美国康复医学进展与中医针灸医学PPT课件.ppt

美国康复医学进展与中医针灸,什么是康复医学?,现代医学的一支.综合性地预防,诊断和治疗一切有关大脑,神经,骨胳和肌肉的疾病.重建功能.改进生活质量.,康复医学的历史,FrankH.Krusen,M.D.现代康复医学之父.二战大量伤残老兵的需要.1947年经美国医学专业委员会批准,正式成为一个独立专科.康复医生的训练:四年大学本科四年医学院(临床医学博士)一年内科或外科住院医生训练三年康复医学住院医生训练亚专科训练(选修),现代康复医学的内容,疼痛医学儿童康复医学脊椎损伤医学神经肌肉医学运动医学临终医学残肢医学肌肉骨胳医学电子诊断医学(肌电图,神经电图,脑电图,脊髓传导电图,视觉导电图,等等)脑损伤康复医学.心肺康复医学.,美国康复治疗团队-康复系(科),康复主治医生物理治疗师生活治疗师音乐治疗师听力治疗师消化治疗师呼吸治疗师精神治疗师假肢,轮椅制造师护士营养师针灸师,病例:王先生,45岁,患有某型白血病2年.接受骨髓移植后发生排异反应,进入北京某大医院住院.该院用大剂量激素抑制排异反应后,发现病人骨质疏松,因惧怕病人摔倒,引起骨折.医嘱卧床,不得下床.2月后,发现病人肌肉萎缩,关节僵硬.嘱咐病人在美国购买睾丸酮加强肌力,但没有效果,病人虚弱到不能坐在床上.一月后,肺部霉菌感染,所有的抗菌素均无效,宣告死亡.,废用综合征DeconditioningSyndrome,Deconditioningdecreasedfunctionalcapacityofmultipleorgansystems.由废用引起的多器官系统功能的降低.Deconditionmayresultfromdecreasedphysicalactivity,prescribedbedrest,orthopediccasting,paralysis,aging,etc.一般由降低日常活动和卧床太久,骨折固定,中风偏瘫,年老体弱引起.,废用综合征DeconditioningSyndrome影响多器官和系统,Cardiovascular心脏Respiratory呼吸Muscular肌肉Skeletal骨胳Joint99(3):283-9.Epub2006Dec22.Hip,thighandcalfmuscleatrophyandbonelossafter5-weekbedrestinactivity.BergHE,EikenO,MiklavcicL,MekjavicIB.DepartmentofOrthopedics,KarolinskaUniversityHospitalHuddinge,Stockholm,Sweden.,5周卧床后,用CT检测,髋关节,大腿,小腿肌力下降20%肌肉切面面积下降2-12%.大腿切面面积下降最多.,对肌肉骨胳系统的影响,Progressivedecreaseinmusclestrength/enduranceStrengthdeclines肌力下降1-3%/day10-20%perweek(plateausat25-40%in3-5wks)Greaterinantigravitymuscles(quadriceps,backextensors,plantarflexors)Type1(slowtwitch,oxidative)musclesFatigability疲劳DecreasedATP69(2):125128.PMCID:ReductioninleftventricularwallthicknessafterdeconditioninginhighlytrainedOlympicathletes.BJMaron,APelliccia,ASpataro,andMGranataDepartmentofMedicine,ItalianNationalOlympicCommittee,Rome.,六名88年奥林匹克运动员奥运会后自愿停止训练13周.超声心动图检查发现左心室平均厚度从13.8MM降到10.5MM,降幅达平均30%,P值小于0.0005.,废用综合征对心血管系统的影响,Increasedheartrate(restingtachycardia)HRrises0.5bpm/dayoverfirst3to4weeks心率升高每天0.5次每分钟.Exaggeratedwithexercise(eventrivialexertion)心悸心慌,心绞痛,左心室舒张末期血量降低.Angina,decreasedLV-EDVDecreasedstrokevolume15%in2weeks二周内心博输出量降低15%CardiacOutputremainslargelyunchangedCardiacmusclemassmaydecrease心肌重量下降,对血管的影响,BloodpoolsinthelegsBloodvesselsmaylosetheirabilitytoconstrictinresponsetoposturalchange弹性降低Decreased降低venousreturn静脉回流Strokevolume心博量Bloodpressure血压ORTHOSTASIS!体位性低血压Rx:earlymobilization,isometricLEexercise,positioning/gradualtilting,TEDs,fluids,meds早期运动.,对血液的影响,Prolongedrecumbenceleadstovolumeloss长期卧床引起血容量降低(4-7天可见)Shifts700cctothorax,increasedCOby25%Gradualdiuresis(proteinloss)蛋白丢失.Decreasedplasmavolume10-15%,Hctmayincrease,thenfallasRBCmassdecreases血浆量下降体位性低血压,肾上腺素分泌不足,血压反馈能力降低,引起头晕,心绞痛,摔倒,等.,静脉血栓形成,“VirchowsTriad”stasis,hypercoagulability,vesseltrauma(riskfactorsforThrombosis)静止,高黏稠度,血管损伤.Venousstasis2ndtodecreasedbloodflow,Incviscosityhypercoagulability,increasedbloodfibrinogenLocation:calfveinshighestrisk,20%propagatetopopliteal,50%ofpoplitealwillembolize(PE)常见于小腿和腘窝静脉.50%腘窝静脉回游离.,静脉血栓形成机制,静脉血栓导致肺栓塞形成机制,静脉血栓导致肺栓塞临床表现,TheClassicTriad:(Hemoptysis,Dyspnea,PleuriticPain)咳血，呼吸急促，胸痛SymptomPercentDyspnea呼吸急促84ChestPain,pleuritic胸痛，胸膜痛74Anxiety焦虑59Cough咳嗽53Hemoptysis咳血30Sweating出汗27ChestPain,nonpleuritic胸痛，无胸膜痛14Syncope头晕13,静脉血栓导致肺栓塞形成机制,massivePE60%reductioninbloodflowrapidlyfatalmajorPE-mediumsizedvesselsblocked.Patientsshortofbreath+/-coughandbloodstainedsputumminorPE-smallperipheralpulmonaryarteriesblocked.AsymptomaticorminorshortnessofbreathrecurrentminorPEsleadtopulmonaryhypertension,静脉血栓导致肺栓塞诊断,ImagingStudiesCXRV/QScansSpiralChestCTPulmonaryAngiographyEchocardiograpyLaboratoryAnalysisCBC,ESR,Hgb/Hct,D-DimerABGsAncillaryTestingEKGPulseOximetry,静脉血栓导致肺栓塞X光诊断,WestermarkssignAdilationofthepulmonaryvesselsproximaltotheembolismalongwithcollapseofdistalvessels,sometimeswithasharpcutoff.HamptonsHumpAtriangularorroundedpleural-basedinfiltratewiththeapextowardthehilum,usuallylocatedadjacenttothehilum.,静脉血栓的高危因素,Age40-60yearsAge60(countas2factors)HistoryofDVTorPE(countas5factors)MalignancyObesity(120%ofIBW)Immobilization(72hrs)MajorSurgeryParalysisTrauma,SevereCOPDPregnancy,orpostpartum1monthSeveresepsisHypercoagulablestateNephroticSyndromeLegulcers,edema,orstasisHistoryofMI,CHF,Stroke,IBD,静脉血栓的预防-早期活动,静脉血栓的预防:JThrombHaemost.2008Mar;6(3):405-14.Anticoagulantprophylaxistopreventasymptomaticdeepveinthrombosisinhospitalizedmedicalpatients:asystematicreviewandmeta-analysis.LloydNS,DouketisJD,MoinuddinI,LimW,CrowtherMA.DepartmentofMedicine,McMasterUniversity,andStJosephsHealthcare,Hamilton,ON,Canada.,Fourtrialsincluding5516patientswereeligible.AnticoagulantprophylaxisconferredanabsoluteriskreductionofanyDVTandproximalDVTof2.6%and1.8%,respectively,andwasassociatedwitha0.5%absoluteriskincreaseinmajorbleedinglow-doseLMWHasor=6000IU/dayorweight-adjusteddoseofor=86IU/kg/day.小分子量肝素.CONCLUSIONS:AnticoagulantprophylaxisiseffectiveinpreventingasymptomaticDVTinat-riskhospitalizedmedicalpatientsbutisassociatedwithanincreasedbleedingrisk.Thetherapeuticbenefitsofanticoagulantprophylaxisappeartooutweightherisksofbleeding.,废用综合征对呼吸系统的影响,废用综合征对呼吸系统的影响,Potentialdecreaseinlungvolumes(2ndtomuscleweakness,positioning/restriction)Vitalcapacity降低2550%TLC降低7%Residualvolume降低19%Expiratoryreserve降低10%Functionalresidualcapacity降低30%A-Vshunting动-静脉短路增加Increasedrespiratoryrate呼吸频率增加最终导致肺不张和低张性肺炎.,废用综合征对呼吸系统的影响胸部物理治疗,1.呼吸训练.,2.位置性引流.,废用综合征对呼吸系统的影响,犒劳性呼吸锻炼器INCENTIVESPIROMETRY,早期下床运动.,废用综合征对消化系统的影响,Decreasedfluidintake,appetite胃口降低,水份吸收减少.Increasedtransittimeinesophagus,stomach食物在胃肠道存留滞留.Reducedsmallbowelmotility(2ndtoincreasedadrenergicactivity)小肠运动降低Constipation便秘Rx:治疗:运动+bowelmeds,fluids,mob,fiber-richdiet(fruits,veg),avoidnarcotics,废用综合征对泌尿系统的影响,Diuresis(2ndtofluidre-mobilization)多尿.Difficultyvoiding(duetopostioning)泌尿困难.UTIs尿道感染Calculusformation(10-15%),结石hypercalciuria(espSCI,Fxs)高钙血尿Rx:运动+fluids,uprightpositioning,d/ccatheters,废用综合征对皮肤系统的影响,废用综合征对皮肤系统的影响预防和治疗,病因:压力PRESSURE,摩擦FRICTION,动力SHEARFORCE,预防为主.