骨骼肌肉系統(tǒng)：基于循證醫(yī)學(xué)觀(guān)點(diǎn)的腦卒中康復(fù)治療

1、基于循證醫(yī)學(xué)觀(guān)點(diǎn)的腦卒中康復(fù)治療The Stroke Rehabilitation Evidence-Based Review ContentIntroductionChallenges in evidence-based stroke RehabilitationPrinciples of stroke rehabilitation based on evidenceSpecic interventionsConclusionsQ:What is impact of stroke?IntroductionStroke is a global health-care problem that

2、is common, serious, and disabling. In most countries, stroke is the second or third most common cause of death and one of the main causes of acquired adult disability. We focus mainly on the evidence-based stroke rehabilitation.Ming L, Bo W, Wen ZW, et al. Stroke in China: epidemiology, prevention,

3、and management strategies. Lancet. 2007; 6: 456464.Peter L, Julie B, Gert K. Stroke rehabilitation. Lancet. Lancet 2011; 377: 16931702.Q:How to classify the impact of stroke?Classication of the impact of strokeDisabling disorders such as stroke can be classied within WHOs international classication

4、of function, disability, and health, which provides a framework for the eect of stroke on the individual in terms of pathology (disease or diagnosis), impairment (symptoms and signs), activity limitations(disability), and participation restriction (handicap).Health condition(Stroke)Body Function and

5、 Structure(Impairment)Activity(limitation)Participation(restriction)Environmental factor(Facilitators and Barriers)Personal factors(No developed)What is measured?How measured?http:/strokengine.ca/Q:What is stroke recovery?Stroke recoveryStroke recovery is heterogeneous in its nature. The long-term e

6、ect of stroke is determined by the site and size of the initial stroke lesion and by the extent of subsequent recovery. Q:What is happened in stroke recovery?Stroke recoveryRecovery is a complex process that probably occurs through a combination of spontaneous and learning-dependent processes, inclu

7、ding Restitution (restoring the functionality of damaged neural tissue) Translation:補(bǔ)充Substitution (re-organization of partly spared neural pathways to relearn lost functions) Translation:補(bǔ)償Compensation (improvement of the disparity between the impaired skills of a patient and the demands of their e

8、nvironment). Translation:代償Q: What is important in stroke recovery?Stroke recoveryAlthough patient outcome is heterogeneous and individual recovery patterns dier, several studies suggest that recovery of body functions and activities is predictable in the rst days after stroke.Kwakkel G, Kollen B, L

9、indeman E. Understanding the pattern of functional recovery after stroke: facts and theories. Restor Neurol Neurosci 2004; 22: 281299.Nijland R, van Wegen E, Verbunt J, van Wijk R, van Kordelaar J, Kwakkel G. A comparison of two validated tests for upper limb function after stroke: the Wolf Motor Fu

10、nction Test and the Action Research Arm Test. J Rehabil Med 2010; 42: 694696.Q:What is stroke rehabilitation?Rehabilitation after strokeStroke rehabilitation typically entails a “Rehab cyclical” process involving: (1) Assessment, to identify and quantify the patients needs; (2) Goal setting, to dene

11、 realistic and attainable goals for improvement; (3) Intervention, to assist in the achievement of goals; (4) Reassessment, to assess progress against agreed goals.Q: What is contained in the rehabilitation cycle?Rehabilitation cycle康復(fù)循環(huán)（Rehab-CYCLE）評(píng)定（Assessment）分配（Assignment）干預(yù)（Intervention）評(píng)估（Eva

12、luation）病歷康復(fù)評(píng)定效果評(píng)估表干預(yù)方式Q: What is principles of rehabilitation?Principles of rehabilitation after strokeProf. Langhorne P. Principles of rehabilitation:Goal setting: establishment of specic, measurable, and time-dependent recovery goals to guide management.High-intensity practice: increased therapy

13、or intervention.Multidisciplinary team care: a team of medical, nursing, therapy, and social-work sta who provide rehabilitation input and coordinate their work with regular meetings.Task-specic training: rehabilitation approaches where specic functional tasks are practised repeatedly.Langhorne P, C

