexogenic zone (lumbosacral region), frequency - 2640 kHz, contact, labile, mode pulsed - 10 ms, Power flux density - 0.2 W / cm ² , time - 3-5 s.

 To improve blood circulation and prevent muscle atrophy, lower limb massage is prescribed. Massage is carried out after eliminating the pain syndrome.

 The third stage lasts from 8 to 12 weeks. During this period, patients are removed external fixation apparatus. In case of pelvic fractures in combination with ruptures of joints and damage to the acetabulum, the apparatus is removed after 10-12 weeks, for fractures of the pelvis without ruptures of joints and without damage to the acetabulum, the apparatus is removed from the pelvis after 8 weeks. At the third stage, the patient performs dynamic and static exercises of the 1st and 2nd stages, which cover all muscle groups. Exercises are performed with the transition from simple to complex exercises, from the periphery to the center, from small to large loads, from a small amplitude of movements in the joints to large, which increases muscle performance, load on the lower limbs and its motor and support function.

To strengthen the muscle corset, massage is performed and electrical stimulation of the muscles of the back and lower extremities is performed. Electrical stimulation is carried out by DDT or by sinusoidal modulated currents (SMT). DDT parameters: LW (2-stroke wave) 3-5 min, 0V (single-cycle wave) 5-10 min. Polarity reversal, current strength - up to average contractions, daily, 15 - 20 procedures. SMT parameters: mode 1 or 2, type of operation 2, modulation frequency 50 - 80 Hz, modulation depth 75 - 100%> 100%, S ₁ - S ₂ (pause time) 4 - 6 min, 10-20 procedures, daily .

After removing the apparatus from the pelvis, the patient is given a repeated massage course of the lumbar, gluteal regions and lower extremities. In order to improve metabolic processes, blood and lymph circulation, SMT are prescribed transversely to the lesion in 1-3 fields. The mode is variable, type of work III and IV, modulation frequency 70 - 80 Hz, modulation depth 75-100%, S ₁ -S ₂ 2 - 3 min, 5-7 min each kind of work, 10-15 procedures daily. Amperage - up to moderate vibration.

 Patients in this period walk without crutches with a full load on the lower extremities and perform exercises that help to master proper walking (see table 3).

 At the third stage, the function of motion and support is fully restored.

The fourth stage is a late recovery period (from 12 weeks to 6 months). During this period, the union of fractures and ruptures of the joints of the pelvic ring completely ends. To consolidate the restored function of the musculoskeletal system, the patient undergoes a course of mechanotherapy, i.e. classes on simulators (on the "Health" wall, exercise bike). To adapt to the natural conditions of walking using a special training track. If possible, the patient performs exercises in the medical swimming pool. In the aquatic environment, it is possible to dose loads, painlessly restore mobility in the joints, and prevent the development of deforming arthrosis. Patients in this period can recommend a sauna 1 time per week (at a temperature of 90 ^o 1-3 entry into the session), pine baths or baths with sea salt.

 Example. Patient E., 15 years old, and.b. N 91044 was admitted to the clinic of UNIITO with a diagnosis of comminuted fracture of the wing of the right iliac bone, bilateral fracture of the pubic and ischial bones. Rupture of the right sacroiliac joint, contusion of the bladder.

 On the second day after admission, closed transosseous osteosynthesis of multiple lesions of the pelvic ring by an external fixation device developed at the UNIITO (Pat. N 1811386) was performed. During the operation, damage was repaired and the front and rear parts of the pelvic ring and the area of fractures of the wing of the right ilium were rigidly fixed. After surgery, according to the proposed method, the patient underwent a course of rehabilitation treatment. On the first day, a course of breathing exercises was performed. From 2 days the patient was activated - performed exercises 1-6, and from 3 days - exercises 7-13 from table 1 (see description), performed pull-ups on the Balkan bedside frame, turned independently. Isometric training of the gluteal muscles and muscles of the anterior surface of the ribs was performed 6-8 times with maximum tension and subsequent relaxation. From 3 days to anesthetize pelvic injuries and stimulate trophic processes, a course of physiotherapy with diadynamic currents was conducted (10 procedures). From the 4th day the patient began to sit down in bed, to rise with emphasis on the hands, on the 5th day - to stand on her feet with support on the back of the bed and on crutches. The standing time with crutches was gradually increased (until fatigue). After 14 days, the patient independently moved around the room with crutches. The second stage of rehabilitation treatment included exercises 1-17 (table 2 in the description). The exercises were carried out with greater amplitude, load and greater repeatability than in the first stage. On day 16, the patient was prescribed a lower limb massage to improve blood circulation and prevent muscle atrophy (10 procedures) and elastic bandaging of the lower extremities was prescribed for the prevention of thromboembolic complications. On day 20, a course of magnetotherapy was prescribed - 15 procedures.

