脑卒中后偏瘫患者下肢H反射的特征表现

目的:通过研究脑卒中后偏瘫患者下肢H反射的特征表现及其与偏瘫下肢肢体功能评定的关系,探讨H反射在脑卒中后偏瘫患者神经电生理评定中的应用价值。方法:选择脑卒中恢复期偏瘫患者40例,分别对患者双侧胫神经和腓总神经所支配的腓肠肌和胫骨前肌进行H反射检查,并对患侧下肢给予临床痉挛指数(CSI)评定。计算胫神经和腓总神经H反射的引出率,并对其所引出的H反射结果以及与CSI的相关性进行比较和分析。结果:患者双侧胫神经所支配的腓肠肌H反射引出率100%,胫骨前肌H反射引出率为10%。患侧胫神经H反射潜伏期平均为(30.09±1.87)ms;非患侧胫神经H反射潜伏期平均为(31.99±2.31)ms。患侧胫神经Hmax/Mmax比值均数中位数平均为0.476;非患侧胫神经Hmax/Mmax比值平均为0.189。患侧与非患侧相比,患侧H反射潜伏期缩短,Hmax/Mmax比值增大,且差异有显著性意义(P<0.05)。将患侧下肢胫神经H反射潜伏期分别与CSI进行Spearman秩相关检验,结果显示患侧下肢胫神经H反射潜伏期与CSI不相关,而患侧下肢胫神经Hmax/Mmax比值与CSI存在秩相关关系。结论:用H反射来评价脑卒中后偏瘫患者患侧痉挛的存在和严重程度,比CSI量表更客观、量化。其中Hmax/Mmax比值是评估下运动神经元兴奋性的较好指标。     

H反射在脑卒中后上肢偏瘫患者中的特征表现及分析

目的:通过研究脑卒中后上肢偏瘫患者H反射的特征表现,及其与偏瘫肢体肌张力的关系,探讨H反射在脑卒中后上肢偏瘫患者神经电生理评定中的应用价值。方法:选择符合本研究入选标准的脑卒中恢复期偏瘫患者42例。分别对患者双侧正中神经、尺神经、桡神经所支配的拇短展肌、小指展肌、指总伸肌进行H反射检查,并对患侧上肢给予改良Ashworth痉挛量表(MAS)评定,确定上述神经中哪些更容易引出H反射,并对其所引出的H反射结果及其与MAS的相关性进行比较和分析。结果:患者双侧正中神经、尺神经所支配的拇短展肌、小指展肌均较易引出H反射,引出率100%。桡神经所支配的指总伸肌不易(3例/42例,引出率7.14%)引出H反射。患侧正中神经和尺神经的H反射潜伏期分别为(25.89±3.66)ms、(25.71±3.26)ms;健侧正中神经和尺神经的H反射潜伏期分别为(26.60±3.11)ms、(26.44±2.87)ms。配对t检验分析,差异均有显著性意义(P<0.05);Hmax/Mmax比值均数用中位数表示,患侧正中神经和尺神经的Hmax/Mmax比值分别为0.185和0.217;健侧Hmax/Mmax比值分别为0.126和0.112,用Wilcoxon符号秩检验分析,患侧与健侧差异均有显著性意义(P<0.05)。用Kruskal-WallisH检验分析显示:患侧上肢正中神经、尺神经H反射潜伏期在MAS不同级别中没有差异,而Hmax/Mmax比值在MAS不同级别中有差异。Spearman秩相关检验结果显示:患侧上肢正中神经H反射潜伏期、Hmax/Mmax比值以及尺神经H反射潜伏期与MAS不相关;而患侧上肢尺神经Hmax/Mmax比值与MAS存在秩相关关系。结论:上肢H反射与MAS存在一定关系,其中Hmax/Mmax比值是评估下运动神经元兴奋性的较好指标,可以成为临床评价痉挛的客观神经电生理指标。     

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。     

TENS对脑卒中患者踝跖屈内翻的影响

目的评价经皮神经电刺激（TENS）治疗脑卒中患者踝跖屈内翻的临床疗效，并探讨其作用机制。方法32例恢复期脑卒中患者，存在不同程度的踝跖屈内翻，随机分为TENS组和对照组各16例，在神经发育疗法、手法治疗以及配戴足托治疗的基础上，TENS组加用患侧胫前肌和腓骨长短肌的TENS治疗。于治疗前后用综合痉挛量表（CSS）、肌电图H反射评定腓肠肌的痉挛程度。结果治疗后，TENS组和对照组CSS评分都有明显降低，和治疗前相比均有统计学意义，TENS组CSS降低较对照组明显，但两组间差异无统计学意义；TENS组H反射波潜伏期延长、H／M降低，和治疗前相比差异有统计学意义，对照组无明显变化；目测TENS组患者的痉挛偏瘫步态得到明显改善。结论TENS能减轻脑卒中患者腓肠肌痉挛，有助于踝跖屈内翻和痉挛偏瘫步态的改善。     

