脑卒中后肢体痉挛的识别与评估：Scoping综述

doi:10.3969/j.issn.1006-9771.2022.01.010

摘要/Abstract

摘要：

目的总结脑卒中后肢体痉挛相关的电生理指标和量表,以实现痉挛临床管理的一体化。方法检索建库至2021年5月15日Web of Science、PubMed、中国知网、万方数据库中脑卒中后肢体痉挛识别与评估的相关文献,对脑卒中后肢体痉挛评估的相关量表和电生理指标进行综述。结果目前临床用于脑卒中后肢体痉挛评估的量表主要包括改良Asworth量表、综合痉挛量表和改良Tardieu量表。F波、H反射、运动诱发电位、惊跳反射响应时间、前庭诱发肌源性电位等电生理指标能用于识别与评估脑卒中后肢体痉挛。结论需进一步开展临床研究探讨如何更加客观、精准地早期识别和评估痉挛。

关键词: 脑卒中, 痉挛, 电生理, 评估, Scoping综述

Abstract:

Objective To summarize the electrophysiological indexes and scales used for evaluation of post-stroke spasticity, for integration of clinical management of spasms. Methods Literatures on identification and evaluation of post-stroke spasticity from databases of Web of Science, PubMed, CNKI, and Wanfang Data up to May 15, 2021 were retrieved and the indicators related to post-stroke spasticity were extracted for a scoping review. Results The scales of modified Asworth Scale, Comprehensive Spasticity Scale and modified Tardieu Scale; the electrophysiological indexes of F wave, H reflex, motor evoked potentials, visual-startle reaction time and vestibular evoked myogenic potentials were used to identify and evaluate post-stroke spasticity. Conclusion More clinical researches are needed to explore earlier identification and evaluation of post-stroke spasticity more objectively and accurately.

Key words: stroke, spasticity, electrophysiology, evaluation, scoping review

中图分类号:

R743.3

陈莉琳,黄牡丹,郑海清. 脑卒中后肢体痉挛的识别与评估：Scoping综述[J]. 《中国康复理论与实践》, 2022, 28(1): 62-68.

CHEN Lilin,HUANG Mudan,ZHENG Haiqing. Identification and evaluation of post-stroke spasticity: a scoping review[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2022, 28(1): 62-68.

图/表 2

图1

表1

纳入文献的一般资料"

