1.Psychological rehabilitation guidance
We believe that psychological rehabilitation should be taken as the pivot of functional rehabilitation, and psychological rehabilitation should be used to promote and facilitate functional rehabilitation, mobilize positive psychological factors, and make them participate in the training of functional rehabilitation subjectively and actively. The patients in this group were suffering from the disease and had a strong desire to restore the function of the limbs, and hoped to “get rid of the disease with the knife”, so there were two kinds of situations before and after the surgery: first, they were eager to achieve, and the exercise progress was blindly over-advanced and random activities; second, they were over-cautious and worried that the surgery would fail after the activities. Therefore, before and after the surgery, we should pay attention to the detailed understanding of the patient’s mental reaction, on the one hand, encourage the patient to enhance the confidence of rehabilitation, on the other hand, introduce the purpose of rehabilitation training, methods and precautions. For those who are eager to achieve, guide them to master the appropriate exercise method, and proceed step by step, according to their ability; for those who are too cautious, try to eliminate their doubts, encourage and help them to exercise, and finally make all patients carry out rehabilitation training with a good psychological state.
2.Pre-operative rehabilitation training
The purpose is to make the patients master the methods of functional exercise and clarify the precautions in advance.
(1) Posture guidance Explain to patients the correct postoperative position to prevent prosthesis dislocation. The patient can lie flat or semi-prone, but the affected hip should be flexed <45°, not lying on the side, the affected limb should be abducted 30° and kept neutral, an abduction frame or thick pillow should be placed between the legs, if necessary, suitable anti-rotation shoes should be prepared, and the patient should be arranged to a bed with a bed puller.
(2) Training pull-up exercise Lie flat or semi-lying, with the affected limb abducted neutrally and the healthy lower limb supported on the bed surface by bending the knee, hanging the pull-up ring with both hands, raising the whole body and lifting the hips off the bed, and then lowering it after a pause of 5 to 10 s.
(3) Training bed defecation The purpose is to prevent urinary retention and constipation due to unaccustomed postoperative position. When placing the potty, raise the buttocks to a sufficient height and avoid external and internal rotation of the affected limb. Use a special female urinal for female patients to avoid excessive use of the potty and to increase hip movement.
(4) Instruct the lower limb muscle exercise method isometric contraction training: dorsiflex the ankle joint, tense the leg muscles for 10 s and then relax, then tense again → relax, and so on. Isotonic contraction training: do straight leg raise, small range of knee and hip flexion activities, calf down bedside kicking exercises. The straight leg raise requires the heel to be 20 cm above the bed, and relax after a pause of 5-10 s in the air.
(5) Joint activity training Instruct the healthy limb, toes and ankle joint of the affected limb to move fully, and when the affected limb is flexed at the knee and hip, the hip joint should be flexed <45°, and avoid inversion and internal rotation of the affected hip.
(6) Instruct the correct use of crutches Prepare suitable double crutches so that the height and middle handle of the crutches are appropriate to the patient’s height and arm length, with rubber devices at the bottom of the crutches (anti-slip) and the top of the crutches wrapped with soft pads (to reduce direct pressure on the axilla), train those who can walk before surgery to master the use of the crutches, practice standing with the support of the double crutches and the healthy leg, and walk without weight on the affected limb.
3.Post-operative rehabilitation care
(1) Functional exercise in bed Avoid excessive activities on the day of surgery, lift the hip carefully when moving, and pay attention to the appropriate position to prevent dislocation of the prosthesis and wound bleeding. Give an air ring or sponge pad or water pad to the buttocks. Help lift the buttocks once every 2 hours and massage to prevent decubitus ulcers. It is important to note that the patient’s family should be informed in detail about the postoperative precautions to obtain cooperation. There was a case in which the patient was reoperated on the night after surgery because the family moved the patient at will, resulting in dislocation of the prosthesis.
