1、从异体手移植看从异体手移植看手康复之发展手康复之发展Introduction 异体手移植是世界外科界的临床难题，它不同于目前成熟的器官（如肾等）移植，其组织主要来源外胚层，皮肤、肌肉等软组织对其具有强烈的排斥反应。1998年9月，法国进行了全球第一例异体手移植。1999年1月，美国进行了国际上第二例异体手移植手术。1999年9月21日广州第一军医大学南方医院创伤骨科裴国献教授、顾立强、朱立军博士等人成功完成了2例异体手移植手术。全世界全世界手手部部异体移植异体移植之统计之统计台湾于2014完成首例异体手移植截至目前已有截至目前已有3例，例，其中其中2例单侧，例单侧，1例双侧例双侧手部移植医疗团
2、队手部移植医疗团队 医疗团队：医疗团队：手外科 骨科 检验科 X光科 精神科 康复科 新陈代谢科 药剂科 社工 护理4 4 Phases of Rehabilitation Pre-operative（術前）（術前）Initial post-operative(weeks 0-4)（術後早期）（術後早期）Intermediate(weeks 48)（中期）（中期）Late(from 8 weeks forward)（後期）（後期）7Phase 1Phase 2Phase 3Phase 4Phase 1Pre-operative Phase collect information:such as
3、 medical history,injury history,previous treatment(s),and occupation.analysis and assessments:stump size,shape,length,sensitivity and baseline pain,ROM,strength,sensory status of both upper extremities from shoulders to digits,functional analyses,and ability to perform ADLs.evaluate the patient/fami
4、lys ability to understand,cope with and follow through with treatment develop reasonable functional goals&plan of care.Rehabilitation ProtocolPhase 2 Initial Phase(Days 0 to 14)Timing Immediately after HA,all therapy takes place in the in-patient setting.Therapy takes place daily,with sessions sprea
5、d throughout the day and active participation by rehabilitation professionals,nursing staff,and the hand transplant recipients family.Rehabilitation program Positioning The transplanted hand(s)are positioned to avoid vascular compromise and edema,protect the repairs,and ensure optimum lengthtension
6、relationships between extensor and flexor tendons.Edema is managed through positioning and later through compression.Splinting Use a volar resting splint fabricated preoperatively,to keep the hand in a resting position while preventing joint contractures.Dynamic crane extension outrigger splint is f
7、abricated as soon as possible after surgery,and the hand transplant recipient wears it continuously during the day.Rehabilitation program Exercise Passive ROM exercises within the first 13 days post-operative,and evaluate perfusion on every digit before treatment.Start early active motion(EAM)of the
8、 metacaprophalangeal(MP)and interphalangeal(IP)joints with emphasis on assisted motion within the confines of the dynamic crane orthosis by the end of post-operative week 1.Once bony healing is evident,begin gentle tenodesis exercises.Phase 3 3 Intermediate Phase(3 to 8 Weeks)Splint Continue to wear
9、 the dynamic crane orthosis a dorsal blocking or anti-claw orthosis with added thumb opposition on post-operative week 4 and use it for as long as needed to prevent clawing,substituting for non-innervated intrinsic muscles.dynamic,static,and staticprogressive orthosis as needed to prevent contractur
10、e,minimize muscle imbalances,and protect and position the hand(s)for function Scar and edema management compression(i.e.,Coban,Tubigrip,Kinesio tape and gloves),mobilization,elevation,and massage.Rehabilitation programExerciseweek 3“place and hold exercises basic light ADLs(such as hand-to-mouth for
11、 self feeding)with assistance,and gradually progress.week 4 3-point pinch and bilateral hand usage,such as picking up pieces of food,stacking blocks,and transferring items from one hand to the other.active ROM of the wrist,active use of the hand for light activitiesweek 5 gentle ROM exercises involv
12、ing the forearm,such as supination and pronation and gentle blocking exercises of digits.week 6 unrestricted ROM.week 8 two-handed ADLs(such as brushing teeth and toileting)as motor control and strength increase,and begin stretching of adhesions using moist heat.initiate strengthening use various to
13、ols such as therapy putty,weights,wall pulley,ergometer,Thera-Bands,hand exerciser and functional hand use.Rehabilitation program cognitive therapeutic training asking hand transplant recipients to make mental representations of the most accurate performance of tasks which increase in complexity and
14、 aim at motor recovery using proprioceptive feedback.心像练习 脑海中演练各种动作技巧 执行心像练习时，特定脑区会被活化(Stephen,2009)以肌电图测量，心像练习会造成执行该动作所需肌群活跃(Harris,1986)17Rehabilitation program Mirror therapy Cortical re-integration of the transplanted hand is crucial to successful functional outcomesRehabilitation programSensory