毛细血管压力为32MMHG.实验:2小时,32MMHGPRESSUREULCER,废用综合征对内分泌系统的影响,ImpairedglucosetoleranceHyperinsulinemia高胰岛素Musclesdevelopinsulinresistance胰岛素抵抗.AlteredregulationofParathyroid,Thyroid,adrenal,pituitary,growthhormones,androgensandplasmareninactivity其他激素改变Alteredcircadianrhythm心率改变Alteredtemperatureandsweatingresponse温度和出汗机制改变.,废用综合征对代谢系统的影响,Urinarylossof:尿氮钙磷丢失Nitrogen(beginsday5-6,peaksat2weeks)Calcium(beginsday2-3,peaksat4-6weeks)PhosphorusReversiblepostmobilization,废用综合征对神经系统的影响,Compressionneuropathies神经压迫Ulnar(attheelbow)尺神经损伤Peroneal(fibularhead)腓神经损伤Decreasedcoordination/balance平衡损伤Decreasedvisualacuity视力损伤,废用综合征对精神系统的影响,Sensorydeprivation(“ICUpsychosis”)decreasedattentionspan,awareness,coordination,精神不集中Depression,labiality,anxiety忧郁,狂躁Sleepdisturbance失眠Increasedauditorythreshold耳鸣Decreasedpainthreshold痛感增强,废用综合征的预防,Earlymobilization早期活动Strengthening体能锻炼ROM关节运动Maintainskinintegrity保持皮肤完整DVTprophylaxis预防静脉血栓Painmanagement治疗痛症Psychologicalassessment/treatment治疗精神疾病AggressiveRespiratorymanagement积极治疗呼吸系统疾病B/Bassessmentnotcurrentlyapprovedforpaintreatment传统抗忧郁药,TxPharmacotherapy治疗3-药物,-SSRIsandSNRIslikefluoxetineandduloxetine,resp,areoftenusedwiththelatterbeingapprovedforneuropathicpainconditions.抗精神忧郁新药有效。-Opioidsshouldbeavoidedasmuchaspossibleastheireffectivenessisnotwellprovedanddependence/addictionareseriousconcernsinCRPSpatients.避免过量鸦片样药物治疗-Intrathecalbaclofen,IVsteroids,IVIG,andanticonvulsantmedicationsarealltreatmentsthathavebeenconsideredandusedwithvariablesuccess,thoughstudiesarestilllacking.激素，贝可洛芬，IgG等等，效果有限，疗效有待证明。,TxInterventionalApproaches介入性治疗,1.Cervicalandlumbarsympatheticblocks。颈，腰丛交感神经节阻断,TxInterventionalApproaches介入性治疗,Beirblockswithlocalanesthetics,guanethidine,orotherneurolyticagentshavebeenperformedwithvaryingsuccess.局部神经阻断，效果有限。SCS,pumpimplantation,andthermocoagulationhavealsobeenusedtotreatpatientswithCRPSwithvariablesuccessrates.吗啡泵等，效果有限。,区域性复杂性疼痛综合征,预后不好，疗效差，因此针灸大有可为。在美国治疗有效，头针，耳针加体针。,中风的预防急救和治疗,李先生,75岁,患有高血压,高血脂和房纤近十年.平时服用抗高血压和抗血脂药.一天早起晨练,忽然觉得右臂和脸部麻痹,他不以为意,以为睡一觉就会好,第二天醒来,他发现整个右侧身体偏瘫.他被送入院.诊断为缺血性MCA中风.住院卧床二月,回家后因为生活不能自理,请了一位保姆照顾,半年后,依然卧床.他平时除了服用抗高血压和抗血脂药,没有其他治疗.,李先生的问题,没有预防措施没有紧急治疗没有康复治疗没有针灸治疗没有再次中风预防,美国NIH中风指导大纲,EligibilityforIVtreatmentwithrt-PA尿激酶治疗标准Age18orolder.18岁以上Clinicaldiagnosisofischemicstrokecausingameasurableneurologicaldeficit.临床诊断为缺血性中风Timeofsymptomonsetwellestablishedtobelessthan180minutesbeforetreatmentwouldbegin.中风发作到治疗必须少于180分钟.CT和/或MRI排除出血性中风.0.9mg/kg(maximumof90mg)infusedover60minuteswith10%ofthetotaldoseadministeredasaninitialintravenousbolusover1minute.