Khoa hoc Gi cdng nghe
NGHIEN CUU Hieu QUA PHUC HOI CHUC NANG TOAN DIEN CHO NGUOI B^NH SAU TAI BIEN MACH M A U N A O TAI THANH PHO DA NANG
Chd nhifm dl tfli: BS.CKII. NGUVfeN TAN D Q N G Co quan chd tri dl ttfi: Bfinh vifin C Dtf Ntfng L DAT VAN Bt:
Tai biln mgch mtfu nao (TBMMN) da vtf dang Itf vtfn dl thtfi sy cap thilt cda y hpe ntfi ehung vtf phye htfi chuc nflng (PHCN) ntfi rifing dtfi vtfi mpi qutfc gia, mpi dtfn tOc. TBMMN ctf thl gfly ttt vong nhanh chtfng hofle dl lgi nhilu di chttng nflng nl dfln din giam chtte nflng vtf ttfn ttft nhilu nhtft. Hifip hOi Tim mgch Hoa KJ utfc tinh hflng nflm ctf khoang tren 700.000 ngutfi mtfc TBMMN, ban 160.000 ngutfi chit vi TBMMN vtfi khotfng 4,8 trifu ngutfi stfng stft sau TNMMN, phan Itfn trong stf hp yfiu cflu cham stfc, dilu tri lau dtfi. Dfly Itf mtft gtfnh nang cho chinh bfln thfln bfinh nhfln, gia dinh vtf xfl hOi. Sau TBMMN 3 thtfng, 20% stf bfinh nhan TBMMN vfln phai nflm tai vifin, tCr 15-30% bi tan tflt vinh vifin. Tdng chi phi chung tf Hoa Ky cho TBMMN ltf 53,6 tJ dO Ia/1 ntfm.
Tgi Viet Nam, TBMMN dang cd ehilu hutfng gia tang cutfp di sinh mang eua nhilu ngutfi hofle de Iai di ehdng ntfng nl. Theo stf' lifiu cua Bo mOn Thfln kinh Trutfng Dgi hpc Y Htf NOi ty If mtfi mflc tf miln Btfc vtf miln Trung ltf 152/100.000 dtfn, ty If tu vong 21,55%. Theo nghifin cuu eda Nguyen Vfln Trifu, Nguyin Xufln Nghien, Cao Minh Chflu tf tinh Htfi Duong, ty If tu vong trong vtfng I nSm dflu tien Itf 40%, etf tren 50% stf ngutfi sau
TBMMN stf'ng stft bi ttfn Iflt tf mttc do nflng vtf vtta. O miln Nam, tlieo btfo ctfo eua BO mOn Thfln kinh trutfng Dai hpc Y Duge TP.
Htf Chi Minh nflm 1995, tJ If mtfi mflc Itf 161/100.000 dtfn, ty If td vong 28%. Stf bfinh nhfln stfng sot sau tai biln ctf di chung vtta vtf nhe 68,42%.
Bfnh nhan TBMMN thupc loai da ttfn tat VI ngotfi kha nflng vfln dOng bfinh nhfln ctfn eo nhilu rO'i logn khac kem theo nhu rO'i loan vl ngOn ngtt, thi giflc, cam giac, nhfln thtte.
Mot vln dl quan trpng hifn nay la chtft iugng cupe stfng (CLCS) cda nhttng ngutfi sau TBMMN tai cOng dong. Chat lugng euOc sdng sau TBMMN bao gtfm 4 vln di Itfn: sttc khoe thl ehtft, sue khoe ehue nflng, phuang difn tflm IJ vfl xa hOi* Nghien cdii chl^t Iugng euOc stfng se gidp ehdng ta btte tranh tofln difn vl su phyc htfi cda ngutfi bfnh. Bilt dugc ctfc ylu ttf lien quan din chat lugng euOc stfng eda ngutfi bfnh se giup chung ta dua ra ctfc chiln luge dl nang cao chit Iugng cutfc stf'ng cua ngirtfi bfnh. d nutfc ngotfi, ngutfi ta dfl nghien cttu khtf nhilu vl vln dl ntfy. Tuy nhien tf Vift Nam, chung ta mtfi etf mOt nghifin ettu vl mtft stf khia canh don le lien quan din ehtft Iugng cuOc stfng eua ngtrtfi bfinh. Han ntta, mtft chuang trinh phuc htfi chtte ntfng totfn difn dl Itfm gitfm ttfi da ctfc di chttng, stfm dua
ngutfi bfnh trtf lgi cutfc stfng dtfc Iflp eda ho tgi gia dinh vtf gidp hp ttfi hoi nhtfp cOng ddng, cfli thifn ehtft lugng euOc sdng cho bfnh nhan Itf rtft cfln thilt vfl ctfp btfeh hifn nay. Xutft phtft ttt thye tl Ifl tinh ctfp thilt eda vln dl, chdng toi tiln htfnh nghifin cuu nfly nhflm dem lgi lai ich thilt thye cho ngutfi bfinh vtf xa hpi.
