中风后的步行水平是参与和残疾的长期预测指标。下肢运动控制降低会影响步行和整体活动能力。本临床实践指南(CPG)的目的是为使用踝足矫形器(AFO)或功能性电刺激(FES)作为改善身体功能和结构的干预措施提供指导临床决策的证据。活动,和国际功能分类所定义的参与,中风后偏瘫患者下肢运动控制下降的残疾与健康(ICF)。
对截至2019年11月发表的所有涉及卒中和AFO或FES的研究的7个数据库进行了文献综述。提取的数据包括中风后的时间,参与者特征,设备类型,评估结果,和干预参数。在初次应用和培训后检查结果。建议是根据证据的强度和潜在的好处来确定的,伤害,风险,或提供AFO或FES的成本。
一百二十二份荟萃分析,系统评价,随机对照试验,纳入了队列研究。有强有力的证据表明,AFO和FES都可以提高步态速度,移动性,动态平衡。有适度的证据表明,AFO和FES提高了生活质量,行走耐力,和肌肉激活,和薄弱的证据存在改善步态运动学。不应使用AFO或FES来减少plant屈肌痉挛。直接比较AFO和FES的研究并未表明一种比另一种的总体优势。但是有证据表明,AFO可能导致更多的代偿作用,而FES可能导致更多的治疗作用。由于中风后任何阶段的潜在增益,最适合个人的设备可能会改变,和重新评估应完成,以确保设备满足个人的需求。
对于大多数结果,本CPG无法解决一种类型的AFO对另一种类型的AFO的影响,因为研究使用了多种AFO类型,很少有区别的效果。这些建议也没有解决偏瘫的严重程度,大多数研究包括具有不同基线步行能力的参与者。
本CPG提示AFO和FES均可导致卒中后改善。未来的研究应该检查供应的时间,设备类型,干预持续时间和交付,长期随访,响应者与非响应者,和损伤更大的个人。
这些建议旨在指导临床医生优化中风后偏瘫患者的康复效果,这些患者下肢运动控制下降,影响下床活动和整体活动能力。视频摘要可作为作者的补充数字内容获得(可在http://链接上获得。www.com/JNPT/A335)。
Level of ambulation following stroke is a long-term predictor of participation and disability. Decreased lower extremity motor control can impact ambulation and overall mobility. The purpose of this clinical practice
guideline (CPG) is to provide evidence to guide clinical decision-making for the use of either ankle-foot orthosis (AFO) or functional electrical stimulation (FES) as an intervention to improve body function and structure, activity, and participation as defined by the International Classification of Functioning, Disability and Health (ICF) for individuals with poststroke hemiplegia with decreased lower extremity motor control.
A review of literature published through November 2019 was performed across 7 databases for all studies involving stroke and AFO or FES. Data extracted included time post-stroke, participant characteristics, device types, outcomes assessed, and intervention parameters. Outcomes were examined upon initial application and after training. Recommendations were determined on the basis of the strength of the evidence and the potential benefits, harm, risks, or costs of providing AFO or FES.
One-hundred twenty-two meta-analyses, systematic reviews, randomized controlled trials, and cohort studies were included. Strong evidence exists that AFO and FES can each increase gait speed, mobility, and dynamic balance. Moderate evidence exists that AFO and FES increase quality of life, walking endurance, and muscle activation, and weak evidence exists for improving gait kinematics. AFO or FES should not be used to decrease plantarflexor spasticity. Studies that directly compare AFO and FES do not indicate overall superiority of one over the other. But evidence suggests that AFO may lead to more compensatory effects while FES may lead to more therapeutic effects. Due to the potential for gains at any phase post-stroke, the most appropriate device for an individual may change, and reassessments should be completed to ensure the device is meeting the individual\'s needs.
This CPG cannot address the effects of one type of AFO over another for the majority of outcomes, as studies used a variety of AFO types and rarely differentiated effects. The recommendations also do not address the severity of hemiparesis, and most studies included participants with varied baseline ambulation ability.
This CPG suggests that AFO and FES both lead to improvements post-stroke. Future studies should examine timing of provision, device types, intervention duration and delivery, longer term follow-up, responders versus nonresponders, and individuals with greater impairments.
These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for people with poststroke hemiplegia who have decreased lower extremity motor control that impacts ambulation and overall mobility.A Video Abstract is available as supplemental digital content from the authors (available at: http://links.lww.com/JNPT/A335).