A型肉毒毒素联合冲击波疗法对脑卒中后下肢痉挛状态的疗效观察

目的:观察A型肉毒毒素(BTX-A)注射联合体外冲击波疗法(ESWT)对脑卒中后下肢肌肉痉挛状态的疗效和安全性。方法:共选取60例脑卒中患者,均伴有下肢肌肉痉挛(小腿三头肌痉挛为主),随机分为常规治疗组、常规治疗+BTXA治疗组、常规治疗+BTX-A+ESWT治疗组,每组各20例患者。常规治疗组(A组)采用各种常规康复训练方法,每日1次,每周6次,共治疗4周;常规治疗+BTX-A组(B组)的患者除了进行常规康复治疗外,还对小腿痉挛肌肉进行BTX-A注射;而常规治疗+BTX-A+ESWT组(C组)除了进行常规康复治疗及局部注射BTX-A外,还给予患者小腿三头肌进行EWST治疗,每周1次,治疗4周。治疗前和治疗后1周、4周和16周分别进行踝关节跖屈肌群肌张力、下肢运动功能以及日常生活活动(ADL)能力评定。结果:(1)肌张力变化情况:三组患者治疗1周后,与治疗前相比,A组和B组略有下降、但是C组肌张力显著性降低(P0.05)。4周后,A、B、C组肌张力均显著性下降(P0.05),而B组、C组较A组效果更为佳(P0.05)。16周随访,A、B、C组肌张力均有所回升,但B、C组肌张力较治疗前仍降低(P0.05),且C组优于B组(P0.05)。(2)运动及ADL能力变化情况:三组患者治疗1周后,A、B、C组患者的运动功能及ADL能力无明显改善;4周后,三组运动功能和ADL能力均有所改善(P0.05),B组、C组改善较A组更好(P0.05)。而16周时,A组、B组运动功能和ADL能力出现下降,B组、C组相比虽有下降,但仍优于A组(P0.05)。结论:A型肉毒毒素联合冲击波疗法可以迅速并且较持久地降低患者肌张力,也能够有效地提高患者的运动功能和ADL能力,对脑卒中后肢体痉挛有明显改善作用。     

A型肉毒毒素联合重复经颅磁刺激对脑卒中后下肢痉挛状态的疗效观察

目的:观察A型肉毒毒素(botulinum toxin type A,BTX-A)注射联合重复经颅磁刺激(repetitive transcranial magnetic stimulation,r TMS)对脑卒中后下肢肌肉痉挛状态的长期疗效和安全性。方法:共选取80例脑卒中患者,均伴有下肢肌肉痉挛,随机分为常规治疗组、常规治疗+BTX-A治疗组、常规治疗+r TMS治疗组、常规治疗+BTX-A+r TMS治疗组,每组各20例患者。常规治疗组(A组)采用各种常规康复训练方法;常规治疗+BTX-A组(B组)的患者除了进行常规康复治疗外,还对下肢痉挛肌肉进行BTX-A注射;常规治疗+r TMS治疗组(C组)则除了常规康复训练,还进行r TMS治疗;而常规治疗+BTX-A+r TMS组(D组)除了进行常规康复治疗及注射BTX-A外,还给予患者r TMS治疗。治疗前和治疗后4周、8周和12周分别进行肌张力、下肢运动功能及ADL能力评定。结果:1肌张力变化情况:4组患者治疗4周后,与治疗前相比,肌张力均有不同程度降低(P0.05),8周后,A组肌张力有所回升,而B组、C组以及D组未见明显回升;12周时,A组肌张力进一步增加,与此同时,B组也有所回升,而C组与D组仍与8周时无显著差异,同时D组肌张力显著低于其余3组(P0.05)。2运动及ADL能力变化情况:4组患者治疗4周后,运动功能和ADL能力均有所改善(P0.05)。8周后,A组患者的运动功能及ADL能力再次出现下降,而其余3组患者未见下降;而12周时,与8周时相比,B组也出现下降,C组与8周时相比无明显变化,而D组则有进一步改善并优于其余3组(P0.05)。结论:A型肉毒毒素联合重复经颅磁刺激可以较持久地降低患者肌张力,也能够有效地提高患者的运动功能和ADL能力,为临床治疗脑卒中患者提供了新的思路。     

Severe Dysphagia after botulinum toxin B injection to the lower limbs and lumbar paraspinal muscles

