Butler Andrew J, Page Stephen J
Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA.
Arch Phys Med Rehabil. 2006 Dec;87(12 Suppl 2):S2-11. doi: 10.1016/j.apmr.2006.08.326.
To measure the efficacy of a program combining mental and physical practice with the efficacy of a program composed of only constraint-induced movement therapy (CIMT) or only mental practice on stroke patients' levels of upper-extremity impairment and upper-extremity functional outcomes and to establish the relationship between changes in blood-oxygen-level dependent (BOLD) functional magnetic resonance imaging response during a specific motor or imagery task and improvement in motor function between intervention groups.
Case series.
Licensed, 56-bed, freestanding, university-affiliated rehabilitation hospital.
Three men and 1 woman with moderate upper-limb hemiparesis after stroke were randomized.
Two patients received mental practice and CIMT, 1 patient received only mental practice, and 1 received only CIMT.
Wolf Motor Function Test (WMFT), Motor Activity Log (MAL), Sirigu break test, Movement Imagery Questionnaire-Revised, and Vividness of Movement Imagery Questionnaire.
The mental practice intervention alone led to slight improvement in certain functional and mental imagery measures (Sirigu, MAL, WMFT) but did not result in a clinically meaningful improvement with notable right cerebellar hemisphere activation that was not present before intervention. After CIMT, only the single patient showed clinically meaningful improvement of his affected hand as exhibited by decreased times on the MAL and WMFT. The patient showed increased bilateral cortical activation in both the motor and premotor areas during execution of a finger flexion and extension task. In contrast, during a second task, which was an imagined flexion and extension task, motor, occipital, and inferior parietal activation mainly in the contralateral hemisphere were observed. After 2 weeks of CIMT plus mental practice a patient with a lesion restricted to the parietal cortex showed little improvement in upper-extremity function and mental imagery in comparison with the patient with damage to nonparietal areas, who showed clinically meaningful improvement. The pattern of activation after 2 weeks of CIMT plus mental practice in the patient with nonparietal damage led to more focal contralateral activation in primary motor cortex when executing a voluntary flexion and extension task.
The case series indicates that for these patients with chronic, moderate upper-extremity impairment after stroke, a 2-week regimen of CIMT or CIMT plus mental practice only (in 1 case) resulted in modest changes occurring as a decrease in impairment, with functional improvement. Mental practice alone did not result in a clinically meaningful improvement in upper-limb impairment. We describe how these interventions may elicit "plastic" changes in the brain. Further investigations to determine the appropriate delivery and dosing of both physical and mental practice, as well as to determine whether mental practice-induced changes positively correlate with distinct patterns of cortical activation, should be undertaken before the efficacy of their use can be ascertained among patients with limitations comparable with these participants.
比较将心理练习与物理练习相结合的方案、仅由强制性使用运动疗法（CIMT）组成的方案或仅心理练习方案对中风患者上肢损伤程度和上肢功能结局的疗效，并确定特定运动或想象任务期间血氧水平依赖（BOLD）功能磁共振成像反应的变化与各干预组运动功能改善之间的关系。
病例系列。
一家拥有56张床位的独立的、附属于大学的持牌康复医院。
3名男性和1名女性中风后出现中度上肢偏瘫患者被随机分组。
2名患者接受心理练习和CIMT，1名患者仅接受心理练习，1名患者仅接受CIMT。
Wolf运动功能测试（WMFT）、运动活动日志（MAL）、西里古氏中断测试、运动想象问卷修订版和运动想象生动性问卷。
仅心理练习干预使某些功能和心理意象测量指标（西里古氏测试、MAL、WMFT）略有改善，但未带来具有临床意义的改善，干预前不存在的右小脑半球有明显激活。CIMT后，仅1例患者的患手有具有临床意义的改善，表现为MAL和WMFT测试时间减少。该患者在执行手指屈伸任务时，双侧运动和运动前区皮质激活增加。相比之下，在第二项任务（想象的屈伸任务）中，主要观察到对侧半球的运动、枕叶和顶下叶激活。CIMT加心理练习2周后，与非顶叶区域受损且有具有临床意义改善的患者相比，1例顶叶皮质局限性病变患者的上肢功能和心理意象改善甚微。非顶叶损伤患者在CIMT加心理练习2周后的激活模式显示，在执行自主屈伸任务时，初级运动皮质对侧激活更集中。
该病例系列表明，对于这些中风后慢性中度上肢损伤患者，2周的CIMT方案或仅CIMT加心理练习方案（1例）导致损伤程度降低，功能有所改善，但变化不大。仅心理练习并未使上肢损伤得到具有临床意义的改善。我们描述了这些干预措施如何在大脑中引发“可塑性”变化。在确定其对与这些参与者情况类似的有局限性的患者的疗效之前，应进一步开展研究，以确定物理练习和心理练习的适当实施方式和剂量，以及确定心理练习引起的变化是否与不同的皮质激活模式呈正相关。
