痉挛型脑瘫神经肌肉功能对步态的影响及针对性干预的研究进展

doi:10.3969/j.issn.1006-9771.2021.03.010

《中国康复理论与实践》 ›› 2021, Vol. 27 ›› Issue (3): 310-315.doi: 10.3969/j.issn.1006-9771.2021.03.010

痉挛型脑瘫神经肌肉功能对步态的影响及针对性干预的研究进展

王仪,张跃()

南京医科大学附属儿童医院康复医学科，江苏南京市 210008

收稿日期:2020-09-29 修回日期:2021-01-08 出版日期:2021-03-25 发布日期:2021-04-02
通讯作者: 张跃 E-mail:feiyuezhang@126.com
作者简介:王仪(1995-)，女，汉族，江苏连云港市人，硕士研究生，主要研究方向：儿童康复|张跃(1961-)，男，汉族，主任医师，主要研究方向：儿童康复。
基金资助:
国家自然科学基金青年基金项目(81401864);江苏省科教强卫青年人才项目(QNRC2016089);江苏省妇幼保健协会课题(FYX201907)

Advance in Neuromuscular Function of Spastic Cerebral Palsy for Gait and Targeted Intervention (review)

Yi WANG,Yue ZHANG()

Department of Rehabilitation Medicine, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu 210008, China

Received:2020-09-29 Revised:2021-01-08 Published:2021-03-25 Online:2021-04-02
Contact: Yue ZHANG E-mail:feiyuezhang@126.com
Supported by:
National Natural Science Foundation of China (Youth)(81401864);Young Talents of Jiangsu Province Science and Education Strengthening Health Care(QNRC2016089);Project of Jiangsu Province Maternal and Child Health Care Association(FYX201907)

摘要/Abstract

摘要：

脑瘫作为脑损伤导致的运动和姿势发育障碍性疾病，符合上运动神经元损伤影响神经肌肉功能导致步态异常的普遍特点，又有它作为发育障碍性疾病的自身属性。本文概述目前对痉挛型脑瘫患者神经肌肉组织结构和功能表现的研究结果，结合步态周期说明他们的神经肌肉功能障碍和异常步态间的特定关系，并在此基础上阐述针对性的干预措施，旨在改善脑瘫的异常步态和长期预后。

关键词: 脑性瘫痪, 痉挛型, 步态, 干预, 综述

Abstract:

Cerebral palsy is a motor and postural developmental disorder caused by brain injury. This disease not only shows the common features of upper motor neurons impairment affecting neuromuscular function and leading to gait abnormality, but also has its unique symptoms as a developmental disorder. This paper summarized the present research of neuromuscular tissue structure and functional performance in patients with spastic cerebral palsy, and explained the specific relationship between neuromuscular dysfunction and abnormal gait in patients with spastic cerebral palsy, according to gait cycle. Based on above, the targeted intervention measures are elaborated. It is aimed to improve the abnormal gait and achieve long-term prognosis of cerebral palsy.

Key words: cerebral palsy, spastic, gait, intervention, review

中图分类号:

R742.3

王仪,张跃. 痉挛型脑瘫神经肌肉功能对步态的影响及针对性干预的研究进展[J]. 《中国康复理论与实践》, 2021, 27(3): 310-315.

Yi WANG,Yue ZHANG. Advance in Neuromuscular Function of Spastic Cerebral Palsy for Gait and Targeted Intervention (review)[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2021, 27(3): 310-315.

