美国康复医学进展与中医针灸课件

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.美国康复医学进展与中医针灸康复医学的历史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)美国康复医学进展与中医针灸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.美国康复医学进展与中医针灸美国康复治疗团队-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美国康复医学进展与中医针灸病例: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.美国康复医学进展与中医针灸废用综合征

DeconditioningSyndromeDeconditioning–decreasedfunctionalcapacityofmultipleorgansystems.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.

美国康复医学进展与中医针灸废用综合征

DeconditioningSyndrome

影响多器官和系统Cardiovascular心脏Respiratory呼吸Muscular肌肉Skeletal骨胳Joint&CTD关节Gastrointestinal胃肠Genitourinary泌尿Integumentary皮肤Endocrine内分泌Neurological神经Psychological精神美国康复医学进展与中医针灸废用综合征

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.美国康复医学进展与中医针灸EurJApplPhysiol.2007Feb;99(3):283-9.Epub2006Dec22.

Hip,thighandcalfmuscleatrophyandbonelossafter5-weekbedrestinactivity.

BergHE,EikenO,MiklavcicL,MekjavicIB.

DepartmentofOrthopedics,Karolinska

UniversityHospitalHuddinge,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.美国康复医学进展与中医针灸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DecreasedATP&glucosestoresandabilitytousefattyacidsATP和糖元储藏下降.美国康复医学进展与中医针灸对肌肉骨胳系统的影响Decreaseinmusclemass&tension肌肉质量和张力下降Muscleatrophy/wasting2ndtodecreasedmusclesynthesis肌纤维合成减少3%/day(decreasedfibersize,not#)肌纤维直径下降3%一天.BodyCompositionchanges机体构成改变Decreasedleanbodymass(肌肉质量减少3%一天)Increasedbodyfat(脂肪增加12%一天)美国康复医学进展与中医针灸如何预防对肌肉骨胳系统的影响Prevention/Treatmentdailyisometriccontractionscanpreventdeterioration每天等张肌肉收缩锻炼Note:itmaytake2-3timeslongerto“regain”lostmusclemass&strengthFES电刺激治疗包括针灸治疗.美国康复医学进展与中医针灸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:弯曲美国康复医学进展与中医针灸肌肉强直和僵硬性萎缩美国康复医学进展与中医针灸肌肉强直和僵硬性萎缩的预防ContracturepreventionBedpositioning躺卧的位置Extofneck,hips,knee…,ankleneutral,”functional”handpositionBIDrangeofmotionexercises(terminal,sustained)关节运动Standing,earlymob&ambulationCPMforTKA美国康复医学进展与中医针灸肌肉强直和僵硬性萎缩的预防Splinting–static,serialcasts夹板Heat(40-43degrees)加热Surgery手术(capsularrelease,tenotomy,tendontransfer/lengthening)Nerve&MPblocks神经元阻滞美国康复医学进展与中医针灸对骨胳系统的影响Wolff’sLaw”–重力越大,骨质越坚,没有重力,骨质溶解.Osteoporosis!–peaksat4-6weeks骨质酥松4-6周最大.Bonedensitydecreases40%after12weeks(acceleratedinSCI)(xraynotsensitiveuntil35-50%boneloss)IncreasedosteoclasticactivityDecreasedrateofboneformationTheWEIGHT_BEARINGbonesarethefirsttolosemass(firstfewdays)Vertebralcolumnsloseupto50%Canleadtofracture,evenwithminortraumaPrevention:weight-bearing&musclecontractions治疗:负重训练美国康复医学进展与中医针灸对骨胳系统的影响ImmobilityHypercalcemiamayoccur2-4weeksafteronset卧床2-4周可开始高钙血症Symptoms:N/V,abdpain,lethargy,muscleweakness症状:呃心呕吐,腹痛,神智惶惑,肌肉萎软Treatment:hydrationandlasixdiuresis,mobilization治疗:生理盐水,速尿,运动HeterotopicOssificationIneitherneurological,osseousormusculartrauma美国康复医学进展与中医针灸HeterotopicOssification

