呼吸训练对脑卒中偏瘫患者运动功能、运动耐力、日常生活能力的meta分析
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摘要
目的评价呼吸训练能否改善脑卒中患者的运动功能、运动耐力和日常生活能力(activity of daily living,ADL)。方法通过计算机系统检索PubMed、Embase、Google Scholar、中国知网、万方、维普数据库中关于呼吸训练对脑卒中患者运动功能、运动耐力、ADL的影响的随机对照试验,检索日期从建库到2018年12月31日。对照组为常规康复治疗、药物治疗或其他干预措施,试验组为在此基础上增加呼吸训练。评价指标包括改良Barthel指数(modified Bathel Index,BI)、Fugl-Meyer运动评分量表(Fugl-Meyer Assessment,FMA)、6分钟步行测试(6-minute walk test,6MWT)。由两位研究者按照纳入和排除标准独立筛选文献,采用物理治疗证据数据库量表和Cochrane风险偏倚评估工具进行文献质量评价。采用RevMan 5.3软件进行统计分析。结果共纳入11篇文献,741例脑卒中患者。Meta分析结果显示,与对照组相比,试验组患者6MWT的距离[均数差(mean difference,MD)=41.50 m,95%置信区间(confidence interval,CI)(7.63,75.37)m,P=0.02]、BI[MD=9.97分,95%CI(3.99,15.96)分,P=0.001]、FMA[MD=8.00分,95%CI(1.29,14.70)分,P=0.02]均提高。亚组分析示,8～10周的干预后试验组BI高于对照组[MD=25.37分,95%CI(16.49,34.25)分,P<0.000 01],8周和12周～3个月的干预后试验组FMA高于对照组[MD=20.40分,95%CI(9.72,31.08)分,P=0.000 2;MD=6.18分,95%CI(3.57,8.79)分,P<0.000 01]。结论呼吸训练能提高偏瘫患者的运动耐力、ADL和运动功能。鉴于该研究纳入文献较少、各研究间存在异质性、缺乏长期随访,将来的学者可采用更优化的呼吸训练方案,进行样本量更大、方法学更严谨的研究。
Objective To evaluate whether respiratory training can improve motor function, exercise endurance,and activity of daily living(ADL) in stroke patients. Methods The randomized controlled trials of the effects of respiratory training on motor function, exercise endurance, and ADL in stroke patients were searched in PubMed,Embase, Google Scholar, China National Knowledge Infrastructure, Wanfang, and VIP Database. The search date was from the establishment of each database to December 2018. The control group received routine rehabilitation, medical treatment or other interventions, and the trial group added respiratory training on that basis. Outcome measures included the Fugl-Meyer Assessment(FMA), the 6-minute walk test(6 MWT), and the modified Barthel Index(BI). The literature was independently screened by two investigators according to the inclusion and exclusion criteria, and the quality of the included articles was evaluated using the Physiotherapy Evidence Database scale and Cochrane Library systematic review criteria. Statistical analysis was performed using RevMan 5.3 software. Results A total of 11 articles with 741 stroke patients were included. Meta-analysis showed that in the trial group the exercise endurance [mean difference(MD)=41.50 m, 95% confidence interval(CI)(7.63, 75.37) m, P=0.02], ADL [MD=9.97, 95%CI(3.99, 15.96), P=0.001], and motor function [MD=8.00, 95%CI(1.29, 14.70), P=0.02] were improved compared with those in the control group.Subgroup analysis showed that after 8-10 weeks of intervention, BI of the trial group was higher than that of the control group [MD=25.37, 95%CI(16.49, 34.25), P<0.000 01]; after 8 weeks and 12 weeks to 3 months of intervention, FMA of the trial group was higher than that of the control group [ after 8 weeks: MD=20.40, 95%CI(9.72, 31.08), P=0.000 2; after 12 weeks to 3 months: MD=6.18, 95%CI(3.57, 8.79), P<0.000 01]. Conclusions The results of this study showed that respiratory training can improve exercise tolerance, ADL, and motor function in stroke patients. In consideration of the limited number of included articles as well as the heterogeneity among included articles in the current study, and the lack of long-term follow-up period, further studies could use more optimized respiratory training programs to conduct highquality researches with bigger sample sizes.
