痉挛型偏瘫和双下肢瘫的步态分型和处理

痉挛型半身瘫和双下肢瘫是临床常见的需要治疗的脑性瘫痪类型。该文对这两种类型脑性瘫痪患儿常见的步态进行了分型,并根据分型提出了相应的治疗原则。通过对脑性瘫痪患儿的步态模式进行分型,根据患儿的功能情况制定个性化的治疗方案,改善患儿的步态和功能。     

脑性瘫痪患儿神经肌肉的病理研究

脑性瘫痪(简称脑瘫)是指从胎儿期到新生儿期由于脑部的非进行性病变而引起的运动和(或)姿势的永久性异常[1]。肌电检查证实部分患儿伴有感觉神经传导速度减慢,脊神经背根病理检查证实存在广泛的脱髓鞘性改变。但对患儿末梢神经及肌的病理改变研究甚少。本文对6例痉挛型脑瘫患儿腓肠肌及其所属末梢周围神经的活检组织进行光镜及透射电镜观察,以探讨其病理改变的特点。对象经临床确诊为痉挛型脑瘫患儿6例,男4例,女2例;年龄4～11岁,平均年龄64岁。双下肢肌张力均为3级以上,膝、跟腱反射亢进,步态为前冲或剪刀步态。方法局麻下取腓肠肌,部分标本…     

A型肉毒毒素治疗儿童痉挛型脑性瘫痪的临床研究

目的　观察局部肌肉注射A型肉毒毒素 (BTX A)治疗痉挛型脑性瘫痪的疗效。方法　于 2 0 0 1年 5月至 2 0 0 3年 9月 ,用BTX A对 73例痉挛型脑性瘫痪的患儿进行局部肌肉注射 ,其中男性 5 2例 ,女性 2 1例。年龄1 6～ 15 (10 4± 2 5 )岁。以改良阿氏量表 (MAS)评定肌张力 ,以运动评价量表 (PRS)评定运动功能。分析治疗前、治疗后 4周及治疗后 3个月的肌张力、PRS评分改变情况 ,并随访治疗后BTX A产生疗效时间及副反应。结果　BTX A治疗前、治疗后 4周及治疗后 3个月肌张力、PRS评分有明显改善。治疗后 4周 ,PRS各项评分均有明显改善 (P <0 0 5 ) ,其中步态、关节弯曲度改善最明显 (P <0 0 0 1)。 4 8例 (6 6 % )患儿在治疗 2～ 3d出现疗效。副反应短暂、轻微 ,无全身副反应。结论　局部肌肉注射BTX A能够安全地治疗痉挛型脑性瘫痪 ,有效改善步态、提高行走能力     

生物电刺激治疗痉挛型脑性瘫痪的研究近况

脑性瘫痪(脑瘫)的治疗仍然是医学界的难题.痉挛型脑瘫肢体痉挛的病理机制在于大脑皮质运动区和锥体束损伤后对脊髓牵张反射的抑制障碍,导致肌肉被动牵张时速度依赖性抵抗力增加,肌张力增高致姿势异常、特殊步态,并有高致残率,严重影响了患儿的生活质量.临床上有很多以降低肌张力为主要治疗目的的治疗于段,如药物、康复治疗、理疗、针灸、推拿等,生物电刺激疗法是最近新兴的治疗手段,其疗效及机制尚在探索中,现对生物电刺激治疗痉挛型脑瘫近期研究进行综述.     

