Summary
POSTURAL HYPOTENTION UNFAVORABLLY AFFECT A RECOVERY RESULTS IN PATIENTS WITH SPINAL CORD INJURY
Objectives: 1) to describe signs characteristic of orthostatic hypotention (OH); 2) to evaluate a effectivness of applied measures in these patients. Method: Cross - sectional and intervention progressive study have been carried out in 70 spinal cord injury (SCI) patients hoospitalized in BachMai Rehabilitation center. Results: 91,1 7% of them are of working ages. Mai / femal rate is approximatelly 4. Among them 48,6% had have a clinical symtoms and 82,35% with cerebral hypotentidn. In subjects with FIP there was 67.7% with paraplegia abc)ve T6; 70.69% of them were classified as ASIA A and B; 82.4% of them hadn't jet leaved their bad. The minimal blood pressure's diference is on midle value 18,03 mmHg. After rehabilitation programme the cerebral hypoinfusion signs had disapeared in 100% of patients. Recovery liiTie had depended on SCI severity. Conclusion: Having a patients early to get up and wear the plastic bandage had evidently affected in treatment of orthostatic hypotention.
Keywords: orthostatic hypotention; spinal cord injury, rehabilitation
DANH GIA KHA NANG DAP L/NG CUA TIM DOI VOil CAC BAI TAP VAN D O N G G A N G SL/C 6 BENH NHAN TAI BIEN MACH MAU
NAO DO HEP VAN HAI LA
Vu Huy Quang^ , Vu Thj Bich Hanh^
'Benh vien Dieu difdng Phuc hoi chifc nang Quang Ninh, "Tnfdng Dai hoc Y Tli Noi Itc'p v,in hai li (HHL) inh hddng den kha nang chiu ddng ging sdc, kel qui phuc hoi ciia benh nhin tai hien mach miu nio CI'BMMN). Muc tieu: Dinh gii kha ning dip dng cua tim benh nhin TBMMN do HHL doi vdi cic hii tip van ddng ging sifc. Doi tugng va phuang phap nghien ctfu: 34 henh nhin TBMMN do I tl II diiu Iri lai Vien Tim mach - Benh vien Bach Mai td thing 2/2008 den thing 8/2008 ddac lip ging sdc, ch nhip tim, thd vi huyel ip trddc va sau di bo, dem thdi gian di bd 10m, thdi gian di bo tdi da vi do quing dddng di tdi da. Kit qua: Tan sd tim vi nhjp thd trung binh cua benh nhin sau khi di bd 10m ting khoang 15 - 18"/,,, huyet ip tim thu vi huye't ip tim tnfdng trung binh cua benh nhan tang khoing 7 - 10°/o so vdi trddc khi di bd. Sau 20 ngiy tip Iuyen, van tdc di bd 10m, quang difdng di tdi da vi thdi gian di bd ting so vdi khi vio vien. Kit luan Cd sd thich dng cua tim mach ddi vdi tip Iuyen ging sdc sau 20 ngiy tip.
Td khoa: Tai bicn mach mau nao, hep van hai la, bai tap gang sue
I. DAT VAN DE k h i nang phuc hdi van ddng cua benh nhan sau HHF la benh van tim thifdng gap nhat d nflde T B M M N . Chinh vi vay ma. chifdng trinh tap Iuyen ta. Day IA mpt benh nang tien trien, ed nhieu chd benh nhan bj T B M M N dd FIHF chfla dflpe bien chflng ludn de doa tfnh mang cua benh thflc hien mpt each phu hdp. Vi vay, ehung tdi nhan. FIFIF I n h hifdng ra't nhieu den k h i nang nghien eflu de tai nay vdi muc tieu: Dan/j g/a/fha chiu dflng bai tap g i n g sflc, ket qua tap Iuyen va nang dap tfng cua tim benh nhan TBMMN do
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TCNCYH 71 (6J - 2010
HHL ddi vdi cac bai tap van dgng gang stfc.
II. DOI TUONG VA PHUdNG PHAP NGHIEN CL/U
1. Doi tUPng nghien cflu
34 benh nhan T B M M N do HHL dieu tri tai Vien Tim maeh - Benh vien Bach Mai trong khoang thdi gian tfl 02/2008 den 8/2008.
