下肢截肢患者的脑功能连接北大核心CSCD

目的探究静息状态下,下肢截肢患者脑电信号在多频段上脑功能连接的变化。方法2020年11月至2021年6月,采集22例健康成年人(对照组)和18例下肢截肢患者(患者组)静息态脑电图,以相位锁值构建功能连接矩阵,比较两组间差异。结果患者组α频段(t=3.433,P=0.001)和β频段(t=3.806,P=0.001)功能连接明显减弱,δ频段(t=1.429,P=0.161)和θ频段(t=1.211,P=0.233)功能连接与对照组无显著性差异。结论下肢截肢患者脑电α、β频段功能连接减弱,导致多个脑区功能重塑,包括相关肢体投射脑区、额叶、颞叶、枕叶等。     

Prosthesis rejection in acquired major upper-limb amputees: a population-based survey

Purpose: To estimate the rates of primary and secondary prosthesis rejection in acquired major upper-limb amputees (ULAs), to describe the most frequently reported reasons for rejection and to estimate the influence of background factors on the risk of rejection. Method: Cross-sectional study analysing population-based questionnaire data (n?=?224). Effects were analysed by logistic regression analyses and Cox regression analyses. Results: Primary prosthesis rejection was found in 4.5% whereas 13.4% had discontinued prosthesis use. The main reasons reported for primary non-wear were a perceived lack of need and discrepancies between perceived need and the prostheses available. The main reasons reported for secondary prosthesis rejection were dissatisfaction with prosthetic comfort, function and control. Primary prosthesis rejection was more likely in ULAs amputated at high age and in ULAs with proximal amputations. Secondary prosthesis rejection was more likely in proximal ULAs and in women. Conclusions: Clinicians should be aware of the increased risk of rejection in proximal ULAs, elderly ULAs and in women. Emphasising individual needs will probably facilitate successful prosthetic fitting. Improved prosthesis quality and individualised prosthetic training may increase long-term prosthesis use. Further studies of the effect of prosthetic training and of the reasons for rejection of different prosthetic types are suggested.

Implications for Rehabilitation

• Most acquired major upper-limb amputees (ULAs) are fitted with prostheses after the amputation.

• This population-based study shows that proximal ULAs, elderly ULAs and women have an increased risk of prosthesis rejection.

• Emphasising individual needs may facilitate successful prosthetic fitting.

• Improved prosthesis quality and individualised prosthetic training may increase long-term prosthesis use.

     

Development of a simple score to predict outcome for unresponsive wakefulness syndrome

Introduction

Accurate assessment of prognosis for patients with unresponsive wakefulness syndrome (UWS; formerly vegetative state) may help clinicians and families guide the type and intensity of therapy; however, there is no suitable and accurate means to predict the outcome so far. We aimed to develop a simple bedside scoring system to predict the likelihood of awareness recovery in patients with UWS.

Methods

We prospectively enrolled 56 patients (age range 10 to 73 years) with UWS 3 to 12 weeks post-onset. We collected demographic data and performed neurological, serological and neurophysiological tests at study entry. Each patient received a one year follow-up, during which awareness recovery was assessed by experienced physicians on the basis of clinical criteria. Univariate and multivariable analyses were employed to assess the relationships between predictors and awareness recovery.

Results

A total of 56 participants were included in the study; of these, 24 patients recovered awareness, 3 with moderate disabilities, 8 with severe disabilities, 12 were in a minimally conscious state, and 1 died after recovery. During the study, 23 patients remained in UWS and 9 died in UWS. Motor response, type of brain injury, electroencephalogram reactivity, sleep spindles and N20 were shown to be independent predictors for awareness recovery. Based on their coefficients in the model, we assigned these predictors with 1 point each and created a 5-point score for prediction of awareness recovery. The resulting score showed good predictive accuracy in the derivation cohort. The area under the receiver operating characteristic curve for the score was 0.918 with 87.50% sensitivity.

Conclusion

This simple bedside prognostic score can be used to predict the probability of awareness recovery in UWS, thus provide families and clinicians with useful outcome information.     

Skin problems in lower limb amputees: a systematic review

Purpose. Skin problems of the stump in lower limb amputees are relative common in daily rehabilitation practice, possibly impeding prosthetic use. This impediment may have great impact in daily life. Our objective was to review literature systematically concerning incidence and prevalence of skin disorders of the stump in lower limb amputees.

