美国康复医学进展与中医针灸.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,美国康复医学进展与中医针灸,徐俊,临床医学博士,(M.D),美国哥伦比亚大学附属斯坦福医院康复医学科主治医师,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,Frank H.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,Deconditioning Syndrome,影响多器官和系统,Cardiovascular,心脏,Respiratory,呼吸,Muscular,肌肉,Skeletal,骨胳,Joint&CTD,关节,Gastrointestinal,胃肠,Genitourinary,泌尿,Integumentary,皮肤,Endocrine,内分泌,Neurological,神经,Psychological,精神,废用综合征,一,.,对肌肉骨胳系统的影响,1.,肌肉力量和耐受性萎缩,.,2.,肌肉强直和僵硬性萎缩,.,3.,肌肉电解质活力和代谢,改变,.,4.,肌肉韧带连接处萎软和,僵硬,.,5.,韧带肌腱和骨胳萎软和,僵硬,.,6.,骨质疏松,7.,关节软骨退行性变,.,8.,骨胳纤维组织浸淪,骨胳浆膜萎缩,.,9.,脊椎弯曲,.,Eur J Appl Physiol.2007 Feb;99(3):283-9.Epub 2006 Dec 22.,Hip,thigh and calf muscle atrophy and bone loss after 5-week bedrest inactivity.,Berg HE,Eiken O,Miklavcic L,Mekjavic IB,.Department of Orthopedics,Karolinska,University Hospital Huddinge,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,Progressive,decrease in muscle strength,/endurance,Strength declines,肌力下降,1-3%/day,10-20%per week(plateaus at 25-40%in 3-5 wks),Greater in antigravity muscles(quadriceps,back extensors,plantarflexors),Type 1(slow twitch,oxidative)muscles,Fatigability,疲劳,Decreased ATP&glucose stores and ability to use fatty acids,ATP,和糖元储藏下降,.,对肌肉骨胳系统的影响,Decrease in muscle mass,&tension,肌肉质量和张力下降,Muscle atrophy/wasting 2,nd,to decreased muscle synthesis,肌纤维合成减少,3%/day(decreased fiber size,not#),肌纤维直径下降,3%,一天,.,Body Composition changes,机体构成改变,Decreased lean,body mass(,肌肉质量减少,3%,一天,),Increased body fat,(,脂肪增加,12,%,一天,),如何预防对肌肉骨胳系统的影响,Prevention/Treatment,daily isometric contractions can prevent deterioration,每天等张肌肉收缩锻炼,Note:it may take 2-3 times longer to“regain”lost muscle mass&strength,FES,电刺激治疗包括针灸治疗,.,肌肉强直和僵硬性萎缩受重力影响所致,颈,:,弯曲,肩膀,:,内收,胸,:,弯曲,上肢,:,弯曲,前肢,:,外展,髋,膝,:,弯曲,肌肉强直和僵硬性萎缩,肌肉强直和僵硬性萎缩的预防,Contracture prevention,Bed positioning,躺卧的位置,Ext of neck,hips,knee,ankle neutral,”functional”hand position,BID range of motion exercises(terminal,sustained),关节运动,Standing,early mob&ambulation,CPM for TKA,肌肉强直和僵硬性萎缩的预防,Splinting static,serial casts,夹板,Heat(40-43 degrees),加热,Surgery,手术,(capsular release,tenotomy,tendon transfer/lengthening),Nerve&MP blocks,神经元阻滞,对骨胳系统的影响,Wolffs Law”,重力越大,骨质越坚,没,有重力,骨质溶解,.,Osteoporosis,!,peaks at 4-6 weeks,骨质酥松,4-6,周最大,.,Bone density decreases 40%after 12 weeks(accelerated in SCI),(xray not sensitive until 35-50%bone loss),Increased osteoclastic activity,Decreased rate of bone formation,The WEIGHT_BEARING bones are the first to lose mass(first few days),Vertebral columns lose up to 50%,Can lead to fracture,even with minor trauma,Prevention:weight-bearing&,muscle contractions,治疗,:,负重训练,对骨胳系统的影响,Immobility,Hypercalcemia,may occur 2-4 weeks after onset,卧床,2-4,周可开始高钙血症,Symptoms:N/V,abd pain,lethargy,muscle weakness,症状,:,呃心呕吐,腹痛,神智惶惑,肌肉萎软,Treatment:hydration and lasix diuresis,mobilization,治疗,:,生理盐水,速尿,运动,Heterotopic Ossification,In either neurological,osseous or muscular trauma,Heterotopic Ossification,异位性骨化症,异位性骨化,主要在人体受伤后,在其它软组织部形成,16%-53%,的脊椎损伤病人患有,HO.,治疗,:,预防为主,关节运动,etidronate disodium(Didronel),严重者外科切除,.,Heterotopic Ossification,异位性骨化症,A pathological formation of mature lamellar bone in non-osseous tissues.Results from an alteration in the normal regulation of skeletogenesis.,Can be classified by its anatomical location and its resultant effect on range of motion.,Most common cause of HO is direct trauma.,Heterotopic Ossification,异位性骨化症,Localized swelling,pain,warmth,and a loss of joint range of motion at the affected site.,Hallmark sign of HO is progressive loss of ROM.,Signs of inflammation will subside with range of