胫神经小腿三头肌运动分支选择性麻醉阻滞对脑卒中痉挛性垂足责任肌筛选的研究

目的 通过胫神经小腿三头肌运动神经分支选择性麻醉阻滞,确定造成脑卒中痉挛性垂足的责任肌。方法 选择30例脑卒中患者,应用2%利多卡因进行腓肠肌和比目鱼肌运动分支神经麻醉阻滞,阻滞前后对肢体痉挛指标包括牵张反射评分（stretch reflex,SR）、痉挛严重程度分级Ashworth评分、踝关节活动角度（range of motion,ROM）包括休息位ROM（rest range of motion,rROM）、主动背屈ROM（active range of motion,AROM）和被动背屈ROM（passive range of motion,PROM）、足跖屈肌肌力以及下肢步行功能状态指标如10m舒适和快速步行速度、步频、3min步行距离、能量消耗指数（physicalconsume index,PCI）以及步长和足偏角进行观察。分别比较腓肠肌阻滞前后、比目鱼肌阻滞前后,以及腓肠肌阻滞后和比目鱼肌阻滞后上述指标的变化和差异。结果 痉挛指标SR评分、Ashworth评分、AROM和PROM在腓肠肌运动分支阻滞后较阻滞前均下降,差异有统计学意义（P均＜0.01）;SR评分、Ashworth评分、rROM、AROM和PROM在比目鱼肌运动分支阻滞后较阻滞前均下降（P均＜0.01）;比目鱼肌运动分支阻滞后痉挛指标低于腓肠肌运动分支阻滞后（SR评分、AROM和PROM的P值均＜0.01,Ashworth评分、rROM P值均＜0.05）。对于足跖屈肌肌力,腓肠肌运动分支阻滞后较阻滞前肌力下降（P＜0.01）,比目鱼肌运动分支阻滞术后对肌力无影响,两种阻滞方法比较差异有统计学意义（P＜0.01）。步行功能指标腓肠肌运动分支阻滞后较阻滞前无统计学差异,比目鱼肌运动分支阻滞后除3min步行距离较阻滞前无差异外,其余指标均有提高（10m快速步行速度、步频的P值均＜0.01,10m舒适步行速度和PCI的P值均＜0.05）;除3min步行距离两种阻滞方法比较无差异外,其余指标比目鱼肌运动分支阻滞后均高于腓肠肌运动分支阻滞后（10m舒适步行速度P值＜0.05,余P值均＜0.01）。患侧步长和足偏角在两种阻滞方法术后较阻滞前差别均无统计学意义,两种方法比较也均无统计学差异。结论 腓肠肌运动分支和比目鱼肌运动分支利多卡因阻滞均能降低痉挛性足下垂患者的痉挛程度,但是比目鱼肌运动分支阻滞较之腓肠肌运动神经阻滞改善患者步行功能更为显著。故认为比目鱼肌是造成小腿三头肌痉挛性足下垂畸形的主要责任肌。     

前置式与后置式踝足矫形器对脑卒中患者步行功能恢复的影响

目的观察前置式与后置式踝足矫形器对脑卒中患者步行功能恢复的影响。方法将52例脑卒中患者随机分为前置组26例和后置组26例。前置组佩戴前置式踝足矫形器,后置组佩戴后置式踝足矫形器。观察指标为恢复至扶拐步行时间,恢复至独立步行时间,3个月时10m最大步行速度和Barthel指数。结果前置组恢复至扶拐步行时间（13．8±8．3）d较后置组（15．3±7．9）d快（P〈0．05）。前置组恢复至独立步行时间（27．4±14．9）d较后置组（35．9±18．0）d快（P〈0．05）。前置组10m最大步行速度（41．5士12．8）m／min较后置组（35．7±13．3）m／min快（P〈0．05）;前置组与后置组3个月时Barthel指数无显著差异（P〉0．05）。结论前置式踝足矫形器与后置式踝足矫形器相比,可加快脑卒中患者步行功能的恢复。     

