脊髓损伤患者营养状况的研究进展

脊髓损伤患者的营养状况影响患者的康复及预后,未得到足够的重视,需要通过饮食控制及运动等联合措施来调节。此外,对医务人员的营养培训和对患者的营养教育都十分必要,医院的相关营养政策也应得到修订。目前关于脊髓损伤患者的营养评估标准还不健全,因脊髓损伤患者具有特殊性,对健康人群的评估标准并不适用,难以对营养不良进行早期发现。应利用评价量表、血液指标和皮肤皮褶厚度等建立适用于中国脊髓损伤患者的综合评估体系,并把营养评估作为日常管理的一部分。     

Nutrition in acute spinal cord injury

Nutrition in acute spinal cord injury is complicated. Not every aspect of nutrition as it relates to the acutely injured spinal cord patient is known. The stress response to injury, fever, infection, sepsis, and surgery alter nutritional needs, as does the spinal cord injury itself. The sequelae of spinal cord injury, including denervation atrophy and paralysis, glucose intolerance, skin and wound breakdown, poikilothermy, anemia, respiratory paralysis, pneumonia, paralytic ileus, gastrointestinal ulcers and hemorrhage, neurogenic bowel and bladder, and depression, all affect the nutritional needs of the patient. Orthopedic appliances, pharmacologic agents, and other injuries can also alter nutritional requirements. Nutritional assessment in acute spinal cord injury is also complex. It should include medical and diet history, physical examination, intake and output measurements, prediction of energy expenditure and protein requirements, or--even better--measurements of energy expenditure with indirect methodology, using the metabolic cart or pulmonary artery catheter. Application of computerized tomography and radioisotope studies may prove valuable in the future. Finally, the direct relationship between nutrition and physiologic alterations of acute spinal cord injury necessitates that the critical care nurse incorporate nutrition-focused thinking into many aspects of the acute spinal cord--injured patient's care.     

The Contribution of Group Learning to the Rehabilitation of Spinal Cord Injured Adults

This study, which involved both quantitative and qualitative methods, investigated the contribution of group learning to the rehabilitation of spinal cord injured adults. The views of spinal cord injured persons, their families, and professional nurses involved in spinal cord injury rehabilitation were compared. A telephone questionnaire that measured attitudes toward group learning and gathered demographic data was administered to 60 adults with spinal cord injuries in northern Illinois. Data analysis indicated a range of positive attitudes for all subjects. Personal interviews then were conducted with 8 spinal cord injured persons, 6 family members, and 8 rehabilitation nurses to compare perceptions about the effects of group learning. All those interviewed stated that contact among spinal cord injured persons is an important factor in adjustment to the injury. Positive attitudes toward group learning were communicated by all three subject groups. Motivation, sharing of experiences, camaraderie with and support from peers, and knowledge that they were not alone were identified as advantages of group learning.     

Closed head injury in spinal cord injured patients: retrospective study of loss of consciousness and post-traumatic amnesia

Previous studies of trauma-related spinal cord injured patients suggest that 25% to 50% of these patients sustain a concomitant cranio-cerebral trauma. A loss of consciousness (LOC) of 20 minutes' duration or a post-traumatic amnesia (PTA) lasting 24 hours has been associated with deficits in concentration, attention, memory, and higher-level cognitive functions. These may present as significant factors influencing learning and adaptation during and after the formal rehabilitation process. A systematic review was performed of the medical records of 101 trauma-related spinal cord injured patients who were admitted to Northwestern Memorial Hospital and the Rehabilitation Institute of Chicago within seven days of injury. The reported incidence of LOC and PTA in spinal cord injured patients was evaluated, and these data were compared with the level and etiology of injury, and with radiographic work-up, if any, for head injury. Eighty-seven percent of all emergency room admissions and 67% of all rehabilitation admissions were assessed for LOC. Fewer than 25% of all patients in both settings were assessed for PTA. Forty-two percent of all patients reported LOC, PTA, or both occurring simultaneously with the spinal cord injury. Assessment and incidence were unrelated to level of injury but were influenced by etiology. One-third of the patients who reported LOC, PTA, or both underwent further evaluation with computed tomographic (CT) scan or radiography of the skull. Assessment of LOC is conducted more consistently in the ER than in the rehabilitation setting. Assessment of PTA is performed infrequently despite its relevance to the rehabilitation process. Head injury may frequently be associated with traumatic spinal cord injury.(ABSTRACT TRUNCATED AT 250 WORDS)     

