早期康复干预对急性脑卒中患者临床疗效观察
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摘要
前言
脑卒中是一组急性起病的脑血液循环障碍疾病,以起病急骤,出现局灶神经功能缺失为特征。其引起的功能障碍主要表现在意识、运动、知觉、认知、语言、精神情绪方面,其大多发生在中老年人,发病率、死亡率及致残率、复发率均较高,致残后严重影响患者日常生活,增加社会及家庭负担。现代康复治疗的介入极大地改善了这种状况,使相当一部分患者生活自理、重返社会。目前多数学者主张脑卒中后应尽早进行康复治疗。为探讨早期康复干预对脑卒中偏瘫患者偏瘫侧肢体的肌张力、上下肢功能恢复及日常生活活动能力(activities of daily living,ADL)的影响,我们对脑卒中急性期的患者进行了研究。
方法
将108例急性脑卒中患者随机分为治疗组和对照组。两组患者均予以常规的药物治疗、心理治疗等,治疗组患者加以规范化的康复训练。所有病例均在入组时、脑卒中病程1个月、3个月时各评定1次肌痉挛、运动功能和日常生活活动能力。量表分别采用改良Ashworth量表(MAS)、简化Fugl-Meyer量表(FMA)和Barthel指数(BI)。
结果
在入组时两组患者间MAS评分、FMA评分和BI比较P＞0.05,具有可比性。1个月时治疗组患者的MAS评分,高于同期的对照组患者(P＜0.05);3个月时,对照组患者的MAS评分高于同期的治疗组患者(P＜0.05);两组患者的FMA评分和BI评分在脑卒中病程1个月、3个月时分别与其前一次评定时比较,均有明显改善(P＜0.001);在脑卒中病程3个月时,治疗组的FMA评分和BI评分均高于对照组(P＜0.01)。
结论
①早期康复训练可缩短脑卒中患者弛缓性瘫痪的时间,有利于肢体运动功能的恢复;②痉挛期,早期康复训练可减轻患者偏瘫侧肢体痉挛从而改善运动功能,提高日常生活活动能力。
Background: Acute stroke is a group of diseases caused by sudden obstruction of cerebral blood circulation, which mainly presents with focal neurological deficiency including dysfunction of perception, cognition, speaking, and emotion. It occurs mainly in the elderly with high morbidity, mortality and recurrence, which will greatly change a patient's daily life and increase social and family burdens if disability developed. Currently, early rehabilitation intervention after stroke has been advocated by many physicians. The aim of our study was to evaluate the effectiveness of such intervention in the acute stroke patients, in aspect of spasticity, activity of daily living (ADL) and motor function recovery of the affected limbs.
Methods: One hundred eight patients with acute stroke were divided randomly into two groups: early rehabilitation group (intervention group) and control group. All the patients in the two groups were given routine treatment of medications and psychological support, but the patients in the intervention group were added early rehabilitation. The baseline of myospasm, motor function, and activities of daily living was recorded for all the subjects with Modified Ashworth table (MAS), Simplified Fugl-Meye table (FMA), and Barthel Index (BI), and then evaluated one month and three months after the treatment, respectively.
Results: At the baseline, the scores of MAS, FMA, and BI between two groups have no significant difference (P>0.05). One month after stroke, the MAS score of the intervention group was higher than the one of the control group (P<0.05), and three months after stroke, the MAS score of the control group was higher than the one of intervention group. One month and three months after stroke, FMA and BI scores of both groups were much higher than their previous ones (P<0.001). Three months after stroke, FMA and BI scores of the intervention group were higher than the ones of control group (P<0.01).
Conclusions: (1)Early rehabilitation for stroke patients can shorten the duration of flaccid paralysis. (2)Early rehabilitation can reduce spasticity of the affected limbs for stroke patients, thus, to improve patients' motor function and then improve patients' ADL.
