认知-运动双任务训练对脑卒中恢复期患者平衡功能和步态效果的随机对照试验

doi:10.3969/j.issn.1006-9771.2024.09.012

摘要/Abstract

摘要：

目的探讨认知-运动双任务训练对脑卒中后6个月内患者平衡功能和步态的影响。
方法 2022年5月至2023年4月，北京市普仁医院脑卒中恢复期患者68例，随机分为对照组和试验组，每组34例。两组均接受常规康复训练，在此基础上，对照组进行单任务步行训练，试验组进行认知-步行双任务训练，共4周。治疗前后进行Fugl-Meyer评定量表下肢部分(FMA-LE)评定，采用平衡测试仪测量单任务和双任务状态下静态平衡姿势轨迹和稳定极限；采用步态分析仪进行步态分析。
结果训练后，两组FMA-LE评分均显著增加(|t| > 10.239, P < 0.001)，两组间比较无显著性差异(P > 0.05)。单任务状态下，训练后两组平衡测试各参数均明显提高(|t| > 2.934, P < 0.01)，试验组闭眼运动轨迹长度明显长于对照组(t = 3.330, P = 0.001)；两组步态分析各参数均改善(|t| > 6.823, P < 0.05)，试验组步速优于对照组(t = 2.355, P = 0.022)。双任务状态下，训练后除对照组睁眼状态下运动轨迹长度无明显变化(P > 0.05)，两组其他平衡测试参数均改善(|t| > 2.472, P < 0.05)，两组间所有参数比较均无显著性差异(P > 0.05)；两组步态分析各参数均改善(|t| > 2.238, P < 0.05)，试验组步幅、步速优于对照组(t > 2.443, P < 0.05)。
结论认知-运动双任务训练可以有效改善恢复期脑卒中患者下肢运动功能、平衡功能和步行能力，在改善步态部分参数方面优于单任务步行训练。

关键词: 脑卒中, 认知, 运动, 双任务训练, 平衡, 步态, 随机对照试验

Abstract:

Objective To investigate the effect of cognitive-motor dual-task training on balance and gait in patients within six months post stroke.
Methods From May, 2022 to April, 2023, 68 stroke patients in Beijing Puren Hospital were randomly divided into control group (n = 34) and experimental group (n = 34). Both groups received conventional rehabilitation training. The control group received single-task walking training, and the experimental group received cognitive-walking dual-task training, in addition, for four weeks. They were assessed with Fugl-Meyer Assessment-Lower Extremities (FMA-LE) before and after training, and measured static balance posture trajectory, stability limits, gait analysis with Pro-kin and OptoGait in both single-task and dual-task states.
Results After training, the scores of FMA-UE increased in both groups (|t| > 10.239, P < 0.001), and no difference was found between two groups (P > 0.05). In single-task state, all the parameters of balance improved in both groups after training (|t| > 2.934, P < 0.01), and the length of movement locus with eyes closed was longer in the experimental group than in the control group (t = 3.330, P = 0.001); all the parameters of gait improved in both groups after training (|t| > 6.823, P < 0.05), and the walk speed was better in the experimental group than in the control group (t = 2.355, P = 0.022). In dual-task state, all the parameters of balance improved in both groups after training (|t| > 2.472, P < 0.05), expect the length of trajectory with eyes open in the control group (P > 0.05), and no difference was found in other parameters between two groups (P > 0.05); and all the parameters of gait improved in both groups after training (|t| > 2.238, P < 0.05), and the stride length and walk speed were better in the experimental group than in the control group (t > 2.443, P < 0.05).
Conclusion Cognitive-motor dual-task training can effectively improve lower limb motor function, balance function and walking ability in convalescent stroke patients, and it is superior to single-task walking training in improving some gait parameters.

Key words: stroke, congnition, motor, dual-task training, balance, gait, randomized contolled trial

中图分类号:

R743.3

李冬, 张皓, 刘楠, 王昕悦, 徐淼. 认知-运动双任务训练对脑卒中恢复期患者平衡功能和步态效果的随机对照试验[J]. 《中国康复理论与实践》, 2024, 30(9): 1082-1091.

LI Dong, ZHANG Hao, LIU Nan, WANG Xinyue, XU Miao. Effect of cognitive-motor dual-task training on balance function and gait in convalescent stroke patients: a randomized contolled trial[J]. Chinese Journal of Rehabilitation Theory and Practice, 2024, 30(9): 1082-1091.

