美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸課件

美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸徐俊,臨床醫(yī)學(xué)博士(M.D)美國(guó)哥倫比亞大學(xué)附屬斯坦福醫(yī)院康復(fù)醫(yī)學(xué)科主治醫(yī)師美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸什么是康復(fù)醫(yī)學(xué)?現(xiàn)代醫(yī)學(xué)的一支.綜合性地預(yù)防,診斷和治療一切有關(guān)大腦,神經(jīng),骨胳和肌肉的疾病.重建功能.改進(jìn)生活質(zhì)量.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸康復(fù)醫(yī)學(xué)的歷史FrankH.Krusen,M.D.現(xiàn)代康復(fù)醫(yī)學(xué)之父.二戰(zhàn)大量傷殘老兵的需要.1947年經(jīng)美國(guó)醫(yī)學(xué)專(zhuān)業(yè)委員會(huì)批準(zhǔn),正式成為一個(gè)獨(dú)立專(zhuān)科.

康復(fù)醫(yī)生的訓(xùn)練:四年大學(xué)本科四年醫(yī)學(xué)院(臨床醫(yī)學(xué)博士)一年內(nèi)科或外科住院醫(yī)生訓(xùn)練三年康復(fù)醫(yī)學(xué)住院醫(yī)生訓(xùn)練亞專(zhuān)科訓(xùn)練(選修)美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸現(xiàn)代康復(fù)醫(yī)學(xué)的內(nèi)容疼痛醫(yī)學(xué)兒童康復(fù)醫(yī)學(xué)脊椎損傷醫(yī)學(xué)神經(jīng)肌肉醫(yī)學(xué)運(yùn)動(dòng)醫(yī)學(xué)臨終醫(yī)學(xué)殘肢醫(yī)學(xué)肌肉骨胳醫(yī)學(xué)電子診斷醫(yī)學(xué)(肌電圖,神經(jīng)電圖,腦電圖,脊髓傳導(dǎo)電圖,視覺(jué)導(dǎo)電圖,等等)腦損傷康復(fù)醫(yī)學(xué).心肺康復(fù)醫(yī)學(xué).美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸美國(guó)康復(fù)治療團(tuán)隊(duì)-康復(fù)系(科)康復(fù)主治醫(yī)生物理治療師生活治療師音樂(lè)治療師聽(tīng)力治療師消化治療師呼吸治療師精神治療師假肢,輪椅制造師護(hù)士營(yíng)養(yǎng)師針灸師美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸病例:王先生,45歲,患有某型白血病2年.接受骨髓移植后發(fā)生排異反應(yīng),進(jìn)入北京某大醫(yī)院住院.該院用大劑量激素抑制排異反應(yīng)后,發(fā)現(xiàn)病人骨質(zhì)疏松,因懼怕病人摔倒,引起骨折.醫(yī)囑臥床,不得下床.2月后,發(fā)現(xiàn)病人肌肉萎縮,關(guān)節(jié)僵硬.囑咐病人在美國(guó)購(gòu)買(mǎi)睪丸酮加強(qiáng)肌力,但沒(méi)有效果,病人虛弱到不能坐在床上.一月后,肺部霉菌感染,所有的抗菌素均無(wú)效,宣告死亡.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸廢用綜合征

DeconditioningSyndromeDeconditioning–decreasedfunctionalcapacityofmultipleorgansystems.由廢用引起的多器官系統(tǒng)功能的降低.Deconditionmayresultfromdecreasedphysicalactivity,prescribedbedrest,orthopediccasting,paralysis,aging,etc.一般由降低日常活動(dòng)和臥床太久,骨折固定,中風(fēng)偏癱,年老體弱引起.