motion continuing to decrease.,Radiographic imaging used to confirm diagnosis of HO.,Heterotopic Ossification,异位性骨化症,Radiograph,HO is typically seen 6 weeks after injury on film,but can be identified as early as 2 weeks after injury.,Reveals both location a maturity of the ectopic bone.,CT Scan:Identifies the definite location of ectopic ossification and reveals the complex architecture of articular surfaces.,Heterotopic Ossification,异位性骨化症,废用综合征二,.,对心血管系统的影响,心脏,(,休息,):,心率上升,心输出量下降,.,心脏容量下降,左心室舒张期末容量下降,.,心脏,(,运动,):,心率上升,最大含氧量下降,每博量和心输出量下降,动静脉氧分压差升高,.,体位性低血压,血浆量降低,全血量降低,红细胞降低,矿物质血浆蛋白降低,静脉血栓形成增加,血纤维蛋白元增加,.,Br Heart J.1993 February;69(2):125128.PMCID:Reduction in left ventricular wall thickness after deconditioning in highly trained Olympic athletes.,B J Maron,A Pelliccia,A Spataro,and M GranataDepartment of Medicine,Italian National Olympic Committee,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,Increased heart rate,(resting tachycardia),HR rises 0.5 bpm/day over first,3 to 4,weeks,心率升高每天,0.5,次每分钟,.,Exaggerated with exercise(even trivial exertion),心悸心慌,心绞痛,左心室舒张末期血量降低,.,Angina,decreased LV-EDV,Decreased stroke volume,15%in 2 weeks,二周内心博输出量降低,15%,Cardiac Output remains largely unchanged,Cardiac muscle mass may decrease,心肌重量下降,对血管的影响,Blood pools in the legs,Blood vessels may lose their ability to constrict in response to postural change,弹性降低,Decreased,降低,venous return,静脉回流,Stroke volume,心博量,Blood pressure,血压,ORTHOSTASIS,!,体位性低血压,Rx:early mobilization,isometric LE exercise,positioning/gradual tilting,TEDs,fluids,meds,早期运动,.,对血液的影响,Prolonged,recumbence,leads to volume loss,长期卧床引起血容量降低,(4-7,天可见,),Shifts 700cc to thorax,increased CO by 25%,Gradual,diuresis,(protein loss),蛋白丢失,.,Decreased plasma volume 10-15%,Hct may increase,then fall as RBC mass decreases,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,“,Virchows Triad”stasis,hypercoagulability,vessel trauma(risk factors for Thrombosis),静止,高黏稠度,血管损伤,.,Venous stasis,2,nd,to decreased blood flow,Inc viscosity,hypercoagulability,increased blood fibrinogen,Location:calf veins highest risk,20%propagate to popliteal,50%of popliteal will embolize(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,The Classic Triad:(,Hemoptysis,Dyspnea,Pleuritic Pain),咳血，呼吸急促，胸痛,SymptomPercent,Dyspnea,呼吸急促,84,Chest Pain,pleuritic,胸痛，胸膜痛,74,Anxiety,焦虑,59,Cough,咳嗽,53,Hemoptysis,咳血,30,Sweating,出汗,27,Chest Pain,nonpleuritic,胸痛，无胸膜痛,14,Syncope,头晕,13,静脉血栓导致肺栓塞形成机制,massive PE 60%reduction in bloodflow rapidly fatal,major PE-medium sized vessels blocked.Patients short of breath+/-cough and blood stained sputum,minor PE-small peripheral pulmonary arteries blocked.Asymptomatic or minor shortness of breath,recurrent minor PEs lead to pulmonary hypertension,静脉血栓导致肺栓塞诊断,Imaging Studies,CXR,V/Q Scans,Spiral Chest CT,Pulmonary Angiography,Echocardiograpy,Laboratory Analysis,CBC,ESR,Hgb/Hct,D-Dimer,ABGs,Ancillary Testing,EKG,Pulse Oximetry,静脉血栓导致肺栓塞,X,光诊断,Westermarks sign,A dilation of the pulmonary vessels proximal to the embolism along with collapse of distal vessels,sometimes with a sharp cutoff.,Hamptons Hump,A triangular or rounded pleural-based infiltrate with the apex toward the hilum,usually located adjacent to the hilum.,静脉血栓的高危因素,Age 40-60 years,Age 60(count as 2 factors),History of DVT or PE,(count as 5 factors),Malignancy,Obesity(120%of IBW),Immobilization(72hrs),Major Surgery,Paralysis,Trauma,Severe COPD,Pregnancy,or post partum 1 month,Severe sepsis,Hypercoagulable state,Nephrotic Syndrome,Leg ulcers,edema,or stasis,History of MI,CHF,Stroke,IBD,静脉血栓的预防,-,早期活动,静脉血栓的预防,:,J Thromb