Objective To evaluate whether respiratory training can improve motor function, exercise endurance,and activity of daily living(ADL) in stroke patients. Methods The randomized controlled trials of the effects of respiratory training on motor function, exercise endurance, and ADL in stroke patients were searched in PubMed,Embase, Google Scholar, China National Knowledge Infrastructure, Wanfang, and VIP Database. The search date was from the establishment of each database to December 2018. The control group received routine rehabilitation, medical treatment or other interventions, and the trial group added respiratory training on that basis. Outcome measures included the Fugl-Meyer Assessment(FMA), the 6-minute walk test(6 MWT), and the modified Barthel Index(BI). The literature was independently screened by two investigators according to the inclusion and exclusion criteria, and the quality of the included articles was evaluated using the Physiotherapy Evidence Database scale and Cochrane Library systematic review criteria. Statistical analysis was performed using RevMan 5.3 software. Results A total of 11 articles with 741 stroke patients were included. Meta-analysis showed that in the trial group the exercise endurance [mean difference(MD)=41.50 m, 95% confidence interval(CI)(7.63, 75.37) m, P=0.02], ADL [MD=9.97, 95%CI(3.99, 15.96), P=0.001], and motor function [MD=8.00, 95%CI(1.29, 14.70), P=0.02] were improved compared with those in the control group.Subgroup analysis showed that after 8-10 weeks of intervention, BI of the trial group was higher than that of the control group [MD=25.37, 95%CI(16.49, 34.25), P<0.000 01]; after 8 weeks and 12 weeks to 3 months of intervention, FMA of the trial group was higher than that of the control group [ after 8 weeks: MD=20.40, 95%CI(9.72, 31.08), P=0.000 2; after 12 weeks to 3 months: MD=6.18, 95%CI(3.57, 8.79), P<0.000 01]. Conclusions The results of this study showed that respiratory training can improve exercise tolerance, ADL, and motor function in stroke patients. In consideration of the limited number of included articles as well as the heterogeneity among included articles in the current study, and the lack of long-term follow-up period, further studies could use more optimized respiratory training programs to conduct highquality researches with bigger sample sizes.
引文
1 Thrift AG, Thayabaranathan T, Howard G, et al. Global stroke statistics. Int J Stroke, 2017,12(1):13-32.
2 Hardwick RM, Rajan VA, Bastian AJ, et al. Motor learning in stroke:trained patients are not equal to untrained patients with less impairment. Neurorehabil Neural Repair, 2017, 31(2):178-189.
3 Han P, Zhang W, Kang L, et al. Clinical evidence of exercise benefits for stroke. Adv Exp Med Biol, 2017, 1000:131-151.
4 Ivey FM, Prior S, Hafer-Macko CE, et al. Strength training for skeletal muscle endurance after stroke. J Stroke Cerebrovasc Dis,2017, 26(4):787-794.
5 Rochester CL, Vogiatzis I, Holland AE, et al.An official American Thoracic Society/European Respiratory Society policy statement:enhancing implementation, use, and delivery of pulmonary rehabilitation. Am J Respir Crit Care Med, 2015, 192(11):1373-1386.
6陈彦,吴霜.肺康复训练对脑卒中患者肺功能影响的Meta分析.华西医学,2018, 33(10):1277-1286.
7 Pollock RD, Rafferty GF, Moxham J, et al. Respiratory muscle strength and training in stroke and neurology:a systematic review.Int J Stroke, 2013, 8(2):124-130.
8 Menezes KK, Nascimento LR, Avelino PR, et al. Efficacy of interventions to improve respiratory function after stroke. Respir Care, 2018, 63(7):920-933.
9中华医学会神经病学分会脑血管病学组急性缺血性脑卒中诊治指南撰写组.中国急性缺血性脑卒中诊治指南2010.中国全科医学,2011,14(12B):4013-4017.
10 Steiner T,Kaste M,Forsting M,et al.脑出血治疗指南.王文娟,刘艳芳,赵性泉,译.中国卒中杂志,2006,1(12):888-899.
11 de Morton NA. The PEDro scale is a valid measure of the methodological quality of clinical trials:a demographic study. Aust J Physiother, 2009, 55(2):129-133.
12 Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ, 2003, 327(7414):557-560.
13 Higgins JP, Thompson SG. Quantifying heterogeneity in a metaanalysis. Stat Med, 2002, 21(11):1539-1558.
14 Chen PC, Liaw MY, Wang LY, et al. Inspiratory muscle training in stroke patients with congestive heart failure:a CONSORTcompliant prospective randomized single-blind controlled trial.Medicine(Baltimore), 2016, 95(37):e4856.