美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸廢用綜合征

DeconditioningSyndrome

影響多器官和系統(tǒng)Cardiovascular心臟Respiratory呼吸Muscular肌肉Skeletal骨胳Joint&CTD關(guān)節(jié)Gastrointestinal胃腸Genitourinary泌尿Integumentary皮膚Endocrine內(nèi)分泌Neurological神經(jīng)Psychological精神美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸廢用綜合征

一.對(duì)肌肉骨胳系統(tǒng)的影響1.肌肉力量和耐受性萎縮.2.肌肉強(qiáng)直和僵硬性萎縮.3.肌肉電解質(zhì)活力和代謝改變.4.肌肉韌帶連接處萎軟和

僵硬.5.韌帶肌腱和骨胳萎軟和

僵硬.6.骨質(zhì)疏松7.關(guān)節(jié)軟骨退行性變.8.骨胳纖維組織浸淪,

骨胳漿膜萎縮.9.脊椎彎曲.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸EurJApplPhysiol.2007Feb;99(3):283-9.Epub2006Dec22.

Hip,thighandcalfmuscleatrophyandbonelossafter5-weekbedrestinactivity.

BergHE,EikenO,MiklavcicL,MekjavicIB.

DepartmentofOrthopedics,Karolinska

UniversityHospitalHuddinge,Stockholm,Sweden.5周臥床后,用CT檢測(cè),髖關(guān)節(jié),大腿,小腿肌力下降20%肌肉切面面積下降2-12%.大腿切面面積下降最多.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸對(duì)肌肉骨胳系統(tǒng)的影響Progressivedecreaseinmusclestrength/enduranceStrengthdeclines肌力下降1-3%/day10-20%perweek(plateausat25-40%in3-5wks)Greaterinantigravitymuscles(quadriceps,backextensors,plantarflexors)Type1(slowtwitch,oxidative)musclesFatigability疲勞DecreasedATP&glucosestoresandabilitytousefattyacidsATP和糖元儲(chǔ)藏下降.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸對(duì)肌肉骨胳系統(tǒng)的影響Decreaseinmusclemass&tension肌肉質(zhì)量和張力下降Muscleatrophy/wasting2ndtodecreasedmusclesynthesis肌纖維合成減少3%/day(decreasedfibersize,not#)肌纖維直徑下降3%一天.BodyCompositionchanges機(jī)體構(gòu)成改變Decreasedleanbodymass(肌肉質(zhì)量減少3%一天)Increasedbodyfat(脂肪增加12%一天)美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸如何預(yù)防對(duì)肌肉骨胳系統(tǒng)的影響Prevention/Treatmentdailyisometriccontractionscanpreventdeterioration每天等張肌肉收縮鍛煉Note:itmaytake2-3timeslongerto“regain”lostmusclemass&strengthFES電刺激治療包括針灸治療.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸肌肉強(qiáng)直和僵硬性萎縮

受重力影響所致

頸:彎曲肩膀:內(nèi)收胸:彎曲上肢:彎曲前肢:外展髖,膝:彎曲美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸肌肉強(qiáng)直和僵硬性萎縮美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸肌肉強(qiáng)直和僵硬性萎縮的預(yù)防ContracturepreventionBedpositioning躺臥的位置Extofneck,hips,knee…,ankleneutral,”functional”handpositionBIDrangeofmotionexercises(terminal,sustained)關(guān)節(jié)運(yùn)動(dòng)Standing,earlymob&ambulationCPMforTKA美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸肌肉強(qiáng)直和僵硬性萎縮的預(yù)防Splinting–static,serialcasts夾板Heat(40-43degrees)加熱Surgery手術(shù)(capsularrelease,tenotomy,tendontransfer/lengthening)Nerve&MPblocks神經(jīng)元阻滯美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸對(duì)骨胳系統(tǒng)的影響Wolff’sLaw”–重力越大,骨質(zhì)越堅(jiān),沒(méi)有重力,骨質(zhì)溶解.Osteoporosis!–peaksat4-6weeks骨質(zhì)酥松4-6周最大.Bonedensitydecreases40%after12weeks(acceleratedinSCI)(xraynotsensitiveuntil35-50%boneloss)IncreasedosteoclasticactivityDecreasedrateofboneformationTheWEIGHT_BEARINGbonesarethefirsttolosemass(firstfewdays)Vertebralcolumnsloseupto50%Canleadtofracture,evenwithminortraumaPrevention:weight-bearing&musclecontractions治療:負(fù)重訓(xùn)練美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸對(duì)骨胳系統(tǒng)的影響ImmobilityHypercalcemiamayoccur2-4weeksafteronset臥床2-4周可開(kāi)始高鈣血癥Symptoms:N/V,abdpain,lethargy,muscleweakness癥狀:呃心嘔吐,腹痛,神智惶惑,肌肉萎軟Treatment:hydrationandlasixdiuresis,mobilization治療:生理鹽水,速尿,運(yùn)動(dòng)HeterotopicOssificationIneitherneurological,osseousormusculartrauma美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸HeterotopicOssification

異位性骨化癥異位性骨化,主要在人體受傷后,在其它軟組織部形成,16%-53%的脊椎損傷病人患有HO.治療:預(yù)防為主,關(guān)節(jié)運(yùn)動(dòng),etidronatedisodium(Didronel),嚴(yán)重者外科切除.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸HeterotopicOssification

異位性骨化癥Apathologicalformationofmaturelamellarboneinnon-osseoustissues.Resultsfromanalterationinthenormalregulationofskeletogenesis.Canbeclassifiedbyitsanatomicallocationanditsresultanteffectonrangeofmotion.MostcommoncauseofHOisdirecttrauma.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸HeterotopicOssification

異位性骨化癥Localizedswelling,pain,warmth,andalossofjointrangeofmotionattheaffectedsite.HallmarksignofHOisprogressivelossofROM.Signsofinflammationwillsubsidewithrangeofmotioncontinuingtodecrease.RadiographicimagingusedtoconfirmdiagnosisofHO.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸HeterotopicOssification

異位性骨化癥RadiographHOistypicallyseen6weeksafterinjuryonfilm,butcanbeidentifiedasearlyas2weeksafterinjury.Revealsbothlocationamaturityoftheectopicbone.CTScan:Identifiesthedefinitelocationofectopicossificationandrevealsthecomplexarchitectureofarticularsurfaces.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸HeterotopicOssification

異位性骨化癥美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸廢用綜合征

二.對(duì)心血管系統(tǒng)的影響心臟(休息):心率上升,心輸出量下降.心臟容量下降,左心室舒張期末容量下降.心臟(運(yùn)動(dòng)):心率上升,最大含氧量下降,每博量和心輸出量下降,動(dòng)靜脈氧分壓差升高.體位性低血壓血漿量降低,全血量降低,紅細(xì)胞降低,礦物質(zhì)血漿蛋白降低靜脈血栓形成增加,血纖維蛋白元增加.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸BrHeartJ.1993February;69(2):125–128.PMCID:ReductioninleftventricularwallthicknessafterdeconditioninginhighlytrainedOlympicathletes.

BJMaron,APelliccia,ASpataro,andMGranataDepartmentofMedicine,ItalianNationalOlympicCommittee,Rome.六名88年奧林匹克運(yùn)動(dòng)員奧運(yùn)會(huì)后自愿停止訓(xùn)練13周.超聲心動(dòng)圖檢查發(fā)現(xiàn)左心室平均厚度從13.8MM降到10.5MM,降幅達(dá)平均30%,P值小于0.0005.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸廢用綜合征

對(duì)心血管系統(tǒng)的影響Increasedheartrate(restingtachycardia)HRrises0.5bpm/dayoverfirst3to4

