RU2813048C2 - Method of rehabilitation of patients after oncological endoprosthetics of humeral dhaphysus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to the rehabilitation of patients after oncological endoprosthetics of the humeral diaphysis. After endoprosthetics of the shoulder joint, a set of rocking-push exercises is performed, including flexion, extension, abduction, adduction and elevation of the upper limb, as well as internal and external rotation of the arm, performed from a state of pre-tension, within the threshold of pain with an amplitude from 20 to 40 degrees 4 times a day. On days 2–3, the following exercises are performed: the patient stands on the floor, leaning his healthy arm on a couch, bed or window sill, the affected arm is in a relaxed state and performs smooth rocking movements back and forth, left and right for 2–5 minutes, or this exercise is performed while sitting on a chair, while the operated arm is in a hanging, relaxed position and it is used to perform smooth pendulum swinging movements back and forth, left and right for 1–2 minutes. The patient sits on a chair, the operated arm is in a hanging position, the doctor-instructor flexes the elbow joint, turning the arm towards the patient’s chest towards the shoulder, while the shoulder does not move, the palm is turned up and down, bending it at a right angle for 1–2 minutes. The patient sits on a bed or on a chair with the operated upper limb lowered so that the arm hangs freely, and alternately performs flexion and extension movements in the elbow joint 10–12 times within the pain syndrome. On days 3–4: standing, stretching the operated arm forward and holding a load of up to 1 kg in one hand, the patient begins to “draw” letters of the alphabet or numbers in the air for 2–3 minutes. On days 5–7: active movements are performed without the support of a healthy upper limb: flexion and extension around the frontal axis, abduction and adduction around the sagittal axis, supination and pronation around the vertical axis, circular movements, free movement of the forearm and radius.

EFFECT: reduction of pain in patients after oncological endoprosthetics of the humeral diaphysis.

1 cl, 4 dwg, 2 ex

Description

The invention relates to the field of medicine, in particular to methods of physical therapy, and can be used in the rehabilitation of patients after oncological endoprosthetics of the humeral diaphysis.

The maximum return of motor potential is facilitated by rehabilitation after shoulder arthroplasty, which plays a role no less significant than the operation itself. Only after qualitatively going through the entire path of postoperative rehabilitation can a person count on a favorable prognosis - restoration of the functionality of the operated area by 95% -100%. Of course, provided that the prosthetics were performed without flaws - at the highest professional level.

This is due to the need to adhere to the basic principles of surgical interventions in oncological orthopedics, such as sheathing, ablasticity, radicality, performing adequate muscle plasticity, covering the endoprosthesis with soft tissue to reduce the risk of infection.

The existing rehabilitation complexes after operations for endoprosthetics of the humerus of nonspecific origin are aimed primarily at achieving good and excellent functional results in cases of damage to the shoulder and elbow joints.

Rehabilitation methods for treating patients in traumatology and orthopedics are known in the world and domestic literature.

However, the rehabilitation tactics for cancer patients differ significantly from existing standards.

The closest (prototype) is the rehabilitation program after shoulder arthroplasty: exercises and exercise therapy (https://msk-artusmed.ru/reabilitatsiya/posle-endoprotezirovaniya-plechevogo-sustava/). The program includes the introduction of antibiotics, antiseptic treatment of the surgical wound against the activation of infection; therapy with antithrombosis drugs against the formation of blood clots in blood vessels; optimal immobilization of the limb using a bandage with a wedge-shaped pillow installed in the armpit, a bandage or an orthosis for the successful regeneration of soft structures and repair of bone tissue; prescription from the first hours of breathing exercises for pulmonary congestion and the development of pneumonia; the use of highly effective training strictly in stages that load the arm in doses and do not threaten the integrity of the artificial structure; the use of physiotherapy procedures that help improve the trophism of periarticular tissues, stimulate blood circulation, eliminate hematomas, relieve swelling and painful signs, get rid of muscle hypotonicity, etc. Exercises begin to be performed from the first day: from a lying position, the hand is moved behind the head using the healthy hand; movements of the hand in a tilt, first of small and then of greater amplitude; squeezing a ball or any suitable object with a brush. At about 3-4 days, passive mechanotherapy starts. Classes are conducted on a specialized automatic simulator in which the problematic limb is fixed. After 2-3 weeks, they begin to implement a late recovery program, which is based on more intense exercises: the patient stands sideways to the wall and moves his arm to the side (performed initially with a small load, with a gradual increase); stands with his back to the wall and presses his elbow into the wall 5-10 times; performs exercises with an expander. The rehabilitation stage is completed after 12-13 weeks. In the future, it is recommended to continue to engage in exercise therapy at least 3 times a week.