儿童痉挛型脑性瘫痪蹲伏步态多学科团队治疗的初步经验CSCD

目的总结多学科团队联合治疗儿童痉挛型脑性瘫痪(以下简称脑瘫)蹲伏步态的初步经验。方法以2018年6月至2020年1月在上海交通大学医学院附属上海儿童医学中心和上海同济大学附属养志康复医院诊治的29例存在蹲伏步态的痉挛型脑瘫患儿为研究对象,男20例,女9例;平均年龄14.3岁(12~16.5岁)。患儿均行三维步态分析,由骨科医生、康复治疗师及步态研究员共同分析步态检查报告,并商定治疗方案,包括:手术前予康复宣教及康复训练3~4周(其中家庭康复1~3周),包括体位摆放、体位转移、轮椅训练、肌力训练等。采取单次多平面手术,包括髋关节重建术、髌韧带推进术、股骨远端短缩伸展截骨术等,如患儿存在扁平外翻足则行Mosca术。术后2周开始院内康复训练,时间8周;予居家康复训练+线上指导10个月。术后每3个月门诊复查,12个月以后行三维步态分析,评价临床疗效。结果29例痉挛型脑瘫蹲伏步态患儿均完成多学科团队治疗方案,医院康复训练及康复指导时间0.5~2周,家庭康复训练2~3周,家庭康复训练指导经互联网完成;均行单次多平面手术,其中髌韧带推进术29例,股骨远端短缩伸展术20例,内收肌切断术10例,股直肌延长术1例,髂腰肌松解术15例,Dega骨盆截骨+股骨近端内翻去旋转截骨术3例,腘绳肌延长术14例,距舟关节复位+距下关节融合术5例,Mosca手术13例。术后复查三维步态分析时间平均为术后13.5个月(12~15个月)。结果显示,患儿术后髋关节在支撑相中末期最大伸展角度较术前平均改善了12.29°,术后膝关节在支撑相中期屈曲角度较术前平均改善了26.84°,术后踝关节在支撑相中期背屈角度较术前平均改善了7.05°。康复评定发现,患儿髋外展、伸髋、伸膝及踝跖屈肌群的肌力均明显提升,平衡稳定性较术前增强,但步行过程中躯干横向位移问题未能改善。结论本研究已经验证了多学科团队治疗儿童痉挛型脑瘫蹲伏步态可有效改善膝关节的僵直状态,提升各关节运动肌群的肌力,明显改善异常的步态外观。儿童痉挛型脑瘫蹲伏步态骨科和康复科联合治疗模式短期疗效良好,远期疗效还有待进一步观察。     

股直肌远端转移在脑瘫患儿膝关节功能重建中的应用

改善脑瘫患儿行走功能的一个重要问题是重建膝关节的屈伸功能。强直膝或蹲位步态常常造成走路疲劳，严重影响患儿行走匹离和生活质量。传统的软组织松解术以胞绳肌腱松解延长来校正伸膝功能，容易造成膝关节过伸和步态跨步早期的屈膝障碍，而膝关节的动态活动范围并未得到改善[1]。Perry[2]根据步态分析的结果提出在胭绳肌松解的同时，应解除股直肌的痉挛，并将其远端转移到膝关节后方，使此肌肉既能屈伪，又能在跨步时屈膝，有助于将尼抬高地面，增加膝关节的动态活动范围。本人将在巴西SARAH医院研修期间行股直肌远端转移术重建膝关节…     

吡拉西坦治疗服性瘫痪

脑性瘫痪 (ＣＰ)是小儿大脑在尚未发育成熟阶段受到各种因素损伤后出现的以中枢性运动障碍和姿势异常为主要临床表现的一组综合征 ,是儿童时期主要的致残性疾病之一 ,治疗较为困难[1] ;我们在综合治疗的基础上 ,对 44例患儿加吡拉西坦静脉滴注 ,并观察疗效 ,现报告如下。对象和方法一、对象　 1999～ 2 0 0 1年我院儿科住院脑性瘫痪患儿112例 ;男 6 0例 ,女 5 2例 ;年龄 3个月～ 2岁 ;诊断参照 1988年全国脑性瘫痪座谈会修订的标准及分型[2 ] ;随机分为对照组和治疗组 ,去除病历资料不完整者。其中痉挛型 82例(73.2 % ) ,肌张力低下型 13例 …     

上田法治疗小儿脑性瘫痪的临床运用及疗效分析

上田法是日本田正博士1988年创立，用于治疗小儿脑性瘫痪等运动功能障碍性疾病，上田法对痉挛性瘫痪可降低肌张力，缓解肌痉挛，抑制异常姿势，防止关节挛缩变形，对恢复运动功能有良好作用。目前广泛运用于小儿脑瘫等中枢运动功能障碍性疾病，尤其为痉挛型脑性瘫痪小儿在降低肌张力，缓解痉挛方面有显著效果。     

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目的探讨粗大运动功能分级系统(GMFCS)在痉挛型脑性瘫痪患儿中的再测信度。方法收集2005年2月至2008年2月北京儿童医院治疗的痉挛型脑性瘫痪患儿83例,予以运动疗法(PT)、作业疗法(OT)、水疗(HT)、针灸及按摩治疗,在治疗前后对其采用GMFCS进行粗大运动功能分级并评估。结果 83例中1例治疗前后粗大运动功能级别发生变化,82例并未发生变化。GMFCS对于痉挛型脑性瘫痪患儿具有良好的再测信度(P<0.01),在<2岁阶段的再测信度低于其他年龄组(P<0.01)。结论 GMFCS是目前惟一针对脑性瘫痪患儿粗大运动水平进行标准化评价的工具,具良好再测信度,但在<2岁的再测信度低于其他年龄组。应进一步进行多中心合作研究,将全部类型、全部级别的脑性瘫痪患儿纳入研究以证实GMFCS在脑性瘫痪康复中作用及意义     