We report a case of severe dysphagia in a 29-yr-old woman with cerebral palsy after she was injected with botulinum toxin B to her lower limbs and lumbar paraspinal muscles. Four days after the treatment, she developed difficulty swallowing, more severe for solid foods than for liquids, accompanied by dry mouth, blurred vision, and voice hoarseness. Fifteen days after the injection, with worsening of her dysphagia, she was hospitalized. A laryngoscopic evaluation revealed bilateral vocal cord paresis, and a modified barium swallow test demonstrated delayed oral initiation, upper airway penetration, and no reflexive cough. In the following days, she improved spontaneously and was discharged 12 days later when she re-acquired the ability to swallow solid foods. Her symptoms resolved completely only 75 days after the injection. Although dysphagia is a common side effect of botulinum injection in the neck, to our knowledge, this is the first reported case of severe dysphagia after injection in a distant anatomic site.     

Effect of intramuscular botulinum toxin injection on upper limb spasticity in stroke patients

OBJECTIVE: To evaluate the therapeutic effect of intramuscular injection of botulinum toxin on spasticity of the upper limb, with emphasis on its influence over limb function. DESIGN: An open-label, noncontrolled trial with a duration of 12 wk was designed to determine the safety and efficacy of intramuscular botulinum toxin A injection in the treatment of 16 patients with stroke with spastic hemiparesis. Electromyographically guided intramuscular botulinum toxin A injections were applied to the spastic limbs. A detailed scale system was used for the evaluation of muscle tone and functional changes induced by botulinum toxin A treatment. RESULTS: No major side effect secondary to botulinum toxin A injection was reported. Statistically significant (P < 0.05) improvements of muscle tone, joint range of motion, hand muscle strength, and muscular pain were seen after the injection. The improvements lasted up to 8-12 wk after the treatment. However, there was no significant functional improvement except in two of the patients. CONCLUSIONS: Botulinum toxin A injection may help relieve upper limb spasticity and pain in patients with stroke. Its effect on function is probably determined by case selection.     

Muscle tone changes in the lower limbs of stroke patients induced by trunk stabilization exercises

bstract. [Purpose] The purpose of this study was to identify the effects of trunk stabilization exercises on the spasticity of the lower limbs in stroke patients. [Subject] The subject of this study was a 38-year-old male patient who experienced a spontaneous intracranial hemorrhage, and had motor paralysis symptoms and spasticity on the left side. [Methods] The Hmax/Mmax ratio was measured before and after the trunk stabilization exercises, by using proprioceptive neuromuscular facilitation techniques. [Results] The Hmax/Mmax ratio changed from 37% to 20%. [Conclusion] Trunk stabilization exercises help control the muscle tone in stroke patients.Key words: Trunk stability, Stroke, Spasticity     

A型肉毒毒素在治疗脑卒中后上肢痉挛中的应用

肉毒毒素（botulinum toxin, BTX）是治疗肌张力障碍和肌肉痉挛十分有效的药物.在我国,多应用于颜面部和颈部的肌肉痉挛.对于脑损伤后所致的肢体痉挛,我国应用这种方法治疗的情况并不多.本文就肉毒毒素治疗脑卒中后上肢痉挛的治疗应用进行综述.     

超声联合电刺激引导下A型肉毒毒素注射对卒中早期患者肌痉挛的临床研究

目的观察超声联合电刺激引导下A型肉毒毒素（BTX A）注射对早期脑血管意外患者肌痉挛的影响。方法选取早期脑血管意外后小腿肌痉挛患者46例,随机分为治疗组（23例）及对照组（23例）。对照组给予常规康复训练,治疗组在常规康复训练基础上辅以超声联合电刺激引导下BTX A注射治疗。于治疗前和治疗6周后分别采用改良Ashworth量表(MAS)、简化Fugl Meyer量表（FMA）、世界卫生组织生存质量量表简表（WHOQOL BREF）、表面肌电积分值（iEMG）对2组功能进行评定。结果经6周治疗后,治疗组较对照组改善,治疗组MAS、 FMA、WHOQOL BREF、iEMG评分显著高于对照组（P<0.05）。结论超声联合电刺激引导下A型肉毒毒素注射对早期脑卒中患者肌痉挛定位准确、安全有效。     

Use of botulinum toxin type A and type B for spasticity in upper and lower limbs

BT is likely effective in controlling spasticity in the smaller muscles of the arm and hand, although there has been only one large controlled trial. For lower limb spasticity, the outcomes are more mixed. No large randomized, controlled trials have been done, and the larger size of the muscles results in a decreased ability to treat widespread spasticity. For more focal treatment in the legs and feet, however, and when combined with other denervating agents or physical modalities, BT is probably effective. Careful analysis is warranted before performing any chemodenervation on a limb muscle or muscles.     

