脑卒中患者功能恢复的影响因素分析

背景：脑卒中患者的康复结局多种多样，哪些因素能够影响此类患者的功能恢复，文献报道有差异。 目的：采用广泛应用的功能独立性评测来评定脑卒中患者康复前后的效果，分析入院时的运动功能、认知功能、年龄、从发病到康复机构的时间、性别、有无合并症、瘫痪侧别对脑卒中患者功能恢复的影响。 设计：前后对照观察。 单位：山东省立医院康复医学中心，首都医科大学康复医学院。 对象：选择2000-03／2002—12山东省立医院收治的脑卒中住院患者55例。均为首次发病，排除双侧大脑半球均受累患者。 方法：患者生命体征稳定、已渡过危险期（31～75d）后根据病情给予改善微循环及营养神经药物除外，还进行以Bobath技术、PNF技术、Rood方法为主的康复训练，每日一两个小时，每周训练5次。 主要观察指标：患者入院7d内及出院前3d应用功能独立性评测评分进行初期和末期评定。功能独立性评测包括运动、认知等18项，总分126分，108-126分为基本至完全独立，72～107分为轻度依赖；54～71分为中度依赖；36-53分为重度依赖；18-35分为极重度至完全依赖。应用多元逐步回归分析上述因素与功能恢复（以FIM总分增长值表示）之间的关系。 结果：55例全部进入结果分析。①患者出院时FIM总分显著高于入院时（93．8&;#177;12．0，68.8&;#177;11．6，P〈0．001），运动、认知得分均高于入院时（P〈0．001）。②功能独立性评测运动分的平均每天增长值与总分的增长值相似（0．56&;#177;0．21，0．59&;#177;0．21），但大于认知分的平均每天增长值（0．03&;#177;0．03）。③多元逐步回归方程提示入院时的功能独立性评测运动分、认知分、年龄和从发病到康复科的时间与功能独立性评测总分的增长值高度相关，但瘫痪侧别、性别、有无合并症则与其无相关性（P〉0．05）。对功能恢复贡献由大到小的因素依次为入院时的运动功能、认知功能、年龄、从发病到康复科的时间。 结论：脑卒中患者的功能恢复与入院时的运动功能、认知功能、患者年龄、康复开始时间的早晚呈显著相关性，其中入院时的运动分对功能恢复影响最大，呈正相关。因此在制定康复治疗方案时应考虑上述因素，因人而异。     

脑卒中患者功能恢复的影响因素分析

背景:脑卒中患者的康复结局多种多样,哪些因素能够影响此类患者的功能恢复,文献报道有差异。目的:采用广泛应用的功能独立性评测来评定脑卒中患者康复前后的效果,分析入院时的运动功能、认知功能、年龄、从发病到康复机构的时间、性别、有无合并症、瘫痪侧别对脑卒中患者功能恢复的影响。设计:前后对照观察。单位:山东省立医院康复医学中心,首都医科大学康复医学院。对象:选择2000-03/2002-12山东省立医院收治的脑卒中住院患者55例。均为首次发病,排除双侧大脑半球均受累患者。方法:患者生命体征稳定、已渡过危险期(31～75d)后根据病情给予改善微循环及营养神经药物除外,还进行以Bobath技术、PNF技术、Rood方法为主的康复训练,每日一两个小时,每周训练5次。主要观察指标:患者入院7d内及出院前3d应用功能独立性评测评分进行初期和末期评定。功能独立性评测包括运动、认知等18项,总分126分,108～126分为基本至完全独立,72～107分为轻度依赖;54～71分为中度依赖;36～53分为重度依赖;18～35分为极重度至完全依赖。应用多元逐步回归分析上述因素与功能恢复(以FIM总分增长值表示)之间的关系。结果:55例全部进入结果分析。①患者出院时FIM总分显著高于入院时(93.8±12.0,68.8±11.6,P<0.001),运动、认知得分均高于入院时(P<0.001)。②功能独立性评测运动分的平均每天增长值与总分的增长值相似(0.56±0.21,0.59±0.21),但大于认知分的平均每天增长值(0.03±0.03)。③多元逐步回归方程提示入院时的功能独立性评测运动分、认知分、年龄和从发病到康复科的时间与功能独立性评测总分的增长值高度相关,但瘫痪侧别、性别、有无合并症则与其无相关性(P>0.05)。对功能恢复贡献由大到小的因素依次为入院时的运动功能、认知功能、年龄、从发病到康复科的时间。结论:脑卒中患者的功能恢复与入院时的运动功能、认知功能、患者年龄、康复开始时间的早晚呈显著相关性,其中入院时的运动分对功能恢复影响最大,呈正相关。因此在制定康复治疗方案时应考虑上述因素,因人而异。     