weeks心率升高每天0.5次每分鐘.Exaggeratedwithexercise(eventrivialexertion)心悸心慌,心絞痛,左心室舒張末期血量降低.Angina,decreasedLV-EDVDecreasedstrokevolume–15%in2weeks二周內(nèi)心博輸出量降低15%CardiacOutputremainslargelyunchangedCardiacmusclemassmaydecrease心肌重量下降美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸對(duì)血管的影響B(tài)loodpoolsinthelegsBloodvesselsmaylosetheirabilitytoconstrictinresponsetoposturalchange彈性降低Decreased降低venousreturn靜脈回流Strokevolume心博量Bloodpressure血壓ORTHOSTASIS!體位性低血壓Rx:earlymobilization,isometricLEexercise,positioning/gradualtilting,TEDs,fluids,meds早期運(yùn)動(dòng).美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸對(duì)血液的影響Prolongedrecumbenceleadstovolumeloss長(zhǎng)期臥床引起血容量降低(4-7天可見(jiàn))Shifts700cctothorax,increasedCOby25%Gradualdiuresis(proteinloss)蛋白丟失.Decreasedplasmavolume–10-15%,Hctmayincrease,thenfallasRBCmassdecreases血漿量下降體位性低血壓,腎上腺素分泌不足,血壓反饋能力降低,引起頭暈,心絞痛,摔倒,等.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸靜脈血栓形成“Virchow’sTriad”–stasis,hypercoagulability,vesseltrauma(riskfactorsforThrombosis)靜止,高黏稠度,血管損傷.Venousstasis2ndtodecreasedbloodflow,Incviscosityhypercoagulability,increasedbloodfibrinogenLocation:calfveinshighestrisk,20%propagatetopopliteal,50%ofpoplitealwillembolize(PE)常見(jiàn)于小腿和腘窩靜脈.50%腘窩靜脈回游離.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸靜脈血栓形成機(jī)制美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸靜脈血栓導(dǎo)致肺栓塞形成機(jī)制美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸靜脈血栓導(dǎo)致肺栓塞臨床表現(xiàn)TheClassicTriad:(Hemoptysis,Dyspnea,PleuriticPain)咳血，呼吸急促，胸痛

Symptom Percent

Dyspnea 呼吸急促 84 ChestPain,pleuritic 胸痛，胸膜痛 74 Anxiety焦慮 59 Cough 咳嗽 53 Hemoptysis咳血 30 Sweating 出汗 27 ChestPain,nonpleuritic胸痛，無(wú)胸膜痛 14 Syncope 頭暈 13美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸靜脈血栓導(dǎo)致肺栓塞形成機(jī)制massivePE>60%reductioninbloodflowrapidlyfatalmajorPE-mediumsizedvesselsblocked.Patientsshortofbreath+/-coughandbloodstainedsputumminorPE-smallperipheralpulmonaryarteriesblocked.AsymptomaticorminorshortnessofbreathrecurrentminorPEsleadtopulmonaryhypertension美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸靜脈血栓導(dǎo)致肺栓塞診斷ImagingStudiesCXRV/QScansSpiralChestCTPulmonaryAngiographyEchocardiograpyLaboratoryAnalysisCBC,ESR,Hgb/Hct,D-DimerABG’sAncillaryTestingEKGPulseOximetry美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸靜脈血栓導(dǎo)致肺栓塞X光診斷Westermark'ssignAdilationofthepulmonaryvesselsproximaltotheembolismalongwithcollapseofdistalvessels,sometimeswithasharpcutoff.Hampton’sHumpAtriangularorroundedpleural-basedinfiltratewiththeapextowardthehilum,usuallylocatedadjacenttothehilum.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸靜脈血栓的高危因素Age40-60yearsAge>60(countas2factors)HistoryofDVTorPE(countas5factors)MalignancyObesity(>120%ofIBW)Immobilization(>72hrs)MajorSurgeryParalysisTraumaSevereCOPDPregnancy,orpostpartum<1monthSeveresepsisHypercoagulablestateNephroticSyndromeLegulcers,edema,orstasisHistoryofMI,CHF,Stroke,IBD美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸靜脈血栓的預(yù)防-早期活動(dòng)美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸靜脈血栓的預(yù)防:JThrombHaemost.2008Mar;6(3):405-14.

Anticoagulantprophylaxistopreventasymptomaticdeepveinthrombosisinhospitalizedmedicalpatients:asystematicreviewandmeta-analysis.

LloydNS,DouketisJD,MoinuddinI,LimW,CrowtherMA.

DepartmentofMedicine,McMasterUniversity,andStJoseph'sHealthcare,Hamilton,ON,Canada.