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,etidronatedisodium(Didronel),严重者外科切除.美国康复医学进展与中医针灸HeterotopicOssification

异位性骨化症Apathologicalformationofmaturelamellarboneinnon-osseoustissues.Resultsfromanalterationinthenormalregulationofskeletogenesis.Canbeclassifiedbyitsanatomicallocationanditsresultanteffectonrangeofmotion.MostcommoncauseofHOisdirecttrauma.美国康复医学进展与中医针灸HeterotopicOssification

异位性骨化症Localizedswelling,pain,warmth,andalossofjointrangeofmotionattheaffectedsite.HallmarksignofHOisprogressivelossofROM.Signsofinflammationwillsubsidewithrangeofmotioncontinuingtodecrease.RadiographicimagingusedtoconfirmdiagnosisofHO.美国康复医学进展与中医针灸HeterotopicOssification

异位性骨化症RadiographHOistypicallyseen6weeksafterinjuryonfilm,butcanbeidentifiedasearlyas2weeksafterinjury.Revealsbothlocationamaturityoftheectopicbone.CTScan:Identifiesthedefinitelocationofectopicossificationandrevealsthecomplexarchitectureofarticularsurfaces.美国康复医学进展与中医针灸HeterotopicOssification

异位性骨化症美国康复医学进展与中医针灸废用综合征

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.美国康复医学进展与中医针灸BrHeartJ.1993February;69(2):125–128.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.美国康复医学进展与中医针灸废用综合征

对心血管系统的影响Increasedheartrate(restingtachycardia)HRrises0.5bpm/dayoverfirst3to4

weeks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-EDVDecreasedstrokevolume–15%in2weeks二周内心博输出量降低15%CardiacOutputremainslargelyunchangedCardiacmusclemassmaydecrease心肌重量下降美国康复医学进展与中医针灸对血管的影响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.美国康复医学进展与中医针灸对血液的影响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.Decreasedplasmavolume–10-15%,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.美国康复医学进展与中医针灸静脉血栓形成“Virchow’sTriad”–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.美国康复医学进展与中医针灸静脉血栓形成机制美国康复医学进展与中医针灸静脉血栓导致肺栓塞形成机制美国康复医学进展与中医针灸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

Symptom Percent

Dyspnea 呼吸急促 84 ChestPain,pleuritic 胸痛，胸膜痛 74 Anxiety焦虑 59 Cough 咳嗽 53 Hemoptysis咳血 30 Sweating 出汗 27 ChestPain,nonpleuritic胸痛，无胸膜痛 14 Syncope 头晕 13美国康复医学进展与中医针灸静脉血栓导致肺栓塞形成机制massivePE>60%reductioninbloodflowrapidlyfatalmajorPE-mediumsizedvesselsblocked.Patientsshortofbreath+/-coughandbloodstainedsputumminorPE-smallperipheralpulmonaryarteriesblocked.AsymptomaticorminorshortnessofbreathrecurrentminorPEsleadtopulmonaryhypertension美国康复医学进展与中医针灸静脉血栓导致肺栓塞诊断ImagingStudiesCXRV/QScansSpiralChestCTPulmonaryAngiographyEchocardiograpyLaboratoryAnalysisCBC,ESR,Hgb/Hct,D-DimerABG’sAncillaryTestingEKGPulseOximetry美国康复医学进展与中医针灸静脉血栓导致肺栓塞X光诊断Westermark'ssignAdilationofthepulmonaryvesselsproximaltotheembolismalongwithcollapseofdistalvessels,sometimeswithasharpcutoff.Hampton’sHumpAtriangularorroundedpleural-basedinfiltratewiththeapextowardthehilum,usuallylocatedadjacenttothehilum.美国康复医学进展与中医针灸静脉血栓的高危因素Age40-60yearsAge>60(countas2factors)HistoryofDVTorPE(countas5factors)MalignancyObesity(>120%ofIBW)Immobilization(>72hrs)MajorSurgeryParalysisTraumaSevereCOPDPregnancy,orpostpartum<1monthSeveresepsisHypercoagulablestateNephroticSyndromeLegulcers,edema,orstasisHistoryofMI,CHF,Stroke,IBD美国康复医学进展与中医针灸静脉血栓的预防-早期活动美国康复医学进展与中医针灸静脉血栓的预防: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.美国康复医学进展与中医针灸废用综合征对呼吸系统的影响美国康复医学进展与中医针灸废用综合征对呼吸系统的影响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.美国康复医学进展与中医针灸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.美国康复医学进展与中医针灸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.美国康复医学进展与中医针灸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美国康复医学进展与中医针灸废用综合征对泌尿系统的影响Diuresis(2ndtofluidre-mobilization)多尿.Difficultyvoiding(duetopostioning)泌尿困难.UTI’s尿道感染Calculusformation(10-15%),结石hypercalciuria(espSCI,Fxs)高钙血尿Rx:运动+fluids,uprightpositioning,d/ccatheters美国康复医学进展与中医针灸废用综合征对皮肤系统的影响美国康复医学进展与中医针灸美国康复医学进展与中医针灸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美国康复医学进展与中医针灸废用综合征对内分泌系统的影响Impairedglucosetolerance

