不同强化训练对脑性瘫痪儿童上肢运动功能效果的网状Meta分析

doi:10.3969/j.issn.1006-9771.2024.04.009

《中国康复理论与实践》 ›› 2024, Vol. 30 ›› Issue (4): 437-448.doi: 10.3969/j.issn.1006-9771.2024.04.009

不同强化训练对脑性瘫痪儿童上肢运动功能效果的网状Meta分析

崔甜甜¹, 杨钰琳¹, 崔腾腾², 马丽虹¹()

1.山东中医药大学康复医学院，山东济南市 250355
2.山东第二医科大学康复医学院，山东潍坊市 261100

收稿日期:2023-12-25 修回日期:2024-03-05 出版日期:2024-04-25 发布日期:2024-05-08
通讯作者: 马丽虹(1975-)，女，山东曲阜市人，硕士，教授，主要研究方向：神经系统疾病康复。E-mail： lhma2002@163.com
作者简介:崔甜甜(2000-)，女，汉族，山东枣庄市人，硕士研究生，主要研究方向：神经系统疾患的康复研究。
基金资助:
山东省高等医学教育研究中心科研规划项目

Effect of different intensive training on upper limb motor function in children with cerebral palsy: a network meta-analysis

CUI Tiantian¹, YANG Yulin¹, CUI Tengteng², MA Lihong¹()

1. College of Rehabilitation, Shandong University of Traditional Chinese Medicine, Ji'nan, Shandong 250355, China
2. College of Rehabilitation, Shandong Second Medical University, Weifang, Shandong 261100, China

Received:2023-12-25 Revised:2024-03-05 Published:2024-04-25 Online:2024-05-08
Contact: MA Lihong, E-mail： lhma2002@163.com
Supported by:
Research Planning Project of Shandong Higher Medical Education Research Center

摘要/Abstract

摘要：

目的系统评价上肢强化训练对脑瘫儿童上肢运动功能的效果。

方法构建PICO架构，检索PubMed、Embase、Cochrane Library、Scopus、Web of Science、中国知网、中国生物医学文献数据库、维普和万方数据库，搜集关于上肢强化训练改善脑瘫儿童上肢运动功能的随机对照试验，检索时限均为2010年1月至2024年3月。按照Cochrane系统评价手册和物理治疗证据数据库量表对纳入文献进行质量评价，由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后，采用RevMan 5.4和Stata 17.0进行网状Meta分析。

结果共纳入27篇文献，包括1 173例患者，涉及3种上肢强化训练。强制性运动疗法、改良强制性运动疗法和手-臂双侧强化训练均可提高辅助手功能评分与Peabody精细运动功能评分；强制性运动疗法和改良强制性运动疗法可提高上肢技能质量量表评分；手-臂双侧强化训练可提高儿童生活功能量表评分。在提高辅助手功能、上肢技能质量量表评分和Peabody精细运动功能评分方面，强制性运动疗法为最佳干预方式；在提高儿童生活功能量表评分方面，手-臂双侧强化训练为最佳干预方式。

结论上肢强化训练可显著改善脑瘫儿童的上肢运动功能、精细运动功能和日常生活活动能力，强制性运动疗法在改善上肢运动功能和精细运动功能方面效果最好，手-臂双侧强化训练在提高日常生活活动能力方面疗效最佳。

关键词: 脑性瘫痪, 上肢, 强化训练, 强制性运动疗法, 运动功能, 网状Meta分析

Abstract:

Objective To systematically review the effect of upper extremity intensive training on upper limb motor function in children with cerebral palsy.

Methods The PICO framework was constructed. PubMed, Embase, Cochrane Library, Scopus, Web of Science, CNKI, CBM, VIP and Wanfang data were retrieved for randomized controlled trials on the improvement of upper limb motor function in children with cerebral palsy by upper extremity intensive training from January, 2010 to March, 2024. The quality of the included researches was evaluated using the Cochrane System Evaluation Manual and Physiotherapy Evidence Database scale. Two reviewers independently screened literature, extracted data and assessed the risk of bias. Network meta-analysis was conducted using RevMan 5.4 and Stata 17.0.

Results A total of 27 randomized controlled trials were selected, including 1 173 cases, involving three kinds of upper extremity intensive training. Constraint-induced movement therapy, modified constraint-induced movement therapy and hand-arm bimanual intensive therapy improved Assistive Hand Assessment score and Peabody Developmental Motor Scale-Fine Motor score; constraint-induced movement therapy and modified constraint-induced movement therapy improved the Quality of Upper Extremity Skills Test score; hand-arm bimanual intensive therapy improved Pediatric Evaluation of Disability Inventory score. Constraint-induced movement therapy was the best in improving the Assistive Hand Assessment score, Quality of Upper Extremity Skills Test score and Peabody Developmental Motor Scale-Fine Motor score, while hand-arm bimanual intensive therapy was the best in improving the Pediatric Evaluation of Disability Inventory score.