A型肉毒毒素辅助综合康复训练治疗痉挛型脑性瘫痪

目的研究A型肉毒毒素辅助综合康复训练对痉挛型脑性瘫痪的治疗效果。方法选择43例痉挛型脑性瘫痪患儿用国产BTX-A进行下肢痉挛肌肉局部注射辅助综合康复训练，应用改良Ashworth痉挛等级量表（MAS）、医师等级评价量表（PRS）方法进行治疗前后的疗效评价。结果BTX-A注射后不同时间与注射前比较肌张力降低及异常姿势改善有统计学差异。结论BTX-A注射辅助综合康复训练治疗痉挛型脑瘫较好地改善了肌肉痉挛状态及异常姿势，提高了康复疗效。     

脑瘫髋内收痉挛性内收肌组织化学和超微结构研究

目的研究小儿脑性瘫痪痉挛性髋内收肌肌纤维分型和肌细胞超微结构损害。 方法对16例脑性瘫痪痉挛性髋内收患儿的内收大肌用肌球蛋白ATP酶染色方法，对肌纤维进行分型和超微结构观察。 结果痉挛组内收大肌Ⅰ型肌纤维(慢缩纤维)比例70．92％，比对照组(57．43％)明显增高，并可见同型肌纤维聚集。超微结构显示肌纤维内线粒体和肌纤维结构受到损害。 结论提示Ⅰ型肌纤维增多和肌纤维的超微结构损害是脑瘫痉挛性髋内收手术治疗效果不佳的原因之一，引起肌纤维型改变的确切原因尚需进一步研究。     

Aetiology and epidemiology of cerebral palsy

Cerebral palsy is a common and significant disorder of motor development, with an incidence of 2–2.5 per 1000 live births. Despite improvements in antenatal and perinatal care, there has been little change in the overall numbers of children developing cerebral palsy in the last 40 years. More extremely premature infants are surviving and have more severe forms of cerebral palsy. The common risk factors are prematurity, small-for-gestational age, multiple pregnancy, and maternal genitourinary infections. Many children have more than one risk factor for developing cerebral palsy and it is useful to consider causal pathways to cerebral palsy rather than singe causal events. Only by understanding the aetiology and epidemiology of cerebral palsy can programmes be developed to prevent cerebral palsy and plan health services to meet the needs of the affected children.     

150例小儿脑性瘫痪的临床、CT与磁共振分析

研究目的 探讨小儿脑瘫患者CT及磁共振(MRI)形态学改变。 研究方法 对150例脑瘫患儿进行CT与MRI检查,并对其结果进行分析。 结果 150例中,CT异常者97例,占64.65%。弥漫性脑萎缩(42例)、脑软化灶(24例)、脑穿通畸形(9例)、局限性脑萎缩(7例)等是儿童脑瘫常见的CT形态学改变。CT检查正常者53例中,30例行MRI检查,异常25例,占83.3％。脑白质髓鞘形成延迟(14例)是主要的MRI形态学异常。 结论 CT和MRI检查对小儿脑瘫的病因学诊断有重要价值,两者结合可提高诊断符合率。     

