超声引导下A型肉毒毒素治疗卒中后不同时期的跖屈肌痉挛
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摘要
背景:A型肉毒毒素用于治疗脑卒中患者下肢痉挛的理想时间目前尚无统一定论。目的:分析A型肉毒毒素治疗卒中后不同时期跖屈肌痉挛的效果是否存在差异。方法:纳入脑卒中后跖屈肌痉挛患者97例,其中失访6例。临床研究的实施符合广西医科大学第一附属医院对研究的相关伦理要求。根据跖屈肌痉挛发病时间将患者划分为3组:30例早期组(6个月内),29例中期组(6个月至1年),32例晚期组(>1至2年)。超声引导下给予患者腓肠肌、比目鱼肌、胫骨后肌各注射A型肉毒毒素100U(合并有足内翻者同时选取胫骨后肌注射A型肉毒毒素80U),每块肌肉注射2个点。注射后配合常规康复训练:每日1次,每周6次,连续治疗8周。注射后2,4,8周应用改良Ashworth量表、10 m步行试验、功能性步行量表(FAC)对治疗效果进行评价。结果与结论:①3组患者在注射后的步态和痉挛程度均有所改善,注射后2周改良Ashworth量表评估中位数值显著减小(P <0.001);②注射后4和8周3组患者功能性步行量表中位数值显著增大(P <0.001);③10m步行试验早期组能产生更大的步态速度变化;④结果说明,对于不同时期卒中后跖屈肌痉挛患者,进行A型肉毒毒素治疗都有望持续降低患者的肌张力和改善步态;尤其是早期(6个月以内)注射A型肉毒毒素治疗效果更加明显。
BACKGROUND: The ideal time of botulinum toxin A for treating lower limb spasm of stoke patients still remains controversial.OBJECTIVE: To evaluate whether the outcomes after botulinum toxin A injection for plantar flexion spasticity can be different according to stroke chronicity.METHODS: Ninety-seven patients with metatarsal flexor spasm after stroke were enrolled, 6 cases of loss to follow up. The study was in accordance with the ethics requirement of the First Affiliated Hospital of Guangxi Medical University. The patients were allocated into three groups based on onset time: early-term(within 6 months, n=30), middle-term(6-12 months, n=29), and late-term(1-2 years, n=32). The patients received 100 U botulinum toxin A injection at the gastrocnemius and soleus(for patients combined with varus, 80 U botulinum toxin A injection at the tibialis posterior) under ultrasound guidance, two injection points at each muscle. After injection, conventional rehabilitation training was conducted, once daily, six times per week for 8 consecutive weeks. The Modified Ashworth Scale, 10-meter walking test and Functional Ambulation Category were used for outcome evaluation at 2, 4 and 8 weeks after administration.RESULTS AND CONCLUSION:(1) The gait and spasm degree after administration were improved in all groups. Significant improvement in the Modified Ashworth Scale(P < 0.001) was observed at 2 week post-injection.(2) There was a significant difference in Functional Ambulation Category(P < 0.001) in all three groups at 4 and 8 weeks post-injection.(3) The early-term group of the 10-m walking test produced a great change in gait speed.(4) These results indicate that for patients with plantar flexor spasticity after stroke at different stages,botulinum toxin A treatment is expected to continuously reduce muscle tension and improve the gait. The effect is especially pronounced in patients who have been treated within 6 months.
BACKGROUND: The ideal time of botulinum toxin A for treating lower limb spasm of stoke patients still remains controversial.OBJECTIVE: To evaluate whether the outcomes after botulinum toxin A injection for plantar flexion spasticity can be different according to stroke chronicity.METHODS: Ninety-seven patients with metatarsal flexor spasm after stroke were enrolled, 6 cases of loss to follow up. The study was in accordance with the ethics requirement of the First Affiliated Hospital of Guangxi Medical University. The patients were allocated into three groups based on onset time: early-term(within 6 months, n=30), middle-term(6-12 months, n=29), and late-term(1-2 years, n=32). The patients received 100 U botulinum toxin A injection at the gastrocnemius and soleus(for patients combined with varus, 80 U botulinum toxin A injection at the tibialis posterior) under ultrasound guidance, two injection points at each muscle. After injection, conventional rehabilitation training was conducted, once daily, six times per week for 8 consecutive weeks. The Modified Ashworth Scale, 10-meter walking test and Functional Ambulation Category were used for outcome evaluation at 2, 4 and 8 weeks after administration.RESULTS AND CONCLUSION:(1) The gait and spasm degree after administration were improved in all groups. Significant improvement in the Modified Ashworth Scale(P < 0.001) was observed at 2 week post-injection.(2) There was a significant difference in Functional Ambulation Category(P < 0.001) in all three groups at 4 and 8 weeks post-injection.(3) The early-term group of the 10-m walking test produced a great change in gait speed.(4) These results indicate that for patients with plantar flexor spasticity after stroke at different stages,botulinum toxin A treatment is expected to continuously reduce muscle tension and improve the gait. The effect is especially pronounced in patients who have been treated within 6 months.