图/表 6

表1

表2

表3

表4

表5

表6

参考文献 39

[1]	OHZUNO T, USUDA S. Cognitive-motor interference in post-stroke individuals and healthy adults under different cognitive load and task prioritization conditions[J]. J Phys Ther Sci, 2019, 31(3): 255-260. doi: 10.1589/jpts.31.255 pmid: 30936641
[2]	STURNIEKS D L, MENANT J, VALENZUELA M, et al. Effect of cognitive-only and cognitive-motor training on preventing falls in community-dwelling older people: protocol for the smart±step randomised controlled trial[J]. BMJ Open, 2019, 9(8): e029409. doi: 10.1136/bmjopen-2019-029409
[3]	阚超杰, 郭川, 朱仕哲, 等. 老年人在认知-平衡双任务下的皮质激活特征[J]. 中国康复理论与实践, 2023, 29(10): 1189-1194. doi: 10.3969/j.issn.1006-9771.2023.10.010
	KAN C J, GUO C, ZHU S Z, et al. Characteristics of cortical activation in older adults under cognition-balance dual tasks[J]. Chin J Rehabil Theory Pract, 2023, 29(10): 1189-1194.
[4]	AN H S, KIM D J. Effects of activities of daily living-based dual-task training on upper extremity function, cognitive function, and quality of life in stroke patients[J]. Osong Public Health Res Perspect, 2021, 12(5): 304-313.
[5]	丰有燕, 权宏磊, 郑洁皎. 可变优先级认知-运动双任务训练对老年脑卒中患者平衡功能的影响[J]. 中国康复医学杂志, 2022, 37(6): 754-759.
	FENG Y Y, QUAN H L, ZHENG J J. Effect of variable priority cognitive-motor dual-task training on balance function in elderly stroke patients[J]. Chin J Rehabil Med, 2022, 37(6): 754-759.
[6]	陈秀恩, 郑洁皎, 庄霁雯, 等. 范式和躯干控制双任务训练对老年脑卒中患者平衡功能的影响[J]. 中国康复医学杂志, 2020, 35(1): 45-49.
	CHEN X E, ZHENG J J, ZHUANG J W, et al. Effects of Stroop paradigm and trunk control dual task training on balance function in elderly stroke patients[J]. Chin J Rehabil Med, 2020, 35(1): 45-49.
[7]	SHU Y, BI M M, ZHOU T T, et al. Effect of dual-task training on gait and balance in stroke patients: an updated meta-analysis[J]. Am J Phys Med Rehabil, 2022, 101(12): 1148-1155.
[8]	EMBRECHTS E, MCGUCKIAN T B, ROGERS J M, et al. Cognitive and motor therapy after stroke is not superior to motor and cognitive therapy alone to improve cognitive and motor outcomes: new insights from a meta-analysis[J]. Arch Phys Med Rehabil, 2023, 104(10): 1720-1734.
[9]	CHIARAMONTE R, BONFIGLIO M, LEONFORTE P, et al. Proprioceptive and dual-task training: the key of stroke rehabilitation, a systematic review[J]. J Funct Morphol Kinesiol, 2022, 7(3): 53.
[10]	ZHOU Q, YANG H, ZHOU Q, et al. Effects of cognitive motor dual-task training on stroke patients: a RCT-based meta-analysis[J]. J Clin Neurosci, 2021, 92: 175-182. doi: 10.1016/j.jocn.2021.08.009 pmid: 34509248
[11]	EINSTAD M S, SALTVEDT I, LYDERSEN S, et al. Associations between post-stroke motor and cognitive function: a cross-sectional study[J]. BMC Geriatr, 2021, 21(1): 103. doi: 10.1186/s12877-021-02055-7 pmid: 33546620
[12]	中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组. 中国各类主要脑血管病诊断要点2019[J]. 中华神经科杂志, 2019, 52(9): 710-715.
	Chinese Society of Neurology, Chinese Stroke Society. Diagnostic criteria of cerebrovascular diseases in China (version 2019)[J]. Chin J Neurol, 2019, 52(9): 710-715.
[13]	张卫, 恽晓平, 于一宁. 大脑中动脉供血区不同梗死灶所致认知障碍的特点[J]. 中国康复理论与实践, 2014, 20(7): 651-655.