脑卒中是一组急性起病的脑血液循环障碍疾病,以起病急骤,出现局灶神经功能缺失为特征。其引起的功能障碍主要表现在意识、运动、知觉、认知、语言、精神情绪方面,其大多发生在中老年人,发病率、死亡率及致残率、复发率均较高,致残后严重影响患者日常生活,增加社会及家庭负担。现代康复治疗的介入极大地改善了这种状况,使相当一部分患者生活自理、重返社会。目前多数学者主张脑卒中后应尽早进行康复治疗。为探讨早期康复干预对脑卒中偏瘫患者偏瘫侧肢体的肌张力、上下肢功能恢复及日常生活活动能力(activities of daily living,ADL)的影响,我们对脑卒中急性期的患者进行了研究。
方法
将108例急性脑卒中患者随机分为治疗组和对照组。两组患者均予以常规的药物治疗、心理治疗等,治疗组患者加以规范化的康复训练。所有病例均在入组时、脑卒中病程1个月、3个月时各评定1次肌痉挛、运动功能和日常生活活动能力。量表分别采用改良Ashworth量表(MAS)、简化Fugl-Meyer量表(FMA)和Barthel指数(BI)。
结果
在入组时两组患者间MAS评分、FMA评分和BI比较P＞0.05,具有可比性。1个月时治疗组患者的MAS评分,高于同期的对照组患者(P＜0.05);3个月时,对照组患者的MAS评分高于同期的治疗组患者(P＜0.05);两组患者的FMA评分和BI评分在脑卒中病程1个月、3个月时分别与其前一次评定时比较,均有明显改善(P＜0.001);在脑卒中病程3个月时,治疗组的FMA评分和BI评分均高于对照组(P＜0.01)。
结论
①早期康复训练可缩短脑卒中患者弛缓性瘫痪的时间,有利于肢体运动功能的恢复;②痉挛期,早期康复训练可减轻患者偏瘫侧肢体痉挛从而改善运动功能,提高日常生活活动能力。
Background: Acute stroke is a group of diseases caused by sudden obstruction of cerebral blood circulation, which mainly presents with focal neurological deficiency including dysfunction of perception, cognition, speaking, and emotion. It occurs mainly in the elderly with high morbidity, mortality and recurrence, which will greatly change a patient's daily life and increase social and family burdens if disability developed. Currently, early rehabilitation intervention after stroke has been advocated by many physicians. The aim of our study was to evaluate the effectiveness of such intervention in the acute stroke patients, in aspect of spasticity, activity of daily living (ADL) and motor function recovery of the affected limbs.
Methods: One hundred eight patients with acute stroke were divided randomly into two groups: early rehabilitation group (intervention group) and control group. All the patients in the two groups were given routine treatment of medications and psychological support, but the patients in the intervention group were added early rehabilitation. The baseline of myospasm, motor function, and activities of daily living was recorded for all the subjects with Modified Ashworth table (MAS), Simplified Fugl-Meye table (FMA), and Barthel Index (BI), and then evaluated one month and three months after the treatment, respectively.
Results: At the baseline, the scores of MAS, FMA, and BI between two groups have no significant difference (P>0.05). One month after stroke, the MAS score of the intervention group was higher than the one of the control group (P<0.05), and three months after stroke, the MAS score of the control group was higher than the one of intervention group. One month and three months after stroke, FMA and BI scores of both groups were much higher than their previous ones (P<0.001). Three months after stroke, FMA and BI scores of the intervention group were higher than the ones of control group (P<0.01).
Conclusions: (1)Early rehabilitation for stroke patients can shorten the duration of flaccid paralysis. (2)Early rehabilitation can reduce spasticity of the affected limbs for stroke patients, thus, to improve patients' motor function and then improve patients' ADL.
引文
[1]南登昆.康复医学.北京:人民卫生出版社,1997:255.
[2]全国第四届脑血管病学术会议.各类脑血管病诊断要点.中华神经科杂志,1996,29(6):379-380.
[3]霍文景,泮克勤,殷建权.脑卒中偏瘫患者的综合康复治疗.中国康复,2002,3(1):169.
[4]姜从玉,胡永善.康复训练促进脑梗死后功能恢复机制的基础研究进展.中华物理医学与康复杂志,2002,24(7):443-445.
[5]朱镛连.神经康复学基本理论.北京:人民军医出版社,2001:1-14.
[6]Wood Pauplinel SL,Ivan Williams PTJ,Shapiro SH.Examining outcome measures in a clinical study of stroke.Stroke,1990,21(5):731-739
[7]胡永善,朱玉连,杨培君,等.早期康复治疗对急性脑卒中患者运动功能的影响.中国康复医学杂志,2002,17(3):145-147.
[8]Feydy A,Carlier R,Roby-Brami A,et al.Longitudinal study of motor recovery after stroke:trcruitment and focusing of brain activation.Stroke,2002,33(6):1610-1618.
