脑卒中后肢体痉挛的识别与评估：Scoping综述

目的总结脑卒中后肢体痉挛相关的电生理指标和量表,以实现痉挛临床管理的一体化。方法检索建库至2021年5月15日Web of Science、PubMed、中国知网、万方数据库中脑卒中后肢体痉挛识别与评估的相关文献,对脑卒中后肢体痉挛评估的相关量表和电生理指标进行综述。结果目前临床用于脑卒中后肢体痉挛评估的量表主要包括改良Asworth量表、综合痉挛量表和改良Tardieu量表。F波、H反射、运动诱发电位、惊跳反射响应时间、前庭诱发肌源性电位等电生理指标能用于识别与评估脑卒中后肢体痉挛。结论需进一步开展临床研究探讨如何更加客观、精准地早期识别和评估痉挛。     

A型肉毒毒素治疗脑卒中后肢体痉挛状态的应用现状

脑卒中后肢体痉挛状态严重影响患者的肢体运动功能和生活质量，局部注射肉毒毒素具有较好的抗痉挛效果。本文对脑卒中后肢体痉挛状态的定义、病理生理、治疗概况和A型肉毒毒素的有效性和安全性进行了总结，也指出了目前临床应用A型肉毒毒素治疗肢体痉挛所存在的一些问题，旨在为其临床应用提供客观依据。     

针灸在中风后肢体痉挛中的应用

脑卒中后肢体痉挛所致的功能障碍是阻碍患者独立生活、回归社会的主要原因。针灸是治疗、缓解偏瘫肢体痉挛的重要方法，本文重点介绍针灸在中风后肢体痉挛的应用现状及优势。     

中药熏蒸结合肌电生物反馈治疗中风后痉挛性偏瘫的临床分析

脑卒中是中老年常见病、多发病,存活者中约有3／4的人留有不同程度的残疾,尤以痉挛性偏瘫多见,发病率达80％^[1],随着脑卒中发病率的升高,对脑卒中患者偏瘫肢体因痉挛而致的废用综合征的治疗日益引起康复医学界的重视。脑卒中后肢体痉挛严重影响患者的日常生活和自理能力,而深入研究脑卒中后肢体痉挛的发生机制,探索有效的抗痉挛疗法,提高患者的生活质量,成为目前医学领域中所必须解决的重大课题^[2]。     

MOTOmed智能运动训练系统对脑卒中患者下肢痉挛的影响

脑卒中后病人常会出现下肢痉挛(即脑卒中恢复期),脑卒中后肢体痉挛是由于上运动神经元受损,使运动系统失去高位中枢的控制,从而使原始的、被压抑的、皮层以下的运动反射释放,引起运动模式异常。表现为肌张力增高甚至痉挛僵直,肌群间协调紊乱,出现异常的反射运动即共同运动、联合反应和紧张反射等。笔者采用MOTOmed智能运动训练系统治疗脑卒中后下肢痉挛的患者,在临床上取得了良好疗效。     

居家抗痉挛护理对脑卒中肢体痉挛患者的影响

目的探讨居家抗痉挛护理对脑卒中肢体痉挛患者功能康复的影响。方法选取2014年10月—2015年12月在上海市黄浦区打浦桥街道社区卫生服务中心就诊的早期脑卒中肢体痉挛患者50例。成立居家护理干预小组,由专业护士针对患者及其照顾者进行评估后,实施居家肢体抗痉挛护理。干预6个月后,采用改良Ashworth痉挛量表(modified Ashworth scale,MAS)评估患者肢体痉挛情况;采用简化Fugl-Meyer运动功能评定量表(Fugl-Meyer Assessment,FMA)评估患者肢体运动功能;采用Barthel指数(Barthel Index,BI)评估患者日常活动能力。结果干预6个月后,患者肢体痉挛情况改善,肢体运动功能改善,日常活动能力改善,干预前后比较差异均有统计学意义(P0.05)。结论居家抗痉挛护理有助于脑卒中肢体痉挛患者的功能康复,可有效提高患者的日常生活自理能力。     