Ultrasound-guided injection of botulinum toxin A in the treatment of iliopsoas spasticity

PurposeIntramuscular injection of botulinum toxin A (BTX-A) is a common treatment for iliopsoas muscle spasticity, but it is not easy to position the needle in this muscle without guidance. In this paper we describe an ultrasound-guided technique for the intramuscular injection of BTX-A to treat spasticity of the iliopsoas muscle. Its effectiveness was assessed in 10 patients.Method and materialsThe ultrasound-guided technique for BTX-A injection was used on 10 patients. The needle was inserted into the muscle belly at an angle of 45° along the longitudinal axis of the muscle when allowed by patient's condition.ResultsIn all cases, the iliopsoas muscle was easily identified and both the iliac and psoas components were assessed. Introduction of the needle and drug injection were entirely carried out under ultrasonographic guidance. The procedure was successful in all patients, even in those with a high-grade spasticity, and general anesthesia was not required.ConclusionsThis ultrasound-guided technique allows accurate guidance for the injection of BTX-A, and it can be considered as an alternate supportive therapy in patients with spasticity and dystonia.     

The effects of very early mirror therapy on functional improvement of the upper extremity in acute stroke patients

[Purpose] The aim of the study was to evaluate the effects of a very early mirror therapy program on functional improvement of the upper extremity in acute stroke patients. [Subjects] Eight stroke patients who were treated in an acute neurology unit were included in the study. [Methods] The patients were assigned alternatively to either the mirror therapy group receiving mirror therapy and neurodevelopmental treatment or the neurodevelopmental treatment only group. The primary outcome measures were the upper extremity motor subscale of the Fugl-Meyer Assessment, Motricity Index upper extremity score, and the Stroke Upper Limb Capacity Scale. Somatosensory assessment with the Ayres Southern California Sensory Integration Test, and the Barthel Index were used as secondary outcome measures. [Results] No statistically significant improvements were found for any measures in either group after the treatment. In terms of minimally clinically important differences, there were improvements in Fugl-Meyer Assessment and Barthel Index in both mirror therapy and neurodevelopmental treatment groups. [Conclusion] The results of this pilot study revealed that very early mirror therapy has no additional effect on functional improvement of upper extremity function in acute stroke patients. Multicenter trials are needed to determine the results of early application of mirror therapy in stroke rehabilitation.Key words: Acute stroke, Mirror therapy, Upper extremity     

Gait improvement in stroke patients by Gait Exercise Assist Robot training is related to trunk verticality

[Purpose] Various types of Gait Exercise Assist Robot (GEAR) have been developed recently, some of which have enabled early improvement in patients with stroke. However, none has yet resulted in independent walking in these patients. Hence, we conducted an exploratory study of the effect of GEAR on achieving independent walking in stroke patients. [Participants and Methods] The participants were 16 patients with severe stroke. We evaluated patients’ ability to walk independently after GEAR training. The outcome measure was Stroke Impairment Assessment Set (SIAS) motor score (Hip Flexion, Knee Extension, Foot Pat, Abdominal and Verticality). Differences in five SIAS motor scores were compared between the independent and non-independent walking groups. [Results] There was statistically significant difference between the groups in terms of Verticality among the 5 SIAS items used in the present research . Verticality of SIAS score of 1 was the cut-off value for distinguishing walking independence. [Conclusion] Verticality of SIAS may be a marker of potential walking independence that can be used in rehabilitation plans using walking-assist robots in patients with stroke.     