不同运动功能分级脑瘫患儿步态分析中时-空与运动学参数的对比研究CSCD

目的比较2019年3月至2021年3月上海市儿童医院骨科收治的不同运动功能分级脑瘫患儿步态分析中时-空与运动学参数的差异,探索通过三维步态分析中时-空与运动学参数来定量评价痉挛型脑瘫患儿下肢运动功能,为痉挛型脑瘫的病情评估提供客观定量方法。方法选取年龄6~12岁、经粗大运动功能分级系统(gross motor function classification system,GMFCS)分级为Ⅰ、Ⅱ、Ⅲ级的痉挛型脑瘫患儿为研究对象,共90例,GMFCS分级为Ⅰ级(Ⅰ级组)、Ⅱ级(Ⅱ级组)、Ⅲ级(Ⅲ级组)各30例。选取30例正常儿童作为正常对照组。通过三维步态分析系统采集90例脑瘫患儿和正常对照组儿童步态分析中的时-空与运动学参数,利用方差分析和多样本均数间多重比较,分析不同运动功能分级脑瘫患儿之间以及与正常对照组儿童之间的差异。结果脑瘫患儿步态分析时-空参数中步长、步宽、步速、步频、跨步长较正常对照组儿童明显减小(P<0.05),且随GMFCS分级的升高而逐渐减小;脑瘫患儿步态周期和双支撑时间较正常对照组儿童明显延长(P<0.05),且随GMFCS分级的升高而逐渐延长。运动学参数中,脑瘫患儿髋关节、膝关节和踝关节活动角度较正常对照组儿童明显减小(P<0.05),髋关节最大屈曲角度、膝关节最大和最小屈曲角度、踝关节最大背屈角度明显减小,而髋关节最小屈曲角度明显增大(P<0.05);随GMFCS分级的升高,关节活动角度逐渐减小,髋关节最大屈曲角度、膝关节最大和最小屈曲角度、踝关节最大背屈角度逐渐减小,而髋关节最小屈曲角度逐渐增大;仅踝关节最大跖屈角度在不同GMFCS分级患儿中无明显差异(P>0.05)。结论步态分析中时-空参数和运动学参数可以定量评估痉挛型脑瘫患儿的下肢运动功能。GMFCS分级越高的脑瘫患儿与正常儿童之间的差异越大,下肢的运动功能越差。     

Cerebral palsy in twins: a national study

BACKGROUND: Cerebral palsy is more common in twins than singletons. Among twins, if one twin suffers a fetal death or dies in infancy, the prevalence of cerebral palsy in the surviving co-twin is considerably increased, and those from like-sex pairs are particularly at high risk. AIM: To compare birthweight specific cerebral palsy prevalence in like-sex and unlike-sex twins where both twins survive infancy and to provide a comparative and composite picture of cerebral palsy prevalence according to whether a co-twin died or where both twins survived. METHODS: Parents of twins born in England and Wales in 1994 and 1995 completed a booklet with open ended questions asking whether their twins had any medical, physical, visual, genetic, or chromosomal problems. Any mention of cerebral palsy, hemiplegia, diplegia, or quadriplegia allowed the child to be included as a case of cerebral palsy. Birthweight specific prevalence rates of cerebral palsy were determined for like and unlike-sex twins in birthweight groups < 1000 g, 1000-1499 g, 1500-1999 g, 2000-2499 g, and > or = 2500 g. RESULTS: When both twins survived infancy, like-sex were at greater risk of cerebral palsy than unlike-sex twins, but the difference was not statistically significant. If both twins survived infancy, the birthweight specific prevalence of cerebral palsy was significantly less than if the co-twin had died. CONCLUSIONS: Among the generality of twins, like-sex compared with unlike-sex twins are at greater risk of cerebral palsy particularly if one twin suffers a fetal or infant death. Although it is not possible to subdivide the twins according to zygosity, it is postulated that monozygosity and, specifically, monochorionicity may be the crucial feature that leads to the higher prevalence of cerebral impairment among like-sex twins.     

儿童脑性瘫痪CT形态学改变与临床关系的分析

研究目的 探讨儿童脑性瘫痪CT形态学改变与临床的关系。 研究方法 儿童脑瘫患者100例,男66例,女34例。所有患者共分为5个年龄组,分别行颅脑CT检查。 结果 儿童脑瘫多发于6个月～3岁间。100例患儿中CT扫描异常者73例,异常率为73％。脑室周萎缩(PVL)为最常见的CT形态学改变,共23例。中间部异常18例,皮质或皮质下萎缩20例,其它改变 13例。CT扫描正常者(27例)症状大多较轻,较严重的PVL,脑皮质及皮质下缩萎、脑囊性变,临床上多有严重的运动障碍。 结论 CT形态学检查对儿童脑瘫患者的诊断及预后判定具有重要意义。     

