预期性姿势调整在脑卒中步态康复中的应用及脑机制探索

在步行等动作开始前的姿势控制调整称之为预期性姿势调整,而脑卒中患者在步态启动前,由于脑损伤导致的异常预期性姿势控制模式可能会激活本不该被激活的肌肉,从而诱发异常步态。目前临床常见的步态训练更多注重患者行走时的下肢肌力、肌张力、关节活动度以及支撑摆动相比值等参数,而鲜有针对步行前预期性姿势控制的临床干预。本文将针对步态启动前预期性姿势调整的相关概念、机制假说、治疗等方面进行简要总结,以促进临床医师更多关注和利用预期性姿势调整提高脑卒中患者的步行能力。     

预测性姿势调节对人体站立受扰后姿势响应影响的研究

目的:对比研究有预判和无预判两种状态下,站立姿势受到水平方向外部干扰(站立支持面向后移动)刺激时,人体运动表现及其可能的控制机制。从肌电学及运动学角度探讨预测性姿势调节对人体动态姿势控制能力的影响,更好地了解人体基本姿势控制机能。方法:使用三维高速摄像系统(100Hz)、无线表面肌电采集系统(4000Hz)采集13例男性青年受试者在有预判和无预判两种状态下,受到站立支持面水平方向后移干扰刺激时,姿势控制过程中的肌电及运动学数据,对比研究下肢三关节及躯干的角度变化、Co M前后方向位移峰值及峰值出现时间、APAs阶段(干扰发生前100ms至发生后50ms)及CPAs阶段(干扰发生后50ms至200ms)内相应肌肉平均积分肌电值。结果:(1)有预判状态下,下肢三关节及躯干角度变化小于无预判时,且Co M前后方向位移峰值较小,峰值时刻出现时间较早;(2)有预判状态下,APAs阶段,腹直肌(P=0.04)、股直肌(P=0.04)、胫骨前肌(P=0.04)平均积分肌电值显著大于无预判情况,CPAs阶段,竖脊肌(P=0.01)、股二头肌(P=0.04)、腓肠肌内侧头(P=0.04)平均积分肌电值显著较小。结论:预测性姿势调节可通过相应肌群的预激活,使干扰发生后关节角度变化减小,肌肉活动强度下降,并能有效的减小身体摆动幅度,促进姿势稳定性的提高。     

脊柱旋转下不同非均匀姿势和持重时躯干肌的表面肌电活动规律

目的观察脊柱旋转下不同非均匀姿势和持重时躯干肌的表面肌电活动规律。 方法选取正常健康成年男性10名，每名受试者以足底顺时针方向（0°、45°、90°、135°、180°）依次旋转站立，右手在0°位置抓住手柄负重，除0°位置外，受试者均为单纯侧屈姿态。每个测试位置均由带脊柱旋转的3个非均匀姿势组成，即直立位、左侧及右侧伸屈位。测试时，采用VICON三维拍摄测试系统观察躯干角的三维角度运动轨迹，利用表面肌电图仪记录受试者双侧腹直肌（RA）、腹外斜肌（EO）、竖脊肌（ES）、多裂肌（LM）、臀中肌（GM）的肌电变化。 结果不持重0°足位下，双侧RA、EO、ES、LM、GM的最大自主静态收缩值（MVC）百分比为1%～2%；持重20kg时，MVC%增高至3%～13%。不持重45°足位下，双侧各躯干肌的MVC%值在2%～18%之间；持重20kg时，除RA外，左侧各肌肉的肌电活动均较右侧活跃。不持重90°、135°及180°足位下，双侧各肌肉的肌电活动均有不同程度变化，少数情况下还伴随有其它肌肉的活跃肌电现象，多见于LM，其次为ES；持重20kg时，任一姿势下双侧腹肌的肌电活动均均减少，但是背侧肌均增高。45°直立位和135°左侧前屈位不持重情况下，受试者腰部闪动次数显著增多，与负重20kg下同一姿势比较，差异有统计学意义（P<0.05）。 结论脊柱旋转下，双侧躯干肌可产生不均匀的活跃肌电活动，以对抗其不均匀受力状况，所产生的腰部闪动现象可能是急性腰扭伤的病理基础之一。     

