运动想象疗法对脑卒中偏瘫患者上肢功能恢复的影响
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摘要
目的：脑卒中后遗留运动功能障碍严重影响患者的生活质量,脑卒中患者下肢功能恢复较上肢理想。人们一直在研究新的康复疗法对上肢进行康复治疗,近年来“运动想象疗法”作为脑卒中偏瘫康复的一种新疗法,成为目前研究热点。运动想像(Mental practice, MP; motor imagery, MI)是指精神上模拟一个特定动作的动态过程,不伴有任何明显的实际运动。运动想象疗法治疗脑卒中的疗效已经得到证实。运动想象能力对于训练效果有一定的影响,然而国内多数涉及运动想象疗法在脑卒中康复中的应用研究均未涉及想象能力测试,仅在治疗前进行运动想象知识的指导。国外研究报道已有人使用运动想象问卷评估偏瘫患者想象能力,并认为得分<25分者不宜进行运动想象训练。本研究在开始运动想象治疗前,对脑卒中偏瘫患者进行想象能力测评,而且本研究所使用的运动想象指导语的设计与康复训练项目、评估指标相一致,使康复训练内容得到重复和强化,更好的对运动想象疗法在脑卒中偏瘫患者上肢功能恢复中的作用进行评估。
方法：选择27例符合入选标准的脑卒中偏瘫患者,随机分为治疗组(14例)和对照组(13例)两组,其中治疗组采用常规康复训练联合运动想象治疗,对照组只进行常规康复训练。两组常规康复训练时间相同,为每日一次,每次40min,共治疗8周。运动想象治疗于常规康复训练后在安静的房间进行,25min/次,1次/d,共治疗8周。分别在治疗前、治疗后2周、4周、8周进行患侧上肢Fugl-Meyer(FMA)、运动评估量表(MAS)评分,肌力评定,观察患侧上肢功能恢复情况。
结果：治疗前两组各项评分差异无统计学意义。治疗2周后,治疗前后比较治疗组MAS评分与治疗前比较明显提高,差异有统计学意义,治疗组其余各项指标治疗前后及对照组各项指标治疗前后比较均无统计学意义,两组间肌力比较治疗组较对照组明显提高,差异有统计学意义,余各项指标两组间比较均无统计学意义；治疗4周后,两组患者各项评分较治疗前比较均有提高,差异有统计学意义；而且治疗组FMA评分及肌力均高于对照组,差异有统计学意义,但两组MAS评分差异无统计学意义；治疗8周后,两组患者各项指标均较治疗前明显改善(P<0.05),治疗组上肢FMA、MAS及肌力均显著高于对照组水平(P<0.05)。
结论：运动想象疗法结合常规康复训练可以改善脑卒中偏瘫患者上肢功能。与以往的研究结果基本一致。本研究采用运动想象疗法结合常规康复治疗的治疗方案,强化了主动运动学习,促进患肢运动功能恢复,从而提高了偏瘫上肢的功能。不仅调动了患者主动参与训练积极性,增强其主观能动性,而且解决了治疗时间长、费用高和治疗人员紧张的问题。
Objective Movement disorder due to stroke influence the quality of patients' life seriously. Function of lower extremity recovers better than the upper extremity in Stroke Patients. Researchers are studying new rehabilitation therapy to help the Stroke patients to facilitate the recovery upper extremity function. As a new rehabilitation therapy, the mental practice has become the researching hot spot at present. Mental practice (MP), sometimes called "motor imagery,"is defined as an active process during which the representation of a specific action is internally reproduced within working memory, without any corresponding motor output. The efficacy of mental practice has been proved. Motor imagery ability has definite effects on its efficacy however it is rather rare to assess patients'motor imagery ability in many studies of motor imagery. The foreign researchers have evaluated motor imagery ability by using KVIQ (Kinesthetic and Visual Imagery Questionnaire) in stroke patients, and they think the patients who have scores lower than 25 are not suitable to motor imagery therapy. In this study, we used the Kinesthetic and Visual Imagery Questionnaire (KVIQ--10) as a screening test to assess the ability of motor imagery. Only the patients whose scores exceeded 25 points were included in this study, thus enrolled patients had the ability to carry out the motor imagery therapy. The actions in motor imagery therapy were similar to the assessment and the training content, thus the effect of motor imagery on function of upper extremity can be reflected better. Methods Twenty-seven sub-acute stroke patients with upper limb paralysis and fitting with inclusion criterion were randomly divided into two groups:a treatment group(n=14) and a control group(n=13). The patients in control group were treated traditional rehabilitation therapy. The patients in treatment group were treated with motor imagery therapy once a day focused on improving arm function in addition to traditional rehabilitation therapy. The training intensity and time of traditional therapy was similar for both groups(40min for one session everyday except weekend;8 weeks period of treatment).All patients were assessed with Fugl-Meyer motor assessment(FMA), motor assessment scale(MAS), manual muscle testing(MMT) before the therapy,2weeks,4weeks and 8weeks after therapy. Results There were no significant differences between the two groups with regard to the scores with all the scales before the therapy(p<0.05). After 2weeks,the MAS scores of upper limb in the treatment group improved significantly compared with