促通技术与推拿手法抗偏瘫上肢屈肌痉挛的效果比较

Facilitation technipue versus massage in treatment of flexor muscle spasm of upper limbs in hemiplegic patients

目的:对西方现代促通技术与中国传统推拿手法治疗偏瘫上肢屈肌痉挛患者痉挛缓解时间进行比较,分析两种方法治疗偏瘫上肢屈肌痉挛效果。方法:①选择2002-12/2004-12上海几家医院及社区(奉贤中医院、龙华医院、长寿路地段医院、静安老年医院、市一医院宝山分院、市六医院、瑞金医院、华山医院以及田林社区)中的28例上肢屈肌痉挛的偏瘫患者,男17例,女11例;年龄31～85岁;改良Ashworth痉挛分级2～4级。均对干预方案知情同意。②抑制患侧上肢屈肌痉挛统一采用的现代促通技术:Rood易化技术中的快速刷擦、叩击等方法刺激患侧上肢伸肌;抑制技术中的持续缓慢牵伸方法,沿上肢长轴挤压肘、腕关节,在肘、腕关节伸展位时让患者将身体的重心移到患侧使之负重,必要时用分指板辅助伸指。中医推拿手法:刺激性手法中的滚法、揉法、捏拿等治疗手法施于患侧上肢伸肌。根据患者的情况每天或隔天做1次抗痉挛治疗。6次治疗分别是:第1次:促通技术5min;第2次:促通技术20min;第3次:推拿手法5min;第4次:推拿手法20min;第5次:结合治疗10min(先用促通技术结合推拿手法将肘、腕关节伸展,再负重保持至10min);第6次:结合治疗20min(先用促通技术结合推拿手法将肘、腕关节伸展,再负重保持至20min)。6次治疗在一两周内完成。③疗效评价:采用改良Ashworth痉挛分级标准(0～5级:0级:无肌张力的增加;5级:受累部分僵直)评估患者每次治疗前后上肢屈肌痉挛的程度,将治疗后改良Ashworth痉挛分级下降1级以上视为痉挛缓解;从治疗结束后痉挛缓解开始计算时间,到痉挛再次回到原来的级数所经过的时间视为痉挛缓解时间,将该时间作为疗效判定依据。④应用配对的秩和检验分析,用中位数表示均数,用四分位数间距表示均数的范围。结果:上肢屈肌痉挛的偏瘫患者28例均进入结果分析。①相同治疗时间下,治疗效果比较:治疗时间为5min时,促通技术治疗与推拿手法疗效相同,痉挛缓解的时间分别是9.5和10.0min(P>0.05)。治疗时间为20min时,促通技术治疗后痉挛缓解的时间明显长于推拿手法(37.5和26.0min,P<0.05),两种方法结合治疗10min与推拿手法单独治疗20min痉挛缓解时间相近(P>0.05)。两种方法结合治疗20min与促通技术单独治疗20min痉挛缓解时间相近(P>0.05),促通技术和两种方法结合治疗明显优于推拿手法(P<0.01)。②相同治疗方法,不同作用时间治疗效果比较:促通技术治疗20min痉挛缓解的时间明显长于促通技术治疗5min(37.5和9.5min,P<0.01);推拿手法治疗20min痉挛缓解的时间明显长于推拿手法治疗5min(26.0和10.0min,P<0.01);两种方法结合治疗20min痉挛缓解的时间明显长于两种方法结合治疗10min(41.0和24.5min,P<0.01)。结论:促通技术和推拿手法在对偏瘫患者的抗痉挛治疗方面都有效,相同的治疗方法下,治疗时间越长,疗效越好。在相同治疗时间下,治疗时间为5min时,两种治疗方法治疗效果相同。治疗时间为20min时,促通技术显优势,与两种方法结合治疗效果相近,疗效均优于推拿手法。

AIM： To compare the time of spasm alleviation on the hemiplegic upper limb with modern facilitation technique and traditional massage so as to analyze the effects of anti-spasm with two approaches. METHODS： ① From December 2002 to December 2004, 28 hemiplegic patients （17 males and 11 females; 31-85 years old） of spastic upper limb were selected from 8 hospitals and 1 community in Shanghai （Fengxian Hospital of Traditional Chinese Medicine, Longhua Hospital, Changshoulu Hospital, Jing＇an Hospital, Baoshan Sub-hospital of the First Municipal Hospital, the Sixth Municipal Hospital, Ruijin Hospital, Huashan Hospital and Tianlin Community）. The Modified Ashworth Scale score was between 2-4 grades. All the patients understood and accepted the approaches we arranged. ②To alleviate the spasm on the hemiplegic upper limb by using one of the modern facilitation techniques-Rood： Its facilitation techniques were quick stretch and tapping on the extension muscle of upper limb. Its inhibition techniques were slow stroking down posterior rami and prolonged stretch or deep pressure on the joint of elbow and wrist. Made the elbow and wrist extended and body weight moved to the affected side. Assisted fingers extension if need. Traditional massage was using its stimulating manipulations such as rolling manipulation, pushing manipulation and pinching munipulation on the extension muscle of upper limb. According to the condition of the patients, the treatment was applied once a day or two. Total six treatments were as followed respectively： 1^st facilitation technique for 5 minutes; 2^nd facilitation technique for 20 minutes; 34 massage for 5 minutes; 4^th massage for 20 minutes; 5^th combination treatment of facilitation technique and massage for 10 minutes; 6^th combination treatment of facilitation technique and massage for 20 minutes. The six treatments were finished within a week or two. ③ Assessment of the effects： Using the Modified Ashworth Scale （0-5 grade, Grade 0： No increase in muscle tone, Grade 5： affected part rigid） to assess the spasm on the upper limb before and after the treatments. If the grade of Modified Ashworth Scale reduced over one grade, the effect of the treatment can be confirmed. The time of the spasm alleviation started to account from the end of the treatment to the spasm returned back.④ Using the rank paired analysis, the median express the mean and the quartiles expressed the range of the mean. RESULTS： Total 28 hemiplegic patients of spastic upper limb were involved in the analysis of the results. ① Comparing the effects under the same treatment time： When the treatment time was 5 minutes, the effect of facilitation technique was the same as massage, the each time of the spasm alleviation was 9.5 minutes and 10.0 minutes （P 〉 0.05）, when the treatment time was 20 minutes, the effect of facilitation technique was better than massage evidently （37.5 and 26.0 minutes, P 〈 0.05）; the effect of using a combination of the two approaches for 10 minutes in total was the same as massage alone for 20 minutes （P 〉 0.05）; the effect of using a combination of the two approaches for 20 minutes in total was the same as facilitation technique alone for 20 minutes （P 〉 0.05）. Both effects of facilitation technique and combination of the two approaches were better than massage （P 〈 0.01）. ② Comparing the effects under the same treatment approach and different treatment time： The effect of using facilitation technique alone for 20 minutes was longer than it for 5 minutes 07.5 and 9.5 minutes, P 〈 0.01）; the effect of using massage alone for 20 minutes was longer than it for 5 minutes （26.0 and 10.0 minutes, P〈 0.01）; the effect of using a combination of the two approaches for 20 minutes was longer than it for 10 minutes （41.0 and 24.5 minutes, P 〈 0.01）, CONCLUSION： Both facilitation technique and massage have the effects of anti-spasm on hemiplegic patients. Under the same treatment approach, the longer the treatment time is, the better the treatment effects get. Under the same treatment time： for 5 minutes, the effects of two approaches are the same; for 20 minutes, facilitation technique is better, the same as r combination of the two approaches. Both are better than massage.