肌电诱发神经肌肉电刺激对脑卒中偏瘫患者上肢运动功能的疗效

目的观察肌电诱发神经肌肉电刺激对改善早期脑卒中偏瘫患者肢体运动功能的临床疗效。方法发病4 周内、不能主动完成腕背伸运动,且患侧腕背伸时所测收缩肌电值=基础肌电值的患者60 例,分为2 组：对照组(n=30)应用神经肌肉电刺激疗法, 治疗组(n=30)应用肌电诱发的神经肌肉电刺激疗法, 共治疗4 周。治疗前后测定患者静态及收缩时肌电值, 应用简式Fugl-Meyer 运动功能评定(FMA)、Barthel 指数对患者进行评定。结果两组患者治疗后的肌肉静态及收缩时肌电值、FMA 评分、Barthel 指数评分均有显著改善(P=0.000),治疗组比对照组改善更多(P<0.05)。结论肌电诱发的神经肌肉电刺激疗法即使于发病早期,未检测到肌肉收缩肌电值变化的情况下也可以用于偏瘫患者上肢瘫痪肌肉的功能治疗,其疗效优于神经肌肉电刺激疗法。     

Functional electrical therapy for hemiparesis alleviates disability and enhances neuroplasticity

Impaired motor and sensory function is common in the upper limb in humans after cerebrovascular stroke and it often remains as a permanent disability. Functional electrical stimulation therapy is known to enhance the motor function of the paretic hand; however, the mechanism of this enhancement is not known. We studied whether neural plasticity has a role in this therapy-induced enhancement of the hand motor function in 20 hemiparetic subjects with chronic stroke (age 53 ± 6 years; 7 females and 13 males; 10 with cerebral infarction and 10 with cerebral haemorrhage; and time since incident 2.4 ± 2.0 years). These subjects were randomized to functional electrical therapy or conventional physiotherapy group. Both groups received upper limb treatment (twice daily sessions) for two weeks. Behavioral hand motor function and neurophysiologic transcranial magnetic stimulation (TMS) tests were applied before and after the treatment and at 6-months follow-up. TMS is useful in assessing excitability changes in the primary motor cortex. Faster corticospinal conduction and newly found muscular responses were observed in the paretic upper limb in the functional electrical therapy group but not in the conventional therapy group after the intervention. Behaviourally, faster movement times were observed in the functional electrical therapy group but not in the conventionally treated group. Despite the small number of heterogeneous subjects, functional exercise augmented with individualized electrical therapy of the paretic upper limb may enhance neuroplasticity, observed as corticospinal facilitation, in chronic stroke subjects, along with moderate improvements in the voluntary motor control of the affected limb.     

Non-invasive brain stimulation (NIBS) and motor recovery after stroke

Recovery of motor function after stroke occurs largely on the basis of a sustained capacity of the adult brain for plastic changes. This brain plasticity has been validated by functional imaging and electrophysiological studies. Various concepts of how to enhance beneficial plasticity and in turn improve functional recovery are emerging based on the concept of functional interhemispheric balance between the two motor cortices. Besides conventional rehabilitation interventions and the most recent neuropharmacological approaches, non-invasive brain stimulation (NIBS) has recently been proposed as an add-on method to promote motor function recovery after stroke. Several methods can be used based either on transcranial magnetic stimulation (repetitive mode: rTMS, TBS) via a coil, or small electric current via larges electrodes placed on the scalp, (transcranial direct current stimulation tDCS). Depending on the different electrophysiological parameters of stimulation used, NIBS can induce a transient modulation of the excitability of the stimulated motor cortex (facilitation or inhibition) via a probable LTP-LTD-like mechanism. Several small studies have shown feasible and positive treatment effects for most of these strategies and their potential clinical relevance to help restoring the disruption of interhemispheric imbalance after stroke. Results of these studies are encouraging but many questions remain unsolved: what are the optimal stimulation parameters? What is the best NIBS intervention? Which cortex, injured or intact, should be stimulated? What is the best window of intervention? Is there a special subgroup of stroke patients who could strongly benefit from these interventions? Finally is it possible to boost NIBS treatment effect by motor training of the paretic hand or by additional neuropharmacological interventions? There is clearly a need for large-scale, controlled, multicenter trials to answer these questions before proposing their routine use in the management of stroke patients.     