电针对脑卒中患者网状脊髓束激活和预期性姿势调整的影响

目的：以惊吓启动上肢够取运动范式为手段探究电针对脑卒中患者网状脊髓束（RST）的易化及预期性姿势调整（APA）的影响。方法：13例脑卒中患者在进行20min电针（合谷和曲池）干预前后分别进行惊吓启动上肢够取测试。此测试任务要求患者在坐位下根据80分贝（普通）或114分贝（惊吓）启动声音使用患侧上肢完成30次够取任务,同时采集双侧胸锁乳突肌（SCM）、双侧下斜方肌和运动侧的三角肌、桡侧腕屈肌及桡侧腕伸肌的表面肌电数据。另外,根据SCM是否发生提前激活将114分贝声音启动任务划分为SCM＋和SCM－启动状态。基于肌电数据处理输出电针干预前后惊吓反应阳性发生率和不同启动状态下的运动前反应时、各肌肉APA激活启动延时及幅值等进行统计分析。结果：电针干预后患者惊吓反应阳性发生率明显升高（P＝0.048）,且运动前反应时显著缩短（P＝0.038）。另外,电针干预后桡侧腕伸肌在惊吓阳性测试中的启动延时显著缩短（P＜0.001）,且APA幅值明显提高（P＝0.049）。同时,电针干预后运动对侧下斜方肌在惊吓阴性测试中的启动延时显著延迟（P＜0.001）,在普通声音启动（P＝0.003）和惊吓阳性启动状态下（P＝0.01）的APA幅值显著降低。结论：电针对脑卒中患者RST通路存在易化作用,表现为阳性反应增强和前臂肌肉预期性姿势调节的增强。     

18~22岁女性Y平衡测试的下肢表面肌电和姿势稳定性特征

目的 探究Y平衡测试时下肢肌肉肌电特征和姿势稳定性,以及两者间的关系。     

前后方向水平姿势扰动对人体站立平衡响应的影响

目的:对比受试者在受到站立平台突然前移和后移两方向外部干扰下,姿势控制过程中运动学及相关肌肉动员表现,为平衡障碍人群的康复提供理论指导。方法:使用三维红外运动捕捉系统(100Hz)、无线表面肌电采集系统(4000Hz)采集13例男性青年受试者分别受到站立平台前、后两方向水平移动干扰刺激时,姿势控制过程中的肌电及运动学数据,对比研究下肢三关节及躯干的角度变化、身体质心前后方向位移及平衡恢复过程中各相关肌肉平均积分肌电值。结果:两方向水平刺激下身体质心位移方向相反,各关节表现出了方向相反的角度变化;在站立平台后移时,腓肠肌的活动强度要显著大于站立平台前移时(P0.05),而股直肌、胫骨前肌和腰段竖脊肌的肌电活动则表现为站立平台前移时显著较大(P0.05);除腹直肌和竖脊肌外,其他肌肉的激活时间无显著差异。结论:中枢神经系统会根据不同方向扰动自动调节人体的响应,通过协调主动肌与拮抗肌的活动强度,控制人体各主要环节的运动,从而将人体质心控制在支撑面内,维持机体的稳定。     

力量和平衡训练对帕金森病患者运动及姿势控制功能的影响

目的:评价力量和平衡训练改善帕金森病(PD)患者运动及姿势控制能力的差异。方法:PD患者64例,随机分为力量训练组31例和平衡训练组33例,分别给予8周肢体力量强度训练和站姿、步态平衡训练。评价2组训练第8周富尔顿高级平衡量表(FAB)评分、计时起立-步行测验(TUGT)、临床总体印象量表(CGI)评分、帕金森病统一评分量表(UPDRS)评分、步长和步速的改善情况。结果:2组均顺利完成康复训练,无随访脱落病例。治疗第8周力量训练组FAB评分、TUGT值、UPGRS评分、步长和步速均较治疗前改善(P<0.05),平衡训练组只有步长和步速较治疗前改善(P<0.05);力量训练组64.52%(20/31)的患者达到CGI临床改善,而只有42.42%(14/33)的平衡训练组患者达到临床改善,组间比较差异无统计学意义(χ2=3.133,P=0.077)。结论:力量训练改善PD患者运动及姿势控制的能力优于平衡训练。     