A型肉毒毒素治疗贲门失弛缓及远期疗效观察

目的 评价内镜下注射肉毒毒素治疗贲门失弛缓的临床效果。方法 对 57例贲门失弛缓病人采用内镜下注射 A型肉毒毒素治疗,通过对治疗前后主要症状评分及食管下括约肌压力（ LESP）测定评价近期疗效。治疗后半年、 1年、 2年随访,评价中远期疗效。结果 在 57例病人中有 54例治疗后症状缓解占 95％,无合并症发生。随访观察治疗后半年以上有 41例,其中 36例未复发占 88％; 1年以上 30例,有 25例未复发占 83％; 2年以上 12例,有 8例未复发占 67％。结论 内镜下注射 A型肉毒毒素治疗贲门失弛缓是一简单、安全、有效的方法。     

A型肉毒毒素在下面部提升的临床观察

目的观察A型肉毒毒素在下面部提升的临床疗效。方法随机选取我院门诊收治的13例下面部松垂的求美者,给于A型肉毒毒素双侧咬肌(选择性)、颈阔肌注射,分别于治疗前、治疗后3月及6月对求美者面部正位片进行标准化摄影,采用Photoshop CS6测量其治疗前后下面部提升的距离,应用SPSS 17.0进行统计学分析,比较前后治疗效果。结果治疗后3月、6月与治疗前相比下面部提升差异均有统计学意义(P<0.05)。治疗后3月求美者总满意度69.23%;治疗后6月求美者总满意度49.15%。结论A型肉毒毒素提升下面部6个月内安全有效,操作简便,不良反应少,值得临床推广应用。     

利多卡因诊断性阻滞在脑卒中患者足下垂内翻A型肉毒毒素注射治疗中的应用

目的:研究利多卡因诊断性阻滞在脑卒中患者足下垂内翻A型肉毒毒素注射中的作用.方法:将符合标准的45例患者随机分为两组,其中25例组患者先进行彩超引导下利多卡因注射,注射完成后观察10min,如无特殊不适,徒手检查患者踝关节肌张力,并让患者行走,肌张力明显下降,目测足下垂内翻明显改善者有19例,这19例患者为利多卡因诊断性阻滞组(诊断性阻滞组),48h后进行彩超引导下A型肉毒毒素注射治疗.另一组20例患者为A型肉毒毒素直接注射组(直接注射对照组),不进行利多卡因注射,直接进行彩超引导下A型肉毒毒素注射治疗.以上两组患者在进行A型肉毒毒素阻滞治疗24h后进行常规康复训练,训练内容包括Bobath方法、运动再学习和日常生活活动(ADL)训练等,训练每次40min,每日2次.所有患者训练至少持续2个月.两组39例患者于治疗前、治疗后1周、2周、4周、8周由未参与注射及康复训练的医师进行肌张力、步速、步长的评价、下肢运动功能的评价(MAS,FMA,FIM评分)、ADL能力评分.结果:治疗后1周两组患者肌张力有下降趋势,但差异无显著性意义,治疗2周、4周、8周后肌张力的下降MAS评分较治疗前差异有显著性意义,在治疗2周、4周、8周后两组间踝关节跖屈肌肌张力差异无显著性意义;两组患者治疗1周后步长、步速、FMA评分、FIM评分无明显变化,直接注射组治疗2周后步长、步速、FMA评分、FIM评分较治疗前有增加趋势,但差异无显著性意义,诊断性阻滞组治疗2周后步长、步速、FMA评分、FIM评分较治疗前增加(P＜0.05),治疗4周及8周后两组患者步长、步速、FMA评分、FIM评分较治疗前均增加(P＜0.05),在治疗4周和8周后诊断性阻滞组步长、步速、FMA评分、FIM评分均较直接注射组高(P＜0.05).结论:在脑卒中患者足下垂内翻的治疗中,先用利多卡因进行诊断性阻滞后再行A型肉毒毒素注射,可缩短疗程,而且在对步态、ADL能力、肢体运动功能方面的长期疗效亦优于直接A型肉毒毒素注射.     

Effects of fast and slow squat exercises on the muscle activity of the paretic lower extremity in patients with chronic stroke

[Purpose] The purpose of this study was to investigate the effects of the speed of squat exercises on paretic lower extremity muscle activity in patients with hemiplegia following a stroke. [Subjects and Methods] Ten stroke patients performed fast and slow squat exercises for 2 seconds and 8 seconds, respectively. The muscle activities of the paretic and non-paretic sides of the rectus femoris muscle, the biceps femoris muscle, and the tibialis anterior muscle were assessed and compared using surface electromyography. [Results] The paretic side of the rectus femoris muscle showed statistically significant differences in the fast squat exercise group, which demonstrated the highest muscle activity during the rapid return to the upright position. [Conclusion] The rectus femoris muscle showed the highest muscle activity during the return to the upright position during the fast squat exercise, which indicates that the rectus femoris muscle is highly active during the fast squat exercise.Key words: Fast and slow squat exercise, Muscle activity, Chronic strokes     