Fourtrialsincluding5516patientswereeligible.AnticoagulantprophylaxisconferredanabsoluteriskreductionofanyDVTandproximalDVTof2.6%and1.8%,respectively,andwasassociatedwitha0.5%absoluteriskincreaseinmajorbleedinglow-doseLMWHas<or=6000IU/dayorweight-adjusteddoseof<or=86IU/kg/day.小分子量肝素.CONCLUSIONS:AnticoagulantprophylaxisiseffectiveinpreventingasymptomaticDVTinat-riskhospitalizedmedicalpatientsbutisassociatedwithanincreasedbleedingrisk.Thetherapeuticbenefitsofanticoagulantprophylaxisappeartooutweightherisksofbleeding.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸廢用綜合征對(duì)呼吸系統(tǒng)的影響美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸廢用綜合征對(duì)呼吸系統(tǒng)的影響Potentialdecreaseinlungvolumes(2ndtomuscleweakness,positioning/restriction)Vitalcapacity降低25–50%TLC降低7%Residualvolume降低19%Expiratoryreserve降低10%Functionalresidualcapacity降低30%A-Vshunting動(dòng)-靜脈短路增加Increasedrespiratoryrate呼吸頻率增加最終導(dǎo)致肺不張和低張性肺炎.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸廢用綜合征對(duì)呼吸系統(tǒng)的影響

胸部物理治療1.呼吸訓(xùn)練.2.位置性引流.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸廢用綜合征對(duì)呼吸系統(tǒng)的影響犒勞性呼吸鍛煉器INCENTIVESPIROMETRY早期下床運(yùn)動(dòng).美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸廢用綜合征對(duì)消化系統(tǒng)的影響Decreasedfluidintake,appetite胃口降低,水份吸收減少.Increasedtransittimeinesophagus,stomach食物在胃腸道存留滯留.Reducedsmallbowelmotility(2ndtoincreasedadrenergicactivity)小腸運(yùn)動(dòng)降低Constipation便秘Rx:治療:運(yùn)動(dòng)

+bowelmeds,fluids,mob,fiber-richdiet(fruits,veg),avoidnarcotics美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸廢用綜合征對(duì)泌尿系統(tǒng)的影響Diuresis(2ndtofluidre-mobilization)多尿.Difficultyvoiding(duetopostioning)泌尿困難.UTI’s尿道感染Calculusformation(10-15%),結(jié)石hypercalciuria(espSCI,Fxs)高鈣血尿Rx:運(yùn)動(dòng)+fluids,uprightpositioning,d/ccatheters美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸廢用綜合征對(duì)皮膚系統(tǒng)的影響美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸廢用綜合征對(duì)皮膚系統(tǒng)的影響

預(yù)防和治療病因:

壓力

PRESSURE,摩擦

FRICTION,動(dòng)力SHEARFORCE,

預(yù)防為主.毛細(xì)血管壓力為32MMHG.實(shí)驗(yàn):2小時(shí),32MMHGPRESSUREULCER美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸廢用綜合征對(duì)內(nèi)分泌系統(tǒng)的影響Impairedglucosetolerance

Hyperinsulinemia高胰島素Musclesdevelopinsulinresistance胰島素抵抗.AlteredregulationofParathyroid,Thyroid,adrenal,pituitary,growthhormones,androgensandplasmareninactivity其他激素改變Alteredcircadianrhythm心率改變Alteredtemperatureandsweatingresponse溫度和出汗機(jī)制改變.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸廢用綜合征對(duì)代謝系統(tǒng)的影響Urinarylossof:尿氮鈣磷丟失Nitrogen–(beginsday5-6,peaksat2weeks)Calcium–(beginsday2-3,peaksat4-6weeks)PhosphorusReversiblepostmobilization美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸廢用綜合征對(duì)神經(jīng)系統(tǒng)的影響Compressionneuropathies

神經(jīng)壓迫Ulnar(attheelbow)尺神經(jīng)損傷Peroneal(fibularhead)腓神經(jīng)損傷Decreasedcoordination/balance平衡損傷Decreasedvisualacuity視力損傷美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸廢用綜合征對(duì)精神系統(tǒng)的影響Sensorydeprivation(“ICUpsychosis”)decreasedattentionspan,awareness,coordination,精神不集中Depression,labiality,anxiety憂郁,狂躁Sleepdisturbance失眠Increasedauditorythreshold耳鳴Decreasedpainthreshold痛感增強(qiáng)美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸廢用綜合征的預(yù)防Earlymobilization早期活動(dòng)Strengthening體能鍛煉ROM關(guān)節(jié)運(yùn)動(dòng)Maintainskinintegrity保持皮膚完整DVTprophylaxis預(yù)防靜脈血栓Painmanagement治療痛癥Psychologicalassessment/treatment治療精神疾病AggressiveRespiratorymanagement積極治療呼吸系統(tǒng)疾病B/Bassessment&care大小便檢護(hù)運(yùn)動(dòng)每天1小時(shí),或每天死亡24小時(shí)?美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸區(qū)域性復(fù)雜性疼痛綜合征