Predictive ability of 2-day measurement of active range of motion on 3-mo upper-extremity motor function in people with poststroke hemiparesis

OBJECTIVE. We determined (1) whether active range of motion (AROM) of shoulder flexion and wrist extension measured at the initial therapy evaluation in the acute hospital predicted upper-extremity (UE) motor function 3 mo after stroke and (2) whether the presence of nonmotor impairments influenced this prediction. METHOD. We collected AROM data from 50 people with stroke during their initial acute hospital therapy evaluation and UE motor function data 3 mo later. Multiple regression techniques determined the predictive ability of initial AROM on later UE motor function. RESULTS. Initial AROM explained 28% of the variance in UE motor function 3 mo poststroke. Nonmotor deficits did not contribute to the variance. CONCLUSION. Compared with later AROM measurements, initial values did not adequately predict UE motor function 3 mo after stroke. Clinicians should use caution when informing clients of UE functional prognosis in the early days after stroke.     

Recent progress in physical therapy of the upper-limb rehabilitation after stroke: emphasis on thermal intervention

Poor recovery of arm function after stroke can often have a negative impact on the patient and his/her family. These patients often need assistance from the society and may need to rely on government resources. Numerous therapeutic treatments are currently available for stroke rehabilitation. Traditional rehabilitation strategies (Bobath, Brunnstrom, proprioception neuromuscular facilitation, and motor relearning) have been used for many years. However, few of these interventions have been tested in clinical trials and are thus practiced on an empirical basis. Various evidence-based therapies (electric stimulation, electromyographic biofeedback, constraint-induced movement therapy, robotic aided system, and virtual reality) have been added to classic rehabilitation approaches and seem to improve function. Recently, we demonstrated that a novel intervention, thermal stimulation, facilitated upper-limb functional recovery after acute stroke. In this review, we describe detailed thermal stimulation procedures and outcomes in stroke patients. We found that thermal stimulation in combination with other physiotherapies or chemotherapies was of great benefit to stroke patients. Development of a better rehabilitation paradigm that maximizes rapid recovery of arm function is a priority to help stroke patients and society.     

基于WHO-FICs作业治疗改善脑卒中上肢功能效果的系统综述

目的 基于世界卫生组织国际分类家族(WHO-FICs)构建作业治疗改善脑卒中上肢功能的PICO架构,并分析主要作业疗法改善脑卒中患者上肢功能的效果。方法 运用WHO-FICs框架,检索Web of Science、PubMed、CNKI、SinoMed等数据库,收集建库至2022年10月关于作业治疗干预脑卒中上肢功能的相关文献,并进行系统综述。结果 最终纳入10项随机对照试验,382例参与者(≥18岁),来自6个国家,主要来源于康复医学、物理和康复医学、神经科学、生物工程医学、作业治疗等研究领域,发表年限集中于2013年以后。纳入文献物理治疗证据数据库(PEDro)量表评分平均7.5分。基于WHO-FICs框架,纳入文献中涉及的疾病类型涵盖脑出血(8B00)、缺血性脑卒中(8B11)、蛛网膜下腔出血(8B01)、肌张力和异常反射(MB47)、偏瘫(MB53)。主要功能障碍包括关节活动功能(b710)、关节稳定性功能(b715)、肌肉力量功能(b730)、肌张力功能(b735)、运动反射功能(b750)、随意运动控制功能(b760)、不随意运动功能(b765)。主要活动受限和参与局限包括...     