Ddi tflpng nghien cflu difpe Ifla chpn theo e l e tieu c h u i n sau;
Benh nhan bj benh lan dau (chfla can thiep neng van hdae thay van hai 11).
Benh nhan suy tim dp 1 - 2 thee N Y H A da difdc: die'm tri on dinh eae ehfle nang than kinh, tim mach, hd" hap trflde khi b i t dau can thiep phue hoi ehfle nang van dpng.
Benh nhan b i t dau di lai difde mpt each dec lap (10 - 15 diem thee thang diem Barthel d i n h gia k h i nang di ehuyen) vA chifa tham gia met ehfldng trinh phue hdi chflc nang nAd.
Benh nhan cd k h i nang giae tiep vA hdp tac vdi ngifdi tap vA ddng y tham gia ehfldng trlnh phue hdi ehfle nang il nha't 20 ngAy.
Fat ea cic benh nhan tren deu dflpe dieu trj bang thude ehdng ddng.
2. Phflpng phap nghien cflu: Can thiep ddi chflng trflde sau:
- Tham kham, chan d d l n xae djnh "FBMMN do HHF, mi'fc dp suy tim.
- Ficn hAnh danh gia kha nang d i p dng cua tim benh nhan ddi vdi eae bAi tap van dpng gang sflc ldc vao vien; (Do co Iflc benh nhan yeu va k h i nang thang bang dieu hpp kem nen ehdng tdi tien hanh d i n h gia k h i nang d i p flng eua tim benh nhan vdi bAi tap di bp tren nen b i n g phang). Khi thu thap so' lieu ehung tdi de BN thfle hien e l e npi dung sau;
-\- Benh nhan di bd 10m vdi van tdc te)'i da; l-)o nhip tim vA e l e trj so huyet ap tam thu, huyet I p tam trfldng, nhip thd trifdc vA sau khi thflc hie^n b l i tap. Ghi lai thdi ijiem.ngflng tap, tfl dd tfnh van td'c di bp 1 Om.
-I- Sau khi di bp lOm, ehdng tdi eho benh nhan nghi 30 phut rdi cho benh nhan di bp vdi thdi gian tdi da tdi khi hp ed e l m g i l c met nhieu, khd thd.
Dfla vao b l i tap dp dieu ehinh ehfldng trinh tap eua benh nhan vdi eae k h o i n g nghi sao cho benh nhan khdng cd e l m g i i e met khi tap. Mdi ngay tap mpt l l n , thdi gian tap tfl 30 - 60 phut, tdy thupe vao kha nang chju dflng eua ngifdi benh.
- Tien hanh danh gia lai k h i nang dap flng cua tim benh nhan ddi vdi e l e bAi tap van dpng gang sdc tren sau 20 ngAy tap Iuyen.
- Do nhjp tim (bang e l c h nghe tim dem nhjp) vA cac tri so' huyet ap tam thu, huyc'^'t ap tam trfldng, nhjp thd trflde vA sau khi thfle hien bAi tap. Ghi lai thdi diem ngflng tap, dd k h d i n g each tdi da ma benh nhan ee the di be dflpe.
3. PhUPng phap xfl ly sd lieu: Cac so lic^ii nghien eflu difde xfl ly tren may vi tinh theo phfldng phap thdng ke y hpe bang ehflpng trinh Epi - Infc 6.04 eua Td ehfle Y te Fhe gidi.
i n . K E T Q U A
1. Tinh hinh benh nhan
Cd 22 benh nhan nfl ehiem 64,7%; 12 t)enh nhan nam chiem 35,3%.
Tudi mac benh trung binh la 47,7 ± 10,1 (tudi). Dp tudi 40 - 59 (chiem 70,59%). Thdi gian tfl khi p h l t hien F1HF den khi bi FBMMN trung binh la 5,6 ± 3,9 nam.
Cd 29 benh nhan cd rung nhi (ehiem 85,3%).
22 benh nhan ed am eupn tfl nhien hoac huyet khdi d tam nhT trai vA tieu nhT trai (chiem 64,7%).
