踝关节矫正板站立训练对脑卒中患者踝关节痉挛及步行能力的影响

目的观察脑卒中踝关节痉挛患者行踝关节矫正板站立训练对踝关节痉挛及步行能力的影响。方法选取2012-07-09在我科诊治的存在踝关节痉挛的脑卒中患者40例,按随机数字表法分成对照组和治疗组,每组20例。2组均给予基础治疗:康复科脑卒中偏瘫常规治疗,包括神经发育疗法、主/被动牵伸、ADL训练、传统中医治疗等,同时对照组和治疗组分别行直接站立训练、踝关节矫正板站立训练。治疗前及治疗4周后采用改良Ashworth痉挛量表、Berg平衡量表(BBS)、踝关节活动角度、6min步行测试(6MWT)对患者进行康复评价。结果行踝关节矫正板站立训练患者的踝关节痉挛程度较直接站立训练的患者改善明显,且步行能力得以提高。结论踝关节矫正板站立训练可使脑卒中患者的踝关节痉挛程度明显降低,并提高其步行能力,较常规的直接站立训练更具优势。     

老年脑卒中患者慢性期康复效果调查：日本综合医院康复门诊与日间医院患者肢体功能比较

背景：有研究表明日间医院的康复服务与综合医院康复门诊比较,患者的功能和生活质量方面差异无显著性意义,但两者间有关脑卒中患者慢性期肢体功能的差异及其影响因素却少有报道。 目的：比较日本老年脑卒中患者慢性期分别在综合医院康复门诊和日间医院康复期间的肢体功能差异,分析影响功能差异的相关因素,以便改进老年脑卒中患者康复方案。 方法：分别对医院门诊和日间医院进行康复训练的老年脑卒中患者119例(年龄60~75岁)实施为期1年的调查分析,比较两组入选时和1年后的肢体功能指标的差异,包括健侧和偏瘫侧的股四头肌肌力、患侧膝关节伸展和踝关节背屈的关节活动度和10 m步行时间。采用逐步回归分析确定影响肢体功能指标变化的显著因素。 结果与结论：医院门诊组患者肢体健侧和偏瘫侧股四头肌肌力在入选时和1年后均大于日间医院组(P < 0.05),而两组的10 m步行时间差异均无显著性意义。医院门诊组在入选时患者患侧膝关节伸展和踝关节背屈关节活动度均小于日间医院组(P < 0.05),而1年后两组以上指标比较差异无显著性意义。逐步回归分析结果显示入选时健侧和偏瘫侧股四头肌肌力、患侧膝关节伸展和踝关节背屈关节活动度是其各自功能指标变化的显著影响因素,而偏瘫侧膝关节伸展、踝关节背屈的关节活动度越受限的患者,训练的效果越好。因此,日间医院组需要采取针对性的肌力增强或维持训练和膝关节活动度训练。     

偏瘫早期康复基础训练疗效观察

目的 探讨偏瘫早期康复基础训练对急性脑卒中患者并发症发生率和患肢功能恢复程度的影响.方法 选择急性脑卒中偏瘫患者88例,随机分成2组,对照组进行常规药物治疗,康复组除药物治疗同时给予康复基础训练.结果 康复组在肢体痉挛、肩关节半脱位、肩关节痛、足下垂内翻、废用综合征的发生及患肢功能恢复程度与对照组存在明显差异.结论 早期对偏瘫患者实施基础康复训练有利于降低脑卒中患者并发症的发生,能够改善偏瘫肢体功能,降低致残率,提高生存质量.     

下肢康复机器人训练对脑卒中偏瘫患者下肢运动功能的康复作用

目的探讨下肢康复机器人训练对脑卒中偏瘫患者下肢运动功能的康复作用。方法共60例发病6个月的脑卒中偏瘫患者随机接受常规康复训练联合减重步行训练(BWSTT组,30例)或常规康复训练联合下肢康复机器人训练(Robot组,30例),分别于训练前和训练8周时采用Fugl-Meyer下肢评价量表(FMA-LE)评价下肢运动功能、Berg平衡量表(BBS)评价平衡功能、下肢康复机器人力矩反馈系统评价下肢肌力。结果与训练前相比,两组患者训练8周时FMA-LE(P=0.000)和BBS(P=0.000)评分、步态周期中患侧髋关节(P=0.000)和膝关节(P=0.000)反馈力矩值均增加;与BWSTT组相比,训练8周时Robot组仅步态周期中患侧髋关节(P=0.000)和膝关节(P=0.000)反馈力矩值增加。结论常规康复训练联合减重步行训练和下肢康复机器人训练均可以改善脑卒中偏瘫患者下肢运动功能,下肢康复机器人训练在提高下肢肌力方面优于减重步行训练。     

