【作者】 赵冰；

【导师】 杜青；

【作者基本信息】 上海交通大学 ， 康复医学与理疗学， 2020， 硕士

【摘要】 背景:特发性脊柱侧凸患病率较高,生长发育期存在进展风险,严重的脊柱畸形将会带来一系列身体状况影响。骨骼未成熟前,患者脊柱柔韧性高,早期介入康复可减少手术和残疾发生率。若未能早发现、早诊断、早干预,使畸形得不到有效控制,影响患者身心发展。我国该病康复需求巨大,但目前骨科医生对特发性脊柱侧凸康复认知不清晰,专病康复仍局限于少数三级医院康复医学科,整体康复资源和人才匮乏、诊疗不规范且未普及。为推进优质康复医疗资源整合推广、共享及下沉,提高多数三级医院骨科对专病康复的正确意识,提升三级医院、二级医院康复医学科及基层医疗机构对该专病的康复诊疗能力,实现范围更广的早期干预,应积极构建完善的特发性脊柱侧凸康复分级诊疗体系。方法:本研究通过文献资料法以特发性脊柱侧凸、康复、康复分级诊疗、rehabilitation medical service system等为关键词检索数据库,收集近10年文献,对特发性脊柱侧凸康复诊疗及分级诊疗方式进行文献筛选及综述,初步建立康复分级诊疗体系草案。再通过专家访谈法以半结构化形式访谈多位相关领域专家学者(从事脊柱侧凸诊疗工作10年以上的康复专家,职称为主治医师及以上或有转诊经验的医师等),对草案进行修改优化和完善,最终形成符合现阶段我国国情的特发性脊柱侧凸康复分级诊疗体系。结果:本研究通过对近10年国内外文献进行检索,经检索相关文献共1684篇,其中特发性脊柱侧凸康复诊疗文献875篇,分级诊疗文献566篇,康复医疗服务体系文献243篇,根据近十年来不断更新的IS康复理念及国内分级诊疗政策的更新进行筛选,最终保留文献共824篇。目前,IS康复治疗主要包括运动疗法、支具疗法,运动疗法又包括一般运动疗法和脊柱侧凸特定运动疗法,根据患者的侧凸程度和进展风险等制定治疗方案。本研究建议目前我国迫切需要在全国推广IS筛查,既包括家庭自我筛查的推广,也需要社会尽多支持开展学校筛查和健康教育,以实现关口前移,早期发现、早期诊断、早期干预,减少侧凸进展。本研究发现国内外暂无特发性脊柱侧凸康复分级诊疗相关研究,并结合脊柱侧凸的康复治疗特点提出依据IS进展风险开展康复分级诊疗,内容包括首诊、转诊、分级诊治、连续性随访、人才培养、医疗信息平台建设和康复管理提出详细建议。本研究结合专家访谈对IS分级诊疗体系进行优化,明确各级医院在分级诊疗体系中的角色和功能定位。其中,三级医院康复医学科在IS康复分级诊疗体系中扮演着患者诊断、评估、治疗连续性诊治医疗服务“运筹者”角色,其患者管理分为五方面包括高进展风险和疑难患者的康复治疗,所有患者的明确诊断、康复评定、随访及转诊管理,此外兼顾患者的科普宣教;二级医院负责中度进展风险患者的康复治疗、观察其病情变化,完善转诊工作,并兼顾区域内科普;一级医院掌握筛查方法,负责社区内健康宣教、对明确诊断为IS的患者进行转诊管理,并负责患者的监督管理和健康监测。结论:本研究从骨科专病出发,通过文献综述法和专家访谈法构建了特发性脊柱侧凸分级诊疗体系,全面考虑特发性脊柱侧凸康复诊疗的上下联通的各个环节,以专病为核心建立康复分级诊疗体系,将国际水平的专病治疗方案下沉至一级、二级医院,对不同进展风险患者进行分层、分级诊疗,促进患者的早发现、早诊断、早干预,保障儿童青少年脊柱健康。兼顾双向转诊、康复人才培训、医疗信息平台建设和康复管理,最大化整合康复优质医疗资源。本体系的建立可逐渐在全国普及,也将为其他专病康复分级诊疗体系的建立提供医疗新思路。更多还原

