軀干控制測量量表在腦性癱瘓中的應(yīng)用進(jìn)展

譚朱江，張丹婷，趙秋旭，曹建國

深圳市兒童醫(yī)院康復(fù)科，廣東深圳市518038

Chae等[1]認(rèn)為，復(fù)雜軀體活動是完成高級運(yùn)動技能的先決條件，軀干控制則是進(jìn)行復(fù)雜軀體活動的先決條件。軀干作為身體的中心，是支持肢體活動、重心調(diào)節(jié)和其他一切活動的基礎(chǔ)，對人體姿勢平衡、運(yùn)動功能活動及日常生活能力具有重要作用[2-6]。腦癱是一組由于發(fā)育中胎兒或嬰幼兒腦部非進(jìn)行性損傷所致的持續(xù)存在的中樞性運(yùn)動和姿勢發(fā)育障礙、活動受限癥候群，常表現(xiàn)為軀干控制不良和平衡反應(yīng)欠佳，從而造成姿勢控制不良，日常生活活動和功能由此受到顯著限制[7-10]。目前，有許多臨床工具用于評估腦癱患者坐位軀干控制能力，但這些工具只適合評估腦癱患者坐位軀干控制的靜動態(tài)平衡能力[11]。

為了準(zhǔn)確、有效地評估腦癱患者坐位軀干控制下所有的功能和活動，并評估基于功能活動的軀干控制的基本要素，Heyrman等[12]開發(fā)了軀干控制測量量表(Trunk Control Measurement Scale,TCMS)，它是目前評估腦癱患者軀干控制較全面、準(zhǔn)確的測量量表[13]。隨著研究發(fā)展深入，研究人員還進(jìn)行TCMS與其他功能性量表的關(guān)聯(lián)性研究，如軀干控制能力與上肢功能、下肢功能、粗大運(yùn)動功能等之間的關(guān)系[14-16]。TCMS具有高信度和高效度，是評估腦癱患者坐位軀干控制能力的合適且可靠的量表[17]。目前國內(nèi)尚未引進(jìn)TCMS，在腦癱患者的評估和治療中，對軀干控制沒有足夠準(zhǔn)確、全面的測量方法，臨床上軀干控制訓(xùn)練的針對性和有效性較差。

本文詳細(xì)介紹TCMS的評估方法及其在國外的應(yīng)用現(xiàn)狀，期待將來能夠引進(jìn)國內(nèi)，用于指導(dǎo)臨床。

1 TCMS評估方法與內(nèi)容

1.1 評估方法

①受試者脫掉矯形器、鞋子或者軀干繃帶。

②每一項(xiàng)目的起始姿勢均相同。受試者坐在治療床的邊緣，背部、手臂和腳不能支撐，大腿緊貼桌子。

③雙手貼著身體并放松地置于腿上。受試者在開始每個項(xiàng)目之前都會被要求坐直，在完成任務(wù)的表現(xiàn)過程中需要維持直立姿勢。“直立”是指的是受試者能夠執(zhí)行的最直坐姿，因人而異，是識別患者是否畸形或者代償?shù)膮⒖甲藙?。每個項(xiàng)目重復(fù)執(zhí)行3次，選擇最好的表現(xiàn)得分計入總分。

④受試者在完成分量表的任務(wù)時，若靜態(tài)平衡需要單手支撐，僅允許將手平放于桌面，不允許緊抓。

1.2 評估內(nèi)容

①靜態(tài)坐位平衡：測試受試者在沒有支持的情況下保持靜態(tài)穩(wěn)定姿勢的能力。

②選擇性運(yùn)動控制：主動的或預(yù)期的平衡調(diào)整，檢查受試者的動態(tài)平衡能力。

③動態(tài)可達(dá)性：即反應(yīng)性平衡，檢查受試者在短暫的擾動后保持或恢復(fù)平衡的能力。

對TCMS總分及3個子量表進(jìn)行評價，總分的最大值為58分，包括靜態(tài)坐位平衡測試(5項(xiàng)，20分)和動態(tài)坐位平衡測試(10項(xiàng))，后者包括選擇性運(yùn)動控制(7項(xiàng)，28分)和動態(tài)可達(dá)性測試(3項(xiàng)，10分)[11-12,18]。見附表。

2 TCMS適用范圍

TCMS適用于評估5歲及以上神經(jīng)運(yùn)動功能障礙患者，包括腦癱、獲得性腦損傷、脊髓損傷、脊髓脊膜膨出、皮質(zhì)網(wǎng)狀束損傷等[19-21]，其中在腦癱患者功能評估中應(yīng)用最為廣泛。

3 TCMS信度和效度

Heo等[17]、Heyrman等[12,22]和Jeon等[18]對痙攣型腦癱患者進(jìn)行研究，結(jié)果均表明TCMS在評估痙攣型腦癱患者時具有高的信度和效度，以及較高重測信度和評分者間信度。此外，TCMS是評估痙攣型腦癱患者軀干控制能力合適、可靠的工具，且該量表可反映腦癱患者軀干控制的優(yōu)勢和劣勢，可有效判斷腦癱患者軀干損害程度，并為改善患者整體功能水平的治療干預(yù)方案提供具體線索。