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

目的初步观察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。方法将40例脑卒中后下肢痉挛患者根据随机数字表法分为治疗组和对照组,每组20例,对照组给予下肢痉挛肌群A型肉毒素局部注射加常规康复治疗,治疗组在此基础上强化运动治疗。分别于治疗前、治疗后4周、治疗后8周对2组患者进行MAS(改良Ashworth量表)、IEMG(肌表面肌电积分值)、PROM(被动关节活动度)、10m MWS(10m最快步行速度)、FMA(Fugl-Meyer运动功能)、PCI(生理消耗指数)评分。结果治疗4周及8周后,2组MAS、IEMG、PROM、10m MWS、FMA、PCI评分较组内治疗前均显著改善,差异有统计学意义(P0.05);治疗4周后,治疗组PROM(4.39±1.25)°、10 m MWS(18.12±3.47)m/s、FMA(25.16±2.55)分、PCI(0.51±0.21)等指标显著优于对照组,差异有统计学意义(P0.05),而MAS(1.54±0.48)分、IEMG(37.95±4.48)分等指标差异无统计学意义(P0.05);治疗8周后,治疗组PROM(4.42±1.01)°、10m MWS(14.11±2.83)m/s等指标显著优于对照组,差异有统计学意义(P0.05),而MAS(1.63±0.57)分、IEMG(46.94±8.17)分、FMA(26.44±2.12)分、PCI(0.47±0.15)等指标差异无统计学意义(P0.05)。结论 A型肉毒素局部注射结合强化运动治疗可改善脑卒中后下肢痉挛患者的步行能力,可作为一种康复治疗手段应用于临床。     

双任务步行对缺血性卒中患者步态参数影响的研究

目的 探讨双任务步行（dual-task walking,DTW）对缺血性卒中患者步态参数的影响。 方法 前瞻性入组2020年6月-2021年3月于首都医科大学附属北京天坛医院康复科住院的缺血性 卒中患者。选择时钟任务作为DTW中的认知任务,受试者依次完成单任务步行（single-task walking, STW）和DTW。使用Codamotion三维动作捕捉系统采集患者执行任务时步态的运动学参数（膝关节、踝 关节活动范围、最大屈膝角度、最大伸膝角度、最大踝背屈角度、最大踝跖屈角度）和时空参数（步 速、跨步长、跨步时间、跨步速度、步长、步长时间、步频、支撑期百分比）,计算时空参数的变异系数。 比较患者进行STW和DTW时上述步态参数的差异。 结果 本研究共纳入28例缺血性卒中患者,男性20例（71.4%）。患者进行STW和DTW时步态的 运动学参数差异无统计学意义。在时空参数方面,与STW时相比,进行DTW时患者的步速降低 （0.69±0.23 m/s vs 0.80±0.27 m/s,P＜0.001）、步长（0.41±0.11 m vs 0.46±0.12 m,P＜0.001）和跨 步长缩短（0.85±0.20 m vs 0.95±0.22 m,P＜0.001）。在时空参数变异性方面,与STW比较,卒中患 者进行DTW时步长时间变异性[4.47（2.98～7.34）vs 2.58（1.76～4.27）,P＝0.013]及步频变异性[4.59 （2.78～7.78）vs 2.71（1.84～4.44）,P＝0.020]增加。 结论 卒中患者在进行DTW时更容易发现步态问题。与STW相比,双任务条件下的步态评估可能是 更有效的卒中康复评估指标,也更适用于卒中后康复训练计划。     

踝足矫形器及针灸对偏瘫患者足内翻、足下垂步行能力的影响

目的 从步行速度和步行效率两方面来研究踝足矫形器(AFO)及针灸对偏瘫患者足内翻、足下垂步行能力的影响.方法 选择20例年龄相匹配的健康人和30例偏瘫足内翻、足下垂患者分别在穿着AFO加针灸和仅穿着AFO及不穿着AFO的情况下评测10米平均步行速度和生理消耗指数(PCI).结果 患者的步行速度在穿着AFO加针灸比仅穿着AFO情况明显提高(P<0.01) ;穿着AFO比不穿着AFO情况明显提高(P<0.01) ;患者的PCI在穿着AFO加针灸比仅穿着AFO情况明显降低(P<0.01),穿着AFO比不穿着AFO情况明显降低(P<0.01).健康人在穿着AFO情况下不但步行速度没有得到改善(P>0.05 ) , PCI反而明显升高(P<0.01).结论 AFO加针灸可以提高偏瘫足内翻、足下垂患者步行速度和步行效率,改善患者的步行能力.     