Functional improvement after pediatric spinal cord injury

OBJECTIVE: To describe the functional gain (FGain) with pediatric spinal cord injury inpatient rehabilitation and to identify the relationship of various factors to FGain in pediatric spinal cord injury inpatient rehabilitation. DESIGN: Retrospective chart review of a series of 91 children with spinal cord injury admitted from 1993 to 1998 in a freestanding rehabilitation hospital. Admission and discharge functional status were assessed with the Pediatric Functional Independence Measure (WeeFIM) instrument for children 7 yr. The outcome measure is the FGain (difference between the discharge and admission functional status). RESULTS: Significant gains in functional status were observed in all patients. FGain was not significantly related to age, sex, length of inpatient rehabilitation, pathogenesis, or completeness or neurologic level of injury. However, there was a trend for higher FGain for patients with incomplete spinal cord injury and traumatic spinal cord injury. CONCLUSIONS: Functional improvement occurs with pediatric spinal cord injury inpatient rehabilitation. There is a trend for higher FGain in patients with less severe injury and traumatic injury. The lack of relationship between FGain and length of inpatient rehabilitation suggests that a variety of other factors influence the relationship between FGain and length of inpatient rehabilitation.     

Discharge disposition from model spinal cord injury care system rehabilitation programs.

OBJECTIVE: To identify and quantify factors associated with discharge to a nursing home for people with spinal cord injuries. DESIGN: Case control within a cohort of spinal cord injured persons. SETTING: Model spinal cord injury care systems throughout the United States. PATIENTS: A total 16,633 patients consecutively discharged alive between 1973 and 1996 who were admitted to the model system within 1 year of injury, who were both injured in and resided in the catchment area of the model system, and who were discharged to either a nursing home or a community residence. MAIN OUTCOME MEASURE: Discharge disposition. RESULTS: Overall, 4.3% of patients were discharged to a nursing home. Factors that were significantly associated (p < .0001) with place of discharge were age, race, employment status at injury, bladder management method at discharge, education level, marital status, Frankel grade, functional independence in performing activities of daily living, independent ambulation, geographic region, neurologic level of injury, ventilator dependency, and third-party sponsor of rehabilitation. A multivariate predictive model was developed from these factors and was both 78% sensitive and specific in identifying patients who were discharged to a nursing home. CONCLUSIONS: Knowing the probability of nursing home placement can assist in evaluating the success of a rehabilitation program by allowing adjustment for case-mix differences across facilities.     

Intravenous pamidronate attenuates bone density loss after acute spinal cord injury

OBJECTIVE: To compare the effects of a 6-month treatment with intravenous pamidronate (30-mg infusion once per month) to conventional rehabilitation without pamidronate on bone density of the spine and leg bones and on the excretion rate of N-telopeptide, a urinary marker of bone catabolism, in acutely spinal cord injured patients. DESIGN: A nonrandomized control trial in which 24 spinal cord injured subjects entered the study within 6 weeks of their injury. Fourteen subjects received pamidronate; 10 did not. OUTCOME MEASURES: Bone density measurements by dual x-ray absorptiometry were performed before the initial treatment (within 6 weeks of the injury) and at 3, 6, and 12 months postinjury and was the primary efficacy parameter. Urine for N-telopeptide levels was the secondary efficacy parameter. RESULTS: After acute spinal cord injury, patients treated with intravenous pamidronate had significantly less bone density loss compared with those who did not receive pamidronate (parametric ANOVA, p<.02). Also, ambulatory subjects had significantly less bone density loss over the study period (p<.05) than nonambulatory subjects. In general, a high excretion level of the urinary bone-breakdown product N-telopeptide was found before intravenous pamidronate treatment, followed by a dramatic reduction in excretion after pamidronate treatment. Ambulatory subjects excreted significantly less N-telopeptide than motor-complete subjects at all time points. CONCLUSION: Intravenous pamidronate treatment and ambulatory ability in the first 6 months after an acute spinal cord injury prevents bone density loss.     