[9]Sherrill,Susan R.Early intervention cares in the acute stroke patients.Arch Phys Med Rehabil,1986,67(5):319-321.
[10]南登昆,缪鸿石,主编.康复医学.北京:人民卫生出版社,2002:208-212.
[11]李友莲,戚晓昆,钱海蓉.脑卒中患者早期神经康复疗效评价.中国 临床康复,2002,6(13):1928-1929.
[12]王鸿祥,王左生.脑梗塞患者急性期康复治疗观察.中国康复医学杂志,1996,11(2):74-761
[13]Stromer RP,Kent TA,Hulsebosceh CE.Neocortical neural sprouting,synaptogenesis,and behavioral recovery after neocortical infarction in rats.Stroke,1995,26:2135.
[14]Davies SJA,Fitch MT,Memberg SP,et al.Regeneraton of the adult axonsin white matter tracts of the entral nervous system.Nature,1997,18:390.
[15]南登昆,缪鸿石主编.康复医学.北京:人民卫生出版社,1993.208-2121
[16]邱纪方.中风偏瘫的全程运动治疗方案及其安全性初探.中国康复医学杂志,1995,10(3):1161
[17]赵汰.现代偏瘫治疗学.北京:人民军医出版社,1996.174-1871
[18]马诚,彭丽萍,谢志强,等.综合康复治疗对脑卒中偏瘫痉挛的影响.中华物理医学与康复杂志,2004,26(1)50-51.
[19]侯红,王彤.抗痉挛技术对偏瘫患者上肢肌痉挛改善的疗效观察.中国康复医学杂志,2004,199(6):437-438.
[20]胡永善,朱玉连,杨佩君,等.早期康复治疗对急性脑卒中患者日常生活能力的影响.中国康复医学杂志,2002,17(4):215-217.
[21]刘鹏,黄东锋,毛玉榕,等.早期康复对脑卒中患者功能恢复的影响.中国康复医学杂志,2003,18(2):99-100.
[22]燕铁斌主编.现代康复治疗学.广州:广东科技出版社,2004.363-367.
[23]Zemke A C,Heagerty PJ,Lee C,e tal.Motor cortex organizations after strokeis related to side of stroke and level of recovery.Stroke,2003,34(5):23-30.
[1]Lance JW.The control of muscle tone,reflexes,and movement:Robert Wartenberg Lecture.Neurology,1980,30:1303-1313.
[2]Watkins CL,Leathley MJ,Gregson JM,et al.Prevalence of spasticity post stroke.Clin Rehabil,2002,16:515-522.
[3]Ju MS,Chen JJ,Lee HM,et al.Time-course analysis of stretch reflexes in hemiparetic subjects using an on-line spasticity measurement system.J Electrom yogr Kinesiol,2000,10:1-14.
[4]Thilmann AF,Fellows SJ.The time-course of bilateral changes in the reflex excitability of relaxed triceps surae muscle in human hemiparetic spasticity.J Neurol,1991,238:293-298.
[5]Krebs HI,Ferraro M,Buergerr SP,et al.Rehabilitation robotics:pilot trial of a spatial extension for MIT-Manus.J Neuroengineering Rehabil,2004,1:1-15.
[6]缪鸿石.康复医学理论与实践.上海:上海科学技术出版社,2000.1 190-1 191,1 198.
[7]金荣疆、罗荣、扬玉龙.脑卒中后痉挛性瘫痪的治疗对策.四川中医,2005,23(9):15.
[8]缪鸿石.康复医学理论与实践.上海:上海科学技术出版社,2000.1 198,1207.
[9]Bohannon RW.Tilt table standing for reducing spasticity after spinal cord injury.Arch Phys Med Rehabil,1993,74:1121-1122.
[10]Bobath B.Adult hemiplegia:evaluation and treatment Ox-ford:Butter-worth-Heinemann Ltd,1990.70-150.
[11]丁葆丽,麻淑清,朱迎九,等.水疗在脊髓损伤患者康复治疗中的应用.中国康复理论与实践,2005,11(10):862-863.
[12]Bobth K,Bobth B.A treatment of cerebral palsy based on the analysis of the patient's motor behaviour.Br J Phys Med,1952:15:107-117.
[13]Nurens GE,De Weerdt WJ,Spaepen AJ Jr,et al.Reduction of spastic hypertonia during repeated passice knee movements in stroke patients.Arch Phys Med Rehabil,2002,83:930-935.