2. Dap flng ve mach, nhjp thd, huye't ap vdl bai tap gang siifc
Bang 1. Cac chi sd do trtfdc khi benh nhan thUc hien bai tap gang stfc (n - 34)
STT 1 2 3 4
Thong sd Tan sd tim (ck/p) Nhjp thd (ek/p)
Huyet I p tam thu (mmhlg) Huyet I p tam trfldng (mmHg)
Khi vao vien 86,15 ± 10,73
20,59 ± 1 , 7 1 113,82 ± 16,38
73,24 ± 1 1 , 7 3
Sau 20 ngay 80,32 ± 5,54 19,97 ± 0 , 7 6 '11 2,06 ± 14,36
73,38 ± 9 , 6 7
P
> 0 , 0 5
> 0 , 0 5
> 0 , 0 5
> 0 , 0 5 Nhan xet: 6 thdi diem vao vien va sau tap 20 ngay, tinh trang mach, huyit ip, nhjp thd tnfdc khi thifc hien bai lap khdng cd sd khie biet.
Bang 2. Cac chi sd do sau khi benh nhan di bg 10m (n = 34)
STT 1 2 3 , 4
5 6
Thong sd Tan s d t i m (ck/p) Nhjp thd (ck/p)
Huyet I p tam thu (mmHg) Huyet ap tam trifdng (mmHg) Thdi gian di bet 1 Om (s) Van tde di (m/s)
Khi vao vien X ± S D 1 02,24 ± 12,71
23,79 ± 1,07 121,91 ± 16,33 •
81,03 ± 10,36 45,56 ± 2 2 0,28 ± 0 , 1 4
Sau.20 ngay X + SD 95,74 ± 8,8 , 22,71 ± 0 , 9 1 2 0 ± 16,14 81,03 ± 9 , 0 3 37,35 ± 18,33
0,34 ± 0 , 1 7
P
< 0 , 0 5
< 0 , 0 5
> 0 , 0 5
> 0 , 0 5
< 0,05
< 0,05 Nhin xet: Sau lap di bo 20 ngay, tin sd tim,'nhjp thd giam; thdi gian di 10m giam; van td'c di 10m tang len mgt cich cd y nghTa.
Bang 3. Cac chi sd do sau khi benh nhan di bg vdi khoang each tdi da (n = 34)
STT 1 2 3 4 5 6
Thong sd T i n s d t i m (ck/p) Nhip thd (ek/p)
Huyet I p tam thu (mmHg) Eluyet I p tam trfldng (mmEIg) Quang dfldng di tdi da (m) Thdi gian di bp (s)
Khi vao v|en X ± S D 1 30,97 ± 13,9
27,27 ± 1 , 0 5 136,91 ± 16,14
89,71 ± 8 , 8 7 67,12 ± 4 2 , 9 8 253,38 ± 75,08
Sau 20 ngay X ± S D 123,97 ± 10,94
26,56 ± 0 , 9 3 132,94 ± 14,41
87,79 ± 7,71 101,82 ± 5 7 , 6 310,18 ± 6 5 , 9
P
< 0 , 0 5
< 0 , 0 5
> 0,05
> 0 , 0 5
< 0 , 0 5
< 0 , 0 5 7 V | n tde di (m/s) _ _ _ ^ 0,27 ± 0 , 1 4 0,33 ± 0 , 1 7 < 0,05 Nhin xet: Sau khi ging sifc (di bo cang xa cang tdt); cie ehi sd mach, nhjp thd giam cd y nghia; cdn quing difdng di tdi'da, thdi gian di tang len rd ret.
IV. B A N L U A N nhan T B M M N do HHL ed 12 nam (35,3%), 22 nfl Tinh hinh chung ve benh nhan (64,7%). Ty le nfl/nam la 1,83. Tudi mac benh Phan bd theo tudi va gidi: Trong 34 benh trung binh 47,7 ± 10,1 tuqi. Pham Gia K h I i va
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TCNCYH 71 (6J - 2010
edng sfl nghien eflu 169 benh nhan T B M M N do l)enh van tim c:6.60 nam (35,5%), 109 nfl (64,5%).
l y le nfl/nam la 1,82. Tudi mae benh trung binh la 46,9 + 11,9 tudi | 2 l . Treng nghien eflu eua Kanter. MC vA Sherman. DG thi benh nhan T B M M N dd benh van tim thfldng gap d Ifla tudi dfldi 50, nfl gidi bj benh nhieu hdn nam gidi [6].
Thdi gian phit hien hep van hai li den khi bj nhoi niiii nio: Fheo nghien cdu cua Nguyen Thi Dung, thdi gian tfl khi benh nhan biet bi HEIL de'n khi bj FBMMN trung binh la 8,7 ± 6,6 (nam) [1].
