《中国康复理论与实践》

《中国康复理论与实践》 ›› 2023, Vol. 29 ›› Issue (2): 140-150.doi: 10.3969/j.issn.1006-9771.2023.02.002

• 专题 • 上一篇    下一篇

基于WHO-FICs作业治疗改善脑卒中上肢功能效果的系统综述

徐悦莹1,2, 郑洁皎1,2(), 高文1(), 丁建伟1, 陈茜2   

  1. 1.复旦大学附属华东医院，上海市 200040
    2.上海中医药大学，上海市 201203
  • 收稿日期:2022-10-26 修回日期:2023-02-13 出版日期:2023-02-25 发布日期:2023-03-16
  • 通讯作者: 徐悦莹,郑洁皎,高文 E-mail:zjjcss@163.com;gaowen5921@163.com
  • 作者简介:徐悦莹(1987-)，女，汉族，河南洛阳市人，硕士研究生，副主任治疗师，主要研究方向：ICF、作业治疗。
  • 基金资助:
    国家重点研发计划项目(2020YFC2008700);国家重点研发计划项目(2020YFC2008702);上海康复医学临床研究中心计划项目(21MC1930200);上海市科委科技创新行动计划项目(22Y31900201)

Effects of occupational therapy on upper extremity for patients with stroke: a systematic review using WHO-FICs

XU Yueying1,2, ZHENG Jiejiao1,2(), GAO Wen1(), DING Jianwei1, CHEN Xi2   

  1. 1. Huadong Hospital Affiliated to Fudan University, Shanghai 200040, China
    2. Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
  • Received:2022-10-26 Revised:2023-02-13 Published:2023-02-25 Online:2023-03-16
  • Contact: XU Yueying, ZHENG Jiejiao, GAO Wen E-mail:zjjcss@163.com;gaowen5921@163.com
  • Supported by:
    Supported by National Key Research and Development Program No.(2020YFC2008700);Supported by National Key Research and Development Program No.(2020YFC2008702);Shanghai Rehabilitation Medicine Clinical Research Center Program No.(21MC1930200);Shanghai Science and Technology Commission Science and Technology Innovation Action Plan No.(22Y31900201)

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摘要：

目的 基于世界卫生组织国际分类家族(WHO-FICs)构建作业治疗改善脑卒中上肢功能的PICO架构，并分析主要作业疗法改善脑卒中患者上肢功能的效果。 方法 运用WHO-FICs框架，检索Web of Science、PubMed、CNKI、SinoMed等数据库，收集建库至2022年10月关于作业治疗干预脑卒中上肢功能的相关文献，并进行系统综述。 结果 最终纳入10项随机对照试验，382例参与者(≥ 18岁)，来自6个国家，主要来源于康复医学、物理和康复医学、神经科学、生物工程医学、作业治疗等研究领域，发表年限集中于2013年以后。纳入文献物理治疗证据数据库(PEDro)量表评分平均7.5分。基于WHO-FICs框架，纳入文献中涉及的疾病类型涵盖脑出血(8B00)、缺血性脑卒中(8B11)、蛛网膜下腔出血(8B01)、肌张力和异常反射(MB47)、偏瘫(MB53)。主要功能障碍包括关节活动功能(b710)、关节稳定性功能(b715)、肌肉力量功能(b730)、肌张力功能(b735)、运动反射功能(b750)、随意运动控制功能(b760)、不随意运动功能(b765)。主要活动受限和参与局限包括上肢的活动和参与，如举起和搬运物体(d430)，手和手臂的使用(d445)，精巧手的使用(d440)；以及日常生活活动和社会参与能力，如自理(d510-d570)，家庭生活(d610-d660)，主要生活领域(d810-d879)，社区、社会和公民生活(d910-d950)。涉及身体功能的治疗类干预措施有肌肉功能电刺激(MU2.SC.BP)、协助和指导运动功能训练(MV2.PG.ZZ)；涉及活动和参与的治疗类干预措施有举起和搬运物体训练(SIA.PH.ZZ)、使用精巧手的训练(SIG.PH.ZZ)、使用上肢和手的训练(SIJ.PH.ZZ)、自理的干预措施(SM1-SMH)、主要生活领域的干预措施(SO2-SOD)、游戏训练(SXD.PH.ZZ)。每次干预15~60 min，每周3~10次，持续3~8周。干预场所一般为医院或居家。干预效果分为3个层面：身体功能层面，涉及神经运动传导功能、反射功能、随意运动控制能力、协调性与速度改善，关节活动度和握力增加；活动和参与层面，涉及上肢活动能力和速度、手的精细功能和速度、上肢活动参与的频率和质量，日常生活活动能力提高，参与日常活动任务的困难程度降低；生活质量和福祉层面，涉及获得愉悦感和成就感，生活质量提高。结论 基于WHO-FICs构建了作业治疗改善脑卒中上肢功能效果的PICO架构。涉及的疾病类型涵盖脑出血、缺血性脑卒中、蛛网膜下腔出血、肌张力和异常反射以及偏瘫。上肢运动功能障碍主要有随意运动控制功能障碍，运动反射功能减弱或亢进，肌张力异常，肌肉协调障碍，关节活动稳定性差，肌力减退等，活动受限和参与局限性表现为手臂和手的活动参与功能障碍，手的精细活动功能障碍，影响日常生活活动和社会参与能力。涉及身体功能的治疗类干预措施有基于脑机接口的神经肌肉电刺激治疗、单上肢镜像训练；涉及活动和参与的治疗类干预措施有动作观察训练、双上肢镜像训练、任务导向训练、双上肢训练及上肢机器人训练。健康和功能效益主要表现为上肢运动功能、上肢的活动和参与水平、日常生活活动能力和社会参与能力提高，生活质量与福祉改善。

