疗养院开展持续植物状态患者综合促醒康复治疗

目的探讨综合促醒康复方法对持续植物状态(PVS)患者的治疗作用,以及疗养院开展促醒治疗的意义。方法 19例PVS患者,采用药物治疗、高压氧治疗、针灸治疗、物理因子治疗、神经功能重建治疗、前庭功能训练等综合康复治疗方法治疗6个月~1年。按PVS评分标准、GCS评分、CRS-R、改良Barthel指数进行疗效评定。结果 19例PVS患者中,初步脱离植物状态9人,完全脱离植物状态6人,治疗总有效率为78.95%,促醒率31.58%。结论采用综合促醒康复治疗效果明显,适合在疗养院开展。     

Sleep and Chronic Daily Headache

Disorders of consciousness (DOCs) include coma, vegetative state (VS), and minimally conscious state (MCS). Coma is characterized by impaired wakefulness and consciousness, while VS and MCS are defined by lacking or discontinuous consciousness despite recovered wakefulness. Conversely, locked-in syndrome (LIS) is characterized by quadriplegia and lower cranial nerve paralysis with preserved consciousness. Intrathecal baclofen (ITB) is a useful treatment to improve spasticity both in patients with DOCs and LIS. Moreover, it supports the recovery of consciousness in some patients with VS or MCS. The precise mechanism underlying this recovery has not yet been elucidated. It has been hypothesized that ITB may act by reducing the overload of dysfunctional sensory stimuli reaching the injured brain or by stabilizing the imbalanced circadian rhythms. Although the current indication of ITB is the management of severe spasticity, its potential use in speeding the recovery of consciousness merits further investigation.     

脑外伤后持续性植物状态的研究现状

持续性植物状态 ( Persistent Vegetative State, PVS) 是指一种持续觉醒而无意识状态 , 目前各国间对 PVS的诊断标准尚未达到统一 . PVS以脑外伤最为多见 , 其主要病理表现为弥漫性轴索损害、脑皮层弥漫性坏死及选择性丘脑坏死 . 正电子发射型计算机断层显像是目前检查 PVS最有意义的方法 . PVS目前没有确切有效的治疗方法 , 脑外伤后 PVS较其他原因的 PVS预后好 .     

正中神经刺激治疗颅脑损伤后持续性植物状态7例报告

目的　对于持续性植物状态（ＰＶＳ） 的治疗,目前尚无满意的方法,我们应用正中神经刺激（ＭＮＳ）对７ 例颅脑损伤后ＰＶＳ促醒治疗,旨在探索其应用价值。方法　对７ 例ＰＶＳ患者应用国产低频诊疗仪行低频脉冲电刺激,刺激电极置于双侧腕关节掌面正中神经点,刺激前后检测脑电图（ＥＥＧ）、脑干诱发电位（ＢＡＥＰ） 。结果　３ 例意识恢复,４ 例无变化,患者ＥＥＧ、ＢＡＥＰ 均缺乏特异性,但ＢＡＥＰ的改善与临床的好转是一致的。结论　本组病例尚少,但可看出ＭＮＳ对ＰＶＳ的促醒具有一定的作用,值得进一步研究。     

Baclofen toxicity in an 8-year-old with an intrathecal baclofen pump

Baclofen delivered by intrathecal pumps (ITB) is increasingly being utilized in the pediatric population, however, resources and education to support problems with these devices are limited. Typical management strategies for systemic baclofen overdose include removal of baclofen from the device reservoir or removal of cerebrospinal fluid from the adjacent device catheter. Appropriate care of these patients requires awareness of the clinical patterns of toxicity and mechanics of the ITB pump delivery system. This report describes the clinical presentation, unfamiliar dilemmas, and the management of a pediatric patient with intrathecal baclofen toxicity, noting problems that may arise in the care of these patients.     

小儿重型颅脑损伤49例救治的临床体会

目的总结小儿重型颅脑损伤的救治体会。方法回顾性分析49例小儿重型颅脑损伤患者的临床资料,对其救治过程和效果进行记录并且统计,出院时按GOS评分进行疗效判定。结果根据格拉斯预后评分(GOS)判定疗效:存活44例,经4至12个月随访,恢复良好25例,中残11例,重残8例,植物状态生存0例,死亡5例。结论小儿重型颅脑损伤的临床表现与损伤程度不一致,低血压发生率高,通过积极治疗,预后较成人好。     

Characterization and Modification of Brain Activity with Deep Brain Stimulation in Patients in a Persistent Vegetative State: Pain-Related Late Positive Component of Cerebral Evoked Potential