A型肉毒毒素在脑卒中后下肢体肌肉痉挛治疗中的护理

目的 探讨A型肉毒毒素（BTX-A）在脑卒中后肢体肌肉痉挛治疗中的护理方法.方法 选取接受注射BTX-A治疗的脑卒中肢体肌肉痉挛患者52例,注射前进行心理疏导,在注射过程中、注射后进行针对性护理,并及时对并发症进行处理.结果 本组患者注射BTX-A治疗后肢体肌肉痉挛程度得到明显缓解或减轻,同时配合各项护理措施,有效防止并发症的发生并发挥最好的疗效.结论 在脑卒中后肢体肌肉痉挛注射BTX-A治疗的过程中护理工作的及时准确有效的配合医生的工作有助于患者肢体痉挛程度的缓解或减轻,提高患者的舒适度.     

中药湿热敷治疗脑卒中后肢体痉挛的疗效观察

目的观察中药湿热敷对脑卒中后肢体痉挛的疗效。方法将60例脑卒中后肢体痉挛患者用数字表法分为观察组和对照组各30例。两组均予神经内科常规处理及中医针灸、推拿等综合治疗,观察组在此基础上加用中药湿热敷。采用改良Ashworth量表对两组治疗前后肢体痉挛状态作评价。结果观察组治疗后上、下肢痉挛评分较治疗前有明显改善,与对照组比较有统计学意义。结论中药湿热敷能明显改善脑卒中患者的肢体痉挛状态,减轻卒中后遗症状。     

针刺对脑卒中后偏瘫肢体痉挛患者神经功能缺损的影响

目的探讨针刺对脑卒中后偏瘫肢体痉挛患者神经功能缺损的影响。方法选取收治的82例脑卒中后偏瘫肢体痉挛的患者,依治疗方法不同分为对照组和研究组。对照组给予常规基础治疗与康复治疗,研究组于对照组基础上加施针刺治疗,比较两组治疗前后的神经功能缺损情况与治疗效果。结果两组治疗前NIHSS、HAMD、HDMD评分比较,无明显差异(P>0.05),治疗后均有所下降,且研究组明显低于对照组(P<0.05);研究组治疗总有效率为82.93%,明显高于对照组的65.85%,差异显著(P<0.05)。结论针刺可有效缓解脑卒中后偏瘫肢体痉挛患者的痉挛症状,减少神经功能缺损,值得临床推广应用。     

手法与徒手牵引相结合治疗脑卒中后上肢痉挛临床观察

脑卒中后病人常会出现上肢痉挛（即达到BrunnstromⅢ阶段）,痉挛（spasticity）是由不同的中枢神经系统疾病引起的,是以肌肉的不自主收缩反应和速度依赖性的牵张反射亢进为特征的运动障碍,是上运动神经元综合征的一个组成部分。脑卒中患者偏瘫肢体在恢复过程中出现肌张力增高或痉挛状态是严重影响肢体功能恢复的重要因素,如不积极治疗可导致患肢永久性的高肌张力、关节挛缩和运动模式异常,严重影响患者的生活质量。现代康复医学主要采用A型肉毒毒素、矫形器、手术等进行治疗。笔者运用手法与徒手牵引相结合治疗脑卒中后上肢痉挛在临床上取得了良好疗效。     

Onset,time course and prediction of spasticity after stroke or traumatic brain injury

ObjectiveTo describe spasticity from the onset of acquired brain injury, time course over the first year and factors associated with prediction of the development of spasticity.MethodsRecent relevant literature known to the authors, along with a complementary search yielding a total of 9 articles, represented the base for this scoping review.ResultsSpasticity can be seen in the first week after brain injury and is more common in the upper than lower extremity. The severity of upper-limb impairment is a major factor in the development of spasticity during the first year after stroke. The prevalence of severe spasticity seems to increase during the first year. The combination of reduced arm motor function and spasticity in an early phase (4 weeks post-stroke) is an important predictor of the development of severe spasticity after 12 months. Spontaneous reduction in spasticity was seldom reported but may occur, especially in mild forms of spasticity.ConclusionSigns of spasticity can often be noted within the first 4 weeks after brain injury and is more common in the upper than lower extremity. Impaired sensorimotor function is a predictor. These findings highlight the importance to follow up patients with increased risk of developing severe spasticity to be able to start adequate spasticity treatment and prevent the negative consequences of spasticity. Understanding spasticity onset and progression also provides a basis for the development of effective therapies.     

