不同输出压力体外冲击波对脑卒中后小腿三头肌痉挛的影响

目的观察不同输出压力体外冲击波治疗(ESWT)对脑卒中患者小腿三头肌痉挛的疗效差异及可能的电生理机制。方法 2015年1月至2017年12月,脑卒中后偏瘫侧小腿三头肌痉挛住院患者90例,随机分为对照组、治疗组1和治疗组2,各30例。3组均予基础和常规康复治疗,两个治疗组在此基础上增加ESWT治疗,输出压力分别为1.5 bar和2.0 bar,共4周。治疗前后采用踝关节综合痉挛量表(CSS)、踝关节被动活动度(PROM)、10米步行时间(10MWT)和神经电生理(H反射潜伏期、Hmax/Mmax)进行评定。两个治疗组在每次ESWT治疗结束后,采用视觉模拟评分(VAS)评估治疗时疼痛。结果治疗后,3组患者CSS评分、PROM和10MWT均较治疗前显著改善(t 7.261, P 0.001),两个治疗组CSS评分和10MWT均低于对照组(P 0.05),治疗组2 10MWT低于治疗组1 (P 0.05)。治疗后,两个治疗组H反射潜伏期显著延长(t 15.025, P 0.001),Hmax/Mmax均显著下降(t 14.850, P 0.001),治疗组1 H反射潜伏期长于对照组(P 0.01)。两个治疗组VAS评分无显著性差异(t=0.735, P 0.05)。结论 2.0 bar和1.5 bar ESWT均可有效改善脑卒中后小腿三头肌痉挛,提高步行功能,2.0 bar较1.5 bar对步行功能的改善更大。其电生理机制尚需进一步研究。     

放散式体外冲击波治疗脑卒中后小腿三头肌痉挛的疗效研究

目的:观察放散式体外冲击波(rESWT)对脑卒中后小腿三头肌痉挛的疗效.方法:22例脑卒中后小腿三头肌痉挛患者随机分为rESWT组和对照组,每组11例.rESWT组给予有效刺激1次,参数设置为压力强度100kPa,频率8Hz,冲击次数3000次.对照组仅给予安慰刺激1次.比较治疗前、治疗结束后即刻、治疗后1周、4周两组患者关节被动活动度(PROM)、改良Ashworth分级(MAS)及胫神经H反射的H波最大波幅和M波最大波幅比值(Hmax/Mmax值).结果:rESWT组治疗结束后即刻及治疗后1周、4周评估PROM及MAS,均优于治疗前,差异具有显著性意义(P＜0.05);治疗后1周、4周,rESWT组PROM及MAS均优于对照组,差异有显著性意义(P＜0.05).两组治疗前后Hmax/Mmax值比较,差异无显著性意义(P＞0.05).试验过程中两组患者均未发现任何不良反应.结论:放散式体外冲击波治疗可有效改善卒中后小腿三头肌痉挛.     

A型肉毒毒素联合低频体外冲击波治疗脑卒中后小腿三头肌痉挛的疗效观察

目的 观察A型肉毒毒素(BTX-A)联合低频体外冲击波(ESWT)治疗脑卒中后小腿三头肌痉挛的疗效。 方法 采用随机数字表法将36例脑卒中后小腿三头肌痉挛患者分为观察组及对照组,每组18例。2组患者在常规康复训练基础上均给予BTX-A局部注射,观察组患者于BTX-A注射后辅以低频ESWT治疗,对照组则辅以伪体外冲击波治疗。于治疗前、治疗2周、4周后分别采用改良Ashworth量表(MAS)、关节活动度、简化Fugl-Meyer运动功能评分(FMA)及改良Barthel指数（MBI）对2组患者进行疗效评定。 结果 治疗前2组患者MAS、下肢FMA、MBI评分及PROM组间差异均无统计学意义（P>0.05）。治疗2周后发现2组患者上述指标均较治疗前明显改善(P<0.05);并且观察组MAS评分［(2.15±0.56)分］及PROM［(44.37±8.02)°］亦显著优于对照组水平(P<0.05);治疗4周后2组患者MAS、下肢FMA、MBI评分及PROM均较治疗前进一步改善(P<0.05),并且上述指标均以观察组患者的改善幅度较显著,与对照组间差异均具有统计学意义（P<0.05）。 结论 BTX-A联合低频ESWT治疗可显著缓解脑卒中后小腿三头肌痉挛,降低肌张力,改善患肢运动功能及日常生活能力,可作为治疗脑卒中后小腿三头肌痉挛的有效手段在临床推广、应用。     

