从异体手移植看手康复之发展课件

1、从异体手移植看手康复之发展Introduction异体手移植是世界外科界的临床难题，它不同于目前成熟的器官（如肾等） 移植，其组织主要来源外胚层，皮肤、肌肉等软组织对其具有强烈的排斥反应。1998年9月，法国进行了全球第一例异体手移植。1999年1月，美国进行了国际上第二例异体手移植手术。1999年9月21日广州第一军医大学南方医院创伤骨科裴国献教授、顾立强、朱立军博士等人成功完成了2例异体手移植手术。全世界手部异体移植之统计台湾于2014完成首例异体手移植截至目前已有3例，其中2例单侧，1例双侧手部移植医疗团队医疗团队：手外科骨科检验科X光科精神科康复科新陈代谢科药剂科社工护理4 Phase

2、s of RehabilitationPre-operative （術前）Initial post-operative (weeks 0-4)（術後早期）Intermediate (weeks 48)（中期）Late (from 8 weeks forward)（後期）7Phase 1Phase 2Phase 3Phase 4Phase 1Pre-operative Phasecollect information :such as medical history, injury history, previous treatment(s), and occupation. analysis

3、and assessments :stump size, shape, length, sensitivity and baseline pain, ROM, strength, sensory status of both upper extremities from shoulders to digits, functional analyses, and ability to perform ADLs. evaluate the patient/familys ability to understand, cope with and follow through with treatme

4、ntdevelop reasonable functional goals & plan of care. Rehabilitation ProtocolPhase 2 Initial Phase (Days 0 to 14) TimingImmediately after HA, all therapy takes place in the in-patient setting.Therapy takes place daily, with sessions spread throughout the day and active participation by rehabilitatio

5、n professionals, nursing staff, and the hand transplant recipients family.Rehabilitation programPositioningThe transplanted hand(s) are positioned to avoid vascular compromise and edema, protect the repairs, and ensure optimum lengthtension relationships between extensor and flexor tendons. Edema is

6、 managed through positioning and later through compression.SplintingUse a volar resting splint fabricated preoperatively, to keep the hand in a resting position while preventing joint contractures.Dynamic crane extension outrigger splint is fabricated as soon as possible after surgery, and the hand

7、transplant recipient wears it continuously during the day.Rehabilitation programExercisePassive ROM exercises within the first 13 days post-operative, and evaluate perfusion on every digit before treatment.Start early active motion (EAM) of the metacaprophalangeal (MP) and interphalangeal (IP) joint

8、s with emphasis on assisted motion within the confines of the dynamic crane orthosis by the end of post-operative week 1.Once bony healing is evident, begin gentle tenodesis exercises. Phase 3 Intermediate Phase (3 to 8 Weeks)SplintContinue to wear the dynamic crane orthosis a dorsal blocking or ant

9、i-claw orthosis with added thumb opposition on post-operative week 4 and use it for as long as needed to prevent clawing, substituting for non-innervated intrinsic muscles.dynamic, static, and staticprogressive orthosis as needed to prevent contracture, minimize muscle imbalances, and protect and po

10、sition the hand(s) for functionScar and edema management compression (i.e., Coban, Tubigrip, Kinesio tape and gloves),mobilization, elevation, and massage.Rehabilitation programExerciseweek 3“place and hold exercises basic light ADLs (such as hand-to-mouth for self feeding) with assistance, and grad

11、ually progress.week 43-point pinch and bilateral hand usage, such as picking up pieces of food, stacking blocks, and transferring items from one hand to the other.active ROM of the wrist, active use of the hand for light activitiesweek 5gentle ROM exercises involving the forearm, such as supination

12、and pronation and gentle blocking exercises of digits.week 6 unrestricted ROM. week 8two-handed ADLs (such as brushing teeth and toileting) as motor control and strength increase, and begin stretching of adhesions using moist heat. initiate strengthening use various tools such as therapy putty, weig

13、hts, wall pulley, ergometer, Thera-Bands, hand exerciser and functional hand use.Rehabilitation programcognitive therapeutic trainingasking hand transplant recipients to make mental representations of the most accurate performance of tasks which increase in complexity and aim at motor recovery using

