| Objective:stroke is a high incident disease which disorders the nervous system and causes disability. There is certain way in the recovery of motor function after stroke: the body and limbs lost the control from upper central nervous system. Then the sub-cortical motor reflex was released form inhibition, which caused specific movement including muscle weakness, disorder of muscle coordination and abnormal tension. The typical gait is often shown as foot drop, varus, hemiplegia hip abduction and external rotation of the circle gait. Conditions like decreased gait stability,increased energy consumption, asymmetric walking after stroke has become important factors which affect the quality of life in patients. The purpose of this study is that to use a modified constraint induced movement therapy in early training on post-stroke patients to facilitate the recovery of walking ability, to explore the effects of this therapy on motor function, balance and walking ability in patients, to analyze the biomechanical characteristics of gait changes in patients by a 3D motion analysis system.Methods:40 stroke patients who met the inclusion criteria were selected from Huashan hospital. They were randomly divided into control group of 20 patients who were treated with conventional training group(age 59.1±7.99) and the experimental group of 20 cases of modified constraint induced movement therapy training group(age59.05 ± 6.01, referred to as m CIMT group).Both of them received rehabilitation therapy after preliminary studies in clinical promotion of standardized comprehensive stroke training project, and the m CIMT group add modified constraint induced movement therapy of lower extremity training(2 hours a day for 5 days per week,study last 8 weeks), while the control group increased 3 more assessment based on the standardized comprehensive rehabilitation therapy of stroke rehabilitation guidance,teached patients to complete 2 hours of activities every day under the supervision of families and caregivers since selected. All patients were assessed weekly including clinical evaluation, motor function and walking ability as followed: assessment of motor function(Fugl-Meyer FMA, 0-66&0-34 of upper limb&lower limb), Berg Balance scale(BBS, 0-56), ADL Barthel(BI, 0-100), stand up and walk test(TUG seconds), 10 m walking speed(T10, m) and 6-minute walk test(6MWT, m) at baseline,after 4 weeks of 8 and after 8 weeks; There were 11 informed patients enrolled in the gait test, three-dimensional gait testing at baseline and 4 weeks after treatments: kinematics capture system, synchronous acquisition of the subjects in the trunk and lower limb joint 10 meters walking walkway the 3-D force platform Kistler and Delsys wireless sensor EMG(hip, knee and ankle kinematics / dynamics) data,and the main muscles of EMG signal(erector spinae, rectus femoris, vastus medialis,vastus lateralis muscle, tibialis anterior muscle, gastrocnemius medial, lateral gastrocnemius), using the obtained Visual3 D the data of EMG works etc. Signal analysis software for post-processing and analysis.All the data were analyzed by using excel2010 and SPSS 19.0 statistical software. The differences between the groups were analyzed by repeated ANOVA,while in-group comparison between different time points by using paired t test. P<0.05 was considered statistically significant.Results:1)results of clinical rehabilitation scale The patients in bothgroups showed Fugl Meyer- upper part were increased significantly after treatment, the m CIMT group went from 37.45±4.73 points at the beginning up to 40.55±4.74 points at 4 weeks and 45.5±4.56 points at 8 weeks(P >0.05); the control group from 30.8±5.38 to 33.95±5.45 points and to 37.45±5.05 points at 8 weeks(P > 0.05); there was no significant difference between the two groups in each period(P > 0.05).Before and after the intervention, lower extremities function of patients in both groups were increased significantly by the Fugl Meyer assessment, the m CIMT group started from 24.05±1.04 to 27.3±1.11 points in 4 weeks and to 30.55±0.93 points in 8 weeks(P < 0.05); the control group from 21.7±2.07 to 24.05±1.75 points in 4weeks and of 27.25±1.25 in 8 weeks. There was no significant difference between the two groups in each period(P > 0.05).Before and after the intervention, daily life activities and Barthel score in two groups were significantly increased.The m CIMT group started from 78.25 ± 4.23 points up to of 85 ± 3.0 points at 4 weeks and to 91.90±2.14 points at 8 weeks,in-group comparison between baseline and 8 weeks showed differences(P < 0.05);the control group from 69.25±5.77 points up to 73.0±5.07 points at 4 weeks and to 80.9±4.22 