Orthopedic rehabilitation

    Orthopedic rehabilitation is based on the principle of functional rehabilitation of skeletal muscle and nervous system. On the basis of clinical diagnosis, treatment and functional evaluation of patients in orthopedics, physical therapy, occupational therapy, prosthetic limb orthopedics and other auxiliary medical means are used to improve or  compensate the damaged body function, improve the quality of life, and as soon as possible. Better return to family and society.

   The basic contents of orthopedics rehabilitation therapy should include physical therapy, occupational therapy, functional training, rehabilitation nursing, psychotherapy, artificial limb and orthopedic assistant.

    Department of orthopedics rehabilitation includes preoperative rehabilitation, intraoperative risk control and postoperative rehabilitation. Orthopedic surgeons should not only pay attention to surgical techniques, but also pay attention to perioperative rehabilitation, comprehensive management and postoperative follow-up, which is the premise to ensure functional recovery after operation. Comprehensive management includes reducing trauma, bleeding, pain, preventing infection and venous thromboembolism.

1.Department of orthopedics rehabilitation general assessment: 
(1) Pain assessment: visual analogue scale (VAS) and so on.
(2) Sensory function assessment: including shallow sensations, deep sensations and complex sensory evaluation. 
(3) Assessment of joint activity (ROM): to understand the range of motion of limbs, joints and spine. 
(4) Joint function assessment scale: commonly used include Harris hip score, the United States Special Surgery Hospital (HSS) Knee Joint Scale, Xi'an University of Ontarioand MacMaster University (WOMAC) Osteoarthritis Index, knee joint injury and Osteoarthritis Outcome score. 
(5) Muscle strength assessment: manual muscle strength test, isokinetic muscle strength test and so on.
(6) Gait assessment: hand gait examination and gait analysis system. 
(7) Activity of daily living assessment(ADL): ADL, instrumental activities of daily living (IADL), modified Pap index(MBI). 
(8) Quality of Life Assessment: Health Survey Questionnaire (SF-36),World Health Organization Quality of Life Measurement Scale (WHOQOL-100), etc.
(9) Limb length / circumference measurement. 
(10) Balance function check: Berg balance scale and balance assessment instrument. 
(11) Function determination: timing standing up walking test, five sitting up test (FTSST) and so on. 

(12) Comprehensive capability assessment.

2.Orthopedic rehabilitation special assessment: 
(1) fracture fixation stability assessment.
(2) fracture healing degree assessment.
(3) spinal stability assessment.
(4) spinal cord injury degree assessment (AIS).
(5) urodynamic assessment.

(6) neuroelectrophysiological assessment.

3.Preoperative rehabilitation: 
(1) Preoperative education: to educate patients and their families about relevant medical knowledge, so that they can cooperate actively to complete preoperative and postoperative rehabilitation training. 
(2) Preoperative assessment: To assess the patient's physiological function and psychological status in order to determine whether they can tolerate orthopedic surgery and cooperate with the completion of postoperative rehabilitation. 
(3) Preoperative rehabilitation guidance: pre-operative planned functional training, so that patients can adapt to and learn the rehabilitation exercise. Such as ankle pump, ROM, quadriceps femoris, rouge and other muscle strength training; auxiliary walking equipment(such as walking aids, crutches) preparation and use; airway preparation, such as preoperative nebulization, cough and expectoration training, improve cardiopulmonary function; bed urination training, prevention of urine retention after surgery. 
(4) Preoperative malnutrition, anemia treatment: malnutrition of patients with elective or limited surgery, preoperative nutritional support treatment is needed. Anemia is first treated in patients with anemia, and anemia is treated at the same time. 
(5) Reduce fasting time: patients can eat solid food 8 hours before operation, clear diet 2-3 hours before operation, and encourage patients to drink appropriate high-carbohydrate beverages 2-3 hours before operation. 

(6) Sleep management: the improvement of insomnia symptoms can significantly alleviate postoperative pain, promote early ambulation and functional exercise, improve patients' comfort and satisfaction degree, and accelerate recovery.

4.Reduce intraoperative injury: minimize surgical trauma, and minimally invasive is an important factor in rapid rehabilitation. Small incision and muscle space operation have less tissue damage, less bleeding and quick recovery of patients' function. At the same time, attention should be paid to anesthesia choice, temperature control, fluid management and infection prevention.