引文
[1]Teasell R,Foley N,Pereira S,et al.Evidence to practice:botulinum toxin in the treatment of spasticity post stroke.Top Stroke Rehabil.2012;19(2):115-121.
[2]Rosales RL,Efendy F,Teleg ES,et al.Botulinum toxin as early intervention for spasticity after stroke or non-progressive brain lesion:A meta-analysis.J Neurol Sci.2016;371(371):6-14.
[3]李亚斌,冯海霞,白佳佳,等.A型肉毒素局部注射结合强化运动治疗对脑卒中后下肢痉挛患者步行能力的影响[J].中国实用神经疾病杂志,2017,20(6):5-9.
[4]Tao W,Yan D,Li JH,et al.Gait improvement by low-dose botulinum toxin A injection treatment of the lower limbs in subacute stroke patients.J Phys Ther Sci.2015;27(3):759-762.
[5]Fock J,Galea MP,Stillman BC,et al.Functional outcome following Botulinum toxin A injection to reduce spastic equinus in adults with traumatic brain injury.Brain Injury.2004;18(1):57-63.
[6]中华神经科学会.中华神经外科学会.各类脑血管病诊断要点[J].中华神经科杂志,1996,29(6):379-380.
[7]肉毒毒素治疗成人肢体痉挛状态中国指南(2015),中国康复医学杂志,2015,1(30),81-110.
[8]Oh HM,Park GY,Choi YM,et al.The effects of botulinum toxin injections on plantar flexor spasticity in different phases after stroke.A secondary analysis from a double-blind,randomized trial.PM R.2018 Aug;10(8):789-797.
[9]洪永锋,徐军,沈显山,等.肌电引导A型肉毒毒素早期精准注射对脑卒中偏瘫侧上肢功能恢复的影响[J].中华物理医学与康复杂志,2018,7(40):499-502.
[10]Holden MK,Gill KM,Magliozzi MR,et al.Clinical gait assessment in the neurologically impaired.Reliability and meaningfulness.Phys Ther 1984;64:35-40.
[11]Dong Y,Wu T,Hu X,et al.Efficacy and safety of botulinum toxin type A for upper limb spasticity after stroke or traumatic brain injury:a systematic review with meta-analysis and trial sequential analysis.Eur J Phys Rehabil Med.2017;(2):256-267.
[12]Fheodoroff K,Dressler D,Woldag H,et al.Treatment goals in patients with post-stroke upper limb spasticity following injection of botulinum toxin A:Results of the German-Austrian subgroup of the ULIS-II study,Nervenarzt.2018;(8):245-256.
[13]Li J,Zhang R,Cui BL,et al.Therapeutic efficacy and safety of various botulinum toxin A doses and concentrations in spastic foot after stroke:a randomized controlled trial.Neural Regen Res.2017;12(9):1451-1457.
[14]Ivanhoe CB,Reistetter TA.Spasticity:the misunderstood part of the upper motor neuron syndrome.Am J Phys Med Rehabil.2004;83(10 Suppl):S3-S9.
[15]Im S,Park JH,Son SK,et al.Does botulinum toxin injection site determine outcome in post-stroke plantarflexion spasticity?Comparison study of two injection sites in the gastrocnemius muscle:a randomized double-blind controlled trial.Clin Rehabil.2014;(28):604-613.
[16]Wu T,Li JH,Song HX,et al.Effectiveness of botulinum toxin for lower limbs spasticity after stroke:a systematic review and Meta-Analysis.Top Stroke Rehabil.2016;(23):217-223.
[17]Nair KP,Marsden J.The management of spasticity in adults.BmJ.2014;349:g4737.
[18]Mehrholz J,Wagner K,Rutte K,et al.Predictive validity and responsiveness of the Functional Ambulation Category in hemiparetic patients after stroke.Arch Phys Med Rehabil.2007;88(10):1314-1319.
[19]Hara T,Abo M,Hara H,et al.The Effect of Repeated Botulinum Toxin A Therapy Combined with Intensive Rehabilitation on Lower Limb Spasticity in Post-Stroke Patients.Toxins.2018;10(9):2-12.
[20]Chan J,Winter A,Palit M,et al.Are gait and mobility measures responsive to change following botulinum toxin injections in adults with lower limb spasticity?Disabil Rehabil.2013;35:959-967.
[21]Mohammadi R,Talebian S,Phadke CP,et al.Effects of treadmill incline and speed on ankle muscle activity in subjects after a stroke.Arch Phys Med Rehabil.2016;97(3):445-453.
[22]Fietzek UM,Kossmehl P,Schelosky L,et al.Early botulinum toxin treatment for spastic pes equinovarus--a randomized double-blind placebo-controlled study.Eur J Neurol.2014;21(8):1089-1095.
[23]Suh YW,Uhm CS,Cho YA.Ultrastructural changes in myotendinous nerve endings induced by injection of botulinum toxin into the extraocular muscle.Graefes Arch Clin Exp Ophthalmol.2010;248(12):1795-801..