3D打印膝踝足矫形器改善早期脑卒中患者步行功能的研究

目的：观察3D打印膝踝足矫形器(knee ankle foot orthosis,KAFO)对脑卒中后2周～3个月偏瘫患者步行功能的影响。方法：纳入2018年1月1日—2020年7月31日符合病例选择标准的脑卒中后偏瘫患者30例,按照随机数字表法将其随机分为对照组1,对照组2及观察组,每组各10例。在常规原发病治疗以及康复治疗基础上,3组患者均在站立及步行训练时全程佩戴矫形器。对照组1佩戴传统踝足矫形器(ankle foot orthosis,AFO),对照组2佩戴传统KAFO,观察组佩戴3D打印KAFO。3组患者均接受4周的康复治疗,治疗前后采用10 m步行测试(10-meter walk test,10-MWT)、6 min步行测试(6-minute walk test,6-MWT)、下肢Fugl-Meyer运动能力评估量表、Berg平衡量表进行评估,并测量治疗前后的足间隙数值。结果：3组患者治疗前10-MWT、6-MWT、Fugl-Meyer运动能力评分、Berg平衡量表评分、足间隙数值的差异均无统计学意义(P0.05)。治疗4周后,与治疗前相比,3组患者的10-MWT较前缩短(P0.01),6-MWT较前增加(P0.01),Fugl-Meyer运动功能评分较前增加(P0.05),Berg平衡量表评分较前增加(P0.05),足间隙较前增加(P0.05)。组间比较,观察组上述指标均优于2个对照组(P0.05)。结论：3D打印KAFO可以增强下肢运动能力,改善平衡功能,降低患者的跌倒风险,进而提高步行速度及耐力,优化康复治疗。     

减重步行训练对卒中后遗症期偏瘫患者的康复疗效

目的 探讨减重步行训练对卒中后遗症期偏瘫患者步行功能、下肢运动功能、日常生活能力及生活质量的影响.方法 将广州医学院第二附属医院康复科自2009年5月至2011年6月收治的58例卒中后遗症期偏瘫患者按随机数字表法分为减重步行训练组30例及对照组28例,对照组接受常规康复治疗,减重步行训练组除接受常规康复训练外另接受减重步行训练.在治疗前后采用功能性步行量表(FAC)、FugI-Meyer量表(FMA)、Barthel指数(BI)及生活质量量表(SF-36)分别评价患者步行功能、下肢运动功能、日常生活能力及生活质量.结果 治疗前2组患者FAC、FMA、BI、SF-36评分比较差异均无统计学意义(P＞0.05).治疗后2组患者FAC、FMA、BI、SF-36评分均较治疗前明显提高,差异有统计学意义(P＜0.05),其中减重步行训练组FAC、FMA、BI、SF-36评分改善情况均明显优于对照组,差异有统计学意义(P＜0.05).结论 减重步行训练较常规康复治疗能显著提高卒中后遗症期偏瘫患者的步行功能、下肢运动能力、日常生活能力及生活质量.     