On the 1st postoperative day, most patients have fear of moving the affected limb due to postoperative pain or pain fear. After giving the patients effective medication for pain relief, they can be helped to do passive activities, such as massage of leg muscles, passive activities of ankle and knee joints, pull-up exercises of upper body and hip, etc., 1 to 2 times/h.
On the second postoperative day, deep breathing and back tapping were continued several times a day, and the isometric and isotonic contraction training and joint activities of the leg muscles were strengthened, with 20-30 minutes of exercises in the morning and afternoon and before bedtime, and 3-4 pull-up exercises. Pull-ups 3-4 times/h and try to complete independently. Note that the amount of exercise is from small to large, the duration of activity is from short to long, and all bed activities are carried out in the abducted neutral position of the affected limb.
(2) Functional exercise out of bed After the condition stabilized in 4-5 days after surgery, the semi-prone position was gradually extended before that to prepare for leaving bed. Method of getting out of bed: Patients first move to the bedside of the healthy side, the healthy side leg first off the bed and make the foot on the ground, the affected limb abduction, hip flexion <45°, assisted by others to lift the upper body so that the affected side leg off the bed and make the foot on the ground, and then stand up with double canes.
When getting into bed, proceed in the opposite direction, i.e., the affected limb goes into bed first. On the first day of bedside activities, stand on the double cane for 5-10 min (depending on the physical condition of each person) in the morning and afternoon, and walk a few steps around the bed when there is no discomfort. The nurse supported the patient and observed whether there was any deficiency. There were 4 cases of deficiency when the patient got out of bed for the first time, which was relieved by returning to bed immediately. On the second day, the patient started to walk with the double cane in the hospital room, and the walking distance was gradually extended and the time was gradually increased but not more than 30 min each time, once in the morning, once in the afternoon and once before bedtime.
When walking, the affected limbs were always kept abducted at about 30° and not weight-bearing, with nurses or family members watching over them to prevent accidents.
(3) Self-care training Encourage patients to perform self-care activities in bed, such as washing face, combing hair, changing clothes, eating, etc. After leaving the bed, train the activities in standing condition to increase appetite, improve the quality of self-care, enhance self-confidence and promote functional recovery.
4. Discharge guidance
All patients in this group were discharged from the hospital 12-15 days after surgery. Because of the long postoperative recovery period, the self-rehabilitation care after discharge is crucial and should be given detailed instructions.
(1) Guidance on getting into and out of bed 2 days before discharge, patients were instructed to leave the bed with the assistance of their family members, and movement demonstrations were made to instruct patients to use the support of both upper limbs and the healthy side of the lower limbs to get into and out of bed by themselves so that they can take care of themselves after discharge.
(2) Postural guidance: Lie flat or semi-lying, avoid lying on the side for 3 months; sit on a chair with armrests as much as possible, flex the hip <45° within 3 weeks, gradually increase the degree of hip flexion later, but avoid >90°, do not put the affected limb on the other leg or cross-legged; stand with the affected limb abducted, avoid internal retraction and internal rotation of the affected limb within 6 months.
(3) Muscle and joint activity training and weight-bearing instruction: Perform the training in bed or standing according to the pre-discharge training method, and gradually increase the training time and intensity. No weight-bearing on the affected limb, walking with a double cane. 3 months after surgery, the affected limb can be gradually weight-bearing, from double cane → single cane → abandoned cane, but must avoid squatting with the affected hip flexed.
(4) Guidance on daily activities Instruct patients to change clothes correctly (such as putting on pants on the affected side first and then on the healthy side), put on socks (hip extension and knee flexion) and shoes (shoes without laces); pay attention to reasonable dietary adjustment, ensure nutrition but avoid excessive weight gain, quit smoking and alcohol; try not to move alone when on crutches; use a cane when abandoning crutches to go out, which is self-protection on the one hand and a hint to the surrounding people on the other hand, to prevent Accidents. When carrying out all activities, try to reduce the weight-bearing degree of the affected hip and all lateral stresses.