Rousseaux Marc, Kozlowski Odile, Froger Jérome
Service de Rééducation Neurologique, Hĵpital Swynghedauw, CHU, Lille, France.
J Neurol. 2002 Jan;249(1):76-84. doi: 10.1007/pl00007851.
Botulinum toxin A has been reported to reduce spasticity and increase the comfort of hemiplegic patients. The aim of this study was to assess the efficacy of the treatment on disability, especially in manual activities, and to attempt to identify predictive factors of improvement. Twenty patients (mean age: 54.4 years; M: 14; right hemiplegia: 12) were included, with a delay of at least three months after unilateral hemispheric stroke. Botulinum toxin A (BOTOX) was injected into the arm adductors (8 cases), forearm flexors (17 cases), pronators, wrist and finger flexors (20 cases),with a total dose of 200 to 300 U. Examination (day 1 and 15, month 2 and 5) consisted of spasticity assessment (modified Ashworth scale), muscle strength, passive range of motion (goniometry), and pain, followed by functional tests, especially the Rivermead Motor Assessment (RMA) and Nine-hole Peg Test (NHPT). Performance in daily living was assessed with the Functional Independence Measure (FIM), and an original analysis of hand grasp, grip and pinches used in domestic activities (9 items), and of comfort of patients and caregivers. Significant reduction in spasticity was observed on the elbow flexors, pronators, wrist and fingers flexors, especially at day 15 (mean 0.90 to 1 point), with wide variations in effect. Muscle strength was increased in wrist and fingers extensors, with concomitant increase in the opening of the thumb to index finger space. There was no effect on the NHPT requiring distal manipulation, but the RMA, which especially concerned picking up and releasing a tennis ball, showed significant improvement. Furthermore, use of the upper limb in daily living increased, particularly for internal grasping of objects, and for grasping by the top, transporting and releasing of objects. Patients and caregivers re ported facilitation in dressing, and in proximal and distal care of the upper limb. The global flexor position of the limb improved. Ad verse reactions were rare and mostly consisted of transitory pain during injection. The improvement in the RMA was better explained by the quality of the initial motor command on distal prehension (positive correlation with motor strength), and that in hand using in domestic activities by a lower level of spasticity on pronators and wrist flexors (negative correlations with spasticity). Conversely, the severity of the motor deficit (negative correlations with motor strength) and a high level of spasticity before injection (positive correlations with spasticity) mostly explained the improvement in comfort. In conclusion, botulinum toxin A is efficient in improving hand use in patients with relatively preserved distal motricity, and in increasing comfort in patients with severe global disorders.
据报道，A型肉毒毒素可减轻偏瘫患者的痉挛并提高其舒适度。本研究的目的是评估该治疗对残疾状况的疗效，尤其是对手部活动的疗效，并试图确定改善的预测因素。纳入了20例患者（平均年龄：54.4岁；男性14例；右侧偏瘫12例），单侧半球卒中后至少延迟三个月。将A型肉毒毒素（保妥适）注射到手臂内收肌（8例）、前臂屈肌（17例）、旋前肌、腕部和手指屈肌（20例），总剂量为200至300单位。检查（第1天和第15天、第2个月和第5个月）包括痉挛评估（改良Ashworth量表）、肌肉力量、被动活动范围（测角法）和疼痛，随后进行功能测试，尤其是Rivermead运动评估（RMA）和九孔插钉试验（NHPT）。使用功能独立性测量（FIM）评估日常生活表现，并对家庭活动中使用的手部抓握、握持和捏取（9项）以及患者和护理人员的舒适度进行原始分析。观察到肘屈肌、旋前肌、腕部和手指屈肌的痉挛明显减轻，尤其是在第15天（平均减轻0.90至1分），效果差异较大。腕部和手指伸肌的肌肉力量增加，同时拇指与示指间距增大。对需要远端操作的NHPT没有影响，但特别涉及捡起和释放网球的RMA显示有显著改善。此外，日常生活中上肢的使用增加，特别是用于物体的内部抓握，以及从顶部抓握、运输和释放物体。患者和护理人员报告穿衣以及上肢近端和远端护理变得更加便利。肢体的整体屈肌姿势得到改善。不良反应很少见，主要包括注射期间的短暂疼痛。RMA的改善更好地由远端抓握时初始运动指令的质量来解释（与运动力量呈正相关），而家庭活动中手部使用的改善则由旋前肌和腕屈肌较低水平的痉挛来解释（与痉挛呈负相关）。相反，运动缺陷的严重程度（与运动力量呈负相关）和注射前较高水平的痉挛（与痉挛呈正相关）主要解释了舒适度的改善。总之，A型肉毒毒素对于改善远端运动功能相对保留的患者的手部使用以及提高严重整体功能障碍患者的舒适度是有效的。