II. MUC Tl£U NGHlfiN CUU:
1. Muc tieu chung:
Nghifin ettu thyc trgng chit Iugng cuOe stfng va tfp dung mO hinh phuc htfi chirc nang toan difn trong nang cao chat lugng cuOc stfng eua nguoi bfnh sau TBMMN tai thtfnh phtf Dtf Nflng.
2. Muc tieu cu the:
Mtf ttf thyc trgng chat lugng cuOe stfng vfl mOt sd ylu ttf anh huong din chtft lugng cuOc sdng eda nhttng ngutfi sau TBMMN tai eOng ddng.
Dtfnh gia butfc dflu hifu qufl ttng dyng md hinh phue hoi chtte nflng tofln difn trong vific nflng eao chit lugng cutfc stf'ng cfla ngutfi bfinh sau TBMMN tai ctfng dtfng.
III. N O I D U N G NGHlfiN
ciru:
MO ta thue trang efla ngutfi bfnh sau TBMMN: khilm khuyit, dtfc lflp chtte ntfng, mttc dtf giflm kha nflng vtf chtft lugng cuOe sdng vl sttc khoe thl chtft, sttc khtfe chtte ntfng, phuong difin ttfm IJ va xa hoi.
Khoa hoc ra
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K h o a hoc S. cong nghe
Dtfnh gia mO'i lifin hf cfla mtft stf ylu ltf- nhu tudi, gitfi, nu're dtf khilm khuyit thtfn kinh, suy giflm nhfln Ihuc, ngtfn ngtt, rO'i logn eg trtfn, nuO'l khtf vtf trflm c.im vtfi dtfe Iflp ehire nflng cflc hogt dtfng sinh hogt htfng ngtfy, giflm khfl nflng cfla ngutfi bfnh sau TBMMN mtft nflm.
Dtfnh gifl intf'i Hfin hf cfla mtft stf ylu tO: nhu tutfi. gitfi, noi tf, nghl nghifp, irinh dtf vfln htfa, htfn nhtfn, hotfn cflnh kinh ll, mtfi trutfng stf'ng, chflm stfc gia dinh, y ll. PHCN, dtfi stf'ng linh due, mde dp khilm khuyit thfln kinh. suy giam nhfln thttc. ngOn ngtt, rtfi logn ca iron, nudt klid. mil ehd y, dOc lflp chtte nflng vtf trflm cflm vtfi chit lugng cutfc stfng lifin quan sttc khtfe sau TBMMN ba thtfng vtf mOt nflm.
IV. PHUONG PHAP NGHIEN CUU:
- Nghien ettu mO tfl cflt ngang.
- Nghifin ctiu can thtfp.
- Phuong phtfp triln khai.
V. KET QUA NGHlfiN CUU;
1. Thuc trang blnh nhfln tai bien mach mau nao:
/ L Dac dt/m chung cua d/ft tuong nghiSn ciiu:
- Ctfc ylu tO nguy ca TBMMN' + Trong stf nhttng ngutfi mfle TBMMN, ylu tO nguy co chinh ltf tflng huylt ap chiem 79,9%. Ty If TBMMN thoang qua ltf 5%.
Khtfng etf su khtfc bift ctf J nghia thtfng ke vl tJ If tflng huylt tfp.
TBMMN thotfng qua gitta nam vtf ntt vtfi p > 0,05.
+ Dai thtfo dutfng tf nhttng ngutfi mtfc TBMMN chilm ty If khtf cao 16,8%. Chua ctf sy kliae bift ctf J nghia thtfng kfi vl ty If dai thtfo dutfng gitta nam vtf ntt vtfi p > 0,05.
+ Ty If bfnh tim vtf rtfi loan lipid mau tf nhttng ngutfi mfle
TBMMN Ifln lugt ltf 20.8% vtf 13,4%. KhOng ctf sy khtfe bift etf J nghTa thtf'ng kfi vl tJ tf bfnh tim vtf rtfi lugn lipid mtfu giOa nam vtf ntt vai p > 0,05.
+ Hai ylu ttf etf nguy eg utfng rugu bia vfl hdt thutfc Itf ly If tugng ttng 33.7% vtf 10.9%. Ctf Ny khtfe bifI etf J nghla thtfng kS vl tJ If utfng rugu bia vfl hdt thutfc Itf gitta nam vtf nft vtfi p < 0.001.
- Dflnh gifl llnh irgng ctf khilm khuyit thfln kinh ihco nhtfm:
+ Stf bfnh nhtfn TBMMN ctf khilm khuyit J ihde, ihtfl dilu ehi vtf rtf'i logn vfln ngtfn Idc vflo vifn (tuang ttng Itf 38,1%, 91.1% vtf 33,7%) vtf Ide ra vifn (luong dng Itf 2.'i.9%.. 78.6% vtf 29,8%), tgi thtfi dilm suu TBMMN ba thtfng (luong ttng 16,9%. 70,1% vfl 25,4%) vtf mtft nflm (tuang ttng 7,1%, 55,8% vfl 17.3%). Ctf sy khtfe biet etf J nghla thtfng ke tinh trgng kliilm khuyit vfln dOng mfli, tay vtf chtfn tai 4 thtfi dilm vtfo vifn, ra vifn, sau TBMMN ba thflng vfl mtft ntfm vtfi p < 0,05.