Method. A literature search was performed in several medical databases (MEDLINE, CINAHL, EMBASE, RECAL) using database specific search strategies. Reference lists in the identified publications were used as threads for retrieving more publications missed in the searches. Only clinical studies and patient surveys were eligible for further assessment.

Results. 545 publications were initially found. After selection, 28 publications were assessed for research methodology. Only one publication fulfilled the selection criteria. The prevalence of skin problems in a series of 45 lower leg amputees of 65 years and older was 16%.

Conclusions. Prevalence and incidence of skin problems of the stump in lower limb amputees are mainly unknown.     

APACHE II scoring to predict outcome in post-cardiac arrest

Introduction

Despite advancements in management of cardiac arrest, mortality remains high and few severity of illness scoring systems have been calibrated in this population. The goal of the current investigation was to assess the Acute Physiology and Chronic Health Evaluation II score in post-cardiac arrest.

Measurements

This is a prospective observational study of adult post-cardiac arrest patients at a tertiary-care center. The primary outcome variable was in-hospital mortality and secondary outcome variable was neurologic outcome. APACHE II scores were used to predict outcomes using logistic modeling.

Main results

A total of 228 subjects were included in the analysis. The median age of the cohort was 70 (IQR: 64–71) and 32% (72/228) of the patients were female. The median downtime was 15 min (IQR: 7–27) and initial lactate 5.9 mmol/L (IQR: 3.5–8.4). 71 (57%) of deaths occurred prior to the 72-h follow-up and overall in-hospital mortality was 55% (125/228). Discrimination of APACHE II score in all cardiac arrest patients increased in stepwise fashion from 0-h to 72-h follow-up (AUC: 0-h: 0.62; 24-h: 0.75; 48-h: 0.82; 72-h: 0.86).

Conclusions

APACHE II score is a poor predictor of outcome at time zero for out-of-hospital cardiac arrest (OHCA) post-arrest patients consistent with the original development of the score in the critically ill. For in-hospital cardiac arrest (IHCA) at time zero and for both IHCA and OHCA at 24 h and beyond, the APACHE II score was a modest indicator of illness severity and predictor of mortality/neurologic morbidity.     

Effect of endurance training program based on anaerobic threshold (AT) for lower limb amputees

We have already reported that the one-leg cycling test driven by the subject's sound leg as the exercise load test is effective in measuring the anaerobic threshold (AT) of unilateral lower limb amputees. The aim of this research is to investigate whether or not endurance training based on each subject's AT gained from the one-leg cycling test is useful in improving the physical fitness of lower limb amputees. The test subjects were all unilateral transfemoral amputees comprising a group of 14 undertaking endurance training and a control group of 10. The form of endurance training is driving an ergometer with the sound limb only in the same way as the load test. The training program was designed so that the subjects would exercise at a target heart rate corresponding to AT point for 30 minutes per day, 3-5 days each week for 6 weeks. After the training periods, in the training subjects the AT and maximum oxygen uptake (__O2max) increased significantly. The rate of increase averaged 36.5%, 26.0%, respectively, compared to their levels before the training. On the contrary, no changes occurred in the control subjects. These results suggest that our chosen training program based on each subject's AT is effective in improving the physical fitness of lower limb amputees.     

Transcutaneous oxygen tension measurements in the assessment of limb ischaemia

Summary. The measurement of transcutaneous oxygen tension (TcPo₂) has been adapted for the assessment of the blood supply of the lower limb. This study was undertaken to determine the most useful means of expressing TcPo₂ measurements. We studied 176 patients with peripheral vascular disease and/or diabetes and 34 normal volunteers. Approxiately half of the patients studied had ulceration or gangrene of the foot. A comparison of three methods of expressing TcPo, measurement for predicting presence of ulceration was made using ROC A analysis. The absolute value of TcPo, on the dorsum of the foot was the best predictor of the presence of ulceration or gangrene. An absolute value of TcPo, of 30 mmHg on the dorsum of the foot had a sensitivity of 42% and specificity of 91%. The sensitivity of the test was as good in diabetic patients as in non-diabetic patients.     

