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上肢機(jī)器人輔助訓(xùn)練對腦卒中恢復(fù)期患者上肢功能的康復(fù)作用

2022-07-18 17:10:41梁俏俏李燕君馮靜
中國現(xiàn)代醫(yī)生 2022年17期
關(guān)鍵詞:日常生活能力

梁俏俏 李燕君 馮靜

[摘要] 目的 探討上肢機(jī)器人輔助訓(xùn)練對腦卒中恢復(fù)期患者上肢功能的康復(fù)作用。 方法 選取2019年9月~2020年6月就診于浙江省臺州醫(yī)院康復(fù)治療部的78例腦卒中恢復(fù)期伴偏癱患者,隨機(jī)分為兩組。對照組予常規(guī)康復(fù)訓(xùn)練,干預(yù)組在此基礎(chǔ)上加上肢康復(fù)機(jī)器人輔助康復(fù)訓(xùn)練,兩組均干預(yù)8周。觀察兩組干預(yù)前后肩關(guān)節(jié)活動(dòng)度、上肢功能[Fugl-Meyer運(yùn)動(dòng)功能評定上肢部分(FMA-UE)評分]及日常生活能力[改良Bathel指數(shù)(MBI)評分]的變化。 結(jié)果 干預(yù)8周后,兩組肩關(guān)節(jié)前屈、后伸、水平外展和水平內(nèi)收活動(dòng)度顯著上升(P<0.05或P<0.01),且干預(yù)組上升幅度更顯著(P<0.05);同時(shí)兩組FMA-UE評分顯著上升,差異有統(tǒng)計(jì)學(xué)意義(P<0.05或P<0.01),且干預(yù)組上升幅度更顯著(P<0.05)。 結(jié)論 上肢機(jī)器人輔助訓(xùn)練用于腦卒中恢復(fù)期患者不僅能增加其肩關(guān)節(jié)的活動(dòng)度,而且可改善上肢運(yùn)動(dòng)功能,改善日常生活活動(dòng)能力。

[關(guān)鍵詞] 腦卒中恢復(fù)期;上肢機(jī)器人輔助訓(xùn)練;肩關(guān)節(jié)活動(dòng)度;上肢功能;日常生活能力

[中圖分類號] R743.3? ? ? ? ? [文獻(xiàn)標(biāo)識碼] B? ? ? ? ? [文章編號] 1673-9701(2022)17-0118-03

Rehabilitation effect of robot-assisted upper limb training on upper limb function of stroke patients in recovery period

LIANG Qiaoqiao1,2 LI? Yanjun3 FENG? Jing4

1.Department of Rehabilitation, Taizhou Hospital of Zhejiang Province , Linhai 317000, China;2.Department of Rehabilitation, Luqiao Hospital, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou 318050, China;3.Health Management Center, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University,Taizhou 318050, China;4.Department of Nursing, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University,Linhai 317000,China

[Abstract] Objective To investigate the rehabilitation effect of robot-assisted upper limb training on the upper limb function of stroke patients in recovery period. Methods Seventy-eight stroke patients with hemiparesis in recovery period attending the rehabilitation department of Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University from September 2019 to June 2020 were selected and randomly divided into the intervention group and the control group, with 39 cases each. The control group was given conventional rehabilitation training, while the intervention group was supplemented with robot-assisted upper limb rehabilitation training,and both groups were intervened for 8 weeks. The changes in shoulder mobility, upper limb function (Fugl-Meyer Assessment for Upper Extremity (FMA-UE) score) and activities of daily living (Modified Bathel Index (MBI) score) were observed and compared between the two groups before and after 8 weeks of intervention. Results Shoulder mobility indicators including forward flexion, backward extension, horizontal abduction and adduction in both groups after 8 weeks of intervention were respectively? riseal, which were significantly higher than those before intervention (P<0.05 or P<0.01). And the increase in the intervention group was more significant than that in the control group, with statistically significant difference(P<0.05). Meanwhile, the FMA-UE scores and MBI scores in both groups after intervention were significantly higher than those before intervention(P<0.05 or P<0.01). And the increase in the intervention group was more significant than that in the control group, with statistically significant difference(P<0.05). Conclusion Robot-assisted upper limb training for stroke patients in recovery period not only increases the shoulder mobility,but also improves the motor function of the upper limb and enhances activities of daily living.