离心收缩训练联合体外冲击波疗法治疗网球肘的疗效观察

目的 观察离心收缩训练（EE）联合体外冲击波疗法（ESWT）对网球肘(TE)的疗效。 方法 选择TE患者60例，按随机数字表法随机分为EE治疗组、ESWT治疗组和联合治疗组，每组患者20例。EE治疗组进行EE训练，ESWT治疗组采用ESWT进行治疗，联合治疗组则采用EE联合ESWT进行治疗。2组患者均于治疗前、治疗结束4周、8周、12周和1年后进行疼痛（VAS）和握力评估，并于治疗结束1年后进行疗效评估。 结果 3组患者治疗结束后各时间点的VAS评分均显著优于组内前一时间点，且均以治疗结束后1年改善最为显著，差异均有统计学意义（P<0.05）。3组患者治疗结束后各时间点的握力值均显著优于组内前一时间点，且均以治疗结束后1年改善最为显著，差异均有统计学意义（P<0.05）；联合治疗组治疗结束后各时间点的握力值分别与EE治疗组和SWT治疗组同时间点比较，差异均有统计学意义（P<0.05）。治疗结束1年后，联合治疗组的总有效率为94.73%，显著优于EE治疗组的76.47%与和ESWT治疗组的78.95%，差异均有统计学意义（P<0.05）。 结论 EE联合ESWT可显著改善TE患者的握力，并提高疗效。     

声触诊组织成像量化技术评估痉挛型脑性瘫痪患儿康复疗效

目的 探讨声触诊组织成像量化（VTIQ）评估痉挛型脑性瘫痪（简称脑瘫）患儿康复疗效的价值。方法 将40例脑瘫患儿随机分成2组,每组20例。在康复训练基础上,对A型肉毒杆菌毒素（BTA）组患儿行BTA治疗;BTA+体外冲击波治疗（ESWT）组加行ESWT。于治疗前和治疗后1、4、12、16周进行改良Ashworth痉挛量表（MAS）评估,并测量小腿三头肌的剪切波速度（SWV）。结果 2组患儿治疗前后MAS评分和SWV总体差异均有统计学意义（P均<0.01）。与治疗前相比,BTA组患儿于治疗后4周MAS评分和SWV下降至最低（P均<0.05）;BTA+ESWT组患儿于治疗后1周即刻出现MAS评分和SWV明显下降（P均<0.05）。随着治疗后时间延长,2组患儿MAS评分和SWV均逐渐升高,但与治疗前相比差异仍有统计学意义（P均<0.05）。结论 VTIQ能够客观、定量反映痉挛肌的硬度变化,可作为评估痉挛型脑瘫患儿康复治疗效果的有效方法。     