H反射在腰腿痛患者中的应用

目的：探讨H反射在腰腿痛患者中的应用价值。方法：对象为腰腿痛患者113例,女性38例,男性75例;年龄18－62岁;病程2周－20年。嘱患者安静放松。室温26－28℃。针电极记录。记录电极插入腓肠肌内侧头或外侧头肌腹,表面电极刺激Guo部胫神经,逐渐增加电流刺激强度,直至引出最大波幅H波至M波开始出现为止,并且进行双下肢自身对照。结果：健侧／患侧H反射潜伏期平均值分别为：腓肠肌内侧头28.75ms/30.41ms;外侧头28.65ms/30.09ms。两侧之间的差异有显著性,同侧之间均无差异。健肢H反射与年龄、身高、性别均呈正相关,同侧H反射潜伏期之间高度相关。回归方程分别为：H反射（内侧头）＝4.98 0.04年龄（岁） 0.13身高（cm);H反射（外侧头）=6.78 0.06年龄 0.11身高（cm)。H反射潜伏期的异常与下肢痛、直腿抬高、跟腱反射相关,与腰痛、椎旁压痛关系不大。结论：H反射潜伏期与年龄、身高和性别相关。运用所得方程,临床医生可通过患者的年龄和所测身高来预测H反射潜伏期正常值。H反射潜伏期可用于判断腰腿痛患者腰骶神经损害的部位及程度。     

功能性电刺激联合电针拮抗肌治疗脑卒中后痉挛型足下垂的疗效观察

目的 观察四通道功能性电刺激（FES）联合电针拮抗肌治疗脑卒中后痉挛型足下垂的临床疗效。 方法 采用随机数字表法将90例脑卒中后痉挛型足下垂患者分为对照组、电刺激组及观察组,每组30例。3组患者均给予常规康复训练,电刺激组在此基础上给予四通道FES治疗,观察组则给予四通道FES及电针拮抗肌治疗。于治疗前、治疗4周后分别对3组患者进行疗效评定,包括临床痉挛指数（CSI）评定、步态时空参数（包括步频、步幅、患侧支持相、患侧摆动相）及肌电检查等。 结果 治疗4周后3组患者CSI评分均较治疗前明显降低（P<0.05）,并且观察组CSI评分［（7.9±2.5）分］亦显著低于电刺激组及对照组［分别为（8.4±2.4）分和（10.1±2.7）分］（P<0.05）;治疗后3组患者各项步态时空参数均较治疗前明显改善（P<0.05）,并且观察组改善幅度均明显优于电刺激组及对照组（P<0.05）;治疗后3组患者偏瘫侧下肢H反射潜伏期较治疗前明显延长（P<0.05）,Hmax/Mmax比值较治疗前明显降低（P<0.05）,并且观察组上述指标［分别为（30.39±1.96）ms和（0.36±0.11）］亦显著优于电刺激组及对照组水平（P<0.05）。 结论 四通道FES联合电针拮抗肌治疗脑卒中后痉挛型足下垂患者具有协同作用,能进一步改善患者踝关节痉挛病情和步态,提高踝关节稳定性及步行功能。     

重复性外周磁刺激联合运动疗法对脑卒中患者踝跖屈肌痉挛的影响

目的 观察重复性外周磁刺激联合运动疗法对脑卒中患者踝跖屈肌痉挛的影响。 方法 选取脑卒中患者60例，按随机数字表法分为治疗组和对照组，每组30例，2组患者均行常规运动疗法，治疗组在此基础上辅以重复性外周磁刺激疗法。分别于治疗前及治疗4周后（治疗后），采用表面肌电图记录踝关节背伸最大等长收缩时胫前肌及腓肠肌的积分肌电值（IEMG），计算协同收缩率（CO）；采用Fugl-Meyer下肢运动功能评分(FMA-LE)、Holden功能性步行分级（FAC）和综合痉挛量表（CSS）分别评定2组患者的下肢运动功能、步行功能以及踝跖屈肌张力。 结果 治疗后，2组患者踝背伸最大等长收缩时的胫前肌积分肌电值（IEMG）［治疗组(52.25±6.97)μV·s、对照组(47.01±9.02)μV·s］、FMA-LE评分［治疗组(20.13±6.20)分、对照组(16.07±5.10)分］及FAC分级［治疗组(2.53±0.90)分、对照组(2.03±0.81)分］均较组内治疗前明显提高（P<0.05）；2组患者的综合痉挛评分（CSS）［治疗组(8.90±1.81)分、对照组(9.83±1.49)分］及踝背伸协同收缩率（CO）［治疗组(33.50±4.95)％、对照组(39.93±4.58)％］均较组内治疗前明显降低（P<0.05）；组间比较，治疗组治疗后的上述指标改善较对照组更为明显，组间差异均有统计学意义(P<0.05)。 结论 重复性外周磁刺激联合运动疗法可以更有效的减轻脑卒中患者踝跖屈肌痉挛，同时提高下肢的运动功能和步行能力。     