Conclusion Upper extremity intensive training can significantly improve upper limb motor function, fine motor function and activities of daily living in children with cerebral palsy. Constraint-induced movement therapy is the best in improving upper limb function and fine motor function, and hand-arm bimanual intensive therapy is the best in improving the activities of daily living.

Key words: cerebral palsy, upper extremity, intensive training, constraint-induced movement therapy, motor function, network meta-analysis

中图分类号:

R742.3

崔甜甜, 杨钰琳, 崔腾腾, 马丽虹. 不同强化训练对脑性瘫痪儿童上肢运动功能效果的网状Meta分析[J]. 《中国康复理论与实践》, 2024, 30(4): 437-448.

CUI Tiantian, YANG Yulin, CUI Tengteng, MA Lihong. Effect of different intensive training on upper limb motor function in children with cerebral palsy: a network meta-analysis[J]. Chinese Journal of Rehabilitation Theory and Practice, 2024, 30(4): 437-448.

图/表 18

表1

图1

图2

表2

纳入文献的PEDro量表评分结果"

纳入文献	资格标准	随机分配	分配隐藏	基线均衡	被试施盲	治疗师施盲	评估者施盲	被试流失率≤15%	意向性分析	组间统计比较	点估计和变异性测量	总分
Abd El Wahab等^[15](2015)	√	√		√				√	√	√	√	6
Fedrizzi等^[16](2013)	√	√		√	√		√	√	√	√	√	8
Figueiredo等^[17](2020)	√	√		√				√	√	√	√	6
李巧秀^[18](2017)	√	√		√				√	√	√	√	6
孙瑞雪等^[19](2016)	√	√		√				√	√	√	√	6
王臣等^[20](2021)	√	√		√				√	√	√	√	6
Araneda等^[21](2022)	√	√		√				√	√	√	√	6
Araneda等^[22](2024)	√	√	√	√	√		√	√	√	√	√	9
Bleyenheuft等^[23](2015)	√	√	√	√	√	√		√	√	√	√	9
Saussez等^[24](2023)	√	√		√			√	√	√	√	√	7
De Brito Brandão等^[25](2010)	√	√	√	√			√	√	√	√	√	8
Eliasson等^[26](2018)	√	√		√	√		√	√	√	√	√	8
Ramey等^[27](2021)	√	√	√	√			√	√	√	√	√	8
Chen等^[28](2013)	√	√	√	√	√	√	√	√	√	√	√	10
Gordon等^[29](2011)	√	√		√	√	√		√	√	√	√	8
Sakzewski等^[30](2011)	√	√	√	√	√			√	√	√	√	8
Zafer等^[31](2016)	√	√		√				√	√	√	√	6
Choudhary等^[32](2013)	√	√	√	√	√		√	√	√	√	√	9
Hoare等^[33](2013)	√	√	√	√	√	√	√	√	√	√	√	10
Hwang等^[34](2020)	√	√		√			√	√	√	√	√	7
Mohamed等^[35](2021)	√	√	√	√	√		√	√	√	√	√	9
刘鹏等^[36](2022)	√	√		√			√	√	√	√	√	7
Bingöl等^[37](2022)	√	√	√	√	√	√	√	√	√	√	√	10
Bingöl等^[38](2023)	√	√	√	√	√		√	√	√	√	√	9
Chamudot等^[39](2018)	√	√		√	√		√	√	√	√	√	8
Deppe等^[40](2013)	√	√	√	√	√		√	√	√	√	√	9
Sakzewski等^[41](2015)	√	√	√	√	√		√	√	√	√	√	9

表2

表3

纳入文献基本特征"