肌内效贴联合A型肉毒素局部注射和常规康复训练对脑卒中后下肢痉挛患者步行能力的影响

目的 观察肌内效贴联合A型肉毒素局部注射和常规康复训练对脑卒中后下肢痉挛患者步行能力的影响。 方法 选取脑卒中后下肢痉挛患者40例，按随机数字表法分为治疗组和对照组，每组患者20例，对照组给予下肢痉挛肌群A型肉毒素局部注射和常规康复治疗，治疗组在此基础上增加肌内效贴治疗。分别于治疗前、治疗4周和8周后对2组患者进行改良Ashworth量表（MAS）、被动关节活动度（PROM）、10 m最快步行速度（10 m MWS）、Fugl-Meyer运动功能（FMA）、生理消耗指数（PCI）评估。 结果 治疗4周后，2组患者的MAS、PROM、10 m MWS、FMA、PCI评分较组内治疗前均有显著改善，差异均有统计学意义（P<0.05）；治疗组治疗4周后的PROM、10 m MWS、FMA、PCI均显著优于对照组同时间点，差异均有统计学意义（P<0.05），而MAS与对照组同时间点比较，差异则无统计学意义（P>0.05）。治疗8周后，2组患者的MAS、PROM、10 m MWS、FMA、PCI评分较组内治疗前均有显著改善，差异均具有统计学意义（P<0.05）；治疗组治疗8周后的PROM、10 m MWS分别为（4.21±1.01）°和（11.09±2.80）m/s，均优于对照组同时间点，差异均有统计学意义（P<0.05），而MAS、FMA、PCI与对照组同时间点比较，差异则无统计学意义（P>0.05）。 结论 肌内效贴联合A型肉毒素局部注射和常规康复训练可改善脑卒中后下肢痉挛患者的步行能力。     

体外冲击波治疗脑瘫肌痉挛的疗效观察

目的:观察体外冲击波对脑瘫患儿小腿三头肌痉挛的疗效和安全性。方法:脑瘫肌痉挛患儿50例分为观察组24例和对照组26例,2组均给予常规康复治疗,观察组加用冲击波治疗,治疗前后对2组患儿的被动关节活动度(PROM)、改良的Asworth分级(MAS)、粗大运动功能评分(GMFM)、足底支持面积和足底压力进行评定。结果:观察组治疗1周及4周后,小腿三头肌MAS评分较治疗前明显下降(P<0.05),且呈逐渐下降趋势(P<0.05),且各时间段各项评分均更低于对照组(P<0.05);对照组治疗1周后,小腿三头肌MAS评分及踝关节PROM与治疗前比较差异无统计学意义,治疗4周后,小腿三头肌MAS评分较治疗前及治疗1周时明显下降(P<0.05)。观察组治疗1周及4周后,踝关节PROM、GMFM评分、足底面积及足底压力均较治疗前明显增加(P<0.05),且呈逐渐上升趋势(P<0.05),且各时间段各项评分均更高于对照组(P<0.05);对照组治疗1周后,踝关节PROM、GMFM评分、足底面积及足底压力与治疗前比较差异无统计学意义,治疗4周后,踝关节PROM、GMFM评分、足底面积及足底压力均较治疗前及治疗1周时明显增加(P<0.05)。结论:体外冲击波治疗可以降低脑瘫患儿小腿三头肌张力,缓解肌肉痉挛,改善其粗大运动功能。     

胫神经局部振动对脑卒中患者小腿三头肌痉挛的影响及神经生理机制研究

目的 观察胫神经局部振动治疗对脑卒中患者小腿三头肌痉挛及神经电生理功能的影响。 方法 选取脑卒中后偏瘫下肢功能障碍患者60例,按随机数字表法将其分为治疗组和对照组,每组30例。2组均给予常规康复训练,治疗组在此基础上增加局部振动治疗。治疗前、后,采用改良Ashworth量表(MAS)、Clonus阵挛分级法分别评价2组患者的肌张力和痉挛程度,并对胫神经运动与感觉传导、F波、H反射进行检测。 结果 治疗前,2组患者小腿三头肌MAS、Clonus分级评分、胫神经H反射的H/M比值、Hmax、Hmax刺激强度比较,差异无统计学意义（P＞0.05）。与组内治疗前比较,2组患者治疗后上述指标均改善（P＜0.05）,且治疗组治疗后小腿三头肌MAS［(0.62±0.63)分］、Clonus分级评分［(1.05±1.02)分］、胫神经H反射的H/M比值(0.48±0.28)、Hmax［(3.75±2.09)mV］、Hmax刺激强度［(38.18±12.79)mA］较对照组改善优异,差异有统计学意义（P＜0.05）。 结论 在常规康复训练基础上辅以胫神经局部振动治疗,可通过抑制神经反射通路的兴奋性,有效缓解脑卒中患者小腿三头肌的痉挛程度,降低肌肉张力。     

