Chinese Journal of Tissue Engineering Research ›› 2014, Vol. 18 ›› Issue (38): 6205-6209.doi: 10.3969/j.issn.2095-4344.2014.38.024
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Wang Pu, Zhang Chi, Yang Xiao-tian, Yang Lin, Yang Yong-hong, He Hong-chen, He Cheng-qi
Received:
2014-08-21
Online:
2014-09-10
Published:
2014-09-10
Contact:
He Cheng-qi, M.D., Professor, Department of Rehabilitation Medicine, West China Hospital of Sichuan University, Key Laboratory of Rehabilitation Medicine in Sichuan, Chengdu 610041, Sichuan Province, China
About author:
Wang Pu, M. D., Attending physician, Department of Rehabilitation Medicine, West China Hospital of Sichuan University, Key Laboratory of Rehabilitation Medicine in Sichuan, Chengdu 610041, Sichuan Province, China
CLC Number:
Wang Pu, Zhang Chi, Yang Xiao-tian, Yang Lin, Yang Yong-hong, He Hong-chen, He Cheng-qi. Whole body vibration training improves limb motor dysfunction in stroke patients: lack of evidence[J]. Chinese Journal of Tissue Engineering Research, 2014, 18(38): 6205-6209.
2.1 全身振动对脑卒中患者患侧肢体肌力影响 肌力是肌肉最大收缩时产生的力量,肌力大小与肌纤维的数量和粗细成正比,生理横断面越大,肌肉收缩时产生的力量也愈大。除肌纤维本身的因素影响肌力外,控制肌肉的神经也起着重要的作用。神经冲动的频率越高,运动神经元同时兴奋的数目愈多,参与收缩的运动单位愈多,肌力愈大。 研究发现全身振动可以通过神经因素提高正常人肌力,其作用机制为[4]:通过外源性机械振动刺激肌梭、腱梭等本体感受器,诱发神经环路所支配的骨骼肌牵张反射,从而增强其神经肌肉的功能。全身振动训练中,快速的肌肉牵伸和关节活动,可反复刺激肌梭传入纤维,特别是初级肌梭末梢纤维的兴奋性,导致γ运动神经元冲动频率加快、强度增大,而γ运动神经元的兴奋能进一步引起梭内肌收缩并维持肌梭兴奋的传入,反馈性增加牵张反射和运动神经元输出的强度,从而增加肌力。 Osawa等[5]通过系统评价10个关于全身振动提高股四头肌肌力的随机对照实验,纳入314例受试者,经Meta分析后发现全身振动具有提高股四头肌肌力的作用。Kvorning等[6]研究发现振动治疗能提高神经肌肉活性达12.6%-82.4%,从而增强神经肌肉的控制能力。脑卒中患者由于中枢神经系统受到损伤后,丧失或减弱了对肌肉控制的能力。因此,是否能将全身振动运用于脑卒中后运动功能障碍的患者,通过提高下肢关键肌肉的肌力,从而减轻患者下肢运动功能障碍,还需进一步的研究证实。 