14、 proprioceptive feedback.心像练习脑海中演练各种动作技巧执行心像练习时，特定脑区会被活化(Stephen, 2009)以肌电图测量，心像练习会造成执行该动作所需肌群活跃(Harris, 1986)17Rehabilitation programMirror therapyCortical re-integration of the transplanted hand is crucial to successful functional outcomesRehabilitation programSensory ReeducationFocus: the Hand es

15、p. fingertipsCortical maps- reorganizationReinnervation (nerve repair & recovery)TimeLimited by scar tissueAtrophy of sensory receptorsMalalignment of axonal fibersPurpose: help learn to recognize the distorted cortical impressionOutcome dependent on:Cognitive capacities learning abilities & visuosp

16、atial cognitionMotivationcompliance18Rehabilitation programElectrical stimulation simultaneous to the start of active ROM of the wrist. Two types of electrical stimulation: transcutaneous electrical nerve stimulation (TENS) - pain control. use frequencies50 Hz for 2030 min while performing ROM exerc

17、ises .neuromuscular electrical stimulation (NMES).-muscle reeducation. use 3550 pps, 300 width, 35 s ramp and a 4:12 on/off duty.Phase 4 Late Phase (Week 9 Onwards)Reduce treatment frequency to 4 h/day, 3 days per week.do progressive work with ADLs, function of the transplanted hand(s), and reintrod

18、uction of prior activities. week 12recipients who live away from the treatment center may return home and continue treatment there. week 24reduce the schedule to 4 h, twice per week. recipient can work to gradually return to his/her prior routine during the next 24 weeks and may be able to RTW.yearl

19、y reassessment at the transplant center.Follow-up Evaluation : Outcome Measurement Nerve regeneration testing:Tinel signspins and needles“ Sensibility testing: SemmesWeinstein monofilament test two-point discrimination testStrength: Dynamometer Pinch meterROM: GoniometerBasic testingStandardized sco

20、re systemsDisability of the Arm, Shoulder and Hand (DASH) Questionnaire, an evaluative outcome measure that is a self-administered questionnaire on symptoms and functional status.Hand Transplantation Score System(HTSS), a specific functional score developed by the International Registry of Hand and

21、Composite Tissue Transplantation.Short Form 36 (SF-36), a generic survey to measure functional health and well-being. EQ-5D, a standardized, simple instrument that provides a single index value for health outcome.Action Research Arm Test (ARAT): originally designed to assess recovery in an upper lim

22、b after cortical damage.Disability of the Arm, Shoulder and Hand (DASH) Questionnaire24The DASH Outcome Measure is a 30-item, self-report questionnaire designed to measure physical function and symptoms in people with any of several musculoskeletal disorders of the upper limb.Hand Transplantation Sc

23、ore System(HTSS)This evaluates six aspects of the hand transplant: (1) appearance (15 points); (2) sensibility (20 points); (3) motility (20 points); (4) psychological and social acceptance (15 points); (5) daily activities and work status (15 points);(6) patient satisfaction (15 points). A total re

24、sult of 81100 points is graded as an excellent outcome, 6180 as good, 3160 as fair, and 030 as poor.SF-36SF-36为一个一般性（generic）的心理测量工具，并不是针对特定年龄、疾病或是治疗而设计。SF-36美国版（SF-36 Standard Version）在1990年定稿，共有36项问题。主要测量受访者身心健康状态的8个面向（concept），分别为身体生理功能（physical functioning）、因生理功能角色受限（role limitation due to physi

25、cal problems）、身体疼痛（bodily pain）、一般健康（general health）、活力（vitality）、社会功能（social functioning）、因情绪角色受限（role limitation due to emotional problems）、心理健康（mental health），此外另含一项自评健康变化（reported health transition）。由于其简短及信效度皆佳，目前已有多国版本（含德国、法国、意大利、日本、荷兰、比利时、丹麦等国）。EQ-5DEQ-5D健康问卷评核，得分有二部分，一为生活质量之整体评价EQ-5D指标(index)，另一为受访者自觉目前健康相关的生活质量EQ-5D VAS。EQ-5D指针分数有二面向(精神及身体健康)， 为5题自我分类题(self-classifier)，包含：可移动性、自我照顾、一般活动(如工作、读书、家事、家庭或休闲活动)、疼痛/不适、焦