Relationship between self- and clinically rated spasticity in spinal cord injury

OBJECTIVES: To assess the relation between self- and clinically rated spasticity in spinal cord injury (SCI) and to determine the extent to which symptoms like pain are included in the patients' self-rating of spasticity. DESIGN: Part 1: an observational, prospective, cross-sectional study and part 2: an observational, prospective, longitudinal study. SETTING: Swiss paraplegic center. PARTICIPANTS: Forty-seven (part 1) and 8 (part 2) persons with spastic SCI (American Spinal Injury Association grade A or B). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Clinical rating of movement-provoked spasticity using the Ashworth Scale; self-rating of general and present spasticity by the subject on a 4-point spasm severity scale and by using a visual analog scale (VAS); and questionnaires asking for antispasticity medication, impact of spasticity on daily life, body segment affected by spasticity, and symptoms associated with its occurrence. RESULTS: There was a poor correlation (rho=.36) between clinically rated (Ashworth Scale) spasticity and self-rated general spasticity and a modest correlation (rho=.70) between Ashworth Scale and self-rated present spasticity in the cross-sectional study in 47 subjects. Questionnaires showed that symptoms like pain and other sensations were associated by the patients with spasticity. There was a significant, but weak, correlation between VAS and Ashworth Scale in the longitudinal study in 3 of the 8 subjects and nonsignificant correlations in the remaining 5 subjects. CONCLUSIONS: A single clinical assessment of spasticity is a poor indication of a patient's general spasticity. Clinical measures of muscle tone-related spasticity should be complemented by self-rating that distinguishes muscle tone-related spasticity from spasticity affecting the sensory nervous system.     

Spasticity After Stroke: An Overview of Prevalence, Test Instruments, and Treatments

ABSTRACT: The objective of this study was to present an overview of the prevalence of spasticity after stroke as well as of test instruments and treatments. Recent studies show that spasticity occurs in 20%-30% of all stroke victims and in less than half of those with pareses. Although spasticity may occur in paretic patients after stroke, muscle weakness is more likely to be the reason for the pareses. Spasticity after stroke is more common in the upper than the lower limbs, and it seems to be more common among younger than older people. To determine the nature of passive stretch, electromyographic equipment is needed. However, the Modified Ashworth Scale, which measures the sum of the biomechanical and neural components in passive stretch, is the most common instrument used to grade spasticity after stroke. Treatment of spasticity with physiotherapy is recommended, although its beneficial effect is uncertain. The treatment of spasticity with botulinum toxin in combination with physiotherapy is suggested to improve functioning in patients with severe spasticity. A task-specific approach rather than a neurodevelopmental approach in assessing and treating a patient with spasticity after stroke seems to be preferred.     

Spasticity after traumatic spinal cord injury: nature, severity, and location

OBJECTIVE: To assess spasticity in a prevalence population of persons with traumatic spinal cord injury (SCI), and determine the degree of correspondence between self-reported spasticity and investigator-elicited spasticity using the modified Ashworth scale. DESIGN: Survey of a near total (88%) prevalence population. SETTING: Outpatient clinic of a university hospital. PATIENTS: A total of 354 individuals with SCI. MAIN OUTCOME MEASURES: The survey includes self-reported symptoms, neurologic examination (American Spinal Injury Association [ASIA] classification), physical therapy examination, range of motion (ROM), and complications. RESULTS: Presence of problematic spasticity was significantly correlated with cervical incomplete (ASIA B-D) injury. Reports of beneficial effects of spasticity were significantly less common in women. Self-reported problematic spasticity was significantly correlated with extensor spasticity. Spasticity was elicitable by movement provocation in 60% of the patients reporting spasticity. Significant correlations were found between elicitable spasticity and limited ROM. CONCLUSION: Flexion, extension, and abduction movements performed with the patient placed in a standardized supine test position are suitable both for test of ROM and degree of spasticity. Spasticity was not elicitable by movement provocation on physical examination in 40% of the patients who reported spasticity, thus indicating that the patient's self-report is an important complement to the clinical assessment. A significant association between spasticity and contractures (reduced ROM) was seen.     