14、oupar F, Pollock A. Motor recovery after stroke: a systematic review. Lancet Neurol 2009; 8: 741754.Q: What are challenges?Challenges in evidence-based stroke rehabilitationFirst, although learning of skills and theories of motor control are crucial to many rehabilitation interventions, the neurophy

15、siology underpinning stroke rehabilitation is often poorly established. Secondly, interventions can occur at dierent points on a continuum of complexity ranging between highly complex treatments and specic treatments.Finally, Description of stroke rehabilitation terminology is unclear. ICD-10ICHIICF

16、ICFICFICFICFICHIICHIICHIICHIICHIEBMOutcomesResearches and experimentsTMChallenges in evidence-based stroke rehabilitation-Complex rehabilitation interventions-Cognitive rehabilitation interventionsEarly supported discharge serviceIntegrated-care pathwaysMultidisciplinary stroke unitOutpatient rehabi

17、litation serviceOccupational therapy interventionsPhysiotherapy interventionsInterventions for speech and language therapyServices with stroke liaison workersTherapy-based rehabilitation serviceChallenges in evidence-based stroke rehabilitation-Specic rehabilitation treatments-Ankle-foot orthosis Be

18、havioural therapies for urinary incontinenceBilateral arm training Biofeedbackforce and position feedbackConstraint-induced movement therapy Electromyographic biofeedbackElectromechanical-assisted gait training ElectrostimulationFitness training or physical tness training High-intensity therapyMenta

19、l practice with motor imagery Mirror therapyMoving platform training Music therapyRepetitive task training Rhythmic gait cueingRobotics Splinting or orthosisStrength training Treadmill training plus bodyweight supportWalking aids Seating and positioning policiesSummary of evidence for complex rehabi

20、litation interventions and their recommendation in clinical guidelinesBenecial or likely to be benecial:Multidisciplinary stroke-unit care to improve independence; recommended (A)Early supported discharge services to improve independence; recommended (A)Therapy-based rehabilitation services at home

21、(within 1 year of stroke) to improve ADL; recommended (A,B)Outpatient (day-hospital, community team) rehabilitation services to improve ADL; selected use (A,B)Rehabilitation services in long-term care settings to improve ADL; not mentioned or selected use (B)Occupational therapy services to improve

22、ADL; recommended (A,B)Occupational therapy services at home to improve ADL and extended ADL; recommended (A)Uncertain benet:Integrated-care pathways to improve independence; not recommended or selected use (B)Services with stroke liaison workers to improve independence and participation; not mention

23、edInformation provision to improve knowledge and independence; recommended (A)Therapy-based rehabilitation services at home (after 1 year) to improve ADL; selected use (B,C)Speech and language therapy interventions for aphasia; recommended (B)Speech and language therapy interventions for dysphagia;

24、recommended (B)Sta -led training interventions to improve oral hygiene; not mentioned or selected use (B)Cognitive rehabilitation for spatial neglect; not mentioned or selected use (B)Summary of evidence for complex rehabilitation interventions and their recommendation in clinical guidelinesUnknown

25、eect:Cognitive rehabilitation for attention de cits; not mentioned or selected use (B)Cognitive rehabilitation for memory de cits; not mentioned or selected use (C)Cognitive rehabilitation for motor apraxia; not mentioned or selected use (B,C)Interventions for perceptual disorders; not mentioned or

26、selected use (C)Occupational therapy for cognitive impairment; not mentioned or selected use (C)Home-based intervention for arm recovery; not mentionedSpeech and language therapy for speech apraxia; recommended (C)Speech and language therapy for dysarthria; recommended (C)Goal setting in rehabilitat

27、ion to improve recovery; not mentioned or recommended (C)Behavioural therapies for urinary incontinence; recommended (C)Pre-discharge home assessments; selected use (C)Summary of evidence for complex rehabilitation interventions and their recommendation in clinical guidelinesSummary of the evidence

28、for specic rehabilitation treatmentsBenecial or likely to be benecialArm:CIMT or modied CIMT for arm impairment and motor function; selected use (A,B)Robot-assisted training for upper limb function; selected use (A,B)Leg:Electromechanical-assisted gait training for walking; selected use (B)Task-orie