减重步行训练在卒中后偏瘫康复中的应用

目的 探讨卒中后偏瘫患者早期开展减重步行训练(PBWSTT)对下肢运动功能,步行能力和日常生活能力的影响.方法 选择病程在3个月内,偏瘫肢体分级Brunstrom分级≥Ⅱ级的稳定性卒中患者122例,随机分为PBWSTT组(63例)和对照组(59例).对照组患者采用神经促进技术进行康复训练;PBWSTT组患者在接受与对照组相同的康复训练基础上,进行PBWSTT训练.治疗前及治疗后4周采用功能性步行量表(FAC)表,简式Fugl-Meyer运动功能量表(FMA)及独立功能评定量表(FIM),评定2组患者步行能力,下肢运动功能及日常生活能力.结果 对照组治疗前FAC、FMA和FIM评分分别为0.42±0.23,17.1±5.2和35.3±3.8.治疗后为2.5±1.3,23.6±7.3和67.9±9.2.治疗前后评分比较,差异有显著意义(P＜0.05);PBWSTT组治疗前为0.36±0.13、16.7±6.2和35.1±3.4,治疗后为3.8±1.4、39.3±7.6和90.1±10.0,治疗前后比较,差异有显著性(P＜0.01).2组治疗后FAC,FMA评分比较差异亦有极显著性(P＜0.01),FIM评分差异有显著性(P＜0.05).对照组治疗前后能够独立步行者分别占44.1%、57.6%(P＜0.05);PBWSTT组为34.9%、88.9%(P＜0.01).治疗后对照组与PBWSTT组比较差异有显著性(P＜0.05).结论 卒中偏瘫患者早期在传统的康复治疗基础上应用减重步行训练,能更大程度提高下肢运动功能,步行能力及日常生活能力.     

节律性听觉刺激联合减重步行训练改善帕金森病患者步态功能

目的探讨对帕金森病(PD)患者进行节律性听觉刺激联合减重步行训练后,观察其对PD患者步态功能的影响。方法本研究纳入101例PD患者。对照组采用常规抗PD药物治疗,减重步行训练组采用药物治疗配合减重步行训练,综合训练组在药物治疗基础上采用节律性听觉刺激联合减重步行训练指导步行训练。监测3组受试者训练前后的步频、步长、步速步行参数,同时均采用功能独立性测量和计时起立行走测试评估PD患者的运动功能受损程度,采用Berg平衡量表评价PD患者平衡功能。结果训练后4 w及训练后8 w减重步行训练组与综合训练组的步长、步频、步速、功能独立性测量评分、计时起立行走测试时间、Berg平衡量表评分与训练前比较有显著差异(P0.05)。综合训练组在训练后4 w及训练后8 w步长、步频、步速、功能独立性测量评分、计时起立行走测试时间、Berg平衡量表评分与对照组、减重步行训练组比较有统计意义(P0.05)。结论 PD患者经节律性听觉刺激联合减重步行训练后步态运动功能和平衡功能得到改善,可推广应用。     

MOTOmed下肢运动训练联合阅读疗法对脑卒中偏瘫患者步行步态功能、病耻感及幸福度的影响

目的 分析脑卒中偏瘫患者应用阅读疗法联合MOTOmed下肢运动训练干预后其步行步态功能、幸福度及病耻感变化.方法 将我院109例脑卒中偏瘫患者应用掷币法进行分组,对照组54例给予常规康复训练结合MOTOmed下肢运动训练,观察组55例在此基础上联合阅读疗法,观察两组患者干预后神经功能、步行步态功能、病耻感、幸福度改变.结果 干预后,观察组MUNSH、Tinetti评分、步长、步行速度、步频水平均高于对照组(P＜0.05),NIHSS、Link评分低于对照组(P＜0.05).结论 阅读疗法联合MOTOmed下肢运动训练能够显著消除脑卒中偏瘫患者疾病羞耻感,缓解患者心理障碍,促进神经功能恢复及步行步态功能改善,提升患者幸福感.     