A series of eight patients in a persistent vegetative state (PVS) were subjected to chronic deep brain stimulation (DBS) for the purpose of promoting recovery from the PVS. The characteristics of the brain activity in these patients were evaluated from the late positive component of the cerebral evoked potential in response to painful stimuli (pain-related P250). While any neurological scoring system for the comatose state includes evaluations of motor reactions to painful stimuli, the pain-related P250 is unique in terms of its ability to assess the cortical responsiveness to painful stimuli directly and quantitatively without involving functions of the motor system. It was found that the pain-related P250 was more or less depressed in patients in a PVS. It was repeatedly demonstrated in four patients, however, that the pain-related P250 could be transiently increased by preceding stimulation of the mesencephalic reticular formation. Furthermore, a persistent increase in the pain-related P250 was produced in these four patients following chronic DBS of the mesencephalic reticular formation or nonspecific thalamic nuclei for more than 6 months, and this was correlated with the clinical improvements. These results imply that responsiveness at the cortical level to pain is depressed in the PVS. It also appears that some fraction of the depression may, however, be functionally produced and potentially reversible.     

加强颈部治疗在持续性植物状态康复中的疗效观察

目的将加强颈部治疗应用于持续性植物状态（PVS）患者的临床康复中,观察加强颈部治疗对PVS的疗效,为PVS患者的促醒治疗和康复训练提供另一种较为针对性、具体性的治疗思路。方法收集我科2008-01—2011-12收治的PVS患者85例,在传统综合康复的基础上,加强了对颈部这一特定部位的治疗,包括：①颈部风府、风池、颈夹脊、大椎、肩中腧、肩外腧等穴位的针灸治疗;②颈部肌肉的按摩治疗;③颈部龙氏整脊手法的应用;④颈部PNF的应用。结果 85例PVS患者意识恢复38例,意识恢复率达44.7%。结论加强颈部治疗可以纠正PVS患者颈项强直、斜颈,降低颈部肌肉张力,又可对PVS患者的促醒治疗起到积极的促进作用。临床治疗时应给予重视。     

Dexmedetomidine for Acute Management of Intrathecal Baclofen Withdrawal

BackgroundIntrathecal baclofen (ITB) is a mainstay of treatment for patients with chronic spasticity. Up to 40% of all patients receiving ITB experience overdose or withdrawal symptoms, which in the most severe cases can lead to multisystem organ failure and death. There is currently no well-established treatment for ITB withdrawal. One previous case report details an intubated pediatric patient who underwent baclofen pump removal in which dexmedetomidine was used in combination with other medications to prevent baclofen withdrawal.Case ReportWe report a case of baclofen withdrawal where the decision was made to initiate a dexmedetomidine infusion, with subsequent improvement of the patient's hypertension and tachycardia. At no point during her stay did the patient require intubation for airway protection, and the patient was ultimately discharged to her previous nursing facility on hospital day 9 with no new neurologic deficits.Why Should an Emergency Physician Be Aware of This?Emergency physicians should be aware of dexmedetomidine as a promising option for the treatment of ITB withdrawal in the acute setting. Although little evidence is currently present, dexmedetomidine was used successfully in this case, and should be considered as a temporizing treatment for ITB withdrawal. Dexmedetomidine holds promise in the management of ITB withdrawal compared to other previously described treatments, including oral baclofen, cyproheptadine, and dantrolene. In addition, dexmedetomidine has a superior safety profile compared to propofol or large doses of benzodiazepines. Further research will be useful in supporting the use of dexmedetomidine for this purpose.     

高频rTMS、脑仿生电及其序贯治疗脑外伤持续植物状态患者的临床观察

目的:观察高频重复经颅磁刺激(rTMS)、脑仿生电刺激及其序贯治疗脑外伤持续植物状态(PVS)患者的临床疗效.方法:入组的脑外伤PVS患者予常规药物及康复治疗,并随机分为3组:rTMS组(24例),予高频rT-MS治疗;脑仿生电组(23例),予脑仿生电治疗;rTMS与脑仿生电联合组(简称联合组,26例),先高频rTMS...     

