【作者】 张婷；

【导师】 许卓；

【作者基本信息】 吉林大学 ， 医学技术， 2024， 硕士

【摘要】 研究目的:本研究旨在联合应用主观临床量表与客观的肌张力测试及表面肌电(Surface Electromyography,s EMG)量化评定方法,明确体外冲击波疗法(Extracorporeal Shock Wave Therapy,ESWT)对脑卒中慢性期肱二头肌痉挛患者肌张力、肌肉僵硬程度、顺应性、异常放电情况与上肢运动功能的影响,分析痉挛肌肉张力与生物力学及电生理学性质的相关性,探讨ESWT产生的具体作用与机制,为其临床应用与基础研究开展提供依据。研究方法:本研究为单中心、前瞻性、单盲随机对照试验。于长春市某三甲医院康复科招募48名符合纳排标准的脑卒中慢性期肱二头肌痉挛患者,随机分为试验组与对照组,每组24例。对照组仅接受常规康复训练,每周6次,共4周。试验组除常规康复训练外,还接受聚焦式ESWT,能流密度为0.012～0.04 m J/mm2,频率6～8 Hz,脉冲次数2000次,每次治疗时长约5 min,每周2次,每次间隔2～3天,疗程为4周,总治疗次数共8次。于治疗前、治疗中期、治疗末期时采用改良Ashworth量表(Modified Ashworth Scale,MAS)、Fugl-Meyer上肢功能评估(Fugl-Meyer Assessment Scale-Upper Extremity,FMA-UE)评定患者的肱二头肌主观痉挛程度与上肢功能情况。此外,采用肌张力测试仪分别在肌肉放松与牵伸状态下记录组织压力作用下的最大位移量(Lmax)、压力—位移曲线下面积(Area Under the Curve,AUC)及曲线斜率(即顺应性);采用s EMG记录静息状态下肱二头肌的肌电平均值(s EMGmean)与最大值(s EMGmax)、快速被动牵伸状态下的积分肌电值(Integrated Electromyography,i EMG)与s EMGmax、主动伸肘时肱二头肌的协同收缩率(Co-contraction Ratio,CR),评价患者治疗前后痉挛肌肉的外周生物力学与电生理学变化。采用SPSS 26.0软件进行统计分析,P<0.05为具有统计学意义。研究结果:(1)最终共45人完成全部治疗与评估,试验组22人,对照组23人,两组患者基线信息差异无统计学意义(P>0.05),具有可比性。(2)ESWT治疗后患者肱二头肌MAS等级显著降低(P<0.05),治疗末期时两组患者肱二头肌MAS等级差异显著(P<0.05)。治疗前后MAS等级的时间效应、组别与时间交互效应(P<0.05)显著。(3)ESWT治疗后患者FMA-UE评分显著升高(P<0.05),治疗末期时两组间差异有统计学意义(P<0.05)。治疗前后FMA-UE评分的时间效应、组别与时间的交互效应显著(P<0.05)。(4)ESWT治疗末期时痉挛肱二头肌放松状态下Lmax与基线相比显著增加(P<0.05),两组间差异无统计学意义(P>0.05)。ESWT治疗后痉挛肱二头肌牵伸状态下Lmax显著增加(P<0.05),治疗末期时组间差异有统计学意义(P<0.05)。治疗前后牵伸状态下Lmax的时间效应、组别与时间交互效应显著(P<0.05)。(5)ESWT治疗后痉挛肱二头肌放松状态下AUC显著增大(P<0.05),组间比较差异无统计学意义(P>0.05),治疗前后的时间效应、组别与时间交互效应显著(P<0.05)。ESWT治疗后痉挛肱二头肌牵伸状态下AUC显著增大(P<0.05),治疗末期时组间差异有统计学意义(P<0.05),治疗前后的时间效应、组别与时间交互效应显著(P<0.05)。(6)ESWT治疗后痉挛肱二头肌放松状态下顺应性显著提高(P<0.05),组间差异无统计学意义(P>0.05),治疗前后的时间效应、组别与时间交互效应显著(P<0.05)。ESWT治疗后痉挛肱二头肌牵伸状态下顺应性显著提高(P<0.05),治疗末期时两组间差异显著(P<0.05),治疗前后的时间效应、组别与时间交互效应显著(P<0.05)。(7)ESWT治疗后痉挛肱二头肌静息状态下s EMGmean与s EMGmax显著降低(P<0.05),治疗末期时组间静息s EMGmean差异有统计学意义(P<0.05)。治疗前后s EMGmean与s EMGmax的时间效应、组别与时间交互效应显著(P<0.05)。(8)ESWT治疗后痉挛肱二头肌快速被动牵伸时的i EMG与s EMGmax显著降低(P<0.05),治疗末期时组间差异有统计学意义(P<0.05),治疗前后i EMG与s EMGmax的时间效应、组别与时间交互效应显著(P<0.05)。(9)ESWT治疗后CR值显著降低(P<0.05),治疗末期时组间差异有统计学意义(P<0.05),治疗前后组别、时间效应、组别与时间交互效应均有统计学意义(P<0.05)。(10)相关性分析结果显示,MAS等级与牵伸状态下客观肌张力测试指标(Lmax、AUC、顺应性)呈负相关(P<0.05);与静息状态下(s EMGmean、s EMGmax)、快速被动牵伸(i EMG、s EMGmax)、主动伸肘时(CR)的客观s EMG指标呈正相关(P<0.05)。结论:(1)ESWT能降低脑卒中慢性期患者肱二头肌痉挛程度,改善痉挛肌肉的生物力学与电生理学性质,促进患者上肢功能恢复。(2)客观肌张力测试与s EMG评估指标能反映ESWT对脑卒中慢性期患者痉挛肌肉的生物力学与电生理学影响。更多还原

【Abstract】 Objective:The aim of this study is to combine subjective clinical scales with objective myotonometer and surface electromyography(s EMG)quantification assessment methods to clarify the effects of extracorporeal shock wave therapy(ESWT)on muscle tone,stiffness,compliance,abnormal muscle discharge,and upper limb motor function in chronic stroke patients with biceps brachii spasticity.The correlation between spastic muscle tone and biomechanical and electrophysiological properties is analyzed.The specific effects and mechanisms of ESWT are explored to provide evidence for its clinical application and basic research.Methods:This study is a single-center,prospective,single-blind randomized controlled trial.A total of 48 chronic stroke patients with biceps brachii spasticity who met the inclusion criteria were recruited from