Management of spasticity in spinal cord injury: nursing concerns

Nursing diagnoses are proposed for the management of spasticity in the spinal cord-injured person. The diagnoses, pain and self-care deficit related to spasticity, can guide independent nursing management to reduce nociceptive stimulation and increase self-management of spasticity in spinal cord injury. The Gate Control Theory helps to explain alpha muscle susceptibility to nociceptive stimulation and offers rationale underlying nursing management of spasticity. The Modified Ashworth Scale is used to define, measure and evaluate the effectiveness of management of spasticity. Independent nursing management provides the foundation for spasticity intervention. Other interdisciplinary team interventions, including therapist intervention, pharmacological intervention and invasive procedures supplement the nursing management framework.     

脊髓损伤后肌痉挛机制与治疗

肌痉挛是脊髓损伤所致截瘫患者中常见并发症之一。痉挛常可导致患者肢体酸胀疼痛、关节挛缩、畸形，进而影响行走及在轮椅上保持姿势的能力，并增加异位骨化和骨折的发生率，从而严重影响患者日常生活及康复治疗效果。目前痉挛的治疗方法很多，如药物治疗、运动疗法和物理治疗、神经阻滞疗法、手术治疗等。但单一的治疗方法效果往往不理想，故目前联合应用多种方法来治疗肌痉挛在临床上较受欢迎。本文通过复习文献，就脊髓损伤后肌痉挛的发生机制、症状特点、评定方法进行简要介绍，并针对其临床治疗进行讨论。     

Intrathecal baclofen for spasticity management in Rett syndrome

Intrathecal baclofen infusions have proven to be effective for management of spasticity during the last two decades. Efficacy of intrathecal baclofen for spasticity of spinal origin has been well established and has shown promise in treatment of spasticity that is not spinal in origin. Rett syndrome is a neurodevelopmental disorder primarily affecting girls and women. Manifested in the advanced stages of this syndrome is increased spasticity leading to functional decline. Presented is a case report of a 32-yr-old white woman with Rett syndrome, diagnosed before the age of 2 yr, and significant spasticity that was successfully managed with intrathecal baclofen. After placement of an intrathecal baclofen pump, the dose was increased slowly during 1 yr to 800 microg/day with good clinical response. There was observed a significant decrease in upper and lower limb Ashworth scores, from an average of 3-4 to 2-3, during this 1-yr period. The decrease in spasticity in this patient eventually led to improved range of motion, positioning, skin care, hygiene, and quality of life. Intrathecal baclofen is an effective option in managing severe spasticity from Rett syndrome.     

Occurrence and temporal evolution of upper limb spasticity in stroke patients admitted to a rehabilitation unit

Kong KH, Lee J, Chua KS. Occurrence and temporal evolution of upper limb spasticity in stroke patients admitted to a rehabilitation unit.ObjectivesTo document the temporal development and evolution of upper limb spasticity, and to establish clinical correlates and predictors of upper limb spasticity in a cohort of stroke patients.DesignProspective cohort study.SettingA rehabilitation unit.ParticipantsPatients (N=163) with a first-ever ischemic stroke.InterventionsNot applicable.Main Outcome MeasuresAshworth Scale for measuring upper limb spasticity, Motor Assessment Scale for upper limb activity, Motricity Index for upper limb strength, and Modified Barthel Index for self-care. Upper limb spasticity was defined as an Ashworth Scale score of 1 or greater.ResultsUpper limb spasticity occurred in 54 patients (33%) at 3 months after stroke. Development of spasticity at later stages of the stroke was infrequent, occurring in only 28 patients (17%). In patients with mild spasticity (Ashworth Scale score 1) at 3 months after stroke, worsening of spasticity occurred in only 1 patient. On the other hand, almost half of the patients with moderate spasticity (Ashworth Scale score 2) at 3 months progressed to severe spasticity (Ashworth Scale score 3). Poor upper limb activity was the most important correlate of “moderate to severe spasticity” (Ashworth Scale score ≥2) (P<.001), and poor upper limb strength on admission to rehabilitation, the most important predictor of “moderate to severe spasticity” (P<.001).ConclusionsUpper limb spasticity was relatively infrequent in this study, occurring in 33% of patients at 3 months after stroke. Selective monitoring to detect severe spasticity is recommended for patients with an Ashworth Scale score of 2 or greater at 3 months after stroke, and in patients with severe upper limb weakness on admission to rehabilitation.     