Mechanisms of increased passive compliance of hamstring muscle-tendon units after spinal cord injury

Background

People with spinal cord injury sometimes develop abnormally compliant hamstring muscle-tendon units. This study investigated whether the increased muscle-tendon compliance is due to a change in the passive properties of the muscle fascicles or tendons, or to muscle tears.

Methods

Semimembranosus muscle fascicle lengths were measured from ultrasound images obtained from 15 spinal cord injured subjects and 20 control subjects while the hip was passively flexed with the knee extended. Semimembranosus muscles of spinal cord injured subjects were inspected for tears using ultrasound imaging.

Findings

The mean (SD) hip angle at 30 Nm was 97 (SD 24) degrees in spinal cord injured subjects and 70 (SD 11) degrees in control subjects, indicating that spinal cord injured subjects had very compliant hamstring muscle-tendon units. The ratio of change in fascicle length to change in muscle-tendon length was not statistically different between spinal cord injured subjects and control subjects: muscle fascicles lengthened by 0.30 (SD 0.24) mm/mm in spinal cord injured subjects and 0.42 (SD 0.29) mm/mm in control subjects. These data were used to show that there was evidence of increased tendon compliance of spinal cord injured subjects compared to control subjects, but no evidence of increased muscle fascicle compliance. No tears were observed in semimembranosus muscles of spinal cord injured subjects.

Interpretation

The increased hamstring muscle-tendon compliance apparent in some spinal cord injured subjects is due, at least in part, to increased tendon compliance. There was no evidence that the increased muscle-tendon compliance was due to muscle tears.     

Malnutrition in the elderly: its recognition and treatment

Malnutrition plays a critical role in morbidity and mortality of the elderly. It is unacceptable to deny any patient, regardless of age, adequate nutrition when there are so many alternate methods of nutritional rehabilitation. Healthcare professionals must be concerned with the important role of nutritional therapy in the overall management of the elderly. It is extremely important to maintain the patient's nutritional status throughout periods of stress, disease, injury, and during periods of recovery. In developing a nutritional support plan, the clinician must consider the degree of malnutrition; the degree of hypermetabolism and specific organ dysfunction; the goals of nutritional therapy; and the route of nutrient delivery. The clinician must recognize the earliest signs of malnutrition and should be acquainted with the modalities of nutritional intervention to repair the deficit and prevent further deterioration. Another important consideration is that malnutrition is frequently a systemic manifestation of disease. Therapeutic nutritional support is cost-effective, reduces morbidity, and saves lives.     

Rehabilitation starts in the intensive care unit

Each year between 10 000 and 12 000 spinal cord injuries occur in the United States. Once injured, many of these patients will receive a portion of their care in an intensive care unit (ICU), where their treatment will begin. Harborview Medical Center in Seattle, Washington, provides comprehensive care to approximately 60 to 70 cervical spinal cord injuries each year. Because of many factors such as hemodynamic instability, pulmonary complications, and risk of infection, patients with cervical spinal cord injuries can spend up to 2 or more weeks in the ICU before they transfer to a rehabilitation unit. To achieve optimal outcomes, it is imperative that members of the interdisciplinary team work together in a consistent, goal-oriented, collaborative manner. This team includes physicians, nurses, respiratory therapists, physical and occupational therapists, speech pathologists, dieticians, and rehabilitation psychologists. An individual plan is developed for each patient and rehabilitation starts in the ICU as soon as the patient is medically stable. This article will highlight the management strategies used in the neuroscience ICU at Harborview Medical Center and will include a case study as an example of the typical experience for our patients with high cervical cord injury.     

Rehabilitation from the Other Side: A Patient's Perspective

Many rehabilitation nurses deal regularly with spinal cord injured patients, but rarely are those patients themselves nurses. This article offers a frank and realistic view of the rehabilitation process from the perspective of its author, a nurse who sustained a spinal cord injury in December 1977.     

Posttraumatic erectile potential of spinal cord injured men: how physiologic recordings supplement subjective reports.