Cdn trong nghien eflu eua ehdng tdi thi khoang thdi gian nAy 11 5,6 ± 3,9 (nam).
Loai nhjp lim: Theo Wdlf P.A, rung nhf lam tang nguy ed T B M M N gap 5 l l n . Rung nhT do benh thap tim lam tang nguy ed t i e mach nao gap 17 lan |8|. Trong nghien eflu eua ehdng tdi, benh nhan T B M M N do HHL cd rung nhi (85,3%) eao hdn 5,8 lan sd vdi khi tim cdn nhip xoang (14,7%).
Tinh trang ddng m l u ; Ty le benh nhan cd huyet khdi vA am eupn tfl nhien trong tam nhT t r i i va tieu nhT trai chiem 64,7%. Ket q u i nghien cflu eua N g u y i n Thj Dung la (65,2%) [ I j .
Cac thong so cua nhom benh nhan nghien cu'u trflde tap
F i n so' tim, nhip thd, huyet ap t i m thu, huyet ap lam trifpng cua benh nhan trflde tap gifla hai l l n danh gia ed sfl khac biet nhflng khdng ed y nghTa thdng ke vdi p > 0,05.
Sao tap di bg 10m:
Chung tdi nhan thay ed sfl gia tang t i n so'tim trung binh va nhjp thd trung binh eua benh nhan khoang 15 - 18%, sfl gja tang huyet I p t i m thu trung binh va huyet I p t i m trflpng trung binh cua benh nhan so vdi trflde khi di bp 10m khoang 7 - 10%. Sau 20 ngay tap Iuyen, gia trj trung binh t i n sd tim, nhip thd, huyet ap t i m thu va huyet ap tam trifpng cua benh nhan khi di bp 10m giam so
vdi l l n d i n h gia khi vao vien. Sfl giam t i n sd tim va nhjp thd gifla hai l l n d i n h g i l c;d y nghTa thdng ke vdi p < 0,05.
Van tde di trung binh 10m cua benh nhan T B M M N trong nghien eflu cua Bohannon. RW la 0,39 ± 0,26 m/s [4], Suzuki.K la 0,32 ± 0,25 m/s [7], Brandstater. ME la 0,31 ± 0,21 (m/s) [5|, Pham Thi H I i Yen la 0,31 ± 0,19 m/s [31. Ke't qua nghien eflu eua chdng tdi eho tha'y benh nhan T B M M N do EIEIL cd van tde di trung binh 10m khi vao vien la 0,28 ± 0,14 m/s.
Sau 20 ngay tap Iuyen, van tde di trung binh 10m I I 0,34 ± 0 , 1 7 m/s. Ke't q u i d i n b gia cho t h i y sau 20 ngay tap Iuyen ed sfl cai thien rd ret ve van tdc di trung binh 10m so vdi l l n d i n h gia khi vao vien. Sfl k h i c biet ed y nghTa thdng ke vdi p < 0,05.
Sau tap di bg vdi khoang each tdi da:
Sfl gia tang t i n so' tim eua benh nhan van n l m trong ngfldng 60 - 8 0 % nhjp tim td'i da theo edng thfle tfnh nhjp tim an toan khi tap Iuyen. Sau 20 n g l y tap Iuyen, t i n s d t i m trung binh va nhip thd trung b i n b cua benh n h i n khi di bd giam so vdi lan d i n h g i l khi vao vien. Sfl giam nay ed y nghTa thd'ng ke vdi p < 0,05.
Sau 20 n g l y tap Iuyen, quang dfldng di trung binh, thdi giari di trung binh eua benh nhan khi di bp tang so vdi lan danh gia khi vao vien. Sfl khic biet cd y nghTa thdng ke vdi p < 0,05. Dieu nay chflng td cd sfl thich dng cua tim mach ddi vdi tap
Iuyen eung nhfl sfl phuc hdi van dpng cua benh nhan trong q u i trinh dieu trj.
V. KET LUAN
Dac diem nhdm benh nhan nghien ciJu:
T B M M N do HHL gap nhieu d nfl gidi (64,7%) so vdi nam gidi (35,3%), ty le nfl/nam la 1,83.