镜像疗法对偏瘫患者上肢功能康复疗效的观察

目的 观察镜像疗法对卒中后偏瘫患者上肢功能康复的疗效。方法 选择30例入选卒中后8周内偏瘫患者随机分为两组：镜像疗法组和对照组,分别于治疗前及治疗后4周采用Fugl-Meyer运动评价（Fugl-Meyer motor assessment,FMA）（上肢部分）,上肢运动研究测试（the action research arm test,ARAT）、运动功能评估量表（motor assessment scale,MAS）对上肢运动功能进行评分,同时评定患者的视觉模拟评分（visual analogue scale/score,VAS）、痉挛程度以及改良Barthel指数,以观察镜像疗法对偏瘫患者上肢功能康复的疗效。结果 治疗4周后,两组上肢运动能力FMA评分、ARAT评分、MAS评分、改良Barthel指数均较治疗前提高（P＜0.01）;治疗组FMA评分、ARAT评分高于对照组（P＜0.05）,两组间MAS评分、改良Barthel指数提高,但差别无统计学意义（P＞0.05）。治疗组VAS评分较治疗前有下降（P＜0.05）,但对照组治疗前后,VAS评分差异无统计学意义（P＞0.05）,治疗后两组间的VAS差异有统计学意义（P＜0.05）。两组治疗前后及治疗后组间痉挛改善差异无统计学意义（P＞0.05）。结论 镜像疗法能提高偏瘫患者的上肢运动功能,且能减轻患者偏瘫上肢的疼痛,但对患者日常生活活动能力（activity of daily living scale,ADL）及患肢痉挛程度的改善无明显影响。     

双任务步行对缺血性卒中患者认知－运动干扰的影响研究

目的 探讨缺血性卒中患者和健康人在进行双任务步行（dual-task wal ki ng,DTW）时,不同认知任 务对步态和认知-运动干扰（cogni ti ve-motor interference,CMI）的影响。 方法 选取24例急性缺血性卒中患者为卒中组,并选取与卒中组性别、年龄、受教育程度相匹配的 16例健康志愿者为对照组。所有被试者依次完成坐姿下两项认知单任务（single-tas k,ST）,包括连 续减法任务（serial subtraction,SS）和单词生成任务（word list generation,WLG）。然后完成单任务步行 （single-task walking,STW）、连续减法时双重任务步行（SS-DTW）和单词生成时双重任务步行（WLGDTW） 。使用Codamotion三维动作捕捉系统采集步态参数,包括步速、步频、跨步长和跨步时间,记录 认知任务正确反应数量。比较两组在DTW时步行和认知任务的双重任务成本差异。 结果 ①在STW和两种DTW时,卒中组步速、跨步长和步频明显低于对照组,跨步时间长于对照组, 差异有统计学意义（P <0.05）。与STW相比,卒中组在不同DTW时步速降低、步频减慢且跨步时间延长, 在SS-DTW时跨步长变短,差异有统计学意义（P <0.05）;对照组在不同DTW时步速降低、步频减慢、 跨步长变短和跨步时间延长,差异有统计学意义（P <0.05）。②与认知ST相比,卒中组在两种DTW中, 认知任务正确次数均减少（P <0.05）;对照组仅在SS-DTW时,认知任务正确次数减少,差异有统计学 意义（P <0.05）。 结论 执行双重任务（dual -task,DT）会导致缺血性卒中患者和健康者步态表现下降,卒中患者在 DTW时更易出现步态障碍。工作记忆任务和语义记忆任务对步态的干扰程度是相似的。DTW更能反映 日常生活活动能力,关于DTW时CMI模式的探索可为评估实际步行功能和DT训练效果提供理论依据。     

Gait variability in community dwelling adults with Alzheimer disease

Studies have shown that measures of gait variability are associated with falling in older adults. However, few studies have measured gait variability in people with Alzheimer disease, despite the high incidence of falls in Alzheimer disease. The purpose of this study was to compare gait variability of community-dwelling older adults with Alzheimer disease and control subjects at various walking speeds. Ten subjects with mild-moderate Alzheimer disease and ten matched control subjects underwent gait analysis using an electronic walkway. Participants were required to walk at self-selected slow, preferred, and fast speeds. Stride length and step width variability were determined using the coefficient of variation. Results showed that stride length variability was significantly greater in the Alzheimer disease group compared with the control group at all speeds. In both groups, increases in walking speed were significantly correlated with decreases in stride length variability. Step width variability was significantly reduced in the Alzheimer disease group compared with the control group at slow speed only. In conclusion, there is an increase in stride length variability in Alzheimer disease at all walking speeds that may contribute to the increased incidence of falls in Alzheimer disease.     