[Key words] Stroke recovery period; Robot-assisted upper limb training; Shoulder mobility; Upper limb function; Activities of daily living

腦卒中是康復(fù)科的常見和多發(fā)病,致殘率高達(dá)80%以上,治療后約50%以上患者會(huì)遺留上肢功能障礙,嚴(yán)重影響其日常生活自理能力,導(dǎo)致患者生活質(zhì)量下降[1]。傳統(tǒng)的上肢康復(fù)訓(xùn)練方法與人體正常的運(yùn)動(dòng)鍛煉模式并不相似,訓(xùn)練效果不甚理想[2,3]??祻?fù)機(jī)器人技術(shù)是一種新型的以任務(wù)為導(dǎo)向的康復(fù)訓(xùn)練技術(shù),輔助治療腦卒中后上肢功能障礙患者具有一定的效果[4~6]。本研究觀察上肢機(jī)器人輔助訓(xùn)練對腦卒中恢復(fù)期患者上肢功能的康復(fù)作用,現(xiàn)報(bào)道如下。

1 資料與方法

1.1 一般資料

選擇2019年9月~2020年6月就診于浙江省臺州醫(yī)院康復(fù)治療部的腦卒中恢復(fù)期伴偏癱患者78例。納入標(biāo)準(zhǔn)[7]:①符合腦卒中恢復(fù)期的診斷標(biāo)準(zhǔn)[8];②均首次發(fā)病;③偏癱上肢Brunnstrom分級≥Ⅲ期;④病程<6個(gè)月;⑤年齡40~70歲。排除標(biāo)準(zhǔn)[9]:①以往存在運(yùn)動(dòng)障礙性疾病者;②嚴(yán)重視覺、聽覺、認(rèn)知、語言或溝通障礙者。根據(jù)隨機(jī)數(shù)字表法分為兩組,每組各39例。兩組的一般資料比較,差異無統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性。見表1。本研究經(jīng)浙江省臺州醫(yī)院醫(yī)學(xué)倫理委員會(huì)批準(zhǔn),且患者知情同意。

1.2 方法

對照組予常規(guī)康復(fù)訓(xùn)練,包括運(yùn)動(dòng)鍛煉、物理治療及作業(yè)鍛煉等。干預(yù)組基于對照組加上肢康復(fù)機(jī)器人輔助康復(fù)訓(xùn)練,采用上肢智能反饋訓(xùn)練系統(tǒng)(廣州一康,A2型號),通過評估患者偏癱上肢各關(guān)節(jié)最大活動(dòng)范圍和患手握力選擇適合患者難度的單個(gè)或多個(gè)游戲進(jìn)行訓(xùn)練,訓(xùn)練時(shí)可通過語音和圖像向患者提供實(shí)時(shí)視覺和語音反饋信息,逐漸提高訓(xùn)練強(qiáng)度和難度;30 min/次,1次/d,5 d/周。兩組均干預(yù)8周。

1.3 觀察指標(biāo)

觀察兩組干預(yù)前后肩關(guān)節(jié)活動(dòng)度、上肢功能及日常生活能力的變化。

1.3.1 肩關(guān)節(jié)活動(dòng)度評估? 測定肩關(guān)節(jié)前屈、后伸、水平外展和水平內(nèi)收活動(dòng)度,由上肢康復(fù)機(jī)器人系統(tǒng)進(jìn)行評估,分?jǐn)?shù)越大提示肩關(guān)節(jié)活動(dòng)度越大。

1.3.2 上肢肌力評估? 采用Fugl-Meyer運(yùn)動(dòng)功能評定中的上肢部分(fugl-meyer assessment upper extremity,F(xiàn)MA-UE)評估,包括協(xié)調(diào)運(yùn)動(dòng)、上肢反射、協(xié)調(diào)動(dòng)作和分離運(yùn)動(dòng),共66分,分?jǐn)?shù)越高提示上肢功能越好[10]。

1.3.3 日常生活能力評估? 采用改良Bathel指數(shù)(modified Barthel index, MBI)評分進(jìn)行評估,包括穿衣、進(jìn)食、修飾、用廁、步行、洗澡、轉(zhuǎn)移、排便控制、排尿控制和爬樓梯共10項(xiàng),總分100分,分?jǐn)?shù)越高提示日常生活自理能力越好[11]。

1.4 統(tǒng)計(jì)學(xué)方法

應(yīng)用SPSS 20.0統(tǒng)計(jì)學(xué)軟件處理數(shù)據(jù),計(jì)量資料用(x±s)表示,采用t檢驗(yàn),計(jì)數(shù)資料用[n(%)]表示,采用χ2檢驗(yàn),P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

2.1 兩組肩關(guān)節(jié)活動(dòng)度比較

干預(yù)前兩組肩關(guān)節(jié)前屈、后伸、水平外展和水平內(nèi)收活動(dòng)度比較,差異無統(tǒng)計(jì)學(xué)意義(均P>0.05)。干預(yù)8周后,兩組肩關(guān)節(jié)的前屈、后伸、水平外展和水平內(nèi)收活動(dòng)度顯著上升(P<0.05或P<0.01),且干預(yù)組上升幅度更顯著(P<0.05)。見表2。

