儿童手烧伤后瘢痕挛缩家庭康复治疗模式的探索

朱婵; 何林; 张博文; 梁英; 赵海洋; 齐宗师; 梁敏; 韩军涛; 胡大海; 刘佳琦

doi:10.3760/cma.j.cn501225-20220622-00253

儿童手烧伤后瘢痕挛缩家庭康复治疗模式的探索

doi: 10.3760/cma.j.cn501225-20220622-00253

1.
空军军医大学第一附属医院全军烧伤中心，烧伤与皮肤外科，西安　　710032
2.
西安交通大学第一附属医院整形美容颌面外科，西安　　710061
3.
空军军医大学统计教研室，西安　　710032

基金项目:

国家自然科学基金面上项目 82172208

陕西省重点研发计划 2022SF-279

详细信息

通讯作者:
刘佳琦，Email：anlhw07@fmmu.edu.cn

计量
- 文章访问数: 8269
- HTML全文浏览量: 81
- PDF下载量: 68
- 被引次数: 0
出版历程
- 收稿日期: 2022-06-22

Exploration of family rehabilitation model for children with scar contracture after hand burns

1.
Department of Burns and Cutaneous Surgery, Burn Center of PLA, the First Affiliated Hospital, Air Force Medical University, Xi'an 710032, China
2.
Department of Plastic, AestheticMaxillofacial Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
3.
Department of Statistics, Air Force Medical University, Xi'an 710032, China

Funds:

General Program of National Natural Science Foundation of China 82172208

Shaanxi Provincial Key Research and Development Plan 2022SF-279

More Information

Corresponding author: Liu Jiaqi, Email: anlhw07@fmmu.edu.cn

摘要

摘要: 目的探索儿童手烧伤后瘢痕挛缩的家庭康复治疗模式并观察其疗效。方法采用回顾性非随机对照研究方法。2020年3月—2021年3月，空军军医大学第一附属医院全军烧伤中心收治30例符合入选标准的手深Ⅱ或Ⅲ度烧伤后瘢痕挛缩患儿。根据采取的康复治疗模式，将18例患儿（23只患手）纳入家庭康复治疗为主组（以下简称家庭康复组）、12例患儿（15只患手）纳入医院康复治疗为主组（以下简称医院康复组），前组患儿中男11例、女7例，年龄（4.8±2.1）岁，创面愈合后（3.1±0.8）d开始康复治疗；后组患儿中男7例、女5例，年龄（4.6±2.1）岁，创面愈合后（2.8±0.7）d开始康复治疗。医院康复组患儿以在院主被动康复训练为主，辅以回家后自主康复训练；家庭康复组患儿接受在院主被动康复训练1~2周后，在家通过微信平台接受康复治疗师指导进行主被动康复训练。2组患儿均治疗6个月，治疗期间均佩戴压力手套并联合使用手屈曲训练带和分指支具。治疗前及治疗6个月后，分别采用改良温哥华瘢痕量表、手总主动活动度法和Carroll上肢功能评定法对患手瘢痕（计算治疗前后瘢痕评分差值）、关节活动度（计算优良比）和患肢功能进行评分/评级。对数据行独立样本t检验、等效性检验、Fisher确切概率法检验及Mann-Whitney U检验。结果家庭康复组、医院康复组患儿治疗6个月后患手瘢痕评分与治疗前的差值分别为3.0（2.0，7.0）、3.0（2.0，8.0）分（95%置信区间分别为2.37~5.38、1.95~5.91分），2组差值间差值的95%置信区间为-2.43~2.21分，在等效性界值-3~3分之内（P<0.05）。家庭康复组、医院康复组患儿患手关节活动度优良比治疗前分别为3/23和2/15，治疗6个月后分别为15/23和12/15。家庭康复组、医院康复组患儿治疗6个月后患手关节活动度评级均较治疗前明显升高（Z值分别为3.58、2.30，P<0.05），但2组之间治疗前、治疗6个月后患手关节活动度评级均相近（Z值分别为0.39、0.55，P>0.05）。家庭康复组、医院康复组患儿治疗6个月后患肢功能评级均较治疗前显著提高（Z值分别为3.98、3.51，P<0.05），但2组之间治疗前、治疗6个月后患肢功能评级均相近（Z值分别为1.27、0.38，P>0.05）。结论基于微信平台辅助的以家庭康复为主联合应用手屈伸组合支具的康复治疗，可有效减轻儿童手烧伤后瘢痕，改善患手关节活动度，促进患肢功能恢复，与以医院康复为主的康复治疗效果相近，为无法持续接受在院治疗的患儿提供了可选的康复治疗方法。
- 烧伤 /
- 瘢痕 /
- 手 /
- 儿童 /
- 家庭康复 /
- 支具
Abstract: Objective To explore the family rehabilitation model for children with scar contracture after hand burns and observe its efficacy. Methods A retrospective non-randomized controlled study was conducted. From March 2020 to March 2021, 30 children with scar contracture after deep partial-thickness to full-thickness burns of hands, who met the inclusion criteria, were hospitalized in the Burn Center of PLA of the First Affiliated Hospital of Air Force Medical University. According to the rehabilitation model adopted, 18 children (23 affected hands) were included in a group mainly treated by family rehabilitation (hereinafter referred to as family rehabilitation group), and 12 children (15 affected hands) were included in another group mainly treated by hospital rehabilitation (hereinafter referred to as hospital rehabilitation group). In the former group, there were 11 males and 7 females, aged (4.8±2.1) years, who began rehabilitation treatment (3.1±0.8) d after wound healing; in the latter group, there were 7 males and 5 females, aged (4.6±2.1) years, who began rehabilitation treatment (2.8±0.7) d after wound healing. The children in hospital rehabilitation group mainly received active and passive rehabilitation training in the hospital, supplemented by independent rehabilitation training after returning home; after 1-2 weeks of active and passive rehabilitation training in the hospital, the children in family rehabilitation group received active and passive rehabilitation training at home under the guidance of rehabilitation therapists through WeChat platform. Both groups of children were treated for 6 months. During the treatment, they wore pressure gloves and used hand flexion training belts and finger splitting braces. Before treatment and after 6 months of treatment, the modified Vancouver scar scale, the total active movement of the hand method, and Carroll quantitative test of upper extremity function were used to score/rate the scar of the affected hand (with the difference of scar score between before treatment and after treatment being calculated), the joint range of motion (with excellent and good ratio being calculated), and the function of the affected limb, respectively. Data were statistically analyzed with independent sample t test, equivalence test, Fisher's exact probability test, and Mann-Whitney U test. Results The differences of scar scores of the affected hands of children in family rehabilitation group and hospital rehabilitation group between after 6 months of treatment and those before treatment were 3.0 (2.0, 7.0) and 3.0 (2.0, 8.0) respectively (with 95% confidence interval of 2.37-5.38 and 1.95-5.91). The 95% confidence interval of the difference between the differences of the two groups was -2.43-2.21, which was within the equivalent boundary value of -3-3 (P<0.05). The excellent and good ratios of joint range of motion of the affected hand of children in family rehabilitation group and hospital rehabilitation group were 3/23 and 2/15 respectively before treatment, and 15/23 and 12/15 respectively after 6 months of treatment. The ratings of joint range of motion of the affected hand of children in family rehabilitation group and hospital rehabilitation group after 6 months of treatment were significantly higher than those before treatment (with Z values of 3.58 and 2.30, respectively, P<0.05), but the ratings of joint range of motion of the affected hand between the two groups were similar before treatment and after 6 months of treatment (with Z values of 0.39 and 0.55, respectively, P>0.05). The functional ratings of the affected limbs of children in family rehabilitation group and hospital rehabilitation group after 6 months of treatment were significantly higher than those before treatment (with Z values of 3.98 and 3.51, respectively, P<0.05), but the functional ratings of the affected limbs between the two groups were similar before treatment and after 6 months of treatment (with Z values of 1.27 and 0.38, respectively, P>0.05). Conclusions The WeChat platform assisted rehabilitation treatment with mainly family rehabilitation, combined with hand flexion and extension brace can effectively reduce the scarring after children's hand burns, improve the joint range of motion of the affected hands, and promote the recovery of affected limb function. The effect is similar to that of hospital-based rehabilitation providing an optional rehabilitation, treatment method for children who cannot continue to receive treatment in hospital.
- Burns /
- Cicatrix /
- Hand /
- Child /
- Family rehabilitation /
- Braces
朱婵：酝酿和设计研究、实施研究、分析数据、撰写论文；何林：酝酿和设计研究、分析数据、参与撰写论文；张博文：查阅文献、实施研究、收集资料；梁英：数据统计；赵海洋、齐宗师、梁敏：实施研究、收集资料；韩军涛、胡大海：对文章的专业性知识进行审阅、修改文章及指导，提供行政支持；刘佳琦：指导研究的设计及实施、修改论文