OBJECTIVE: To investigate by means of a neurophysiologic model the remaining erectile function in spinal cord injured men. DESIGN: A nonrandomized control trial. SETTING: A Referred Care Center. SUBJECTS: Forty-seven spinal cord injured men and 7 noninjured controls. INTERVENTION: The subject penile responses were recorded by a penile strain gauge during two sessions--one to obtain baseline responses, and one with reflexogenic stimulation (masturbation) and psychogenic stimulation (film). MEASURES: Average tumescence, maximal tumescence, percentage rigidity, and duration of tumescence and rigidity. RESULTS: Significant results were found for subjects with lower lesions using psychogenic stimulation as their optimal mode compared with reflexogenic stimulation as an alternate mode, and for subjects with higher lesions using reflexogenic stimulation as their optimal mode, compared with psychogenic stimulation as an alternate mode. The responses with optimal stimulation modes were comparable to those achieved by controls. CONCLUSION: The findings validate the neurophysiologic model of posttraumatic erectile potential as a function of the lesion type and stimulation source. The results were comparable to those of noninjured subjects; the potential for normal function is present and may be amenable to sexual rehabilitation or use in conjunction with new oral drug treatments for impotence.     

干细胞治疗与运动性脊髓损伤

背景：截止目前仍难以找到一种良好的针对运动性脊髓损伤的治疗方法。随着干细胞技术的发展,应用干细胞技术治疗为运动性脊髓损伤修复带来了强大的潜力。目的：通过检索干细胞技术及其运动性脊髓损伤防治等方面的研究文献资料,探讨干细胞移植、干细胞神经营养因子以及基因修饰的干细胞疗法在脊髓损伤修复中的作用。方法：应用计算机检索PubMed数据库、万方数据库、维普数据库有关干细胞移植、干细胞神经营养因子以及基因修饰的干细胞疗法修复脊髓损伤的文章,英文检索时间为1987/2010,中文检索时间为1997/2010;英文检索词为＂stem cells,transplantation,neurotrophic factor,sports spinal cord injury,rehabilitation＂,中文检索词为＂干细胞;移植;神经营养因子;运动性脊髓损伤;康复治疗＂。排除重复性、陈旧的文献,共保留37篇文献进行综述。结果与结论：以干细胞所具有的移植性、迁移性、自我更新和多向分化潜能等的优势,将干细胞技术应用于运动性脊髓损伤的修复也已成为必然。但运动性脊髓损伤修复过程中,由于多种细胞因子和基因参与了调控,其基本机制还不清楚,因此仍需要对干细胞移植、诱导分化机制及其基因治疗和营养因子的作用等多方面进行深入的研究。     

中国热带海岛患者营养相关指标与压力性损伤风险的相关性研究

目的探讨中国热带海岛患者营养与压力性损伤风险的相关性,为压力性损伤集束化管理中个体化营养指导和定期监测的指标提供依据。方法2019年1-2月采取便利抽样法选取海南省某三级甲等医院住院患者1078例患者为研究对象,采用营养风险筛查表(nutritional risk screening2002,NRS-2002)及Braden压力性损伤评估量表对其进行调查,分析两者的相关性。结果是否有压力性损伤风险(NRS≤18分)的两组患者在营养风险(NRS≥3分)、体质量指数、上臂围、小腿围、血清白蛋白、水肿、ICU治疗、营养支持、过去3个月体重下降、过去1周摄入减少等方面差异有统计学意义(P<0.05);Logistics结果表明,小腿围是独立的保护因素,营养风险(NRS≥3分)、营养不良、水肿、ICU治疗、过去3个月体重下降是独立危险因素。结论对住院患者进行有效的营养及压力性损伤风险评估,警惕营养不良、ICU治疗、水肿患者,动态监控实验室指标和营养状态,有助于预防压力性损伤和营养不良的形成。     

骨髓间充质干细胞静脉移植脊髓损伤大鼠肿瘤坏死因子α及白细胞介素1β的表达

背景：研究认为间充质干细胞的营养支持在脊髓损伤治疗中起了主要作用,其同损伤宿主神经组织间的相互作用可导致一些不利于损伤修复的炎症因子表达减少。目的：观察大鼠骨髓间充质干细胞静脉注射移植对脊髓损伤后肿瘤坏死因子α、白细胞介素1β表达的影响。方法：运用改良Allen法制备大鼠T10脊髓外伤性截瘫模型,随机分为对照组和骨髓间充质干细胞移植组,设未损伤脊髓的假手术组做对照。骨髓间充质干细胞移植组、假手术组均接受大鼠骨髓间充质干细胞静脉注射移植,对照组静脉注射等量PBS。结果与结论：对照组和骨髓间充质干细胞移植组损伤脊髓肿瘤坏死因子α、白细胞介素1β蛋白表达较假手术组有明显增加（P〈0.05）;骨髓间充质干细胞移植组与对照组比较,肿瘤坏死因子α、白细胞介素1β蛋白表达受到明显抑制（P〈0.05）。提示大鼠骨髓间充质干细胞静脉移植后能使损伤脊髓局部的肿瘤坏死因子α、白细胞介素1β表达程度降低。这可能是改变脊髓损伤区的微环境,减少脊髓继发性损伤,促进损伤大鼠运动功能恢复的机制之一。     