Spasticity in spinal cord injury: self- and clinically rated intrinsic fluctuations and intervention-induced changes

OBJECTIVES: (1) To determine patterns of intrinsic fluctuations in spasticity, using repeated self-ratings, in subjects with spinal cord injury (SCI); and (2) To determine the relation between self-ratings of spasticity using a visual analogue scale (VAS) and clinical ratings of spasticity using the Modified Ashworth Scale (MAS) before and after spasticity-reducing treatment. DESIGN: Part I: observational, prospective cross-sectional study; part II: experimental, prospective longitudinal study. SETTING: Outpatient clinic of the Karolinska Hospital, Stockholm, Sweden. PATIENTS: Forty-five persons with SCI (39 men, 6 women); mean age at injury, 26 yrs; mean time since injury, 11 yrs. INTERVENTION: Repetitive passive movements of standardized range of motion in three different body positions, performed by two motorized tables. MAIN OUTCOME MEASURES: VAS ratings of spasticity, every other hour when awake, and of movement-provoked spasticity, rated before and after each treatment session, and MAS ratings of movement-provoked spasticity, before and after each treatment session. RESULTS: The spasticity of cervical SCI subjects fluctuated significantly (p < .05) during the day, unlike the spasticity of thoracic SCI subjects. Immediately after intervention with passive movements, spasticity ratings in thoracic motor complete SCI patients decreased by 11 to 14 mm (90%, p < .001) as self-rated on VAS and by 1 to 2 grades (50%, p < .001) as measured with MAS. A 30% (p < .018) decrease in VAS values of intrinsic pattern of spasticity was maintained over time when treatment was given regularly and was maintained for at least 1 week after discontinuation of treatment. VAS ratings correlated significantly with MAS ratings (r = .44 to .62, p < .001). CONCLUSION: Repetitive passive movement intervention decreased spasticity when performed regularly, as assessed by VAS and MAS ratings. VAS and MAS ratings were significantly correlated. It is recommended that SCI patients repeatedly rate their spasticity to establish a baseline before and to track changes after interventions aimed at reducing spasticity. The time of day when spasticity is measured seems more important in cervically injured individuals, because of their more pronounced intrinsic fluctuations.     

Understanding spasticity from patients' perspectives over time

bhimani r.h., mc alpine c.p. & henly s.j. (2012)?Understanding spasticity from patients' perspectives over time. Journal of Advanced Nursing68(11), 2504-2514. ABSTRACT: Aim. The purpose of this paper was to report patients' understanding and perceptions of personal spasticity experiences over time. Background. Spasticity is an unpleasant and poorly understood experience associated with upper motor neuron disease. Design. An original qualitative study was conducted in 2008-2009. Method. Content analysis was used to extract meaning from the responses of 23 patients to semi-structured interviews during 7?days of acute rehabilitation for neurological diseases associated with spasticity. Findings. Patients used words reflecting muscle tone and spasms to describe spasticity. Themes reflecting the spasticity experience over time were Ambiguous Experiences, Navigating Symptom Experience, Wounded Self, and Unending Journey. Conclusion. Spasticity as experienced is complex, involving a wide range of unusual sensations sensitive to stressors in everyday life. Clinical evaluation of spasticity should include patient reports. Knowledge about patient word choice used to describe spasticity can enhance communication with healthcare providers.