Haemost.2008 Mar;6(3):405-14.,Anticoagulant prophylaxis to prevent asymptomatic deep vein thrombosis in hospitalized medical patients:a systematic review and meta-analysis.,Lloyd NS,Douketis JD,Moinuddin I,Lim W,Crowther MA,.Department of Medicine,McMaster University,and St Josephs Healthcare,Hamilton,ON,Canada.,Four trials including 5516 patients were eligible.,Anticoagulant prophylaxis conferred an absolute risk reduction of any DVT and proximal DVT of 2.6%and 1.8%,respectively,and was associated with a 0.5%absolute risk increase in major bleeding,low-dose LMWH as or=6000 IU/day or weight-adjusted dose of or=86 IU/kg/day.,小分子量肝素,.,CONCLUSIONS:Anticoagulant prophylaxis is effective in preventing asymptomatic DVT in at-risk hospitalized medical patients but is associated with an increased bleeding risk.The therapeutic benefits of anticoagulant prophylaxis appear to outweigh the risks of bleeding.,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,Potential,decrease in lung volumes,(2,nd,to muscle weakness,positioning/restriction),Vital capacity,降低,25 50%,TLC,降低,7%,Residual volume,降低,19%,Expiratory reserve,降低,10%,Functional residual capacity,降低,30%,A-V shunting,动,-,静脉短路增加,Increased respiratory rate,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,INCENTIVE SPIROMETRY,早期下床运动,.,废用综合征对消化系统的影响,Decreased fluid intake,appetite,胃口降低,水份吸收减少,.,Increased transit time,in esophagus,stomach,食物在胃肠道存留滞留,.,Reduced small bowel motility,(2,nd,to increased adrenergic activity),小肠运动降低,Constipation,便秘,Rx:,治疗,:,运动,+,bowel meds,fluids,mob,fiber-rich diet(fruits,veg),avoid narcotics,废用综合征对泌尿系统的影响,Diuresis,(2,nd,to fluid re-mobilization),多尿,.,Difficulty voiding(due to postioning),泌尿困难,.,UTIs,尿道感染,Calculus,formation(10-15%),结石,hypercalciuria,(esp SCI,Fxs),高钙血尿,Rx:,运动,+,fluids,upright positioning,d/c catheters,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,SHEAR FORCE,预防为主,.,毛细血管压力为,32MMHG.,实验,:,2,小时,32MMHG,PRESSURE ULCER,废用综合征对内分泌系统的影响,Impaired glucose tolerance,H,yperinsulinemia,高胰岛素,Muscles develop insulin resistance,胰岛素抵抗,.,Altered regulation of Parathyroid,Thyroid,adrenal,pituitary,growth hormones,androgens and plasma renin activity,其他激素改变,Altered circadian rhythm,心率改变,Altered temperature and sweating response,温度和出汗机制改变,.,废用综合征对代谢系统的影响,Urinary loss of:,尿氮钙磷丢失,Nitrogen (begins day 5-6,peaks at 2 weeks),Calcium (begins day 2-3,peaks at 4-6 weeks),Phosphorus,Reversible post mobilization,废用综合征对神经系统的影响,Compression neuropathies,神经压迫,Ulnar(at the elbow),尺神经损伤,Peroneal(fibular head),腓神经损伤,Decreased coordination/balance,平衡损伤,Decreased visual acuity,视力损伤,废用综合征对精神系统的影响,Sensory deprivation(“ICU psychosis”),decreased attention span,awareness,coordination,精神不集中,Depression,labiality,anxiety,忧郁,狂躁,Sleep disturbance,失眠,Increased auditory threshold,耳鸣,Decreased,pain,threshold,痛感增强,废用综合征的预防,Early mobilization,早期活动,Strengthening,体能锻炼,ROM,关节运动,Maintain skin integrity,保持皮肤完整,DVT prophylaxis,预防静脉血栓,Pain management,治疗痛症,Psychological assessment/treatment,治疗精神疾病,Aggressive Respiratory management,积极治疗呼吸系统疾病,B/B assessment&care,大小便检护,运动每天,1,小时,或每天死亡,24,小时,?,区域性复杂性疼痛综合征,Complex Regional Pain Syndrome,区域性复杂性疼痛综合征,1.,名称：,Complex Regional Pain Syndrome,Reflex Sympathetic Dystrophy,2.,历史：,美国国内战争时期，,Dr.Wilas Weir Mitchell,观察到神经损伤的战士患有慢性疼痛综合征，主要表现是：慢性烧灼性疼痛，肌肉萎缩性肿大。,区域性复杂性疼痛综合征,后来发现与交感神经有关，阻断交感神经后，疼痛减轻，故称为：,Reflex Sympathetic Dystrophy,反应性交感神经萎缩综合征。,1993,年,the International Association for the study of pain,正式命名为：,Complex regional Painn Syndrome,区域性复杂性疼痛综合征,区域性复杂性疼痛综合征机理,区域性复杂性疼痛综合征,Often seen after injury to a limb or related to some inciting event.,具有肢体损伤历史。