图/表 2

表1

表2

参考文献 54

1	唐久来,秦炯,邹丽萍,等. 中国脑性瘫痪康复指南(2015):第一部分[J]. 中国康复医学杂志, 2015, 30(7): 747-754.
	Tang J L, Qin J, Zou L P, et al. Guidelines for rehabilitation of cerebral palsy in China (Part1) [J]. Chin J Rehabil Med, 2015, 30(7): 747-754.
2	李晓捷,邱洪斌,姜志梅,等. 中国十二省市小儿脑性瘫痪流行病学特征[J]. 中华实用儿科临床杂志, 2018, 33(5): 378-383.
	Li X J, Qiu H B, Jiang Z M, et al. Epidemiological characteristics of cerebral palsy in twelve provinces in China [J]. Chin J Appl Clin Pediatr, 2018, 33(5): 378-383.
3	Surveillance of Cerebral Palsy in Europe. Surveillance of cerebral palsy in Europe: a collaboration of cerebral palsy surveys and registers. Surveillance of Cerebral Palsy in Europe (SCPE) [J]. Dev Med Child Neurol, 2000, 42(12): 816-824.
4	Cadwgan J, Goodwin J, Fairhurst C. Fifteen-minute consultation: modern-day art and science of managing cerebral palsy [J]. Arch Dis Child Educ Pract Ed, 2019, 104(2): 66-73.
5	Arnfield E, Guzzetta A, Boyd R. Relationship between brain structure on magnetic resonance imaging and motor outcomes in children with cerebral palsy: a systematic review [J]. Res Dev Disabil, 2013, 34(7): 2234-2250.
6	McDowell B. The Gross Motor Function Classification System: expanded and revised [J]. Dev Med Child Neurol, 2008, 50(10): 725.
7	Nielsen J B, Crone C, Hultborn H. The spinal pathophysiology of spasticity: from a basic science point of view [J]. Acta Physiol (Oxf), 2007, 189(2): 171-180.
8	Michelsen J S, Lund M C, Alkjaer T, et al. Wearable electromyography recordings during daily life activities in children with cerebral palsy [J]. Dev Med Child Neurol, 2020, 62(6): 714-722.
9	Ito J, Araki A, Tanaka H, et al. Muscle histopathology in spastic cerebral palsy [J]. Brain Dev, 1996, 18(4): 299-303.
10	Smith L R, Pichika R, Meza R C, et al. Contribution of extracellular matrix components to the stiffness of skeletal muscle contractures in patients with cerebral palsy [J]. [ahead of print]. Connect Tissue Res, 2019. doi: 10.1080/03008207.2019. 1694011. doi: 10.1080/03008207.2019. 1694011
11	Smith L R, Chambers H G, Subramaniam S, et al. Transcriptional abnormalities of hamstring muscle contractures in children with cerebral palsy [J]. PLoS One, 2012, 7(8): e40686.
12	Fedrizzi E, Avanzini G, Crenna P, et al. Motor development in children [M]. New York: Libbey, 1994: 103-118.
13	Sanger T D, Chen D, Delgado M R, et al. Definition and classification of negative motor signs in childhood [J]. Pediatrics, 2006, 118(5): 2159-2167.
14	张忠良,史惟,邓红岩,等. 痉挛型双瘫与正常儿童下肢肌力对照分析[J]. 中国康复医学杂志, 2015, 30(9): 915-918.
	Zhang Z L,Shi W, Deng H Y, et al. Chin J Rehabil Med, 2015, 30(9): 915-918.
15	Pitcher C A, Elliott C M, Valentine J P, et al. Muscle morphology of the lower leg in ambulant children with spastic cerebral palsy [J]. Muscle Nerve, 2018, 58(6): 818-823.
16	Smith L R, Lee K S, Ward S R, et al. Hamstring contractures in children with spastic cerebral palsy result from a stiffer extracellular matrix and increased in vivo sarcomere length [J]. J Physiol, 2011, 589(Pt 10): 2625-2639.
17	Rose J, McGill K C. Neuromuscular activation and motor-unit firing characteristics in cerebral palsy [J]. Dev Med Child Neurol, 2005, 47(5): 329-336.
18	Multani I, Manji J, Hastings-Ison T, et al. Botulinum toxin in the management of children with cerebral palsy [J]. Paediatr Drugs, 2019, 21(4): 261-281.
19	Kraus T, Gegenleitner K, Svehlik M, et al. Long-term therapy with intrathecal baclofen improves quality of life in children with severe spastic cerebral palsy [J]. Eur J Paediatr Neurol, 2017, 21(3): 565-569.
