脑卒中康复临床实践指南推荐意见研究

doi:10.3969/j.issn.1006-9771.2020.02.007

《中国康复理论与实践》 ›› 2020, Vol. 26 ›› Issue (2): 170-180.doi: 10.3969/j.issn.1006-9771.2020.02.007

• 专题康复指南研究:理论架构、方法体系、发展状况与质量评价 • 上一篇下一篇

脑卒中康复临床实践指南推荐意见研究

张先卓^1,^2,^3,^4,⁵,吕萌⁶,罗旭飞⁶,玉炫^3,⁴,卢姝亚^7,⁸,王玲⁶,石秀娥^9,¹⁰,陈耀龙^2,^3,^4,⁵(),杨克虎^2,^3,^4,⁵()

1.兰州大学第一临床医学院,甘肃兰州市730000
2.兰州大学基础医学院循证医学中心,甘肃兰州市730000
3.世界卫生组织指南实施与知识转化合作中心,甘肃兰州市730000
4.GRADE中国中心,甘肃兰州市730000
5.甘肃省循证医学与临床转化重点实验室,甘肃兰州市730000
6.兰州大学公共卫生学院,甘肃兰州市730000
7.四川省人民医院,四川成都市610000
8.电子科技大学,四川成都市610000
9.甘肃省康复中心医院,甘肃兰州市730000
10.甘肃省循证康复医学研究中心,甘肃兰州市730000

收稿日期:2020-02-02 修回日期:2020-02-10 出版日期:2020-02-25 发布日期:2020-03-19
通讯作者: 陈耀龙,杨克虎 E-mail:chenyaolong@vip.163.com;kehuyangebm2006@126.com
作者简介:张先卓(1997-),男,苗族,湖北恩施市人,主要研究方向:循证医学、临床指南、临床医学和基础外科。|吕萌(1995-),女,汉族,甘肃兰州市人,硕士,主要研究方向:公共卫生、循证医学。
基金资助:
1.国家社科基金重大项目(19ZDA142);2.甘肃省循证医学与临床转化重点实验室创新基金项目(CXJJ2019002)

Recommendations of Clinical Practice Guidelines of Stroke Rehabilitation

ZHANG Xian-zhuo^1,^2,^3,^4,⁵,LÜ Meng⁶,LUO Xu-fei⁶,YU Xuan^3,⁴,LU Shu-ya^7,⁸,WANG Ling⁶,SHI Xiu-e^9,¹⁰,CHEN Yao-long^2,^3,^4,⁵(),YANG Ke-hu^2,^3,^4,⁵()

1. the First School of Clinical Medicine, Lanzhou University, Lanzhou, Gansu 730000, China
2. Evidence-based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu 730000, China
3. WHO Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou, Gansu 730000, China
4. Chinese GRADE Center, Lanzhou, Gansu 730000, China
5. Key Laboratory of Evidence-based Medicine and Clinical Transformation of Gansu Province, Lanzhou, Gansu 730000, China
6. School of Public Health, Lanzhou University, Lanzhou, Gansu 730000, China
7. Sichuan Provincial People's Hospital, Chengdu, Sichuan 610000, China
8. School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan 610000, China
9. Rehabilitation Center Hospital of Gansu, Lanzhou, Gansu 730000, China
10. Gansu Evidence-based Rehabilitation Medical Research Center, Lanzhou, Gansu 730000, China

Received:2020-02-02 Revised:2020-02-10 Published:2020-02-25 Online:2020-03-19
Contact: CHEN Yao-long,YANG Ke-hu E-mail:chenyaolong@vip.163.com;kehuyangebm2006@126.com
Supported by:
Major Project of the National Social Science Fund(19ZDA142);Gansu Key Laboratory of Evidence-based Medicine and Clinical Translation Innovation Fund(CXJJ2019002)