15 Cho JE, Lee HJ, Kim MK, et al. The improvement in respiratory function by inspiratory muscle training is due to structural muscle changes in patients with stroke:a randomized controlled pilot trial.Top Stroke Rehabil, 2018, 25(1):37-43.
16 Jung KM, Bang DH. Effect of inspiratory muscle training on respiratory capacity and walking ability with subacute stroke patients:a randomized controlled pilot trial. J Phys Ther Sci, 2017,29(2):336-339.
17 Kim J, Park JH, Yim J. Effects of respiratory muscle and endurance training using an individualized training device on the pulmonary function and exercise capacity in stroke patients. Med Sci Monit,2014, 20:2543-2549.
18 Lee HJ, Kang TW, Kim BR. Effects of diaphragm and deep abdominal muscle exercise on walking and balance ability in patients with hemiplegia due to stroke. J Exerc Rehabil, 2018,14(4):648-653.
19马硕,王维.呼吸训练联合常规康复训练对偏瘫患者功能康复的研究.中国康复医学杂志,2016, 31(10):1111-1116.
20宋征宇,张鹏,赵红梅,等.不同呼吸训练方式在脑卒中后疲劳治疗中的效果及对患者膈肌功能的影响.中国临床医生杂志,2018,46(12):1450-1453.
21苏国栋,刘惠林,黄梦洁,等.呼吸肌训练对急性脑卒中患者运动功能的效果.中国康复理论与实践,2016, 22(9):1008-1010.
22吴红琴,张兰香,王速敏,等.呼吸训练器对脑卒中患者肺功能及日常生活自理能力的影响.江苏医药,2015,41(19):2328-2329.
23余旭芳,吴李秀,俞坤强,等.Breathelink呼吸训练器对脑卒中患者肺功能及日常生活活动能力的影响.现代实用医学,2018,30(9):1180-1182.
24俞长君,李雪萍,林强,等.呼吸肌训练对亚急性期脑卒中患者呼吸功能的影响.中华物理医学与康复杂志,2016, 38(10):735-739.
25 Ezeugwu VE, Olaogun M, Mbada CE, et al. Comparative lung function performance of stroke survivors and age-matched and sex-matched controls. Physiother Res Int, 2013,18(4):212-219.
26 Lista Paz A, Gonzalez Doniz L, Ortigueira Garcia S, et al.Respiratory muscle strength in chronic stroke survivors and its relation with the 6-minute walk test. Arch Phys Med Rehabil, 2016,97(2):266-272.
27 Gladstone DJ, Danells CJ, Black SE. The Fugl-Meyer Assessment of motor recovery after stroke:a critical review of its measurement properties. Neurorehabil Neural Repair, 2002, 16(3):232-240.
28 Stinear CM. Prediction of motor recovery after stroke:advances in biomarkers. Lancet Neurol, 2017,16(10):826-836.
29 Oh D, Kim G, Lee W, et al. Effects of inspiratory muscle training on balance ability and abdominal muscle thickness in chronic stroke patients. J Phys Ther Sci, 2016, 28(1):107-111.
30 Bellet RN, Adams L, Morris NR. The 6-minute walk test in outpatient cardiac rehabilitation:validity, reliability and responsiveness--a systematic review. Physiotherapy, 2012, 98(4):277-286.
31中华医学会神经病学分会,中华医学会神经病学分会神经康复学组,中华医学会神经病学分会脑血管病学组.中国脑卒中早期康复治疗指南.中华神经科杂志,2017, 50(6):405-412.
32 Matos-Garcia BC, Rocco IS, Maiorano LD, et al. A home-based walking program improves respiratory endurance in patients with acute myocardial infarction:a randomized controlled trial. Can J Cardiol, 2017, 33(6):785-791.
33 Aznar-Lain S, Webster AL, Canete S, et al. Effects of inspiratory muscle training on exercise capacity and spontaneous physical activity in elderly subjects:a randomized controlled pilot trial. Int J Sports Med, 2007,28(12):1025-1029.
34 Reyes A, Ziman M, Nosaka K. Respiratory muscle training for respiratory deficits in neurodegenerative disorders:a systematic review. Chest, 2013,143(5):1386-1394.
35 Okada T, Huxel KC, Nesser TW. Relationship between core stability, functional movement, and performance. J Strength Cond Res, 2011, 25(1):252-261.
