侯樹勛

?

建立團(tuán)隊(duì)康復(fù)新模式是提高康復(fù)水平的前提

侯樹勛

【關(guān)鍵詞】康復(fù)；臨床醫(yī)學(xué)；臨床路徑；病人醫(yī)護(hù)管理

作者單位：100048 北京，解放軍總醫(yī)院第一附屬醫(yī)院、全軍骨科研究所、北京市骨科植入醫(yī)療器械工程技術(shù)研究中心

康復(fù)醫(yī)學(xué) ( rehabilitation medicine ) 是針對(duì)傷病導(dǎo)致的功能障礙進(jìn)行研究及治療，以最大限度減輕患者的殘障，促進(jìn)其生活自理并早日重返社會(huì)為目的的科學(xué)[1]?？祻?fù)醫(yī)學(xué)與臨床醫(yī)學(xué)有著密切的聯(lián)系，但也有自己本身的特點(diǎn)。臨床醫(yī)學(xué)是針對(duì)原發(fā)傷病進(jìn)行治療，以逆轉(zhuǎn)或阻止疾病的進(jìn)程為目的；而康復(fù)醫(yī)學(xué)則側(cè)重于預(yù)防和減輕傷病導(dǎo)致的殘障，促進(jìn)功能的最大恢復(fù)[2]?？祻?fù)醫(yī)學(xué)與臨床醫(yī)學(xué)兩者只有緊密結(jié)合，才符合現(xiàn)代醫(yī)學(xué)生物－心理－社會(huì)模式的要求，才能適應(yīng)當(dāng)代社會(huì)發(fā)展的需要。

縱觀其發(fā)展歷程，康復(fù)醫(yī)學(xué)與臨床醫(yī)學(xué)，特別是骨科學(xué)有著密切的聯(lián)系?，F(xiàn)代康復(fù)醫(yī)學(xué)是在第二次世界大戰(zhàn)以后發(fā)展壯大起來的，這與二戰(zhàn)后四肢脊柱戰(zhàn)創(chuàng)傷傷病員的增多及骨科治療的發(fā)展不無關(guān)系[3]。骨科是研究四肢、脊柱運(yùn)動(dòng)系統(tǒng)疾病的學(xué)科，各類骨科傷病或多或少都會(huì)引起肢體的功能障礙；康復(fù)醫(yī)學(xué)是研究功能障礙的預(yù)防、評(píng)定 ( 診斷 ) 及治療的學(xué)科。兩者的有機(jī)結(jié)合，不僅是治療疾病的需要，更是社會(huì)發(fā)展的需要[4]。在歐美發(fā)達(dá)國(guó)家，骨科疾病的治療早已按照生物－心理－社會(huì)的現(xiàn)代醫(yī)學(xué)模式進(jìn)行。骨科醫(yī)師，康復(fù)醫(yī)師和康復(fù)治療師各自為政的舊醫(yī)學(xué)模式已經(jīng)轉(zhuǎn)變?yōu)閳F(tuán)隊(duì)治療 ( team approach ) 的新模式，骨科醫(yī)師、康復(fù)醫(yī)師、康復(fù)治療師和護(hù)士組成一個(gè)治療小組 ( team work )，共同查房并制訂患者手術(shù)和康復(fù)方案，骨科手術(shù)治療和功能康復(fù)有機(jī)地整合在一起，使患者更好、更快、更全面、更有效地康復(fù)，并重返社會(huì)[5]?？祻?fù)治療貫穿綜合醫(yī)院骨科圍手術(shù)期全程，入院后術(shù)前即對(duì)患者進(jìn)行相關(guān)康復(fù)指導(dǎo)，術(shù)后更是強(qiáng)調(diào)早期康復(fù)，例如在美國(guó)梅奧醫(yī)院，對(duì)于全膝關(guān)節(jié)置換術(shù)后患者，術(shù)后 2 h 即開始在康復(fù)師的指導(dǎo)下進(jìn)行膝關(guān)節(jié)主動(dòng)屈伸功能訓(xùn)練，術(shù)后當(dāng)天即可借助步行器下床行走。不僅如此，康復(fù)治療還完全覆蓋各級(jí)醫(yī)院－社區(qū)－家庭，出院時(shí)醫(yī)師開具康復(fù)處方，安排患者在社區(qū)康復(fù)中心繼續(xù)接受康復(fù)治療，如德國(guó)的患者術(shù)后免費(fèi)接受 5～10 次康復(fù)治療，其目的就是鼓勵(lì)其繼續(xù)康復(fù)，以鞏固療效，防止復(fù)發(fā)，促進(jìn)早日恢復(fù)工作，回歸社會(huì)。實(shí)踐證明，這種骨科康復(fù)一體化的康復(fù)模式有著明顯的優(yōu)越性和強(qiáng)大的生命力，可以明顯縮短患者術(shù)后的康復(fù)時(shí)間，降低住院費(fèi)用，更快速地改善功能，并最終降低致殘率，提高治療效果[6-9]。