摘要/Abstract

摘要：

目的分析国内外脑卒中康复临床实践指南的推荐意见内容,为脑卒中康复临床实践指南的制订和使用人员提供参考和建议。方法系统检索PubMed、EMBASE、中国知网(CNKI)、中国生物医学文献数据库(CBM)、万方数据库及指南相关网站,时间为从建库之日起至2020年1月,搜集国内外脑卒中康复临床实践指南,参照世界卫生组织指南制订手册(第二版)的流程,对国内外脑卒中康复临床实践指南主要关注的康复内容、推荐意见是否基于证据、基于证据的类型及证据分级范围进行分析。结果共纳入12篇脑卒中康复临床实践指南,其中中文1篇,英文11篇。制订国家包括美国(3篇)、英国(3篇)、加拿大(3篇)、澳大利亚(2篇)和中国(1篇),发表时间为2005年9月至2019年2月。脑卒中康复临床实践指南中质量评价采用指南研究与评价(AGREE)的有3篇(25.0%),分级系统采用GRADE的有2篇(16.7%)。指南推荐意见内容涉及领域有:认知功能障碍4个维度,推荐最多为认知功能的评估(7篇,66.7%);言语及吞咽功能障碍5个维度,推荐最多为吞咽相关并发症(10篇,83.3%);运动功能障碍6个维度,推荐最多为对痉挛的治疗(10篇,83.3%);心理及行为功能障碍4个维度,推荐最多为评估(6篇,50.0%)。4个领域推荐意见中基于的证据类型不一,多为观察性研究和/或随机对照试验。结论推荐意见基于的证据类型和推荐强度分级不尽相同。建议脑卒中康复临床实践指南制订应该参照世界卫生组织指南制订手册的方法和流程规范推荐意见的撰写,提高康复指南的整体质量和可实施性,并进一步提高康复的质量和安全性。

关键词: 脑卒中, 康复, 指南, 推荐意见

Abstract:

Objective To analyze the contents of the recommendations of stroke clinical rehabilitation guidelines in order to provide advice for the development and implementation of stroke rehabilitation guidelines.Methods PubMed, EMBASE, CNKI, China Biology Medicine disc, Wanfang databases and guideline-related websites were retrieved from the date of establishment to January 2020, to collect stroke clinical rehabilitation guidelines. The main content, recommendations based on evidence, the type of evidences, and the scope of evidence classification had been explored based on World Health Organization Handbook for Guideline Development-2nd Edition.Results A total of twelve guidelines were included in this study, one in Chinese and eleven in English. They were from the United States (3 guidelines), United Kingdom (3 guidelines), Canada (3 guidelines), Australia (2 guidelines) and China (1 guidelines), and published from September, 2005 to February, 2019. Three articles (25.0%) used the Appraisal of Guidelines for Research and Evaluation (AGREE) for quality evaluation, and two articles (16.7%) used Grading of Recommendations Assessment, Development and Evaluation (GRADE) as the grading system. The recommendations covered the areas such as: cognitive dysfunction (4 dimensions) with a recommendation of cognitive function assessment at most (7 guidelines, 66.7%), language and swallowing dysfunction (5 dimensions) with a recommendation of swallowing-related complications at most (10 guidelines, 83.3%), motor dysfunction (6 dimensions) with a recommendation of spasm treatment at most (10 guidelines, 83.3%), and psychological and behavioral dysfunction (4 dimensions) with a recommendation for assessment or monitoring at most (6 guidelines, 50.0%). There were many recommendations in these areas, but the types of evidence were different, and observational studies and/or randomized controlled trials accounted for most.Conclusion There are different types of evidence and levels of recommendation strength. It is proposed for future guideline developers in stroke rehabilitation to follow World Health Organization Handbook for Guideline Development-2nd Edition to improve the quality and the overall implementation of the rehabilitation guidelines, and to improve the quality and safety of rehabilitation.

Key words: stroke, rehabilitation, guideline, recommendation

中图分类号:

张先卓,吕萌,罗旭飞,玉炫,卢姝亚,王玲,石秀娥,陈耀龙,杨克虎. 脑卒中康复临床实践指南推荐意见研究[J]. 《中国康复理论与实践》, 2020, 26(2): 170-180.

ZHANG Xian-zhuo,LÜ Meng,LUO Xu-fei,YU Xuan,LU Shu-ya,WANG Ling,SHI Xiu-e,CHEN Yao-long,YANG Ke-hu. Recommendations of Clinical Practice Guidelines of Stroke Rehabilitation[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2020, 26(2): 170-180.

图/表 6

图1

表1

脑卒中康复临床实践指南基本信息表"