points at 8 weeks, it showed no significant difference within(P > 0.05)and between groups(P > 0.05), which suggested that the daily life activity in m CIMT group is better than those in control group.2) Results of walking ability.The standing up and walking time test showed that,before and after intervention, the m CIMT group started from 41.85±3.7 seconds down to 23.91±3.17 after 4 weeks and to 19.73±3.94 seconds after 8 weeks, there was no significant difference after 4 weeks(P>0.05), and the stand-walking time showed statistically significant difference after 8 weeks(P<0.05); the control group started from 44.68 ±26.50 seconds down to 38.31 ± 23.70 seconds at 4 weeks and to 33.96 ± 20.95 seconds at 8 weeks, t had there was no difference in control group(P>0.05); there was significant differences between two groups(P<0.05), and there was no significant difference in the rest of the period. The results indicated that, after 8-weeks ’intervention for stroke patients, walking up coordination ability of modified constraint induced movement therapy is better than conventional intervention group.10 meters walking speed test results showed that after 8 weeks of intervention,walking speed in m CIMT group was significantly better than those in the control group(P<0.05), and the rest of the two groups had no significant difference. The m CIMT group started from 41.67±4.94 seconds down to 25.46±3.82 seconds at 4weeks and to 19.16 ± 2.69 seconds at 8 weeks. The m CIMT group showed no difference after 4-week ’ s treatment(P>0.05), but had statistically significant differences after 8-week’s treatment(P<0.05); The control group started from 42.98±5.58 seconds down to 37.97±4.93 seconds at 4 weeks and to 34.31±4.33 seconds at 8 weeks. The control group had no difference before and after the intervention(P>0.05);The results suggested that after 8-week’s training by the modified constraint induced movement therapy,the walking speed improvement is better than conventional treatment group.6 minutes walking ability examination. After 8-week’s treatment, patients in m CIMT group, walking distance was significantly longer than the control group(P<0.05), there was no statistical differences between the two groups in the rest of the same period. The m CIMT group started from 113.95 ±19.14 meters up to 175.43±22.36 meters at 4 weeks, and to 223.81 ± 22.29 meters at 8 weeks. There was statistically significant difference Before and after the treatment(P<0.05), the statistical analysis after 4-week’s intervention group showed no difference(P>0.05),and after-8 week’s intervention the difference was statistically significant(P<0.05);the control group started from 107.29±17.34 meters up to119.45±17.61 meter at 4weeks and to 129.90 ± 17.65 meters after 8 weeks. The control group showed no significant difference after treatment(P>0.05). The results suggested that after8-week ’ s training, the m CIMT treatment was better than conventional treatment group in walking ability.3) Changes in the dynamic balance ability Before and after the intervention, results of Berg balance scale showed that the balance ability of patients in the m CIMT group and the control group were improved significantly, and had a statistical significant difference between the two groups after8 weeks(P<0.05).The m CIMT group started from 43.6±1.78 points to 47.05±1.15 at4 weeks, and to 50.7±1.01 at 8 weeks. By statistical analysis, the intervention group had no significant difference after 4-week’s treatment(P>0.05), and showed statistical difference after 8-week ’s intervention when compared with baseline(P<0.05); the control group started from 41.4±3.03 points to 45.85±2.44 at 4 weeks, and to 48.7 ±1.01 at 8 weeks. And the control group before and after the intervention had no difference(P>0.05). The results suggested that after 8-week’s m CIMT training in stroke patients, the balance ability improvement was better than conventional treatment group.In the process of walking, the body position of COM on stroke patients showed that the peak height in the m CIMT group after treatment, the affected side support phase COM increased from 91.04 cm to 92.38 cm, which had statistically significant difference(P<0.05), COM swing in the frontal axis interval maximum value decreased from 10.15 cm to 7.83 cm,which significantly better than the control group(P<0.05). The result indicated that after 4-week ’ s modified constraint induced movement therapy, the centroid of stroke patients tended to be normal, gait stability was improved.4) Changes in temporal parameters and kinematic After the intervention, the basic temporal and spatial parameters of gait of patients in two groups were improved. The