 After 8 weeks, the patient began to walk with a cane. On X-ray gammograms, there were signs of fusion of fractures of the pelvic bones, there was no secondary displacement in the area of fractures and joints of the pelvis.

 On the 70th day after the operation (the third stage of treatment), the patient was prescribed massage to strengthen the back muscles and electrical stimulation of the back muscles - 15 procedures. Consistently with exercises 1-2 stages of treatment, the patient performed additional exercises 1-9 (table 3 descriptions). The external fixation apparatus was removed from the pelvis after 87 days of fixation during joint fusion of joints, after clinical and radiological examinations and functional tests with a relaxed apparatus.

 The patient walked without additional support. Movement in the joints of the lower extremities was restored in full.

 89 days after the operation, the patient was discharged for outpatient treatment to undergo the fourth stage of rehabilitation treatment, which included a set of exercises of the previous three stages at a more intense pace, a course of exercises on a stationary bike. The patient underwent a general course of massage and took therapeutic baths.

 Inspected after a year. There are no complaints. The patient began classes at school. A comprehensive biomechanical study was carried out, which confirmed the complete restoration of the function of the musculoskeletal system (all indicators of the musculoskeletal system in walking are normal). An x-ray showed complete restoration of the bony structures of the pelvic ring.

 Thus, the rehabilitation treatment of patients with severe pelvic injuries after transosseous osteosynthesis with external fixation devices, using phased connection of special therapeutic physical exercises in combination with massage and physiotherapeutic procedures from the first days after the operation, allows completely restoring the stereotype of support and walking, restoring physical performance and working capacity patient, significantly reduce the duration of treatment.

Claims (3)

 1. A method of rehabilitation treatment of patients with pelvic fractures after surgery, including physiotherapy, massage and a complex of therapeutic exercises with phased respiratory, passive and active exercises, characterized in that the entire period of rehabilitation treatment of patients with an external fixation apparatus is divided into four stages : from 1 to 14 days, from 15 days to 8 weeks, from 8 weeks to 12 weeks and from 12 weeks to 6 months, and at the first stage from 2 to 3 days, active packs are connected to respiratory and passive exercises the exercises that are carried out first in the supine position by pulling on the bed frame, performing circular and flexion movements in the joints of the upper and lower extremities, performing turns in bed, and then from 3 to 4 days they sit in bed with emphasis on the hands, and from 4 to 5 days, the patient is lifted with support, while physiotherapy is carried out daily with diadynamic currents, in the second stage after exercises in the supine position, exercises are performed while standing at the support, by tilting the body, alternately direct abduction of the legs forward and to the side, alternating bending of the legs in the knee and hip joints, with the load on the muscular system of the trunk, hip belt and lower extremities gradually increasing, the complex includes walking in place without additional support and walking with support on crutches first horizontal plane, and then up the stairs, and conduct a course of magnetotherapy or ultrasound, acting on the lumbosacral region, conduct a course of massage of the lower extremities, at the third stage of exercise the first and The various stages are performed with greater effort and in greater volume, with the transition from smaller loads to larger ones, from a small amplitude of movements in the joints to a larger one, and electrostimulation of the muscles of the back and lower extremities is performed, and after removal of the external fixation apparatus, massage of the lumbar, buttock, lower limbs and conduct exercises aimed at restoring the stereotype of walking in a standing position without support, kneeling and standing on all fours, in the fourth stage, mechanotherapy and / or exercises in swimming pool are connected sseyne.  2. The method according to claim 1, characterized in that at the 1st - 2nd or 1st - 2nd - 3rd stages of treatment, exercises are performed with isometric training of weakened muscles with the maximum possible tension and subsequent relaxation and periodically, at least two times per lesson, control the general condition of the patient by measuring blood pressure and determining the number of heart contractions by peripheral pulse.  3. The method according to claim 1, characterized in that in case of an isolated pelvic ring injury, the first and second stages of rehabilitation treatment are carried out in a hospital, and the third and fourth stages can be performed on an outpatient basis.

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