作者	国家	n	部位	评价工具	结局
Poon等^[4](2009)	中国	78	踝	CSS 比目鱼肌牵张反射肌电图肌肉共收缩指数	重测信度0.78~0.97
Choi等^[7](2018)	韩国	28	膝、踝	基于惯性传感器的MTS 传统MTS	基于惯性传感器准确率高(均方根误差< 3.2°),重测信度和评估者间信度高(组内相关系数> 0.8)
Udby Blicher等^[12] (2009)	丹麦	42	肘、腕	MAS F波振幅 F波频率 M波振幅	痉挛组和非痉挛组间F波频率无显著性差异
Leng等^[13](2021)	中国	27	腕	MAS NeuroFlexor神经、弹性和黏性成分 MyotonPRO中F值、S值 EIM中电阻和电抗	MAS评分降低不伴痉挛相关神经成分的变化
Phadke等^[14](2012)	美国	36	腕	MAS H反射 M波 H_max/M_max H_slp/M_slp H_TH/M_TH	H_max/M_max、H_slp/M_slp和H_TH/M_TH重测组内相关系数分别为0.85、0.88和0.69;H反射相关指标与MAS评分无相关性
Kumru等^[15](2010)	西班牙	21	膝	MAS H反射 M波 H_max/M_max T反射屈肌反射	MAS评分降低不伴H反射相关指标变化
Fujiwara等^[20](2015)	日本	61	腕	MAS SICI RI	RI-3的变化与腕痉挛程度的变化负相关
Sangari等^[22](2019)	美国	60	膝	MAS 钟摆实验 H_max/M_max MEP MRI	MEP与痉挛程度相关(r = 0.55)
Piscitelli等^[23](2020)	加拿大	44	肘	CSS MEP TSRT	MEP阈值与痉挛程度呈正相关(r = 0.62);MEP振幅增量与痉挛程度负相关(r = -0.464),与TSRT增量强相关(r = 0.691)
Choudhury等^[26](2019)	英国、印度	114	腕	MAS ARAT 关节活动席 VRT VART VSRT	痉挛程度越高,惊跳反射越强
Miller等^[27](2014)	美国	17	肘、踝	MAS AGSI VEMP不对称指数、非痉挛侧校正振幅、痉挛侧校正振幅	不对称指数与抗重力痉挛指数正相关;非痉挛侧与痉挛侧校正振幅比与抗重力痉挛指数负相关
Chen等^[28](2019)	美国	22	肘、腕、指	MAS 背景肌电均方根值肌电平均振幅 MEP	痉挛相关的RST兴奋抑制皮质脊髓束电活动
Rasool等^[29](2017)	美国	25	肘	MAS 肌电均方根值肌肉激活模式图(支持向量机) 肌电相关性和欧几里得距离肌肉活动域	肌肉活动域的增大、肌肉激活区的转变与痉挛程度相关
Misgeld等^[30](2016)	德国	14	膝、踝	MAS 肌电图 I_CA	I_CA与MAS评分线性相关
Ellis等^[31](2017)	丹麦	26	肘	MAS 肌电平均振幅	屈肌协同运动是脑卒中患者功能障碍的主要原因,屈肌痉挛与被动支撑下运动受阻有关
Yu等^[32](2020)	中国	15	肘	MAS 肌电图 TSRT	sEMG-ANFIS模型与MAS线性相关,R² = 0.97
Afzal等^[34](2019)	美国	19	肘	MAS 肌电图 TSRT	脑卒中患者的痉挛侧和非痉挛侧均存在TSRT调节紊乱,与RST双侧下行调节脊髓运动神经元有关
Turpin等^[36](2017)	加拿大	13	肘	DSRT TSRT ΔTSRT	ΔTSRT与CSS负相关(r = -0.68),主动与被动伸肘时的TSRT有显著性差异,与不同活动状态下脊髓运动神经元兴奋性调节有关
Levin等^[37](2018)	加拿大	33	肘	MAS DSRT TSRT	亚急性期与慢性期脑卒中患者间TSRT无显著性差异;拮抗肌和主动肌过度共同激活和交互抑制障碍可能与两组肌肉TSRT调节障碍有关

