虚拟现实技术在卒中后偏瘫上肢康复中的应用及机制研究

doi:10.3969/j.issn.2095-4344.2872

中国组织工程研究 ›› 2020, Vol. 24 ›› Issue (32): 5228-5235.doi: 10.3969/j.issn.2095-4344.2872

• 组织构建综述 tissue construction review • 上一篇下一篇

虚拟现实技术在卒中后偏瘫上肢康复中的应用及机制研究

蔡丹娴1，曾庆1，何龙龙1，黄国志1，2

1南方医科大学珠江医院康复医学科，广东省广州市 510280；2南方医科大学康复医学院，广东省广州市 510280

收稿日期:2020-02-22 修回日期:2020-02-29 接受日期:2020-04-10 出版日期:2020-11-18 发布日期:2020-09-26
通讯作者: 黄国志，博士，主任医师，南方医科大学珠江医院康复医学科，广东省广州市 510280；南方医科大学康复医学院，广东省广州市 510280
作者简介:蔡丹娴，女，1994年生，广东省揭阳市人，汉族，南方医科大学在读博士，主要从事脑卒中康复研究。
基金资助:
国家自然科学基金面上项目(81874032)；广东省医学科学技术研究基金项目(A2017610)

Application and mechanism of virtual reality technology in post-stroke rehabilitation of the hemiplegic upper limb

Cai Danxian1, Zeng Qing1, He Longlong1, Huang Guozhi1, 2

¹Department of Rehabilitation, Zhujiang Hospital of Southern Medical University, Guangzhou 510280, Guangdong Province, China; ²Medical College of Rehabilitation, Southern Medical University, Guangzhou 510280, Guangdong Province, China

Received:2020-02-22 Revised:2020-02-29 Accepted:2020-04-10 Online:2020-11-18 Published:2020-09-26
Contact: Huang Guozhi, MD, Chief physician, Department of Rehabilitation, Zhujiang Hospital of Southern Medical University, Guangzhou 510280, Guangdong Province, China; Medical College of Rehabilitation, Southern Medical University, Guangzhou 510280, Guangdong Province, China
About author:Cai Danxian, MD candidate, Department of Rehabilitation, Zhujiang Hospital of Southern Medical University, Guangzhou 510280, Guangdong Province, China
Supported by:
the National Natural Science Foundation of China (General Program), No. 81874032; Guangdong Provincial Medical Science and Technology Research Project, No. A2017610

摘要/Abstract

摘要：

文题释义：

虚拟现实技术：指通过计算机创建虚拟环境，结合三维定位、传感器、计算机仿真、人工智能及高速运算等技术，使用户沉浸于计算机模拟出来的三维世界中，实现人机交互式操作。

卒中：是指脑血管因破裂或梗死导致相应脑区脑组织损伤，出现局部或全脑功能障碍的临床症状，持续24 h或死亡的急性脑血管疾病，包括缺血性和出血性卒中。

背景：虚拟现实技术是近年来上肢运动功能康复的重要辅助手段，其在运动功能恢复中的可能机制已成为神经康复领域的研究热点之一。

目的：综述虚拟现实技术在卒中后偏瘫上肢运动功能康复中的运用现状及其可能的机制，并展望其未来的发展前景。

方法：在PubMed、Web of Science、万方数据库、CNKI中国期刊全文数据库检索2000年6月至2019年12月相关文献，英文检索词为“stroke；brain hemorrhage；brain infarction；virtual reality；upper limb；hand；motor function；rehabilitation；neurorehabilitation；mechanism”，中文检索词为“卒中；脑出血；脑梗；虚拟现实技术；上肢；手；运动功能；偏瘫；康复；神经康复；机制”。经过筛选后对102篇文献进行归纳总结。

结果与结论：①虚拟现实技术作为传统康复治疗的辅助手段，可显著提高卒中后偏瘫上肢的运动功能，且在提高患者依从性、节约人力成本等方面有超越传统康复的优势，但暂无充足的临床证据证明单纯虚拟现实训练优于传统康复治疗，卒中各期患者接受单纯虚拟现实训练的治疗效果可能受不同因素的影响；②虚拟现实训练可能通过视觉反馈激活感觉运动中枢以及促进大脑皮质重组以实现运动功能的恢复，但目前的理论模型均不完善，需要进一步的研究来论证。

ORCID: 0000-0001-9111-6463(蔡丹娴)

中国组织工程研究杂志出版内容重点：组织构建；骨细胞；软骨细胞；细胞培养；成纤维细胞；血管内皮细胞；骨质疏松；组织工程

关键词: 脑, 卒中, 神经, 虚拟现实, 运动功能, 康复, 神经机制, 综述

Abstract:

BACKGROUND: Virtual reality is an important assistive technology of upper limb motor function rehabilitation in recent years. The possible mechanism has become one of the research hotspots in the field of neural rehabilitation.