The Change in Knee Angle during the Gait by Applying Elastic Tape to the Skin

[Purpose] The aim of this study was to verify how the application of elastic tape to the anterior surface of the thigh changes the knee angle pattern during gait. [Subjects] The subjects were 10 people who showed an abnormal knee angle change pattern during usual walking. They did not show the so-called double knee action. [Methods] Subjects were asked to walk as usual, and then to walk with elastic tape attached to the anterior surface of the thigh. The knee angle was measured during gait with an electronic goniometer. We graphed the temporal changes of the knee angle and compared them with the normal gait pattern. [Results] The knee angle gait pattern of six of the 10 subjects improved after application of the tape and became like a normal gait pattern. The changes in the knee angle resulted from a stimulus via the skin, rather than voluntary muscular adjustment, suggesting that the changes may have originated due to differences in reflexive tensile strength. [Conclusion] In normal speed gait, it is suggested that the knee angle was altered such that it exhibited a normal pattern by applying elastic tape to the anterior surface of the thigh. We suspect that application of the elastic tape may change the muscle tonus.Key words: Gait, Knee angle, Kinesio tape     

Post stroke hemiplegia: interest of botulinum toxin injection at the upper limb]

OBJECTIVES: To present data about the effect of botulinum toxin injection on the upper limb of stroke patients. METHODS: We used the Medline data bank. Analysis took into account the international classification of functioning and disability. Important technical or pragmatic points were analysed separately. RESULTS: Botulinum toxin reduces spasticity of the injected muscles, with a mean gain of about 1 point on the Ashworth scale in the 4 to 6 weeks post injection, but with a large variability. This is associated to an increase in the passive range of motion, especially at wrist, and at times to a facilitation of active movements, when they are still possible. Improvement in functional tests is observed when fair proximal and distal motricity persists. Reduction in the dependence in daily living activities has not been shown by group studies. Several patients have an improvement in using the hand for blocking and transporting objects, mainly in a facilitating position (pronation, partial wrist flexion). Comfort of patients and caregivers is more regularly improved. Results are partially predictable; improvement in function is observed in patients with fair distal motricity (extension) and low spasticity, and improvement in comfort in those with severe spasticity and low motricity. CONCLUSION: Further studies are required, on one hand for better assessment of distal functional improvement, on the other hand at earlier phases of the disease.     

A modified method of botulinum toxin injection in patients with achalasia: a pilot trial

BACKGROUND AND AIMS: Injection of botulinum toxin (BT) from direct vision into the lower esophageal sphincter (LES) lowers its basal tone and improves symptomatology in most of the patients with achalasia. We hypothesized that the effect could be improved by better degree of LES infiltration by toxin administered from both prograde and retrograde views. The aim of the study was to investigate the feasibility, safety and efficacy of this modified method of intrasphincteric BT injection in patients with achalasia. PATIENTS AND METHOD: Sixteen patients with achalasia were treated with BT injection. Hundred units of BT (Botox) were diluted with 4 ml of normal saline. Aliquots of 0.5 ml were injected into four quadrants of the LES from retrovision and then into each quadrant from direct vision. The patients were followed up for a median of 25.5 months (range 19-31). RESULTS: No serious adverse events were noted. All patients responded well to the injection within one week and 3 patients (18.7 %) experienced an early relapse. The remaining 13 patients were classified as responders. After a single BT injection, 11 responders reported a relapse and 2 patients remained asymptomatic. The median symptom-free interval was 17 months (8-28). Five patients with a relapse underwent BT reinjection. Three of them remained asymptomatic and two experienced the second relapse. After BT reinjection, the median symptom-free interval was 16 months (10-19). All other patients with a relapse and without BT reinjection were treated with either balloon dilatation or surgery and are currently asymptomatic. CONCLUSION: Combining injection of BT into the LES from both direct vision and retrovision was feasible, safe and produced a rapid response which was sustained for more than 1 year in the majority of patients. This method of BT administration might be superior to the traditional injection from direct view only, and a randomized and prospective study comparing those techniques of administration should be performed.