纳入文献	国家	场所	n		年龄/岁 (试验组/对照组)	干预措施		干预周期	结局指标
纳入文献	国家	场所	试验组	对照组	年龄/岁 (试验组/对照组)	试验组	对照组	干预周期	结局指标
Abd El Wahab等^[15](2015)	埃及	医院	15	15	3.64±0.48/4.11±0.93	HABIT	CRT	12周	①
Fedrizzi等^[16](2013)	意大利	机构	39(T1)	33	2~8	mCIMT(T1)	CRT	10周	②
Fedrizzi等^[16](2013)	意大利	机构	33(T2)	33	2~8	HABIT(T2)	CRT	10周	②
Figueiredo等^[17](2020)	巴西	机构	19	20	9.42±3.58/9.67±4.16	HABIT	CRT	3周	③
李巧秀^[18](2017)	中国	医院	43	43	4.3±0.8	HABIT	CRT	8周	①②③
孙瑞雪等^[19](2016)	中国	医院	20	20	2.5~6	HABIT	CRT	12周	①②③
王臣等^[20](2021)	中国	医院	45	50	4.64±2.15/4.68±2.26	HABIT	CRT	8周	①
Araneda等^[21](2022)	比利时	实验室	16	15	9.3±4.25/9.3±5.3	HABIT	CRT	2周	④
Araneda等^[22](2024)	比利时	医院	25	24	3±3.46/2.76±3.51	HABIT	CRT	2周	③④
Bleyenheuft等^[23](2015)	比利时	医院	12	12	8.9 ± 1.7/8.5 ± 1.7	HABIT	CRT	2周	③④
Saussez等^[24](2023)	比利时	实验室	20	20	9.1±2.9/9.0±3.1	HABIT	CRT	2周	③④
De Brito Brandão等^[25](2010)	巴西	机构	8	7	5.5±1.92/6.58±1.11	CIMT	CRT	2周	③
Eliasson等^[26](2018)	瑞典	医院	18	13	0.5±0.49/0.42±0.46	CIMT	CRT	6周	④
Ramey等^[27](2021)	美国	医院	25	23	3.4±1.2/4.5±2.1	CIMT	CRT	4周	①②③④
Chen等^[28](2013)	中国	医院	24	23	8.7±1.9/8.8±2.0	CIMT	CRT	4周	①
Gordon等^[29](2011)	美国	实验室	21	21	6.3±2.2/6.4±1.11	CIMT	HABIT	3周	②④
Sakzewski等^[30](2011)	澳大利亚	实验室	32	32	10.2±2.7	CIMT	HABIT	3周	④
Zafer等^[31](2016)	巴基斯坦	研究所	9	9	8.75±3.06	CIMT	HABIT	2周	②
Choudhary等^[32](2013)	印度	医院	16	15	4.88±5.11/5.22±5.2	mCIMT	CRT	4周	②
Hoare等^[33](2013)	澳大利亚	诊所	17	17	3±4.5/2.97±4.73	mCIMT	CRT	8周	②③④
Hwang等^[34](2020)	韩国	医院	12	12	1.33±2.42/1.44±1.79	mCIMT	CRT	3周	①③
Mohamed等^[35](2021)	埃及	医院	20	20	7.7±0.86/7.75±0.91	mCIMT	CRT	12周	②
刘鹏等^[36](2022)	中国	医院	20	20	2.94±0.88/3.04±0.86	mCIMT	CRT	12周	①②
Bingol等^[37](2022)	土耳其	学校	16	16	10.75±2.95/10.12±2.96	mCIMT	HABIT	10周	②
Bingol等^[38](2023)	土耳其	学校	15	15	8.73±1.66/8.33±1.44	mCIMT	HABIT	16周	②
Chamudot等^[39](2018)	以色列	机构	17	16	0.93±0.64	mCIMT	HABIT	8周	④
Deppe等^[40](2013)	德国	机构	24	18	5.83±1.83/6.83±2.08	mCIMT	HABIT	4周	③④
Sakzewski等^[41](2015)	澳大利亚	医院	32	31	10.1±2.6/10.2±2.6	mCIMT	HABIT	2周	④

表3

图3

表4

图4

图5

表5

图6

图7

表6

图8

图9

表7

图10

表8

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人群 (Population)		干预 (Intervention)	比较 (Comparison)	结局 (Outcome)
脑瘫儿童	8D2Z脑瘫	干预措施	干预前后比较	上肢运动功能(QUEST)
< 18岁		常规康复治疗	干预方式比较	b710关节活动功能
		常规康复治疗＋上肢强化训练	干预组和对照组比较	b760随意运动控制功能
		干预时间		精细运动功能(AHA与PDMS-FM)
		干预场所		d440精细手的使用
				d445手和手臂的使用
				日常生活活动能力(PEDI)
				d599自我照顾能力

结局指标	n	样本量	偏倚风险	不一致性	证据质量
AHA评分	12	501	1^①	1^②	低
QUEST评分	12	513	1^①	0	中
PDMS-FM评分	8	439	1^①	0	中
PEDI评分	12	472	1^①	1^②	低

不同强化训练对脑性瘫痪儿童上肢运动功能效果的网状Meta分析

Effect of different intensive training on upper limb motor function in children with cerebral palsy: a network meta-analysis

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方法	CIMT	mCIMT	HABIT
mCIMT	1.11 (0.58, 2.11)
HABIT	1.44 (0.81, 2.56)	1.30 (0.86, 1.96)
CRT	1.91 (1.06, 3.43)^a	1.72 (1.21, 2.45)^a	1.33 (0.90, 1.95)

方法	CIMT	mCIMT	HABIT
mCIMT	1.69 (0.99, 2.86)
HABIT	1.32 (0.89, 1.97)	0.78 (0.54, 1.14)
CRT	2.74 (1.80, 4.17)^a	1.63 (1.04, 2.55)^a	2.07 (1.49, 2.88)^a

方法	CIMT	mCIMT	HABIT
mCIMT	1.95 (0.98,3.87)
HABIT	1.72 (1.02,2.89)^a	0.88 (0.48,1.62)
CRT	3.38 (2.20,5.19)^a	1.74 (1.02,2.96)^a	1.97 (1.47,2.63)^a

方法	CIMT	mCIMT	HABIT
mCIMT	1.60 (0.29,8.81)
HABIT	0.98 (0.22,4.33)	0.61 (0.20,1.91)
CRT	2.30 (0.61,8.70)	1.44 (0.49,4.21)	2.35 (1.21,4.59)^a

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