Tankisheva等[7]使用35-40 Hz,波幅为1.7-2.5 mm的振动频率,对实验组脑卒中患者进行每周3次,共6周的全身振动干预后,通过等速肌力测定发现实验组股四头肌的肌力大于对照组,说明全身振动对脑卒中患者下肢肌力恢复具有潜在研究价值,并建议研究针对性提高具体肌群的振动方案。 Brogårdh等[8]对实验组采用25 Hz,波幅为3.75 mm的振动频率,进行2次/周,共6周的全身振动干预,发现虽然与治疗前相比膝关节周围肌肉肌力有提高,但与对照组比较无明显区别,不能说明全身振动优于传统肌力训练。对比以上2个研究,发现在振动治疗方案上差别较大,其方案选择理由分别基于Verschueren在2004年的临床随机对照研究和Rehn等在2007年的系统评价[9-10]。由于全身振动是利用机械振荡刺激神经肌肉系统,所以其治疗强度取决于振动频率与振幅[11],且不同的振动平台、振动体位、振动加速度对肌肉强度的影响也不同。因此,振动方案将直接关系到疗效的好坏,而且何种方案更有利于脑卒中患者下肢肌力恢复,是否需要个性化的方案,仍需进一步研究。 此外,有部分研究在设计对照组假性对照方法时,忽略了实验组患者在振动台上进行全身振动训练时也含有肌力训练的成分。如果不排除该干预因素对实验的影响,可能会造成实验设计对照不全。研究中只有实验组患者进行全身振动训练也很容易导致盲法失控,基于以上考虑,Brogårdh[8]提出对照组也使用波幅接近0的假性全身振动治疗,不但可以解决对照不全的问题,同时也有利于对盲法的监控。 在治疗效果方面,Lau等[12]与Pang等[13]采用样本量大于80例的随机对照实验研究后发现,治疗组与对照组股四头肌和腘绳肌肌力均大于治疗前,但两组间肌力比较却并无差别,从而认为全身振动与对照组传统治疗相比无明显区别,所以全身振动对脑卒中患者下肢肌力的疗效仍有待确定。文章通过分析近年来关于这一方向的研究,发现目前研究主要针对对股四头肌、腘绳肌、股二头肌的干预和评估,且在肌力评定方法的选择上较为统一,多采用等速肌力测试,但全身振动干预方案却存在较大差异。 2.2 全身振动对脑卒中患者患侧肢体肌张力影响 肌张力是指肌肉在运动或静止时的紧张度,是支撑体质量,维持肢体位置,保证肢体运动控制能力的基础。肌张力受精神状态、局部压力、体位、神经控制等因素影响,其中神经控制系统的影响较大。脑卒中后由于中枢神经系统对低位中枢的抑制作用减低,导致下运动神经元神经冲动不受控制,从而导致肌肉在静息或者运动时的紧张度增加,其肌张力增高主要以速度依赖为特征,伴随腱反射亢进,被动活动关节活动时抵抗明显[14]。异常的肌张力将限制患者的自主活动,从而降低日常生活活动能力,严重影响患者康复效果和生存质量[15]。 虽然全身振动对中枢系统疾病导致的肌张力增高的影响机制尚未明确,但来自神经生理方面的研究发现:Ⅰa神经纤维主要传导从感受肌肉长度变化的环形螺旋末梢感受器感受到的肌肉信息,将其传入脊髓后角,再到脊髓前角的α神经元,最终引起肌肉收缩,而全身振动可通过激活拮抗肌的Ⅰa抑制神经元[16],使得单突触反射减弱,导致拮抗肌的兴奋受到抑制而降低肌张力。 此外,研究者通过振动治疗脑卒中患者后,检测神经肌电图发现其F波在短时间内受到抑制,提出可能与激活运动神经元兴奋后抑制机制有关[17]。临床观察发现患者下肢容易呈现伸肌痉挛的模式,股四头肌肌张力在运动和静止时升高,导致膝关节的控制障碍,因此目前研究相对集中于对膝关节周围肌群的研究,尤其是股四头肌肌张力的观察。 Ahlborg等[18]研究发现全身振动能降低脑瘫患者股四头肌肌张力。Ness等[19]通过临床随机试验以及Sadeghi等[20]通过系统评价发现全身振动能降低脊髓损伤患者股四头肌肌张力。但Schyns等[21]将其用于多发性硬化的患者,发现并不能明显降低患者下肢肌张力。在对同为中枢神经系统疾病的脑卒中患者的研究中,全身振动是否具有降低患肢肌张力的作用也仍未确定。 