36吴希希,钱竞光,康延琳.步态分析技术在偏瘫康复中的应用研究.南京体育学院学报(自然科学版),2016,15(3):37-41,81.
37 Ohura T, Hase K, Nakajima Y, et al. Validity and reliability of a performance evaluation tool based on the modified Barthel Index for stroke patients. BMC Med Res Methodol, 2017,17(1):131.
38 Sandhya KM, Sri KV, Madhavi K. Effectiveness of supervised fitness and mobility exercise program on fitness, mobility and muscle strength in young adults with stroke. Int J Physiother, 2014,1(3):158-168.
39 Britto RR, Rezende NR, Marinho KC, et al. Inspiratory muscular training in chronic stroke survivors:a randomized controlled trial.Arch Phys Med Rehabil, 2011, 92(2):184-190.
40 Sutbeyaz ST, Koseoglu F, Inan L, et al. Respiratory muscle training improves cardiopulmonary function and exercise tolerance in subjects with subacute stroke:a randomized controlled trial. Clin Rehabil, 2010,24(3):240-250.
2 Hardwick RM, Rajan VA, Bastian AJ, et al. Motor learning in stroke:trained patients are not equal to untrained patients with less impairment. Neurorehabil Neural Repair, 2017, 31(2):178-189.
3 Han P, Zhang W, Kang L, et al. Clinical evidence of exercise benefits for stroke. Adv Exp Med Biol, 2017, 1000:131-151.
4 Ivey FM, Prior S, Hafer-Macko CE, et al. Strength training for skeletal muscle endurance after stroke. J Stroke Cerebrovasc Dis,2017, 26(4):787-794.
5 Rochester CL, Vogiatzis I, Holland AE, et al.An official American Thoracic Society/European Respiratory Society policy statement:enhancing implementation, use, and delivery of pulmonary rehabilitation. Am J Respir Crit Care Med, 2015, 192(11):1373-1386.
6陈彦,吴霜.肺康复训练对脑卒中患者肺功能影响的Meta分析.华西医学,2018, 33(10):1277-1286.
7 Pollock RD, Rafferty GF, Moxham J, et al. Respiratory muscle strength and training in stroke and neurology:a systematic review.Int J Stroke, 2013, 8(2):124-130.
8 Menezes KK, Nascimento LR, Avelino PR, et al. Efficacy of interventions to improve respiratory function after stroke. Respir Care, 2018, 63(7):920-933.
9中华医学会神经病学分会脑血管病学组急性缺血性脑卒中诊治指南撰写组.中国急性缺血性脑卒中诊治指南2010.中国全科医学,2011,14(12B):4013-4017.
10 Steiner T,Kaste M,Forsting M,et al.脑出血治疗指南.王文娟,刘艳芳,赵性泉,译.中国卒中杂志,2006,1(12):888-899.
11 de Morton NA. The PEDro scale is a valid measure of the methodological quality of clinical trials:a demographic study. Aust J Physiother, 2009, 55(2):129-133.
12 Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ, 2003, 327(7414):557-560.
13 Higgins JP, Thompson SG. Quantifying heterogeneity in a metaanalysis. Stat Med, 2002, 21(11):1539-1558.
14 Chen PC, Liaw MY, Wang LY, et al. Inspiratory muscle training in stroke patients with congestive heart failure:a CONSORTcompliant prospective randomized single-blind controlled trial.Medicine(Baltimore), 2016, 95(37):e4856.
15 Cho JE, Lee HJ, Kim MK, et al. The improvement in respiratory function by inspiratory muscle training is due to structural muscle changes in patients with stroke:a randomized controlled pilot trial.Top Stroke Rehabil, 2018, 25(1):37-43.
16 Jung KM, Bang DH. Effect of inspiratory muscle training on respiratory capacity and walking ability with subacute stroke patients:a randomized controlled pilot trial. J Phys Ther Sci, 2017,29(2):336-339.
17 Kim J, Park JH, Yim J. Effects of respiratory muscle and endurance training using an individualized training device on the pulmonary function and exercise capacity in stroke patients. Med Sci Monit,2014, 20:2543-2549.
18 Lee HJ, Kang TW, Kim BR. Effects of diaphragm and deep abdominal muscle exercise on walking and balance ability in patients with hemiplegia due to stroke. J Exerc Rehabil, 2018,14(4):648-653.
19马硕,王维.呼吸训练联合常规康复训练对偏瘫患者功能康复的研究.中国康复医学杂志,2016, 31(10):1111-1116.
