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144-11-第十一节 常见风湿病之康复原则
一、多发性关节炎急性期 # A0 Q; z3 {6 l l7 w( b
4 H: o* M! J5 D. [" I 此情况以类风湿关节炎的急性期为代表，患者可能有发热、全身倦怠、多处关节肿胀等现象。治疗首先要使患者获得充分的休息，必要时甚至要住院完全卧床休息。为了防止关节挛缩，可在治疗师的协助下，做主动辅助性关节运动，全身各大关节一天至少做几次全范围(fullrange)的关节运动。特别发炎肿胀的关节可使用冰敷或休息性副木以消肿、止痛;特别疼痛的部位也可用电刺激止痛。若急性期持续数天以上，为了防止肌肉萎缩，应以等长收缩来训练肌力，此时不宜使用等张或等速收缩。有些患者在肿胀关节附近的肌肉会痉挛、疼痛，可在肌肉上按摩、热敷或冰敷。& V$ ^0 p: ?" l- z4 d3 s7 I& _
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二、多发性关节炎之亚急性期及慢性期
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视患者的病情，休息的时间可逐渐减少，运动的时间逐渐增多。关节活动可由辅助性主动运动逐渐改为主动运动。若是有些关节已经挛缩或僵硬，可在热疗之后再加上关节或软组织的牵张运动。运动之后可再加上冷疗，或使用副木牵张关节或软组织。肌力强化运动可由等长收缩逐渐增加等张收缩运动。早期的运动也可由水中运动开始。若情况良好，则可逐渐加强心肺耐力训练，包括:水中运动、自行车运动、步行、有氧舞蹈、网球、高尔夫球及改良式的太极拳等。此时大部分关节已无发炎、肿胀现象，故冷疗可逐渐改为热疗，包括热敷、水疗、温泉疗法等。此外，患者需学习如何保护关节及如何节省体力。情况必要时，可使用手杖、拐杖、助行器及日常生活所需的各种辅具。足部疼痛、变形的患者，须选择合适的鞋子，并配制适当的鞋垫，以改善步态。
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1 R3 Q3 J E) h8 {3 a 三、侵犯脊椎为主的关节炎
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/ i, K; {* X' V6 ^' G2 m1 o m 代表性的疾病是强直性脊椎炎。患者除了背痛、颈痛、胸痛及他处关节疼痛之外，驼背会愈来愈厉害，躯体会愈来愈僵硬。若是侵犯髓关节，更会造成患者行动及日常生活(包括性生活)上诸多的困难。康复治疗最主要的是运动，颈椎、肩关节、舰关节每天须作全范围的关节运动;胸、腰椎须加强后仰运动，以防止询楼变形;胸肌、背肌、骸关节屈肌、膝关节屈肌等须加强牵张运动，以避免挛缩;背肌、腹肌及股四头肌须加强肌力训练。此外，呼吸训练可与胸肌之牵张运动合并进行。若患者情况良好，亦可从事各种心肺耐力训练。由于多数患者脊椎硬而脆，骨密度亦低，故应避免会直接碰撞的运动(如足球、橄榄球、篮球、柔道等)，以避免脊椎骨折。背痛或其他部位的慢性疼痛可用热敷、电刺激、水疗或温泉浴来缓解。& _2 R5 C% b% k( l2 w
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四、下肢单一负重关节的病变 3 d, j7 L: }9 j; Q+ S$ O( K9 j
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风湿病(如骨关节炎)若侵犯膝或骸关节，常会造成患者行动的困难。治疗的原则是在急性期先用冰敷或电刺激止痛，亦可使用弹性护膝以防止肿胀(当然关节内积水要先抽出)。其次是适当的摆位及关节运动，以避免关节挛缩。为了防止肌肉萎缩，肌力训练可从等长收缩开始，再逐渐增加等张收缩。情况良好的患者，可建议心肺耐力训练，如游泳、自行车、低冲撞的有氧运动、网球、高尔夫球等。若患者在慢性期有关节挛缩的现象，则可使用水疗、热敷、超声波等再加上牵张运动。下肢疼痛的患者亦可在对侧以手杖支撑，以减少关节的负荷。若膝关节炎有内翻(varus)变形时，可在鞋垫加装外侧楔形突起(lateral wedge)以减轻内侧胫股关节(tibiofemoral joint)承受的压力。! q3 J( z+ o% g2 _& Z2 ~
（ 谢霖芬 周昌德 ）
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