外周磁刺激结合经颅磁刺激对脑卒中后上肢痉挛的影响

目的:观察外周结合经颅磁刺激对脑卒中后上肢痉挛的影响。方法:将30例脑卒中后上肢痉挛的患者随机分为治疗组和对照组,每组15例。使用"8"字形磁刺激线圈给予治疗组患者非受累侧皮层M1区强度为80%静息运动阈值,频率1Hz共1200个脉冲磁刺激,随后给予患侧上肢Erb's点iTBS模式刺激共600个脉冲,刺激强度为能引起患侧拇短屈肌肉眼可见细微收缩最小强度。对照组给予假刺激,治疗组和对照组均接受相同的常规康复治疗。治疗共持续5周,每周治疗5天,每天治疗1次。观察其对患者患侧上肢改良Ashworth评分、Tardieu评分的影响,同时观察治疗前后患侧上肢正中神经腕水平H反射潜伏期及H_(max)/M_(max)肌电生理指标的变化,与对照组做比较。结果:治疗组偏瘫侧上肢MAS评分治疗前后分值差:肘屈曲、肘伸展、屈指间关节、伸指间关节与对照组差值比较具有显著性差异(P0.05)。Tardieu评分治疗前后分值差:肩水平内收、肘屈曲(肩内收位)、肘伸展(肩外展位)和对照组比较有显著性差异(P0.05)。但肩前屈、肩外展、肘伸展、腕屈曲、伸腕MAS评分、肩内旋、前臂旋前(肩内收位)、前臂旋后(肩内收位)Tardieu评分差值两组比较无显著性差异(P0.05),治疗组偏瘫侧上肢正中神经H反射潜伏期、H_(max)/M_(max)治疗前后差值和对照组比较有显著性差异(P0.05)。结论:外周磁刺激结合经颅磁刺激治疗可能有助于缓解脑卒中后上肢痉挛患者的痉挛状态。     

不同体位下肢被动踏踩训练对脑卒中下肢痉挛的影响

目的:观察不同体位下肢被动踏踩训练对脑卒中患者患侧下肢痉挛的疗效。方法:脑卒中患者66例,随机分为直立组35例和坐位组31例,2组在接受常规康复训练的基础上分别进行直立位和坐位的下肢被动踏踩训练。分别在训练前、训练30min及4周后对患侧小腿三头肌、股四头肌、腘绳肌进行改良Ashworth痉挛评定。结果:治疗30min后,2组患者仅患侧小腿三头肌的Ashworth痉挛评分较治疗前明显降低(P<0.05),2组间比较差异无统计学意义;治疗4周后,2组患者除坐位组患侧股四头肌外其余各肌肉痉挛评分均较治疗前明显降低(P<0.05),直立组患侧小腿三头肌痉挛评分分值降低较坐位组更显著(P<0.05)。结论:直立和坐位下肢被动踩踏训练均能降低脑卒中患者偏瘫侧下肢的痉挛,其中直立下肢被动踏踩训练对缓解患侧小腿三头肌的痉挛效果更好。     