序号	题目	脑卒中康复领域	人群	发表年份	指南制订机构	国家	质量评价/分级系统	推荐意见条数	是否提供额外网站
1	Management of Adult Stroke Rehabilitation Care A Clinical Practice Guideline^[11]	①②③④	成人(≥18)	2005	American Heart Association/American Stroke Association(AHA/ASA)	美国	USPSTF^a	146	是
2	Ottawa Panel Evidence-based Clinical Practice Guidelines for Post-Stroke Rehabilitation^[12]	③	成人(≥18)	2006	The Ottawa Panel(Ottawa EBCPGs Development Group)^b	加拿大	AGREE	188	否
3	VA/DoD Clinical Practice Guideline for The Management of Stroke Rehabilitation^[13]	①②③④	成人(≥18)	2010	Department of Veterans Affairs,Department of Defense,and The American Heart Association/American Stroke Association	美国	USPSTF^a	255	是
4	Management of patients with stroke: Rehabilitation, prevention and management of complications, and discharge planning^[14]	①②③④	脑卒中患者	2010	Scottish Intercollegiate Guidelines Network (SIGN), NHS Quality Improvement Scotland (NHS QIS)	英国	AGREE II	26	是
5	Stroke Rehabilitation: Long Term Rehabilitation After Stroke^[15]	①②③④	≥16	2013	National Clinical Guideline Centre (NCGC)	英国	GRADE	120	是
6	Evidence-based Practice and Setting Basic Standards for Stroke Rehabilitation in Canada^[16]	②④	脑卒中患者	2015	Ontario Ministry of Health and Long-Term Care	加拿大	PEDro^c	6	否
7	Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines, update 2015^[17]	②③	全年龄层	2016	Canadian Stroke Best Practice Recommendations	加拿大	American College of Chest Physicians grading system (8th ed.)	173	是
8	Guidelines for Adult Stroke Rehabilitation and Recovery–A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association^[18]	①②③④	成人(≥18)	2016	American Heart Association/American Stroke Association (AHA/ASA)	美国	American Heart Association (AHA) concerning classes and levels of evidence	227	是
9	中国脑卒中早期康复治疗指南^[19]	②③	未报告	2017	中华医学会神经病学分会,中华医学会神经病学分会神经康复学组,中华医学会神经病学分会脑血管病学组	中国	American Academy of Neurology (AAN), Quality Standards Subcommittee (1999)	48	否
10	Stroke in childhood-Clinical guideline for diagnosis, management and rehabilitation^[20]	①②③④	儿童和青少年(29 d~18岁)	2017	The Royal College of Paediatrics and Child Health (RCPCH)	英国	AGREE II	84	是
11	(Australian) Clinical Guidelines for Stroke Management 2017 - Chapter 5 of 8: Rehabilitation^[21]	①②③	成人(≥18)	2019	Stroke Foundation	澳大利亚	GRADE	76	是
12	The Subacute Rehabilitation of Childhood Stroke Clinical Guideline 2019^[22]	①②③④	儿童(29 d~18岁或至完成学业为止)	2019	Victorian Subacute Childhood Stroke Advisory Committee	澳大利亚	critical appraisal checklists developed by the Scottish Intercollegiate Guidelines Network (SIGN) and an NHMRC level of evidence	59	是

表1

表2

表3

言语及吞咽功能障碍推荐意见分析表"

领域		内容	1	2	3	4	5	6	7	8	9	10	11	12
评估		有无推荐意见	√	×	√	√	√	√	√	√	√	√	×	×
		推荐意见数量	8	×	8	1	7	3	6	8	3	13	×	×
		是否基于证据	√	×	√	√	√	√	√	√	√	√	×	×
		证据类型	①②⑤⑥⑨	×	②④⑤⑥	②	①②④⑤⑥	④⑤⑥	④⑤⑨	②④⑤⑥⑨	④	①②⑤⑥⑨	×	×
		证据等级	II2-III/ Poor-Fair/B-C-I	×	I	×	×	B	B-C	I-IIb/A-C	I/A-B	×	×	×
		统计指标	推荐意见总条数:57条						指南数:9篇
并发症干预	失语	有无推荐意见	×	×	×	√	√	×	×	√	×	×	√	×
		推荐意见数量	×	×	×	3	19	×	×	8	×	×	6	×
		是否基于证据	×	×	×	√	√	×	×	√	×	×	√	×
		证据类型	×	×	×	②④⑥⑧	②④⑥⑧	×	×	②④⑥	×	×	②⑧	×
		证据等级	×	×	×	B	×	×	×	I-III/A-B	×	×	×	×
		统计指标	推荐意见总条数:36条						指南数:4篇
	构音障碍	有无推荐意见	×	×	×	×	√	×	×	×	×	√	×	×
		推荐意见数量	×	×	×	×	19	×	×	×	×	2	×	×
		是否基于证据	×	×	×	×	√	×	×	×	×	√	×	×
		证据类型	×	×	×	×	②④⑥⑧	×	×	×	×	④	×	×
		证据等级	×	×	×	×		×	×	×	×	strong-weak	×	×
		统计指标	推荐意见总条数:21条						指南数:2篇
	吞咽	有无推荐意见	√	×	√	√	√	√	√	√	√	√	×	√
		推荐意见数量	11	×	7	3	5	9	10	9	8	15	×	4
		是否基于证据	√	×	√	√	√	√	√	√	√	√	×	√
		证据类型	①②④⑤⑨	×	②④⑤⑥	②④⑥	①	③④⑤⑥⑨⑩	④⑤⑨	③④⑤⑥⑨⑩	④	②⑤⑥⑨	×	⑨
		证据等级	II2-III/ Poor-Fair/B	×	I	×	×	B-C	B-C	I-IIb/III/A-C	I-II/A-B	×	×	×
		统计指标	推荐意见总条数:81条						指南数:10篇
其他康复方法		有无推荐意见	×	×	√	√	√	√	√	√	×	√	×	×
		推荐意见数量	×	×	1	1	10	1	4	3	×	3	×	×
		是否基于证据	×	×	√	×	√	√	√	√	×	√	×	×
		证据类型	×	×	×	⑧	②④⑧	⑨	④⑤⑨	①②⑥	×	①②⑤⑥⑨	×	×
		证据等级	×	×	×	×	×	C	C	I-IIb/B-C	×	×	×	×
		统计指标	推荐意见总条数:23条						指南数:7篇