所有作者均声明不存在利益冲突

HTML全文

参考文献(30)

[1]	付晋凤,张梦思.儿童烧伤治疗及瘢痕防治策略的探讨[J/CD].中华损伤与修复杂志:电子版,2018,13(4):241-246.DOI: 10.3877/cma.j.issn.1673-9450.2018.04.001.
[2]	ProcterF.Rehabilitation of the burn patient[J]. Indian J Plast Surg,2010,43(Suppl):S101-113. DOI: 10.4103/0970-0358.70730.
[3]	陈华玲,李茂君,罗伊美,等.基于标准化沟通制度连续性居家远程探视模式在新型冠状病毒肺炎后疫情时代严重烧伤患者探视管理中的应用[J].中华烧伤杂志,2021,37(11):1070-1077.DOI: 10.3760/cma.j.cn501120-20210315-00088.
[4]	石梦娜,李娜,王冰水,等.联合应用压力手套及压力垫治疗手背烧伤后瘢痕的疗效观察[J].中国美容医学,2013,22(1):133-135.DOI: 10.3969/j.issn.1008-6455.2013.01.053.
[5]	朱婵,易南,石梦娜,等.功能训练联合自制手屈曲训练带治疗手背部烧伤后瘢痕挛缩的效果观察[J].中华烧伤杂志,2017,33(7):426-430.DOI: 10.3760/cma.j.issn.1009-2587.2017.07.007.
[6]	FinlayV,BurrowsS,KendellR,et al.Modified Vancouver Scar Scale score is linked with quality of life after burn[J].Burns,2017,43(4):741-746.DOI: 10.1016/j.burns.2016.11.007.
[7]	魏战杰,颜家琪,杨永刚,等.温哥华瘢痕量表在曲安奈德治疗甲状腺术后增生性瘢痕中的应用[J].中华实验外科杂志,2022,39(5):924-927.DOI: 10.3760/cma.j.cn421213-20210922-01278.
[8]	PriceK,MoiemenN,NiceL,et al.Patient experience of scar assessment and the use of scar assessment tools during burns rehabilitation: a qualitative study[J/OL].Burns Trauma,2021,9:tkab005[2022-06-22].https://pubmed.ncbi.nlm.nih.gov/34212058/.DOI: 10.1093/burnst/tkab005.
[9]	赵海洋,韩军涛,刘佳琦,等.手持续被动运动系统联合功能训练与压力手套治疗手背部烧伤后早期瘢痕挛缩的效果[J].中华烧伤杂志,2021,37(4):319-326.DOI: 10.3760/cma.j.cn501120-20201020-00443.
[10]	李宗瑜,刘锐.小儿烧伤特点及系统性康复治疗进展[J/CD].中华损伤与修复杂志:电子版,2017,12(3):161-163.DOI: 10.3877/cma.j.issn.1673-9450.2017.03.001.
[11]	齐鸿燕.儿童瘢痕的管理策略[J].中华烧伤杂志,2019,35(10):712-714.DOI: 10.3760/cma.j.issn.1009-2587.2019.10.002.
[12]	中国老年医学学会烧创伤分会.烧伤儿童心理康复治疗全国专家共识(2020版)[J].中华烧伤杂志,2020,36(11):987-992.DOI: 10.3760/cma.j.cn501120-20200623-00321.
[13]	郭振荣,李峰,屠海霞,等.我国烧伤康复疗法的建立发展与成效[J].中华烧伤杂志,2018,34(12):835-839.DOI: 10.3760/cma.j.issn.1009-2587.2018.12.002.
[14]	BaraniC,BrossetS,PersonH,et al.How to treat palmar burn sequelae in children, about 49 cases[J].Ann Chir Plast Esthet,2021,66(4):291-297.DOI: 10.1016/j.anplas.2020.09.004.
[15]	范旭升.脑瘫高危儿童家庭康复与机构康复的疗效对比[J].中国实用医药,2020,15(26):180-182.DOI: 10.14163/j.cnki.11-5547/r.2020.26.080.
[16]	ThielbarKO,TriandafilouKM,BarryAJ,et al.Home-based upper extremity stroke therapy using a multiuser virtual reality environment: a randomized trial[J].Arch Phys Med Rehabil,2020,101(2):196-203.DOI: 10.1016/j.apmr.2019.10.182.
