The early intervention of rehabilitation treatment is very important to improve the overall level of treatment of earthquake casualties, prevent and reduce disability, and promote the early return of casualties to society. In order to enable medical personnel to correctly grasp the timing and standards of early rehabilitation treatment for common injuries, treatment principles and methods, and to provide scientific and standardized early rehabilitation services for the injured, this guideline is formulated.
Common injuries in earthquake casualties include spinal cord injury, limb fracture, amputation, traumatic brain injury, and neurogenic bladder.
If the admitting hospital lacks rehabilitation professionals, the relevant medical personnel should carry out early basic rehabilitation treatment and care for the casualty under the guidance of trained and rehabilitation professionals. After the injured person’s vital signs are stable, he should be transferred to a professional rehabilitation institution as soon as possible.
A, the spinal cord injury early rehabilitation treatment principles
(A) the timing and standards of intervention. Injury or surgery after the vitals are stable, spinal fractures, dislocations, spinal stability after fixation, you can start to implement rehabilitation treatment.
(B) Treatment principles and methods.
1.Acute instability period. Refers to the post-injury or spine, spinal cord within 4 weeks after surgery. The following applies to the rehabilitation of all types of spinal cord injury.
(1) to carry out respiratory function training, including thoracic breathing (thoracolumbar segment injury applicable) and abdominal breathing (cervical segment injury applicable) training, postural sputum evacuation training and thoracic movement training.
(2) In the emergency phase, indwelling catheterization is mostly used, and bladder function training such as intermittent catheterization (4-6 times a day), voluntary urination or reflex urination should be started after stopping intravenous rehydration.
(3) Active and passive movements of limb joints should be performed as early as possible. To prevent secondary injury, shoulder joint abduction should not exceed 9O° for cervical instability; hip flexion should not exceed 90° for thoracolumbar instability. Pay attention to the placement of the limb to prevent joint contracture deformity.
(4) In principle, all muscles that can be actively exercised should be trained for muscle strength enhancement to prevent muscle atrophy or muscle strength loss.
(5) Conduct adaptive training to promote blood circulation and autonomic function, including gradually sitting up from the supine position, from sitting on the edge of the bed to sitting in a wheelchair, etc. When available, tilt bed should be used for standing training.
(6) To prevent pressure sores, axial turning should be performed once every 2 hours, and a lower extremity blood circulation pump should be used to prevent deep vein thrombosis when available.
(7) For casualties with simple spinal fractures, this period is mainly for trunk muscle isometric strength training, with braces to protect the spine and prevent further injury.
2.Acute stabilization period. It refers to about 4-12 weeks after the injury or spine and spinal cord surgery. The rehabilitation treatment in this period should be based on the continuation of the above training, according to the type of injury to add the following:
(1) Standing training, position change and mobility and activities of daily living (ADL) training for paraplegic and quadriplegic injured persons with the help of electric rising beds, assistive devices and therapists. Timely training of bowel control, such as clean catheterization, regular water intake, regular urination, defecation and reflex urination and defecation training.
(2) Residual muscle strength training. Depending on the patient’s injury segment, muscle strength training of diaphragm and auxiliary respiratory muscles, core stabilizer of neck, deltoid, biceps, triceps, latissimus dorsi and other residual muscles should be emphasized.
(3) Walking training. For the casualty with good spinal stability, the experienced therapist can instruct the casualty to start walking training with the help of knee-ankle-foot orthosis (KAFO), ankle-foot orthosis (AFO) or weight-shifting walking orthosis (such as Walkabout or RGO) under close supervision.
Acute stage casualties should be trained with protective supports such as neck brace (cervical spine injury) and lumbar brace (lumbar spine injury).
(C) Rehabilitation nursing points.
1.The skin condition of pressure sores should be checked daily, and bedridden casualties should be turned axially once every 2 hours.
