儿童痉挛型脑性瘫痪蹲伏步态多学科团队治疗的初步经验

Preliminary experience of multidisciplinary team therapy for spastic cerebral palsy children with crouch gait

目的总结多学科团队联合治疗儿童痉挛型脑性瘫痪(以下简称脑瘫)蹲伏步态的初步经验。方法以2018年6月至2020年1月在上海交通大学医学院附属上海儿童医学中心和上海同济大学附属养志康复医院诊治的29例存在蹲伏步态的痉挛型脑瘫患儿为研究对象,男20例,女9例;平均年龄14.3岁(12~16.5岁)。患儿均行三维步态分析,由骨科医生、康复治疗师及步态研究员共同分析步态检查报告,并商定治疗方案,包括:手术前予康复宣教及康复训练3~4周(其中家庭康复1~3周),包括体位摆放、体位转移、轮椅训练、肌力训练等。采取单次多平面手术,包括髋关节重建术、髌韧带推进术、股骨远端短缩伸展截骨术等,如患儿存在扁平外翻足则行Mosca术。术后2周开始院内康复训练,时间8周;予居家康复训练+线上指导10个月。术后每3个月门诊复查,12个月以后行三维步态分析,评价临床疗效。结果29例痉挛型脑瘫蹲伏步态患儿均完成多学科团队治疗方案,医院康复训练及康复指导时间0.5~2周,家庭康复训练2~3周,家庭康复训练指导经互联网完成;均行单次多平面手术,其中髌韧带推进术29例,股骨远端短缩伸展术20例,内收肌切断术10例,股直肌延长术1例,髂腰肌松解术15例,Dega骨盆截骨+股骨近端内翻去旋转截骨术3例,腘绳肌延长术14例,距舟关节复位+距下关节融合术5例,Mosca手术13例。术后复查三维步态分析时间平均为术后13.5个月(12~15个月)。结果显示,患儿术后髋关节在支撑相中末期最大伸展角度较术前平均改善了12.29°,术后膝关节在支撑相中期屈曲角度较术前平均改善了26.84°,术后踝关节在支撑相中期背屈角度较术前平均改善了7.05°。康复评定发现,患儿髋外展、伸髋、伸膝及踝跖屈肌群的肌力均明显提升,平衡稳定性较术前增强,但步行过程中躯干横向位移问题未能改善。结论本研究已经验证了多学科团队治疗儿童痉挛型脑瘫蹲伏步态可有效改善膝关节的僵直状态,提升各关节运动肌群的肌力,明显改善异常的步态外观。儿童痉挛型脑瘫蹲伏步态骨科和康复科联合治疗模式短期疗效良好,远期疗效还有待进一步观察。

Objective To summarize the preliminary experiences of multidisciplinary team(MDT)treating crouch gait in spastic cerebral palsy(CP)children.Methods From June 2018 to January 2020,a total of 29 children with spastic CP with crouch gait were recruited.There were 20 boys and 9 girls with an average age of 14.3(12-16.5)years.After three-dimensional gait analysis,treatment protocols were formulated jointly by orthopedic surgeons,gait analysis technicians and rehab therapists.Preoperative rehabilitation education and rehabilitation training were provided for 3-4 weeks(including family rehabilitation 1-3 weeks).Also position placement,position transfer,wheelchair training and strength training were offered.Single event multi-level operations were performed,including hip reconstruction,patellar tendon advancement,shortening extension osteotomy of distal femur and Mosca procedure for flat valgus foot.At 2 weeks post-operation,hospital rehabilitation continued for 8 weeks.Home rehabilitation training and online instructions were offered for 10 months.Outpatient reevaluation was performed every 3 months post-operation and three-dimensional gait analysis at 12 months after evaluating clinical efficacy.Results Twenty-nine children with spastic cerebral palsy with crouch gait completed the MDT treatment program.Time of hospital rehabilitation training and rehabilitation instruction was(0.5-2)weeks and time of family rehabilitation training lasted 2-3 weeks.Family rehabilitation training instruction was completed online.Single event multi-level operations were performed,including patellar tendon advancement(n=29),distal femoral shortening stretch(n=20),adductor release(n=10),rectus lengthening(n=1),iliopsoas release(n=15),Dega pelvic osteotomy with proximal femur derotation osteotomy(n=3),hamstring lengthening(n=14),talonavicular joint reduction with subtalar joint arthrodesis(n=5)and Mosca procedure(n=13).The mean time of postoperative 3D gait analysis was 13.5(12-15)months.The results showed that the maximum extension angle of the postoperative hip joint in the middle and end of the support phase was improved by 12.29°on average,the flexion angle of the knee joint in the mid-support phase was improved by 26.84°on average,and the dorsiflexion angle of the ankle joint in the mid-support phase was improved by 7.05°on average.The rehabilitation assessment demonstrated that the strength of hip abduction,hip extension,knee extension and ankle plantar flexor was significantly improved,and the balance stability was enhanced compared with that before surgery,but the trunk lateral displacement was not improved during walking.Conclusion In children with spastic cerebral palsy,MDT treatment for crouch gait showed promising results by effectively improving knee stiffness,enhancing muscle strength of lower extremities and correcting abnormal gait appearance.Therefore a combination of orthopedic and rehabilitation therapy for crouch gait in children with spastic cerebral palsy has an excellent short-term efficacy.However,MDT mode should be further observed for long-term outcomes.