[17]	唐琳,邬钰玮,李源莉,等.基于现代信息技术的脑瘫儿童远程家庭康复模式的探讨[J].中国康复,2021,36(12):756-759.DOI: 10.3870/zgkf.2021.12.012.
[18]	SgandurraG,LorentzenJ,InguaggiatoE,et al.A randomized clinical trial in preterm infants on the effects of a home-based early intervention with the 'CareToy System'[J].PLoS One,2017,12(3):e0173521.DOI: 10.1371/journal.pone.0173521.
[19]	成路,赵香莲,任玉蓉,等.基于微信平台的延续性治疗指导对儿童烧伤患者瘢痕增生的影响[J].西南军医,2021,23(1):54-56.DOI: 10.3969/j.issn.1672-7193.2021.01.016.
[20]	张宇飞,李靖婕.早期康复治疗联合家庭康复训练对小儿脑损伤及脑瘫的效果观察[J].临床研究,2020,28(8):77-79.
[21]	WisemanJ,SimonsM,KimbleR,et al.Reliability and clinical utility of the Pliance X for measuring pressure at the interface of pressure garments and burn scars in children[J].Burns,2018,44(7):1820-1828.DOI: 10.1016/j.burns.2018.05.002.
[22]	LvK,LiuH,XuH,et al.Ablative fractional CO2 laser surgery improving sleep quality, pain and pruritus in adult hypertrophic scar patients: a prospective cohort study[J/OL].Burns Trauma,2021,9:tkab023[2022-06-22].https://pubmed.ncbi.nlm.nih.gov/34322556/.DOI: 10.1093/burnst/tkab023.
[23]	易南,王冰水,张冬梅,等.支具在小儿烧伤康复中的作用与实施体会[J].中华烧伤杂志,2020,36(8):751-753.DOI: 10.3760/cma.j.cn501120-20190610-00267.
[24]	王旭,夏斯曼,邹仕波,等.矫形器在儿童手烧伤瘢痕畸形植皮修复术后手功能康复中的应用效果研究[J].中国美容医学,2021,30(5):41-44.
[25]	LiP,Li-TsangCWP,DengX,et al.The recovery of post-burn hypertrophic scar in a monitored pressure therapy intervention programme and the timing of intervention[J].Burns,2018,44(6):1451-1467.DOI: 10.1016/j.burns.2018.01.008.
[26]	ThomasR,WicksS,DaleM,et al.Outcomes of early and intensive use of a palm and digit extension orthosis in young children after burn injury[J].J Burn Care Res,2021,42(2):245-257.DOI: 10.1093/jbcr/iraa137.
[27]	HosseiniM,BrownJ,KhosrotehraniK,et al.Skin biomechanics: a potential therapeutic intervention target to reduce scarring[J/OL].Burns Trauma,2022,10:tkac036[2022-10-22].https://pubmed.ncbi.nlm.nih.gov/36017082/.DOI: 10.1093/burnst/tkac036.
[28]	中华医学会烧伤外科学分会,中国医师协会烧伤科医师分会.烧伤康复治疗指南(2013版)[J].中华烧伤杂志,2013,29(6):497-504.DOI: 10.3760/cma.j.issn.1009-2587.2013.06.001.
[29]	MeixnerC,O'DonoghueCR,HartV.Impact of the Brain Injury Family Intervention (BIFI) training on rehabilitation providers: a mixed methods study[J].NeuroRehabilitation,2017,40(4):545-552.DOI: 10.3233/NRE-171441.
[30]	谢琳,黄裕斌.微信群式健康教育在脑瘫出院患儿家庭康复护理中的应用[J/CD].世界最新医学信息文摘:电子版,2018,18(73):204.DOI: 10.19613/j.cnki.1671-3141.2018.73.154.

