卒中偏瘫患者出院后习得性废用发展情况的调查研究

目的 调查卒中亚急性期偏瘫患者出院后习得性废用发展情况，分析习得性废用与患者人口学因素、 临床特点及功能恢复的相关性。 方法 前瞻性连续纳入2018年7月-2019年12月期间南方医科大学深圳医院预备出院的卒中偏瘫患 者。收集患者一般资料和临床特点，并在出院后4周、8周和12周用运动活动记录表（motor activity log， MAL）评估患者的习得性废用情况，在出院前3 d，出院后4周、8周和12周用改良Ashworth指数测试肘 腕屈肌群肌张力，偏瘫上肢功能测试香港版、Fugl-Meyer评定量表上肢部分和箱块测试评价上肢功 能，功能独立性评定评价日常生活能力。对各随访时间点MAL与其他评估量表、人口学因素和临床特 点进行相关性分析。 结果 研究完成随访患者47例，男性36例（76.6%），平均年龄58.74±11.08岁，平均发病时间 48.00±28.38 d，其中缺血性卒中32例（68.1%），出血性卒中15例（31.9%）。MAL的患手使用频率/ 患者活动质量在出院后4周、8周和12周时分别为2.66（1.38～4.03）分/2.87（1.03～3.56）分、3.30 （1.93～4.41）分/3.17（1.55～3.77）分和3.59（2.00～4.33）分/3.28（2.00～3.96）分，除8周与12周 之间的患手使用频率差异无统计学意义之外，其他时间点之间差异均具有统计学意义。各随访时间 点患者肘屈肌群张力变化差异无统计学意义（P =0.076），其余功能表现均显著恢复（均P <0.05）。出 院后4周、8周和12周各时间点，MAL与年龄呈一般正相关（ρ=0.33～0.39），与发病时间呈一般负相关 （ρ=-0.49～-0.33），与肘腕部屈肌张力呈一般至中等负相关（ρ=-0.58～-0.38），与日常生活能力 呈一般至中等正相关（ρ=0.30～0.60），与上肢运动功能呈一般至强正相关（ρ=0.49～0.76）。 结论 卒中亚急性期偏瘫患者出院后患肢仍然可以保持显著的功能恢复，但依然面临习得性废用 的挑战，且习得性废用与年龄、发病时间、腕肘屈肌群张力、日常生活生活能力和上肢功能相关。

Investigation on Learned Nonuse in Stroke Hemiplegic Patients after Discharge

Objective To investigate the development of learned nonuse in subacute stroke patients with
hemiplegia after discharge, and to analyze the correlations between learned nonuse and related
demographic factors, clinical characteristics and functional recovery.
Methods This prospective study consecutively enrolled stroke hemiplegic patients who were ready
to discharge from Shenzhen Hospital, Southern Medical University from July 2018 to December
2019. Baseline information and clinical characteristics were collected. Motor activity log (MAL)
was used to assess learned nonuse at 4, 8, and 12 weeks after discharge. The following assessments
were implemented within 3 days before discharge and at 4, 8, and 12 weeks after discharge,
including modified Ashworth scale (MAS) for muscle tone of flexors on elbow and wrist, functionaltest for the hemiplegic upper extremity-Hong Kong version (FTHUE-HK), Fugl-Meyer assessment
upper extremity section (FMA-UE) and box and block test (BBT) for upper extremity function,
functional independence measure (FIM) for activities of daily living (ADL). Correlations between
MAL and other assessments, demographic factors and clinical characteristics were analyzed.
Results 47 patients were included, with an average age of 58.74±11.08 years old and 36 males (76.6%),
and including 32 (68.1%) ischemic stroke patients and 15 (31.9%) hemorrhagic stroke patients. The
mean time since stroke onset was 48.00±28.38 days. Amount of use (AOU)/quality of movement
(QOM) of MAL recorded at 4, 8, and 12 weeks were 2.66 (1.38-4.03)/2.87 (1.03-3.56), 3.30 (1.93-
4.41)/3.17 (1.55-3.77) and 3.59 (2.00-4.33)/3.28 (2.00-3.96), respectively; and their difference among
the three time points were statistically significant except the AOU between 8 and 12 weeks. Except
the muscle tone of flexor on the elbow (P =0.076), other functional assessments all showed significant
improvement (all P <0.05). MAL showed positive correlation with age (ρ =0.33-0.39), negative
correlation with the time after onset (ρ =-0.49- -0.33), negative correlation with muscle tone of flexors
on elbow and wrist (ρ =-0.58- -0.38), positive correlation with ADL (ρ =0.30-0.60), and positive
correlation with upper extremity motor function (ρ =0.49-0.76).
Conclusions The affected limb of stroke hemiplegic patients showed significant functional
improvement after discharge, however, learned nonuse was still a big challenge, which was related
to age, time since onset of stroke, muscle tone of flexors on wrist and elbow, ADL and upper
extremity function.