Miyara等[22]使用波幅为4-8 mm,振动频率为30 Hz,治疗时间为5 min的全身振动治疗方案,发现能降低脑卒中患者腘绳肌、腓肠肌、比目鱼肌的肌张力。 Chan等[23]在对30例脑卒中患者的临床随机对照研究中发现,使用12 Hz,4 mm波幅的振动治疗能降低患者比目鱼肌的肌张力。该研究为采用全身振动干预脑卒中患者肌张力的影响提供了参考信息,可进行进一步探索其针对具体肌张力增高肌群的振动方案以及配合其他治疗增加降张效果的方法。 然而也有研究者得出不同结论,Brogårdh等[8]采用随机双盲临床对照实验,评估髋内收、屈曲、后伸肌群,膝屈伸肌群,踝背伸、跖屈肌群的肌张力,发现全身振动并不能降低患者以上肌群总的肌张力。 分析全身振动针对肌张力的研究可发现:①振动方案,目前全身振动改善脑卒中患者下肢肌张力的治疗方案尚未统一,也无针对性降低某一肌群的具体振动方案。振动方案存在干预时间短,远期疗效不可预测的问题。②评定方法,研究中对肌张力的评估广泛采用的是改良Ashworth评定量表(Modified Ashworth Scale,MAS),该量表在由单一评估者使用时具有较高的信度,但由2人或以上评估者使用时存在评估者间效度的问题,可能影响最终评估结果[24],是不可忽视的问题。除MAS外,表面肌电图也是较好的评估方法,尤其有利于评估静息肌张力,同时它具有适时、精度高、数据采集方便、利于统计分析等优点[25]。 2.3 全身振动对脑卒中患者平衡与步态的影响 人体平衡分为静态平衡与动态平衡,可简单描述为3个环节,即感觉输入、中枢整合、运动控制[26]。感觉输入包括皮肤触觉、视觉、本体觉和前庭系统的信息输入。感觉信息经过脊髓、中脑、小脑及大脑皮质等多级神经中枢进行整合加工,分别经γ与α运动纤维传出的冲动调整梭内肌纤维的紧张度与骨骼肌的舒缩。脑卒中发生后,大脑神经细胞受损,整合传入信息及控制肌肉收缩的能力降低,从而导致平衡功能障碍。 早在1989年Roll等[27]就发现振动刺激能导致神经发放冲动频率加快、强度增大、皮肤感觉传入冲动以及耳前庭机械感受器和神经中枢机制发生变化。也有研究发现全身振动能促进本体感觉恢复[28],从而有利于患者平衡功能恢复。然而振动刺激所引起皮肤感觉和本体感觉所致中枢改变是否能引起患者平衡功能改变还需进一步的观察。 van Nes等[29]在一项全身振动干预脑卒中患者的临床随机对照实验中,实验组采用30 Hz,3 mm波幅的振动治疗,5次/周,干预6周。通过Berg平衡量表(Berg Balance Scale,BBS)评价平衡功能,躯干控制测试评价躯干控制能力,Rivermead运动指数测试评估患者活动能力,发现与对照组相比并无区别。该实验选择发病时间在6周以内的脑卒中患者进行干预,较其他研究更早开始全身振动干预,并且跟踪观察患者12周,对全身振动干预脑卒中后肌张力的远期疗效进行了评估,具有较大的参考价值。 Brogårdh等[8]在2012年发表的研究中,采用随机双盲对照实验设计,6周的全身振动干预后,实验组与对照组差别无统计学意义。Lau等[12]在随机单盲对照临床实验中也发现实验组在平衡、姿势控制、步行能力与对照组差别无统计学意义。 阅读近年相关研究,少有研究支持全身振动能有效提高脑卒中患者平衡及步行能力[23],这可能与全身振动本身的疗效有关,但也不可忽视目前研究存在的局限性。比如在振动治疗的具体方法中是让患者静止站立于振动台还是作动态运动[30-31],或者将两者结合[32],在目前的研究中不同的研究者采用不同的方法,这可能会影响最终研究结果。或可通过对比3种方法,研究哪种方法更有效,更适宜临床推广。此外,由于平衡及步态功能需要大脑中枢主动控制肢体才能完成,患者参与全身振动训练的主动性对研究结果会产生影响,而部分脑卒中患者存在认知功能障碍,参与训练的主动性和配合度较低,因此需要考虑纳入标准和排除标准中对患者认知功能障碍的具体限制。"
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