下载: 全尺寸图片幻灯片

1 手屈伸支具的制作和佩戴。1A.为手指掌侧瘢痕患儿定制的分指支具；1B.分指支具佩戴于患儿手掌侧；1C. 为手背侧瘢痕患儿定制的手屈曲训练带；1D.手屈曲训练带佩戴于患儿手背侧

下载: 全尺寸图片幻灯片

2 家庭康复治疗为主组双手热液深Ⅱ度烫伤患儿瘢痕康复治疗前后情况。2A.治疗前，左手背侧，可见虎口处瘢痕增生；2B.治疗前，左手掌侧，拇指屈曲障碍；2C.治疗前，右手背侧，全手背瘢痕增生，爪形手畸形；2D.治疗前，右手掌侧，手指屈曲障碍；2E.治疗6个月后，左手背侧，瘢痕明显改善；2F.治疗6个月后，左手可正常屈曲握拳；2G.治疗6个月后，右手背侧，瘢痕明显改善，无爪形手畸形；2H.治疗6个月后，右手可正常握笔写字

下载: 全尺寸图片幻灯片

表1 2组手深Ⅱ或Ⅲ度烧伤后瘢痕挛缩患儿患手资料比较

组别	患手数（只）	累及患手（只）		伤后创面愈合时间（d，x¯±s）	瘢痕面积（%TBSA，x¯±s）	创面愈合后开始康复治疗时间（d，x¯±s）
组别	患手数（只）	左	右	伤后创面愈合时间（d，x¯±s）	瘢痕面积（%TBSA，x¯±s）	创面愈合后开始康复治疗时间（d，x¯±s）
家庭康复治疗为主组	23	11	12	22±5	1.3±0.7	3.1±0.8
医院康复治疗为主组	15	7	8	23±4	1.4±0.6	2.8±0.7
t值		—		0.42	0.55	1.00
P值		>0.999		0.680	0.585	0.324
注：“—”表示无此项，TBSA为体表总面积

下载: 导出CSV

表2 2组手深Ⅱ或Ⅲ度烧伤后瘢痕挛缩患儿康复治疗前后患手瘢痕评分比较（分）

组别	患手数（只）	治疗前（x¯±s）	治疗6个月后（x¯±s）	治疗前后差值［M（Q₁，Q₃）］	95%置信区间
家庭康复治疗为主组	23	10.1±2.7	6.3±2.9	3.0（2.0，7.0）	2.37~5.38
医院康复治疗为主组	15	10.6±2.8	6.7±3.4	3.0（2.0，8.0）	1.95~5.91

下载: 导出CSV

表3 2组手深Ⅱ或Ⅲ度烧伤后瘢痕挛缩患儿康复治疗前后患手关节活动度评级比较（只）

组别	患手数（只）	治疗前				治疗6个月后				Z值	P值
组别	患手数（只）	优	良	中	差	优	良	中	差	Z值	P值
家庭康复治疗为主组	23	0	3	6	14	5	10	6	2	3.58	<0.001
医院康复治疗为主组	15	0	2	5	8	3	9	2	1	2.30	0.021

下载: 导出CSV

表4 2组手深Ⅱ或Ⅲ度烧伤后瘢痕挛缩患儿康复治疗前后患肢功能评级比较（只）

组别	患手数（只）	治疗前						治疗6个月后						Z值	P值
组别	患手数（只）	Ⅰ级	Ⅱ级	Ⅲ级	Ⅳ级	Ⅴ级	Ⅵ级	Ⅰ级	Ⅱ级	Ⅲ级	Ⅳ级	Ⅴ级	Ⅵ级	Z值	P值
家庭康复治疗为主组	23	0	7	12	4	0	0	0	0	4	8	11	0	3.98	<0.001
医院康复治疗为主组	15	1	5	9	0	0	0	0	0	2	5	8	0	3.51	<0.001