3D打印膝踝足矫形器改善早期脑卒中患者步行功能的研究

目的：观察3D打印膝踝足矫形器(knee ankle foot orthosis,KAFO)对脑卒中后2周～3个月偏瘫患者步行功能的影响。方法：纳入2018年1月1日—2020年7月31日符合病例选择标准的脑卒中后偏瘫患者30例,按照随机数字表法将其随机分为对照组1,对照组2及观察组,每组各10例。在常规原发病治疗以及康复治疗基础上,3组患者均在站立及步行训练时全程佩戴矫形器。对照组1佩戴传统踝足矫形器(ankle foot orthosis,AFO),对照组2佩戴传统KAFO,观察组佩戴3D打印KAFO。3组患者均接受4周的康复治疗,治疗前后采用10 m步行测试(10-meter walk test,10-MWT)、6 min步行测试(6-minute walk test,6-MWT)、下肢Fugl-Meyer运动能力评估量表、Berg平衡量表进行评估,并测量治疗前后的足间隙数值。结果：3组患者治疗前10-MWT、6-MWT、Fugl-Meyer运动能力评分、Berg平衡量表评分、足间隙数值的差异均无统计学意义(P0.05)。治疗4周后,与治疗前相比,3组患者的10-MWT较前缩短(P0.01),6-MWT较前增加(P0.01),Fugl-Meyer运动功能评分较前增加(P0.05),Berg平衡量表评分较前增加(P0.05),足间隙较前增加(P0.05)。组间比较,观察组上述指标均优于2个对照组(P0.05)。结论：3D打印KAFO可以增强下肢运动能力,改善平衡功能,降低患者的跌倒风险,进而提高步行速度及耐力,优化康复治疗。     

痉挛肌治疗仪治疗痉挛型脑瘫患儿踝趾屈肌群痉挛临床观察

目的观察痉挛肌治疗仪对尖足痉挛型脑瘫患儿踝关节改善角度的作用。方法将符合入选标准的痉挛型脑性瘫痪患儿按就诊时间、性别随机分为2组：治疗组（痉挛肌治疗仪加综合康复治疗组）和对照组（综合康复治疗组）,连续治疗3个月,治疗前和治疗结束后分别以足背屈角改善角度作为评估指标进行评估。结果痉挛肌治疗组患儿踝关节改善角度明显高于对照组（P〈0．05）。结论痉挛肌治疗仪可以辅助降低踝趾屈肌群痉挛,明显改善踝关节活动度,从而可以改善痉挛型脑瘫患儿的站立、行走模式,是脑性瘫痪患儿安全、有效的临床康复治疗手段之一。     

肌电生物反馈联合康复训练对脑卒中偏瘫患者下肢运动功能的影响

目的探讨肌电生物反馈治疗联合康复训练对脑卒中偏瘫患者下肢运动功能的影响。方法将60例脑卒中偏瘫患者分为对照组(30例)和治疗组(30例)。两组均给予神经内科药物及康复训练,治疗组同时增加患侧下肢肌电生物反馈训练。同一治疗师分别于治疗前和治疗4 w后评定两组患者Fugl-Meyer下肢运动功能评分(FMA-L)、改良Barthel指数(MBI)、Fugl-Meyer平衡功能评分、胫前肌最大收缩时肌电积分(i EMG)值,并进行统计学分析比较。结果治疗前,两组患者各项指标组间比较,差异无统计学意义(P>0.05);治疗后,两组治疗前后比较均有显著性差异(P<0.01);治疗组4 w后Fugl-Meyer下肢运动功能评分、MBI、Fugl-Meyer平衡功能评分和i EMG值恢复优于对照组(P<0.05、P<0.01)。结论肌电生物反馈治疗能明显改善偏瘫患者下肢运动功能。     