经颅直流电刺激结合功能性电刺激对脑卒中平台期患者上肢运动功能康复影响的研究

目的:将经颅直流电刺激(tDCS)和功能性电刺激(FES)结合,观察这种联合治疗干预方式对脑卒中平台期患者上肢功能的影响。方法:3例脑卒中后平台期偏瘫患者在4周基线期后接受4周的tDCS结合FES治疗干预。干预前后用Fugl-Meyer上肢运动功能评分(U-FMA)、表面肌电图(sEMG)、经颅磁刺激(TMS)进行评定。结果:干预后U-FMA分数较干预前提高。7个主动肌中有5个表面肌电激活性干预前后有明显变化。用TMS成对刺激方法评估受试者健侧大脑短潜伏期皮质内抑制与短潜伏期皮质内易化结果显示部分的干预前后变化。结论:tDCS结合FES治疗干预改善了受试者上肢的运动功能,该方案可能是针对脑卒中平台期患者的一种有前景的干预康复方案。     

Effects of robotic therapy on motor impairment and recovery in chronic stroke

OBJECTIVE: To examine whether robotic therapy can reduce motor impairment and enhance recovery of the hemiparetic arm in persons with chronic stroke. DESIGN: Pre-posttest design. SETTING: Rehabilitation hospital, outpatient care. PARTICIPANTS: Volunteer sample of 20 persons diagnosed with a single, unilateral stroke within the past 1 to 5 years, with persistent hemiparesis. INTERVENTIONS: Robotic therapy was provided 3 times weekly for 6 weeks. Subjects able to reach robot targets were randomly assigned to sensorimotor or progressive-resistive robotic therapy groups. Robotic therapy consisted of goal-directed, planar reaching tasks to exercise the hemiparetic shoulder and elbow. MAIN OUTCOME MEASURES: The Modified Ashworth Scale, Fugl-Meyer test of upper-extremity function, Motor Status Scale (MSS) score, and Medical Research Council motor power score. RESULTS: Evaluations by a single blinded therapist revealed statistically significant gains from admission to discharge (P<.05) on the Fugl-Meyer test, MSS score, and motor power score. Secondary analyses revealed group differences: the progressive-resistive therapy group experienced nonspecific improvements on wrist and hand MSS scores that were not observed in the sensorimotor group. CONCLUSIONS: Robotic therapy may complement other treatment approaches by reducing motor impairment in persons with moderate to severe chronic impairments.     

Functional vibratory stimulation on the hand facilitates voluntary movements of a hemiplegic upper limb in a patient with stroke

The use of a new device consisting of a small vibrator to deliver functional vibratory stimulation (FVS) to the arm resulted in improvements of flexion of the hemiparetic shoulder in a man with thalamic bleeding. FVS delivered to the palm enabled the patient to repeat flexing his hemiparetic shoulder to manipulate objects with his hand. The functions of the patient's hemiparetic shoulder and fingers improved after treatments using FVS for 1 month. We examined whether FVS of the hemiplegic upper limb could facilitate voluntary movements of the limb by increasing the excitability of the motor cortex or the spinal motor neurons using somatosensory-evoked potentials, transcranial magnetic stimulation, F-wave, and single photon emission computed tomography. Our results did not detect an increase of excitability in the motor cortex or in spinal motor neurons by FVS.     

Correlated change in upper limb function and motor cortex activation after verum and sham acupuncture in patients with chronic stroke

BACKGROUND: Acupuncture may improve motor function in patients with chronic hemiparetic stroke, yet the neural mechanisms underlying such an effect are unknown. As part of a sham-controlled, randomized clinical trial testing the efficacy of a 10-week acupuncture protocol in patients with chronic hemiparetic stroke, we examined the relationship between changes in function of the affected upper limb and brain activation using functional magnetic resonance imaging (fMRI). METHODS: Seven (7) chronic hemiparetic stroke patients underwent fMRI and testing of function of the affected upper limb (spasticity and range-of-motion) before and after a 10-week period of verum (N=4) or sham (N=3) acupuncture. The correlation between changes in function of the affected upper limb and brain activation after treatment was tested across patients. RESULTS: We found a significant positive correlation between changes in function of the affected upper limb (spasticity and range of motion) and activation in a region of the ipsilesional motor cortex. Patients treated with verum acupuncture showed a trend toward a greater maximum activation change in this motor cortical area as compared to those treated with sham acupuncture. CONCLUSIONS: Acupuncture may improve function of the affected upper limb in chronic hemiparetic stroke patients by increasing activity in the ipsilesional motor cortex.     