Tudi mac benh trung binh la 47,7 ± 1 0 , 1 tudi.
Khoang thdi gian tfl khi phat hien H H L den
khi bj TBMMN la 5,6 ± 3,9 nam.
85,3% benh nhan ed rung nhi. 6 4 , 7 % benh nhan cd am eupn tfl nhien hoac huye't khd'i d t i m nhT trai vA tieu nhT t r i i .
Kha nang dap iifng cua tim benh nhan TBMMN do hep van hai la ddi vdl cac bai tap van dong ging su'c:
-I- Tan s d t i m va nhip thd trung binh eua benh nhan sau khi di bp 10m tang k h o i n g 15.- 18%, con huyet ap tam thu va huyet I p tam trfldng trung binh cua benh nhan sau khi di bp 10m tang khoang 7 - 10% so vdi trflde khi di bd.
+ Khi di bd tren quang dfldng tdi da, sfl gia tang t i n sd tim eua benh nhan v i n nam d trong ngfldng 60 - 8 0 % nhjp tim tdi da nhfl theo cdng thdc tfnh nhip tim an toan khi tap Iuyen.
+ Cd sfl thich dng cua tim mach dd'i vdi tap luyen: sau 20 ngay tap luyen, van tde di bp 10m, quang dfldng di tdi da va thdi gian di bp tang ed y nghia so vdi khi vao vien.
TAI LIEU THAM KHAO
1. Nguyin Thj Dung (2005). Dac diem lam sang - can lam sang va dieu tri 46 benh nhan van tim do thap bi- tai bien mach mau nao tai Benh vien Viet - Tiep, Hai Phdng nam 2004. Tap ehi Y hpe Viet Nam sd 11/2005. 4 - 9.
2. Pham Gia Khai (2004). Tinh hinh lai bien mach m l u nao tai vien Tim maeh Viet Nam. Tap ehi Y hpe Viet Nam sd dac biet thang 8. 1 7 - 2 1 . 3. Pham Thi Hal Yen (2002). Nghien cdu mpt sd thay ddi ve dang di tren benh nhan Met nfla ngfldi sau tai bien mach mau nao vung ban c l u . Luan van tdt nghiep bac sy npi trd. Trfldng Dai hpe Y Ha Npi.
4. Bohannon RW (1987). Gait performance of hemiparetie stroke patients: selected variables.
Arch.Phys.Med and Rehab, 68, 777 - 7 8 1 .
5. Brandstater ME (1983). Hemiplegie gait:
Analysis of temporal variables. Arch.Phys.Med and Rehab, 64 (12), 5 8 3 - 587.
6. Kanter M C , Sherman DC (1992). Neurologi- cal aspects of cadiogenic embolism. Neurological medicine. Science - Thru - media, INC, New York, 5 2 7 - 5 3 1 .
7. Suzuki K, Nakamura R, Yamada Y (1994).
Deterininants of maximum walking speed in hemi- paretie stroke patients - influence of duration of gait training. Jpn. Rehabil Med. 3 1 , 339 - 345.
8. Wolf PA, Dawber TR, Thomas HE, Kannel WB (1978). Epidemiologic assessment of chronic atrial fibrillation and risk of stroke. The Framingham study. Neurology. 23, 973 - 977.
Summary
CARDIAC TOLERANCE CAPACITY TO STRESS EXCERSISES IN STIJOKE PATIENTS DUE TO MITRAL STENOSIS
The mitral stenosis much affect the tolerance capacity to stress, to rehabilitation results in cerebral vascular accident patients. Objectives: To assess the heart's tolerance capacity to stress exeersises in stroke patients due to mitral stenosis. Method: 34 stroke patients due to mitral stenosis in Institute of Cardiology - Baeh Mai Hospital (from 02/2008 to 8/2008) had been suffered from stress exercises. Heart rate, respiration rate and blood pressure before and after the walking had been measured. 10 - meters walking time, duration and maximum walking distance was calculated. Results: Average heart's and respiration's rates after 10m - warking had been increased 16 - 18%; average max and min blood pressures had been riscd up to 7 - 10% in compairing with moment before trainning. After 20day's trainning, the 10m warking speed, duration and maximum walking distance had been improved significantly. Conclusion;
There had been an adaptation of the heart tolerance to stress exercises after 20 days practice.
Keywords: stroke patients, mitral stenosis
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