弹性悬带矫形器对偏瘫患者步行功能的影响

目的 评价新型弹力悬带矫形器对患者下肢运动功能及步行功能恢复的效果。方法 28例卒中后偏瘫患者随机被纳入康复治疗组（对照组）和弹力悬带矫形器治疗组（治疗组）,对照组在治疗师指导下进行常规康复训练,治疗组在常规康复训练的基础上佩带弹力悬带矫形器进行步行训练,连续治疗8周。分别于治疗前,治疗后4周和治疗后8周由同一个治疗师对下肢运动功能评分（Fugl-Meyer,FMA）、能量消耗指数（physical consume index,PCI）及包括10 m舒适步行速度和10 m快速步行速度、步频、步长、足偏角、步基宽在内的步态时空参数进行评测,并比较上述指标在治疗前后的变化,观察弹力悬带矫形器的作用效果。结果 治疗4周后,治疗组和对照组10 m舒适步行速度和10 m快速步行速度、步长、步频较治疗前提高（均P＜0.01）,步基宽、PCI较治疗前降低（均P＜0.01）;2组FMA和足偏角治疗前后差异无统计学意义。治疗后治疗组10 m舒适步行速度和10 m快速步行速度、步长较对照组明显提高（P =0.0298,0.0225,0.025）,步基宽、PCI较对照组明显降低（P =0.001,0.026）;2组步频、FMA和足偏角比较差异无统计学意义。治疗8周后,治疗组和对照组的10 m舒适步行速度和10 m快速步行速度、步长、步频及FMA评分较治疗前提高（均P＜0.01）,步基宽、PCI较治疗前降低（均P＜0.01）;2组足偏角治疗前后差异无统计学意义。治疗后治疗组10 m舒适步行速度和10 m快速步行速度、步长、步频及FMA评分较对照组明显提高（P =0.042、0.015,0.024,0.024,0.038）,步基宽、PCI较对照组明显降低（均P＜0.01）;2组足偏角比较差异无统计学意义。结论 早期使用弹力带矫形器可以纠正偏瘫患者的异常步态,提高步行速度,降低能量消耗,促进步行功能恢复。     

督导员介入在脑卒中偏瘫患者康复护理中的作用

目的探讨康复督导员在脑卒中偏瘫患者康复护理中功能恢复的作用。方法将72例符合入选标准的脑卒中偏瘫患者采用分层随机的方法分为常规护理组(36例)和督导员介入护理组(36例),护理前(0周)、干预护理8周对2组患者由同一康复督导员分别进行偏瘫肢体运动功能、日常生活活动能力和移动能力评定。结果治疗8周后,督导员介入组与常规对照组比较,患侧下肢FMA评分、MBI评分和EMS评分均有明显提高。结论康复督导员在脑卒中偏瘫患者康复护理中能有效提高康复训练及护理效果。     

前置式与后置式踝足矫形器对脑卒中患者步行功能恢复的影响

目的观察前置式与后置式踝足矫形器对脑卒中患者步行功能恢复的影响。方法将52例脑卒中患者随机分为前置组26例和后置组26例。前置组佩戴前置式踝足矫形器,后置组佩戴后置式踝足矫形器。观察指标为恢复至扶拐步行时间,恢复至独立步行时间,3个月时10m最大步行速度和Barthel指数。结果前置组恢复至扶拐步行时间（13．8±8．3）d较后置组（15．3±7．9）d快（P〈0．05）。前置组恢复至独立步行时间（27．4±14．9）d较后置组（35．9±18．0）d快（P〈0．05）。前置组10m最大步行速度（41．5士12．8）m／min较后置组（35．7±13．3）m／min快（P〈0．05）;前置组与后置组3个月时Barthel指数无显著差异（P〉0．05）。结论前置式踝足矫形器与后置式踝足矫形器相比,可加快脑卒中患者步行功能的恢复。     

Hepatic Considerations in the Use of Antiepileptic Drugs

Summary: Virtually all of the major antiepileptic drugs (AEDs) can cause hepatotoxicity, although fatal hepatic reactions are rare. The mechanisms, incidences, and risk profiles for such reactions differ from drug to drug. With carbamazepine and phenytoin, hepatotoxicity may be due to drug hypersensitivity. Although the profiles of patients at risk have not been well-defined for these two antiepileptic drugs, it would appear from reports in the literature that older adolescents and adults are at higher risk than children of developing serious or fatal hepatotoxicity. Once hepatotoxicity develops, mortality rates are 10–38% with phenytoin and 25% for carbamazepine. The risk profile for valproate fatal hepatotoxicity has been more clearly defined. Those at primary risk of fatal hepatic dysfunction are children under the age of 2 years who are receiving multiple anticonvulsants and also have significant medical problems in addition to severe epilepsy. The risk is considerably lower for patients over the age of 2 years on valproate monotherapy. In contrast to the risk profile with other AEDs, adults receiving valproate as monotherapy have the lowest risk of hepatotoxicity. Fatal hepatic dysfunction coincident with valproate may be the result of aberrant drug metabolism. Concomitant use of AEDs that induce microsomal P450 enzymes (e.g., phenytoin and phenobarbital) may enhance the production of a toxic metabolite, and hence the greater risk of hepatotoxicity with polypharmacy.     