2. Keep the urinary catheter open when it is placed, and pay attention to clamping and opening it regularly. Drink 2000ml-2500ml of water daily, control the urine volume at about 400ml each time, and control the urine volume at 1000ml-1500ml in 24 hours. the urine volume can be increased during critical resuscitation. Drink water regularly and quantitatively, try to stop indwelling catheterization and apply intermittent catheterization when possible.
3. Develop the habit of regular defecation, keep defecating 1-2 times a day. If there is fecal incontinence, it is easy to cause perianal skin rupture and induce pressure sores, so the perianal skin should be washed with water and coated with protective oil in time.
4, cervical medullary injury resulting in tetraplegia of the wounded if the following injury site by adverse stimulation (such as bladder filling, pressure sores, muscle spasm, constipation, etc.) can suddenly appear headache, sweating, breath-holding, skin flushing, tachycardia or bradycardia, increased blood pressure and other signs of autonomic reflex hyperactivity. When the above symptoms appear, you should immediately adopt a head-high, foot-low position and eliminate the trigger as soon as possible. If the bladder is full, the urinary tract is not smooth or the stool is difficult to pass, the casualty should be assisted to defecate immediately. For those who cannot relieve the elevated blood pressure can use antihypertensive drugs as appropriate.
(D) the matching of assistive devices.
1, cervical medullary injury should be optional high-backed wheelchair or ordinary wheelchair depending on the casualty, upper cervical medullary injury can be optional electric wheelchair. Early activity can be equipped with a neck brace, if necessary, the configuration of functional hand orthoses.
2, thoracic 1-4 spinal cord injury casualties are routinely equipped with ordinary wheelchairs, toilets, bath chairs and pick-up devices. Those who are eligible can be equipped with paraplegic walking orthoses or hip, knee, ankle and foot orthoses, with walking frames, crutches, lumbar circumference, etc. for therapeutic standing and walking training.
3, most of the thoracic 5 – lumbar 2 spinal cord injury injuries can be paraplegic walking orthosis or knee ankle foot orthosis with walking frame, crutches, waist circumference, etc. for functional walking training.
4.Most of the spinal cord injury patients with lumbar 3 and below can walk independently with the help of ankle-foot orthosis, elbow crutches or cane.
Early rehabilitation principles of limb fracture treatment
(a) Intervention timing and standards. After orthopedic treatment, fracture patients with stable vital signs, good internal/external fixation, no signs of active bleeding and severe wound infection can be rehabilitated.
(B) Treatment principles and methods.
1.Acute instability period. It refers to 4 weeks after the injury or surgery. The focus of rehabilitation treatment during this period is to stop pain and bleeding, promote the absorption of inflammatory exudate and reduce swelling; carry out exercise therapy for uninvolved joints and healthy limbs to promote blood circulation and prevent muscle atrophy and joint adhesions.
(1) Isometric contraction training of the muscles of the affected limb without pain, such as isometric contraction of the quadriceps muscle after femur fracture and tibia fracture. Active and passive activities of non-fixed joints should be implemented 1-2 times a day, and the range of activities should be as normal as possible, and normal movements of the healthy limb can be done as much as possible.
(2) Under the condition of good fracture fixation, the injured person with upper limb fracture should start full weight-bearing activities on the ground as early as possible, and the injured person with lower limb fracture should start partial weight-bearing activities on the ground with the help of orthoses and crutches under the condition of good fracture fixation. Start ADL training.
(3) The injured person should elevate the affected limb and perform abdominal breathing and deep breathing training when resting in bed to prevent crush pneumonia.
2.Acute stabilization period. It refers to about 4-12 weeks after the injury or surgery. The focus of rehabilitation treatment during this period is to promote the growth and hardening of bone scabs, and to strengthen muscle strength and joint mobility training without affecting the stability of the fracture, so as to enhance muscle strength and increase joint mobility.
(1) On the basis of increasing the frequency and intensity of muscle strength and joint mobility training, upper limb fractures can be trained with the help of a functional bicycle. The lower extremity fracture casualty can start to move with weight with the help of crutches and braces, starting from 10%-20% of the casualty’s body weight, and increasing 5%-10% of the casualty’s body weight every week according to the condition.