,The patient complains of and can manifest skin color/temperature/appearance changes in the affected limb.,一侧上肢或下肢表现皮肤颜色，温度，外表改变,Pain often excruciating burning,tingling,electric-like,etc.are often symptoms that patients feel.The pain is often out of proportion to stimulus or the event.,烧灼，电击，刺痛感觉，疼痛与所受的刺激不成比例。,区域性复杂性疼痛综合征,Diagnostic Criteria,诊断标准,IASP(International Assoc for the Study of Pain)diagnostic criteria include 4 subjective and/or objective findings:,1.The presence of an initiating event or a cause of immobilization peripheral injury or central(stroke,etc)*.(Injury),有损伤,2.Continuing pain,allodynia,or hyperalgesia in which the pain is disproportiate to inciting event.(Sensory),疼痛与刺激不成比例,3.Evidence of edema,changes in skin blood flow,or abnormal sudomotor activity in region of pain.(Vasomotor),皮肤变化,4.Diagnosis is excluded by the existence of other conditions that would otherwise account for the degree of pain/dysfunction.,除去其它原因疼痛。,Onesymptom fromeach category(except#1 as 5%of pts lack known event)and at least one sign from 2 categories must be evident to diagnose CRPS,at least by research criteria.,*,Not always present or identifiable.,Tx Functional Restoration,治疗,1-,功能恢复,Functional restoration involves steady progression from gentle movements to gentle,weight bearing movement.Results in more active load bearing with expected gradual desensitization and increased functionality of limb.,慢慢去敏感,Examples include moving from silk stimulation to other cloths and textures,the scrub and carry technique,and contrast baths that widen the temperature range that the patient can tolerate.,If limitations occur then addition of blocks,pharmacotherapy,etc.can help increase the patients tolerance and improvement,.,加用其它治疗,Tx Psychotherapy,治疗,2-,精神治疗,Psychotherapy is critical to improvement in patients with CRPS.There is a high incidence of depression and anxiety noted in many CRPS patients.Unknown at this time if antecedent psychological factors prior to injury are common.,治疗忧郁，焦虑，等等,CRPS patients also developa type of PTSD termed“kinesophobia”or fear of movement related to prior pain or initial injury.The patient develops“negative reinforcements”through fear of initial movements that caused the injury of prior movements that resulted in extreme pain in the past.Fear of movement often results in contractures and reduced functionality.,治疗创伤后压力综合征,Cognitive behavioral therapy is the most beneficial psychotherapy to help patients with these concerns,though other interventions including family therapy are also beneficial.,Tx Pharmacotherapy,治疗,3-,药物,Pharmacotherapy is often on a trial and error basis and is very patient specific.Drugs are considered based on neuropathic pain treatments and then used for CRPS and have yet to be shown effective in RCTs.,-initial drug(s)to consider include gabapentin and pregabalin(both used for neuropathic pain)and are approved for these conditions,神经拮抗药,-TCAs often used for patients with sleep disturbances,but are hindered by their numerous side effects and drug interactions;not currently approved for pain treatment,传统抗忧郁药,Tx Pharmacotherapy,治疗,3-,药物,-SSRIs and SNRIs like fluoxetine and duloxetine,resp,are often used with the latter being approved for neuropathic pain conditions.,抗精神忧郁新药有效。,-Opioids should be avoided as much as possible as their effectiveness is not well proved and dependence/addiction are serious concerns in CRPS patients.,避免过量鸦片样药物治疗,-Intrathecal baclofen,IV steroids,IVIG,and anticonvulsant medications are all treatments that have been considered and used with vari