Vascular Malformations and Epilepsy: Clinical Considerations and Basic Mechanisms

Summary: Vascular malformations (VMs) are associated with epilepsy. The natural history of the various VMs, clinical presentation, and tendency to provoke epilepsy determine treatment strategies. Investigations have probed the mechanisms of epileptogenesis associated with these lesions. Electrophysiologic changes are associated with epileptogenic cortex adjacent to VMs. Putative pathophysiologic mechanisms of epileptogenesis include neuronal cell loss, glial proliferation and abnormal glial physiology, altered neurotransmitter levels, free radical formation, and aberrant second messenger physiology.     

Diagnostic Difficulties and Treatment Implications

Summary: Differentiation between types of epileptic seizures has been aided in recent years by the introduction of intensive neurodiagnostic techniques and the development of increasingly detailed classification systems. Paradoxically, these developments have not simplified the task of matching the appropriate antiepileptic drug to a particular seizure type. It is reasonable to assume that anticonvulsant drugs will have different effects on different types of seizures, but faulty, circular reasoning can enter the picture if one also assumes that responses of seizures to different drugs signify different seizure types. There are several examples of differential diagnoses that can fall prey to this problem, including the diagnosis between partial seizures with secondary generalization and generalized tonic-clonic seizures, and the diagnosis between complex partial seizures and absence seizures with automatisms, among others. Considerations of etiology in future classification systems can further complicate the problem: should one then choose an anticonvulsant drug on the basis of individual seizure type or on the basis of the type of epilepsy? Ramifications of this issue extend even to the drug approval process. Official sanction is not given for use of a drug for a seizure type not included in the original efficacy studies, even if later scientific evidence shows that seizure type to be related to a type that is included. New trials must be undertaken. These problems arise from how we choose to classify seizures.     

Cognitive Dysfunction Associated with Antiepileptic Drug Therapy

Summary: Epilepsy is frequently associated with cognitive dysfunction. However, the reasons for this correlation are unclear. Possible influential factors include patient age; duration, frequency, etiology, and type of seizures; hereditary factors; psychosocial issues; and antiepileptic drug (AED) therapy. Whereas many of these factors are beyond the physician's control, AED therapy is one element that can be addressed in treatment decisions by recognizing the potential cognitive effects of particular AEDs. For example, phenobarbital impairs memory and concentration; phenytoin affects attention, problem solving ability, and performance of visuomotor tasks. In contrast, carbamazepine may affect concentration, while valproate would appear to have minimal effects on cognition. Moreover, cognitive effects of AEDs are amplified with coadministration of multiple anticonvulsants (polytherapy). A review of studies on the cognitive effects of monotherapy with AEDs, as opposed to those of polytherapy, provides evidence that drug-related cognitive dysfunction can be reversed if patients are switched to a simpler therapeutic regimen. Future research should be directed toward developing reliable measures for assessing and monitoring cognition, and understanding the particular cognitive side effects of each AED. Physicians also need to revise their opinions about which side effects are "tolerable" for epileptic patients.     

Epilepsy and anomalies of neuronal migration: MRI and clinical aspects

Neuronal migration disorders are the result of disturbed brain development. In such disorders, neurons are abnormally located. In diagnosing these conditions, magnetic resonance imaging is superior to any other imaging technique. This enables us to improve our knowledge of the clinical correlates of neuronal migration. With reference to migrational disorder, a retrospective study of all 303 patients with epileptic seizures referred for magnetic resonance imaging during a 3-year period was performed, 13 patients (aged 12-41, mean age 27) were identified. They represent 4.3% of the entire study group. Of the patients with known epilepsy, 6.7% and of the mentally retarded, 13.7% had migrational disorders. Four patients had schizencephaly as the dominant finding, one was classified as hemimegalencephaly, 2 had isolated heterotopias, and 6 had localized pachy- and/or poly-microgyria. The clinical pictures are complex. Ectopias of grey matter are recognised foci of epilepsy, but from an epileptological and a clinical viewpoint little attention has been given to these disorders. The present study shows that malmigration is not rare in epilepsy patients, especially not in the mentally retarded.     