[24]Longino D,Frank C,Leonard TR,et al.Proposed model of botulinum toxin-induced muscle weakness in the rabbit.JOrthop Res.2005;(23):1411-1418.
[2]Rosales RL,Efendy F,Teleg ES,et al.Botulinum toxin as early intervention for spasticity after stroke or non-progressive brain lesion:A meta-analysis.J Neurol Sci.2016;371(371):6-14.
[3]李亚斌,冯海霞,白佳佳,等.A型肉毒素局部注射结合强化运动治疗对脑卒中后下肢痉挛患者步行能力的影响[J].中国实用神经疾病杂志,2017,20(6):5-9.
[4]Tao W,Yan D,Li JH,et al.Gait improvement by low-dose botulinum toxin A injection treatment of the lower limbs in subacute stroke patients.J Phys Ther Sci.2015;27(3):759-762.
[5]Fock J,Galea MP,Stillman BC,et al.Functional outcome following Botulinum toxin A injection to reduce spastic equinus in adults with traumatic brain injury.Brain Injury.2004;18(1):57-63.
[6]中华神经科学会.中华神经外科学会.各类脑血管病诊断要点[J].中华神经科杂志,1996,29(6):379-380.
[7]肉毒毒素治疗成人肢体痉挛状态中国指南(2015),中国康复医学杂志,2015,1(30),81-110.
[8]Oh HM,Park GY,Choi YM,et al.The effects of botulinum toxin injections on plantar flexor spasticity in different phases after stroke.A secondary analysis from a double-blind,randomized trial.PM R.2018 Aug;10(8):789-797.
[9]洪永锋,徐军,沈显山,等.肌电引导A型肉毒毒素早期精准注射对脑卒中偏瘫侧上肢功能恢复的影响[J].中华物理医学与康复杂志,2018,7(40):499-502.
[10]Holden MK,Gill KM,Magliozzi MR,et al.Clinical gait assessment in the neurologically impaired.Reliability and meaningfulness.Phys Ther 1984;64:35-40.
[11]Dong Y,Wu T,Hu X,et al.Efficacy and safety of botulinum toxin type A for upper limb spasticity after stroke or traumatic brain injury:a systematic review with meta-analysis and trial sequential analysis.Eur J Phys Rehabil Med.2017;(2):256-267.
[12]Fheodoroff K,Dressler D,Woldag H,et al.Treatment goals in patients with post-stroke upper limb spasticity following injection of botulinum toxin A:Results of the German-Austrian subgroup of the ULIS-II study,Nervenarzt.2018;(8):245-256.
[13]Li J,Zhang R,Cui BL,et al.Therapeutic efficacy and safety of various botulinum toxin A doses and concentrations in spastic foot after stroke:a randomized controlled trial.Neural Regen Res.2017;12(9):1451-1457.
[14]Ivanhoe CB,Reistetter TA.Spasticity:the misunderstood part of the upper motor neuron syndrome.Am J Phys Med Rehabil.2004;83(10 Suppl):S3-S9.
[15]Im S,Park JH,Son SK,et al.Does botulinum toxin injection site determine outcome in post-stroke plantarflexion spasticity?Comparison study of two injection sites in the gastrocnemius muscle:a randomized double-blind controlled trial.Clin Rehabil.2014;(28):604-613.
[16]Wu T,Li JH,Song HX,et al.Effectiveness of botulinum toxin for lower limbs spasticity after stroke:a systematic review and Meta-Analysis.Top Stroke Rehabil.2016;(23):217-223.
[17]Nair KP,Marsden J.The management of spasticity in adults.BmJ.2014;349:g4737.
[18]Mehrholz J,Wagner K,Rutte K,et al.Predictive validity and responsiveness of the Functional Ambulation Category in hemiparetic patients after stroke.Arch Phys Med Rehabil.2007;88(10):1314-1319.
[19]Hara T,Abo M,Hara H,et al.The Effect of Repeated Botulinum Toxin A Therapy Combined with Intensive Rehabilitation on Lower Limb Spasticity in Post-Stroke Patients.Toxins.2018;10(9):2-12.
[20]Chan J,Winter A,Palit M,et al.Are gait and mobility measures responsive to change following botulinum toxin injections in adults with lower limb spasticity?Disabil Rehabil.2013;35:959-967.
[21]Mohammadi R,Talebian S,Phadke CP,et al.Effects of treadmill incline and speed on ankle muscle activity in subjects after a stroke.Arch Phys Med Rehabil.2016;97(3):445-453.
[22]Fietzek UM,Kossmehl P,Schelosky L,et al.Early botulinum toxin treatment for spastic pes equinovarus--a randomized double-blind placebo-controlled study.Eur J Neurol.2014;21(8):1089-1095.
[23]Suh YW,Uhm CS,Cho YA.Ultrastructural changes in myotendinous nerve endings induced by injection of botulinum toxin into the extraocular muscle.Graefes Arch Clin Exp Ophthalmol.2010;248(12):1795-801..
[24]Longino D,Frank C,Leonard TR,et al.Proposed model of botulinum toxin-induced muscle weakness in the rabbit.JOrthop Res.2005;(23):1411-1418.