the scores before therapy(p<0.05). The manual muscle strength in the treatment group was significantly higher than that in the control group(p<0.05). After 4weeks, the FMA,MAS and muscle strenghth scores of upper limb in the two groups were significantly higher than the scores before the therapy (p<0.05), and the scores of FMA and manual muscle strength in the treatment group were significantly higher than that in the control group(p<0.05), however there was no significant difference in MAS scores between the two groups. After 8 weeks, the scores of FMA,MAS and muscle strength of the two groups improved significantly (p<0.05) compared with the scores before the therapy, and the scores of FMA, MAS and muscle strength in the treatment group were significantly higher than that in the control group(p<0.05). Conclusion Mental practice can improve the functional performance of the upper extremity in stroke patients. This study applied motor imagery therapy once a day focused on improving arm function in addition to traditional rehabilitation therapy. Mental practice has many advantages, such as arousing patients' training enthusiasm, facilitating patients' active participation, easy to apply. It also can be practiced at home and accepted easily by patients and their family members. At the same time, the method can save the cost for the patients.
方法：选择27例符合入选标准的脑卒中偏瘫患者,随机分为治疗组(14例)和对照组(13例)两组,其中治疗组采用常规康复训练联合运动想象治疗,对照组只进行常规康复训练。两组常规康复训练时间相同,为每日一次,每次40min,共治疗8周。运动想象治疗于常规康复训练后在安静的房间进行,25min/次,1次/d,共治疗8周。分别在治疗前、治疗后2周、4周、8周进行患侧上肢Fugl-Meyer(FMA)、运动评估量表(MAS)评分,肌力评定,观察患侧上肢功能恢复情况。
结果：治疗前两组各项评分差异无统计学意义。治疗2周后,治疗前后比较治疗组MAS评分与治疗前比较明显提高,差异有统计学意义,治疗组其余各项指标治疗前后及对照组各项指标治疗前后比较均无统计学意义,两组间肌力比较治疗组较对照组明显提高,差异有统计学意义,余各项指标两组间比较均无统计学意义；治疗4周后,两组患者各项评分较治疗前比较均有提高,差异有统计学意义；而且治疗组FMA评分及肌力均高于对照组,差异有统计学意义,但两组MAS评分差异无统计学意义；治疗8周后,两组患者各项指标均较治疗前明显改善(P<0.05),治疗组上肢FMA、MAS及肌力均显著高于对照组水平(P<0.05)。
结论：运动想象疗法结合常规康复训练可以改善脑卒中偏瘫患者上肢功能。与以往的研究结果基本一致。本研究采用运动想象疗法结合常规康复治疗的治疗方案,强化了主动运动学习,促进患肢运动功能恢复,从而提高了偏瘫上肢的功能。不仅调动了患者主动参与训练积极性,增强其主观能动性,而且解决了治疗时间长、费用高和治疗人员紧张的问题。
Objective Movement disorder due to stroke influence the quality of patients' life seriously. Function of lower extremity recovers better than the upper extremity in Stroke Patients. Researchers are studying new rehabilitation therapy to help the Stroke patients to facilitate the recovery upper extremity function. As a new rehabilitation therapy, the mental practice has become the researching hot spot at present. Mental practice (MP), sometimes called "motor imagery,"is defined as an active process during which the representation of a specific action is internally reproduced within working memory, without any corresponding motor output. The efficacy of mental practice has been proved. Motor imagery ability has definite effects on its efficacy however it is rather rare to assess patients'motor imagery ability in many studies of motor imagery. The foreign researchers have evaluated motor imagery ability by using KVIQ (Kinesthetic and Visual Imagery Questionnaire) in stroke patients, and they think the patients who have scores lower than 25 are not suitable to motor imagery therapy. In this study, we used the Kinesthetic and Visual Imagery Questionnaire (KVIQ--10) as a screening test to assess the ability of motor imagery. Only the patients whose scores exceeded 25 points were included in this study, thus enrolled patients had the ability to carry out the motor imagery therapy. The actions in motor imagery therapy were similar to the assessment and the training content, thus the effect of motor imagery on function of upper extremity can be reflected better. Methods Twenty-seven sub-acute stroke patients with upper limb paralysis and fitting with inclusion criterion were randomly divided into two groups:a treatment group(n=14) and a