运动想象对卒中后偏瘫患者手功能康复的疗效观察

Efficacy of movement imagination on rehabilitation of hand function in patients with post-stroke hemiplegia

目的观察运动想象训练(镜像疗法)对卒中偏瘫患者上肢远端运动功能、痉挛和手功能恢复的影响。方法将35例卒中12个月以内的偏瘫患者,按照入院病例号单双的顺序,分为运动想象训练组(20例)和对照组(15例)。所有患者均接受传统的物理疗法、理疗、作业疗法,2～5 h/d,5d/周。运动想象训练组辅助镜像疗法,对照组辅助无镜像疗法的训练(完全避开视觉的训练),训练时间均为30 min/次,2次/d,持续4周。分别在治疗前及治疗后4周时进行Brunnstrom偏瘫恢复六阶段手运动功能评定、痉挛评定(MAS)和功能独立评定(FIM)中自我照顾的评分。两组存治疗后4周和第1、3、6个月,评价Brunnstrom、MAS和FIM评分改变。对出院后继续自我练习3个月的2例患者进行功能磁共抓成像检查和表面肌电图检查。结果①治疗后4周,运动想象组Brunnstorm、FIM评分分别增加0.6±0.5和3.8±1.9,对照组分别增加0.1±0.6和1.5±2.6;两组Brunnstorm增加值比较,t=2.69,P<0.05;两组FIM增加值比较,t=3.03,P<0.01。在痉挛方面,MAS评分运动想象训练组和对照组分别减少0.2±0.4和0.1±0.3。运动想象组治疗后MAS评分较治疗前下降(P<0.05),但与对照组治疗后比较,P>0.05。②运动想象训练组在治疗后1、3、6个月,Brunnstrom和FIM评分均高于对照组,均P<0.05。③表面肌电图检查显示,当进行腕背仲运动时,桡侧腕伸肌群活动比尺侧腕屈肌群活动明显。④头部功能磁共振成像显示,运动想象训练组患者在患侧第一运动区和辅助运动区,均有高信号显示。结论运动想象训练对提高卒中偏瘫患者手功能的恢复和降低于致残率的疗效显著,但对缓解痉挛的作用不明显。

Objective To observe the effect of movement imagination training （mirror therapy） on distal upper-extremity motor function, spasticity, and hand function recovery in patients with post-stroke hemiplegia. Methods Thirty-five patients with post-stroke hemiplegia within 12 months were divided into mirror therapy group （n = 20 ） and control group （n = 15 ） according to their odd and even numbers on admission. All patients received traditional physical therapy and occupational therapy 5 days a week, 2 to 5 hours a day. The patients of mirror therapy group were received ancillary mirror therapy once for 30 minutes, twice a day; the patients of control group were trained without ancillary mirror therapy （avoiding visual training completely） once for 30 minutes, twice a day. The training time was 4 weeks for both groups. The Brunnstrom stage of motor recovery, modified Ashworth scale （ MAS）, and hand motor function （ self-care scores in the functional independence measure [ FIM ] ） were assessed at 4 weeks before and after the treatment. Both groups were followed up at 4 weeks, 1, 3, and 6 months after the treatment, and the changes of Brunnstrom, MAS, and FIM were evaluated. Two patients who continued to do self-rehabilitation program for 3 nronths after discharge were assessed by magnetic resonance imaging and surface eleetromyography. Results （1）Four weeks after the treatment, the Brunnstrom and FIM scores in the mirror therapy group were increased 0.6±0. 5 and 3. 8± 1.9, respectively; thnse in the control group were increased 0. 1± 0. 6 and 1.5± 2. 6, respeetively. There were significant differences between the added values of Brunnstrom and FIM in the two groups. Comparing the added values of Brunnstrom in both groups were t = 2. 69, P 〈 0. 05, and comparing the added values of FIM in both groups were t =3.03, P 〈0. 01. However, the spasticity scores on MAS in the mirror therapy and control groups decreased 0. 2±0. 4 and 0. 1 ±0. 3, respectively. After the treatment, the MAS score in the mirror therapy group was lower than that before treatment （P 〈 0. 05 ）, which indicated the spasticity was improved in this group. （2）Brunnstrom and FIM scores in the mirror group were higher than those in the control group after 1, 3, and 6 months （ P 〈 0. 05 all）. （3）Surface electromyography showed that the time-varying muscle activity of the extensor carpi radialis muscle was more obvious than that of the extensor carpi ulnaris muscle when the movement of wrist dorsal extension was performed. （4）Brain functional magnetic resonance imaging （fMRI） showed that there were high-intensity signals at the right primary motor area and supplementary motor area, and at the left primary motor area in the mirror group. Conclusion The efficacy of movement imagination training is significant for improving hand function and reducing hand disability in patients with post-stroke hemiplegia, however, its effect of relieving spasticity is not obvious.