LiFe: a liver injury score to predict outcome in critically ill patients

Purpose

To develop a liver function-related risk prediction tool to identify acute-on-chronic liver failure patients at greatest risk of in-hospital mortality.

Methods

The LiFe (liver, injury, failure, evaluation) score, was constructed based on the opinions of 157 intensivists within the European Society for Intensive Care Medicine. Experts were surveyed and instructed to weigh the diagnostic importance of each feature of a proposed prediction model. We performed a retrospective cohort study of 1916 patients with chronic liver disease admitted to a medical or surgical ICU between 1997, and 2011 in three large hospitals in Boston, USA, and London, UK, with arterial lactate, total bilirubin and INR drawn at ICU admission. The derivation cohort consisted of ICU patients from Brigham and Women’s Hospital and Massachusetts General Hospital in Boston (n = 945), and the validation cohort comprised patients from Kings College Hospital, London, admitted to the Liver Intensive Therapy Unit (n = 971). A clinical prediction model was derived and validated based on a logistic regression model describing the risk of in-hospital mortality as a function of the predictors (arterial lactate 0–1.9, ≥2.0–3.9, ≥4.0–5.9, ≥6.0 mg/dL; total bilirubin 0–1.9, ≥2.0–3.9, ≥4.0–5.9, ≥6.0 mg/dL; INR 0–1.9, ≥2.0–3.9, ≥4.0–5.9, ≥6.0) at ICU admission. Performance analysis of the LiFe score against SOFA, CLIF-SOFA, APACHE II and SAPS II was completed in the validation cohort of critically ill cirrhotic patients.

Results

The derivation cohort (n = 941) was 53 % male with a mean age of 65 years and an in-hospital mortality rate of 30 %. The validation cohort (n = 971) was 63 % male with mean age of 51 years and an in-hospital mortality rate of 52 %. The C statistic for the prediction model was 0.74 (95 % CI 0.70–0.77) in the derivation cohort and 0.77 (95 % CI 0.74–0.80) in the validation cohort. In the validation cohort, in-hospital mortality was 17 % in the low-risk group (0 risk score points), 28 % in the intermediate-risk group (1–3 points), 47 % in the high-risk group (4–8 points), and 77 % in the very high-risk group (>8 points). In the validation cohort, the C statistics for SOFA, CLIF-SOFA, APACHE II, and SAPS II were 0.80, 0.81, 0.77, and 0.78, respectively. Further, a significant positive correlation exists between LiFe score and acute-on-chronic liver failure grade, (r = 0.478, P < 0.001).

Conclusions

Our LiFe score calculated from arterial lactate, total bilirubin and INR at ICU admission is a simple, quick and easily understandable score that may increase clinical utility for risk prediction in ICU patients with acute-on-chronic liver failure. The LiFe score can be used in place of physiological based scores for early risk prediction in patients with chronic liver disease but is not intended to replace CLIF-SOFA as a benchmark for prognostication.

     

步进式DSA技术在下肢顺行性静脉造影中的应用

目的评价步进式DSA技术在下肢顺行性静脉造影中的应用价值。方法将要求行下肢静脉造影患者40例随机分为2组:研究组20例行步进式DSA造影,对照组20例行传统分段式DSA造影。由介入科主治以上医生及技师共同将图像满意率、造影耗时、吸收辐射剂量(DAP)、造影剂用量等进行比较评价。结果步进式DSA造影与传统分段式DSA造影相比较,2种方法造影图像质量相仿,但步进式DSA造影对观察由下而上血流的连续性,血流动态流向,判断静脉的解剖形态及病理血管血流状况,图像更加富有整体性,一次性成功率85%(17/20)。其次吸收辐射剂量,造影剂用量,总体检查时间均明显减少。结论对下肢静脉病变,步进式DSA造影较传统分段式DSA造影环节更为简化,图像整体观及实用性强,对下肢静脉病变介入治疗方案的决策以及外科手术有很重要的客观指引作用。     

Sensitivity to change and minimal clinically important difference of the Locomotor Capabilities Index-5 in people with lower limb amputation undergoing prosthetic training