关键词: 脑卒中, 作业治疗, 上肢, 活动和参与, 世界卫生组织国际分类家族, 系统综述

Abstract:

Objective To construct a framework of PICO for occupational therapy to improve upper extremity function in stroke patients based on World Health Organization Family of International Classifications (WHO-FICs), and to analyze the functional outcome of major occupational therapies to improve upper extremity in stroke. Methods Using the WHO-FICs framework, the databases such as Web of Science, PubMed, CNKI and SinoMed were searched for literature related to occupational therapy interventions for upper extremity function in stroke patients from the date of establishment to October, 2022, and the contents of the literature were extracted for a systematic review. Results Ten randomized controlled trials from six countries were finally included, involving 382 participants (≥ 18 years old). The literatures were mainly from the fields of rehabilitation medicine, physics and rehabilitation medicine, neuroscience, bioengineering medicine, occupational therapy and other research fields, and were published mainly after 2013. The quality of the included literatures was evaluated using Physiotherapy Evidence Database (PEDro) scale with a mean score of 7.5. Based on the WHO-FICs framework, the types of diseases included intracerebral haemorrhage (8B00), cerebral ischemic stroke (8B11), subarachnoid hemorrhage (8B01), abnormality of tonus and reflex (MB47), and hemiplegia (MB53). The main dysfunctions of the upper extremity after stroke included mobility of joint functions (b710), stability of joint functions (b715), muscle power functions (b730), muscle tone functions (b735), motor reflex functions (b750), control of voluntary movement functions (b760), involuntary movement functions (b765). Activity and participation included activity of upper limb, such as lifting and carrying objects (d430), hand and arm use (d445), and fine hand use (d440); and the daily life activities and social participation, such as self-care (d510-d570), domestic life (d610-d660), major life areas (d810-d879), community, social and civic life (d910-d950). Therapeutic interventions on body functions included electrical stimulation of muscle functions (MU2.SC.BP), assistance and guidance of exercise for involuntary movement reaction (MV2.PG.ZZ); therapeutic interventions involving activity and participation were training in lifting and carrying (SIA.PH.ZZ), training in fine hand use (SIG.PH.ZZ), exercises of arm and hand use (SIJ.PH.ZZ), self care (SM1-SMH), household tasks (SO2-SOD), and playing games (SXD.PH.ZZ); 15 to 60 minutes a time, three to ten times a week, for three to eight weeks, in hospital or at home. The outcomes of the intervention were divided into three levels. At the body function level, patients had improved neuromotor conduction function, reflex function, casual motor control, coordination and speed, joint mobility, and grip strength. At the activity and participation level, there were enhancements in upper limb mobility and speed, fine hand function and speed, frequency and quality of upper limb activity participation, and the capacities of daily living and reduced difficulty in daily activity tasks. In terms of whole functioning, patients had acquired quality of life and well-being and acquainted a feeling of pleasure and accomplishment. Conclusion A PICO framework was constructed for occupational therapy based on WHO-FICs. The health conditions included intracerebral haemorrhage, cerebral ischemic stroke, subarachnoid hemorrhage, abnormality of tonus and reflex, and hemiplegia. Upper extremity motor dysfunction mainly included dysfunction of voluntary motor control, low or hyperactive motor reflexes, abnormalities in muscle tone, impaired muscle coordination, poor stability of joint activities, and reduced muscle strength, etc. Activity limitation and participation restriction were manifested as functioning in the fields of arm and hand activity participation, fine manual activity, and activities of daily living and social participation. Therapeutic interventions at body function level included brain-computer interface-based functional electrical stimulation and unimanual mirror therapy; therapeutic interventions at activity and participation level included action observation training, bimanual mirror therapy, task-oriented training, bilateral arm training and upper extremity robotics training. The health and functional benefits included the improvements in upper extremity motor function, upper extremity mobility and participation levels, activities of daily living and social participation, and quality of life and well-being.

Key words: stroke, occupational therapy, upper extremity, activity and participation, World Health Organization Family of International Classifications, systematic review

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