+ Stf bfinh nhfln TBMMN ctf rtfi loan vfln nhfln Ide vtfo vifn, ra vifn, ba thtfng va 1 nflm (tugng ttng 23,3%, 11,9%, 7,9% vu 5,9%). Sy khtfc bift ctf J nghla thtf'ng kfi rtf'i logn vfln nhfln tgi thtfi dilm vtfo vifn, ra vien. sau TBMMN ba thtfng vtfi p < 0,05.
Khtfc bift khOng ctf J nghia thtfng kfi tgi thtfi dilm sau TBMMN ba thflng vtf mOt nflm vtfi p > 0,05.
+ Stf bfnh nhtfn TBMMN etf rtf'i loan thj ldc vtfo vifin, ra vifn, ba thtfng vtf I ntfm (tuung ttng 4,5%, 3,9%, 2,5% vfl 1,5%). Sy khtfc bift khOng ctf J nghla thtf'ng ke tai thtfi dilm vtfo vifn, ra vifn, sau 3 thtfng vtf 1 nflm vtfi p > 0,05.
+ Stf bfnh nhtfn TBMMN ctf khilm khuyit vfln dOng nua intft, tay vtf chfln rlt eao luc vtfo vifn (tuong ttng ltf 89,1%, 96% vtf
95%) vtf ldc ra vifn (tuong ung lii 84,7%, 76,7% vtf 72,8%), sau dd 6 mttc cao tgi thtfi dilm sau TBMMN ba thtfng (tuang iing 77.2%, 57,9% vtf 54,5%) vfl m^t ntfm (tuong ttng 32,2%, 28,7% vtf 22,3%). Ctf sy khtfe bift c6 J nghia thtfng kfi tinh trgng khilm khuyit vfln dtfng mflt, tay vfl chfln tgi 4 thtfi dilm vtfo vifn, ra vifn, sau TBMMN ba thtfng vfl mft nflm vtri p < 0,05.
+ Stf bfnh nhtfn TBMMN ctf rtfi logn ngtfn ngtt, mit chd J liic vflo vifn ehilm ty If luong dng 12,9% vfl 13,4%. Ty If nfly tf thtfi dilm 3 thtfng (tuang ttng 11,9% vtf 12,4%) vtf mOt ntfm (tuang dug 6,1% vtf 6.4%). Sy khflc bift khtfng ctf J nghla thtfng kfi tai thtfi dilm vtfo vifin, ra vifn, sau TBMMN ba thtfng vtfi p < 0,05.
Sy khac bift etf y nghla Ihdng kfi tgi thtfi dilm sau TBMMN ba thtfng vfl mOt nflm vtfi p < 0.01.
+ Stf bfnh nhfln TBMMN cd rtf'i logn cim gitfc Idc vflo vifn, ra vifn, ba thtfng vit inOt ntfm (tuung ttng 40,8%, 37.8%, 24.4% vJ 20,3%). Su khtfc bifit ctf J nghia thO'ng ke tgi thtfi dilm vtfo vifn, ra vifn, sau ba thtfng vtfi p < 0,05 vi khtfc bif I khtfng ctf J nghia thtfng kfi so stfnh tgi thtfi dilm sau ba' thtfng vtf mOl ntfm vtfi p > 0,05.
L2. Ddnh gid mdl s6 yi'u tS liin quan d^n ddc ldp elide ndng cdi- Iwgl ddng sinlj iiuQt lidng ngdy sau TBMMN mdt ndm:
- Co sy lifin quan giOa mtic df khilm khuyfi't thfln kinh khi vflo vifin vtf dOc lflp chdc nflng sau TBMMN mtft nflm. Nhftng bfnh nhtfn etf dilm stf NIHSS d" 15 khi vtfo vifin dtfe lflp chtte nang cao hon so vtfi nhQng nhom bfnh nhfln etf dilm stf NIHSS > 15 (tuong ling ltf 90,5% so vtfi 9,5%) (OR=3,58). Sy khac bift co j nghla thtfng kfi vtfi p < 0,001.
ra Khoa hoc
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Khoa hoc Si cdng nghe
- Ctf su lien quan gitta mue dO dOc lflp chtte ntfng khi vtfo vifin vtf dtfe lflp chtte nang sau TBMMN mtft nam. Nhung bfnh nhfln ctf chi stf Berthel e" 25 khi vtfo vifn etf dOc lflp chuc nflng cao ban so vtfi nhttng nhom bfinh nhtfn etf ehi stf Berthel < 25 (tuang ttng ltf 79,6%
so vtfi 20,4%) (OR=14,64). Su khtfc bifit CO y nghTa thtfng kfi vtfi p < 0,001.
- Ty If bfnh nhtfn phy thuOc chtte nflng sau TBMMN mtft nflm o' nhdm eO rtfi loan tilu tifin lflc vflo vifin cao ban so vtfi nhtfm khOng rtfi logn tilu tifin ldc vtfo vifn (tuong ttng ltf 94,0% so vO'i 6,0%) (OR=21,47). Sy khtfc bifit gitta hai nhtfm etf J nghla thO'ng kfi vtfi p < 0,001.