20	Campbell M, Varley-Campbell J, Fulford J, et al. Effect of immobilisation on neuromuscular function in vivo in humans: a systematic review [J]. Sports Med, 2019, 49(6): 931-950.
21	何晓清,徐永清,杨曦. 痉挛性脑性瘫痪的精细化诊疗[J]. 中国修复重建外科杂志, 2019, 33(12): 1584-1588.
	He X Q, Xu Y Q, Yang X. Precise diagnosis and treatment of spastic cerebral palsy [J]. Chin J Repar Reconstr Surg, 2019, 33(12): 1584-1588.
22	Dayanidhi S, Dykstra P B, Lyubasyuk V, et al. Reduced satellite cell number in situ in muscular contractures from children with cerebral palsy [J]. J Orthop Res, 2015, 33(7): 1039-1045.
23	Domenighetti A A, Mathewson M A, Pichika R, et al. Loss of myogenic potential and fusion capacity of muscle stem cells isolated from contractured muscle in children with cerebral palsy [J]. Am J Physiol Cell Physiol, 2018, 315(2): C247-257.
24	Corvelyn M, De Beukelaer N, Duelen R, et al. Muscle microbiopsy to delineate stem cell involvement in young patients: a novel approach for children with cerebral palsy [J]. Front Physiol, 2020, 11: 945.
25	Barrett R S, Lichtwark G A. Gross muscle morphology and structure in spastic cerebral palsy: a systematic review [J]. Dev Med Child Neurol, 2010, 52(9): 794-804.
26	Kruse A, Schranz C, Tilp M, et al. Muscle and tendon morphology alterations in children and adolescents with mild forms of spastic cerebral palsy [J]. BMC Pediatr, 2018, 18(1): 156.
27	van Campenhout A, Bar-On L. Knee contracture in children with cerebral palsy: association with muscle lengths [J]. Dev Med Child Neurol, 2018, 60(4): 335-336.
28	Cloodt E, Wagner P, Lauge-Pedersen H, et al. Knee and foot contracture occur earliest in children with cerebral palsy: a longitudinal analysis of 2,693 children [J]. [ahead of print]. Acta Orthop, 2020. doi: 10.1080/17453674.2020.1848154. doi: 10.1080/17453674.2020.1848154
29	Lance J W. Symposium synopsis [M]//
	Feldman R G, Young R R, Koella W P. Spasticity: Disordered Motor Control [M]. Chicago: Year Book Medical Publishers, 1980: 485-494.
30	钟冬灵,杨璐萍,胡益娟,等. 超声弹性成像在肌肉痉挛评定中的应用进展[J]. 中国康复理论与实践, 2018, 24(7): 815-818.
	Zhong D L, Yang L P, Hu Y J, et al. Advance in ultrasound elastography for evaluation of spasticity (review) [J]. Chin J Rehabil Theory Pract, 2018, 24(7): 815-818.
31	Lee S S, Gaebler-Spira D, Zhang L Q, et al. Use of shear wave ultrasound elastography to quantify muscle properties in cerebral palsy [J]. Clin Biomech (Bristol, Avon), 2016, 31: 20-28.
32	Willerslev-Olsen M, Lorentzen J, Sinkjaer T, et al. Passive muscle properties are altered in children with cerebral palsy before the age of 3 years and are difficult to distinguish clinically from spasticity [J]. Dev Med Child Neurol, 2013, 55(7): 617-623.
33	Policy J F, Torburn L, Rinsky L A, et al. Electromyographic test to differentiate mild diplegic cerebral palsy and idiopathic toe-walking [J]. J Pediatr Orthop, 2001, 21(6): 784-789.
34	Thelen D D, Riewald S A, Asakawa D S, et al. Abnormal coupling of knee and hip moments during maximal exertions in persons with cerebral palsy [J]. Muscle Nerve, 2003, 27(4): 486-493.
35	Goudriaan M, Shuman B R, Steele K M, et al. Non-neural muscle weakness has limited influence on complexity of motor control during gait [J]. Front Hum Neurosci, 2018, 12: 5.
36	Steele K M, Munger M E, Peters K M, et al. Repeatability of electromyography recordings and muscle synergies during gait among children with cerebral palsy [J]. Gait Posture, 2019, 67: 290-295.
37	辜禹,陈楠,刘倩,等. 肌肉协同理论在小儿脑性瘫痪康复评定中的应用进展[J]. 中国康复理论与实践, 2020, 26(6): 673-677.