Pruritus after intrathecal baclofen withdrawal: A retrospective study

OBJECTIVES: To determine the frequency of pruritus after intrathecal baclofen (ITB) withdrawal and to study the pathophysiology of this symptom. DESIGN: Retrospective cohort study. SETTING: Rehabilitation department of a general hospital. PARTICIPANTS: Patients (N=102) implanted with an ITB pump who had been followed up since 1988. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Incidence of pruritus after withdrawal. We studied the relation between pruritus and daily dose, concentration and mode of infusion of baclofen, and cause of the central nervous system lesion inducing spasticity. RESULTS: Pruritus was observed in 10 of 23 cases of ITB withdrawal. It never occurred during the first 3 months after pump implantation. It seems likely that the segmental spinal action of baclofen is responsible for pruritus. There was no statistically significant difference between patients with ITB deprivation who did and did not experience pruritus in their daily infused dosage or in concentration and mode of infusion. Surprisingly, no pruritus was observed in patients with multiple sclerosis. CONCLUSIONS: Pruritus is a frequent symptom after ITB withdrawal. Its occurrence is probably subsequent to chronic blocking of the liberation of substance P by baclofen at the spinal level. This symptom is a good clinical predictor of baclofen withdrawal, in contrast to an isolated increase of spasticity that may be due to drug tolerance or irritant factors. Pruritus requires investigation of a possible dysfunction of the infusion system.     

单光子发射型计算机断层显像与脑CT及MRI对持续植物状态患者脑血流灌注的观察

目的观察持续植物状态(persistent vegetative state,PVS)患者脑血流灌注情况,并以此判断高压氧综合治疗的效果分析.方法采用99Tcm-双半胱乙酰(99Tcm-ECD)单光子发射型计算机断层(simple porton emission computertomograph,SPECT)显像方法对26例不同病因所致的PVS患者进行了观察,9例随访60 d至3年,其中17例行脑CT,14例行脑MRI检查.结果26例PVS患者脑血流灌注全部显示异常,9例PVS患者显示部位与脑CT或MRI相符,9例不符.9例随访观察SPECT显示,6例随病情恢复,脑血流灌注亦恢复正常,另3例中,2例患者无明显变化,仍处于PVS,1例患者血流灌注进一步减少,3年后死亡.结论99Tcm-ECD脑SPECT显像检查安全可靠,可明确反映PVS患者脑血流灌注情况,弥补脑CT或MRI之不足,并可作为高压氧综合治疗PVS观察预后的指标.     

Intrathecal baclofen therapy: challenges in patients with multiple sclerosis.

Intrathecal baclofen (ITB) is a recognized therapy for severe spasticity of both spinal and cerebral origin, with documented positive clinical outcomes for many patients with multiple sclerosis (MS). This article reviews some specific considerations concerning the use of ITB in the MS population, based on the author's 10 years of clinical experience. The unpredictable and progressive nature of the disease affects the identification of appropriate goals, the patient's decision-making process, and the evaluation of the response to the treatment over time. Patients with MS may be more sensitive to intrathecal baclofen than patients with other diagnoses, and may need a lower dose for both the screening test and maintenance therapy. Subtle cognitive changes may affect the patient's ability to understand the education needed for successful management of ITB. Some practical strategies are offered for the nurse involved in the care of these patients in each stage of the therapy.     

中文版CRS-R量表的信效度研究

目的验证中文版本CRS-R量表在植物状态或最小意识状态患者评估中的信效度。方法应用中文版CRS-R量表与格拉斯哥量表对103例植物状态或最小意识状态患者的意识进行评估,分析中文版CRS-R量表的内部一致性、评定者间一致性、同时效度以及诊断敏感性。结果中文版CRS-R量表内部一致性比较好,Cronbach’sα系数=0.866;评定者间的一致性分析结果表现中等(P<0.05);对患者同时用中文版CRS-R量表和格拉斯哥量表的测评总分显著相关(Spearman r>0.7);在诊断的敏感性上表现较好(P<0.05)。结论植物状态或最小意识状态患者可采用中文版CRS-R量表评估。     

持续性植物状态患者护理的研究进展

持续性植物状态是患者脑严重损害后出现的一种没有感知的特殊意识状态,由于缺乏有效的治疗手段,给家庭、社会造成的负担极重。患者的照护主要依赖护理,难度大且问题繁杂,但是在临床实践中却缺乏相关指导,使得照护质量无法得到保证。该文从促醒护理、营养支持、并发症防治、家庭照顾者心理支持与健康教育方面综述了研究进展,为提高护理人员认知、构建临床护理规范和路径提供依据或参考。     

Improvement of sleep apnea in a patient with cerebral palsy.

Intrathecal baclofen (ITB) can reduce spasticity in adults and children with cerebral palsy. Benefits of ITB therapy include improved Ashworth scores, activities of daily living, and mobility. The impact of ITB therapy on sleep apnea in patients with cerebral palsy has not been reported. This case report describes a 29-yr-old female with mixed spastic athetoid quadriparetic cerebral palsy with dystonia, gross motor function IV, who had sleep apnea, requiring nightly continuous positive airway pressure. She received ITB with the goal to improve her wheelchair positioning and decrease her excessive movements. After the initiation of the ITB, reduction of her spasticity and dystonia was noted, as well as improvement of her sleep apnea. This case suggests that ITB therapy may improve respiratory function through reduction of respiratory muscle spasticity.     