- TJ If bfnh nhan dOc lflp ehttc nflng sau TBMMN mOt nflm tf nhom ctf rtf'i logn kha nflng nutft ldc vflo vifin thtfp so vai nhtfm khOng rtfi loan kha nflng nudt luc vtfo vifn (tuong dng ltf 31,3% so vtfi 68,7%) (OR=19,76). Sy khac biet gitta hai nhtfm co J nghTa thtfng kfi vdi p < 0,001.
- Nhftng bfnh nhfln ctf chi stf MMSE dutfi 24 ldc vao vifn phu thuOe ehiie nflng cao ban so vtfi
nhttng nhtfm bfnh nhtfn co ehi sO' MMSE Itfn ban hay btfng 24 ldc vtfo vifn (tugng ttng ltf 92,0% so vtfi 8,0%) (OR = 11,34). Sy khflc bift gitta hai nhtfm co J nghla thO'ng kfi vtfi p < 0,001.
- Nhttng bfnh nhtfn cd tudi Itfn han hay btfng 65 mttc dO phy thutfc chtte ntfng cao hon so vtfi nhttng nhdm bfnh nhtfn ed tudi nhtf han 65 (tuang dng ltf 84,0%
so vtfi 16,0%) (OR = 1,31). Sy khtfe bift gitta hai nhOm ctf J nghTa thO'ng ke vOi p < 0,001.
- Trong phtfn lich dan biln ctfc ylu ttf nhu tutfi, chi stf NISHH, chi stf Barthel, dilm stf tam tri ttfi thilu MMSE khi vtfo vifn lien quan vtfi tinh trang dOc lap ehttc ntfng sau TBMMN mOt nam vtfi p
< 0,01. Trong phan tieh da biln btf'n ylu ttf ctf mtfi lifin quan nhlt dinh den tinh trang dtfc lflp ehttc nang sau TBMMN mOt nflm ltf tutfi (r = -0, 135, p < 0,05), chl sd NIHSS lue vtfo vien (r = -0,413, p
< 0,01), ehi stf Barthel ldc vtfo (r = 0,208, p < 0,01), diem ttfm tri tdi thilu lue vflo (r = 0,180, p < 0,01).
1.3. Ddnh gid mdt sd' yeu Id' liin quan din chdt lu</ng cuoc sdng liin quan siic kiide (SS-
QOL) sau TBMMN mdl ndm:
Trong phan lieh dan biln cflc ylu ttf nhu tutfi, ehi stf NIHSS, rtf'i loan J thtfc, ngtfn ngft, chi stf Bailhel, rtfi loan tilu lifn, dilm .stf tflm tti ttfi thilu MMSE khi vtfo vifin, trtfm cflm khi ra vifn lien quan vtfi chtft Iugng cutfc stfng lien quan sttc khtfe sau TBMMN mtft ntfm vtfi p < 0,01. Tuy nhien trong phfln ti'ch da biln chi 5 ylu ttf ltf tudi, chi stf NIHSS. rtfi loan y thue, dilm stf lflm tri ttfi thilu MMSE khi vtfo vifn, trflm cflm khi ra vifin ctf mO'i lien quan nhtft dinh vtfi chit lugng euOc stfng lifin quan sttc khoe sau TBMMN mOt nam tuang ttng [(r = -0,108, p <
0,05), (r=-0,317, p< 0,01), ( r = - 0,28, p < 0,01), (r = 0,2, p < 0,01), (r =-0,187. p < 0,05)].
2. Danh gia hifu qua ap dung mo hinh PHCN totfn dien ntfng cao chtft lirgng cupc song cua ngutfi benh sau TBMMN:
- MOt stf dflc dilm dich tl, tinh trang khilm khuyit, dOe Iflp chtte nang eda ngutfi bfnh nhtfi mtfu nflo vflo vifn tf nhtfm dugc phue htfi chtte nflng totfn difn kit hgp va nhom (nhtfm ehdng) (n = 152)
- Mdi lifin quan gitta phue htfi YSutS
Tudi ( X ± SD) Giai tlnh (%) Nam
NO Tang huyet ap (%) TBMMN thoang qua RO'i loan lipid mau (%) Dai thao duoTlg (%) Benh tim (%) U6'ng ruou bia (%) ThuO'c la (%) Dilm NIHSS ( X ± SD) Dilm Barthel ( X ± SD) Di jm Rankin ( X ± SD)
Nhom PHCN toan dign (n = 77) 69,7 ±11,6
70,1 29.9 76.6 9,1 10,4 23,4 24,7 37,7 9,1 9,4 ±6,19 42,5 ± 27,4 3,8 ± 1,0
Nhom chung C n = 75) 70,3 ±11,8 64,0 36.0 76,0 2,7 9,3 12,0 21,3 3,0 10,7 9,55 ± 5,83 40,5 ±31,5 3,8 ±1,1
P
>0.05
>0,05
>0,05
>0,C5
>0.05
>0.05
>0,C5
>0,05
>0,05
>C,05
>0,05
>0,05
Khoa hoc ( ^
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K h o a hoc & cong nghe
ehttc nang vtf tinh trang doc Iflp chuc ntfng, giflm khfl nang, vtf chtft lugng cuOc sOng cfla ngutfi bfnh sau nhtfi mau nao (n = 152):
+ Thtfi dilm ra vifn: Tinh trang dtfc lflp chtte nflng ctfc boat dtfng stf'ng htfng ngfly (danh gia theo chl stf Barthel), giam kha ntfng (dtfnh gitf theo thang dilm Rankin) vtf ehtft lugng cuOc stf'ng lifin quan sttc khoe (danh gia theo thang dilm SS-QOL) a nhtfm dugc phue htfi ehttc nflng totfn difn kel hap cao ban so vtfi nhtfm chttng (tuong ttng 65,78 ± 30,07, 3,37 ± 1,21 vtf 147,32 ±49,7 so vtfi 64,00 ± 27.18; 3,37 ± 1,21 vtf 145.22 ± 54,01). Tuy nhien sy khac bift khOng eo J nghTa thtfng ke vdi p > 0,05.