不同定位技术引导肉毒毒素治疗脑瘫患儿踝跖屈肌群痉挛的对照研究

目的 比较电刺激定位技术与经验定位引导肉毒毒素A（BTX-A）注射治疗脑瘫患儿踝跖屈肌群痉挛的临床疗效。方法 45例脑瘫患儿随机分为电刺激定位组23例，经验定位组22例。2组接受BTX-A注射后3d，开始进行10d物理治疗，之后改由家长在家治疗。患儿在治疗前和治疗后3d、2周、1个月、2个月、3个月进行以下评定：①踝关节被动活动范围（PROM）；②改良Ashworth量表（MAS）评分；③综合痉挛量表（CSS）评分；④粗大运动功能量表（GMFM）D、E项评分；⑤步行速度。结果 2组患儿的PROM、MAS评分、CSS评分、GMFM评分和步行速度，在治疗后2周、1个月、2个月、3个月分别与治疗前比较，差异均有统计学意义（P〈0．001）。PROM、CSS评分在治疗后3d、2周、1个月、2个月、3个月组间差异有统计学意义（P〈0．05）。MAS评分在治疗后3d、2个月、3个月时组间差异有统计学意义（P〈0．05）。GMFM评分在治疗后2个月、3个月组间差异有统计学意义（P〈0．05）。步行速度差值在治疗后2个月、3个月时组间差异有统计学意义（P〈0．05）。结论 电刺激定位技术较经验定位引导BTX-A注射结合物理治疗能更好地缓解脑瘫患儿踝跖屈肌群痉挛，提高患儿运动能力。     

超声引导下注射A型肉毒毒素联合康复训练治疗尖足畸形脑瘫患儿下肢痉挛的疗效观察

目的观察超声引导下注射A型肉毒毒素（BTX-A）联合康复训练治疗尖足畸形脑瘫患儿下肢痉挛的疗效。 方法选取因下肢痉挛导致尖足的脑瘫患儿47例,按照随机数字表法将其分为注射组（24例）和对照组（23例）,2组均给予康复训练,注射组在此基础上辅以超声引导下BTX-A注射。治疗前及治疗2周后、1个月后、3个月后、6个月后分别采用改良Ashworth量表（MAS）、踝关节被动活动度(PROM)和粗大运动功能测试量表-88（GMFM-88）对患儿下肢痉挛程度进行综合评定。 结果治疗前,注射组患儿MAS评分［（3.31±0.76）分］、PROM值［（108.27±11.38）°］、GMFM-88评分［（54.31±10.31）分］与对照组患儿MAS评分［（3.40±0.65）分］、PROM值［（106.10±11.44）°］、GMFM-88评分［（55.62±10.22）分］比较,差异均无统计学意义（P&rt;0.05）。注射组治疗2周后、1个月后、3个月后、6个月后各指标与治疗前比较,差异均有统计学意义（P<0.05）。对照组除治疗2周后外,剩余时间点各指标与治疗前比较,差异有统计学意义（P<0.05）,与注射组同时间点比较,对照组各指标差异均有统计学意义（P<0.05）。 结论超声引导下注射BTX-A联合康复训练可快速改善尖足畸形脑瘫患儿的下肢痉挛,值得临床应用、推广。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.     