改革開放后，隨著國(guó)際交流的日益深入以及自身的不斷發(fā)展，國(guó)內(nèi)骨科臨床醫(yī)學(xué)取得了巨大進(jìn)步，手術(shù)技術(shù)和器械已經(jīng)接近或達(dá)到國(guó)際先進(jìn)水平，在某些領(lǐng)域，如嚴(yán)重脊柱畸形的矯正和顯微外科方面甚至處于領(lǐng)先地位。然而與之相對(duì)應(yīng)的骨科康復(fù)發(fā)展卻明顯滯后，在患者術(shù)后功能恢復(fù)速度和程度、患者的工作能力、生活質(zhì)量等方面和國(guó)際先進(jìn)水平尚有不小的差距[10]。不少患者術(shù)后雖然病痛得到顯著緩解，但仍殘存關(guān)節(jié)僵硬、力量減弱，功能下降的問題，無法完全恢復(fù)正常的工作和生活能力，而許多優(yōu)秀運(yùn)動(dòng)員傷病后，其手術(shù)雖然可以在國(guó)內(nèi)完成，但術(shù)后康復(fù)不得不到國(guó)外進(jìn)行。總體而言，目前我國(guó)康復(fù)發(fā)展，在大多數(shù)地區(qū)甚至不少大型醫(yī)院，均處于較低水平，與國(guó)際水平相距甚遠(yuǎn)，嚴(yán)重影響了患者術(shù)后的功能恢復(fù)及骨科治療的最終療效，也遠(yuǎn)遠(yuǎn)不能滿足人民群眾的健康需求。

康復(fù)發(fā)展的落后以前被簡(jiǎn)單地認(rèn)為主要和經(jīng)濟(jì)不發(fā)達(dá)有關(guān)，患者經(jīng)費(fèi)多用來治病，沒有多余的費(fèi)用來康復(fù)。但其實(shí)主要原因在于觀念和認(rèn)識(shí)不到位，未將康復(fù)作為疾病干預(yù)的重要環(huán)節(jié)來對(duì)待，普遍存在重治療、輕康復(fù)的現(xiàn)象。多數(shù)現(xiàn)行的骨科康復(fù)模式也并非團(tuán)隊(duì)工作模式，缺乏康復(fù)專業(yè)人員參與，只是骨科醫(yī)師和護(hù)士單方面地籠統(tǒng)地向患者交代一些術(shù)后康復(fù)要點(diǎn)和方法，患者便開始所謂的自行康復(fù)，期間也無系統(tǒng)和針對(duì)性強(qiáng)的監(jiān)督指導(dǎo)，因此通常導(dǎo)致患者術(shù)后的康復(fù)時(shí)間延長(zhǎng)，功能恢復(fù)不良，當(dāng)患者再想到康復(fù)科就診時(shí)，已錯(cuò)過了康復(fù)的最佳時(shí)機(jī)，需要更多的時(shí)間和醫(yī)療費(fèi)用，康復(fù)效果也不理想，容易造成較多的并發(fā)癥，給患者及社會(huì)造成嚴(yán)重的負(fù)擔(dān)。

針對(duì)于此，迫切需要參照先進(jìn)國(guó)家經(jīng)驗(yàn)，結(jié)合我國(guó)實(shí)際，建立規(guī)范合理的骨科康復(fù)新模式和科學(xué)的康復(fù)臨床路徑。2013 年，北京市科委組織全市 9 家三級(jí)甲等醫(yī)院以及二級(jí)醫(yī)院、社區(qū)衛(wèi)生服務(wù)站等各級(jí)醫(yī)療機(jī)構(gòu)，開展實(shí)施了骨科常見疾病術(shù)后康復(fù)模式和臨床路徑研究，通過所有參與單位的不懈努力，該課題目前已順利完成，相信課題的研究成果可以為探索建立適合我國(guó)國(guó)情的康復(fù)模式提供有益的參考，為我國(guó)康復(fù)醫(yī)學(xué)早日達(dá)到世界先進(jìn)水平做出貢獻(xiàn)。

參 考 文 獻(xiàn)

[1] David Ip. Orthopedic Rehabilitation, Assessment, and Enablement. 1st ed, Berlin: Springer publisher, 2007: 3.