control group(n=13). The patients in control group were treated traditional rehabilitation therapy. The patients in treatment group were treated with motor imagery therapy once a day focused on improving arm function in addition to traditional rehabilitation therapy. The training intensity and time of traditional therapy was similar for both groups(40min for one session everyday except weekend;8 weeks period of treatment).All patients were assessed with Fugl-Meyer motor assessment(FMA), motor assessment scale(MAS), manual muscle testing(MMT) before the therapy,2weeks,4weeks and 8weeks after therapy. Results There were no significant differences between the two groups with regard to the scores with all the scales before the therapy(p<0.05). After 2weeks,the MAS scores of upper limb in the treatment group improved significantly compared with the scores before therapy(p<0.05). The manual muscle strength in the treatment group was significantly higher than that in the control group(p<0.05). After 4weeks, the FMA,MAS and muscle strenghth scores of upper limb in the two groups were significantly higher than the scores before the therapy (p<0.05), and the scores of FMA and manual muscle strength in the treatment group were significantly higher than that in the control group(p<0.05), however there was no significant difference in MAS scores between the two groups. After 8 weeks, the scores of FMA,MAS and muscle strength of the two groups improved significantly (p<0.05) compared with the scores before the therapy, and the scores of FMA, MAS and muscle strength in the treatment group were significantly higher than that in the control group(p<0.05). Conclusion Mental practice can improve the functional performance of the upper extremity in stroke patients. This study applied motor imagery therapy once a day focused on improving arm function in addition to traditional rehabilitation therapy. Mental practice has many advantages, such as arousing patients' training enthusiasm, facilitating patients' active participation, easy to apply. It also can be practiced at home and accepted easily by patients and their family members. At the same time, the method can save the cost for the patients.
引文
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[4]中华医学会全国4次脑血管病学术会.各类脑血管病诊断要点.中华神经内科杂志.1996,29：379-380.
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[2]周殿揆 神奇的想象疗法 中国学术期刊.2009,24-29
[3]Decety J, Grezes J. Neural mechanisms subserving the perception of human actions. Trends Cogn Sci,1999,3:172-178.
[4]中华医学会全国4次脑血管病学术会.各类脑血管病诊断要点.中华神经内科杂志.1996,29：379-380.
[5]Francine Malouin,etal. A Motor imagery Questionnaire for personsStroke. INPT.2007,31(3):21-29.
[6]南登崑,郭正成,主编.康复医学临床指南.北京：科学出版社,1999：35.
[7]于兑生 主编 运动疗法与作业疗法.华夏出版社2002：98-99.
[8]王强 运动想象疗法在脑卒中患者康复中的应用.中华物理医学与康复杂志2007,29(11)：782-784.
[9]Maring J R. Effect s of mental practice on rate of skill acquisition[J]. Phys Ther (0031-9023),1990,70 (3):165-172.
[10]李继刚,田宝.运动想象的理论模式生理机制与应用研究[J].武汉体育学院学报,2005,39(5)：64-67.
[11]Page SJ, Levine P, Sisto SA, et al.A randomized efficacy and feasibility study of imagery in acute stroke [J].Clin Rehabil,2001,15:233-240.
[12]Stevens JA, Stoykov ME. Using motor imagery in the rehabilitation of hemiparesis [J]. Arch Phys Med Rehabil (S0003-9993),2003,84 (7):1090-1092.
[13]槐雅萍,闫彦宁,贾子善,等.“运动想象”疗法对脑卒中患者上肢功能恢复的影响：2例报告啊.中国康复医学杂志,2005,20(9)：681-682.
[14]Hall,C. R,Mack,D, Paivio,A. Hausenblas, H. A. Imagery use by athletes:Development of the Sport Imagery Questionnaire[J]. International Journal of Sport Psycholohy, 1998,29:73-89.
[15]Lafleur MF, Jackson PL, Richards C, et al. Motor lerning produces parallel dynamic functional changes during the execution and imagination of sequential foot movements. Neuroimage,2002,16:142-157.
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