a tertiary hospital in Changchun.Eligible patients were randomly divided into the experimental group(n=24)and control group(n=24).The control group only received conventional rehabilitation,six times a week,for a total of four weeks.In addition to conventional rehabilitation,the experimental group also received a total of eight sessions of focused ESWT(0.012-0.04 m J/mm2,6-8Hz,2000shots),each treatment lasts about five minutes,twice a week with an interval of 2-3 days for four weeks.The outcome measurement,including the modified Ashworth scale(MAS)and Fugl-Meyer scale-upper extremity(FMA-UE)were performed to Vassess the subjective spasticity level of the biceps brachii and upper limb function of the affected side.Myotonometer was used to evaluate the peripheral biomechanical changes of spastic muscle,which includes indicators of maximum displacement(Lmax),area under the curve(AUC),and curve slope(i.e.compliance)of the tissue under pressure during 2 protocols(muscle relaxed or stretched position).s EMG was used to record the electrophysiological changes of spastic muscle,including indicators of s EMGmean and s EMGmax values of the biceps brachii at rest,integrated electromyography(i EMG)and s EMGmax during passive stretch reflex,as well as the co-contraction ratio(CR)of the biceps brachii during active elbow extension.Indicators were assessed at baseline,after four treatments,and after eight treatments of ESWT.Statistical analysis was conducted using SPSS 26.0 software,with P<0.05 indicating statistical significance.Results:(1)In the end,a total of 45 people completed all the treatment and evaluation,with22 in the experimental group and 23 in the control group.The baseline information between the two groups was comparable,with no statistically significant difference(P>0.05).(2)ESWT can significantly downgrade MAS level of biceps brachii in patients after treatment(P<0.05).There was a significant improvement in the MAS of the biceps brachii between the two groups at the end of treatment(P<0.05).The time effects and the interaction effect between groups and time of MAS level were statistically significant before and after treatment(P<0.05).(3)After ESWT treatment,the FMA-UE score of patients significantly increased(P<0.05).The intergroup comparison showed a statistically significant difference in FMA-UE scores at the end of treatment(P<0.05).The time effects of FMA-UE scores and the interaction effect between groups and time were statistically significant before and after treatment(P<0.05).(4)At the end of ESWT treatment,the Lmax of spastic biceps brachii in relaxed position significantly increased compared to baseline(P<0.05).There was no statistically significant difference between the two groups(P>0.05).ESWT can significantly increase Lmax of spastic biceps brachii in stretched position(P<0.05).When comparing between the two groups,there was a statistically significant difference in Lmax at the end of treatment(P<0.05).Before and after treatment,the time effects,interaction effects between groups and time of Lmax were statistically significant(P<0.05).