Carbamazepine Efficacy and Utilization in Children

Summary: Carbamazepine is effective for preventing partial and generalized tonic-clonic seizures in children. Although absence epilepsies are more common in children than adults, an estimated 80% of children with epilepsy have seizure types or epilepsies that are potentially responsive to carbamazepine. The differential diagnosis of ictal staring is an especially important issue in children because absence and atypical absence seizures are more prevalent in children than adults. Age-related pharmacokinetic differences and drug interactions are major considerations in children. On average, children have higher clearance rates of carbamazepine, shorter half-lives, and higher ratios of carbamazepine-10, 11-epoxide to carbamazepine than adults. In addition, children with severe epilepsy are more likely to require multiple-drug therapy, which can lead to complex drug interactions. When carbamazepine is administered along with valproate, drug protein binding interactions can cause intermittent side effects.     

Carbamazepine Efficacy in Adults With Partial and Generalized Tonic-Clonic Seizures

Summary: Carbamazepine and phenytoin are drugs of choice in initial monotherapy for adult partial and secondarily generalized tonic-clonic seizures. These designations reflect the results of the Veterans Administration Epilepsy Cooperative Study Group of 1985. An earlier comparative study of carbamazepine and phenytoin by Ramsay and associates found both drugs equally effective in controlling new-onset seizures. Among the advantages of carbamazepine is that it causes relatively few cognitive and dysmorphic side effects. Its disadvantages are its unavailability in parenteral formulation and its metabolic autoinduction. The latter must be compensated for by planned dosage increases to maintain therapeutic plasma steady-state levels during the first 2 or 3 months of treatment. Carbamazepine is judged a drug of choice in the treatment of these secondarily generalized tonic-clonic seizures, and the drug of choice in children, adolescents, and women susceptible to the dysmorphic side effects associated with other anticonvulsant agents.     

Etiologic and Preventive Aspects of Epilepsy in the Child–Bridging the Gap Between Laboratory and Clinic

Summary: Four broad categories of basic phenomena are pertinent to developing ways to prevent epilepsy. These include mechanisms of epileptogenesis, ictal initiation and temporary entrainment by the seizure discharge of normally functioning brain, seizure propagation, and control mechanisms that function both to restrain the cascade of epileptic events culminating in a seizure and to arrest the epileptic event and restore the interictal state. In newborns and children, hypoxia-ischemia is a major factor leading to epileptogenesis, and several schemes are proposed to classify, quantify, and prevent hypoxic-ischemic encephalopathy. Control mechanisms must be better understood in order to develop prophylactic recommendations for epilepsy, and an experimental model of "kindling antagonism" may increase our understanding of these. Programs of prevention of seizures in children will evolve only if basic researchers and clinicians work productively together to develop an adequate understanding of factors important in epileptogenesis and antiepileptogenic control mechanisms.     

Predisposing and Causative Factors in Childhood Epilepsy

Summary: We review information from large studies of defined populations, examining the role of known factors and especially of prenatal and perinatal factors in contributing to nonfebrile seizure disorders of early childhood. We depend especially, but not exclusively, on the recently completed analyses from the Collaborative Perinatal Project of the National Institute of Neurological and Communicative Disorders and Stroke, the NCPP. About 4% of children in the NCPP who had at least one non-febrile nonsymptomatic seizure by the age of 7 years had a previous seizure during acute neurologic illness, such as meningitis or during the acute illness after trauma. Many such seizures should potentially be preventable. Of children with seizures, 10% had had a neonatal seizure and 13% had had a febrile seizure. Among the hundreds of prenatal and perinatal factors explored as predictors of childhood seizure disorders, the principal predictors identified were congenital malformations of the fetus, cerebral and noncerebral; family history of certain neurologic disorders; and neonatal seizures. In agreement with the British National Child Development Study, labor and delivery factors in the NCPP appeared to contribute very little to childhood seizure disorders. Maldevelopment, rather than damage at birth to an initially intact nervous system, appeared to be the more common mechanism. Most seizure disorders of early childhood remained unexplained by the large set of prenatal and perinatal characteristics examined.     

Classification of methods in transcranial Electrical Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations

Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.