OBJECTIVE: To summarize the application status and possible mechanism of virtual reality technology in post-stroke functional rehabilitation of the hemiplegic upper limb, as well as its future development.

METHODS: We searched the articles in PubMed, Web of Science, WanFang and CNKI with the keywords of “stroke; brain hemorrhage; brain infarction; virtual reality; upper limb; hand; motor function; rehabilitation; neurorehabilitation; mechanism” in English and Chinese, respectively. The search time was from June 2000 to December 2019. Eventually, 102 articles that met the criteria were recruited.

RESULTS AND CONCLUSION: Combined with conventional rehabilitation, virtual reality can significantly improve the motor function of the hemiplegic upper limb in post-stroke patients, and do better in improving patients’ compliance and saving labor cost than conventional training. However, there is insufficient clinical evidence to prove that virtual reality training alone is superior to conventional rehabilitation. The training effect may be affected by different factors in different stages of post-stroke patients. Virtual reality training may activate sensorimotor center by visual feedback and achieve motor recovery through improving cortical reorganization. Due to the imperfection of current theoretical models, further researches are expected.

Key words: brain, stroke, nerve, virtual reality, motor function, rehabilitation, neuromechanism, review

中图分类号:

蔡丹娴, 曾庆, 何龙龙, 黄国志. 虚拟现实技术在卒中后偏瘫上肢康复中的应用及机制研究[J]. 中国组织工程研究, 2020, 24(32): 5228-5235.

Cai Danxian, Zeng Qing, He Longlong, Huang Guozhi. Application and mechanism of virtual reality technology in post-stroke rehabilitation of the hemiplegic upper limb[J]. Chinese Journal of Tissue Engineering Research, 2020, 24(32): 5228-5235.

图/表（结果） 2

1.3 数据的提取检索文献420篇，其中英文354篇，中文66篇，如图1所示，排除与研究目的相关性差、重复性文献，最终纳入文献及指南共102篇，其中5篇文章介绍了卒中偏瘫上肢运动功能康复的必要性和传统康复治疗的缺点，59篇文章总结了虚拟现实技术的优势以及在卒中偏瘫上肢运动功能康复的应用现状；38篇文章涉及虚拟现实技术促进卒中偏瘫上肢运动功能恢复的可能机制。

目前关于运动功能恢复机制的主流观念是基于半球间抑制模型，认为半球间失衡与偏瘫肢体运动功能障碍有关。据统计，大多数研究将半球间不平衡状态的恢复作为治疗目标。依据半球抑制模型的理论假设，健侧半球在卒中早期应该处于高度兴奋状态，但是XU等^[87]对卒中后上肢轻-中度偏瘫患者进行为期1年的观察却发现，患者运动前半球间失衡从急性/亚急性期到慢性期呈现的变化为从正常进展为异常。而最近一项利用经颅磁比较脑卒中患者和健康成人双侧半球兴奋性的荟萃分析也得出结论，无论是在卒中后的急性期还是慢性期，“没有明确的证据表明健侧半球具有高度兴奋性”^[88]。这些发现都与半球间抑制模型相违背，那么应该存在另一个可能更合适的理论来解释卒中早期运动功能的恢复——如替代模型。TAKAHASHI等^[89]认为，运动的结果更多的是由患侧感觉运动皮质邻近的皮质区域募集激活而非原受损皮质的改变。对早期卒中后患者的神经影像学研究也发现患者的双侧运动前皮质、辅助运动区及未受影响半球的激活均对良好的上肢功能恢复有贡献^[90-91]，其中可能的机制见图2。

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引言

材料方法

1.1 资料来源第一作者于2019年12月应用计算机在PubMed，Web of Science、万方数据库、CNKI中国期刊全文数据库检索2000年6月至2019年12月相关文献，以“stroke；brain hemorrhage；brain infarction；virtual reality；upper limb；hand； motor function；rehabilitation；neurorehilitaion；mechanism”为英文检索词，以“卒中；脑出血；脑梗；虚拟现实技术；上肢；手；运动功能；康复；神经康复；机制”为中文检索词。检索文献类型：研究性论文、综述、著作、指南等。由第三作者进行再次检索，并与第一作者共同讨论最终纳入文献。