20宋征宇,张鹏,赵红梅,等.不同呼吸训练方式在脑卒中后疲劳治疗中的效果及对患者膈肌功能的影响.中国临床医生杂志,2018,46(12):1450-1453.
21苏国栋,刘惠林,黄梦洁,等.呼吸肌训练对急性脑卒中患者运动功能的效果.中国康复理论与实践,2016, 22(9):1008-1010.
22吴红琴,张兰香,王速敏,等.呼吸训练器对脑卒中患者肺功能及日常生活自理能力的影响.江苏医药,2015,41(19):2328-2329.
23余旭芳,吴李秀,俞坤强,等.Breathelink呼吸训练器对脑卒中患者肺功能及日常生活活动能力的影响.现代实用医学,2018,30(9):1180-1182.
24俞长君,李雪萍,林强,等.呼吸肌训练对亚急性期脑卒中患者呼吸功能的影响.中华物理医学与康复杂志,2016, 38(10):735-739.
25 Ezeugwu VE, Olaogun M, Mbada CE, et al. Comparative lung function performance of stroke survivors and age-matched and sex-matched controls. Physiother Res Int, 2013,18(4):212-219.
26 Lista Paz A, Gonzalez Doniz L, Ortigueira Garcia S, et al.Respiratory muscle strength in chronic stroke survivors and its relation with the 6-minute walk test. Arch Phys Med Rehabil, 2016,97(2):266-272.
27 Gladstone DJ, Danells CJ, Black SE. The Fugl-Meyer Assessment of motor recovery after stroke:a critical review of its measurement properties. Neurorehabil Neural Repair, 2002, 16(3):232-240.
28 Stinear CM. Prediction of motor recovery after stroke:advances in biomarkers. Lancet Neurol, 2017,16(10):826-836.
29 Oh D, Kim G, Lee W, et al. Effects of inspiratory muscle training on balance ability and abdominal muscle thickness in chronic stroke patients. J Phys Ther Sci, 2016, 28(1):107-111.
30 Bellet RN, Adams L, Morris NR. The 6-minute walk test in outpatient cardiac rehabilitation:validity, reliability and responsiveness--a systematic review. Physiotherapy, 2012, 98(4):277-286.
31中华医学会神经病学分会,中华医学会神经病学分会神经康复学组,中华医学会神经病学分会脑血管病学组.中国脑卒中早期康复治疗指南.中华神经科杂志,2017, 50(6):405-412.
32 Matos-Garcia BC, Rocco IS, Maiorano LD, et al. A home-based walking program improves respiratory endurance in patients with acute myocardial infarction:a randomized controlled trial. Can J Cardiol, 2017, 33(6):785-791.
33 Aznar-Lain S, Webster AL, Canete S, et al. Effects of inspiratory muscle training on exercise capacity and spontaneous physical activity in elderly subjects:a randomized controlled pilot trial. Int J Sports Med, 2007,28(12):1025-1029.
34 Reyes A, Ziman M, Nosaka K. Respiratory muscle training for respiratory deficits in neurodegenerative disorders:a systematic review. Chest, 2013,143(5):1386-1394.
35 Okada T, Huxel KC, Nesser TW. Relationship between core stability, functional movement, and performance. J Strength Cond Res, 2011, 25(1):252-261.
36吴希希,钱竞光,康延琳.步态分析技术在偏瘫康复中的应用研究.南京体育学院学报(自然科学版),2016,15(3):37-41,81.
37 Ohura T, Hase K, Nakajima Y, et al. Validity and reliability of a performance evaluation tool based on the modified Barthel Index for stroke patients. BMC Med Res Methodol, 2017,17(1):131.
38 Sandhya KM, Sri KV, Madhavi K. Effectiveness of supervised fitness and mobility exercise program on fitness, mobility and muscle strength in young adults with stroke. Int J Physiother, 2014,1(3):158-168.
39 Britto RR, Rezende NR, Marinho KC, et al. Inspiratory muscular training in chronic stroke survivors:a randomized controlled trial.Arch Phys Med Rehabil, 2011, 92(2):184-190.
40 Sutbeyaz ST, Koseoglu F, Inan L, et al. Respiratory muscle training improves cardiopulmonary function and exercise tolerance in subjects with subacute stroke:a randomized controlled trial. Clin Rehabil, 2010,24(3):240-250.