[14]Lieber RI,Friden J.Spasticity causes a fundamental rearrangement of muscle-joint interaction.Muscle Nerve,2002,25:265-270.
[15]Gordon AM,Huxley AF,Julian FJ,et al.The variation in isometric tention with sarcomere length in verterbrate muscle fibres.J Physiol,1966,184:170-192.
[16]Ross Z,Elie PE,LisaL.Acute care management of Post-TBI spasticity.J Head Trauma Rehabil,2004,19(2):89-100.
[17]Krach L.Pharmacotherapy of spasticity:Oral medication and intrathecal baclofen.J Child Neurol,2001,16:31.
[18]Gelber DA,Good De,Dromerick A,et al.Open label dose titration safety and efficacy study of tizanidine in the treatment of spasticity associated hydrochloride with chronic stroke.Stroke,2001, 32:1841-1846.
[19]Groves L,Shellenberger MK,Davis CS.Tizanidine treatment of spasticity A meta-analysis of controlled,double-blind,comparative studies with baclofen and diazepam.Adv Ther,1998,15:241-251.
[20]Blasi J,Chapman E,Link E,et al.Botulinum neurotoxin A selectively cleaves the synapse prote in SNAP225.Nature,1993,265:160-163.
[21]吴小丽等肌电引导下注射A型肉毒毒素治疗脑损伤后下肢痉挛的临床观察.海南医学2007,18(3):89,28.
[22]李哲、郭钢花、熊华春等膝矫形器对脑卒中后腘绳肌痉挛患者步行功能恢复的影响。中国康复医学杂志,2007,22(4):349-350.
[23]Burchiel KJ,Hsu FPK.Pain and spasticity after spinal cord injury mechanisms and treatment.Spine,2001,26:S146-S160.
[24]Putty TK,Shapiro SA.Efficacy of dorsal longitudinal myelotomy in treating spinal spasticity:a review of 20 cases.J Neurosurg,1991,75:397-401.
[2]全国第四届脑血管病学术会议.各类脑血管病诊断要点.中华神经科杂志,1996,29(6):379-380.
[3]霍文景,泮克勤,殷建权.脑卒中偏瘫患者的综合康复治疗.中国康复,2002,3(1):169.
[4]姜从玉,胡永善.康复训练促进脑梗死后功能恢复机制的基础研究进展.中华物理医学与康复杂志,2002,24(7):443-445.
[5]朱镛连.神经康复学基本理论.北京:人民军医出版社,2001:1-14.
[6]Wood Pauplinel SL,Ivan Williams PTJ,Shapiro SH.Examining outcome measures in a clinical study of stroke.Stroke,1990,21(5):731-739
[7]胡永善,朱玉连,杨培君,等.早期康复治疗对急性脑卒中患者运动功能的影响.中国康复医学杂志,2002,17(3):145-147.
[8]Feydy A,Carlier R,Roby-Brami A,et al.Longitudinal study of motor recovery after stroke:trcruitment and focusing of brain activation.Stroke,2002,33(6):1610-1618.
[9]Sherrill,Susan R.Early intervention cares in the acute stroke patients.Arch Phys Med Rehabil,1986,67(5):319-321.
[10]南登昆,缪鸿石,主编.康复医学.北京:人民卫生出版社,2002:208-212.
[11]李友莲,戚晓昆,钱海蓉.脑卒中患者早期神经康复疗效评价.中国 临床康复,2002,6(13):1928-1929.
[12]王鸿祥,王左生.脑梗塞患者急性期康复治疗观察.中国康复医学杂志,1996,11(2):74-761
[13]Stromer RP,Kent TA,Hulsebosceh CE.Neocortical neural sprouting,synaptogenesis,and behavioral recovery after neocortical infarction in rats.Stroke,1995,26:2135.
[14]Davies SJA,Fitch MT,Memberg SP,et al.Regeneraton of the adult axonsin white matter tracts of the entral nervous system.Nature,1997,18:390.
[15]南登昆,缪鸿石主编.康复医学.北京:人民卫生出版社,1993.208-2121
[16]邱纪方.中风偏瘫的全程运动治疗方案及其安全性初探.中国康复医学杂志,1995,10(3):1161
[17]赵汰.现代偏瘫治疗学.北京:人民军医出版社,1996.174-1871
[18]马诚,彭丽萍,谢志强,等.综合康复治疗对脑卒中偏瘫痉挛的影响.中华物理医学与康复杂志,2004,26(1)50-51.