Use of intrathecal baclofen in a pediatric cerebral palsy patient with refractory hemiplegia to maintain orthopaedic surgery gains

Spasticity, a common symptom accompanying cerebral palsy (CP), can severely affect patients' function and cause disability in childhood. Intrathecal baclofen (ITB) therapy is a widely used treatment to reduce spasticity in quadriparetic CP patients. Likewise, adults sustaining strokes and subsequent spastic hemiplegic have proven excellent candidates as well from ITB therapy. However, data on ITB treatment in pediatric patients with hemiplegic CP are lacking. This is the first report to present such a case. A nine-year old girl with spastic hemiplegic CP failed chemical denervation and serial casting of lower extremity spasticity and an associated equinovarus contracture. An ITB bolus test revealed an improvement in her Ashworth score from a mean of 2.8 to 1.2 on the involved side, whereas the unaffected side stayed constant from a mean of 1.3 to 1.2. The patient was subsequently treated with continuous ITB with improvement of Ashworth scores from a mean of 2.8 at baseline to 1.1 at 17 months after implantation of the ITB pump. Subsequent surgery was performed to correct the residual ankle deformity resulting in improvements in passive range of motion, gait function and brace tolerance. Hemiplegic CP pediatric patients can be successfully treated with ITB to reduce spasticity, improve function, and retain postoperative surgical correction without affecting the normal side.     

Patient experiences with intrathecal baclofen as a treatment for spasticity – a pilot study

Abstract

Purpose: This study describes how patients experience intrathecal baclofen (ITB) treatment. Methods: Data were collected from interviews with 14 patients (19–76 years old) who were diagnosed with spinal cord injury (SCI), multiple sclerosis (MS), or cerebral palsy (CP). Data were analyzed using conventional content analysis. Result: The analysis resulted in 16 subcategories arranged into five main categories: procedures before treatment, the effect of ITB on daily life and activities, continuous follow-up, expected and unexpected consequences of ITB, and overall level of satisfaction with ITB. Together these categories described the patients' experiences with ITB treatment. When the patients were asked whether they would undergo ITB again, they all stated that they would. Conclusion: Patients stated that they were highly satisfied with the ITB treatment. However, the patients identified several areas that could be improved. Specifically, the patients wanted more information about the different steps in the treatment process and what to expect from ITB treatment.

• Implications for Rehabilitation

• An overall satisfaction with the effect from ITB treatment was shown, but some areas still need to be improved.

• Complications following ITB treatment still remain a major concern for the patient group.

• Future clinical practice, should address how to take into account patients' expectations and define relevant goals with respect to ITB treatment as well as how to supply professional information.

     

A clinical study of intrathecal baclofen using a programmable pump for intractable spasticity

OBJECTIVE: To determine the impact of intrathecal baclofen (ITB) therapy on outcomes of functional independence, pain, subjective improvement, performance, and standard measures of spasticity. DESIGN: A noncomparative, multicenter, prospective cohort trial of patients with implanted pumps followed up over a 12-month period for the assessment of spasticity, pain, and function. SETTING: Twenty-four European centers of neurology or rehabilitation familiar with implantable pump technique participated. PARTICIPANTS: Patients with intractable spasticity (N=138) who responded positively to a trial dose of baclofen (n=133) and who began ITB therapy (n=129) were enrolled. INTERVENTION: Implantation of a Medtronic SynchroMed Infusion System with the administration of ITB therapy. MAIN OUTCOME MEASURES: Ashworth Scale assessment, Penn Spasm Frequency Scale scores, pain assessment, FIM instrument scores or WeeFIM scores for children, Canadian Occupational Performance Measure (COPM), and subjective ratings of overall relief were the tools administered. RESULTS: Muscle tone, spasm scores, and pain intensity reductions were observed. Overall FIM scores increased significantly in cognitive and motor function. COPM scores for both performance and satisfaction also improved significantly. Patients reported increased relief from pain and spasticity, supported by physician reports. Forty-three percent of patients reported adverse events, mostly related to patients' underlying conditions (20%), the device implant surgery (10%), or complications with the catheter (9%). CONCLUSIONS: ITB therapy using a programmable pump is clinically effective and well tolerated, despite a seemingly high level of adverse events, in patients with intractable spasticity of spinal or cerebral origin and may offer improvements in pain relief and function.