+ Thai dilm sau nhdi mau ntfo 3 thtfng:
Dtfc lflp chuc ntfng eac hogt dtfng stfng htfng ngtfy, giam kha ntfng tf nhtfm dugc phyc htfi chtte ntfng tofln difn kit hgp cao hgn so vtfi nhtfm chiing (tuong dng 79,48
±26,60; 2,53 ± 1,13 so vtfi 72,93
± 26,73; 2,97 ± 1,19). Sy khtfe bift nfly CO y nghTa thtfng ke vtfi p <
0,05.
Chll lugng cutfc stf'ng lien quan sttc khtfe 6 nhtfm dinrc phyc htfi chtte nflng totfn difin kit hgp cao hon so vtfi nhtfm ehung (tuong ling 159,72 ± 49,22 so vtfi 157,99
± 51,99). Tuy nhifin su khtfc bift khOng etf J nghTa thtfng kfi vtfi p >
0,05.
+ Thtfi dilm sau nhtfi mtfu nflo mtft ntfm: Ttnh trgng dOc lflp chdc nflng cflc hoal dOng stfng htfng ngtfy, giflm khfl ntfng vfl chit lugng cutfc stfng liCn quan sttc khoe tf nhtfm duac phue hfli chtte nang totfn difn kit hgp eao ban so vtfi nhtfm chttng (tuang ttng 85,06
± 19.67; 2,09 ± 1,08 vtf 183,01 ± 45,34 so vtfi 78.27 ± 22,03, 2.71 ± 1,23 vtf 168.41 ± 40,39). Sy khtfc bift ctf J nghia thtf'ng kfi vtfi p <
0.05.
- Mtf'i lifin quan gitta PHCN vtf tinh trgng dtfc Itfp chuc ntfng, gitfm khfl ntfng vfl chtft lugng cuOc stfng cda ngutfi bfnh sau xutft huylt nflo (n = 45): Tgi ctf 3 thtfi dilm ra vifn, sau ba thtfng vtf sau xult huyll nao mOt ntfm, tinh trgng dOc lflp chtte nflng ctfc hogt dOng stfng htfng ngtfy, giflm khfl ntfng vtf chit Iugng cuOc stfng Ufin quan siic
khtfe tf nhtfm duac phuc htfi chdc nflng totfn difn cao han so vtfi nhtfm chiing. Tuy nhifin su khac bift khtfng ctf J nghTa ihtfng kfi vtfi p > 0.05.
- Mtf'i lien quan gitta PHCN vfl tinh trgng dtfc Iflp ehttc ntfng, giam khtf nflng va chit lugng cutfc sdng cfla ngutfi bfnh sau TBMMN (n = 197):
+ Thtfi dilm ra vifn: Tinh trang dOc Iflp ehttc ntfng cac hoal dtfng stf'ng htfng ngtfy. giflm kha nang \-a chll lugng cuOc sO'ng lien quan sttc khoe tff nhtfm dugc phuc htfi ehttc ntfng totfn difn kit hyp cao ban so vtfi nhom chttng (tuong ttng 61.07 ± 31.34; 3.34 ± 1,31 vS 137,77 ± 53.80 so vtfi 59,59.±
30.04; 3.49 ± 1.24 vtf 137,72 ± 53.22) Sy khtfe bifit khtfng cl y nghia thO'ng ke vtfi p > 0,05.
+ Thtfi dilm sau TBMMN 3 ditfng;
DOc Itfp ehttc nflng cac hoat dtfng stfng htfng ngtfy, giam khfl nflng tf nhtfm duge phyc htfi chdc ntfng tofln difn kit hgp cao hgn so vtfi nhtfm chttng (tuang ung 75,78
± 24,42; 2,71 ± 1,24 so vtfi 68,62
± 28,77; 3,15 ± 1,23). Sy khtfc bift
ra Khoa hoc
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Khoa hoc S. cong nghe
nfly etf J nghTa thtfng kfi vtfi p <
0,05.
