艾灸联合功能锻炼在全膝关节置换术后康复治疗中的应用

目的:探讨艾灸联合功能锻炼在全膝关节置换(total knee arthroplasty,TKA)术后康复治疗中的应用价值。方法:将240例接受TKA的膝骨关节炎(knee osteoarthritis,KOA)患者随机分为联合治疗组(120例)和功能锻炼组(120例),前者采用艾灸联合功能锻炼治疗,后者单纯采用功能锻炼治疗。TKA后2 d开始艾灸治疗,选取梁丘穴和足三里穴,每穴灸15 min,每日上午8时和下午4时各灸1次,连续治疗7 d为1个疗程,共治疗2个疗程。TKA后1～14 d进行踝泵训练和卧位膝关节主动屈伸锻炼,TKA后3～14 d进行坐位膝关节主动屈伸锻炼。采用徒手肌力检查分级标准评定下肢肌力,采用视觉模拟量表(visual analogue scale,VAS)评定患膝静息痛和运动痛,采用美国特种外科医院(Hospital for Special Surgery,HSS)膝关节功能评分标准评价患膝运动功能。记录患者首次主动直腿抬高时间、首次下床时间,观察不良反应发生情况。结果:联合治疗组1例患者,因吸入艾灸烟雾后出现胸闷、咳嗽症状而退出研究;功能锻炼组1例患者,因术后2 d下床活动跌倒造成假体周围骨折而退出研究。膝部静息痛VAS评分,时间因素和分组因素存在交互效应(F=13. 251,P=0. 000); 2组患者膝部静息痛VAS评分总体比较,组间差异有统计学意义,即存在分组效应(F=10. 528,P=0. 009);术后不同时间点膝部静息痛VAS评分的差异有统计学意义,即存在时间效应(F=6. 353,P=0. 000); 2组患者膝部静息痛VAS评分随时间变化均呈下降趋势,但2组的下降趋势不完全一致(2. 59±0. 49)分,(2. 54±0. 43)分,(2. 09±0. 31)分,(1. 99±0. 40)分,F=0. 890,P=0. 000;(2. 70±0. 51)分,(2. 68±0. 35)分,(2. 64±0. 40)分,(2. 26±0. 29)分,F=3. 625,P=0. 000];术后24 h、48 h,2组患者膝部静息痛VAS评分的组间差异均无统计学意义(t=-0. 311,P=0. 710; t=-0. 324,P=0. 751);术后72 h、96 h,联合治疗组的膝部静息痛VAS评分均低于功能锻炼组(t=9. 335,P=0. 000; t=6. 640,P=0. 000)。膝部运动痛VAS评分,时间因素和分组因素存在交互效应(F=8. 741,P=0. 003); 2组患者膝部运动痛VAS评分总体比较,组间差异有统计学意义,即存在分组效应(F=9. 283,P=0. 023);术后不同时间点膝部运动痛VAS评分的差异有统计学意义,即存在时间效应(F=5. 336,P=0. 000); 2组患者膝部运动痛VAS评分随时间变化均呈下降趋势,但2组的下降趋势不完全一致(3. 51±0. 66)分,(3. 13±0. 53)分,(2. 59±0. 39)分,(2. 23±0. 38)分,F=5. 632,P=0. 000;(3. 63±0. 73)分,(3. 31±0. 59)分,(3. 08±0. 40)分,(2. 71±0. 39)分,F=4. 850,P=0. 000];术后24 h、48 h,2组患者膝部运动痛VAS评分的组间差异均无统计学意义(t=-1. 105,P=0. 272; t=-2. 105,P=0. 068);术后72 h、96 h,联合治疗组的膝部运动痛VAS评分均低于功能锻炼组(t=6. 015,P=0. 000; t=6. 163,P=0. 000)。下肢肌力评分,时间因素和分组因素存在交互效应(F=10. 201,P=0. 000); 2组患者下肢肌力评分总体比较,组间差异有统计学意义,即存在分组效应(F=12. 661,P=0. 000);术后不同时间点下肢肌力评分的差异有统计学意义,即存在时间效应(F=8. 635,P=0. 000); 2组患者下肢肌力评分随时间变化均呈增高趋势,但2组的增高趋势不完全一致(2. 68±0. 86)分,(3. 00±0. 78)分,(3. 75±0. 63)分,(4. 08±0. 73)分,F=6. 214,P=0. 000;(2. 40±0. 81)分,(2. 54±1. 02)分,(3. 31±0. 67)分,(3. 39±0. 65)分,F=2. 553,P=0. 000];术后24 h、48 h、72 h、96 h,联合治疗组的下肢肌力评分均大于功能锻炼组(t=2. 184,P=0. 029; t=3. 390,P=0. 001; t=4. 535,P=0. 000; t=6. 119,P=0. 000)。联合治疗组的首次主动直腿抬高时间及首次下床时间均短于功能锻炼组(31. 03±10. 78) h,(47. 23±15. 78) h,t=-8. 462,P=0. 000;(25. 76±7. 00) h,(33. 12±11. 18) h,t=-8. 544,P=0. 000],术后7 d HSS膝关节功能评分高于功能锻炼组(79. 55±7. 26)分,(70. 35±8. 10)分,t=15. 041,P=0. 001]。2组患者均未出现恶心、呕吐、肢体麻木及皮肤烫伤等不良反应。结论:对接受TKA的KOA患者在功能锻炼的基础上进行艾灸治疗,可有效减轻患膝静息痛及运动痛、提高下肢肌力,能够早期进行主动直腿抬高训练、早期下床,有助于促进患膝运动功能恢复,且安全性高。

Application of moxa-moxibustion and functional exercises to knee rehabilitation after total knee arthroplasty