ComplexRegionalPainSyndrome美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸區(qū)域性復(fù)雜性疼痛綜合征1.名稱(chēng)：ComplexRegionalPainSyndromeReflexSympatheticDystrophy2.歷史：美國(guó)國(guó)內(nèi)戰(zhàn)爭(zhēng)時(shí)期，Dr.WilasWeirMitchell觀察到神經(jīng)損傷的戰(zhàn)士患有慢性疼痛綜合征，主要表現(xiàn)是：慢性燒灼性疼痛，肌肉萎縮性腫大。美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸區(qū)域性復(fù)雜性疼痛綜合征后來(lái)發(fā)現(xiàn)與交感神經(jīng)有關(guān)，阻斷交感神經(jīng)后，疼痛減輕，故稱(chēng)為：ReflexSympatheticDystrophy反應(yīng)性交感神經(jīng)萎縮綜合征。1993年theInternationalAssociationforthestudyofpain正式命名為：ComplexregionalPainnSyndrome區(qū)域性復(fù)雜性疼痛綜合征美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸區(qū)域性復(fù)雜性疼痛綜合征機(jī)理美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸區(qū)域性復(fù)雜性疼痛綜合征Oftenseenafterinjurytoalimborrelatedtosomeincitingevent.具有肢體損傷歷史。Thepatientcomplainsofandcanmanifestskincolor/temperature/appearancechangesintheaffectedlimb.一側(cè)上肢或下肢表現(xiàn)皮膚顏色，溫度，外表改變Painoftenexcruciating–burning,tingling,electric-like,etc.areoftensymptomsthatpatientsfeel.Thepainisoftenoutofproportiontostimulusortheevent.燒灼，電擊，刺痛感覺(jué)，疼痛與所受的刺激不成比例。美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸區(qū)域性復(fù)雜性疼痛綜合征美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸DiagnosticCriteria診斷標(biāo)準(zhǔn)IASP(InternationalAssocfortheStudyofPain)diagnosticcriteriainclude4subjectiveand/orobjectivefindings:1.Thepresenceofaninitiatingeventoracauseofimmobilization–peripheralinjuryorcentral(stroke,etc)*.(Injury)有損傷2.Continuingpain,allodynia,orhyperalgesiainwhichthepainisdisproportiatetoincitingevent.(Sensory)疼痛與刺激不成比例3.Evidenceofedema,changesinskinbloodflow,orabnormalsudomotoractivityinregionofpain.(Vasomotor)皮膚變化4.Diagnosisisexcludedbytheexistenceofotherconditionsthatwouldotherwiseaccountforthedegreeofpain/dysfunction.除去其它原因疼痛。One

symptomfrom

eachcategory(except#1as5%ofptslackknownevent)andatleastonesignfrom2categoriesmustbeevidenttodiagnoseCRPS,atleastbyresearchcriteria.*Notalwayspresentoridentifiable.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸Tx–FunctionalRestoration

治療1-功能恢復(fù)Functionalrestorationinvolvessteadyprogressionfromgentlemovementstogentle,weightbearingmovement.Resultsinmoreactiveloadbearingwithexpectedgradualdesensitizationandincreasedfunctionalityoflimb.慢慢去敏感Examplesincludemovingfromsilkstimulationtootherclothsandtextures,thescrubandcarrytechnique,andcontrastbathsthatwidenthetemperaturerangethatthepatientcantolerate.Iflimitationsoccurthenadditionofblocks,pharmacotherapy,etc.canhelpincreasethepatient‘stoleranceandimprovement.加用其它治療美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸Tx–Psychotherapy

治療2-精神治療PsychotherapyiscriticaltoimprovementinpatientswithCRPS.ThereisahighincidenceofdepressionandanxietynotedinmanyCRPSpatients.Unknownatthistimeifantecedentpsychologicalfactorspriortoinjuryarecommon.