Chfl't lugng cutfc stfng lifin quan sttc khoe o nhtfm dugc phuc hdi chtte ntfng totfn difin kit hgp cao hon so vtfi nhtfm chiing (tircmg ttng 154,49 ± 49,87 so vtfi 150,74
± 52,63). Tuy nhifin sy klifle bift khOng CO y nghTa thtfng ke vtfi p >
0,05.
+ Thtfi dilm sau nhtfi mtfu nflo mOt nam: Tinh trang dOc lflp chtte nang ctfc hogt dOng sO'ng hflng ngtfy. gitfm kha ntfng vfl chtft lugng cuOe stfng lifin quan sttc khtfe tf nhdm dugc phuc htfi chtte nflng totfn difn kit hgp cao ban so vtfi nhtfm chung (tugng ung 82,28
± 22,00; 2,20 ± 1,17 va 179,22 ± 44,43 so vai 74,95 ± 24,03; 2,82 ± l,3i va 163,18 ± 44,82). Sy khac biet eo J nghia thtfng ke vtfi p <
0,05.
3. Btfn lutfn:
3.1. Thuc trang benh nhan TBMMN va mtft so yeu ttf Ii6n quan den ket qua hoi phuc chtte nang sau TBMMN:
- Kit qud chung vi d&i tucmg ngliiSn ciiu: Kit qutf nghifin ettu cua chung toi cho thtfy TBMMN hay gtfp tf nhttng ngutfi trfin 60 tutfi. Ty If TBMMN tf nam nhieu hon ntt, phd hgp vtfi nhieu nghien cttu. TBMMN thl nhoi mau nao ehilm iru thl so vtfi the xutft huylt nflo voi p < 0,001. Khong etf sy khtfe biet ctf J nghia thtfng kfi giua ctfc Ioai nhtfi mau nflo, bfin lift nu'a ngutfi cua nam va ntt vtfi p >
0,05. Dilu ntfy phu hgp vtfi nghifin edu cda nhilu ttfe gia trong va ngotfi nirtfc.
- Thai gian dieu tri: Kit qua nghifin ettu eua ehdng tOi eho thtfy thtfi gian ttt Iflc nhflp vifin din khi dugc dilu trj PHCN vtf thai gian ntfm vien dilu tri cfla nhtfm xutft huylt nflo dtfi hon so vtfi nhom nhtfi mtfu nao. Su khtfc nhau ctf y
nghia thtfng ke vtfi p < 0,001. Dilu ntfy dl nhfln Ihly do xull huylt nflo thutfng dl Igi nhilu di chttng nflng vl vfln dOng, nhfln thttc, chdc nflng nuO'l, lO'i logn ca trtfn, nhilu bfinh nhtfn phfli thtf mfly dl kilm sotft phd nao, huylt dtfng vtf phfli phiu thuflt giai tfp nen thtfi gian tiln htfnh dilu iri PHCN edng nhu thtft gian ntfm vifn dilu tri klo dtfi ban so vdi nhtfm nhtfi mflu nao.
Dilu ntfy phd hgp vtfi nhilu nghifin cttu.
- MOt sS' yiu id' nguy co TBMMN:
+ Chdng toi ehl tflp trung etfe ylu ttf nguy eo chinh vfl ctf thl dt,r phtfng hifiu qutf lfl tflng huylt flp.
rdl logn mO mtfu, bfinh lim, lam dyng bia ruou vtf thutfc ltf. Trong nghien ettu cua ehung tOi, ylu ttf' nguy ca ehinh ltf tang huylt tfp 79,7%, khOng etf su khtfc bift eo J nghia thdng ke gitta nam vfl ntt vl ty lfi tflng huylt tfp.
+ Tang huylt tfp duge eoi Itf nguy ea hflng dflu trong co chl benh sinh cua TBMMN. Tflng huyet flp Itf ylu tO nguy co co thl kilm sotft dirge. Ty If cao TBMMN xay ra do nguyen nhfln tryc tilp ttt tang huylt tfp trong cOng dtfng dan cu ctf thl sfi bi loai trii nlu chdng ta kilm sotft huylt ap hifu qua. Thfly thutfc, gia dinli vfl bfinh nhfln cfln nhtfn thttc rO vai tro quan trong cfla vtfn dl kilm soat huylt tfp tai ctfng ddng trong dy phOng TBMMN. Dtfe bift tai Vifit Nam ttfng huylt tfp ngtfy mOt gia tflng ttt khoang 8% vflo nhttng nflm 60 - 70 thi din nhttng nflm 2000 da Itf trfin 20%. Dtf ltf vtfn dl dtfng lo nggi.