ObjectiveTo determine the sensitivity to change and minimal clinically important difference (MCID) for the self-administered Locomotor Capabilities Index-5 (LCI-5) in people with lower limb amputation undergoing prosthetic training.DesignProspective single-group observational study.MethodsThe LCI-5 was administered to 110 patients (69 males [63%]; median [interquartile range] age, 60 [48–69] years) before and after prosthetic training. The external anchor administered after the program was a 7-point Global Rating of Change Scale (GRCS) designed to quantify the effect (improvement or deterioration) of the intervention.ResultsTest–retest reliability of the LCI-5 (n = 30) was high (intraclass correlation coefficient [ICC_2,1] = 0.92). The minimum detectable change at the 95% confidence level was 5.66 points. After triangulating these results with those of the mean-change approach and receiver operating characteristic (ROC) curve analysis (area under the ROC curve ≥ 0.90), based on a different GRCS score splitting, we identified 2 cutoffs for the LCI-5: a change of 7 points, indicating the MCID, and 12 points, indicating “large improvement” in locomotor capabilities (12.5% and 21.4% of the maximum possible score, respectively).ConclusionsThe LCI-5 showed a high ability to detect change over time (responsiveness). The 2 proposed values (MCID of 7 points and large improvement of 12 points), based on a mix of distribution- and anchor-based approaches, represent cutoffs that can accurately identify 2 different levels of true change (as perceived by the patient) in locomotor capability after prosthetic training.     

The prevalence,distribution, and functional importance of lower limb somatosensory impairments in chronic stroke survivors: a cross sectional observational study

Purpose: To investigate the prevalence and distribution of lower limb somatosensory impairments in community dwelling chronic stroke survivors and examine the association between somatosensory impairments and walking, balance, and falls.

Methods: Using a cross sectional observational design, measures of somatosensation (Erasmus MC modifications to the (revised) Nottingham Sensory Assessment), walking ability (10?m walk test, Walking Impact Scale, Timed “Get up and go”), balance (Functional Reach Test and Centre of Force velocity), and falls (reported incidence and Falls Efficacy Scale-International), were obtained.

Results: Complete somatosensory data was obtained for 163 ambulatory chronic stroke survivors with a mean (SD) age 67(12) years and mean (SD) time since stroke 29 (46) months. Overall, 56% (n?=?92/163) were impaired in the most affected lower limb in one or more sensory modality; 18% (n?=?30/163) had impairment of exteroceptive sensation (light touch, pressure, and pin-prick), 55% (n?=?90/163) had impairment of sharp-blunt discrimination, and 19% (n?=?31/163) proprioceptive impairment. Distal regions of toes and foot were more frequently impaired than proximal regions (shin and thigh). Distal proprioception was significantly correlated with falls incidence (r?=?0.25; p?<?0.01), and centre of force velocity (r?=?0.22, p?<?0.01). The Walking Impact Scale was the only variable that significantly contributed to a predictive model of falls accounting for 15–20% of the variance.

Conclusion: Lower limb somatosensory impairments are present in the majority of chronic stroke survivors and differ widely across modalities. Deficits of foot and ankle proprioception are most strongly associated with, but not predictive, of reported falls. The relative contribution of lower limb somatosensory impairments to mobility in chronic stroke survivors appears limited. Further investigation, particularly with regard to community mobility and falls, is warranted.

• Implications for Rehabilitation

• Somatosensory impairments in the lower limb were present in approximately half of this cohort of chronic stroke survivors.

• Tactile discrimination is commonly impaired; clinicians should include an assessment of discriminative ability.

• Deficits of foot and ankle proprioception are most strongly associated with reported falls.

• Understanding post-stroke lower limb somatosensory impairments may help inform therapeutic strategies that aim to maximise long-term participation, minimise disability, and reduce falls.

     

The long-term outcome of upper limb amputees treated at a rehabilitation centre in Sydney,Australia

A follow-up study by questionnaire or interview has been made of the 27 respondents of 41 upper limb amputees (66%) treated at the Royal South Sydney Hospital between 1981 and 1990. Prosthetic use of 8 h/day or more was 37% and occasional use was 18·5%. The prosthetic users were more likely to be distal amputees. The reason for the low level of prosthetic use is not known. The majority of non-users discarded prostheses after leaving their rehabilitation programme. Occupational changes were made by 72% of the amputees. The unemployment rate at follow-up was similar to the rest of the community, which is a better outcome than 25 years ago. Activities of daily living had been affected in all patients, but to a lesser extent in prosthetic users. Leisure pursuits were changed in 70% of patients, with these activities being more sedentary and indoor in nature. Of the 18 car drivers, 15 drove automatic cars with modifications. Phantom pain was experienced by 16 of the respondents (59%) and stump pain was experienced by seven. Only 26% used medication or alcohol for the pain. Pain did not affect prosthetic use or functional ability.     