15、 Reeducation Focus:the Hand esp.fingertips Cortical maps-reorganization Reinnervation(nerve repair&recovery)Time Limited by scar tissue Atrophy of sensory receptors Malalignment of axonal fibers Purpose:help learn to recognize the distorted cortical impression Outcome dependent on:Cognitive capaciti
16、es learning abilities&visuospatial cognition Motivation compliance18Rehabilitation programElectrical stimulation simultaneous to the start of active ROM of the wrist.Two types of electrical stimulation:transcutaneous electrical nerve stimulation(TENS)-pain control.use frequencies50 Hz for 2030 min w
17、hile performing ROM exercises.neuromuscular electrical stimulation(NMES).-muscle reeducation.use 3550 pps,300 width,35 s ramp and a 4:12 on/off duty.Phase 4 4 Late Phase(Week 9 Onwards)Reduce treatment frequency to 4 h/day,3 days per week.do progressive work with ADLs,function of the transplanted ha
18、nd(s),and reintroduction of prior activities.week 12 recipients who live away from the treatment center may return home and continue treatment there.week 24 reduce the schedule to 4 h,twice per week.recipient can work to gradually return to his/her prior routine during the next 24 weeks and may be a
19、ble to RTW.yearly reassessment at the transplant center.Follow-up Evaluation:Outcome Measurement Nerve regeneration testing:Tinel signs pins and needles“Sensibility testing:SemmesWeinstein monofilament test two-point discrimination test Strength:Dynamometer Pinch meter ROM:GoniometerBasic testingSta
20、ndardized score systems Disability of the Arm,Shoulder and Hand(DASH)Questionnaire,an evaluative outcome measure that is a self-administered questionnaire on symptoms and functional status.Hand Transplantation Score System(HTSS),a specific functional score developed by the International Registry of
21、Hand and Composite Tissue Transplantation.Short Form 36(SF-36),a generic survey to measure functional health and well-being.EQ-5D,a standardized,simple instrument that provides a single index value for health outcome.Action Research Arm Test(ARAT):originally designed to assess recovery in an upper l
22、imb after cortical damage.Disability of the Arm,Shoulder and Hand(DASH)Questionnaire24The DASH Outcome Measure is a 30-item,self-report questionnaire designed to measure physical function and symptoms in people with any of several musculoskeletal disorders of the upper limb.Hand Transplantation Scor
23、e System(HTSS)This evaluates six aspects of the hand transplant:(1)appearance(15 points);(2)sensibility(20 points);(3)motility(20 points);(4)psychological and social acceptance(15 points);(5)daily activities and work status(15 points);(6)patient satisfaction(15 points).A total result of 81100 points
24、 is graded as an excellent outcome,6180 as good,3160 as fair,and 030 as poor.SF-3636 SF-36为一个一般性（generic）的心理测量工具，并不是针对特定年龄、疾病或是治疗而设计。SF-36美国版（SF-36 Standard Version）在1990年定稿，共有36项问题。主要测量受访者身心健康状态的8个面向（concept），分别为身体生理功能（physical functioning）、因生理功能角色受限（role limitation due to physical problems）、身体疼痛（b
25、odily pain）、一般健康（general health）、活力（vitality）、社会功能（social functioning）、因情绪角色受限（role limitation due to emotional problems）、心理健康（mental health），此外另含一项自评健康变化（reported health transition）。由于其简短及信效度皆佳，目前已有多国版本（含德国、法国、意大利、日本、荷兰、比利时、丹麦等国）。EQ-5D EQ-5D健康问卷评核，得分有二部分，一为生活质量之整体评价EQ-5D指标(index)，另一为受访者自觉目前健康相关的生活质
26、量EQ-5D VAS。EQ-5D指针分数有二面向(精神及身体健康)，为5题自我分类题(self-classifier)，包含：可移动性、自我照顾、一般活动(如工作、读书、家事、家庭或休闲活动)、疼痛/不适、焦虑/忧郁等5面向题，每题以没有问题为3分、有些问题/有中度问题为2分、无法自理/有极度问题为1分等三个选项，加总后得单一的EQ-5D指标(EQ-index)分数。分数范围介于5至15分，得分愈高表示自觉整体生活质量评价愈好。EQ-VAS则是以个人喜好(preference-based)为基础的一种健康相关生活质量测量工具，由一个垂直总长20公分量尺构成的视觉模拟量表(visual anal
27、og scale)，分数介于0至100分，0分代表想象中最差状况，100分则是想象中最佳，Action Research Arm Test(ARAT)Simple Test for Evaluating Hand Function(STEF)STEF was designed and developed by Kaneko et al.in 1974 in Japan to objectively evaluate the speed of motion of each upper arm and hand.10 procedures are performed including carry
28、ing eight objects that consists of transferring three kinds of spheres(big,moderate,small),two kinds of disks(moderate,small),a kind of rectangular box,two kinds of cubes(moderate,small)to an arranged area,inserting sticks into holes and turning over cloths.29医疗技术持续进步，医疗技术持续进步，手康复如何跟上脚步手康复如何跟上脚步?Technology comes from human nature 科技始终来自于人性科技始终来自于人性团队合作早期介入功能导向