+ Cflc bfnh IJ tim nhu hep hai ltf vtf/hoflc rung nhT Ihip tim, bfinh mach vtfnh... Itf ylu td nguy cg quan trong sinh TBMMN Ihl nhdi mau nao tf etfe nutfc dang phat triln. Nghitfn cthi cfla chflng ttfi
eho thtfy ty If mtfc bfnh tim trong stf nhttng bfnh nhtfn TBMMN Ifl 20,8%. Theo nghifin cttu efla Hotfng Khtfnh, nguy ea TBMMN hflng nflm tren bfnh nhfln rung nhi khtfng do bfnh van tim ltf 3% din 5% vfl lfl nguyfin nhfln cfla 50%
ctfc TBMMN do huylt khtfi lip maeh. Trfin bfinh nhfln etf bfnh van hai ltf do thtfp, rung nhi dugc ghi nhfln Itf nguyfin nhfln cda TBMMN vtf huylt khtfi hf thdng,
•I- Trong nghifin ettu cda chdng toi, ty If utf'ng rugu bia Ifl 33,7%.
Lam dung rugu gia iflng hofle gitfm nguy ca TBMMN phy thuOc vflo intte do tifiu thy rugii vfl thl TBMMN. Thtfi quen utfng trfin 56,70 gam rugu htfng ngtfy hofle say qutf chen lifin quan din sy gia ttfng nguy ca cda TBMMN (dflc biet TBMMN the chay mtfu nflo) vfl ttt vong do TBMMN.
+ Trong nghien ettu eua ehung toi. ty If hut thuO'c ltf 10,9%. Ctf mtfi lien quan gitta stf lugng thudc Itf duac hut vfl nguy eo nhtfi mtfu nflo trfin nam gitfi. Nguy ca tuang dtfi cfla TBMMN tf ngutfi hdt thutf'c ltf nhilu (trfin 40 dilu/ngtfy) gtfp hai Itfn nhttng ngutfi hdt thuO'c la it (dutfi 10 dilu/ngay).
3.2. Hifu qua cua tflp luyen phuc hoi chtte nang doi voi benh nhtfn TBMMN:
- Hifu qutf eda tap luyfin phue htfi ehttc nflng dtfi vtfi chtft lugng euOc sdng: Kit qufl nghien edu eda ehdng tOi cho thiy phue htfi ehttc nang gop phfln ctfi thifn ehtft lugng cuOc stf'ng. Chtft Iugng cutfc stf'ng lifin quan sttc khde o nhtfm dugc tflp luyfn phuc htfi ehttc nang totfn difn tgi thtfi dilm mtft nam cao han so vtfi nhtfm chttng tflp luyfn vfln dtfng don thutfn ctf J nghTa thtfng kfi vtfi p < 0,05. Kit qua ntfy phd hgp vtfi mOt stf nghifin cttu cfla mOt stf tflc gia.
- Thdi diim bdt ddu tdp tuyin
Khoa hoc ra
&phat trien LflJ
K h o a hoc SL c o n g nghe
phiftc hdi elide ndng:
+ Tflp luyfn phyc htfi chd'c ntfng stfm eho bfnh nhfln TB MMN Itf hit sure quun tryng. Ky thuflt vj the' ddng kll hgp vtfi tflp vfln dtfng thutfng xuyfin nd-a ngutfi bfin lift mdi ngtfy ttt 2-3 ifln, sau dtf tdy Uieo sy tiln tnln cda tCrng bfnh nhtfn mfl ttng dyng cflc kJ thuflt phye htfi ehttc ntfng cho phd hgp. Paolucci vtf ctfng sy chttng minh rtfng luyfn lflp PHCN stfm sau TBMMN ltf mOI ylu ttf tien lugng kit qutf PHCN Ufin quan.
+ Maulden ehthig minh thtfi gian tft Idc TBMMN din Idc tflp luyfn PHCN cflng lflu thi ttfng dilm dtfe lflp chtte nflng sinh hogt, vfln dtfng vtf di ehuyin Idc xult vifn ctfng thip. Trong nhtfm nhttng bfnh nhtfn TBMMN mde giflm kha nflng viia, tflp PHCN muOn lifin quan vdi thtfi gian nflm vifn dtfi hem ctf y nghTa (p <
0,001). Ngay ca dtf'i vtfi nhttng bfinh nhan ctf khilm khuyit tri giac nhtfn thttc ntfng thi thtfi gian tu khi bj TBMMN din luc tflp PHCN lfl chl mOt stf tien lugng dtfc lflp ctf J nghTa cua tinh trgng ehire ntfng khi dtfnh gitf thang dilm FIM.
+ Kit qufl nghifin cttu cfla ehdng ttfi nfiu trfin phd hgp vtfi cflc nghifin cttu tf trong nutfe vtf ngotfi nutfc cho thtfy tflp luyfin PHCN stfm ctf mtfi tuong quan vtfi mttc do dOc lflp chue nflng etfe hogt dtfng sinh hogt co ban hflng ngfly vtf chit lugng cutfc sdng ttft ban cfla nhttng ngutfi sau TBMMN mtft nflm.