Evidence for a disorder of locomotor timing in Huntington's disease.

Disturbances of walking have been described in people with Huntington's disease (HD), although the nature of the deficits have not yet been well defined. The purpose of this investigation was to determine whether people with HD have a deficit in the regulation of footstep timing during walking. The footstep patterns of 30 people with HD and 30 matched comparisons were measured at self-selected slow, preferred, and fast speeds. Subjects were also instructed to match their footsteps to auditory metronome cues set at 80 and 120 beats per minute. Gait speed, cadence, stride length, and double limb support as a percentage of the gait cycle were measured using a computerized foot-switch system. People with HD demonstrated a disorder in their ability to regulate cadence, manifest as a reduced step frequency when walking at preferred speed and when required to increase their speed. For all walking conditions, people with HD had increased variability of footstep cadence. They also had difficulty synchronizing their footstep timing to an auditory cue. For all walking conditions, people with HD had reduced stride length. Thus, in HD, there is a disorder in the regulation of footstep timing, with increased variability, a restricted cadence range, difficulty synchronizing footsteps to an auditory cue and reduced stride length. The exact neural correlates of this timing disorder are yet to be determined.     

Ability to modulate walking cadence remains intact in Parkinson''s disease.

Gait hypokinesia (slowness) is a characteristic feature of Parkinson's disease. It is not clear, however, whether the slowness is due to a problem in regulation of the timing of consecutive steps or the control of stride size. Examination of cadence control for slow to medium walking speeds has shown an increase in step frequency that was a compensation for reduced stride length. In this investigation the ability of Parkinsonian patients to modulate their cadence (steps per minute) at the fast walking speeds exhibited by age and height matched controls was examined. The findings indicated that cadence control remains unaffected throughout its entire range in Parkinson's disease and that gait hypokinesia is directly attributable to an inability to internally generate sufficiently large steps.     

Three-dimensional motion analysis of the effects of auditory cueing on gait pattern in patients with Parkinson’s disease: a preliminary investigation

Auditory cueing enhances gait in parkinsonian patients. Our aim was to evaluate its effects on spatiotemporal (stride length, stride time, cadence, gait speed, single and double support duration) kinematic (range of amplitude of the hip, knee and ankle joint angles registered in the sagittal plane) and kinetic (maximal values of the hip and ankle joint power) gait parameters using three-dimensional motion analysis. Eight parkinsonian patients performed 12 walking tests: 3 repetitions of 4 conditions (normal walking, 90, 100, and 110% of the mean cadence at preferred pace cued walking). Subjects were asked to uniform their cadence to the cueing rhythm. In the presence of auditory cues stride length, cadence, gait speed and ratio single/double support duration increased. Range of motion of the ankle joint decreased and the maximal values within the pull-off phase of the hip joint power increased. Thus, auditory cues could improve gait modifying motor strategy in parkinsonian patients.     

Effects of walking distance over robot-assisted training on walking ability in chronic stroke patients

An understanding of the dose-response during training is important to identify the rehabilitation programs to obtain the improvement in chronic stroke patients. The purpose of this study was to determine whether distance-dose (distance walked across all sessions) during robot-assisted training affects the change of walking speed and distance in chronic stroke patients after intervention. Fifteen chronic stroke patients were enrolled in this study. The patients performed 8 gait training sessions using the Hybrid Assistive Limb (HAL) for 3 weeks. Gait speed, stride length, cadence, and 2-minute walk test (2MWT) were measured before and post-intervention. Total walking distance (distance walked across all sessions) in individual patients were also measured. Gait speed, stride length, cadence, and 2-minute walk test (2MWT) improved significantly after training. The average of walking distance for 8 sessions in individual patients was 3793.3 ± 2105.3 m. Moreover, the change of gait speed (r = 0.53) and 2MWT (r = 0.70) were positively correlated with the walking distance during 8 sessions. This study of finding demonstrated that greater total distance walked over all sessions of training using the HAL is directly associated with the better walking outcomes in patients with chronic stroke. Further researches with a larger number of patients and a control group are needed to quantify the study results more precisely.