29、nted physical tness training for walking; recommended (A)Cardiorespiratory tness training for walking distance; recommended (A)High-intensity therapy for gait recovery; recommended (B)Repetitive task training for gait speed and transfers; recommended (A,B)Speed-dependent treadmill training for gait

30、speed and walking distance; selected use (A,B)Uncertain benetArm:Bilateral training for motor function of arm; not mentioned or selected use (B)Mental practice for arm function; selected patients (B,C)High-intensity therapy for arm function; not recommended or recommended (B)Repetitive task training

31、 for arm function; not recommended or recommended (B)Electrostimulation for arm function; not mentioned, not recommended, or selected use (B)Electromyographic biofeedback for arm function; not recommended or selected use (A,B)Mirror therapy for arm (or leg) impairment; selected use (A,B)EMG biofeedb

32、ack for hand function; not mentioned or not recommended (B)Electrostimulation for hand function; not mentioned or not recommended (B)Robotics for hand function; selected use (B)Summary of the evidence for specic rehabilitation treatmentsUncertain benetLeg:External (auditory) rhythmic gait cueing to

33、improve walking; not mentioned or selected use (B)Biofeedback (force and position) for balance or leg function; not recommended or selected use (B)Moving platform for balance or leg function; not mentioned or selected use (B)Treadmill training and bodyweight support for gait for mobile patients; sel

34、ected use (B)Very early mobilisation for mobility; recommended (B)Leg-strengthening programmes for gait; selected use (B)Ankle-foot orthosis for foot drop; selected use (B)Functional electrical stimulation for foot drop; selected patients (B,C)Other:Specic therapy approaches (Bobath, motor relearnin

35、g, mixed); no recommended approach (A)Summary of the evidence for specic rehabilitation treatmentsUnknown eect:Arm:Splinting or orthoses for arm function; not recommended (B,C)Leg:Walking aids for gait; recommended (B,C)Interventions for motor apraxia; not mentionedSeating and positioning policies;

36、recommended (B,C)Other:Interventions for visual eld impairments; not mentioned or selected use (B,C)Treatments for sensory impairments; not mentioned or selected use (B,C)Acupuncture for stroke recovery; not mentioned or not recommended (B)Music therapy for stroke recovery; not mentionedSummary of t

37、he evidence for specic rehabilitation treatmentsQ: What can we do?Upper Extremity Interventions Neurodevelopmental TechniquesA variety of treatment approaches are in use currently. Arguably, the Bobath approach (a neurodevelopmental technique) is the most commonly used, although other methods, such

38、as motor re-learning, orthopedic or mixed technique are also used.The concepts of NDT emphasize that abnormal muscle patterns or muscle tone have to be inhibited, and that normal patterns should be used in order to facilitate functional and voluntary movements. Neurodevelopmental Training (NDT) Appr

39、oaches Studies of Neurodevelopmental Techniques Conclusions Regarding Neurodevelopmental Techniques There is strong (Level 1a) evidence that neurodevelopmental techniques are not superior to other therapeutic approaches. There is moderate (Level 1b) evidence from one “good” RCT that indicates that w

40、hen compared to the Bobath treatment approach, Motor Relearning Programme may be associated with improvements in short-term motor functioning, shorter lengths of hospital stay and better movement quality. Neurodevelopmental techniques are not superior or inferior compared with other therapeutic appr

41、oaches in treatment of the hemiparetic upper extremity. CIMT or modied CIMTConstraint-Induced Movement Therapy (CIMT) refers to a new set of rehabilitation techniques designed to reduce functional deficits in the more affected upper extremity of stroke survivors. The two key features of CIMT are res

42、traint of the unaffected hand/arm and increased practice /use of the affected hand/arm (Fritz et al. 2005)Gauthier LV et al. Improvement After Constraint-Induced Movement Therapy Is Independent of Infarct Location in Chronic Stroke Patients. Stroke.Summary of RCTs Evaluating CIMT in the Acute Phase

43、Following Stroke Summary of RCTs Evaluating CIMT in the Chronic Phase Following Stroke Summary of RCTs Evaluating CIMT in the Chronic Phase Following Stroke Summary of RCTs Evaluating Modified CIMT in the Acute Phase Following Stroke Summary of RCTs Evaluating Modified CIMT in the Sub-acute or Chron