表3

表4

运动功能障碍推荐意见分析表"

领域		内容	1	2	3	4	5	6	7	8	9	10	11	12
评估		有无推荐意见	×	×	√	×	√	×	×	√	×	×	×	×
		推荐意见数量	×	×	2	×	2	×	×	7	×	×	×	×
		是否基于证据	×	×	×	×	√	×	×	√	×	×	×	×
		证据类型	×	×	×	×	⑧	×	×	④⑥⑧	×	×	×	×
		证据等级	×	×	×	×	×	×	×	IIb/C	×	×	×	×
		统计指标	推荐意见总条数:11条						指南数:3篇
并发症干预	痉挛	有无推荐意见	√	√	√	√	√	×	×	√	√	√	√	√
		推荐意见数量	8	36	5	13	9	×	×	15	2	10	8	2
		是否基于证据	√	√	√	√	√	×	×	√	√	√	√	√
		证据类型	②③④⑥⑨	②	②③④	②④⑥⑧	②④⑥	×	×	②③④⑥⑦	⑥	②③⑥⑦	②③⑧	⑨
		证据等级	I-III/Fair-Poor/B-I	A-D	A-I	A-C	×	×	×	I-III/A-B	I-II/A-B	×	strong-weak	×
		统计指标	推荐意见总条数:108条						指南数:10篇
	平衡与步态	有无推荐意见	×	√	√	×	×	×	√	√	×	×	√	×
		推荐意见数量	×	21	1	×	×	×	1	4	×	×	2	×
		是否基于证据	×	√	√	×	×	×	×	√	×	×	√	×
		证据类型	×	④	②④⑥	×	×	×	×	②③④⑥	×	×	②③	×
		证据等级	×	A-D	C	×	×	×	A-C	I-IIb/A-C	×	×	strong-weak	×
		统计指标	推荐意见总条数:29条						指南数:5篇
	下肢	有无推荐意见	×	√	√	×	×	×	√	√	×	×	×	×
		推荐意见数量	×	5	8	×	×	×	14	3	×	×	×	×
		是否基于证据	×	√	√	×	×	×	×	√	×	×	×	×
		证据类型	×	④	②④⑥	×	×	×	×	③④⑥⑦	×	×	×	×
		证据等级	×	A-D	B-D	×	×	×	A-C	I-IIb/A-B	×	×	×	×
		统计指标	推荐意见总条数:30条						指南数:4篇
	上肢	有无推荐意见	×	√	√	√	√	×	×	√	×	×	√	×
		推荐意见数量	×	9	12	7	9	×	×	3	×	×	9	×
		是否基于证据	×	√	√	√	√	×	×	√	×	×	√	×
		证据类型	×	④	②③④⑥	②④⑥⑧	②④⑥	×	×	②④⑥	×	×	②③	×
		证据等级	×	A-D	A-I	×	×	×	×	IIa/A-B	×	×	strong-weak	×
		统计指标	推荐意见总条数:49条						指南数:6篇
辅助器具		有无推荐意见	×	√	√	×	×	×	√	√	×	×	×	×
		推荐意见数量	×	16	5	×	×	×	3	6	×	×	×	×
		是否基于证据	×	√	√	×	×	×	×	√	×	×	×	×
		证据类型	×	④	①⑨	×	×	×	×	②④⑥	×	×	×	×
		证据等级	×	A-D	C	×	×	×	A-C	I-IIb/A-C	×	×	×	×
		统计指标	推荐意见总条数:30条						指南数:4篇

表4

表5

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脑卒中康复临床实践指南推荐意见研究

Recommendations of Clinical Practice Guidelines of Stroke Rehabilitation

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