[2] David Ip. Orthopedic Rehabilitation, Assessment, and Enablement. 1st ed, Berlin: Springer publisher, 2007: 4.

[3] 勵(lì)建安, 周謀望. 中國(guó)骨與關(guān)節(jié)臨床的康復(fù)之夢(mèng). 中國(guó)骨與關(guān)節(jié)雜志, 2014, 3(9):646-648.

[4] 于長(zhǎng)隆. 骨科康復(fù)學(xué). 北京: 人民衛(wèi)生出版社. 2010: 6-10.

[5] 陸麗娟, 許勤, 秦芳艷. 全膝關(guān)節(jié)置換術(shù)后患者康復(fù)問題的研究進(jìn)展. 中國(guó)骨與關(guān)節(jié)雜志, 2014, 3(9):685-688.

[6] Quack V, Ippendorf AV, Betsch M, et al. Multidisciplinary rehabilitation and fast-track rehabilitation after knee replacement: faster, better, cheaper? A survey and systematic review of literature. rehabilitation (Stuttg), 2015, 54(4):245-251.

[7] Oosterhuis T, Costa LO, Maher CG, et al. Rehabilitation after lumbar disc surgery. Cochrane Database Syst Rev, 2014, 3:CD003007.

[8] McGregor AH, Probyn K, Cro S, et al. Rehabilitation following surgery for lumbar spinal stenosis. Cochrane Database Syst Rev, 2013, 12:CD009644.

[9] Momsen AM, Rasmussen JO, Nielsen CV, et al. Multidisciplinary team care in rehabilitation: an overview of reviews. J Rehabil Med, 2012, 44(11):901-912.

[10] 戴閩, 艾江波. 骨科運(yùn)動(dòng)康復(fù)的現(xiàn)狀與展望. 中國(guó)矯形外科雜志, 2011, 19(7):603-604.

( 本文編輯：王萌 )

. 骨科康復(fù) Orthopedic rehabilitation .

New rehabilitation pattern in team is the premise of the improvement

Hou Shu-xun. Orthopaedic Institute of CPLA, the fi rst Af fi liated Hospital of PLA General Hospital, Beijing, 100048, PRC

【Abstract】Rehabilitation medicine is the science to alleviate the patient's disability and promote self-care and early return to the society by the research and treatment of dysfunction caused by injuries. Rehabilitation medicine is closely linked to the clinical medicine with its own characteristics, focusing on the prevention and mitigation of the dysfunction to maximum the recovery. Only closely integrated, can they be consistent with modern medicine pattern biology-psychology-sociology to meet the needs. Orthopaedics is a discipline on the research of limbs and spinal diseases, and orthopedic injuries can cause dysfunction of limbs. Rehabilitation medicine is the research of dysfunction prevention, assessment ( diagnosis ) and treatment. Combination of the two is not only the need of treatment, but the need of social development. In the developed countries in Europe and US, the treatment of orthopedic disorders has already followed bio - psycho - social model of modern medicine. Fragmented treatment of the old medical model by orthopedic surgeons, rehabilitation doctors and rehabilitation therapists has been transformed into a new model in team approach. Orthopedic surgeons, rehabilitation physicians, nurses, and rehabilitation therapists are organized as a team to go the rounds of the wards and individualize rehabilitation schedule, achieving better, faster, more comprehensive and more effective rehabilitation and reintegration into society. After the reform and opening up, the domestic clinical medicine in orthopedics has made tremendous progress and surgical techniques and instruments have been close to or reached the international advanced level with the deepening international exchanges and its continuous development. However, orthopedic rehabilitation has lagged behind in the postoperative recovery speed and extent, patient's ability to work, quality of life, and other aspects with a big gap. To address it, a standard, reasonable new model and scienti fi c clinical pathway are in urgent need, combing the experience of advanced countries and China's reality. 2013, Beijing Municipal Science and Technology Commission organizes the city’s 9 hospitals of class 3 grade 1, hospitals of class 2, community health service stations and other medical institutions at all levels to carry out the research of rehabilitation pattern and clinical pathway. With tireless efforts of all participants, the project has been successfully completed. I believe the research outcomes can provide reference for the exploration of rehabilitation model suitable for China, and make contributions to list China in the advanced level of the world.

【Key words】Rehabilitation; Clinical medicine; Critical pathways; Patient care management

( 收稿日期：2016-03-02 )

基金項(xiàng)目：北京市科技計(jì)劃項(xiàng)目 ( D13110700490000 )

DOI:10.3969/j.issn.2095-252X.2016.03.002

中圖分類號(hào)：R493