However, this rehabilitation program is intended for orthopedic patients after surgical treatment involving shoulder replacement. Rehabilitation tactics for cancer patients differ significantly from existing standards in traumatology and orthopedics. This is due to the need to adhere to the basic principles of surgical interventions in oncological orthopedics, such as sheathing, ablasticity, radicality, performing adequate muscle plasticity, covering the endoprosthesis with soft tissue to reduce the risk of infection.

The technical solution is to improve functional results and reduce pain in patients after surgical treatment of tumor lesions of the humerus with diaphysis replacement.

The specified technical and therapeutic results in the implementation of the invention are achieved due to the fact that, as in known methods, in the preoperative period they carry out psychological preparation, training in verticalization techniques using immobilization means, as well as training in correct deep chest and diaphragmatic breathing during breathing exercises and carrying out a set of physical exercises aimed at strengthening the muscles of the upper limbs.

The peculiarity of the claimed method is that after endoprosthetics of the shoulder joint, a set of rocking-push exercises is performed, which includes flexion, extension, abduction, adduction and elevation of the upper limb, as well as internal and external rotation of the arm, performed from a state of pre-tension, within the pain threshold with an amplitude from 20 to 40 degrees degrees 4 times a day according to the following scheme:

- on days 2-3 perform the following exercises:

the patient stands on the floor, leaning his healthy arm on a couch, bed or window sill, the affected arm is in a relaxed state and perform smooth rocking movements back and forth, left and right for 2-5 minutes, or this exercise is performed while sitting on a chair, while the operated arm is in a hanging, relaxed position and it is used to perform smooth pendulum swinging movements back and forth, left and right for 1-2 minutes;

the patient sits on a chair, the operated arm is in a hanging position, the doctor-instructor performs flexions in the elbow joint, turning the arm towards the patient's chest towards the shoulder, while the shoulder does not move, the palm is turned up and down, bending it at a right angle for 1 -2 minutes;

the patient sits on a bed or on a chair with the operated upper limb lowered so that the arm hangs freely and alternately perform flexion and extension movements in the elbow joint 10-12 times within the limits of the pain syndrome;

- on days 3-4: standing, stretching the operated arm forward and holding a load of up to 1 kg in his hand, he begins to “draw” letters of the alphabet or numbers in the air for 2-3 minutes;

- on days 5-7: active movements are performed without the support of a healthy upper limb: flexion and extension around the frontal axis, abduction and adduction around the sagittal axis, supination and pronation around the vertical axis, circular movements, free movement of the forearm and radius.

The method is explained with a detailed description, an example of practical use, as well as illustrations showing:

Figure 1 - performing rocking and jerking movements in a standing position: a) the sore arm is in a relaxed state; b) smooth rocking movements back and forth.

Figure 2 - performing rocking-push-like movements in a sitting position: a) rocking movements back and forth; b) left-right.

Figure 3 - performing rocking-push-like movements in the elbow joint: a) the operated arm is in a hanging position; b) the doctor-instructor performs flexion in the elbow joint, turning the arm towards the patient’s chest towards the shoulder.

Figure 4 - performing active movements of the hand using a load: a) the operated hand is extended forward and holds a load of up to 1 kg in the hand; b) the patient draws letters of the alphabet or numbers in the air.