(2) According to the situation, ultrasound and audio electric therapy are used to promote fracture healing, scar softening and joint adhesion release.
3.Recovery period. Generally for about 12 weeks after the injury or surgery. During this period, the fracture is basically healed, and the injured person should increase the intensity of rehabilitation treatment to promote the early and rapid return to normal function of the affected limb.
(1) Increase the frequency and intensity of acute treatment; strengthen the active and passive joint mobility training until the joint mobility returns to normal; continue to carry out progressive weight-bearing activities on the ground with the help of crutches and braces until the X-ray examination shows that the fracture heals well and the single leg can fully stand with weight before abandoning the crutches.
(2) Continue ADL training to gradually restore the self-care, work and movement abilities of the injured person.
(3) Teach the casualty to correctly position and move the affected limb, turn over, transfer the position, and correctly implement gait and hand function training in different stages of treatment, which can effectively reduce the pain of the affected limb and the adverse stimulation of the fracture site by training, prevent fracture displacement, and reduce the occurrence of complications.
(iii) Key points of rehabilitation care.
1. Give guidance on body position and movement according to the fracture site of the casualty. Supervise and guide the casualty to perform simple joint mobility, muscle strength, weight-bearing, walking and other training in the ward.
2.Prevent complications, such as secondary injuries (falls, burns, etc.), disuse syndrome, lower limb venous thrombosis, swelling, pain and infection of the affected limb, etc.
3.Psychological care, home and community rehabilitation nursing guidance.
(iv) The matching of auxiliary appliances.
1.Apply functional orthoses and functional training orthoses according to the injury. Lower limb fractures can be configured with the corresponding parts of the load-free orthosis or fixed orthosis.
2.People with swollen limbs need to make pressure limb sleeves or pressure garments, and lower limb fractures can use axillary canes, elbow canes, walking sticks and other walking aids, and some injured people need to use wheelchairs, toilets and bathing chairs.
Early rehabilitation treatment principles of amputation
(A) Intervention timing and criteria.
1.Wound healing 1 week after amputation, stable vital signs, no serious infection and bleeding signs.
2. If there are bad stumps (including deformity, scar, neuroma, infected sinus tract) affecting prosthetic assembly after amputation and need to be treated by surgery again, rehabilitation treatment will be given before and after surgery again.
(B) Treatment principles and methods.
1, early can give the stump change, pressure bandage or apply pressure limb sleeve. The pain of the residual limb can be given analgesic drugs or local closure treatment. In case of undesirable stumps affecting the prosthetic assembly, stump shaping surgery or neuroma resection surgery is required.
2.If the stump is swollen, ice, air pressure and ultrashort wave therapy can be used; stump wound infection can be treated with ultrashort wave, ultraviolet light and electromagnetic wave therapy; stump pain can be treated with transcutaneous electrical nerve stimulation, modulated medium frequency electrical therapy and microwave therapy; stump scar can be treated with ultrasound, audio electrical and wax therapy. Neuromuscular electrical stimulation, myoelectric biofeedback therapy can prevent residual limb muscle atrophy.
3, carry out residual limb training, including residual limb passive movement, joint loosening, stretching, active movement, muscle strength and endurance training, stump weight-bearing training, sensory training, etc. Upper limb amputation of the wounded should be coordinated movement of the upper limb, prosthetic wear and use training, etc.; lower limb amputation of the wounded should be progressive weight training, transition prosthesis standing weight training, weight loss walking training, wearing prosthesis walking training, balance training, gait training and aerobic training, etc.
4.Implementation of limb function, hand function, prosthesis use, ADL ability training depending on the condition of the injured person.