	ZHANG W, YUN X P, YU Y N. Correlation of cognitive impairment and areas of middle cerebral artery territory infarction[J]. Chin J Rehabil Theory Pract, 2014, 20(7): 651-655.
[14]	AL-YAHYA E, DAWES H, SMITH L, et al. Cognitive motor interference while walking: a systematic review and meta-analysis[J]. Neurosci Biobehav Rev, 2011, 35(3): 715-728.
[15]	PERRY J, GARRETT M, GRONLEY J K, et al. Classification of walking handicap in the stroke population[J]. Stroke, 1995, 26(6): 982-989. doi: 10.1161/01.str.26.6.982 pmid: 7762050
[16]	HUBER S K, KNOLS R H, ARNET P, et al. Motor-cognitive intervention concepts can improve gait in chronic stroke, but their effect on cognitive functions is unclear: a systematic review with meta-analyses[J]. Neurosci Biobehav Rev, 2022, 132: 818-837.
[17]	LEISMAN G, MOUSTAFA A A, SHAFIR T. Thinking, walking, talking: integratory motor and cognitive brain function[J]. Front Public Health, 2016, 4: 94. doi: 10.3389/fpubh.2016.00094 pmid: 27252937
[18]	ZANOTTO T, BERGAMIN M, ROMAN F, et al. Effect of exercise on dual-task and balance on elderly in multiple disease conditions[J]. Curr Aging Sci, 2014, 7(2): 115-136. doi: 10.2174/1874609807666140328095544 pmid: 24679341
[19]	GOBBO S, BERGAMIN M, SIEVERDES J C, et al. Effects of exercise on dual-task ability and balance in older adults: a systematic review[J]. Arch Gerontol Geriatr, 2014, 58(2): 177-187.
[20]	CHOI J H, KIM B R, HAN E Y, et al. The effect of dual-task training on balance and cognition in patients with subacute post-stroke[J]. Ann Rehabil Med, 2015, 39(1): 81-90. doi: 10.5535/arm.2015.39.1.81 pmid: 25750876
[21]	GHAI S, GHAI I, EFFENBERG A O. Effects of dual tasks and dual-task training on postural stability: a systematic review and meta-analysis[J]. Clin Interv Aging, 2017, 12: 557-577. doi: 10.2147/CIA.S125201 pmid: 28356727
[22]	蔡庆, 谢丽君, 赵绿玉, 等. 基于反重力跑台训练系统的双重运动任务训练对脑卒中患者平衡功能的效果[J]. 中国康复理论与实践, 2018, 24(11): 1315-1319.
	CAI Q, XIE L J, ZHAO L Y, et al. Effects of dual-task motor training with anti-gravity treadmill on motor and balance after stroke[J]. Chin J Rehabil Theory Pract, 2018, 24(11): 1315-1319.
[23]	TSANG C S L, MILLER T, PANG M Y C. Association between fall risk and assessments of single-task and dual-task walking among community-dwelling individuals with chronic stroke: a prospective cohort study[J]. Gait Posture, 2022, 93: 113-118. doi: 10.1016/j.gaitpost.2022.01.019 pmid: 35134650
[24]	CHOI J Y, YOO T, BURCAL C J, et al. Dual-task differences in individuals with chronic ankle instability: a systematic review with meta-analysis[J]. Gait Posture, 2023, 106: 28-33. doi: 10.1016/j.gaitpost.2023.08.013 pmid: 37639962
[25]	URSIN M H, BERGLAND A, FURE B, et al. Gait and balance one year after stroke; relationships with lesion side, subtypes of cognitive impairment and neuroimaging findings: a longitudinal, cohort study[J]. Physiotherapy, 2019, 105(2): 254-261.
[26]	VERSTRAETEN S, MARK R E, DIELEMAN J, et al. Motor impairment three months post stroke implies a corresponding cognitive deficit[J]. J Stroke Cerebrovasc Dis, 2020, 29(10): 105-119.
