摘要目的 探讨不同康复方法对手部深度烧伤保留变性真皮+大张自体皮移植术患者手功能和焦虑心理的影响. 方法 选择中南大学湘雅医院烧伤重建外科2014年1月-2015年6月收治的符合入选标准的手部深度患者44例,根据随机数字表法并结合患者意愿分为宣教康复组23例和专人康复组21例,2组分别有36、33只患手,均于伤后3～7d行保留变性真皮+大张自体皮移植术.2组患者均于术后10 d开始使用硅酮凝胶进行手部抗瘢痕治疗,此外,宣教康复组患者在责任护士的指导下进行主动功能锻炼,由持有二级心理咨询师证的责任护士进行心理指导;专人康复组患者在康复治疗师的指导下进行主动与被动相结合的功能锻炼,由中级心理治疗师进行心理指导.术后1、3、6个月,用关节角度尺测量2组患者患手各手指关节的主动活动度,计算其总主动活动度(TAM)优良率;用电子握力计测量患者患手握力值,并用焦虑自评量表(SAS)对患者焦虑心理进行评分.对数据行x2检验、独立样本t检验、McNemar检验、重复测量方差分析、SNK检验及Bonferroni校正. 结果 (1)专人康复组患者仅术后6个月患手手指关节TAM优良率显著高于宣教康复组(x2 =10.745,P＜0.0167).2组患者术后3个月患手手指关节TAM优良率均显著高于组内术后1个月(P值均小于0.0167).(2)专人康复组患者术后1、3、6个月患手握力值分别为(8.2±2.6)、(21.6±2.6)、(30.1±2.3)kg,显著高于宣教康复组的(5.3±1.3)、(12.8±2.7)、(20.0±1.8)kg(t值为5.934 ～20.403,P值均小于0.01).2组患者术后3、6个月患手握力值均明显高于组内前一时相点(P值均小于0.05).(3)专人康复组患者术后1、3、6个月SAS评分明显低于宣教康复组(t值为2.944 ～4.758,P值均小于0.01).2组患者术后3、6个月SAS评分均明显低于组内前一时相点(P值均小于0.05). 结论 与宣教康复相比,专人康复治疗可提高手部深度烧伤保留变性真皮并移植大张自体皮患者患手手指关节TAM、握力值,改善患者的焦虑心理.

abstractsObjective To investigate influences of different rehabilitative methods on function of hands and psychological anxiety of patients with deeply burned hands retaining denatured dermis and grafting large autologous skin.Methods Forty-four patients with deeply burned hands,conforming to the study criteria were admitted to Department of Burns and Reconstructive Surgery of Xiangya Hospital of Central South University from January 2014 to June 2015.Patients were divided into propaganda education rehabilitation group (PER,n =23) and specially-assigned person rehabilitation group (SAPR,n =21) according to the random number table and patients' willingness.On post injury day 3 to 7,36 burned hands in group PER and 33 burned hands in group SAPR underwent operation of retaining denatured dermis and grafting large autologous skin.Patients in 2 groups received anti-scar treatment of hands with silicone gel from postoperative day 10.Besides,patients in group PER underwent active functional exercise under guidance of duty nurse and received psychological guidance from duty nurse with grade two psychological consultant certificate.Patients in group SAPR underwent active and passive functional exercise under guidance of rehabilitation therapist and received psychological guidance from psychotherapist with intermediate title.In postoperative month (POM) 1,3 and 6,ranges of active motion of burned finger joints of patients in 2 groups were measured with joint goniometer to calculate excellent and good ratio of total active motion (TAM) range.Values of grip strength of burned hands of patients were measured with electronic hand dynamometer,and psychological anxiety was scored with Self-rating Anxiety Scale (SAS).Data were processed with chi-square test,independent sample t test,McNemar test,analysis of variance of repeated measurement,SNK test and Bonferroni correction.Results (1) Ratio of excellent and good of TAM range of burned finger joints of patients in group SAPR in POM 6 was obviously higher than that in group PER (x 2 =10.745,P ＜ 0.0167).Ratio of excellent and good of TAM range of burned finger joints of patients in 2 groups in POM 3 were obviously higher than that in POM 1 of the same group,respectively (with P values below 0.0167).(2) Values of grip strength of burned hands of patients in group SAPR in POM 1,3,and 6 were respectively (8.2 ± 2.6),(21.6 ± 2.6) and (30.1 ± 2.3) kg,obviously higher than those in group PER [(5.3 ± 1.3),(12.8 ± 2.7),(20.0 ± 1.8) kg,respectively,with t values from 5.934 to 20.403,P values below 0.01].Values of grip strength of burned hands of patients in 2 groups in POM 3 and 6 were obviously higher than those at the previous time point of the same group (with P values below 0.05).(3) SAS scores of patients in group SAPR in POM 1,3 and 6 were significantly lower than those in group PER (with t values from 2.944 to 4.758,P values below 0.01).SAS scores of patients in 2 groups in POM 3 and 6 were significantly lower than those at the previous time point of the same group (with P values below 0.05).Conclusions Compared with rehabilitation of propaganda and education,rehabilitation under specially-assigned person can improve TAM range of burned finger joints,value of grip strength,and psychological anxiety of patients with deeply burned hands retaining the denatured dermis and grafting large autologous skin.