Development and validation of a movement and activity in physical space score as a functional outcome measure

Herrmann SD, Snook EM, Kang M, Scott CB, Mack MG, Dompier TP, Ragan BG. Development and validation of a Movement and Activity in Physical Space score as a functional outcome measure.

Objective

To develop and validate a functional measure, the Movement and Activity in Physical Space (MAPS) score, that encompasses both physical activity and environmental interaction.

Design

Observational matched-pair cohort with 2-month follow-up.

Setting

General community under free-living conditions.

Participants

Adult participants (N=18; n=9 postsurgical, n=9 matched control; mean age ± SD, 28.9±12.0y) were monitored by an accelerometer and global positioning system receiver for 3 days within 1 week (4.1±2.8d) after knee surgery (T=0) and 2 months later (T+2). The healthy controls were matched for age, sex, smoking, perceived physical activity level, and occupation of a postsurgical participant. Correlation, t test (with Bonferroni adjustment: α=.05/2), analysis of variance, and intraclass correlation coefficient were used to establish validity and reliability evidence.

Interventions

Not applicable.

Main Outcome Measure

MAPS scores.

Results

MAPS scores were moderately correlated with the Knee Injury and Osteoarthritis Outcome Score (P<.05). There was a significant group difference at T = 0 for MAPS (t_9.9=–3.60; P=.01). Analysis of variance results for the MAPS indicated a time and group interaction (F_1,12=4.60, P=.05). Reliability of 3 days of MAPS scores ranged from 0.75 to 0.81 (postsurgical and control), and 2-month test-retest reliability in the control group was 0.94.

Conclusions

The results provide a foundation of convergent and known-group difference validity evidence along with reliability evidence for the use of MAPS as a functional outcome measure.     

Development and acceptability testing of decision trees for self-management of prosthetic socket fit in adults with lower limb amputation

Purpose: The most common complaint lower limb prosthesis users report is inadequacy of a proper socket fit. Adjustments to the residual limb–socket interface can be made by the prosthesis user without consultation of a clinician in many scenarios through skilled self-management. Decision trees guide prosthesis wearers through the self-management process, empowering them to rectify fit issues, or referring them to a clinician when necessary. This study examines the development and acceptability testing of patient-centered decision trees for lower limb prosthesis users.

Methods: Decision trees underwent a four-stage process: literature review and expert consultation, designing, two-rounds of expert panel review and revisions, and target audience testing.

Results: Fifteen lower limb prosthesis users (average age 61 years) reviewed the decision trees and completed an acceptability questionnaire. Participants reported agreement of 80% or above in five of the eight questions related to acceptability of the decision trees. Disagreement was related to the level of experience of the respondent.

Conclusions: Decision trees were found to be easy to use, illustrate correct solutions to common issues, and have terminology consistent with that of a new prosthesis user. Some users with greater than 1.5 years of experience would not use the decision trees based on their own self-management skills.

• Implications for Rehabilitation

• Discomfort of the residual limb-prosthetic socket interface is the most common reason for clinician visits.

• Prosthesis users can use decision trees to guide them through the process of obtaining a proper socket fit independently.

• Newer users may benefit from using the decision trees more than experienced users.

     

Cognitive functioning in persons with lower limb amputations: a review

Purpose: To review the literature on cognitive functioning in persons with lower limb amputations. Method: A search of the MEDLINE, PsycINFO and Web of Science databases was carried out. Results: Thirty papers were found that met the inclusion criteria. The studies were characterised by heterogeneity of design, methodological quality, sample characteristics, assessment of cognitive functioning, and outcomes examined. The research published to date suggests that cognitive impairment is more prevalent among persons with lower limb amputations than in the general population, and is linked with a number of important outcomes in this patient group, including mobility, prosthesis use, and maintenance of independence following amputation. Conclusions: These findings highlight the importance of assessing the cognitive abilities of persons with lower limb amputations. An understanding of the cognitive profile of these patients could assist rehabilitation teams in determining their suitability for prosthetic or wheelchair rehabilitation, ascertaining appropriate and realistic goals for rehabilitation, and tailoring rehabilitation programmes to patients’ strengths so that maximal mobility and independence is achieved.