The method is carried out as follows.

In the preoperative period, the rehabilitation program includes: psychological preparation of the patient, training in verticalization techniques and the use of immobilization means together with a rehabilitation physician, training in correct deep chest and diaphragmatic breathing during breathing exercises and a set of physical exercises aimed at strengthening the muscles of the upper limbs.

In the early postoperative period (from day 0), rehabilitation measures are carried out: postoperative pain syndrome is relieved, the patient is verticalized (in order to prevent hypodynamic complications from the respiratory system), the upper limb is immobilized using a bandage with a wedge-shaped pillow, which is installed in the in the armpit, or a special fixing orthosis, breathing exercises are taught to achieve correct positioning of the operated limb.

The set of exercises in the postoperative period includes the following stages.

I. On the 2-3rd day after surgery, they enter a period of relative immobilization, including isometric exercises on the muscles of the operated limb. All exercises (flexion, extension, abduction, adduction and elevation of the upper limb, as well as internal, external rotation and circumduction) are performed from a state of pre-tension within the pain threshold, rocking and jerking, with an amplitude from 20 to 40 degrees:

- an exercise aimed at developing abduction, adduction, elevation and circular movements of the upper limb: the patient stands on the floor, leaning his healthy arm on a couch, bed or window sill, the affected arm is in a relaxed state (Fig. 1 a) and performs smooth rocking movements forward - back (Fig. 1 b), left and right for 2-5 minutes - 4 times a day, or this exercise is performed while sitting on a chair (depending on the patient’s condition), while the operated arm is in a hanging relaxed position and it is used to perform smooth pendulum swinging movements back and forth (Fig. 2 a), left and right (Fig. 2 b) - for 1-2 minutes 4 times a day;

- an exercise aimed at developing flexion, extension, abduction, adduction, elevation, internal and external rotation of the upper limb: the patient sits on a chair, the operated arm is in a hanging position (Fig. 3 a), then the doctor-instructor performs elbow flexion joint, turning the hand towards the patient's chest towards the shoulder (Fig. 3 b), while the shoulder does not move, the palm is turned up and down, bending it at a right angle, performed for 1-2 minutes 4 times a day;

- sitting on the bed sideways, on a chair with the operated upper limb lowered onto its back so that the arm hangs freely and alternately perform flexion and extension movements in the elbow joint up to 10-12 times within the limits of the pain syndrome, changing the angle of inclination if desired.

II. On days 3-4, a set of exercises is carried out aimed at developing flexion, extension, abduction, adduction, elevation, internal and external rotation of the upper limb with the help of supporting a healthy upper limb with a small load of up to 1 kg (mug, water bottle, etc. .): standing, stretching the operated arm forward, holding the load in the hand (Fig. 4 a), they begin to “draw” letters of the alphabet or numbers in the air (Fig. 4 b) for 2-3 minutes 4 times a day.

III. On days 5-7, active movements are performed without the support of a healthy upper limb: flexion and extension around the frontal axis, abduction and adduction around the sagittal axis, supination and pronation around the vertical axis, circular movements, free movement of the forearm and radius.

In addition to the exercises listed, any others can be included in the complex, including performing movements from a state of pre-tension, rocking and jerking with the specified amplitude.

All classes are completed with exercises aimed at muscle relaxation.

All exercises are performed within the pain threshold.

Classes are conducted regularly during the period of hospitalization, first (1 month) under the guidance of a physical therapy instructor, and then independently, including at home.

The practical use of the method is illustrated by the following clinical case.

Patient Sh., 42 years old, was treated in the department of oncology orthopedics with a diagnosis of left kidney cancer pT2aN0M1 stage IV, solitary metastasis to the distal part of the left tibia. Surgical treatment 2018 Progression 04.2021 Metastatic lesion of the diaphysis of the left humerus. Pain syndrome of oncological origin. In April 2021 Surgical treatment included resection of the diaphysis of the left humerus with endoprosthetics.