脑卒中偏瘫的早期康复护理和高压氧治疗

目的 :探讨早期康复护理和高压氧治疗对脑卒中患者瘫痪肢体功能恢复的影响。方法 :42 9例脑卒中偏瘫患者按入院时间分为A组 2 11例和B组 2 18例 ,A组接受早期康复护理和高压氧治疗 ,B组接受常规治疗护理 ,分别在入院时和入院第 2 8天测定 2组患者上、下肢体肌力 ,评价日常生活能力及肢体运动功能。结果 :入院时2组患者瘫痪肢体的肌力、日常生活能力及肢体运动功能比较差异无显著性 (P >0 .0 5 ) ,入院第 2 8天 2组患者各项指标均有一定程度的改善 ,与B组比较 ,A组改善程度更显著 (P值分别小于 0 .0 1、0 .0 1、0 .0 0 5、0 .0 0 5 )。结论 :早期康复护理和高压氧治疗能减轻脑卒中患者因缺血缺氧对脑组织的进一步损伤 ,充分调动患者对治疗的主观能动性 ,促进瘫痪功能和患者身心的全面康复 ,提高生存质量。     

脑卒中偏瘫患者躯干和下肢运动能力的预后分析

目的:通过分析影响脑卒中偏瘫患者躯干和下肢运动能力的相关因素,预测运动功能恢复程度。方法:53例脑卒中偏瘫患者均经临床和CT或MRI确诊入院治疗。评估内容包括躯干和下肢运动能力(MOA)、日常生活活动能力(ADL)以及包括病史和检查在内的20余项相关因素。结果:患者治疗前运动能力(MOA0)和治疗前ADL(ADL0)分别为(18.77±12.78)个月和(58.71±3.22)分;治疗后运动能力(MOA1)和治疗后ADL(ADL1)分别提高到(27.34±14.26)个月和(74.86±3.02)分,均有显著差异。多元回归分析显示,MOA0与年龄、发病到康复入院时间、合并吞咽障碍、弛缓性瘫痪、觉醒障碍等因素呈负相关,与痉挛性瘫痪、吸烟、发病后住院时间及ADL0等因素成正相关。影响MOA1预后的自变量包括发病到康复入院时间、弛缓性瘫痪、患肢腱反射的程度等负性因素,以及MOA0、痉挛性瘫痪等正性因素。结论:患者年龄越轻,接受康复治疗的时间越早,运动能力恢复越快。伴有肌张力低下的弛缓性瘫痪是运动能力恢复的阻碍因素,而表现为肌张力增高的痉挛性瘫痪,由于重视了抗痉挛治疗,反而成为有利于运动功能恢复的因素。     

影响中老年脑卒中患者偏瘫肢体早期康复相关因素分析

目的　探讨影响中老年脑卒中患者偏瘫肢体康复程度的相关因素。方法　对 6 2例脑卒中患者治疗情况进行调查 ,采用Brunstrom 6级运动功能评价法对采用早期综合康复治疗 (32例 )和未采用此疗法(30例 )的两组患者瘫肢运动功能恢复状况进行评价。结果　早期进行综合康复治疗与未进行此疗法的患者上下肢运动功能恢复状况差异显著 (P <0 0 1)。瘫痪肢体的功能恢复除与早期康复治疗有关外 ,还与年龄、文化程度、出血部位、有无并发症和社会心理因素密切相关。结论　脑卒中患者早期康复治疗同时 ,不能忽视相关因素的治疗     