Implications for Rehabilitation

• Cognitive impairment appears to be more prevalent among persons with lower limb amputations than in the general population.

• Cognitive impairment is negatively associated with mobility, prosthesis use, and maintenance of independence following amputation.

• Cognitive screening prior to rehabilitation could assist in determining patients’ suitability for prosthetic or wheelchair use, ascertaining appropriate goals, and tailoring rehabilitation to patients’ strengths so as to optimise their mobility and independence.

     

Care of elderly lower limb amputees, as described in medical and nursing records

The aim of this study was to characterize elderly lower limb amputees and explore problems/requirements inherent in their care. A retrospective study of medical and nursing records of patients who had undergone lower limb amputation (LLA) at Uddevalla General Hospital in 1997 was conducted. Demographic data were compared with those from a comparable regional health care district. Hospitalization, rehabilitation and nursing-related data related to subjects alive after 6 months were compared with data concerning those deceased during hospital stay and within 6 months after amputation. During the defined period, the study population consisted of 45 patients aged 60 and above. Fifty-six percent were men, with a mean age of 81.6. Eight patients died in the hospital post-amputation and five died within 6 months of surgery. The aetiology of the diagnosis leading to the LLA was cardiovascular disease in the majority of cases. The most common amputation level was below the knee. LLA patients were reported to have major problems maintaining physical and mental functions, markedly deteriorated general health status and severe pain problems. LLA patients require well functioning and qualified care and rehabilitation. The patients surviving after 6 months had permanent problems in the area of nutrition, elimination, skin ulceration, sleep, pain and pain alleviation. The patients who died during the hospital stay had problems in all these areas. With increasing shorter stays in hospital and decreasing resources in primary and municipal care, there is a risk that these patients' needs and requirements for professional care might be underestimated and thus remain unfulfilled.     

Exoskeletons' design and usefulness evidence according to a systematic review of lower limb exoskeletons used for functional mobility by people with spinal cord injury

Purpose: Rehabilitation professionals have little information concerning lower limb exoskeletons for people with paraplegia. This study has four objectives: (1) Outline the characteristics of the exoskeletons’ design and their usefulness evidence as assistive mobility devices in the community for the Rewalk?, Mina, Indego®, Ekso? (previously known as the eLEGS?) and Rex®; (2) document functional mobility outcomes of using these exoskeletons; (3) document secondary skills and benefits achieved with these exoskeletons, safety, user satisfaction and applicability in the community; and (4) establish level of scientific evidence of the selected studies. Method: A systematic review of the literature (January 2004 to April 2014) was done using the databases PubMed, CINAHL and Embase and groups of keywords associated with “exoskeleton”, “lower limb” and “paraplegia”. Results: Seven articles were selected. Exoskeleton use is effective for walking in a laboratory but there are no training protocols to modify identified outcomes over the term usage (ReWalk?: 3 months, Mina: 2 months and Indego®: 1 session). Levels of evidence of selected papers are low. Conclusions: The applicability and effectiveness of lower limb exoskeletons as assistive devices in the community have not been demonstrated. More research is needed on walking performance with these exoskeletons compared to other mobility devices and other training contexts in the community.

• Implications for rehabilitation

• Characteristics of the exoskeletons’ design and their usefulness evidence as assistive mobility devices in the community are addressed for the Rewalk?, Mina, Indego®, Ekso? and Rex® ReWalk?, Indego® and Mina lower limb exoskeletons are effective for walking in a laboratory for individuals with complete lower-level SCI.

• The ReWalk? has the best results for walking, with a maximum speed of 0.51 m/s after 45 sessions lasting 60 to 120 min; it is comparable to the average speed per day or per week in a manual wheelchair.

• The level of scientific evidence is low. Other studies are needed to provide more information about performance over the longer term when walking with an exoskeleton, compared to wheelchair mobility, the user’s usual locomotion, the use of different exoskeletons or the training context in which the exoskeleton is used.