Upon admission, he complained of pain and limitation of movements in the left upper limb. To relieve pain, the patient took NSAIDs (diclofenac, nise, etc.) repeatedly throughout the day; According to the VAS pain scale, the pain syndrome corresponded to 5 points. Functional results on the MSTS scale at the time of presentation were 68%.

The patient underwent a rehabilitation course according to the set of exercises proposed above for 30 days:

From day 0 in the early postoperative period, rehabilitation measures were carried out: the postoperative pain syndrome was relieved, the patient was verticalized, the upper limb was immobilized using a bandage-scarf with a wedge-shaped pillow, which was installed in the armpit, and breathing exercises were taught.

On the 2nd day after surgery, we entered a period of relative immobilization, including isometric exercises on the muscles of the operated limb. All exercises (flexion, extension, abduction, adduction and elevation of the upper limb, as well as internal, external rotation and circumduction) were performed from a state of pre-tension within the pain threshold, rocking-push-like, with an amplitude from 20 to 40 degrees:

- the patient stood on the floor, leaning his healthy arm on the couch, the affected arm was in a relaxed state (Fig. 1 a) and performed smooth rocking movements back and forth (Fig. 1 b), left and right for 5 minutes - 4 times per day. This exercise was also performed while sitting on a chair, while the operated arm was in a hanging relaxed position and was used to perform smooth pendulum swinging movements back and forth (Fig. 2 a), left and right (Fig. 2 b) - for 2 minutes 4 times in a day;

- the patient was sitting on a chair, the operated arm was in a hanging position (Fig. 3 a), then the doctor-instructor flexed the elbow joint, turning the arm towards the patient’s chest towards the shoulder (Fig. 3 b) for 2 minutes 4 times in a day;

- the patient sat on the bed so that the arm hung freely and performed alternate flexion and extension movements in the elbow joint up to 12 times within the pain syndrome.

Starting from the 3rd day, for 4 days (3, 4, 5, 6 days), a set of exercises was carried out aimed at developing flexion, extension, abduction, adduction, elevation, internal and external rotation of the upper limb with the help of supporting a healthy upper limb with a bottle of water weighing 1 kg: standing, stretching the operated arm forward, holding a load in his hand (Fig. 4 a) “drawn” letters and numbers in the air (Fig. 4 b) for 3 minutes 4 times a day.

On day 7, active movements were performed without the support of a healthy upper limb: flexion and extension around the frontal axis, abduction and adduction around the sagittal axis, supination and pronation around the vertical axis, circular movements, free movement of the forearm and radius.

After a complex of exercise therapy, an excellent functional result was achieved on the MSTS scale of up to 90%. There was a persistent decrease in pain, the patient significantly reduced the intake of painkillers (up to 2 times a week). On the VAS scale it was 2-3 points.

Clinical example 2

Patient D., 76 years old, was treated in the department of oncology orthopedics with a diagnosis of right kidney cancer pT2aN0M1 stage IV, solitary metastasis of the right humerus. Pain syndrome of oncological origin. In January 2022 Surgical treatment including resection of the diaphysis of the right humerus with endoprosthetics was performed.

Upon admission, she complained of pain and limitation of movements in the right upper limb. To relieve pain, the patient repeatedly took NSAIDs + Tramadol 100 mg 2 times a day throughout the day; on the VAS pain scale, the pain syndrome corresponded to 7 points. Functional results according to the MSTS scale at the time of presentation were 62%.

The patient completed a rehabilitation course using the set of exercises proposed above for 30 days:

From day 0 in the early postoperative period, rehabilitation measures were carried out: the postoperative pain syndrome was relieved, the patient was verticalized, the upper limb was immobilized using a bandage-scarf with a wedge-shaped pillow, which was installed in the armpit, and breathing exercises were taught.