表1

参考文献 37

[1]	Report on Stroke Prevention and Treatment in China Writing Group. Brief report on stroke prevention and treatment in China, 2019[J]. Chin J Cerebrovasc Dis, 2020, 17(5):272-281.
[2]	URBAN P P, WOLF T, UEBELE M, et al. Occurence and clinical predictors of spasticity after ischemic stroke[J]. Stroke, 2010, 41(9):2016-2020. doi: 10.1161/STROKEAHA.110.581991
[3]	LI S, FRANCISCO G E, RYMER W Z. A new definition of poststroke spasticity and the interference of spasticity with motor recovery from acute to chronic stages[J]. Neurorehabil Neural Repair, 2021, 35(7):601-610. doi: 10.1177/15459683211011214
[4]	POON D M, HUI-CHAN C W. Hyperactive stretch reflexes, co-contraction, and muscle weakness in children with cerebral palsy[J]. Dev Med Child Neurol, 2009, 51(2):128-135. doi: 10.1111/dmcn.2009.51.issue-2
[5]	FOSANG A L, GALEA M P, MCCOY A T, et al. Measures of muscle and joint performance in the lower limb of children with cerebral palsy[J]. Dev Med Child Neurol, 2003, 45(10):664-670. doi: 10.1111/dmcn.2003.45.issue-10
[6]	BARNES M P, JOHNSON G R. Upper Motor Neurone Syndrome and Spasticity: Clinical Management and Neurophysiology [M]. 2nd ed. Cambridge: Cambridge University Press, 2008.
[7]	CHOI S, SHIN Y B, KIM S Y, et al. A novel sensor-based assessment of lower limb spasticity in children with cerebral palsy[J]. J Neuroeng Rehabil, 2018, 15(1):45. doi: 10.1186/s12984-018-0388-5
[8]	LI R Q, REN Y F, WU M L, et al. Research progress on the assessment of post-stroke spasticity[J]. Chin J Rehabil Med, 2018, 33(6):742-745.
[9]	MAYO M, DEFOREST B A, CASTELLANOS M, et al. Characterization of involuntary contractions after spinal cord injury reveals associations between physiological and self-reported measures of spasticity[J]. Front Integr Neurosci, 2017, 11:2.
[10]	EISEN A, ODUSOTE K. Amplitude of the F wave: a potential means of documenting spasticity[J]. Neurology, 1979, 9(1):1306-1309.
[11]	WUPUER S, YAMAMOTO T, KATAYAMA Y, et al. F-wave suppression induced by suprathreshold high-frequency repetitive trascranial magnetic stimulation in poststroke patients with increased spasticity[J]. Neuromodulation, 2013, 16(3):206-211. doi: 10.1111/j.1525-1403.2012.00520.x
[12]	UDBY BLICHER J, NIELSEN J F. Evidence of increased motoneuron excitability in stroke patients without clinical spasticity[J]. Neurorehabil Neural Repair, 2009, 23(1):14-16. doi: 10.1177/1545968308317439
[13]	LENG Y, LO W L A, HU C, et al. The effects of extracorporeal shock wave therapy on spastic muscle of the wrist joint in stroke survivors: evidence from neuromechanical analysis[J]. Front Neurosci, 2021, 14:580762. doi: 10.3389/fnins.2020.580762
[14]	PHADKE C P, ROBERTSON C T, CONDLIFFE E G, et al. Upper-extremity H-reflex measurement post-stroke: reliability and inter-limb differences[J]. Clin Neurophysiol, 2012, 123(8):1606-1615. doi: 10.1016/j.clinph.2011.12.012
[15]	KUMRU H, MURILLO N, SAMSO J V, et al. Reduction of spasticity with repetitive transcranial magnetic stimulation in patients with spinal cord injury[J]. Neurorehabil Neural Repair, 2010, 24(5):435-441. doi: 10.1177/1545968309356095
[16]	DAY B L, MARSDEN C D, OBESO J A, et al. Reciprocal inhibition between the muscles of the human forearm[J]. J Physiol, 1984, 349:519-534. doi: 10.1113/jphysiol.1984.sp015171
[17]	NAKASHIMA K, ROTHWELL J C, DAY B L, et al. Reciprocal inhibition between forearm muscles in patients with writer's cramp and other occupational cramps, symptomatic hemidystonia and hemiparesis due to stroke[J]. Brain, 1989, 112(3):681-697. doi: 10.1093/brain/112.3.681
[18]	FUJIWARA T, TSUJI T, HONAGA K, et al. Transcranial direct current stimulation modulates the spinal plasticity induced with patterned electrical stimulation[J]. Clin Neurophysiol, 2011, 122(9):1834-1837. doi: 10.1016/j.clinph.2011.02.002
[19]	BURKE D, WISSEL J, DONNAN G A. Pathophysiology of spasticity in stroke[J]. Neurology, 2013, 80(3 Suppl 2):S20-S26.