脑卒中康复结局预测的临床研究

目的探讨预测脑卒中康复结局的重要因素和可靠的预测模型。方法采用回顾性研究的方法 ,对北京博爱医院1999年 1月— 2 0 0 1年 7月收治的 2 2 5例首次脑卒中患者的临床资料进行分析。患者的功能状态按照自行设计的日常生活活动能力 (activitiesofdailyliving ,ADL)量表进行评定。 结果尽管许多因素都会影响患者的功能恢复 ,但最有意义的 3个因素是年龄、入院时的功能状态 (ADL入院)和发病到康复治疗的间隔时间 (onset addmisioninterval ,OAI)。年龄较小、ADL入院 值较高、康复训练开始较早患者的ADL出院 值较高。年龄与ADL增加 值无关。预测模型 :ADL出院 =49.5 2— 0 .14×年龄 0 .66×ADL入院 -0 .0 3×发病到康复治疗间隔时间 (R2 =0 .62 ,P =0 .0 0 0 1)。结论根据此模型 ,可预测患者出院时的功能状态 (ADL出院) ,制定合理的康复目标和康复训练计划。     

中重型颅脑损伤患者的康复治疗

目的 :研究中重型颅脑损伤患者综合康复治疗效果及影响因素。方法 :6 4例中重型颅脑损伤患者采用综合康复措施进行治疗 ,并运用Glasgow昏迷量表 (GCS)、简易精神状态检查量表 (MMSE)、平衡功能量表、运动功能 (Fugl Meyer)量表及日常生活活动能力 (ADL)进行疗效评定。结果 :6 4例患者平均治疗 12 0d ,其认知功能、平衡功能、运动功能及ADL均有明显改善。ADL的恢复主要受损伤程度和治疗时间的影响 (P <0 .0 5 ) ,认知功能的恢复与GCS和病程有关 (P <0 .0 5 )。结论 :中重型颅脑损伤患者ADL及认知能力恢复受颅脑损伤程度影响 ,综合康复治疗可降低颅脑损伤的残疾率 ,提高ADL。     

脑卒中患者瘫痪侧别对功能恢复预后影响的分析

目的:探讨脑卒中患者不同瘫痪侧别对功能预后的影响,为临床康复策略的制订提供理论基础。方法:脑卒中患者278例,分为两组:利手侧瘫痪组和非利手侧瘫痪组;两组都予以规范的三级康复治疗,分别于入选时、第1个月末、第3个月末和第6个月末进行瘫痪侧肢体功能评定(Brunnstrom分期、Fugl-Meyer评定)和生活功能评定(生存质量评定、日常生活活动能力评定和综合功能评定)。结果:利手侧瘫痪组和非利手侧瘫痪组患者在各次随访时的瘫痪侧肢体功能无明显差异(P0.05);利手侧瘫痪组和非利手侧瘫痪组的患者在各次随访时的生活功能有明显差异(P0.05),其中非利手侧瘫痪组的患者生活功能更好。结论:非利手侧瘫痪组的脑卒中患者生活功能的恢复进程和预后要优于利手侧瘫痪组的患者;而非利手侧瘫痪组与利手侧瘫痪组对脑卒中患者瘫痪侧肢体功能的恢复速度和预后无影响。     

脑卒中康复运动功能评定量表的临床应用分析

目的：运动脑卒中康复运动功能评定量表（stroke rehabilitation assessment of movement,STREAM）比较脑卒中偏瘫患者患侧上、下肢运动功能损害程度、恢复结果以及不同临床特征偏瘫患者运动功能恢复的差异。方法：用STREAM方法对114例脑卒中偏瘫患者治疗前、后进行评定并进行统计分析。结果：康复治疗前、后STREAM平均上、下肢运动分无明显差异（P＞0．05），平均下肢改变值和恢复效率高于上肢（P＜0．05）。病程≤1个月的脑卒中患者其治疗后的平均STREAM总分、改变值和效率均高于病程＞1个月的患者（P＜0．05）。年轻患者（＜65岁）的平均STREAM改变值和恢复效率均高于年老组（≥65岁）。脑出血患者平均STREAM改变值高于脑梗死患者（P＜0．05）。男、女患者间以及不同偏瘫侧患者间的运动功能恢复结果无明显差异（P＞0．05）。结论：脑卒中偏瘫患者偏瘫侧下肢运动功能恢复的幅度和速度都高于上肢。早期康复的结果和治疗效率要好于延迟康复的患者。年轻患者运动功能恢复的幅度和速度要优于年老患者。故在康复治疗初期，制定训练计划和进行训练时应考虑脑卒中患者偏瘫侧上、下肢恢复的差异以及患者病程、年龄等因素的差异。     