On the 3rd day after surgery, there is a transition to a period of relative immobilization, including isometric exercises on the muscles of the operated limb. All exercises (flexion, extension, abduction, adduction and elevation of the upper limb, as well as internal, external rotation and circumduction) were performed from a state of pre-tension within the pain threshold, rocking-push-like, with an amplitude from 20 to 40 degrees:

- the patient stood on the floor, leaning her healthy arm on the couch, the affected arm was in a relaxed state and performed smooth rocking movements back and forth, left and right for 2 minutes - 4 times a day;

- the patient was sitting on a chair, the operated arm was in a hanging position, then the doctor-instructor flexed the elbow joint, turning the arm towards the patient’s chest towards the shoulder for 1 minute 4 times a day;

- the patient sat sideways on the bed so that the arm hung freely and alternately performed flexion and extension movements in the elbow joint up to 10 times within the pain syndrome.

Starting from the 4th day, for 3 days (4, 5, 6 days), a set of exercises was carried out aimed at developing flexion, extension, abduction, adduction, elevation, internal and external rotation of the upper limb with the help of supporting a healthy upper limb with a bottle of water weighing 0 .5 kg: standing, stretching the operated arm forward, holding a load in the hand, “drew” letters and numbers in the air for 2 minutes, 4 times a day.

On day 7, active movements were performed without the support of a healthy upper limb: flexion and extension around the frontal axis, abduction and adduction around the sagittal axis, supination and pronation around the vertical axis, circular movements, free movement of the forearm and radius.

After a complex of exercise therapy, an excellent functional result was achieved on the MSTS scale of up to 86%. There was a persistent decrease in pain, the patient significantly reduced her intake of painkillers (up to 3 times a week). On the VAS scale it was 3-4 points.

The use of the proposed method of perioperative rehabilitation at the Moscow Research Institute of Orthopedics named after. P.A. Herzen - a branch of the Federal State Budgetary Institution "National Medical Research Center of Radiology" of the Ministry of Health of Russia provides improved functional results and reduces pain in patients undergoing oncological endoprosthetics of the humeral diaphysis.

Claims (7)

A method of rehabilitation of patients after oncological endoprosthetics of the humeral diaphysis, including in the preoperative period psychological preparation, training in verticalization techniques using immobilization devices, as well as training in correct deep chest and diaphragmatic breathing during breathing exercises and a set of physical exercises aimed at strengthening the muscles of the upper belt limbs, characterized in that after endoprosthetics of the shoulder joint, a set of rocking-push exercises is carried out, involving flexion, extension, abduction, adduction and elevation of the upper limb, as well as internal and external rotation of the arm, performed from a state of pre-tension, within the threshold of pain with amplitude from 20 to 40 degrees 4 times a day according to the following scheme: - on days 2-3 perform the following exercises: the patient stands on the floor, leaning his healthy arm on a couch, bed or window sill, the affected arm is in a relaxed state and performs rocking movements back and forth, left and right for 2-5 minutes, or this exercise is performed while sitting on a chair, while the operated the hand is in a hanging, relaxed position and performs pendulum swinging movements back and forth, left and right for 1-2 minutes; the patient sits on a chair, the operated arm is in a hanging position, the doctor-instructor performs flexions in the elbow joint, turning the arm towards the patient's chest towards the shoulder, while the shoulder does not move, the palm is turned up and down, bending it at a right angle for 1 -2 minutes; the patient sits on a bed or on a chair with the operated upper limb lowered so that the arm hangs freely and alternately performs flexion and extension movements in the elbow joint 10-12 times within the limits of the pain syndrome; - on days 3-4: standing, stretching the operated arm forward and holding a load of up to 1 kg in his hand, he begins to “draw” letters of the alphabet or numbers in the air for 2-3 minutes; - on days 5-7: performs active movements without the support of a healthy upper limb: flexion and extension around the frontal axis, abduction and adduction around the sagittal axis, supination and pronation around the vertical axis, circular movements, free movement of the forearm and radius.