治療憂郁，焦慮，等等CRPSpatientsalsodevelop

atypeofPTSDtermed“kinesophobia”orfearofmovementrelatedtopriorpainorinitialinjury.Thepatientdevelops“negativereinforcements”throughfearofinitialmovementsthatcausedtheinjuryofpriormovementsthatresultedinextremepaininthepast.Fearofmovementoftenresultsincontracturesandreducedfunctionality.治療創(chuàng)傷后壓力綜合征Cognitivebehavioraltherapyisthemostbeneficialpsychotherapytohelppatientswiththeseconcerns,thoughotherinterventionsincludingfamilytherapyarealsobeneficial.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸Tx–Pharmacotherapy

治療3-藥物Pharmacotherapyisoftenonatrialanderrorbasisandisverypatientspecific.DrugsareconsideredbasedonneuropathicpaintreatmentsandthenusedforCRPSandhaveyettobeshowneffectiveinRCTs.

-initialdrug(s)toconsiderincludegabapentinandpregabalin(bothusedforneuropathicpain)andareapprovedfortheseconditions神經(jīng)拮抗藥-TCAsoftenusedforpatientswithsleepdisturbances,butarehinderedbytheirnumeroussideeffectsanddruginteractions;notcurrentlyapprovedforpaintreatment傳統(tǒng)抗憂郁藥美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸Tx–Pharmacotherapy

治療3-藥物-SSRIsandSNRIslikefluoxetineandduloxetine,resp,areoftenusedwiththelatterbeingapprovedforneuropathicpainconditions.抗精神憂郁新藥有效。-Opioidsshouldbeavoidedasmuchaspossibleastheireffectivenessisnotwellprovedanddependence/addictionareseriousconcernsinCRPSpatients.避免過(guò)量鴉片樣藥物治療-Intrathecalbaclofen,IVsteroids,IVIG,andanticonvulsantmedicationsarealltreatmentsthathavebeenconsideredandusedwithvariablesuccess,thoughstudiesarestilllacking.激素，貝可洛芬，IgG等等，效果有限，療效有待證明。美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸Tx–InterventionalApproaches

介入性治療1.Cervicalandlumbarsympatheticblocks。 頸，腰叢交感神經(jīng)節(jié)阻斷美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸Tx–InterventionalApproaches

介入性治療Beirblockswithlocalanesthetics,guanethidine,orotherneurolyticagentshavebeenperformedwithvaryingsuccess.局部神經(jīng)阻斷，效果有限。SCS,pumpimplantation,andthermocoagulationhavealsobeenusedtotreatpatientswithCRPSwithvariablesuccessrates.嗎啡泵等，效果有限。美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸區(qū)域性復(fù)雜性疼痛綜合征預(yù)后不好，療效差，因此針灸大有可為。在美國(guó)治療有效，頭針，耳針加體針。美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸中風(fēng)的預(yù)防急救和治療李先生,75歲,患有高血壓,高血脂和房纖近十年.平時(shí)服用抗高血壓和抗血脂藥.一天早起晨練,忽然覺(jué)得右臂和臉部麻痹,他不以為意,以為睡一覺(jué)就會(huì)好,第二天醒來(lái),他發(fā)現(xiàn)整個(gè)右側(cè)身體偏癱.他被送入院.診斷為缺血性MCA中風(fēng).住院臥床二月,回家后因?yàn)樯畈荒茏岳?請(qǐng)了一位保姆照顧,半年后,依然臥床.他平時(shí)除了服用抗高血壓和抗血脂藥,沒(méi)有其他治療.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸李先生的問(wèn)題沒(méi)有預(yù)防措施沒(méi)有緊急治療沒(méi)有康復(fù)治療沒(méi)有針灸治療沒(méi)有再次中風(fēng)預(yù)防美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸美國(guó)NIH中風(fēng)指導(dǎo)大綱EligibilityforIVtreatmentwithrt-PA