Marsico等[20]調(diào)查TCMS及其子量表在腦癱、獲得性腦損傷和脊髓損傷等神經(jīng)運(yùn)動障礙患者中的信度和效度；其中，90例神經(jīng)運(yùn)動障礙患者(年齡5～18歲，平均11歲)參加信度研究，50例神經(jīng)運(yùn)動障礙患者(年齡5～18歲，平均11歲)參與效度研究；結(jié)果表明TCMS在5歲以上神經(jīng)運(yùn)動障礙患者中具有良好的信度和效度。此外，他們通過對患者的TCMS評分和功能獨(dú)立性量表(Functional Independence Measure,FIM)評分進(jìn)行比較來判別TCMS的有效性，結(jié)果顯示，若靜態(tài)平衡評分小于80%、動態(tài)可達(dá)性評分小于55%或選擇性運(yùn)動控制評分小于35%左右的患者，在日常生活活動中需要輔助。

TCMS評估腦癱患者具有較高的信度與效度，以及較高重測信度和評估者間信度，且TCMS評估其他神經(jīng)運(yùn)動障礙患者也具有良好的信度和效度。

4 TCMS與同類量表比較

坐姿量表(Level of Sitting Scale,LSS)、坐姿姿勢控制量表(Seated Postural Control Measure,SPCM)以及脊柱校準(zhǔn)和運(yùn)動范圍量表(Spinal Alignment and Range of Motion Measure,SAROMM)已在臨床實(shí)踐中用于評估腦癱患者的軀干控制能力[23-25]，但它們只適用于評估患者的靜態(tài)坐位平衡和動態(tài)坐位平衡，不能檢測出患者的反應(yīng)性平衡。TCMS總評分能夠準(zhǔn)確有效評估腦癱患者的靜態(tài)坐位平衡、動態(tài)坐位平衡和反應(yīng)性平衡的能力。TCMS評估內(nèi)容范圍較為全面，具有較高的可靠性和有效性[26]。

Ba?as等[27]通過研究后得出，TCMS評分與粗大運(yùn)動功能測量(Gross Motor Function Measure,GMFM)評分之間相關(guān)程度高于兒童伸手測試(Pediatric Reach Test,PRT)評分，表明TCMS較PRT可以更準(zhǔn)確地評估腦癱患者運(yùn)動功能水平；且SPCM、神經(jīng)運(yùn)動功能障礙兒童坐位評估(Sitting Assessment for Children with Neuromotor Dysfunction,SACND)和軀干控制的分段評估(Segmental Assessment of Trunk Control,SATCo)評估前均需要準(zhǔn)備具有規(guī)定尺寸的特定材料，而TCMS不涉及任何設(shè)備和材料，只需患者能夠遵循口頭指示，即可進(jìn)行評估，可節(jié)約大量成本。

此外，Hong[28]等對軀干損傷量表(Trunk Impairment Scale,TIS)和TCMS的結(jié)構(gòu)效度和反應(yīng)性進(jìn)行比較，結(jié)果顯示TCMS是TIS的擴(kuò)展版本，雖然評估比TIS更耗時，但TCMS有更高的檢測軀干功能變化的潛力，因?yàn)樗喔?xì)化的評估項(xiàng)目。

總之，TCMS是目前衡量功能活動期間軀干控制穩(wěn)定的基礎(chǔ)和軀干控制下的主動運(yùn)動的唯一量表[29]。它可以更有效、全面地評估腦癱患者靜態(tài)和動態(tài)下軀干控制能力及變化；鑒于TCMS在臨床康復(fù)中具有高度可靠性、有效性，建議廣泛用于臨床實(shí)踐。

5 TCMS與其他功能量表關(guān)聯(lián)性研究

為研究軀干控制能力與上肢功能之間的關(guān)系，Kim等[14]選用上肢技巧質(zhì)量測試(Quality of Upper Extremity Skills Test,QUEST)評估15例腦癱患者的上肢操作水平，同時對患者進(jìn)行TCMS評分，結(jié)果顯示患者的QUEST得分與TCMS得分呈正相關(guān)?？紤]到軀干功能與上肢的靈活性、協(xié)調(diào)性及抓握能力的相關(guān)性，可以認(rèn)為TCMS評分結(jié)果對于腦癱患者的上肢功能具有一定的提示作用。

