A型肉毒毒素联合利多卡因注射治疗对脑卒中患者踝关节稳定性和步态的影响

Effects of botulinum toxin type A reconstituted in lidocaine on the ankle stability and walking capacity of stroke patients with lower limb spasticity

目的探讨A型肉毒毒素（BTX．A）联合利多卡因注射治疗对脑卒中患者踝关节稳定性和步态的影响。方法选取脑卒中后足下垂内翻患者24例，按照随机数字表法将其分为治疗组和对照组，每组12例。2组患者注射BTX-A前后均接受常规康复治疗，治疗组局部分点注射溶于利多卡因的BTX—A，对照组注射溶于生理盐水的BTX—A。注射前、注射后1d、注射后2周、注射后4周、注射后12周，对2组患者进行Clonus量表、改良Ashworth量表（MAS）、简易Fugl—Meyer量表（FMA）下肢部分、步态不对称指数（GAI）、最大步行速度、步行能力分级（FAC）和改良Bathel指数（MBI）评定。结果注射前，2组患者Clonus评分、MAS评分、FMA下肢部分评分、GAI、最大步行速度、FAC评分、MBI评分之间比较，差异均无统计学意义（P〉0．05）。注射后1d、2周、4周、12周，治疗组Clonus评分、MAS评分均较组内注射前低（P〈0．05）。注射后2周、4周，治疗组FMA下肢部分评分较组内注射前升高（P〈0．05）。对照组注射后1d，MAS评分[（2．83±1．03）分]较组内注射前[（2．42±0．99）分]高（P〈0．05），注射后2周[（1．50±0．67）分]、4周[（1．58±0．79）分]MAS较组内注射前[（2．42±0．99）分]低（P〈0．05）。与对照组注射后同时间点比较，治疗组Clonus评分均较低（P〈0．05）。治疗组注射后1d[（1．42±0．67）分]、12周[（1．08±0．67）分]的MAS评分显著低于对照组注射后1d[（2．83±1．03）分]、12周[（2．08±0．66）分]的MAS评分（P〈0．05）。与组内注射前比较，治疗组注射后各时间点GAI均较低（P〈0．05）。治疗组注射后2周、4周、12周的最大步行速度、MBI评分显著高于组内注射前（P〈0．05）。治疗组注射后4周、12周的FAC评分均较组内注射前高（P〈0．05）。对照组注射后4周、12周的GAI低于组内注射前（P〈0．05），注射后4周、12周的最大步行速度、FAC评分显著高于组内注射前（P〈0．05）。与对照组注射后同时间点比较，治疗组注射后1d、4周、12周的GAI较低（P〈0．05），注射后12周的最大步行速度较大（P〈0．05）。结论BTX—A联合利多卡因局部注射治疗可以快速缓解脑卒中偏瘫患者下肢的肌痉挛，减轻注射部位疼痛，对踝关节稳定性和步行能力的近期及远期康复疗效均明显优于单纯BTX—A注射治疗。

Objective To compare the efficacy of lidocaine-diluted botulinum toxin type A （BTXA） with that of saline-diluted BTXA for promoting the ankle stability and walking ability of stroke patients with the lower limb spastieity. Methods Twenty-four stroke patients with lower limb spastieity were randomly divided into a treatment and a control group. The treatment group was injected with BTXA diluted in 1% lidocaine, and the control group was injected with BTXA diluted in normal saline. The patients were followed up for 12 weeks. This study was performed by assessing spasticity （ clonus scale and modified Ashworth scale （MAS） ） , motor function （Fugl-Meyer lower limb assessment FMA） , walking （gait asymmetry index GAt; walking speed; funetional ambulation categorization FAC） and ability in the activities of daily living （ modified Bathel index MBI） before and 1 day, 2 weeks, 6 weeks, and 12 weeks after the BTXA injections. The pain associated with the BTXA injections was evaluated using a 100 mm visual analogue scale. Results There were no significant differences between the two groups in clonus or walking speed or in their MAS, FMA, GAI, FAC or MBI results at baseline. Compared with pretreatment, clonus and MAS ratings were significantly reduced after 1 day in the treatment group. The MAS improvement was also seen in the control group, but it subsequently declined while that in the treatment group was maintained. Their average FMA rating was significantly improved after 2 weeks. At each time point, clonus was significantly better in the treatment group than in the control group and the average MAS score was also significantly better after 1 day and at 12 weeks. Both groups showed significant GAI decreases, but the average decrease in the treatment group at 4 and 12 weeks was significantly greater than that of the control group, and their average walking speed and FACs were significantly more improved. Pain score during the injections was rated significantly less by the treatment group than by the control group. Conclusions Botulinum toxin A diluted in lidocaine is helpful for rapidly reducing lower limb muscle spasticity and improving the gait of stroke patients. Moreover, its injection is significantly less painful. It is a safe and effective treatment with low incidence of adverse reactions.