Prospects for the control of neglected tropical diseases by mass drug administration

The prospects for the control of neglected tropical diseases, including soil-transmitted helminthiasis, shistosomiasis, lymphatic filariasis, onchocerciasis and trachoma, through mass drug administration, are exemplified by the elimination of the trachoma as a public-health problem in Morocco. In spite of this and other striking successes, mass drug administration programs are faced with major challenges resulting from suboptimal coverage and lack of efficacy. At current suboptimal coverage rates, programs may need prolongation for an extended period, increasing costs and undermining sustainability. Community participation through health education and information appears to be crucial to improve coverage and to achieve sustainability. Implementation of complementary measures, such as vector control, improved hygiene and environmental sanitation, are important to further control transmission and to prevent re-emergence of the infection and, again, may only be achieved effectively through community-based initiatives. To reduce costs and to relieve pressure on the health system, combining neglected tropical disease programs in areas where diseases coexist and integration with existing control programs for malaria, tuberculosis and HIV/AIDS is advocated. The risk of developing drug resistance is of particular concern in view of the lack of alternative drugs, and reduced treatment efficacy due to emerging resistance is evident for the soil-transmitted helminths and onchocerciasis. Given the risk for the development of drug resistance and the need for a high degree of participation, close attention should be paid to the monitoring of the coverage and efficacy of the different program components.     

Clinical Trial Updates and Hotline Sessions presented at the European Society of Cardiology Congress 2007

This article provides information and commentaries on trials which were presented at the Hotline and Clinical Trial Update Sessions at the European Society of Cardiology Congress 2007 in Vienna. The key presentations were performed by leading experts in the field with relevant positions in the trials or registries. It is important to note that unpublished reports should be considered as preliminary data, as the analysis may change in the final publications. The comprehensive summaries have been generated from the oral presentation and the webcasts of the European Society of Cardiology and should provide the readers with the most comprehensive information of relevant publications.     

Balance and Boundaries in Grief Counseling: An Intervention Framework for Volunteer Training

Volunteers or paraprofessional counselors are commonly used to provide supportive care to the bereaved. These counselors generally are trained in basic listening skills, providing a generic, nonspecific approach to intervention that remains to be proven effective. The present paper outlines a framework that provides paraprofessionals with a broader model for intervention with the bereaved. Attention to boundaries as a helper and balance in the grief recovery are central to the model. Interventions are described that provide the paraprofessional counselor with more options for tailoring their counseling strategy to the individual. These include techniques that are presumed to be more specific to the enhancement of grief recovery.     

Bacterial meningitis: an update of new treatment options

The outcome of bacterial meningitis critically depends on the rapid initiation of bactericidal antibiotic therapy and adequate management of septic shock. In community-acquired meningitis, the choice of an optimum initial empirical antibiotic regimen depends on the regional resistance patterns. Pathogens resistant to antibacterials prevail in nosocomial bacterial meningitis. Dexamethasone is recommended as adjunctive therapy for community-acquired meningitis in developed countries. In comatose patients, aggressive measures to lower intracranial pressure <20 mmHg (in particular, external ventriculostomy, osmotherapy and temporary hyperventilation) were effective in a case–control study. Although many experimental approaches were protective in animal models, none of them has been proven effective in patients. Antibiotics, which are bactericidal but do not lyse bacteria, and inhibitors of matrix metalloproteinases or complement factor C5 appear the most promising therapeutic options. At present, vaccination is the most efficient method to reduce disease burden. Palmitoylethanolamide appears promising to enhance the resistance of the brain to infections.     

Imaging choices in occult hip fracture

Background: Hip fracture is a common injury, with an incidence rate of > 250,000 per year in the United States. Diagnosis is particularly important due to the high dependence on the integrity of the hip in the daily life of most people. Objectives: In this article we review the literature focused on hip fracture detection and discuss advantages and limitations of each major imaging modality. Discussion: Plain radiographs are usually sufficient for diagnosis as they are at least 90% sensitive for hip fracture. However, in the 3–4% of Emergency Department (ED) patients having hip X-ray studies who harbor an occult hip fracture, the Emergency Physician must choose among several methods, each with intrinsic limitations, for further evaluation. These methods include computed tomography, scintigraphy, and magnetic resonance imaging. Conclusion: We present an evidence-based algorithm for the evaluation of a patient suspected to have an occult hip fracture in the ED. Also outlined are future directions for research to distinguish more effective techniques for identifying occult hip fractures.