动态失稳训练对脑卒中患者姿势控制能力、平衡与步行功能的影响

目的 观察动态失稳训练对脑卒中患者姿势控制、平衡与步行功能的影响。 方法 采用随机数字表法将40例脑卒中患者分为对照组和观察组,每组20例。所有患者均接受常规康复治疗,观察组在此基础上给予动态失稳训练,对照组增加相同时长的常规康复治疗。治疗前、治疗8周后（治疗后）,采用表面肌电图（sEMG）检测2组患者双侧股直肌、股二头肌、竖脊肌的表面肌电信号,包括预期姿势调节(APAs)阶段的激活时间和激活强度,补偿姿势调节(CPAs)阶段的激活强度。采用Berg平衡量表（BBS）、Fugl-Meyer运动功能量表(FMA)下肢部分、GaitWatch步态分析系统评估患者的平衡与步行能力。 结果 与对照组治疗后比较,观察组患侧股直肌［(-71.68±2.64)s］、股二头肌［(-90.07±3.65)s］和健侧股二头肌［(-84.31±5.74)s］、竖脊肌［(-67.29±5.04)s］APAs阶段的激活时间提前较多（P＜0.05）,患侧股直肌［(9.90±0.77)］、竖脊肌［(10.18±0.72)］APAs阶段的激活强度较高（P＜0.05）。2组患者治疗后CPAs阶段各肌群的激活强度组间比较,差异无统计学意义（P＞0.05）。观察组治疗后BBS评分［(48.80±3.52)分］、下肢FMA评分［(29.20±2.42)分］、步幅［(71.25±4.81)cm］、步速［(70.20±5.00)cm/s］改善优于对照组（P＜0.05）。 结论 动态失稳训练联合常规康复训练能进一步改善脑卒中患者的姿势控制能力,促进平衡与步行功能恢复,提高下肢运动功能。     

悬吊推拿运动技术对脑卒中患者核心肌群及姿势控制能力的影响

目的：探讨悬吊推拿运动技术对脑卒中患者核心肌群及姿势控制能力的影响。方法：选取符合纳排标准的脑卒中后姿势控制障碍患者58例,采用随机数字表法分为对照组和试验组,每组29例。最终对照组纳入27例,试验组纳入29例。对照组选用常规康复训练,试验组在对照组的基础上运用悬吊推拿运动技术治疗。分别在治疗前和治疗4周后采用脑卒中患者姿势评定量表（PASS）、Berg平衡量表（BBS）、简式FuglMeyer运动功能量表下肢部分（FMA-LE）、改良Barthel指数（MBI）进行评价,运用表面肌电图（sEMG）测定患者双侧竖脊肌和多裂肌的中值频率（MF）和积分肌电值（iEMG）。结果：2组治疗前PASS、BBS、FMA-LE、MBI评分以及双侧竖脊肌和多裂肌MF值、iEMG值比较,差异无统计学意义（P>0.05）。2组治疗后PASS、BBS、FMA-LE、MBI评分均高于同组治疗前（P<0.05）。试验组患侧竖脊肌和多裂肌MF值、iEMG值及健侧竖脊肌和多裂肌MF值均高于同组治疗前（P<0.05）。治疗后组间比较,2组PASS、BBS、FMA-LE、MBI评分比较,差异均有统计学...     

双重任务训练结合轮椅坐姿矫正对脑卒中患者姿势控制的影响

目的 探讨步行-认知双重任务训练结合轮椅坐姿矫正对脑卒中患者姿势控制的影响。方法 选取2021年3月-2022年8月收治于上海市第三康复医院的脑卒中患者60例为研究对象,按随机数字表法随机分为对照组(n=30)和观察组(n=30)。在常规康复治疗措施基础上,对照组实施步行单任务训练加轮椅坐姿训练指导,观察组在对照组的基础上实施相同频次与时长的步行-认知双重任务训练指导。评估并比较两组干预前,干预后第一月及第三月的脑卒中姿势控制量表(PASS)、Berg平衡量表(BBS)和改良 Barthel 指数(MBI)评分及护理满意度。结果 干预前两组PASS、BBS、MBI评分差异无统计学意义(P＞0.05)。干预后两组均取得一定的康复疗效,干预一月、三月后,观察组各项指标明显优于对照组,差异均具有统计学意义(P＜0.05)。且干预三月后试验组护理满意显著高于对照组(P＜0.05)。结论 步行-认知双重任务训练结合轮椅坐姿矫正可有效改善脑卒中患者的姿势控制,对提高患者平衡功能和日常生活活动能力具有积极意义。     