脊髓损伤患者居家护理的干预及效果

目的探讨居家护理干预对脊髓损伤患者康复知识与技能的影响,以期改善脊髓损伤患者的生活质量。方法采用便利抽样法选择2010年4-10月广西桂林医学院附属医院辖区范围内、在本院康复科出院且便于随访的脊髓损伤患者38例,通过建立居家护理干预团队、及时对患者进行康复知识与技能的指导,对其实施居家护理干预;干预前后采用同一问卷测评患者康复知识及技能掌握情况、训练情况以及并发症发生情况。结果 36例患者通过居家护理干预,康复技能掌握情况及自我训练情况明显改善,并发症发生率明显减少(P0.01)。结论对脊髓损伤患者实施居家护理干预,能明显提高患者康复技能,促进其健康行为的养成,同时可降低并发症发生率。     

康复对颈髓损伤患者功能恢复的影响

目的探讨康复治疗对颈髓损伤患者功能恢复的影响。方法对92例脊髓损伤患者进行常规康复治疗,根据损伤部位分为颈髓损伤、胸髓损伤、腰髓损伤3组,治疗前后采用Barthel指数、功能独立性评定(FIM)进行评定。结果经过60～426d治疗后,3组患者的Barthel指数及FIM评分均有显著提高(P<0.001),三组间比较,腰髓损伤患者优于胸髓损伤,而胸髓损伤又优于颈髓损伤患者(P<0.05)。结论康复治疗能促进颈髓损伤患者的功能恢复,但效果不如胸、腰段脊髓损伤者。     

Human umbilical cord blood stem cells infusion in spinal cord injury: engraftment and beneficial influence on behavior

The use of human umbilical cord blood (hUCB)--a rich source of nonembryonic or adult stem cells--has recently been reported to ameliorate behavioral consequences of stroke. In this study, we tested whether human cord blood leukocytes also ameliorate behavioral impairments of spinal cord injury. Rats were divided into five groups: (1) laminectomy (without spinal cord injury) only; (2) laminectomy + cord blood infusion; (3) spinal cord injury + cord blood infused 1 day post injury; (4) spinal cord injury + cord blood infused 5 days post injury; and (5) spinal cord injury only. Spinal cord injury was induced by compressing the spinal cord for 1 min with an aneurysm clip calibrated to a closing pressure of 55 g. Open-field behavior was assessed 1, 2, and 3 weeks after intravenous injection of prelabeled human cord blood cells. Open-field test scores of spinal cord injured rats treated with human cord blood at 5 days were significantly improved as compared to scores of rats similarly injured but treated at day 1 as well as the otherwise untreated injured group. The results suggest that cord blood stem cells are beneficial in reversing the behavioral effects of spinal cord injury, even when infused 5 days after injury. Human cord blood-derived cells were observed in injured areas, but not in noninjured areas, of rat spinal cords, and were never seen in corresponding areas of spinal cord of noninjured animals. The results are consistent with the hypothesis that cord blood-derived stem cells migrate to and participate in the healing of neurological defects caused by traumatic assault.     

Spinal Cord Injury: The Relationship Between Time Out of Bed and Significant Events

This study evaluated time out of bed as (a) a means of documenting spinal cord patients' physical and psychological status and (b) a predictor of complications. Sixty spinal cord injured patients admitted to a physical rehabilitation hospital for comprehensive rehabilitation were subjects. An electronic device, the Rest Time Monitor (RTM), measured time spent out of bed. Medical records provided information on significant events. Patterns of time out of bed quantitatively documented the occurrence of several medical complications and emotional upsets. Patients who experienced infections spent less time out of bed prior to onset than did control patients. Time out of bed can be used by clinical staff and researchers to document the physical and psychological status of the patients and potentially to predict the onset of some complications.