	Gu Y, Chen N, Liu Q, et al. Advance of muscle synergy theory in rehabilitation assessment for children with cerebral palsy (review) [J]. Chin J Rehabil Theory Pract, 2020, 26(6): 673-677.
38	Steele K M, Rozumalski A, Schwartz M H. Muscle synergies and complexity of neuromuscular control during gait in cerebral palsy [J]. Dev Med Child Neurol, 2015, 57(12): 1176-1182.
39	Bekius A, Bach M M, van der Krogt M M, et al. Muscle synergies during walking in children with cerebral palsy: a systematic review[J]. Front Physiol, 2020, 11: 632.
40	Rüber T, Schlaug G, Lindenberg R. Compensatory role of the cortico-rubro-spinal tract in motor recovery after stroke [J]. Neurology, 2012, 79(6): 515-522.
41	Miller A, Heckert K D, Davis B A. 3分钟骨骼肌肉和周围神经检查[M]. 杨荣森,译. 北京:化学工业出版社, 2012: 168.
	Miller A, Heckert K D, Davis B A. The3-Minute Musculoskeletal & Peripheral Nerve Exam [M]. Yang R S, trans. Beijing: Chemical Industry Press, 2012: 168.
42	van Vulpen L F, de Groot S, Rameckers E A A, et al. Improvements in muscle strength are associated with improvements in walking capacity in young children with cerebral palsy: a secondary analysis [J]. Pediatr Phys Ther, 2021, 33(1): 24-30.
43	Willerslev-Olsen M, Petersen T H, Farmer S F, et al. Gait training facilitates central drive to ankle dorsiflexors in children with cerebral palsy [J]. Brain, 2015, 138(Pt 3): 589-603.
44	Ryan J M, Cassidy E E, Noorduyn S G, et al. Exercise interventions for cerebral palsy [J]. Cochrane Database Syst Rev, 2017, 6(6): Cd011660.
45	Mooney J A, Rose J. A scoping review of neuromuscular electrical stimulation to improve gait in cerebral palsy: the arc of progress and future strategies [J]. Front Neurol, 2019, 10: 887.
46	Bland D C, Prosser L A, Bellini L A, et al. Tibialis anterior architecture, strength, and gait in individuals with cerebral palsy [J]. Muscle Nerve, 2011, 44(4): 509-517.
47	Steele K M, Demers M S, Schwartz M H, et al. Compressive tibiofemoral force during crouch gait [J]. Gait Posture, 2012, 35(4): 556-560.
48	Østergaard C S, Pedersen N S A, Thomasen A, et al. Pain is frequent in children with cerebral palsy and negatively affects physical activity and participation [J]. Acta Paediatr, 2021, 110(1): 301-306.
49	高睿琦,唐成林,曹净,等. 电针对失神经骨骼肌萎缩大鼠胰岛素样生长因子1、肌肉生长抑制素及肌卫星细胞增殖的影响[J]. 中国康复理论与实践, 2016, 22(11): 1259-1263.
	Gao R Q, Tang C L, Cao J, et al. Effects of electroacupuncture on insulin-like growth factor-1, myostatin and satellite-cell proliferation in rats with denervated skeletal muscle atrophy [J]. Chin J Rehabil Theory Pract, 2016, 22(11): 1259-1263.
50	刘开鑫,巩朝阳,向高,等. A型肉毒毒素治疗神经系统疾病的研究进展[J]. 中国康复理论与实践, 2019, 25(9): 1038-1042.
	Liu K X, Gong C Y, Xiang G, et al. Advance of Botulinum toxin a in neurological disorders (review) [J]. Chin J Rehabil Theory Pract, 2019, 25(9): 1038-1042.
51	Williams S A, Elliott C, Valentine J, et al. Combining strength training and Botulinum neurotoxin intervention in children with cerebral palsy: the impact on muscle morphology and strength [J]. Disabil Rehabil, 2013, 35(7): 596-605.
52	Shuman B R, Goudriaan M, Desloovere K, et al. Muscle synergies demonstrate only minimal changes after treatment in cerebral palsy [J]. J Neuroeng Rehabil, 2019, 16(1): 46.
53	Eken M M, Braendvik S M, Bardal E M, et al. Lower limb muscle fatigue during walking in children with cerebral palsy [J]. Dev Med Child Neurol, 2019, 61(2): 212-218.
54	Noorkoiv M, Lavelle G, Theis N, et al. Predictors of walking efficiency in children with cerebral palsy: lower-body joint angles, moments, and power [J]. Phys Ther, 2019, 99(6): 711-720.