5.The prevention and treatment of common complications. Common complications include: hip flexion and abduction deformity, knee flexion and contracture deformity, chronic osteomyelitis, neuralgia, and pain of the affected limb. For hip flexion and abduction deformity, postoperative plaster bandage or orthotic fixation and good limb position should be used; for knee flexion and contracture deformity, plaster or orthotic fixation should be gradually straightened and surgical treatment should be performed if necessary; for chronic osteomyelitis, drug exchange, drug flushing and physiotherapy should be used, and surgical treatment should be performed if necessary; for neuralgia, physiotherapy and local closure should be used, and surgical treatment should be performed if necessary The wounded with phantom limb pain should use pain medication, physiotherapy, local closed treatment, acupuncture treatment and psychotherapy, etc.
(C) rehabilitation care points.
1.The skin condition of the residual limb (swelling, wound healing, skin temperature, blood flow and sensation, etc.) and the degree of knowledge of the injury should be assessed first.
2.Maintain the appropriate position of the residual limb, such as above-knee amputation with the affected hip joint straightened and soft pillow padded on the outside of the hip to prevent hip flexion and abduction; below-knee amputation with the knee joint straightened, etc.
3.Guide the injured person to control the weight to prevent the body from being too fat or too thin to affect the adaptability of the prosthesis receiving cavity.
4.Under the guidance of the rehabilitation physician and rehabilitation therapist, supervise and guide the injured person to carry out rehabilitation training in the ward.
5.Prevent secondary injuries (such as falls, burns, etc.), disuse syndrome, lower limb venous thrombosis, residual limb swelling, pain, various infections, cardiovascular diseases, etc.
6. Pay attention to psychological care and family rehabilitation guidance.
(D) the matching of assistive devices.
1, upper limb amputation wounded according to the amputation site, the residual limb condition to install mechanical prosthesis, prosthetic hand, when possible to install myoelectric prosthesis; lower limb amputation wounded to install temporary prosthesis after wound healing, residual limb deformation after replacement for permanent prosthesis, the conditions can be used after surgery that hard dressing.
2, upper limb amputation wounded can be configured according to the needs of different types of self-help devices, pressure limb set, lower limb amputation can choose to configure pressure limb set, wheelchair, walking frame, axillary cane, elbow cane, cane, toilet seat and bath chair.
Early rehabilitation treatment principles of traumatic brain injury
(A) intervention timing and standards. The earlier the rehabilitation treatment of traumatic brain injury, the better, and should be throughout the acute period to the recovery period. Any injured person with neurological dysfunction should receive rehabilitation treatment to varying degrees.
(B) Treatment principles and methods.
1, the acute period. Generally refers to 2-4 weeks after a mild injury, 4-6 weeks after a moderate injury, 6-8 weeks after a severe or very severe injury.
(1) the casualty should maintain the natural position when lying in bed. Rock the head of the bed several times a day for 20-30 minutes each time. In principle, turn over once every 2 hours.
(2) Encourage the casualty who is conscious to take the initiative to perform light physical activities. If active movement is not possible, passive joint movement must be performed to avoid joint contracture.
(3) The casualty should be given positive environmental stimulation, including music, touch, and calls from relatives, etc., and ensure adequate nutrition. Back patting, breathing exercises and postural drainage should be given to casualties with respiratory impairment.
(4) Any treatment should avoid inducing epilepsy and cranial pressure increase, etc.
2.Recovery period. During this period, the casualty’s vital signs are relatively stable, neurological symptoms are not aggravated, cerebral edema and intracranial hypertension have been controlled, and no new changes in condition requiring surgical treatment have occurred. The external cerebrospinal fluid drainage tube has been removed or the ventricular-abdominal drainage tube is open, and there is no cerebrospinal fluid leakage. No serious dysfunction of other important organs, no progressive development of lesions on CT or other imaging, no serious infection, diabetic ketoacidosis. There is still persistent neurological dysfunction or complications that affect self-care.
During this period, treatment should be arranged in a targeted manner for the type and degree of functional impairment of the casualty, with gradual progress and attention to changes in condition and casualty safety. In addition to rehabilitation professionals and technicians, the joint participation of family members and other relevant personnel is also required.
(1) Assess the casualty’s physical function, mental and psychological state, speech and swallowing function, etc., to understand in detail the degree of functional impairment, and develop rehabilitation treatment plans and goals accordingly.