Hyperinsulinemia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.美国康复医学进展与中医针灸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美国康复医学进展与中医针灸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视力损伤美国康复医学进展与中医针灸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痛感增强美国康复医学进展与中医针灸废用综合征的预防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/Bassessment&care大小便检护运动每天1小时,或每天死亡24小时?美国康复医学进展与中医针灸区域性复杂性疼痛综合征

ComplexRegionalPainSyndrome美国康复医学进展与中医针灸区域性复杂性疼痛综合征1.名称：ComplexRegionalPainSyndromeReflexSympatheticDystrophy2.历史：美国国内战争时期，Dr.WilasWeirMitchell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。美国康复医学进展与中医针灸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：ReflexSympatheticDystrophy反应性交感神经萎缩综合征。1993年theInternationalAssociationforthestudyofpain正式命名为：ComplexregionalPainnSyndrome区域性复杂性疼痛综合征美国康复医学进展与中医针灸区域性复杂性疼痛综合征机理美国康复医学进展与中医针灸区域性复杂性疼痛综合征Oftenseenafterinjurytoalimborrelatedtosomeincitingevent.具有肢体损伤历史。Thepatientcomplainsofandcanmanifestskincolor/temperature/appearancechangesintheaffectedlimb.一侧上肢或下肢表现皮肤颜色，温度，外表改变Painoftenexcruciating–burning,tingling,electric-like,etc.areoftensymptomsthatpatientsfeel.Thepainisoftenoutofproportiontostimulusortheevent.烧灼，电击，刺痛感觉，疼痛与所受的刺激不成比例。美国康复医学进展与中医针灸区域性复杂性疼痛综合征美国康复医学进展与中医针灸DiagnosticCriteria诊断标准IASP(InternationalAssocfortheStudyofPain)diagnosticcriteriainclude4subjectiveand/orobjectivefindings:1.Thepresenceofaninitiatingeventoracauseofimmobilization–peripheralinjuryorcentral(stroke,etc)*.(Injury)有损伤2.Continuingpain,allodynia,orhyperalgesiainwhichthepainisdisproportiatetoincitingevent.(Sensory)疼痛与刺激不成比例3.Evidenceofedema,changesinskinbloodflow,orabnormalsudomotoractivityinregionofpain.(Vasomotor)皮肤变化4.Diagnosisisexcludedbytheexistenceofotherconditionsthatwouldotherwiseaccountforthedegreeofpain/dysfunction.除去其它原因疼痛。One

symptomfrom

eachcategory(except#1as5%ofptslackknownevent)andatleastonesignfrom2categoriesmustbeevidenttodiagnoseCRPS,atleastbyresearchcriteria.*Notalwayspresentoridentifiable.美国康复医学进展与中医针灸Tx–FunctionalRestoration

