van Kuijk A A, Geurts A C H, Bevaart B J W, van Limbeek J
Department of Rehabilitation Medicine, Sint Maartenskliniek, Nijimegen, The Netherlands.
J Rehabil Med. 2002 Mar;34(2):51-61. doi: 10.1080/165019702753557836.
Studies published from January 1966 until October 2000 on the clinical effects of focal neuronal and neuromuscular blockade in post stroke upper limb spasticity were identified. Twelve studies were included and evaluated on 13 methodological criteria. Ten studies on Botulinum toxin type A (BTX-A) treatment were found (of which 4 were randomised controlled trials (RCTs) and 6 were uncontrolled observational studies) as well as one uncontrolled observational study on phenol blockade of the subscapular muscle and one on alcohol blockade of the musculocutaneus nerve. The homogeneity of the patient groups with regard to diagnosis and their comparability with regard to functional prognosis and other sources of bias were generally unsatisfactory. Only two RCTs met predetermined criteria of minimal validity. There is evidence of effectiveness of BTX-A treatment on reducing muscle tone (varying between 0.8 and 2.0 points on the modified Ashworth scale) and improving passive range of motion at all arm-hand levels in chronic stroke patients for approximately 3-4 months. There is also preliminary evidence of a synergistic effect of concomitant electrostimulation. Taking into account a critical maximum dose of 100 MU Botox" (300-500 MU Dysport) for preserving active finger flexion, BTX-A treatment seems to be a safe focal spasmolytic treatment. Effectiveness of BTX-A treatment on improving functional abilities could not be convincingly demonstrated, although two subgroups may be identified that might specifically benefit at a functional level: (1) patients with mild spasticity and a potential for voluntary extensor activity and (2) patients with severe spasticity suffering from problems with positioning and taking care of the affected arm and hand. Larger controlled studies are needed to compare the effectiveness of BTX-A with other focal spasmolytic techniques paying special attention to individual goal assessment, the (duration of) functional benefits, co-treatment and aftercare, side-effects and cost-effectiveness.
检索了1966年1月至2000年10月发表的关于局灶性神经元和神经肌肉阻滞对中风后上肢痉挛临床疗效的研究。纳入了12项研究，并根据13项方法学标准进行评估。发现了10项关于A型肉毒毒素（BTX-A）治疗的研究（其中4项为随机对照试验（RCT），6项为非对照观察性研究），以及1项关于肩胛下肌酚阻滞的非对照观察性研究和1项关于肌皮神经酒精阻滞的研究。患者组在诊断方面的同质性以及在功能预后和其他偏倚来源方面的可比性总体上不尽人意。只有两项RCT符合预定的最低有效性标准。有证据表明，BTX-A治疗对降低慢性中风患者的肌张力（改良Ashworth量表上变化在0.8至2.0分之间）以及改善所有手臂-手部水平的被动活动范围有效，持续约3至4个月。也有初步证据表明联合电刺激有协同作用。考虑到为保留主动手指屈曲的100MU保妥适（300 - 500MU得保松）的临界最大剂量，BTX-A治疗似乎是一种安全的局灶性解痉治疗。尽管可以确定两个可能在功能水平上特别受益的亚组：（1）轻度痉挛且有自愿伸肌活动潜力的患者，以及（2）严重痉挛且在受影响手臂和手部的定位和护理方面存在问题的患者，但BTX-A治疗对改善功能能力的有效性尚未得到令人信服的证明。需要进行更大规模的对照研究，以比较BTX-A与其他局灶性解痉技术的有效性，特别要关注个体目标评估、功能益处（持续时间）、联合治疗和后续护理、副作用和成本效益。