脑卒中患者言语功能障碍的发生及影响因素

目的：研究脑卒中患者言语障碍的发病情况和有关因素。方法：对连续住院的100名脑卒中患者，进行失语症的筛查和有关功能评定。结果：脑卒中后言语障碍发生率达43％，多发生在左侧半球的皮层或皮下区域。结论：言语障碍与患者性别、年龄、文化程度、病程、病变性质、病变部位、有无伴发病及日常生活活动无关，与意识、认知功能、病变所在侧别、颜面失用、言语失用、吞咽功能和上下肢运动功能有关。     

Rehabilitation outcome of elderly patients after a first stroke: effect of cognitive status at admission on the functional outcome

OBJECTIVE: To assess whether, and to what extent, cognitive outcome relates to overall functional outcome among elderly stroke patients. DESIGN: Nonconcurrent prospective study. SETTING: Geriatric rehabilitation division at a large, urban, academic, freestanding hospital in Israel. PARTICIPANTS: Three hundred thirty-six patients aged 60 years and older admitted consecutively for rehabilitation after first acute stroke. Inclusion criteria were met by 315 patients, who were included in the final analysis. Average age was 75.3 years. The stroke was right sided in 44.1%. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The motor subscale of the FIM instrument assessed functional status. Absolute functional gain was determined by the FIM motor gain. Relative functional gain was calculated according to the Montebello Rehabilitation Factor Score. Cognitive status was assessed with the Mini-Mental State Examination (MMSE) and the FIM cognitive subscale. RESULTS: FIM scores increased significantly during rehabilitation, mainly due to improvement in motor functioning. A strong association was found between the cognitive scales (r=.853, P<.001). Better rehabilitation outcomes were observed in patients with higher admission cognitive status, adjusting for the effect of age, sex, onset to admission interval, length of stay, and severity of stroke (odds ratio = 2.0; 95% confidence interval, 1.5-2.5). CONCLUSIONS: Impaired cognitive status at admission negatively affects the rehabilitation outcome of elderly stroke patients. The utility of routinely using a cognitive test for all patients before admission to rehabilitation, preferably the MMSE, is emphasized. The time, cost, and effort involved in performing such a test are negligible, and the potential benefits are considerable.     

Stroke rehabilitation outcome: the Turkish experience

The objectives of this study were to examine the demographic and clinical characteristics of stroke patients admitted for inpatient rehabilitation, to study the occurrence of medical problems/complications, and to document functional outcome and possible factors influencing outcome. The mean age of this cohort (30 females, 53 males) was 58+/-12 years and the mean length of hospital stay was 45.7+/-23 days. The most common medical comorbidity was hypertension (65%), followed by heart disease (42%) and diabetes mellitus (22%). The length of hospital stay was related to the number of medical comorbidities (r=0.24, P<0.05). Almost all patients experienced several medical problems during rehabilitation stay (average 7.1 events/patient). Shoulder dysfunction (80.7%), symptomatic blood pressure fluctuations (72.3%) and psychosocial problems (57.8%) were among the most common problems. There was a statistically significant improvement in total Functional Independence Measure scores from admission to discharge (56.5 vs. 74.6), with a mean gain of 18.1. Functional Independence Measure gain was significantly correlated with onset to admission time (r=-0.21, P<0.05), length of hospital stay (r=0.50, P<0.001) and the number of previous strokes (r=-0.23, P<0.05), but not with age, onset to admission interval, comorbidities and the presence of medical problems. Discharge total Functional Independence Measure scores were significantly correlated only with the admission total Functional Independence Measure scores (r=0.72, P<0.001) and onset-admission interval (r=-0.23, P<0.05). Significant functional improvements were documented in this cohort of stroke patients after an interdisciplinary rehabilitation approach. Discharge functional status was best correlated with admission functional status. Medical problems/complications were common among patients undergoing stroke rehabilitation. In our patients, functional outcomes were not significantly influenced by the occurrence of medical problems.     