【Abstract】 BACKGROUND: Idiopathic scoliosis(IS)is a progressive disease during growth and development with high prevalence and severe spinal deformities will have an influence on physical conditions.Patients before bone mature have good flexibility and early rehabilitation can reduce the incidence of surgery and disability.Failure to early detect,diagnose,and intervene will lead to the progression of the deformity,which will affect the physical and mental development of the patient.The prevalence of IS in China is very high and the demand for rehabilitation is huge,but the resources and talents for rehabilitation are scarce and limitedly distributed,and the process of diagnosis and treatment is not standard.In order to promote the integration,sinking and sharing of high-quality rehabilitation medical resources,and to improve the ability of IS rehabilitation diagnosis and treatment in primary medical institutions and secondary hospitals,and to achieve early intervention in IS,the establishment of a comprehensive rehabilitation classification system in diagnosis and treatment is imperative.METHODS: This study reviewed idiopathic scoliosis,rehabilitation and hierarchical medical system and rehabilitation medical service system through database,and collected for the past 10 years.Reviewing and initially establishing a draft system of rehabilitation hierarchical medical system.Then through interviews with experts and scholars in related fields(rehabilitation experts who have been engaged in scoliosis diagnosis and treatment for more than 10 years,with the title of chief physician and above or doctors with referral experience,etc.),the draft was revised,optimized and perfected,and finally a Chinese rehabilitation hierarchical medical system formed.RESULTS: In this study,we searched the domestic and foreign literatures in the past 10 years.A total of 1684 related literatures were retrieved,including 875 articles for the diagnosis and treatment of idiopathic scoliosis,566 articles for the graded diagnosis and treatment,and 243 articles for the rehabilitation medical service system.After ten years of continuous updating of the IS rehabilitation concept and the update of the domestic grading diagnosis and treatment policy,a total of 824 articles were retained.At present,IS rehabilitation treatment mainly includes exercise therapy,brace therapy,exercise therapy includes general exercise therapy and scoliosis-specific exercise therapy,and develops treatment plans based on the degree of scoliosis and the risk of progression of the patient.This study suggested that there is an urgent need to promote IS screening in the country,including the promotion of family self-screening,as well as policy support for school screening and health education to achieve advancement of barriers,early detection,early diagnosis,and early intervention.This study found that there is no relevant research on the diagnosis and treatment of idiopathic scoliosis at home and abroad,and combined with the characteristics of rehabilitation treatment of scoliosis,it is proposed to carry out rehabilitation classification diagnosis and treatment based on the risk of IS progress.The content includes first diagnosis,referral,graded diagnosis and treatment,continuous Provide detailed recommendations on sexual follow-up,talent training,medical information platform construction and rehabilitation management.This study combined with expert interviews to optimize the IS graded diagnosis and treatment system,clarifying the role and functional positioning of hospitals at all levels in the graded diagnosis and treatment system.Among them,the Department of Rehabilitation Medicine of the tertiary hospitals plays the role of “operation strategist” in the diagnosis and evaluation of patients in the IS rehabilitation grading diagnosis and treatment system.The patient management is divided into five aspects including the rehabilitation of high-risk patients and difficult patients Treatment,definite diagnosis,rehabilitation assessment,follow-up and referral management of all patients,in addition to taking care of patients’ popular science education;secondary hospitals are responsible for rehabilitation treatment of patients with moderate progression risk,observe changes in their conditions,improve referral work,and take into account regional Internal science;first-level hospitals are responsible for health education in the community,referral management of patients with a clear diagnosis of IS,and supervision and management of family rehabilitation training and health monitoring.CONCLUSION: This study is based on the orthopedic disease,and established a hierarchical medical system for idiopathic scoliosis through literature review and expert interview,comprehensively considering the various links of upper and lower communication of idiopathic scoliosis rehabilitation diagnosis and treatment,with the disease as the core establish a rehabilitation hierarchical medical system,sink the international-level special disease treatment plan to the first and second-level hospitals,stratify and hierarchical medical for patients with different progression risks,promote early detection,early diagnosis and early intervention of patients to protect spine health of children and adolescent.It also considers two-way referrals,rehabilitation training,medical information platform construction and rehabilitation management to maximize the integration of high-quality rehabilitation medical resources.The establishment of this system can be gradually popularized throughout the country,and it will also provide new medical ideas for the establishment of other disease rehabilitation hierarchical medical system.更多还原