Development and pilot testing of HEXORR: Hand EXOskeleton Rehabilitation Robot

Background  

Following acute therapeutic interventions, the majority of stroke survivors are left with a poorly functioning hemiparetic hand. Rehabilitation robotics has shown promise in providing patients with intensive therapy leading to functional gains. Because of the hand's crucial role in performing activities of daily living, attention to hand therapy has recently increased.     

Systematic review of the effect of robot-aided therapy on recovery of the hemiparetic arm after stroke

A limited number of clinical studies have examined the effect of poststroke rehabilitation with robotic devices on hemiparetic arm function. We systematically reviewed the literature to assess the effect of robot-aided therapy on stroke patients' upper-limb motor control and functional abilities. Eight clinical trials were identified and reviewed. For four of these studies, we also pooled short-term mean changes in Fugl-Meyer scores before and after robot-aided therapy. We found that robot-aided therapy of the proximal upper limb improves short- and long-term motor control of the paretic shoulder and elbow in subacute and chronic patients; however, we found no consistent influence on functional abilities. In addition, robot-aided therapy appears to improve motor control more than conventional therapy.     

早期介入镜像疗法对缺血性脑卒中患者偏瘫肢体功能恢复的影响

目的 观察早期介入镜像疗法对缺血性脑卒中后偏瘫患者上、下肢功能恢复的影响。 方法 选取病程小于1个月的36例早期缺血性脑卒中患者作为研究对象,采用随机数字表法将其分为观察组及对照组,2组患者均接受卒中后规范化药物治疗及常规康复训练。观察组在此基础上辅以镜像治疗,每次治疗45min,每周治疗5次,持续治疗3周;对照组则辅以与观察组相同时间、相同强度但无镜像反射面的运动训练。于治疗前、治疗后、出院后随访1个月及2个月时分别采用Fugl-Meyer运动功能量表（FMA）、Wolf运动评价量表（WFMT）、功能性步行量表（FAC）、Brunnstrom分期和改良Ashworth痉挛量表(MAS)对患者偏瘫侧上、下肢运动功能恢复情况进行评定。 结果 经治疗后2组患者肢体运动功能均较治疗前明显改善。与同期对照组比较,观察组经3周治疗及出院后随访1个月、2个月时其上肢FMA评分均明显改善(均P<0.05);与同期对照组比较,观察组出院后随访1个月及2个月时其WMFT评分也明显增高(均P<0.05)。与同期对照组比较,观察组随访2个月时其下肢FMA评分和FAC分级指数均明显进步(均P<0.05)。与同期对照组比较,观察组随访1个月、2个月时其上肢Brunnstrom分期也明显改善(均P<0.05),但下肢Brunnstrom分期与同期对照组间差异无统计学意义(均P>0.05)。与同期对照组比较,观察组患者经3周治疗后、出院后随访1个月、2个月时其上肢及下肢MAS评级指数均无明显改善(均P>0.05)。 结论 早期介入镜像疗法能明显加速缺血性脑卒中患者偏瘫侧上肢及手功能恢复进程,对患者下肢运动功能及步行能力亦有改善作用,该疗法值得在脑卒中患者中推广、应用。     