Cognitive status at admission: does it affect the rehabilitation outcome of elderly patients with hip fracture?

OBJECTIVES: To determine the effect of cognitive status at admission on functional gain during rehabilitation of elderly hip-fractured patients. DESIGN: Cohort study. SETTING: A hospital geriatric rehabilitation department. PATIENTS: Two hundred twenty-four elderly patients admitted consecutively for rehabilitation after surgery for hip fracture. MEASUREMENTS: Cognitive status was assessed by the Mini-Mental State Examination and the cognitive subscale of the Functional Independence Measure (cognFIM); functional status was assessed by the motor subscale of FIM; absolute functional gain was determined by the motor FIM gain (deltamotFIM); and relative functional gain (based on the potential for improvement) by the Montebello rehabilitation factor score (MRFS). RESULTS: A significant increase in FIM scores (19.7) occurred during rehabilitation, mainly due to motor functioning (19.1). When the relative functional gain (as measured by both motor MRFS efficacy [r = .591] and efficiency [r = .376] was compared with the absolute gain (as measured by deltamotFIM [r = .304]), a stronger association between cognFIM and the relative measures was found. In addition, motor FIM efficacy and efficiency were significantly lower in the cognitively impaired patients (p<.01). A better rehabilitation outcome was seen in patients with higher admission cognitive status, adjusting for the effects of age, sex, length of stay, and type of fracture (odds ratio = 2.2, 95% confidence interval 1.5-3.7). CONCLUSIONS: Impaired cognitive status at admission lowered the rehabilitation outcome of elderly hip fracture patients. Cognitive impairment was strongly and directly associated with functional gain in these patients. Absolute motor gain appeared to be independent of cognitive status, whereas the relative motor gain depended on it. These findings support the implementation of comprehensive rehabilitation for selected cognitively impaired elderly hip fracture patients.     

急性脑卒中偏瘫患者认知功能障碍的相关研究

目的　探讨急性脑卒中患者早期认知功能障碍 ,及其与运动功能障碍间的相关性。方法　选择急性脑卒中偏瘫患者 44例 ,应用洛文斯顿作业疗法认知评定成套测验 (LOTCA)评定其认知功能 ,采用简式Fugl Meyer运动量表 (FMA)评定其运动功能 ,评定时间为发病后半个月内。应用SPSS统计软件进行统计学分析。结果　皮层下病变所致的偏瘫患者的认知功能LOTCA总积分与FMA积分呈显著相关 (r =0 .5 2 3 ,P <0 .0 1) ,其中定向力、知觉力及视运动组织能力的LOTCA积分与FMA积分呈显著正相关 (r =0 .5 15 ,0 .5 83 ,0 .495 ,P <0 .0 1) ,思维运作能力的LOTCA评分与FMA积分无显著相关性 (r =0 .3 0 6,P >0 .0 5 )。右侧与左侧偏瘫患者的各项LOTCA评分经t检验 ,差异均无统计学意义 (P >0 .0 5 )。结论　皮层下病变所致的急性脑卒中患者的认知功能障碍与运动功能障碍呈显著正相关 ;左、右两侧半球病变均可引起不同程度、不同类型的认知损害 ;对于偏瘫较重的患者应注意其认知功能的评估与治疗。     