在60分钟之内静脉点滴0.9mg/kg(maximumof90mg),在头一分钟点滴10%的剂量.同时控制血压和监控出血.来源:/guidelines/tpa_guidelines.html,T-PA必须在三小时内注射,ABCDEFSystolicBP*95-105130-148130-148130-148130-148130-148DiabetesNoNoYesYesYesYesCigarettesNoNoNoYesYesYesPriorAtrialFib.NoNoNoNoYesYesPriorCVDNoNoNoNoNoYes,Estimated10-yearstrokeriskin55-year-oldadultsaccordingtolevelsofvariousriskfactors(FHS).55岁成年人中风的发病因素和风险Source:Wolfetal.,Stroke.1991;22:312-318.,*BPinmillimetersofmercury(mmHg),EffectivenessofStrokePreventionAbsoluteriskreductioninayear:一年预防降低中风率,StrategyARR(%)Warfarinforatrialfibrillation双香豆素治疗房纤8Carotidendarterctomyforsymptomaticdz颈动脉内壁切除4Smokingcessation戒烟2AntihypertensivetherapyifBPelevated降血压2Cholesterolloweringmedications降血脂2Aspirin阿斯匹林1-2Total总共降低19to20%,PatientRelativeRiskOddsPopulationTherapyReduction(%)Reduction(%),EfficacyofAntiplateletAgentsforPreventionofStroke,MI,orVascularDeath,AllVascularAllantiplatelet2227DiseasesregimensStroke/TIAAllantiplatelet1722regimensStroke/TIAAspirin1316,Source:AntiplateletTrialistsCollaboration,1994:AlgraandVanGijn1996.,RiskReductions,EfficacyofAntiplateletAgentsvsPlaceboforPreventionofStroke,MI,orVascularDeathinStroke/TIAPatients,Aspirin(alldoses)1013Ticlopidine123Dipyridamole+ASA430AllAntiplateletAgents1817,RelativeRiskAntiplateletAgentNo.ofStudiesReduction(%),Source:AlgraandVanGijn1996;Gentetal.1989;Tijssen,1998;AntiplateletTrialistsCollaboration,1994.,FDARecommendsLow-DoseAspirin,FDAreviewedtrialsofaspirinvsplaceboThe“positivefindingsatlowerdosagesaresufficientreasontolowerthedosageofaspirin.forsubjectswithTIAandischemicstroke.”For“ischemicstrokeandTIA:50to325mgaspirinonceaday.Continuetherapyindefinitely.”美国FDA推荐小剂量ASA预防初次和二次中风,一般每天口服81毫克,无停药的要求.,FDA,FederalRegister.1998.63:5680256819.,Strokerehabilitation(1):treatingimpairments,Spasticitymanagement僵直处理Physiotherapy物理治疗Orthotics夹板botulinumtoxin生物毒素针灸,Strokerehabilitation(1):treatingimpairments,Nutritionalmanagementswallowingassessment(SALT)吞咽检查Dietarymodification改变食物类型palatalstimulationenteralfeeding肠道营养.,Strokerehabilitation(2):reducedisabilitybyre-learning,Transfertraining转移训练.,Gaittraining走路训练,Strokerehabilitation(2):reducedisabilitybyre-learning,Strokerehabilitation-生活训练,餐具改造(3):reducedisabilitybymodification,行动工具,拐杖步行器(WALKER),轮椅,21世纪中风治疗和康复,NIHRoadmapNIH的路径Newpathwaystodiscovery诊断手段的更新Imaging,CT,MRI核磁共震Bioinformaticsandcomputationalbiology电子计算机化生物学NewresearchteamsofthefutureInterdisciplinaryresearch相关科学共同协作Re-engineeringtheclinicalresearchenterprise加快从实验室到临床的结合.Bench-to-bedsideapproach,21世纪中风治疗和康复,身体部分支持步行器,21世纪中风治疗和康复生物反馈自行车,21世纪中风治疗和康复-电刺激ImplantableCorticalStimulationSystemDevelopedbyNorthstarNeuroscience,Inc,Locatesiteofhandfunction-fMRI功能MRI找到中风位点2.Placeelectrode-Ondura在硬膜上置入电极3.Implantpulsegenerator,在身体上植入脉冲器.4.Stimulateduringrehabilitation在康复运动