闭环肌电反馈电刺激在偏瘫早期康复训练中的应用

目的观察闭环肌电反馈电刺激在改善早期偏瘫患者肢体运动和促进功能恢复方面的效果。方法选发病 4周内的患者 12 0例 ,随机分为治疗组和对照组。两组患者均接受常规康复训练治疗 ,治疗组加用闭环肌电反馈电刺激治疗。使用该仪器测定的肌电值及简式Fugl Meyer功能评价表进行评定。 结果全部患者治疗前后的肌电值及功能评分值均有显著提高 ,治疗组与对照组相比有显著性差异 (P <0 .0 5 ) ,其康复效果与治疗次数正相关。结论闭环肌电反馈电刺激可促进早期偏瘫患者患肢运动功能恢复。     

tDCS联合肌电生物反馈改善脑卒中上肢运动功能障碍的疗效观察

目的:探讨经颅直流电(tDCS)联合肌电生物反馈对脑卒中上肢运动功能障碍的疗效。方法:60例脑卒中患者按随机数字表法分为对照组和联合组各30例,2组均进行常规康复训练,对照组在此基础上采用肌电生物反馈,联合组采用tDCS联合肌电生物反馈治疗。在治疗前和治疗6周后,分别采用Fugl-Meyer上肢评定量表(FMA-UE)、改良Barthel指数(MBI)对患者进行评定,并测定患侧肩外展及腕背伸时的表面肌电均值(sEMG)。结果:治疗6周后,2组患者FMA-UE、MBI评分及肩外展和腕背伸时的表面肌电均值较治疗前比较均明显提高(P<0.05,0.01),且联合组的上述指标较对照组均更高(均P<0.05)。结论:tDCS联合肌电生物反馈能较好地改善脑卒中患者的上肢功能障碍,治疗作用优于单一的肌电生物反馈疗法。     

Cortical reorganization of hand motor function to primary sensory cortex in hemiparetic patients with a primary motor cortex infarct

OBJECTIVE: To show cortical reorganization in hemiparetic patients with a primary motor cortex (M1) infarct including the precentral knob by using functional magnetic resonance imaging (fMRI). DESIGN: Case-control. SETTING: Outpatient clinics in the rehabilitation department of a university hospital. PARTICIPANTS: Two stroke patients and 20 control subjects. INTERVENTIONS: By using fMRI, we evaluated the hand motor function of 2 hemiparetic stroke patients, who had made some recovery from complete paralysis of the affected hand, and 20 control subjects. MAIN OUTCOME MEASURES: fMRI was performed by using the blood oxygen level-dependent technique at 1.5 T with a standard head coil. The motor task paradigm consisted of hand grasp-release movements. RESULTS: The contralateral primary sensorimotor cortex was activated by the hand movements of the control subjects and of the unaffected side of the 2 patients. Only the contralateral (infarct side) primary sensory cortex (S1) was activated by the movements of the affected hand of the 2 patients, a result that was not observed in the control subjects or with the unaffected hand in the stroke patients. CONCLUSIONS: The hand motor function associated with the infarcted M1 in our patients was reorganized into the S1. These results suggest cortical reorganization in patients with an M1 infarct.     

Movement therapy induced neural reorganization and motor recovery in stroke: a review

This paper is a review conducted to provide an overview of accumulated evidence on contemporary rehabilitation methods for stroke survivors. Loss of functional movement is a common consequence of stroke for which a wide range of interventions has been developed. Traditional therapeutic approaches have shown limited results for motor deficits as well as lack evidence for their effectiveness. Stroke rehabilitation is now based on the evidence of neuroplasticity, which is responsible for recovery following stroke. The neuroplastic changes in the structure and function of relevant brain areas are induced primarily by specific rehabilitation methods. The therapeutic method which induces neuroplastic changes, leads to greater motor and functional recovery than traditional methods. Further, the recovery is permanent in nature. During the last decade various novel stroke rehabilitative methods for motor recovery have been developed. This review focuses on the methods that have evidence of associated cortical level reorganization, namely task-specific training, constraint-induced movement therapy, robotic training, mental imaging, and virtual training. All of these methods utilize principles of motor learning. The findings from this review demonstrated convincing evidence both at the neural and functional level in response to such therapies. The main aim of the review was to determine the evidence for these methods and their application into clinical practice.     