[20]	FUJIWARA T, HONAGA K, KAWAKAMI M, et al. Modulation of cortical and spinal inhibition with functional recovery of upper extremity motor function among patients with chronic stroke[J]. Restor Neurol Neurosci, 2015, 33(6):883-894.
[21]	LI S, FRANCISCO G E. New insights into the pathophysiology of post-stroke spasticity[J]. Front Hum Neurosci, 2015, 9:192. doi: 10.3389/fpsyg.2018.00192
[22]	SANGARI S, LUNDELL H, KIRSHBLUM S, et al. Residual descending motor pathways influence spasticity after spinal cord injury[J]. Ann Neurol, 2019, 86(1):28-41.
[23]	PISCITELLI D, TURPIN N A, SUBRAMANIAN S K, et al. Deficits in corticospinal control of stretch reflex thresholds in stroke: implications for motor impairment[J]. Clin Neurophysiol, 2020, 131(9):2067-2078. doi: 10.1016/j.clinph.2020.05.030
[24]	LI S, CHEN YT, FRANCISCO GE, et al. A unifying pathophysiological account for post-stroke spasticity and disordered motor control[J]. Front Neurol, 2019, 10:468. doi: 10.3389/fneur.2019.00468
[25]	VAN LITH B J H, COPPENS M J M, NONNEKES J, et al. Start react during gait initiation reveals differential control of muscle activation and inhibition in patients with corticospinal degeneration[J]. J Neurol, 2018, 265(11):2531-2539. doi: 10.1007/s00415-018-9027-0
[26]	CHOUDHURY S, SHOBHANA A, SINGH R, et al. The relationship between enhanced reticulospinal outflow and upper limb function in chronic stroke patients[J]. Neurorehabil Neural Repair, 2019, 33(5):375-383. doi: 10.1177/1545968319836233
[27]	MILLER D M, KLEIN C S, SURESH N L, et al. Asymmetries in vestibular evoked myogenic potentials in chronic stroke survivors with spastic hypertonia: evidence for a vestibulospinal role[J]. Clin Neurophysiol, 2014, 125(10):2070-2078. doi: 10.1016/j.clinph.2014.01.035
[28]	CHEN Y T, LI S, ZHOU P, et al. A startling acoustic stimulation (SAS)-TMS approach to assess the reticulospinal system in healthy and stroke subjects[J]. J Neurol Sci, 2019, 399:82-88. doi: 10.1016/j.jns.2019.02.018
[29]	RASOOL G, AFSHARIPOUR B, SURESH N L, et al. Spatial analysis of multichannel surface EMG in hemiplegic stroke[J]. IEEE Trans Neural Syst Rehabil Eng, 2017, 25(10):1802-1811. doi: 10.1109/TNSRE.7333
[30]	MISGELD B J, LUKEN M, HEITZMANN D, et al. Body-sensor-network-based spasticity detection[J]. IEEE J Biomed Health Inform, 2016, 20(3):748-755. doi: 10.1109/JBHI.2015.2477245
[31]	ELLIS M D, SCHUT I, DEWALD J P A. Flexion synergy overshadows flexor spasticity during reaching in chronic moderate to severe hemiparetic stroke[J]. Clin Neurophysiol, 2017, 128(7):1308-1314. doi: 10.1016/j.clinph.2017.04.028
[32]	YU S, CHEN Y, CAI Q, et al. A novel quantitative spasticity evaluation method based on surface electromyogram signals and Adaptive Neuro Fuzzy Inference System[J]. Front Neurosci, 2020, 14:462. doi: 10.3389/fnins.2020.00462
[33]	MULLICK A A, MUSAMPA N K, FELDMAN A G, et al. Stretch reflex spatial threshold measure discriminates between spasticity and rigidity[J]. Clin Neurophysiol, 2013, 124(4):740-751. doi: 10.1016/j.clinph.2012.10.008
[34]	AFZAL T, CHARDON M K, RYMER W Z, et al. Stretch reflex excitability in contralateral limbs of stroke survivors is higher than in matched controls[J]. J Neuroeng Rehabil, 2019, 16(1):154. doi: 10.1186/s12984-019-0623-8
[35]	BLANCHETTE A K, MULLICK A A, MOÏN-DARBARI K, et al. Tonic stretch reflex threshold as a measure of ankle plantar-flexor spasticity after stroke[J]. Phys Ther, 2016, 96(5):687-695. doi: 10.2522/ptj.20140243
[36]	TURPIN N A, FELDMAN A G, LEVIN M F. Stretch-reflex threshold modulation during active elbow movements in post-stroke survivors with spasticity[J]. Clin Neurophysiol, 2017, 128(10):1891-1897. doi: 10.1016/j.clinph.2017.07.411
[37]	LEVIN M F, SOLOMON J M, SHAH A, et al. Activation of elbow extensors during passive stretch of flexors in patients with post-stroke spasticity[J]. Clin Neurophysiol, 2018, 129(10):2065-2074. doi: 10.1016/j.clinph.2018.07.007