不同刺激部位和运动方向的肌电生物反馈电刺激疗法治疗脑卒中患者肩关节半脱位的差异性分析

Effect of EMG Biofeedback Therapy on Post-stroke Shoulder Subluxation with Different Stimulus Parts and Direction of Movement:a Differential Analysis

背景肩关节半脱位是脑卒中偏瘫后主要并发症之一,其发病率较高。而在各种治疗方法中,肌电生物反馈电刺激疗法(EMGBF)其疗效较为确切,然而在诸多研究中,其电刺激的位置和运动方向并未统一。目的探讨不同刺激部位和运动方向的EMGBF治疗脑卒中患者肩关节半脱位的疗效。方法选择2017年5月-2018年5月在西南医科大学附属医院收治的脑卒中后肩关节半脱位患者267例,采取随机数字表法将患者分为前屈组、后伸组、外展组,每组89例。根据指诊检查法触诊脱位情况,分为Ⅰ度、Ⅱ度、Ⅲ度。在常规治疗基础上,三组均采用EMGBF,分别把电极片置于三角肌前束、中束以及后束,并引导患者分别做前屈、外展和后伸动作。比较三组治疗前及治疗第3、6、9周肌电积分值(iEMG),以及治疗前及治疗第9周Fugl-Meyer上肢运动功能评分和疼痛视觉模拟评分法(VAS)评分、Barthel指数、脑卒中特殊生活质量量表(SSQOLS)评分并测量患侧肩峰与肱骨头间距(AHI)和两侧肩胛下角顶点间距。结果治疗前及治疗第3周三组Ⅰ度、Ⅱ度、Ⅲ度患者iEMG比较,差异均无统计学意义(P>0.05);治疗第6、9周三组Ⅰ度、Ⅱ度、Ⅲ度患者iEMG比较,差异均有统计学意义(P<0.05);三组Ⅰ度、Ⅱ度、Ⅲ度患者治疗前后比较,差异均有统计学意义(P<0.05)。治疗前三组Ⅰ度、Ⅱ度、Ⅲ度患者Fugl-Meyer上肢运动功能评分、疼痛VAS评分、Barthel指数、SSQOLS评分、AHI和两侧肩胛下角顶点间距比较,差异均无统计学意义(P>0.05);治疗第9周后伸组Ⅰ度、Ⅱ度、Ⅲ度患者Fugl-Meyer上肢运动功能评分较前屈组和外展组升高、疼痛VAS评分较前屈组和外展组降低,外展组Ⅰ度、Ⅱ度患者Fugl-Meyer上肢运动功能评分较前屈组升高,外展组Ⅰ度、Ⅱ度、Ⅲ度患者Barthel指数较前屈组和后伸组升高,后伸组Ⅰ度、Ⅱ度、Ⅲ度患者AHI较前屈组升高,外展组Ⅰ度、Ⅱ度患者AHI较前屈组和后伸组降低,外展组Ⅲ度患者AHI较后伸组降低,后伸组Ⅰ度、Ⅱ度、Ⅲ度患者肩胛下角顶点间距较前屈组和外展组降低(P<0.05)。三组Ⅰ度、Ⅱ度、Ⅲ度患者治疗第9周Fugl-Meyer上肢运动功能评分、Barthel指数、SSQOLS评分、肩胛下角顶点间距高于治疗前,疼痛VAS评分、AHI低于治疗前(P<0.05)。结论 EMGBF选择对三角肌中束的刺激以及外展运动,优于其他两种方案,通过对核心肌束肌力的提高,能改善患者的肩关节脱位情况,减轻疼痛,并提高生活质量。同时也为后续规范化治疗方案提供一定借鉴意义,值得继续研究。

Background Shoulder subluxation is a major complication of stroke-induced hemiplegia with high incidence.Among various treatments,EMG biofeedback(EMGBF) has a definite effect.However,in many studies,the stimulation site and direction of motion are not uniform.Objective To explore the effect of EMGBF on post-stroke shoulder subluxation with different stimulus parts and directions of movement.Methods A total of 267 patients with post-stroke shoulder subluxation were selected from the Affiliated Hospital of Southwest Medical University from May 2017 to May 2018.They were randomly and equally divided into the flexion group,abduction group and extension group.Subluxation degree detected by finger palpation was classified into grade Ⅰ,Ⅱ and Ⅲ.On the basis of routine treatment,all groups were treated with EMGBF.The electrodes were placed in the deltoid muscle anterior bundle,the middle bundle and the posterior bundle,and guidance was given to the patients to perform flexion,abduction and extension movements.Measurements of the electromyographic score(iEMG) before treatment and at the end of the 3rd,6th,9th weeks of treatment,and the scores of Fugl-Meyer upper limb motor function assessment,VAS score,Barthel index,Stroke Specific Quality of Life Scale(SSQOLS) score,interval between the affected acromion and the humeral head(AHI) and the distance between the apex of the bilateral scapula before treatment and at the end of the 9th weeks of treatment were performed.Results Grade Ⅰ,Ⅱ and Ⅲ subluxation patients in three groups showed similar pretreatment iEMG and iEMG at the 3rd week of treatment(P>0.05),but significantly different iEMG at the 6th and 9th weeks of treatment(P<0.05),and they obtained significant improvements in iEMG after treatment(P<0.05).Fugl-Meyer assessment score,VAS score,Barthel index,SSQOLS score,AHI and distance between the apex of the bilateral scapula were similar in grade Ⅰ,Ⅱ and Ⅲ subluxation patients in three groups at baseline(P>0.05).At the end of 9-week treatment,extension group(all patients with different degree of subluxation) showed higher Fugl-Meyer assessment score and lower VAS score than other two groups(P<0.05).Grade Ⅰ and Ⅱ subluxation patients in abduction group showed higher Fugl-Meyer assessment score than those in flexion group(P<0.05).Grade Ⅰ,Ⅱ and Ⅲ subluxation patients in abduction group showed higher Barthel index than those of other two groups(P<0.05).Grade Ⅰ, Ⅱ and Ⅲ subluxation patients in both flexion group and abduction group showed lower AHI than those in extension group(P<0.05).Grade Ⅰ, Ⅱ subluxation patients in abduction group showed lower AHI than those in flexion group(P<0.05).Grade Ⅰ, Ⅱ and Ⅲ subluxation patients in extension group showed less distance between the apex of the bilateral scapula compared with other two groups(P<0.05).When the treatment ended,grade Ⅰ, Ⅱ and Ⅲ subluxation patients in all groups showed improved Fugl-Meyer assessment score,Barthel index,SSQOLS score,decreased VAS score,and AHI,as well as greater distance between the apex of the bilateral scapula compared with baseline(P<0.05).Conclusion The stimulation and abduction of the middle bundle of deltoid muscle are superior to other two schemes in EMGBF.The improvement of the muscle strength of the core bundle can improve the dislocation of shoulder joint,alleviate pain and improve the quality of life.At the same time,it provides a reference for the development of follow-up standardized treatment plan.