| Objective:1. To summarize the understanding and treatment methods of medical practitioners in successive dynasties for apoplexy through reviewsing ancient literatures, explore the treatment methods that can be used for reference in treating apoplexy sequelae from TCM literatures, and comprehend the present treatment status and research progress of apoplexy sequelae stage.2. To understand the evidence-based medicine evidence in treating motor dysfunction of apoplexy sequelae stage through Systematic reviews on the randomized controlled study of treating motor dysfunction of apoplexy sequelae stage.3. To observe the effects of intensive rehabilitation on the motor dysfunction in patients of apoplexy sequelae stage through clinical research and analyze the economic indicators; discuss the effects and significance of providing intensive rehabilitation for patients with motor dysfunction at apoplexy sequelae stage.Methods:1. Literature studyThe theories and ideas of major medical practitioners in successive dynasties about apoplexy were summarized, the treatment methods for apoplexy were studied particularly, and the present treatment status and research progress of apoplexy sequelae stage were comprehended.2. Systematic reviewsInclusion and exclusion criteria as well as retrieval methods were formulated. Literature databases of PubMed, EMBASE, Cochrane Library, CNKI, Wanfang academic journal, CQVIP Chinese periodicals, and SinoMed were retrieved and the retrieval time ranged from the creation time of each database to Oct.2014. Randomized controlled studies on the treatment of apoplexy sequelae stage were searched, Systematic reviews were conducted in accordance with the requirements and standards of the Cochrane Handbook, and data analysis was completed with Revman5.2.3. Clinical rearchA randomized controlled study method was adopted and a total of 60 patients were randomly divided into the treatment group (29 cases) and the control group (31 cases). The control group received family rehabilitation:general medical treatment, dialectic oral administration of Chinese patent medicine and family rehabilitation guidance was provided. The Chinese patent medicines for oral treatment included:Tongsaimai Pian 5 tablets PO tid for fire excess from yin deficiency, Naoxintong Jiaonang 2 capsules PO tid for Qi deficiency and blood stasis, Annao Wan 3g PO bid for phlegm-heat obstructing collaterals, and Huatuo Zaizao Wan 4g PO tid for Qi deficiency and sputum stasis. The treatment group received intensive rehabilitation, which refers to the comprehensive application of conventional treatment methods, dosage much more than conventional dosage, intensive nursing management, and thorough implementation of various treatments on the basis of admission. The specific treatment methods include general medical treatment, oral application of Chinese patent medicine, acupuncture, moxibustion, rehabilitation and nursing management. The content of general medical treatment and dialectical oral application of Chinese patent medicine is identical to that in the control group. Based upon this, acupuncture, moxibustion and rehabilitation that twice the conventional dose was provided in addition to strict nursing management. The treatment course was set as 40 days in both groups.The modified Ashworth muscle tension assessment method was applied to evaluate the muscle tension of upper and lower limbs, the Berg Balance Scale was applied to assess balance function, the Fugl-Meyer Assessment (FMA) was applied to assess motor function and Barthel Index was applied to assess activities of daily living (ADL). Average daily cost, per-capita cost and cost-benefit ratio were calculated. Blood routine and examination on liver and kidney function were conducted and adverse reactions were observed.Result:1. Literature studySince that there was not a staging method of "apoplexy sequelae stage" in TCM before modern times, specific discussions about "apoplexy sequelae stage" do not exist. In terms of etiology and pathogenesis, the TCM understanding of apoplexy experienced a gradual theoretical change from "exopathic wind" to "endogenous wind". By modern times, TCM has established the "endogenous wind" theory and built a relatively sophisticated theoretical system and diagnostic criteria. The principle of "treatment based on syndrome differentiation, modification according to symptoms" was applied for apoplexy treatment, and the principal treatment methods include traditional Chinese medicine, acupuncture and moxibustion. According to the classifications of "three-level rehabilitation system" for apoplexy, apoplexy sequelae stage should receive community-based rehabilitation or family rehabilitation. However, there is no consensus on the treatment program for apoplexy sequelae stage at present in the academic community.The theories of "brain plasticity" and "brain functional reorganization (BFRO) " have provided a theoretical basis for the treatment of apoplexy sequelae stage.2. Systematic reviewsAfter 3 rounds of screening, a total of 9 studies conforming to the requirements and 9 literatures meeting the criteria were included for Systematic reviews. There were 948 included patients and the time of publication ranged from 2002 to 2014. The intervention techniques in the treatment group were rehabilitation training, rehabilitation instruction, rehabilitation nursing, special acupuncture and moxibustion. The principal evaluation criteria include Fugl-Meyer Assessment and Barthel Index score. The quality of included studies was poor and the average score in modified Jadad Scale was 2.22.Meta-analysis on rehabilitation intervention vs blank control was performed, and Fugl-Meyer score and Barthel Index score were applied to evaluate the curative effect. The 95% confidence interval of Fugl-Meyer score effect size was [1.87,6.82], which fell on the right of invalid vertical line, and P< 0.05, indicating that rehabilitation intervention can improve Fugl-Meyer score better. Funnel plot was symmetric, suggesting the absence of publication bias. The 95% confidence interval of Barthel Index score