[19]侯红,王彤.抗痉挛技术对偏瘫患者上肢肌痉挛改善的疗效观察.中国康复医学杂志,2004,199(6):437-438.
[20]胡永善,朱玉连,杨佩君,等.早期康复治疗对急性脑卒中患者日常生活能力的影响.中国康复医学杂志,2002,17(4):215-217.
[21]刘鹏,黄东锋,毛玉榕,等.早期康复对脑卒中患者功能恢复的影响.中国康复医学杂志,2003,18(2):99-100.
[22]燕铁斌主编.现代康复治疗学.广州:广东科技出版社,2004.363-367.
[23]Zemke A C,Heagerty PJ,Lee C,e tal.Motor cortex organizations after strokeis related to side of stroke and level of recovery.Stroke,2003,34(5):23-30.
[1]Lance JW.The control of muscle tone,reflexes,and movement:Robert Wartenberg Lecture.Neurology,1980,30:1303-1313.
[2]Watkins CL,Leathley MJ,Gregson JM,et al.Prevalence of spasticity post stroke.Clin Rehabil,2002,16:515-522.
[3]Ju MS,Chen JJ,Lee HM,et al.Time-course analysis of stretch reflexes in hemiparetic subjects using an on-line spasticity measurement system.J Electrom yogr Kinesiol,2000,10:1-14.
[4]Thilmann AF,Fellows SJ.The time-course of bilateral changes in the reflex excitability of relaxed triceps surae muscle in human hemiparetic spasticity.J Neurol,1991,238:293-298.
[5]Krebs HI,Ferraro M,Buergerr SP,et al.Rehabilitation robotics:pilot trial of a spatial extension for MIT-Manus.J Neuroengineering Rehabil,2004,1:1-15.
[6]缪鸿石.康复医学理论与实践.上海:上海科学技术出版社,2000.1 190-1 191,1 198.
[7]金荣疆、罗荣、扬玉龙.脑卒中后痉挛性瘫痪的治疗对策.四川中医,2005,23(9):15.
[8]缪鸿石.康复医学理论与实践.上海:上海科学技术出版社,2000.1 198,1207.
[9]Bohannon RW.Tilt table standing for reducing spasticity after spinal cord injury.Arch Phys Med Rehabil,1993,74:1121-1122.
[10]Bobath B.Adult hemiplegia:evaluation and treatment Ox-ford:Butter-worth-Heinemann Ltd,1990.70-150.
[11]丁葆丽,麻淑清,朱迎九,等.水疗在脊髓损伤患者康复治疗中的应用.中国康复理论与实践,2005,11(10):862-863.
[12]Bobth K,Bobth B.A treatment of cerebral palsy based on the analysis of the patient's motor behaviour.Br J Phys Med,1952:15:107-117.
[13]Nurens GE,De Weerdt WJ,Spaepen AJ Jr,et al.Reduction of spastic hypertonia during repeated passice knee movements in stroke patients.Arch Phys Med Rehabil,2002,83:930-935.
[14]Lieber RI,Friden J.Spasticity causes a fundamental rearrangement of muscle-joint interaction.Muscle Nerve,2002,25:265-270.
[15]Gordon AM,Huxley AF,Julian FJ,et al.The variation in isometric tention with sarcomere length in verterbrate muscle fibres.J Physiol,1966,184:170-192.
[16]Ross Z,Elie PE,LisaL.Acute care management of Post-TBI spasticity.J Head Trauma Rehabil,2004,19(2):89-100.
[17]Krach L.Pharmacotherapy of spasticity:Oral medication and intrathecal baclofen.J Child Neurol,2001,16:31.
[18]Gelber DA,Good De,Dromerick A,et al.Open label dose titration safety and efficacy study of tizanidine in the treatment of spasticity associated hydrochloride with chronic stroke.Stroke,2001, 32:1841-1846.
[19]Groves L,Shellenberger MK,Davis CS.Tizanidine treatment of spasticity A meta-analysis of controlled,double-blind,comparative studies with baclofen and diazepam.Adv Ther,1998,15:241-251.
[20]Blasi J,Chapman E,Link E,et al.Botulinum neurotoxin A selectively cleaves the synapse prote in SNAP225.Nature,1993,265:160-163.
[21]吴小丽等肌电引导下注射A型肉毒毒素治疗脑损伤后下肢痉挛的临床观察.海南医学2007,18(3):89,28.
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