44、ic Phase Following Stroke Conclusion about CIMT and mCIMTThere is conflicting (Level 4) evidence of benefit of CIMT in the acute stage of stroke. There is strong (Level 1a) evidence of benefit of mCIMT in the acute/subacute stage of stroke. There is strong (Level 1a) evidence of benefit of CIMT and

45、mCIMT in comparison to traditional therapies in the chronic stage of stroke. Benefits appear to be confined to stroke patients with some active wrist and hand movements, particularly those with sensory loss and neglect. CIMT or modied CIMT for arm impairment and motor function; selected use (A,B)Neu

46、ro-Rehabilitation-Robot Studies Evaluating the NeReBot Device The 3 degrees of freedom device can perform spatial movements of the shoulder and elbowRobot is portable and can be used when the patient is either prone or sitting.Robot-assisted training for upper limb function; selected use (A,B)Conclu

47、sion about RobotTranscranial magnetic stimulation, TMSCortical electrical stimulation alone enhances functional recovery and dendritic structures after focal cerebral ischemia in rats Pu Wang, Junbin Ling, Weijing LiaoTranscranial magnetic stimulation, TMSSafety limits of cathodal transcranial direc

48、t current stimulation in rats. Junbin Ling, Pu Wang, Weijing LiaoFunctional improvement and neuroplastic effects of anodal transcranial direct current stimulation (tDCS) delivered 1 day vs. 1 week after cerebral ischemia in ratsWeijing Liao, Pu Wang, Junbin Lin, Qi Wan乙酰天門(mén)冬氨酸/肌酸相對(duì)值值作為軸突功能損害和變性的替代指標(biāo)膽

49、堿/肌酸相對(duì)值：診斷腦梗死的有效值同側(cè)乳酸/肌酸相對(duì)值：腦缺氧的替代標(biāo)志Q: What can we do?Mobility and the Lower Extremity Electromechanical-assisted gait training for walkingPartial Body Weight Support in Stroke Gait Training Conclusions Regarding Partial Body Weight Support and Treadmill TrainingThere is conflicting evidence that th

50、e combination of partial body weight support and treadmill training results in improved gait performance compared with other physiotherapy interventions. Electromechanical-assisted gait training for walking; selected use (B) Intensity of Training The term, “intensity”, most frequently refers to the

51、frequency of repetitions within a given period of time, although more correctly, is defined as the amount of mechanical output of physical activity. Summary of RCTs Evaluating Intensity of Therapy on Assessments of Gait and Mobility Conclusions Regarding Intensity of Training There is strong (Level

52、1a) evidence that augmented physical therapy is associated with improvements in gait. However, there is also strong (Level 1a) evidence that the beneficial effect is not maintained once therapy has ceased. Virtual Reality Training Virtual reality, also known as virtual environment, is a technology t

53、hat allows individuals to experience and interact with three-dimensional environments. The most common forms of virtual environments simulators are head-mounted displays (immersion) or with conventional computer monitors or projector screens (nonimmersion) (Sisto et al. 2002). Although the clinical

54、application of this technology is not widespread, several studies has been published examining its efficacy compared with conventional rehabilitation. Virtual Reality in Stroke Gait Training Conclusions Regarding Virtual Reality Training in Gait Training There is strong (Level 1a) evidence that virt

55、ual reality training can be used to enhance gait recovery following stroke.EMG / BiofeedbackBiofeedback therapy has been used as a means to improve gross motor function, which will lead to improvements in standing balance and gait, using either auditory or visual feedback. EMG/Biofeedback Treatment

56、in Lower ExtremityConclusions Regarding EMG/Biofeedback Treatment in Lower Extremity Biofeedback training improved gait and standing post-stroke in the majority of “fair” to “good” quality RCTs, constituting strong (Level 1a) evidence of a positive benefit in gait retraining. Bilateral Leg Training Bilateral arm training has been used with some success in the rehabilitation of the upper extremity. As a result, a single group of researchers questioned whether the technique could also be used effectively in the lower extremity. Concl