effect size was [17.39,31.86], which fell on the right of invalid vertical line, and P<0.05, indicating that rehabilitation intervention can improve Barthel index score. Funnel plot was symmetric, suggesting the absence of publication bias.Meta-analysis on conventional rehabilitation vs conventional+special rehabilitation was performed, and the 95% confidence interval of Fugl-Meyer score effect size was [5.98,9.02], which fell on the right of invalid vertical line, and P<.0.05, indicating that conventional+special rehabilitation can improve Fugl-Meyer score better in comparison with conventional rehabilitation. Funnel plot was symmetric, suggesting the absence of publication bias.3. Clinical rearchA total of 60 patients of apoplexy sequelae stage with motor dysfunction were included to this study and 2 patients were excluded from the control group. Eventually, a total of 58 patients including 29 cases in the treatment group and 29 cases in the control group completed the study.All the 58 patients presented muscular hypertonia of varying degrees before treatment. This condition was improved in some patients from the treatment group when the treatment course ended; some patients from either the treatment group or the control group experienced aggravated muscular hypertonia. The condition of muscular tension in patients of the treatment group improved from that before treatment and the difference was significant (P<0.05); the evaluation result of muscular tension in patients of the control group worsened than that before treatment but the difference was not significant (P>0.05). A comparison of the curative effects in the treatment group and the control group after treatment found superiority in the treatment group and the difference was significant (P<0.05).The results of Fugl-Meyer Assessment in patients of the treatment group improved after treatment and the difference was significant (P<.0.05); the results of Fugl-Meyer Assessment in patients of the control group also improved after treatment but the difference was not significant (P>0.05). After treatment, the results of Fugl-Meyer Assessment in patients of the treatment group presented statistical significance in comparison with those of the control group (P<0.05).The results of Berg Balance Scale in patients of the treatment group improved after treatment and the difference was significant (P<0.05); the results of Berg Balance Scale in patients of the control group also improved after treatment but the difference was not significant (P>0.05). After treatment, the results of Berg Balance Scale in patients of the treatment group presented statistical significance in comparison with those of the control group (P<0.05).The Barthel Index in patients of the treatment group improved after treatment and the difference was significant (P<0.05); the Barthel Index in patients of the control group also improved after treatment but the difference was not significant (P>0.05). After treatment, the Barthel Index in patients of the treatment group presented statistical significance in comparison with those of the control group (P<0.05).During the entire treatment course, the average cost in patients of the treatment group was 17597.31 yuan; the per-capita average daily cost was 439.93 yuan and the cost-benefit ratio was 2373.59 yuan/point. The average cost in patients of the control group was 648.17 yuan, the per-capita average daily cost was 16.20 yuan and the cost-benefit ratio was 1879.70 yuan/point. Blood routine and liver function (AST, ALT) and renal function (creatinine, BUN) was examined after treatment and no significant abnormalities were found in patients of both groups. Slight subcutaneous congestion occurred 6 person-time after acupuncture in the treatment group during the treatment, and then disappeared automatically in days without special treatment. Other adverse reactions were not observed in patients of both groups during the treatment.Conclusion:1. The treatments of medical practitioners in successive dynasties for apoplexy applied three main methods:traditional Chinese medicine, acupuncture and moxibustion. Currently, there is no universal standard or consensus on the treatment program for apoplexy sequelae stage in the academic community, and corresponding studies are required. The principal studies on the treatment of apoplexy sequelae stage at present mainly include rehabilitation, acupuncture, traditional Chinese medicine, rehabilitation nursing, combination of Chinese traditional and Western medicine, etc. The theories of "brain plasticity" and "BFRO" have provided a theoretical basis for the treatment of apoplexy sequelae stage.2. Currently, there is only a limited amount of specific randomized controlled studies on the treatment for motor dysfunction of apoplexy sequelae stage and all of these studies are low-quality studies. This study applies Meta-analysis to indicate that rehabilitation intervention can improve the motor function and ADL in patients of apoplexy sequelae stage and the method of combining conventional rehabilitation and special rehabilitation can improve the motor function of patients better than conventional rehabilitation. Since that the studies included by this Systematic reviews are low-quality studies and the sample size is relatively small, the obtained inference requires caution. The treatment for motor dysfunction of apoplexy sequelae stage requires high-quality studies to reinforce the clinical evidence.3. Intensive rehabilitation treatment can improve the muscular tension, motor function, balance function and ADL of apoplexy sequelae stage patients with superior safety performance. Intensive rehabilitation treatment significantly outperforms family rehabilitation in improving the muscular tension and ADL of apoplexy sequelae stage patients. Intensive rehabilitation treatment generates higher average daily cost, produces higher cost-benefit ratio and requires support of certain economic base. Accordingly, patients receiving intensive rehabilitation treatment can achieve greater progress. |
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