运动再学习联合针刺法对脑梗死患者下肢痉挛的影响

目的观察运动再学习联合针刺法对脑梗死患者下肢痉挛的影响。 方法选取脑梗死患者50例,按照随机数字表法将其分为阳明经针刺组和综合法针刺组,每组25例。2组均给予神经内科常规药物治疗及运动再学习康复训练,阳明经针刺组在此基础上加用阳明经针刺法治疗,综合法针刺组在此基础上加用综合针刺法治疗。治疗前、治疗4周后（治疗后）,采用表面肌电图仪记录患侧膝屈曲和踝背伸最大等长收缩（MIVC）时主动肌及拮抗肌的肌电活动,采用Holden步行功能分级（FAC）、Fugl-Meyer量表（FMA）下肢部分及综合痉挛量表（CSS）评定患者的下肢运动功能。 结果与组内治疗前比较,2组患者FAC、FMA及CSS评分均较治疗前有所改善,差异有统计学意义（P<0.05）。与阳明经针刺组治疗后［（2.15±0.16）分］比较,综合法针刺组FAC评分［（3.87±0.99）分］显著较高,差异有统计学意义（P<0.05）。与组内治疗前比较,2组患者治疗后膝屈曲肌群MIVC时的股直肌积分肌电值（iEMG）、膝屈曲协同收缩率（CO）、健侧与患侧CO比值均有不同程度的变化,差异有统计学意义（P<0.05）。与阳明经针刺组治疗后［（35.25±4.47）mV?s］比较,综合法针刺组治疗后股直肌iEMG［（30.32±3.98）mV?s］较低,差异有统计学意义（P<0.05）。与组内治疗前比较,2组患者腓肠肌iEMG、踝背伸CO、健侧与患侧CO比值具有不同程度的变化,差异有统计学意义（P<0.05）。综合法针刺组治疗后胫前肌iEMG［（31.32±3.68）mV?s］与组内治疗前［（29.36±4.51）mV?s］比较,差异无统计学意义（P&rt;0.05）。综合法针刺组与阳明经针刺组治疗后各指标比较,差异均无统计学意义（P&rt;0.05）。 结论运动再学习联合综合针刺法较运动再学习联合传统阳明经针刺法更能有效降低脑卒中患者下肢的痉挛程度,增强患侧的步行能力,提高其下肢运动功能。     

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.     

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.     

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.     

Systematic Reviews Published in the April 2012 Issue of the Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD but monthly online. The April 2012 issue (second DVD for 2012) contains 5045 complete reviews, 2182 protocols for reviews in production, and 17,084 short summaries of systematic reviews published in the general medical literature. In addition, there are citations of 674,000 randomized controlled trials, and 15,400 cited papers in the Cochrane methodology register. The health technology assessment database contains just over 11,000 citations. One hundred and seventeen new reviews have been published in the last 3 months of which 12 have potential relevance for practitioners in pain and palliative medicine. The impact factor of the Cochrane Library stands at 6.186. Readers are encouraged to access the full report for any articles of interest as only a brief commentary is provided.     

Platelets,thrombosis, coagulation,and atherosclerosis

When I first got the invitation to join a medical delegation going to Moldova, I thought for a moment that our destination was the fictional country in the old Marx Brothers movie Duck Soup. On further checking, it turns out that entertaining place was called Freedonia. I now know that Moldova is indeed a real country, bordered on the west by Romania and on the other three sides by the Ukraine. It is a proud country, rich with traditions, and its people are warm, giving, eager to learn ways to improve their healthcare system, and deeply appreciative of our attempts to help them in the task.     

Advance Care Planning

Predictors of patient wishes and influence of family and clinicians are discussed. Research findings on patient decision-making relating to preferences in end-of-life care are described. Advance directives and durable powers of attorney are defined and differentiated. Most patients have not participated in advance care planning and the need for more effective planning is documented. Appropriate times for discussions of such planning are described. Scenarios discussed include terminal cancer, chronic obstructive pulmonary disease, AIDS, stroke, and dementia. Patient satisfaction is discussed, as is a structured process for discussions about patient preferences. Results of patient responses to hypothetical scenarios are described. Invasiveness of interventions, prognosis and other factors that favor or discourage patient preferences for treatment are discussed. Findings resulting from research funded by the Agency for Healthcare Research and Quality (AHRQ) are discussed. This research can help providers offer end-of-life care based on preferences held by the majority of patients under similar circumstances.     

Spiritual Dimensions of Nursing Practice. edited by V. B. Carson

The Cochrane Library of Systematic Reviewsis published quarterly. Issue one for 2004 of the library was published in February 2004. This issue contains 3,329 reviews and protocols of which 1,921 are fully published reviews. The trials database now stands at over 400,000 records with an additional 4,427 one-page summaries of non-Cochrane reviews in the NHS database of reviews of effectiveness (DARE). This version of the library contains the results of an extensive search for RCTs on EMBASE. The latest library contains 84 new reviews, seven are considered relevant to practitioners in pain and palliative care. References are published in the same format as the citation for Cochrane reviews.     

Évaluation,par l’imagerie ultrasonore,du recrutement musculaire,de la force motrice et de la détente verticale du quadriceps après électromyostimulation (cas de 15 étudiants de l’INJS)

The increase of strength seems to be an element of performance in some sports.