治疗1-功能恢复Functionalrestorationinvolvessteadyprogressionfromgentlemovementstogentle,weightbearingmovement.Resultsinmoreactiveloadbearingwithexpectedgradualdesensitizationandincreasedfunctionalityoflimb.慢慢去敏感Examplesincludemovingfromsilkstimulationtootherclothsandtextures,thescrubandcarrytechnique,andcontrastbathsthatwidenthetemperaturerangethatthepatientcantolerate.Iflimitationsoccurthenadditionofblocks,pharmacotherapy,etc.canhelpincreasethepatient‘stoleranceandimprovement.加用其它治疗美国康复医学进展与中医针灸Tx–Psychotherapy

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

治疗忧郁，焦虑，等等CRPSpatientsalsodevelop

atypeofPTSDtermed“kinesophobia”orfearofmovementrelatedtopriorpainorinitialinjury.Thepatientdevelops“negativereinforcements”throughfearofinitialmovementsthatcausedtheinjuryofpriormovementsthatresultedinextremepaininthepast.Fearofmovementoftenresultsincontracturesandreducedfunctionality.治疗创伤后压力综合征Cognitivebehavioraltherapyisthemostbeneficialpsychotherapytohelppatientswiththeseconcerns,thoughotherinterventionsincludingfamilytherapyarealsobeneficial.美国康复医学进展与中医针灸Tx–Pharmacotherapy

治疗3-药物Pharmacotherapyisoftenonatrialanderrorbasisandisverypatientspecific.DrugsareconsideredbasedonneuropathicpaintreatmentsandthenusedforCRPSandhaveyettobeshowneffectiveinRCTs.

-initialdrug(s)toconsiderincludegabapentinandpregabalin(bothusedforneuropathicpain)andareapprovedfortheseconditions神经拮抗药-TCAsoftenusedforpatientswithsleepdisturbances,butarehinderedbytheirnumeroussideeffectsanddruginteractions;notcurrentlyapprovedforpaintreatment传统抗忧郁药美国康复医学进展与中医针灸Tx–Pharmacotherapy

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。美国康复医学进展与中医针灸Tx–InterventionalApproaches

介入性治疗1.Cervicalandlumbarsympatheticblocks。 颈，腰丛交感神经节阻断美国康复医学进展与中医针灸Tx–InterventionalApproaches

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。美国康复医学进展与中医针灸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。美国康复医学进展与中医针灸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.美国康复医学进展与中医针灸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康复医学进展与中医针灸美国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:美国康复医学进展与中医针灸T-PA必须在三小时内注射美国康复医学进展与中医针灸 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岁成年人中风的发病因素和风险

Source:Wolfetal.,Stroke.1991;22:312-318.*BPinmillimetersofmercury(mmHg)美国康复医学进展与中医针灸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%美国康复医学进展与中医针灸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美国康复医学进展与中医针灸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.美国康复医学进展与中医针灸FDARecommends

Low-DoseAspirinFDAreviewedtrialsofaspirinvsplaceboThe“positivefindingsatlowerdosages

aresufficientreasontolowerthedosage

ofaspirin...forsubjectswithTIA

andischemicstroke.”For“ischemicstrokeandTIA:50to325mg[aspirin]onceaday.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.1998.63:56802–56819.美国康复医学进展与中医针灸Strokerehabilitation

(1):treatingimpairmentsSpasticitymanagement僵直处理Physiotherapy物理治疗Orthotics夹板botulinumtoxin生物毒素针灸美国康复医学进展与中医针灸Strokerehabilitation

(1):treatingimpairmentsNutritionalmanagementswallowingassessment(SALT)

吞咽检查Dietarymodification改变食物类型palatalstimulationenteralfeeding肠道营养.美国康复医学进展与中医针灸Strokerehabilitation

(2):reducedisabilitybyre-learningTransfertraining转移训练.美国康复医学进展与中医针灸Gaittraining走路训练Strokerehabilitation

(2):reducedisabilitybyre-learning美国康复医学进展与中医针灸Strokerehabilit