肛管外括约肌多通道表面肌电图的初步研究

目的:研究新型16电极肛管表面肌电图(SEMG)系统在记录肛管外括约肌肌电活动中的作用。方法:使用新研发的16电极肛管SEMG系统对35名健康志愿者进行肛管SEMG检测。结果:16电极肛管SEGM系统能够清晰可靠地记录到肛管外括约肌在最大自主性收缩状态下的肌电活动即运动单位动作电势(MUAPs),共检测出1044个传导性MUAPs。传导性MUAPs起点以腹侧为主,止点以背侧为主(76%),其传导方向主要是从腹侧到背侧(57%),传导距离平均为4.82导联,MUAPs在数量上存在明显的性别差异;年龄因素影响MUAPs的传导方向(P<0.001);MUAPs的各项参数不受种族因素的影响。肛管SEMG探头插入肛管内的深度对MUAPs的数量和传导距离以及传导方向均产生一定的影响,未发现组间差异。MUAPs的数量和传导距离方面存在组内差异。结论:新型16电极肛管SEMG系统能够可靠准确地记录到非常有价值的肛管外括约肌MUAPs参数,是一种易于掌握且容易标准化的非侵入性无痛检查新技术。     

Bilateral compensatory postural adjustments to a unilateral perturbation in subjects with chronic ankle instability

BackgroundTo evaluate the magnitude of bilateral compensatory postural adjustments in response to a unilateral sudden inversion perturbation in subjects with chronic ankle instability.Methods24 athletes with chronic ankle instability (14 with functional ankle instability, 10 with mechanical ankle instability) and twenty controls participated in this study. The bilateral electromyography of ankle muscles was collected during a unilateral sudden ankle inversion to assess the magnitude of subcortical and voluntary compensatory postural adjustments in both the perturbed and the contralateral limb (support limb).FindingsIn the support position, compared to the control group, the group with functional ankle instability presented decreased compensatory postural adjustments of the tibialis anterior in both the injured and the uninjured limbs in the support position and of the soleus in the uninjured limb. In the side of the perturbation, participants with functional ankle instability presented decreased soleus compensatory postural adjustments in the uninjured limb when compared to the control group. Increased values of soleus and peroneal brevis compensatory postural adjustments were observed in the group with mechanical instability when compared to the control group and to the group with functional ankle instability.InterpretationSubjects with functional ankle instability present bilateral impairment of compensatory postural adjustments of the tibialis anterior in a support position and of the soleus of the uninjured limb regardless of the position. Subjects with mechanical instability present bilateral increase of these adjustments in the peroneal brevis regardless of the position and in the soleus muscle in the side of the perturbation.     

Influence of prior knowledge on automatic and voluntary postural adjustments in healthy and hemiplegic subjects

The purpose of this study was to analyze the effects of prior instruction on automatic postural responses and voluntary postural sways measured about the ankle joint. Ten subjects with right hemiplegia resulting from a cerebrovascular accident (mean age = 56 +/- 14 years) and 5 healthy subjects (mean age = 47 +/- 6 years) stood symmetrically on a movable force platform. During platform-induced sway, the support surface was translated horizontally to induce antero-posterior body sway about the ankle joints. Surface electromyographs were obtained from the tibialis anterior, quadriceps femoris, gastrocnemius, and hamstring muscles bilaterally. Prior knowledge appeared to have no significant influence on healthy subjects' ability to execute postural adjustments more rapidly during AP displacements. Hemiplegic subjects exhibited longer and more variable latencies in the paretic limb than in the nonparetic limb during voluntary AP weight shifts. When hemiplegic subjects had prior knowledge of the platform's movement (time and direction), latencies were significantly shorter in the paretic limb and could be as brief as those seen in the nonparetic limb. The results showed that prior knowledge may be an important treatment consideration for patients with muscle timing disorders.     

Effects of approximation on postural sway in healthy subjects

The effect of approximation on the postural sway of healthy subjects wearing a weighted belt around their pelvis was measured. Twenty subjects between the ages of 23 and 30 years stood on a polyurethane foam platform that amplified their postural sway and were filmed from a lateral view. All subjects wore markers over their mandibles, hips, and knees and were filmed three times with the weighted belt worn on a randomly selected trial. Frames from a 10-second interval of film from each trial were studied, and the summed displacement at each bony landmark between each frame of film was calculated. A significant decrease in displacement at the mandible (p less than .02) was found when the weighted belt was worn. The decrease in displacement was not significant at the hip or knee. Approximation was shown to decrease the postural sway of healthy subjects. Further study is indicated to investigate the effect of approximation on patient populations.     