步态		发生周期(%)	髂腰肌	臀大肌	臀中肌	腘绳肌	股四头肌	胫骨前肌	腓肠肌
站立期60%	足跟触地	0~2	-	离心+	离心+	离心+	离心+	离心+	-
	足放平	3~10	-	-	离心+	离心+	离心+	离心+	-
	支撑中期	10~30	-	-	离心+	-	-	-	离心+
	足跟离地	30~50	向心+	-	离心+	-	-	-	向心+
	足趾离地	50~60	向心+	-	-	-	离心+	-	向心+
摆动期40%	摆动早期	60~73	向心+	-	-	离心+	离心+	向心+	-
	摆动中期	73~87	向心+	-	-	离心+	-	向心+	-
	摆动末期	87~100	-	-	-	离心+	-	向心+	-

缺陷	下肢主要肌群	步态周期阶段及事件	异常步态表现
肌无力	臀大肌、腘绳肌	足跟触地至支撑期	髋关节伸展不足
	髂腰肌	足跟离地至摆动末期	摆动期髋关节屈曲减少
	臀中肌	单下肢支撑期	对侧骨盆下降及同侧躯干倾斜
	股四头肌	足跟触地至支撑期	膝关节伸展不足
	胫骨前肌	足跟触地摆动期	拍打步态垂足
	腓肠肌	摆动前期	协助屈膝减少
肌肉肌腱单元生长受限及短缩	髂腰肌	站立期	髋关节屈曲增加
	臀中肌	整个步态周期	髋内旋、内八步态
	内收肌	整个步态周期	剪刀步态
	腘绳肌	摆动末期及站立期	膝关节屈曲增加
	腓肠肌、比目鱼肌	整个步态周期	尖足
	胫骨后肌	整个步态周期	马蹄内翻足
痉挛及高肌张力	髂腰肌	足跟离地进入摆动期	髋关节伸展减少
	臀中肌	整个步态周期	髋内旋
	内收肌	整个步态周期	剪刀步态
	股直肌	站立期足跟离地至足趾离地	髋关节伸展减少膝关节屈曲减少
	腓肠肌、比目鱼肌	摆动末期及站立期	尖足
选择性运动控制减少	膝髋屈肌共同激活	摆动末期足跟触地前	膝关节屈曲增加
	膝髋伸展向屈曲过渡减慢	摆动期	拖曳，摆动期足底与地面间隙减少
	跖屈肌与膝伸肌共同激活	摆动末期	前脚掌先着地(尖足)