Feeding problems in children with cerebral palsy

OBJECTIVE: To determine the magnitude and extent of feeding problems in children with cerebral palsy (CP) and to evaluate the effectiveness of nutritional interventions. DESIGN: Prospective hospital based interventional study. METHOD: Children with cerebral palsy of either sex were enrolled randomly and their parents were interviewed for their perception about feeding problems, nutritional status and for their views about the expected outcome of feeding problems. Each case was assessed for feeding problems based on Gisel and Patrick feeding skill score; for nutritional status by measurement of weight, skinfold thickness (at biceps, triceps, suprailiac and subscapular), mid arm circumference and caloric intake; neurologically for type and severity of cerebral palsy and for developmental age by Gasell s developmental scale. Equal number of age and sex matched controls were included for comparison of nutritional status and developmental quotient. Various rehabilitation procedures were applied and their response was observed in the followup ranging from 3-10 months. RESULTS: One hundred children (76 boys and 24 girls) with cerebral palsy of mean age 2.5 years (range 1 to 9 years) and mean developmental age of 7.6 months (range 1 to 36 months) were included in the study. Oral motor dysfunction (OMD) was found in all cases and in each category. Spastic quadriplegic cerebral palsy (SQCP) and hypotonic patients had significantly poor feeding skill score (p < 0.001). Mean duration of feeding session was 31.5 minutes (range 10-60 minutes). Main food of children with cerebral palsy consisted of liquid and semisolid diet. Children with poor OMD were unable to take solid food. Cases with seizures had significantly more feeding problems than those without seizures (p < 0.001). Parental awareness about feeding problems of their children was significantly low and they overestimated the nutritional status of their children. Anthropometric indicators were significantly lower than controls (p < 0.001). Spastic quadreparesis, hypotonia and poor feeding skill score had negative effect on nutritional status. Thirty per cent parents of cerebral palsy patients were pessimistic about the possibility of any improvement in feeding problems. After nutritional rehabilitation, good improvement was seen in feeding problems, OMD and nutritional status. CONCLUSION: Nutritional status of children with cerebral palsy is poor due to summation of several factors. Therefore, they should be thoroughly assessed for feeding problems and nutritional status in order to start timely nutritional rehabilitation which can significantly improve their nutritional status and quality of life.     

Adaptive motor strategy for squatting in spastic diplegia.

Motor strategies, defined by kinetic, kinematic and/or muscle activation patterns, reflect neural planning of movement, which takes into account central as well as peripheral constraints. Major alteration is expected in cerebral palsy, a condition characterized by abnormal posture and movement secondary to early lesion of the brain. The objective of this study was to characterize the motor strategies involved in disruption of posture in cerebral palsy of the spastic diplegia type and compare them with normal controls. The optoelectronic ELITE system was used to record and analyse the movement of squatting from the standing position with the arms extended forward in 11 children with spastic diplegia aged between 3 and 12 years and 11 age-matched normal controls. Normal children maintained gaze and arm horizontality and trunk verticality throughout the movement. The knee followed an oblique trajectory. Its angular velocity profile showed a short, single-peaked, ascending phase. The onset of movement was preceded by deactivation of the semimembranous muscle. In diplegic children, gaze and arm horizontality and trunk verticality were lost. The ankle was rigidified, resulting in spatial fixation of the knee. The ascending phase of the knee velocity profile was prolonged and multi-peaked. There was widespread muscle co-contraction from the outset of movement. No anticipatory deactivation was evidenced, but anticipatory bursts appeared in the soleus. Patients with cerebral palsy have to organize a limited motor repertoire from a restricted neural potential. Consequent motor strategies presently demonstrated in spastic diplegia are distinct and appear as an original alternative to those of normal subjects.     

Is functional electrical stimulation an alternative for orthotics in patients with cerebral palsy? A literature review

Background

Functional electrical stimulation (FES) is a well-known intervention used during walking to improve walking abilities and correct gait deviations by facilitating the proper muscle group at the appropriate timing in the gait cycle. Our aim was to study the types of surface FES currently used in a cerebral palsy (CP) population and examine the evidence of its ability to improve gait deviations, functional ability and therapeutic effects.

痉挛性脑瘫周围神经及骨骼肌亚显微研究的临床意义

目的：探讨痉挛性脑瘫感觉和运动能力障碍的特点与机制，方法：分析102例痉挛性脑瘫患儿临床感觉和运动能力的观察结果，取材25例痉挛性脑瘫的周围神经标本40个，骨骼肌标本54个，进行透射电镜观察。结果：本组临床资料可见，浅感觉一痛觉基本正常，深感觉－关节觉障碍明显主动随意活动能力，上肢远端肌肉比近端肌肉减退明显，而下肢远近端差异不显著，电镜观察，周围神经呈原发性脱髓鞘表现，有髓纤维病变明显于无髓纤维，骨骼肌纤维亚显微结构I型纤维表现突出，结论：痉挛性脑瘫有明显的深感觉障碍，而浅感觉基本正常，周围神经的病变可能是其原因之一，运动能力障碍，在运动精细肌群表现更明显，骨骼肌纤维构型，I型纤维占优势，势必影响其收缩特性。