1.2 入选标准

纳入标准：依据文章题目和摘要进行初步筛选，通过文献泛读和精读后选出涉及虚拟现实技术在卒中后偏瘫上肢运动功能康复中应用以及相关神经机制的研究、指南、综述等，同时纳入文献中的引用文献。

排除标准：与研究目的不相关的文献、重复性研究。

1.4 存在的偏倚选取了2个英文数据库和2个中文数据库进行检索，采用多关键词组合检索以及多作者共同检索，以提高查全率并减少选择偏倚。文章仅纳入英文及中文文献，可能错过非英语国家研究者的研究结果，因此存在语种偏倚。文章纳入部分研究为小样本研究，且中文文献基本为阳性结果，考虑可能存在一定程度的发表偏倚。

讨论

随着科技的进步和现代社会的发展，虚拟现实技术逐渐成为卒中患者康复过程中的重要辅助技术，甚至被纳入卒中康复的七大重要技术之列^[99]。针对卒中各期患者，暂无充足的临床证据证明单纯虚拟现实训练优于传统康复治疗。慢性期患者个体差异大、评估手段的实用性和灵敏度、虚拟现实训练的运动模式设计都是影响慢性期患者虚拟现实训练效果的重要因素。而对于急性期患者，虚拟现实训练效果往往受个体自发恢复速度以及治疗剂量的影响。虽然近年来卒中运动训练指南对虚拟现实训练的推荐级别下降，但不能否认的是它作为传统康复治疗和功能性电刺激、经颅直流电刺激等治疗的辅助手段时，可以显著提高上肢各方面功能，如运动功能、肢体活动范围、灵敏度、肌力。另外，对提高患者依从性、节约人力成本等方面有超越传统康复的优势。因此，未来虚拟现实训练系统的设计方向应在增加训练趣味性的同时，注重日常生活功能的训练，实现更高剂量的任务导向训练。另外，在提高依从性方面，虚拟现实训练依然有提升的空间，如增加多种形式的奖励机制来吸引患者。已有研究发现将虚拟现实运动反馈与金钱奖励相结合可以显著改善治疗效果^[100]。在临床研究设计方面，依据患者功能障碍程度、卒中病程、卒中类型做好更细致的分层，甚至可以从影像学方向入手，以患者皮质兴奋程度或皮质脊髓束完整性为分层方法，可以更全面地评估虚拟现实训练手段的最佳适应人群。另外，更细致、灵敏的评估手段包括运动学参数分析、对目标肌群的独立测量以及通过影像学、神经生理学指标(如正中神经体感诱发电位^[101])分析进一步挖掘虚拟现实训练的治疗潜能。

虚拟现实技术在大众娱乐活动中已发展得相当成熟，一些商业化虚拟现实游戏因成本低、容易获得而被应用于医院或家庭康复训练中。但需要注意的是，专门为偏瘫患者设计的虚拟现实康复训练系统可以利用神经生物学的原理，调动机体恢复机制，实现比商业化虚拟现实游戏更有效的训练^[102]。虚拟现实技术可以通过视觉反馈激活感觉运动中枢，对运动能力有限、治疗训练选择较少的卒中重度偏瘫患者来说，利用虚拟现实技术实现视觉反馈辅助镜像训练无疑是一项值得期待的尝试。在运动功能恢复的另一重要神经机制——皮质重组方面，目前没有一个公认的理论可以解释虚拟现实训练促进运动功能恢复的神经机制，半球间抑制模型研究已相对完善，但替代模型以及与其相关的影响因素如突触再生能力等在卒中各期患者中仍存在较大的研究空间。虚拟现实训练如何诱发邻近皮质区的激活以及能否通过运动学习和高强度训练使大脑产生有效突触，需要进一步的验证。这些都将为虚拟现实训练系统的设计和应用提供证据依据和理论指导。虚拟现实技术是一项具有巨大发展潜能的康复治疗技术，随着研究工作的深入和技术的飞速发展，虚拟现实技术很有可能在卒中偏瘫上肢康复占据更大的应用空间和更重要的地位。

中国组织工程研究杂志出版内容重点：组织构建；骨细胞；软骨细胞；细胞培养；成纤维细胞；血管内皮细胞；骨质疏松；组织工程

虚拟现实技术在卒中后偏瘫上肢康复中的应用及机制研究

Application and mechanism of virtual reality technology in post-stroke rehabilitation of the hemiplegic upper limb

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