尿激酶治療標(biāo)準(zhǔn)Age18orolder.18歲以上Clinicaldiagnosisofischemicstrokecausingameasurableneurologicaldeficit.臨床診斷為缺血性中風(fēng)Timeofsymptomonsetwellestablishedtobelessthan180minutesbeforetreatmentwouldbegin.中風(fēng)發(fā)作到治療必須少于180分鐘.CT和/或MRI排除出血性中風(fēng).0.9mg/kg(maximumof90mg)infusedover60minuteswith10%ofthetotaldoseadministeredasaninitialintravenousbolusover1minute.在60分鐘之內(nèi)靜脈點(diǎn)滴0.9mg/kg(maximumof90mg),在頭一分鐘點(diǎn)滴10%的劑量.同時(shí)控制血壓和監(jiān)控出血.來(lái)源:美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸T-PA必須在三小時(shí)內(nèi)注射美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸 A B C D E FSystolicBP* 95-105 130-148 130-148 130-148 130-148 130-148Diabetes No No Yes Yes Yes YesCigarettes No No No Yes Yes YesPriorAtrialFib. No No No No Yes YesPriorCVD No No No No No YesEstimated10-yearstrokeriskin55-year-oldadultsaccordingtolevelsofvariousriskfactors(FHS).55歲成年人中風(fēng)的發(fā)病因素和風(fēng)險(xiǎn)

Source:Wolfetal.,Stroke.1991;22:312-318.*BPinmillimetersofmercury(mmHg)美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸EffectivenessofStrokePreventionAbsoluteriskreductioninayear:

一年預(yù)防降低中風(fēng)率StrategyARR(%)Warfarinforatrialfibrillation雙香豆素治療房纖

8Carotidendarterctomyforsymptomaticdz 頸動(dòng)脈內(nèi)壁切除 4Smokingcessation戒煙 2AntihypertensivetherapyifBPelevated降血壓 2Cholesterolloweringmedications降血脂 2Aspirin阿斯匹林 1-2Total總共降低 19to20%美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸Patient RelativeRisk OddsPopulation Therapy Reduction(%) Reduction(%)EfficacyofAntiplateletAgents

forPreventionofStroke,MI,

orVascularDeathAllVascular Allantiplatelet 22 27

Diseases regimensStroke/TIA Allantiplatelet 17 22

regimensStroke/TIA Aspirin 13 16Source:AntiplateletTrialists’Collaboration,1994:AlgraandVanGijn1996.RiskReductions美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸EfficacyofAntiplateletAgentsvsPlaceboforPreventionofStroke,MI,orVascularDeathinStroke/TIAPatientsAspirin(alldoses) 10 13 Ticlopidine 1 23 Dipyridamole+ASA 4 30 AllAntiplateletAgents 18 17 RelativeRisk

AntiplateletAgent No.ofStudies Reduction(%) Source:AlgraandVanGijn1996;Gentetal.

1989;Tijssen,1998;AntiplateletTrialists’Collaboration,1994.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸FDARecommends

Low-DoseAspirinFDAreviewedtrialsofaspirinvsplaceboThe“positivefindingsatlowerdosages

aresufficientreasontolowerthedosage

ofaspirin...forsubjectswithTIA

andischemicstroke.”For“ischemicstrokeandTIA:50to325mg[aspirin]onceaday.Continuetherapyindefinitely.”美國(guó)FDA推薦小劑量ASA預(yù)防初次和二次中風(fēng),一般每天口服81毫克,無(wú)停藥的要求.FDA,FederalRegister.1998.63:56802–56819.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸Strokerehabilitation

(1):treatingimpairmentsSpasticitymanagement僵直處理Physiotherapy物理治療Orthotics夾板botulinumtoxin生物毒素針灸美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸Strokerehabilitation

(1):treatingimpairmentsNutritionalmanagementswallowingassessment(SALT)

吞咽檢查Dietarymodification改變食物類(lèi)型palatalstimulationenteralfeeding腸道營(yíng)養(yǎng).美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸Strokerehabilitation

(2):reducedisabilitybyre-learningTransfertraining轉(zhuǎn)移訓(xùn)練.美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸Gaittraining走路訓(xùn)練Strokerehabilitation

(2):reducedisabilitybyre-learning美國(guó)康復(fù)醫(yī)學(xué)進(jìn)展與中醫(yī)針灸Strokerehabilit