5.Postoperative rehabilitation:
(1) Early rehabilitation training: rehabilitation physicians and therapists conduct early intervention after surgery. Elective surgery (such as joint replacement) can begin on the day after surgery. Emergency surgery (such as fractures) can be reduced, fixed, in order to ensure the safety of patients with early rehabilitation training to prevent joint stiffness and muscle contracture. 
(2) Pain management: pain education, rational pain assessment, preemptive analgesia, post-anesthesia management; multi-mode analgesic use,  individualized analgesia, early use of non-steroidal anti-inflammatory drugs; prevention of complications of non-steroidal anti-inflammatory drugs; and ice compress. 
(3) Edema treatment: swelling often affects wound healing, general treatment methods include local pressure bandaging, ice compress, braking, elevation of affected limbs. If necessary, give the swelling medicine. 
(4)Prevention of venous thromboembolism: basic preventive measures: operation as gentle and delicate as possible to avoid venous intima injury; standardized use of tourniquet; postoperative elevation of affected limbs to prevent deep venous reflux obstacles; intraoperative and postoperative moderate rehydration, drinking more water to avoid dehydration; routine education to encourage patients to turn over and early success Can exercise, get out of bed, do deep breathing and cough movements; suggest that patients improve lifestyle, such as smoking cessation, alcohol cessation, control of blood sugar and blood lipids. Physical preventive measures: patients with active ankle pump exercise, intermittent pneumatic compression device and gradient pressure elastic socks, the use of mechanical principles to accelerate the venous flow of the lower extremity, reduce the incidence of deep vein thrombosis of the lower extremity. Patients with or without physical prophylaxis can be prevented on the opposite side. Drug prevention measures: clinical commonly used drugs: ordinary heparin, low molecular weight heparin, factor Xa inhibitors, vitamin K antagonists, etc.
(5) prevention of postoperative infection. 

(6) postoperative fluid management and drainage tube optimization.

6.Discharge treatment: 
(1) Rehabilitation medicine, rehabilitation hospital or community hospital rehabilitation. 

(2) Follow-up management: 2-3 weeks follow-up: examination of incision, take out stitches, assessment of joint function, treatment of pain, sleep disorders and prevention of venous thromboembolism, timely detection and treatment of complications. 3, 6, 12 months after surgery and subsequent annual follow-up, including functional scale measurement, imaging evaluation, complication management Wait.

7.Rehabilitation appliance application: prosthesis, orthosis, Walker 
and wheelchair.
Rehabilitation after upper extremity traumatic fracture surgery: Rehabilitation therapy is based on fracture reduction and fixation, with full consideration to ensure fracture healing, for possible causes of joint dysfunction factors, such as swelling, adhesion, joint stiffness, muscle atrophy and other physical treatment, occupational therapy ,orthosis and other means to restore the maximum function of the injured part of the limbs to meet the needs of daily life and work.
Rehabilitation after orthopedic surgery can be divided into three stages: 
(1) Early rehabilitation: fibrous call us formation stage (0-4 weeks): Acute stage (within 48 hours after operation) rehabilitation goal is to eliminate swelling, relieve pain, prevent complications. Rehabilitation: protect affected limbs, local immobilization, ice compress, pressure bandage and raising the affected limb. The main form of training is isometric contraction of injured limb muscles. Early rehabilitation to prevent secondary dysfunction is carried out at non injured sites. 
(2) Subacute rehabilitation (48 hours to 4 weeks after operation): the swelling and pain of the affected area were significantly improved, which was an important period for rehabilitation. The goal of rehabilitation is to gradually restore the range of motion of the joints, increase muscle strength training, rebuild neuromuscular control and cardiopulmonary function. Rehabilitation content: Limb elevation, maintain the correct position; Isometric contraction training; Distal injury and adjacent joint range of motion training; Physical therapy: pulsed electromagnetic therapy, low intensity pulsed ultrasound, electrical stimulation treatment. 

(3) Medium-term rehabilitation: Rehabilitation objectives during callus formation (5-12 weeks) are to eliminate residual swelling, in order to soften and stretch contracted fibrous tissue, and  increase joint range of motion and muscle strength, restore muscle coordination. 

Rehabilitation contents: 
1.Continue to increase ROM training until the full range of joint motion is restored. 
2. Joint extension or flexion contracture after fracture healing  can be done with extension or flexion traction. Continuous passive terminal drafts were performed by the therapist within the patient's tolerable range. Continue the muscle strength and endurance training, isometric muscle training can gradually transition to resistance training (by the surgeon to determine fracture healing after the beginning), increase the strength of muscle exercise. 
(4)After clinical diagnosis of fracture healing, all muscle group progressive  resistance exercises can be performed, and strengthen aerobic endurance training, encourage activities of daily living, work and entertainment. 

(5) Late rehabilitation: Fracture healing (after 12 weeks):Rehabilitation goals are: full functional range of activity; full functional muscle strength and endurance; normal participation in all functional activities, work and leisure.

 Rehabilitation Contents: 

1.Joint range of motion: In addition to continuing the previous exercise, joint mobilization can be used three-stage, four-stage loosening technology. 
2.Dynamic or static progressive braces can increase the range of motion of the joint in patients with postoperative stiffness of periarticular fractures of the elbow, wrist and hand. 
3.Contracture and stiffness of the joints can be restored by traction and can be sustained by a therapist within the patient's tolerance. Continue early training to avoid muscle fatigue. The whole body has aerobic endurance training to restore physical fitness. 
4.Proprioceptive neuromuscular enhancement.
5.Functional recovery: encourage activities of daily living, work and entertainment.