优化脑卒中后行走康复策略:从助行训练到脑-肢体协同治疗

Optimizing Rehabilitation Strategy for Walking after Stroke:from Assisted Walking Training to Brain-Limb Cooperative Therapy

脑卒中后恢复行走功能是患者及家属最迫切的需求,也是制定康复治疗方案的首要目标。长期以来,神经康复领域的专家们一直在探索如何加速脑卒中后行走功能恢复的有效方法。从针对瘫痪肢体(外周器官)采用的各种中医技术(如肢体针灸、手法等)和现代康复技术(如神经发育疗法、助行功能性电刺激、行走踏车、助行机器人等),到针对病灶脑部(中枢器官)采用非侵入脑刺激技术(如经颅磁刺激、经颅直流电刺激、头部针灸等)。大量的临床循证研究在证据的不同等级上证明了这些技术是行之有效的治疗方法。近年来,借助于20世纪90年代脑的10年研究成果,针对脑卒中后改善行走功能的康复治疗也发生了明显变化。开始由离散的针对单一靶器官(如肢体或脑部)逐渐发展为结合脑部和肢体的多靶点治疗或模式化治疗,由此催生出一种新的治疗模式即脑-肢体协同治疗模式。本文围绕优化脑卒中后行走康复策略这一主题,简要介绍这种脑-肢体协同治疗模式的概念,重点介绍与改善脑卒中后行走功能有关的脑-下肢协同治疗模式的几种优化组合,结合相关的临床应用研究作为佐证,藉此引起国内脑卒中康复专业人员对脑-肢体协同治疗模式的重视,在脑卒中后改善行走功能的康复治疗中加以积极的应用,开展类似的相关研究,并将这种脑-肢体协同治疗模式推广到脑卒中后上肢功能恢复的康复治疗,拓展脑-肢体协同治疗模式的临床应用及其研究。从脑卒中康复的发展趋势来看,未来脑卒中后下肢康复的策略应围绕高效地改善或恢复患者的行走功能。因此,早期介入以行走为核心的"无错法学习"的康复策略应贯彻脑卒中下肢康复的全过程。外周向中枢输入的行走模式正确,中枢输出的行走指令才有可能正确,而脑-肢体协同治疗是实现这一闭环的有效保障。

Recovery of walking function after stroke is the most urgent need of patients and their families.It is also the primary goal when planning rehabilitation treatment plans with patients.For a long time,experts in the field of neurological rehabilitation have been exploring effective methods to accelerate the recovery of walking function after stroke.From various traditional Chinese medicine such as acupuncture on the limbs of patient,and modern rehabilitation technologies for paralyzed limbs(such as neurodevelopmental therapy,functional electrical stimulation,walking bicycle,and walking robot,etc.)to non-invasive brain stimulation technologies for focal brain(such as transcranial magnetic stimulation,transcranial direct current stimulation,and head acupuncture,etc.).A large number of clinical evidence-based studies have proved that these technologies are effective methods at different levels of evidence.In recent years,with the help of the 10-year research findings of brain in the 1990 s,the rehabilitation for improving walking function after stroke has also been changed significantly.It began to develop from discrete target organ(such as limb or brain)to multi-target cooperative or mode therapy combining brain and limb,which gave birth to a new treatment mode:brain-limb cooperative therapy mode.Focusing on the theme of optimizing rehabilitation strategy for walking after stroke,this paper provides a brief introduction on the concept of this brain-limb cooperative treatment mode,focuses on several optimized combinations of brainlower limb cooperative treatment modes related to improving walking function after stroke,and also a few related research papers of clinical application on this mode were published in this issue as supporting data.Through this review and the papers published in this issue,we hope to attract the attention of domestic stroke rehabilitation professionals to the brain-limb cooperative treatment model,and actively apply it in the rehabilitation treatment of improving walking function after stroke.Similar related research could be duplicated to further clarify this mode.By analogy,this brain-limb cooperative treatment model is extended to the rehabilitation treatment of upper limb function recovery after stroke,and the clinical application and research of brain-limb cooperative treatment model are expanded.From the perspective of stroke rehabilitation,the strategy of lower limb rehabilitation after stroke in the future should be to more effectively improve or restore the original walking function of patients.Therefore,the early intervention of"error free learning"rehabilitation strategy with walking as the core should implement the whole process of stroke lower limb rehabilitation.Only when the walking mode input from the periphery to the center is correct,the walking command output from the center can be correct.Brain-limb cooperative therapy is an effective guarantee for realizing this closed loop.