Rehabilitation outcome of Turkish stroke patients: in a team approach setting

The aim of this study was to identify the efficacy of in-patient stroke rehabilitation, to evaluate the relationship between clinical characteristics and functional outcome, and to determine factors predicting functional outcome at discharge in Turkish stroke patients with a team approach. Retrospective data were collected from 102 of 116 patients with first stroke who were admitted to our rehabilitation unit at Ankara University. Demographic data, length of hospital stay (LOHS), onset to admission interval (OAI), type, side and location of stroke lesion, and most common medical complications were recorded. Functional Independence Measure (FIM) and Brunnstrom's motor recovery stages (BMRS) were assessed on admission and at discharge. The mean age was 61.6 +/- 10.9 years and the mean LOHS was 69.7 +/- 28.2 days. The mean FIM total scores were 69.2 +/- 27.4 and 83.2 +/- 25.7 on admission, and at discharge, respectively. The mean FIM total score was significantly correlated to age, LOHS and motor recovery. The FIM total scores of patients with aphasia and depression were found to be lower than those of patients without aphasia and depression. In a stepwise multiple regression analysis, FIM total score on admission, age and OAI were found to be valid predictors of FIM total score at discharge. Functional Independence Measure total score on admission was the strongest variable. Our results suggest that knowledge of the poor prognostic factors effecting functional outcome on admission can provide information to clinicians in identifying severity of stroke. Admission FIM total score, can be used to predict the patients' functional recovery. Advanced age, aphasia and post-stroke depression contribute to lower FIM scores.     

Bone mineral density in patients with stroke

The objectives of this study were to investigate the development and pathogenesis of osteoporosis in stroke in-patients, to compare the bone mineral density (BMD) of the paretic and non-paretic sides, to study longitudinal changes during the period on the rehabilitation ward and to relate BMD to demographic, impairment and disability variables. Participants were 32 first-stroke in-patients (19 men), with an average age of 62.4 +/- 8.1 years. Demographic and clinical characteristics were documented. The BMD of lumbar spine, bilateral distal radius and femoral neck were measured and compared at admission and discharge. The associations between bone loss and age, sex, time since stroke, Brunnstrom motor recovery scores and functional independence measure motor (mFIM) scores were assessed. The mean percentage differences in BMD between paretic and non-paretic arms at discharge were 12% (P < 0.001) and 3.5% (P < 0.05), respectively, and between paretic and non-paretic legs were 5% (P < 0.01) and 2% (P < 0.05), respectively. There was a statistically significant correlation between BMD loss and Brunnstrom stage (r = -0.41) and mFIM score at admission (r = -0.42). In conclusion, patients with hemiparesis due to stroke are at increased risk of developing osteoporosis on the paretic side. Higher motor impairment and functional dependency at admission increases the risk. New strategies are needed for stroke patients to prevent further decreases in BMD and reduce the risk of fractures.     

Health status and functional status in relationship to nursing home subacute rehabilitation program outcomes

OBJECTIVE: To assess the relationship of health status and functional status to key nursing home subacute rehabilitation program outcomes: motor function at discharge, discharge destination, and length of stay in the program. DESIGN: Using a prospective cohort study design, 164 patients were assessed on entering the rehabilitation program for the first time after discharge from an acute hospital. Their median length of stay was 40 days. RESULTS: The patients' motor function improved over time (P < 0.0001), and a large majority were discharged to the community. At admission, health status was positively associated with motor function (P < 0.05) and cognitive function (P < 0.01). Higher cognitive function and higher motor function at admission were correlated with higher motor function at discharge (rs = 0.386, P < 0.0001; rs = 0.563, P < 0.0001 respectively). Better health status was independently associated with discharge to the community (P < 0.01). Only motor function at admission was independently associated with length of stay (P < 0.01). CONCLUSION: Health status and functional status are related, and both are independently associated with nursing home subacute rehabilitation program outcomes. Therefore, an improvement in one may result in an improvement in the other, and both aid in the attainment of positive subacute rehabilitation outcomes.     

Recovery time of independent function post-stroke

Stroke patients undergoing physical rehabilitation were monitored daily to determine the length of time needed to recover independent function. Of the 93 patients admitted, there were 45 who could not attain the sitting position independently, 75 who could not walk independently and 75 who could not negotiate the stairs independently. By discharge, 25 of 45 patients (55.6%) were able to attain sitting from supine independently, 35 of 75 patients (46.7%) achieved the ability to walk independently but only 25 of 75 patients (33.3%) learned to negotiate stairs independently. The time from admission to achievement of independent function and the time from onset of stroke to achievement of independent function was modeled in relation to explanatory variables: age, sex, side of lesion, comorbidity, the presence of depression and the extent of impairment in perception, cognition, auditory comprehension and verbal expression. Four variables were found to influence recovery time: age influenced the rate of recovery of walking and stair climbing; perceptual impairment influenced the rate of achieving independent sitting and stair climbing; and depression and comprehension influenced walking.