[27]	LEE H C, HUANG C L, HO S H, et al. The effect of a virtual reality game intervention on balance for patients with stroke: a randomized controlled trial[J]. Games Health J, 2017, 6(5): 303-311.
[28]	PANG M Y C, YANG L, OUYANG H, et al. Dual-task exercise reduces cognitive-motor interference in walking and falls after stroke[J]. Stroke, 2018, 49(12): 2990-2998. doi: 10.1161/STROKEAHA.118.022157 pmid: 30571419
[29]	RAVI D K, GWERDER M, KÖNIG IGNASIAK N, et al. Revealing the optimal thresholds for movement performance: a systematic review and meta-analysis to benchmark pathological walking behaviour[J]. Neurosci Biobehav Rev, 2020, 108: 24-33. doi: S0149-7634(19)30395-1 pmid: 31639377
[30]	WONSETLER E C, BOWDEN M G. A systematic review of mechanisms of gait speed change post-stroke. Part 1: spatiotemporal parameters and asymmetry ratios[J]. Top Stroke Rehabil, 2017, 24(6): 435-446. doi: 10.1080/10749357.2017.1285746 pmid: 28220715
[31]	BOGEN B, MOE-NILSSEN R, RANHOFF A H, et al. The walk ratio: investigation of invariance across walking conditions and gender in community-dwelling older people[J]. Gait Posture, 2018, 61: 479-482. doi: S0966-6362(18)30101-2 pmid: 29494821
[32]	CHISHOLM A E, MAKEPEACE S, INNESS E L, et al. Spatial-temporal gait variability poststroke: variations in measurement and implications for measuring change[J]. Arch Phys Med Rehabil, 2014, 95(7): 1335-1341.
[33]	FISSLER P, KÜSTER O, SCHLEE W, et al. Novelty interventions to enhance broad cognitive abilities and prevent dementia: synergistic approaches for the facilitation of positive plastic change[J]. Prog Brain Res, 2013, 207: 403-434. doi: 10.1016/B978-0-444-63327-9.00017-5 pmid: 24309264
[34]	王海静, 李庆雯. 双任务训练治疗脑卒中患者平衡障碍的研究进展[J]. 中国康复理论与实践, 2019, 25(9): 1026-1031. doi: 10.3969/j.issn.1006-9771.2019.09.007
	WANG H J, LI Q W. Advances in dual-task training for balance dysfunction after stroke (review)[J]. Chin J Rehabil Theory Pract, 2019, 25(9): 1026-1031.
[35]	MAIER M, BALLESTER B R, VERSCHURE P F M J. Principles of neurorehabilitation after stroke based on motor learning and brain plasticity mechanisms[J]. Front Syst Neurosci, 2019, 13: 74. doi: 10.3389/fnsys.2019.00074 pmid: 31920570
[36]	BAMIDIS P D, VIVAS A B, STYLIADIS C, et al. A review of physical and cognitive interventions in aging[J]. Neurosci Biobehav Rev, 2014, 44: 206-220. doi: 10.1016/j.neubiorev.2014.03.019 pmid: 24705268
[37]	PLUMMER P, ZUKOWSKI L A, FELD J A, et al. Cognitive-motor dual-task gait training within 3 years after stroke: a randomized controlled trial[J]. Physiother Theory Pract, 2022, 38(10): 1329-1344.
[38]	KIM K J, KIM K H. Progressive treadmill cognitive dual-task gait training on the gait ability in patients with chronic stroke[J]. J Exerc Rehabil, 2018, 14(5): 821-828.
[39]	RAICHLEN D A, BHARADWAJ P K, NGUYEN L A, et al. Effects of simultaneous cognitive and aerobic exercise training on dual-task walking performance in healthy older adults: results from a pilot randomized controlled trial[J]. BMC Geriatr, 2020, 20(1): 83. doi: 10.1186/s12877-020-1484-5 pmid: 32122325