中风后的健侧上肢问题

大量证据表明 ,成年人中风后大脑损伤的同侧上肢感觉运动控制也出现异常。一些感觉运动缺损因脑损伤侧的功能不同而异 ,需要精确时序性的快速运动在左半球损伤的患者中对同侧上肢的影响大 ,相反在右半球损伤的患者中对有空间运动需要的同侧上肢影响较大 ,左侧中风的成年人同侧上肢的分离协调动作是正常的 ,但是连续协调动作则异常。中风后同侧上肢的感觉不受影响或仅受轻微影响 ,损伤同侧上肢有肌力缺陷 ,主要表现在右侧半球损伤患者 ,在要求一定时间完成的床功能检查中 ,见损伤同侧操作不能按时完成 ,这种操作缺陷可以反映损伤同侧的运动控制缺陷 ,这种缺陷往往被对侧偏瘫和偏身感觉丧失掩盖 ,集中于特殊运动控制缺陷的干预措施有助于双上肢的功能改善。     

Electrical stimulation of the upper extremity in stroke: cyclic versus EMG-triggered stimulation

OBJECTIVE: To compare the effect of cyclic and electromyography (EMG)-triggered electrical stimulation on motor impairment and function of the affected upper extremity in chronic stroke. DESIGN: Randomized controlled trial. SETTING: Outpatient clinic of a rehabilitation centre. SUBJECTS AND INTERVENTION: Twenty-two subjects in the chronic stage after stroke were randomly assigned to receive either cyclic (n=11) or EMG-triggered electrical stimulation (n=11) of the wrist and finger extensor muscles for a six-week period. OUTCOME MEASURES: The primary outcome measure was the Action Research Arm test (0-57 points) to assess arm function. Grip strength, Fugl-Meyer Motor Assessment and Motricity Index were secondary outcome measures. Assessments were made at the start of the treatment and after 4, 6 and 12 weeks. RESULTS: Both groups improved on the Action Research Arm test. The group receiving cyclic stimulation improved by 2.3 points, and the group receiving EMG-triggered stimulation improved by 4.2 points. The difference in functional gain was not statistically significant. Differences in gain on the secondary outcome measures were not significant either. CONCLUSION: The present study did not detect a significant difference between EMG-triggered and cyclic electrical stimulation with respect to improvement of motor function of the affected arm in chronic stroke.     

Hybrid power-assisted functional electrical stimulation to improve hemiparetic upper-extremity function

OBJECTIVE: The effect on spastic hemiparesis of a hybrid therapy consisting of functional electrical stimulation and block therapy was examined. DESIGN: Sixteen consecutively enrolled stroke patients who had spastic upper-extremity impairments more than 1 yr after stroke were recruited for this nonblinded randomized controlled trial. Patients underwent hybrid functional electrical stimulation therapy on their extensor carpi radialis longus and brevis, extensor digitorum communis, and extensor indicis proprius muscles once or twice a week for 4 mos after motor point blocks at the spastic finger flexor muscles. Surface electrodes picked up the electromyography signal and stimulated those muscles in proportion to the integrated electromyography signal obtained by the functional electrical stimulation device. The root mean square of the extensor carpi radialis longus and extensor digitorum communis maximum voluntary electromyography, active range of motion of wrist extension, finger extension, Modified Ashworth Scale, and two clinical tests were examined before and after training. RESULTS: Root mean square, active range of motion, Modified Ashworth Scale, and two clinical tests showed marked improvement in all patients as compared with the control subjects. CONCLUSIONS: The hybrid therapy was effective for patients with chronic spastic hemiparesis. Proprioceptional sensory feedback may have an important role in power-assisted functional electrical stimulation therapy.