speed of m CIMT group increased from0.31±0.15 m/s to 0.44±0.22 m/s(P<0.05), step width decreased from 0.19±0.09 m to 0.16 + 0.04m(P<0.05), the contralateral step increased from 0.30±0.14 m to 0.35±0.11m(P<0.05), which showed a statistically significant difference. Contralateral swing phase percentage increased from 24.44±7.26 to 29.80±6.58(P<0.01), which appeared statistically significant difference, ipsilateral and contralateral step swing phase percentage has increased, but the difference did not appear significantly in control group. The pace of control group increased from 0.27±0.11m/s to 0.28±0.11m/s, the contralateral step increased from 0.22 ± 0.08 m to 0.26 ± 0.07 m, the percentage of contralateral swing phase time increased from 21.18±7.71 to 23.34±7.57. Although these parameters have been improved, the difference did not come out.Before and after the intervention, the changing trend of the hip, knee, ankle joint angle of two groups were coordinated. In m CIMT group, the ipsilateral ankle plantar flexion angle at toe off by 24.14±6.32 degrees down to 19.80±4.47(P<0.05), in the toe when they hit the ground reduced from 31.11±7.50 to 24.69±6.04 degrees(P<0.05). When compared with the 29.79±3.87 degrees of control group after the intervention, it showed a statistically significant difference(P<0.05); In the toe off time of ipsilateral pelvic tilt between the 2 groups showed significant difference(P<0.05), m CIMT group with contralateral pelvic tilt in the toe off by 5.81±3.06 degrees down to 5.04 ± 2.34 degrees, the control group from 7.20 ± 4.25 degrees down to 6.96±4.06 degrees; In the toe off time of the ipsilateral hip abduction angle changes of the m CIMT group compared with the control group had a significant difference(P<0.05).5) RMS results of surface EMG test In each period, the 2 groups were no significant differences in surface EMG time domain index RMS value(P>0.05), but some muscles showed a significant difference before and after the intervention. The m CIMT group in early support and swing phase, surface EMG RMS of ipsilateral erector spinae value increased significantly(P<0.01), from 36.2% to 82.1% in the early support, from 41.3% to67.2% during the swing phase; the control group three thigh muscles of rectus femoris(i.e. early support of rectus femoris increased from 10.53% to 7.12% at the start, the support increased from 5.67% to 8.22% at the end), vastus lateralis(early support started from 3.36% to 9.68%, increased from 2.35% to 4.48% at the end of the support) and vastus medialis( from 4.27% to 10.02% at early phase, increased from3.83 to 5.84% at the end).In the m CIMT group, before and after treatment in the support phase was increased obviously, and it showed significant difference in the early and late support phase(P<0.01).4 weeks after the intervention, the m CIMT group of anterior tibial muscle RMS value increased significantly during the swing phase(P<0.05), from 5.81% to 9.52%.In the early support phase, the control group significantly increased the lateral head of the gastrocnemius muscle(P<0.05), from 6.87% to 12.51%;in the end support phase,the anterior tibial muscle support increased from 4.03% to 12.23%, showed significant difference(P<0.05).Conclusions:Stroke patients with hemiplegia undergo a lower limb modified constraint induced movement therapy, the BBS balance function and walking up timing test,10 meters walking speed and 6 minutes walking ability is improved after 8 weeks of intervention, which shows the modified constraint induced movement therapy is effective in promoting patient balance, coordination of walking, walking speed and walking endurance clinical.Modified constraint induced movement therapy training for 4 weeks can improve post-stroke patients effectively in pace, step and contralateral swing phase time percentage of spatio-temporal gait parameters.Modified constraint induced movement therapy with induced lower extremity large, repetitive and intensive behavioral plasticity skills training can effectively improve the hip abduction, knee flexion and ankle plantar flexion angle in post-stroke patients.Modified constraint induced movement therapy can improve pelvic tilt, body center position, the stability of walking posture and the dynamic balance ability.By using surface electromyography study speculated that the modified constraint induced movement therapy helps patients to control lower limb extensor spasm, abnormal walking pattern.It is safe and effective to increased mandatory training exercise therapy 2 hours a day for 8 weeks in patients who had stroke within 2-4 month. It is worthy of clinical application. |
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