[1]	邵伟婷, 雷江华. 反应中断再定向干预孤独症谱系障碍儿童刻板语言的效果：Scoping综述[J]. 《中国康复理论与实践》, 2024, 30(1): 10-20.
[2]	王航宇, 葛可可, 范永红, 都丽露, 邹敏, 封磊. 基于ICD-11和ICF主动式音乐疗法改善认知障碍老年人认知功能的系统综述[J]. 《中国康复理论与实践》, 2024, 30(1): 36-43.
[3]	闻嘉宁, 金秋艳, 张琦, 李杰, 司琦. 认知参与型身体活动对发展儿童青少年执行功能的效果：基于ICF的系统综述[J]. 《中国康复理论与实践》, 2024, 30(1): 44-53.
[4]	葛可可, 范永红, 王航宇, 都丽露, 李长江, 邹敏. 失眠老年人正念干预健康效益的系统综述[J]. 《中国康复理论与实践》, 2024, 30(1): 54-60.
[5]	张婧雅, 邹敏, 孙宏伟, 孙昌隆, 朱峻同. 听障儿童青少年焦虑或抑郁情绪心理干预效果的系统综述[J]. 《中国康复理论与实践》, 2023, 29(9): 1004-1011.
[6]	王俊宇, 杨永, 袁逊, 谢婷, 庄洁. 高强度间歇训练对健康儿童青少年执行功能效果的系统综述[J]. 《中国康复理论与实践》, 2023, 29(9): 1012-1020.
[7]	魏晓微, 杨剑, 魏春艳. 特殊教育学校孤独症谱系障碍儿童参与适应性瑜伽活动的心理与行为效益的系统综述[J]. 《中国康复理论与实践》, 2023, 29(9): 1021-1028.
[8]	杨亚茹, 杨剑. 基于WHO-HPS架构学校身体活动相关健康服务及其健康效益：系统综述的系统综述[J]. 《中国康复理论与实践》, 2023, 29(9): 1040-1047.
[9]	史佳伟, 李凌宇, 杨浩杰, 王琴潞, 邹海欧. 预康复对全膝关节置换术后患者的有效性：系统综述的系统综述[J]. 《中国康复理论与实践》, 2023, 29(9): 1057-1064.
[10]	赵盼超, 纪仲秋, 姜桂萍, 文蕊香. 不同任务干扰对儿童早期步态特征和任务成本的影响[J]. 《中国康复理论与实践》, 2023, 29(9): 1072-1082.
[11]	胡晓诗, 张琦, 岳青, 梁艳华, 李晓松, 冯啊美, 张燕庆. 矫形弹力绷带对痉挛性偏瘫脑性瘫痪患儿步态对称性和步行能力的效果[J]. 《中国康复理论与实践》, 2023, 29(9): 1083-1089.
[12]	王少璞, 杨亚茹, 邱卓英, 杨剑, 姚梅林, 孙宏伟, 邹敏. 智力与发展性残疾儿童心理健康服务：基于WHO-FICs的研究[J]. 《中国康复理论与实践》, 2023, 29(9): 993-1003.
[13]	张意彬, 吕杰, 喻洪流. 基于模糊逻辑算法的智能膝关节假肢步态相位识别[J]. 《中国康复理论与实践》, 2023, 29(8): 896-902.
[14]	蒋长好, 黄辰, 高晓妍, 戴元富, 赵国明. 神经反馈训练对老年人认知功能效果的系统综述[J]. 《中国康复理论与实践》, 2023, 29(8): 903-909.
[15]	魏晓微, 杨剑, 魏春艳, 贺启令. 学校环境下适应性体育课程促进智力与发展性残疾儿童心理运动发展的系统综述[J]. 《中国康复理论与实践》, 2023, 29(8): 910-918.

痉挛型脑瘫神经肌肉功能对步态的影响及针对性干预的研究进展

Advance in Neuromuscular Function of Spastic Cerebral Palsy for Gait and Targeted Intervention (review)

RichHTML

PDF (PC)

可视化

摘要/Abstract

引用本文

使用本文

图/表 2

参考文献 54

相关文章 15

Metrics

本文评价

推荐阅读 0