(5)After ESWT treatment,the AUC of spastic biceps brachii in relaxed position significantly increased(P<0.05).No statistically significant difference was found between the two groups(P>0.05).The time effects(P<0.05)and interaction effects between groups and time(P<0.05)were statistically significant before and after treatment.When evaluating in stretched position,the AUC of spastic biceps brachii significantly increased after ESWT(P<0.05).There was a statistically significant difference in AUC between the two groups at the end of treatment(P<0.05).The time effects,interaction effects between groups and time were statistically significant before and after treatment(P<0.05).(6)After ESWT treatment,the compliance of spastic biceps brachii in relaxed position significantly increased(P<0.05).There was no statistically significant difference between the two groups(P>0.05).The time effects and interaction effects between groups and time were statistically significant(P<0.05).When evaluating in stretched position,the compliance of the spastic biceps brachii exhibited a significant increase after ESWT(P<0.05).At the end of treatment,a notable difference in compliance between the two groups emerged(P<0.05).Before and after treatment,statistically significant time effects and interaction effects between groups and time were observed(P<0.05).(7)After ESWT treatment,s EMGmean and s EMGmax of spastic biceps brachii were significantly reduced during resting state(P<0.05).At the conclusion of treatment,the difference in resting s EMGmean between the groups was evident(P<0.05).The time effects along with the interaction effects between groups and time of s EMGmean and s EMGmax of the biceps brachii before and after treatment were statistically significant(P<0.05).(8)After ESWT treatment,the i EMG and s EMGmax of spastic biceps brachii during rapid passive stretching were significantly reduced(P<0.05).A notable difference between the two groups was identified at the end of treatment(P<0.05).Significant time effects and interaction effects between groups and time for i EMG and s EMGmax were observed(P<0.05).(9)After ESWT treatment,the CR value significantly decreased(P<0.05).A significant difference between the two groups was observed at the end of treatment(P<0.05).Before and after treatment,the groups,time effects,and interaction effects between groups and time were statistically significant(P<0.05).(10)The correlation analysis yielded the MAS level was negatively correlated with the objective myotonometer evaluation indicators(Lmax,AUC,compliance)in stretched position(P<0.05).Additionally,positive correlation was observed between MAS level and objective s EMG indicators during rest(s EMGmean,s EMGmax),rapid passive stretching(i EMG,s EMGmax),and active elbow extension(CR)(P<0.05).Conclusion:(1)ESWT has a positive effect on biceps brachii spasticity in patients with chronic stroke,improving the biomechanical and electrophysiological properties of spastic muscles,and promoting the recovery of upper limb function in patients.(2)Objective myotonometer and s EMG evaluation indicators can reflect the biomechanical and electrophysiological effects of ESWT on spastic muscle in chronic stroke patients.更多还原