Objective:To explore the applied values of moxa-moxibustion combined with functional exercises in knee rehabilitation after total knee arthroplasty(TKA).Methods:Two hundred and forty patients with knee osteoarthritis(KOA)were randomly divided into combination therapy group and functional exercise group after TKA,120 cases in each group.The patients in combination therapy group were treated with moxa-moxibustion combined with functional exercises,and the patients in functional exercise group were treated with monotherapy of functional exercises.Since 2 days after TKA,the moxa-moxibustion was performed at Liangqiu(ST34)and Zusanli(ST36),15 minutes for each acupoint at 8 AM and 4 PM respectively for consecutive two courses of treatment,7 days for each course.Ankle pump training and initiative knee flexion and extension exercises were performed in lying position at 1-14 days after TKA,and the initiative knee flexion and extension exercises were performed in sitting position at 3-14 days after TKA.The muscle strengths of low limbs were evaluated by using manual muscle testing(MMT)grading standard,the knee rest pain and motion pain were evaluated by using visual analogue scale(VAS),and the knee motor function was also evaluated according to Hospital for Special Surgery(HSS)knee function scoring standard.The first initiative straight-leg-raise time and bed rest time were recorded and the adverse reactions were observed.Results:One patient in combination therapy group dropped out of the study for chest distress and cough caused by inhaling moxibustion smoke and 1 patient in functional exercise group dropped out of the study for peri-prosthetic fracture caused by tumble after ambulation on postoperative day 2.There was interaction between time factor and group factor in knee rest pain VAS scores(F=13.251,P=0.000).There was statistical difference in knee rest pain VAS scores between the 2 groups in general,in other words,there was group effect(F=10.528,P=0.009).There was statistical difference in knee rest pain VAS scores between different timepoints after surgery,in other words,there was time effect(F=6.353,P=0.000).The knee rest pain VAS scores presented a time-dependent decreasing trend in both of the 2 groups,while the 2 groups were inconsistent with each other in the decreasing trend of knee rest pain VAS scores(2.59+/-0.49,2.54+/-0.43,2.09+/-0.31,1.99+/-0.40 points,F=0.890,P=0.000;2.70+/-0.51,2.68+/-0.35,2.64+/-0.40,2.26+/-0.29 points,F=3.625,P=0.000).There was no statistical difference in knee rest pain VAS scores between the 2 groups at 24th and 48th hour after the surgery(t=-0.311,P=0.710;t=-0.324,P=0.751).The knee rest pain VAS scores were low in combination therapy group compared to functional exercise group at 72nd and 96th hour after the surgery(t=9.335,P=0.000;t=6.640,P=0.000).There was interaction between time factor and group factor in knee motion pain VAS scores(F=8.741,P=0.003).There was statistical difference in knee motion pain VAS scores between the 2 groups in general,in other words,there was group effect(F=9.283,P=0.023).There was statistical difference in knee motion pain VAS scores between different timepoints after surgery,in other words,there was time effect(F=5.336,P=0.000).The knee motion pain VAS scores presented a time-dependent decreasing trend in both of the 2 groups,while the 2 groups were inconsistent with each other in the decreasing trend of knee motion pain VAS scores(3.51+/-0.66,3.13+/-0.53,2.59+/-0.39,2.23+/-0.38 points,F=5.632,P=0.000;3.63+/-0.73,3.31+/-0.59,3.08+/-0.40,2.71+/-0.39 points,F=4.850,P=0.000).There was no statistical difference in knee motion pain VAS scores between the 2 groups at 24th and 48th hour after the surgery(t=-1.105,P=0.272;t=-2.105,P=0.068).The knee motion pain VAS scores were lower in combination therapy group compared to functional exercise group at 72nd and 96th hour after the surgery(t=6.015,P=0.000;t=6.163,P=0.000).There was interaction between time factor and group factor in lower limb muscle strength scores(F=10.201,P=0.000).There was statistical difference in lower limb muscle strength scores between the 2 groups in general,in other words,there was group effect(F=12.661,P=0.000).There was statistical difference in lower limb muscle strength scores between different timepoints after surgery,in other words,there was time effect(F=8.635,P=0.000).The lower limb muscle strength scores presented a time-dependent increasing trend in both of the 2 groups,while the 2 groups were inconsistent with each other in the increasing trend of lower limb muscle strength scores(2.68+/-0.86,3.00+/-0.78,3.75+/-0.63,4.08+/-0.73 points,F=6.214,P=0.000;2.40+/-0.81,2.54+/-1.02,3.31+/-0.67,3.39+/-0.65 points,F=2.553,P=0.000).The lower limb muscle strength scores were higher in combination therapy group compared to functional exercise group at 24th,48th,72nd and 96th hour after the surgery(t=2.184,P=0.029;t=3.390,P=0.001;t=4.535,P=0.000;t=6.119,P=0.000).The first initiative straight-leg-raise time and bed rest time were shorter and the HSS knee function scores measured on postoperative day 7 were higher in combination therapy group compared to functional exercise group(31.03+/-10.78 vs 47.23+/-15.78 hours,t=-8.462,P=0.000;25.76+/-7.00 vs 33.12+/-11.18 hours,t=-8.544,P=0.000;79.55±7.26 vs 70.35±8.10 scores,t=15.041,P=0.001).No adverse reactions such as nausea,vomiting,limb numbness and skin scald were found in the 2 groups.Conclusion:The combination therapy of moxa-moxibustion and functional exercises can effectively relieve knee rest pain and motion pain and improve lower limb muscle strength of patients who received TKA for KOA,and it is helpful to the recovery of motor function of affected knee because patients can perform early initiative straight-leg-raise training and early ambulation.Moreover,it has high safety.