VI. K^T LUAN VA KI^N NGHI:
1. ket lutfn:
Qua nghifin ettu dtfnh gifl hifu qufl cua PHCN totfn difn tren 202 bfnh nhtfn TBMMN tgi thtfnh phtf Dtf Ntfng, chung ttfi ctf mOt stf kit lutfn sau:
- Tht,rc Irgng vfl cflc ylu id lifin quan din dtfc Iflp chtfe nflng cflc hogi dtfng sinh hogt htfng ngtfy vtf chll lugng eiitfc stf'ng eda nhttng iiginVi sau TBMMN mtft nflm:
+ TBMMN xfly ra nhilu nhlt tf nhtfm bfnh nhfln cuo lutfi {trOn 60 ludi). ylu ttf nguy co chlnh ltf ttfng huyll Jp 79,7%.
+ Sau TBMMN mtft nflm:
Khilm khuyit thfln kinh nflng 5,6%, khilm khuyll ehdre nflng lay 29.4%, khilm khuyll ehue nflng chan 22.8%. lift mflt 32,9%. rtf'i logn etfni giflc 20,3%, rtfi logn dilu hgp 55,8%;, mit ehd J nua ngutfi 6,1%, rtfi logn eo trtfn 10.2%. nutf't khtf 2.5%, thll ngtfn 6,1%, logn vflt iigOn 17,3%, gitfm chue nflng nhfln thde 44,6%, trim cflm 15.2%. dOc Iflp hofln totfn trong cflc hogi dtfng stfng eo bfln hflng ngfly 48,9%, giflm khtf ntfng nh? hay binh thutfng 45,2%, chit lugng cutfc stf'ng itft 34,5%.
+ Cae ylu ttf lifin quan din tinh trgng dOc lflp chtte nflng sau TBMMN mtft ntfm ltf tutfi, chi stf NIHSS Ide vtfo, ehi stf Barthel Ide vtfo, dilm ttfm tri ttfi thilu ldc vtfo.
+ Cflc ylu ttf lifin quan din chit lugng cutfe .stfng lifin quan din siie khoe sau TBMMN mOt nflm Itf tudi, chl stf NIHSS Iuc vflo, rO'i logn y Ihttc. dilm tflm tri ttfi Uiilu Idc vtfo, trflm cim ldc ra vifn.
+ Quan tflm din vifc cfli thifn chit lugng eutfe stfng cua bfnh nhan sau TBMMN ltf mtft hutfng dl ddng, cflp nhflt vtf dflp ttng nhu ctfu thilt thyc efla ngutfi bfnh sau TBMMN.
- Hifu qufl eua tflp luyfn PHCN totfn difn dO'i vtfi bfnh nhtfn TBMMN:
+ O nhtfm nhdi mau nao dirge tflp luyfn PHCN totfn difn, miic dtf dOc lflp chdc nflng. giflm kha ntfng, chit lirgng cutfc stf'ng lifin quan din sire khtfe sau TBMMN
mtft ntfm eao hon so vtfi nhdm ehdng. Trong khi dtf tf nhtfm xull huylt nflo sy thay dtfi chua ctf J nghTa thtfng kfi.
+ d nhtfm bfnh nhtfn duge lflp luyfn PHCN totfn difn vtf stfm, mttc do dtfc lflp chtte ntfng, gitfm khfl ntfng, ehit lugng cutfc stfng lifin quan din sttc khtfe sau TBMMN mOt ntfm cao hon so vft nhtfm chiing. Trong khi dtf ly If etfe thuong tflt thtt phtft thip hon nhtfm chttng.
2. Kiln nghj:
Cfln cu vflo cflc kit qufl ihu diR;c qua nghifin cttu nfly, dua trfin nhu cflu thye t l vl phyc htfi chuc nflng vfl ctfi thifn ehtft Iugng cutfc stfng cho bfnh nhtfn sau TBMMN vtf dilu kifn, trang thilt bj, nhfln lyc cfla etfe khoa PHCN tuyln tinh trfin dia ban thflnh phd, ehung lOi xin dl xult mtft stf kiln nghj sau:
•I- Ung dyng rtfng rfli chuong Irinh phyc htfi ehttc nang totfn difn bao gtfm VDTL, HDTL, NNTL. kilm sotft ctfc ylu ltf nguy ea dflc bift kilm soflt trflm cam, dinh du&ng vtf thirc hifn chuong trinh phye htfi chtte nflng tgi nhfl.
+ Khuyin khich gia dinh tham gia tich cyc vflo qutf trinh dilu tri btfng chuang trinh rfn luyfn thl chit, gifli tri eho ngutfi bfnh, huln luyfn thflnh vifin gia dinh ctfch chtfm stfc, lifin hf vtf kit ntf'i vtfi chuong trinh PHCNDVCD tf dja phuang dl phtfi hifn stfm vfl can thifp ngay nhttng ctfn trtf trong qufl trinh hdi phyc nhu nudt khd, suy gitfm nhfln thttc, trflm ctfm...
+ Sflr dyng thang dilm NIHSS vtf chi stf Barthel nhu Ifl chi stf tifin lugng mttc dtf dOc Iflp chtte ntfng ctfc boat dtfng sinh hoat hflng ngtfy vtf sd- dyng thang dilm NIHSS ltf chi stf tifin lugng chit lirgng cuOc stfng cua bfinh nhtfn
sau TBMMN. •
ra Khoa hoc
P*^! &phdttt'iin