组别	n	性别/n		年龄/岁	卒中类型/n		病程/d	偏瘫侧/n		MMSE	Brunnstrom分期
组别	n	男	女	年龄/岁	脑梗死	脑出血	病程/d	左	右	MMSE	Brunnstrom分期
对照组	34	19	15	74.76±7.98	30	4	108.53±19.86	29	5	28.09±1.58	3.79±0.73
试验组	34	23	11	72.09±8.48	32	2	111.29±25.51	32	2	28.24±1.30	3.85±0.74
χ²/t值		0.996		1.570			0.499			0.418	0.372
P值		0.318		0.221	0.673^a		0.620	0.427^a		0.677	0.743

组别	n	测试	$\bar{x}±s$	t值	P值
对照组	34	前测	27.44±1.86	-20.157	< 0.001
		后测	30.24±1.50
试验组	34	前测	26.85±2.79	-10.239	< 0.001
		后测	29.65±1.94
治疗前两组均值差			0.59±3.35	-1.923	0.310
治疗后两组均值差			0.59±2.45	0.416	0.679

指标		组别	n	测试	$\bar{x}±s$	t值	P值
运动椭圆面积/mm²	睁眼	对照组	34	前测	337.74±134.28	4.769	< 0.001
				后测	272.26±126.00
		试验组	34	前测	344.65±126.80	5.258	< 0.001
				后测	273.94±95.47
		治疗前两组均值差			-6.91±184.69	0.218	0.828
		治疗后两组均值差			-1.68±158.08	0.062	0.951
	闭眼	对照组	34	前测	625.53±224.93	9.445	< 0.001
				后测	473.76±183.40
		试验组	34	前测	630.26±199.08	4.344	< 0.001
				后测	509.29±171.42
		治疗前两组均值差			-4.73±300.38	0.092	0.927
		治疗后两组均值差			-35.53±251.04	0.825	0.412
运动轨迹长度/mm	睁眼	对照组	34	前测	457.44±144.48	5.517	< 0.001
				后测	375.85±111.45
		试验组	34	前测	486.21±167.36	5.773	< 0.001
				后测	389.41±122.01
		治疗前两组均值差			-28.77±221.10	0.759	0.451
		治疗后两组均值差			-13.56±165.24	0.478	0.634
	闭眼	对照组	34	前测	800.59±242.02	8.905	< 0.001
				后测	543.91±158.58
		试验组	34	前测	760.62±205.12	2.934	0.006
				后测	700.91±224.53
		治疗前两组均值差			39.97±317.25	-0.735	0.465
		治疗后两组均值差			-157.00±274.87	3.330	0.001
稳定极限/%		对照组	34	前测	58.66±12.96	-37.684	< 0.001
				后测	64.32±11.17
		试验组	34	前测	55.71±11.04	-17.975	< 0.001
				后测	62.10±13.43
		治疗前两组均值差			2.95±17.02	-1.011	0.316
		治疗后两组均值差			2.22±17.46	-0.741	0.461

指标		组别	n	测试	$\bar{x}±s$	t值	P值
运动椭圆面积/mm²	睁眼	对照组	34	前测	479.41±201.50	3.193	0.003
				后测	429.88±139.40
		试验组	34	前测	464.21±188.33	6.126	< 0.001
				后测	402.62±153.47
		治疗前两组均值差			15.20±245.02	-0.321	0.749
		治疗后两组均值差			27.26±207.33	-0.767	0.446
	闭眼	对照组	34	前测	785.06±140.47	2.472	0.019
				后测	688.88±222.30
		试验组	34	前测	876.29±284.16	8.491	< 0.001
				后测	637.76±183.80
		治疗前两组均值差			-91.23±316.98	1.152	0.253
		治疗后两组均值差			51.12±288.34	-1.033	0.305
运动轨迹长度/mm	睁眼	对照组	34	前测	536.06±140.47	1.572	0.125
				后测	520.12±149.56
		试验组	34	前测	594.50±193.22	5.110	< 0.001
				后测	537.38±162.72
		治疗前两组均值差			-58.44±238.88	1.427	0.158
		治疗后两组均值差			-17.26±221.01	0.455	0.650
	闭眼	对照组	34	前测	783.65±226.68	3.622	< 0.001
				后测	698.32±187.84
		试验组	34	前测	891.97±271.12	7.352	< 0.001
				后测	742.68±229.89
		治疗前两组均值差			-108.31±353.40	1.187	0.078
		治疗后两组均值差			-44.36±296.87	0.871	0.387
稳定极限/%		对照组	34	前测	40.82±12.74	-19.357	< 0.001
				后测	53.14±12.26
		试验组	34	前测	41.99±14.38	-9.568	< 0.001
				后测	50.14±14.72
		治疗前两组均值差			-1.17±19.21	0.354	0.725
		治疗后两组均值差			3.00±19.16	-0.913	0.365

指标	组别	n	测试	$\bar{x}±s$	t值	P值
步幅/cm	对照组	34	前测	89.77±9.84	-7.333	< 0.001
			后测	92.98±9.71
	试验组	34	前测	91.29±12.08	-7.724	< 0.001
			后测	95.91±11.35
	治疗前两组均值差			-1.52±15.58	0.566	0.573
	治疗后两组均值差			-2.93±14.94	1.146	0.256
步行周期/s	对照组	34	前测	1.30±0.10	6.823	< 0.001
			后测	1.23±0.09
	试验组	34	前测	1.34±0.16	8.772	< 0.001
			后测	1.21±0.11
	治疗前两组均值差			-0.04±0.19	1.295	0.200
	治疗后两组均值差			0.02±0.14	-1.166	0.248
步频/min^-1	对照组	34	前测	77.37±6.35	-7.187	< 0.001
			后测	81.39±6.08
	试验组	34	前测	75.36±7.92	-10.225	< 0.001
			后测	83.47±7.23
	治疗前两组均值差			2.01±10.15	-1.155	0.252
	治疗后两组均值差			-2.08±9.45	1.283	0.204
步速/(m•s^-1)	对照组	34	前测	0.69±0.07	-11.673	< 0.001
			后测	0.75±0.08
	试验组	34	前测	0.68±0.08	-17.782	< 0.001
			后测	0.79±0.06
	治疗前两组均值差			0.01±0.11	-0.524	0.602
	治疗后两组均值差			-0.04±0.10	2.355	0.022