2.2 兩組FMA-UE評分和MBI評分比較

干預(yù)前兩組患者FMA-UE評分和MBI評分比較,差異無統(tǒng)計(jì)學(xué)意義(均P>0.05)。干預(yù)8周后,兩組FMA-UE評分和MBI評分顯著上升(P<0.05或P<0.01),且干預(yù)組上升幅度更顯著(P<0.05)。見表3。

3 討論

上肢功能障礙是腦卒中后常見并發(fā)癥,會(huì)導(dǎo)致患者產(chǎn)生一系列悲觀消極情緒和挫敗感,影響日常生活質(zhì)量[12]?;谥袠猩窠?jīng)系統(tǒng)可塑性的相關(guān)理論,研究認(rèn)為大腦皮質(zhì)具有較強(qiáng)的結(jié)構(gòu)與功能可塑性,通過大量重復(fù)性的康復(fù)運(yùn)動(dòng)訓(xùn)練可增加感覺信息的傳入,加快由運(yùn)動(dòng)誘導(dǎo)的神經(jīng)可塑性,激活相關(guān)中樞神經(jīng)區(qū)域和神經(jīng)環(huán)路,通過其周圍腦組織代替受損的組織,加快軸突突觸間相互聯(lián)系,加快側(cè)支再生,促進(jìn)中樞神經(jīng)的激活和大腦功能重塑[13]。

傳統(tǒng)上肢康復(fù)訓(xùn)練方法是通過各種較簡單的治療技術(shù)和輔助器械進(jìn)行訓(xùn)練,訓(xùn)練過程單調(diào)乏味,患者對訓(xùn)練缺乏積極性,主觀能動(dòng)性差,易對康復(fù)訓(xùn)練失去興趣和信心,同時(shí)傳統(tǒng)上肢康復(fù)訓(xùn)練缺乏量化指標(biāo),訓(xùn)練療效無法進(jìn)行及時(shí)有效反饋,且易出現(xiàn)疲勞和倦怠,難以保證足夠的訓(xùn)練強(qiáng)度及難度,訓(xùn)練效率低下,急需改進(jìn)工作方法及工作模式[14]。康復(fù)機(jī)器人輔助訓(xùn)練是新發(fā)展起來的一種神經(jīng)康復(fù)手段,可重建肢體的神經(jīng)系統(tǒng),在機(jī)械臂帶動(dòng)下對患者偏癱的肢體進(jìn)行重復(fù)康復(fù)訓(xùn)練,可逐漸提高患者的上肢運(yùn)動(dòng)功能[15,16]。同時(shí)通過上肢支撐系統(tǒng)使上肢處于減重或負(fù)重下開始訓(xùn)練,可提高患肢自主運(yùn)動(dòng)功能;上肢康復(fù)機(jī)器人是一種通過虛擬游戲進(jìn)行的視覺生物反饋技術(shù),消除以往常規(guī)上肢康復(fù)訓(xùn)練的乏味和單一性,增加訓(xùn)練目的性,使患者收獲訓(xùn)練成功的喜悅,實(shí)現(xiàn)人機(jī)之間互動(dòng),極大調(diào)動(dòng)患者參與訓(xùn)練的積極性,加快中樞神經(jīng)系統(tǒng)的功能重建及代償,提高訓(xùn)練效果[17~20]。本研究顯示,干預(yù)8周后,干預(yù)組肩關(guān)節(jié)的前屈、后伸、水平外展和水平內(nèi)收活動(dòng)度上升幅度較對照組更顯著,提示上肢機(jī)器人輔助訓(xùn)練用于腦卒中恢復(fù)期患者可提升肩關(guān)節(jié)的活動(dòng);同時(shí)干預(yù)組FMA-UE評分和MBI評分上升幅度較對照組更明顯,提示上肢機(jī)器人輔助訓(xùn)練用于腦卒中恢復(fù)期患者可改善上肢運(yùn)動(dòng)功能,改善日常生活活動(dòng)能力。

綜上所述,上肢機(jī)器人輔助訓(xùn)練用于腦卒中恢復(fù)期患者不僅能增加肩關(guān)節(jié)的活動(dòng)度,而且可改善上肢運(yùn)動(dòng)功能,改善日常生活活動(dòng)能力。

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[19]? 張海燕,吳方超,李建華,等.上肢康復(fù)機(jī)器人輔助訓(xùn)練對腦卒中患者上肢功能的影響[J].中國運(yùn)動(dòng)醫(yī)學(xué)雜志,2019,38(10):859-863.

[20]? 王娜娜,路微波,吳毅,等.上肢康復(fù)機(jī)器人對腦卒中患者上肢功能及日常生活能力影響的研究進(jìn)展[J].中華物理醫(yī)學(xué)與康復(fù)雜志,2017,39(9):706-708.

[21]? Iida S,Kawakita D,F(xiàn)ujita T,et al. Exercise using a robotic knee orthosis in stroke patients with hemiplegia[J].J Phys Ther Sci,2017,29(10):1920-1924.

(收稿日期:2021-09-23)

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