(2) The casualty with consciousness impairment can be treated with drugs and hyperbaric oxygen to promote the recovery of consciousness, and the family should actively cooperate in the affectionate arousal.
(3) Traumatic brain injury victims often have a combination of memory, attention, orientation, calculation and other impairments, and can be rehabilitated through medication, hyperbaric oxygen therapy and cognitive function training, which requires active cooperation from family members.
(4) If there is a decrease in language expression, comprehension, reading and writing ability, speech training should be conducted. Medical personnel and family members, etc. should communicate more with the casualty verbally.
(5) The way of eating should be determined based on the assessment of the casualty’s articulation and swallowing function, and if necessary, the gastric tube should be retained for articulation and swallowing function training. Family members and other relevant personnel should feed the patient under the guidance of the rehabilitation professional to prevent accidental aspiration or choking.
(6) Assist the casualty in joint movement, sitting, standing, balance and coordination, walking, and motor control training based on full consideration of the casualty’s condition, physical strength, and cardiopulmonary function. Attention should be paid to safety during training to prevent accidents such as falls.
(7) Strengthen the training of the injured person’s ADL ability, strive to restore the self-care function of the healthy limb as soon as possible, and gradually promote and restore the self-care ability of the affected limb. If necessary, assistive devices and orthotics can be used.
(8) For the casualties with defecation dysfunction, we should first find out the cause and carry out targeted treatment. Select appropriate defecation and urination methods and develop correct defecation and urination habits. If there is neurogenic bladder, please refer to the rehabilitation treatment of neurogenic bladder.
V. Principles of early rehabilitation treatment for neurogenic bladder
(A) Timing and criteria for intervention. Rehabilitation treatment can be started after the casualty has urinary storage or voiding dysfunction such as urinary difficulty, urinary retention, urinary incontinence, etc., and the vital signs are stable.
(B) Treatment principles and methods.
1.Acute phase rehabilitation. Generally for about 4 weeks after the injury. When the casualty has difficulty in urination and urinary retention, catheterization can be retained until the condition is stable, and the urinary catheter can be changed regularly to prevent urinary tract infection. Intermittent catheterization should be performed as soon as the condition of the casualty allows, once every 4-6 hours. Drink water regularly and quantitatively, and control the urine volume to about 400ml each time.
2.Recovery period rehabilitation.
(1) Protect renal function and ensure that bladder pressure is within a safe range during the storage and voiding periods.
(2) Improve the ability to urinate, reduce the amount of residual urine, prevent urinary tract infection and improve the quality of life of the injured.
(3) Conservative treatment methods such as behavioral training, pelvic floor muscle function training, pelvic floor electrical stimulation, biofeedback, oral medication, intermittent catheterization, and external urinary collectors can be used.
(4) When conservative treatment is ineffective, surgical treatment can be considered, such as botulinum toxin injection to reduce pressure in the urinary storage period, bladder enlargement, posterior sacral nerve root cut + anterior root stimulator, and forced urinary muscle plication, etc. Surgery to reduce outflow tract resistance such as urethral stenting, external urethral sphincter cut, bladder neck cut, etc. is also feasible, and external urinary collectors are used after surgery.
(5) Take correct urination methods to prevent and control urinary tract infection, and try not to use squeezing method to urinate. Regular urinary routine examination, when the white blood cell <10/high magnification field, bacterial growth but no fever, no need to use antibiotics, can be taken orally clear heat diuretic Chinese medicine, drink more water, closely observe the change of body temperature and urine test results; when the occurrence of suspected urinary tract infection immediately urine bacterial culture, there is bacterial growth but the body temperature <38 ℃ can be treated with oral antibiotics; if the body temperature ≥38 ℃, then intravenous antibiotics in the If the temperature is ≥38℃, bladder irrigation should be performed at the same time as intravenous antibiotics.
(6) Periodically perform residual bladder urine volume measurement or urodynamic examination.