表面肌电在脑卒中患者肢体功能障碍评价中的意义

摘要 目的：探讨表面肌电图评定脑卒中偏瘫患者肢体功能障碍的临床应用价值。 方法：计算机检索中国生物医学文献数据库、万方、维普等中文期刊,MEDLINE、EMBASE等英文期刊,利用纳入、排除标准对所收集文献进行筛选。采用RevMan 5.0软件进行Meta分析。 结果：8篇文献纳入研究。综合效应量：协同收缩率（CR）WMD=17.31,95%CI 5.78—28.84,P＜0.01;力矩WMD=-10.95,95%CI -13.40—-8.51,P＜0.00001。 结论：表面肌电图客观定量评价脑卒中偏瘫患者肢体功能状况,指导其临床康复。     

面肌痉挛患者表面肌电信号特征研究

摘要 目的：探讨面肌痉挛患者眼轮匝肌表面肌电特征,为面肌痉挛的诊断及疗效评价提供依据。 方法：选取面肌痉挛门诊患者60例,采集患者放松状态下及做最大自主收缩闭眼动作时健、患侧眼轮匝肌表面肌电值,观察指标为中位频率（MF）、平均功率频率（MPF）及平均肌电值（AEMG）;同时予以Cohen量表评估,分析两种评价方法的相关性。 结果：在放松状态下,面肌痉挛患者健、患侧眼轮匝肌AEMG值有显著性差异（P<0.05）,健、患侧MF、MPF值比较无显著差异;在收缩状态下,健、患侧MF、MPF值比较有显著性差异（P<0.001）,健、患侧AEMG值比较有显著差异（P<0.05）;但在相关性研究中,表面肌电值与Cohen量表间无相关性。 结论：面肌痉挛患者存在特有的表面肌电信号特征,为临床诊断、评估面肌痉挛提供有效参考依据。     

徒手感觉刺激对脑卒中偏瘫患者手指痉挛效果的表面肌电图观察北大核心CSCD

目的观察脑卒中患者偏瘫侧指部接受徒手感觉刺激前后,手指屈、伸肌表面肌电图(sEMG)的变化规律。方法2020年4月至8月,安徽医科大学第二附属医院康复医学科收治的脑卒中偏瘫患者50例,徒手对患侧各指甲床和末节两侧依次实施感觉刺激,至患侧手指主动伸展。刺激前后,采用改良Ashworth量表(MAS)评估患侧拇短屈肌、指浅屈肌、指伸肌张力;采集双侧拇短屈肌、指浅屈肌、指伸肌sEMG信号,计算均方根值(RMS)。结果刺激后,所有被测肌群MAS等级均明显降低(|Z|>2.699,P<0.01);患侧指伸肌RMS增加(t=-2.069,P<0.05)。患侧拇短屈肌和指伸肌RMS刺激前、后均小于健侧(t>2.450,P<0.05)。结论指部徒手感觉刺激能即时缓解脑卒中患者屈指肌痉挛,可能与促进伸指肌肌力有关。     

A novel approach to surface electromyography: an exploratory study of electrode-pair selection based on signal characteristics

ABSTRACT: A 3 x 4 electrode array was placed over each of seven muscles and surface electromyography (sEMG) data were collected during isometric contractions. For each array, nine bipolar electrode pairs were formed off-line and sEMG parameters were calculated and evaluated based on repeatability across trials and comparison to an anatomically placed electrode pair. The use of time-domain parameters for the selection of an electrode pair from within a gridlike array may improve upon existing electrode placement methodologies.     

The evaluation of walking footwear on postural stability in healthy older adults: an exploratory study

Background

It has been proposed that walking footwear enhances postural stability in healthy older adults. The aim of the study is to evaluate differences between two different types of athletic footwear in relation to postural stability in healthy older adults.

Methods

A convenience sample of 21 healthy older adults with mean (SD) of 74 (5) years was recruited. Postural stability was measured using a force plate for anterior–posterior (AP) and mediolateral (ML) centre of pressure excursion for 30 s with eyes closed and open using two different types of athletic footwear. Each participant performed three repetitions of bipedal standing. Two-way analysis of variance tested the interaction effect of the footwear and eye conditions on anterior–posterior (AP) and mediolateral (ML) postural sway.

Findings

There was no significant footwear–eye condition interaction for anterior-posterior(AP) postural sway but there were significant main effects for both the footwear and eye conditions (P < 0.05). The significant main effects for the footwear conditions occurred between barefeet and the two shoe conditions, but not between the two shoe conditions. For mediolateral (ML) postural sway there was no significant interaction effect and no main effects for the footwear and eye conditions (P > 0.05).

Interpretation

The results suggest that older adults demonstrate an initial destabilisation effect which could possibly be of benefit to functional ability but the long-term effects of ability of athletic footwear to enhance postural stability requires further investigation.