痉挛型偏瘫儿童上肢精细运动功能发育进程研究

目的 采用非线性混合效应模型评估痉挛型偏瘫患儿的患侧和对侧上肢精细运动功能发育进程，进一步明确痉挛型偏瘫患儿的精细运动功能发育特性。方法 纳入2000至2012年在上海地区8家儿童康复机构和6所特殊教育学校接受康复治疗和教育的先天性痉挛型偏瘫连续病例。采用脑瘫患儿精细运动功能测试量表（FMFM）进行精细运动功能评估，分别测定以患侧和对侧为主导的FMFM分值。以非线性混合效应模型构建患侧和对侧的精细运动发育曲线，获得FMFM极限值以及达到极限值90％时的年龄（年龄-90）用于临床解释。结果 536例偏瘫患儿进入分析，男360例（67.2%），女176例，右偏瘫284例(53.0%),左偏瘫252例。首次评估时年龄最小5个月，最大17.8 岁，平均年龄为（3.4±3.2）岁。共有792对FMFM测试结果用于模型构建，平均每例患儿有1.48对FMFM测试结果，其中73例完成了2次测试，54例完成3次以上测试。采用Stable limit模型拟合对侧精细运动发育模型，采用Peak/decline模型拟合患侧精细运动发育模型，两模型均拟合成功。对侧的FMFM极限值为73.4分，明显高于患侧的64.0分。年龄-90对侧为2.7岁，患侧为3.3岁。患侧FMFM分值在到达极限值后呈缓慢下降趋势，降幅约为12%（极限值64.0分降至56.5分）。结论 痉挛型偏瘫患儿患侧上肢的精细运动功能发育极限低于对侧，到达发育极限的时间晚于对侧，且在到达极限后呈逐步下降趋势。针对偏瘫患儿的精细运动功能训练应充分重视两侧功能发育的特性。

Research on the development of fine motor function of upper limbs in children with hemiplegia

Objective To describe the patterns of fine motor development of both the affected and the contralateral upper limbs in children with spastic hemiplegia using nonlinear mixed effect model （NONMEM） , so as to further characterize the patterns of the fine motor development in children with spastic hemiplegia. Methods From 2000 to 2012, patients with congenital spastic hemiplegia were consecutively enrolled from 8 rehabilitation centers and 6 special education schools in Shanghai. Their fine motor functions were assessed with the fine motor function measure scale （FMFM） for children with cerebral palsy （CP）. Both the affected side and the contralateral side were assessed with FMFM, while the scores were analyzed respectively in the nonlinear mixed effect model. Two major parameters obtained from the model were used as clinical interpretations. The first parameter was 90% limits of fine motor function. The second was the age at which children were expected to achieve 90% limit of FMFM. Results A total of 536 children （ 360 male 67.2%, 284 right hemiplegia 53.0%, 252 left hemiplegia 47.0% ） were enrolled in the study. The youngest child was 5 months old at first evaluation, the eldest 17.8 years old, and with average （3.4 ：~3.2） years old. Altogether 792 pairs of FMFM scores were studied, 1.48 pairs for each child. The average age for all 792 pairs of assessments was （4.1 ＋ 3.8） years old. 73 children completed twice evaluations, while 54 completed three times or more. Stable limit model was used to fit the fine motor function model of the contralateral limb, while decline model was used to fit the model of the affected limb. Both models fit successfully. FMFM maximum score of the contralateral limb was 73.4, significantly higher than that of the affected limb, 64.0. Age-90 was 2.7 years for the contralateral side and 3.3 years for the affected limb. After reaching the maximum, FMFM score of the affected limb began to decline and dropped 12% from the peak of 64.0 to 56.5. Conclusions The fine motor development limit of the affected limb was lower than that of the contralateral side. It took more time for the affected limb to reach its developmental limit and the score tended to drop after that. The training of fine motor functions for children with hemiplegia should be based on the different developmental features of both limbs.