為研究軀干控制能力與下肢功能之間的關(guān)系，Balzer等[15]使用改良Ashworth量表、徒手肌力評定(Manual Muscle Test,MMT)、下肢選擇性控制評估(Selective Control Assessment of Lower Extremity,SCAOTLE)和TCMS對52例腦癱患者分別進(jìn)行評定，結(jié)果顯示，在分別以肌肉力量和下肢的選擇性控制以及年齡為自變量的回歸模型中，軀干控制能力是步態(tài)能力的最強(qiáng)預(yù)測因子，且患者的下肢肌肉力量、下肢選擇性控制與軀干控制能力之間表現(xiàn)出強(qiáng)相關(guān)性。

為研究坐位軀干控制能力與粗大運(yùn)動功能能力之間的關(guān)系，Seyyar等[16]使用TCMS、GMFM-88和兒童殘疾評估功能性技能領(lǐng)域測試(PEDI-FSD)評估58例痙攣型腦癱患者，應(yīng)用Spearman相關(guān)分析將TCMS的得分與GMFM-88和PEDI-FSD的得分分別進(jìn)行關(guān)聯(lián)比較，結(jié)果表明TCMS與兩者均呈高度正相關(guān)。由此得出，TCMS可為痙攣型腦癱患者的粗大運(yùn)動功能評估提供有價值的信息。

為研究軀干控制能力與平衡功能之間的關(guān)系，Panibatla等[29]使用TCMS和兒童平衡量表(Paediatric Balance Scale,PBS)評估24例痙攣型腦癱患者，結(jié)果顯示TCMS評分與PBS評分顯著相關(guān)，且TCMS評分越高的患者，其PBS評分也越高。由此可見，痙攣型腦癱患者的軀干控制能力與平衡能力之間呈高度正相關(guān)。

為研究伴有尿失禁的痙攣型雙癱腦癱患者的軀干控制能力與尿失禁之間的關(guān)系，Talu[30]使用功能性失調(diào)和失禁癥狀評分問卷(Dysfunctional Voiding and Incontinence Symptoms Score,DVISS)、功能障礙性排尿癥狀評分(Dysfunctional Voiding Symptom Score,DVSS)、MMT和TCMS對50例痙攣型雙癱腦癱患者進(jìn)行評估，結(jié)果顯示，DVISS和DVSS評分與腹部肌肉力量、TCMS評分之間存在高度負(fù)相關(guān)關(guān)系；此外，研究者發(fā)現(xiàn)粗大運(yùn)動功能分級系統(tǒng)(Gross Motor Function Classification System,GMFCS)和DVISS以及GMFCS和DVSS之間均存在高度正相關(guān)關(guān)系。GMFCS評級越高，DVISS和DVSS評分越高，TCMS評分越低，提示痙攣型雙癱腦癱患者的軀干控制能力與尿失禁癥狀之間呈高度負(fù)相關(guān)。

6 小結(jié)

TCMS是目前評估腦癱患者軀干控制較全面、準(zhǔn)確的測量量表，適于評估坐姿軀干姿勢控制下所有功能活動，觀察患者軀干姿勢控制的優(yōu)勢與劣勢，有效區(qū)分患者日常生活活動的獨(dú)立性與依賴性，可為臨床治療提供指導(dǎo)，為通過干預(yù)軀干控制來改善患者的功能活動提供依據(jù)。此外，TCMS也可與其他功能量表聯(lián)合檢測，為腦癱患者的功能能力提供更詳細(xì)更有價值的信息，更全面地評估患者目前的運(yùn)動功能水平，為改善患者整體功能水平的治療干預(yù)方案提供具體線索，從而提高患者的生活質(zhì)量。同時，TCMS適用于5歲及以上患有各類神經(jīng)損傷患者的軀干功能評估，雖然目前相關(guān)文獻(xiàn)研究報道較少，尚無足夠研究證據(jù)支持，但相信將來相關(guān)研究會越來越多、越來越深入。鑒于TCMS的各種優(yōu)良特性，我們期待未來能將其引進(jìn)國內(nèi)，豐富腦癱患者功能評估內(nèi)容，指導(dǎo)治療，評定治療效果，造福更多的腦癱患者。

附錄：Trunk Control Measurement Scale

Right Item 1 Static Sitting Balance Testing procedure：Each item is verbally explained to the patient and demonstrated by the tester if needed.Starting position(unsupported sitting,hands on legs)Patient isinstructed to sit upright and hold this position for 10 seconds Bilat/Left□0□1□2 2Starting position Patient lifts both arms at eye height in one second and returns to starting position□0□1 3Starting position Therapist crosses one leg over the other leg□2□0□0 Patient falls or can only maintain upright sitting with double arm support Patient can only maintain upright sitting with single arm support for 10 seconds Patient can maintain upright sitting without arm support for 10 seconds If score=0,then total score=0 Patient falls or can not lift arms Patient can lift arms without falling but with compensations.Possible compensations are：(1)backward lean,(2)increase of trunk flexion,(3)lateral flexion,and(4)other Patient liftsarms without compensations Patient falls,can not cross legs or can only maintain sitting with double arm support Patient can maintain sitting with single arm support for 10 seconds Patient can maintain sitting without arm support for 10 seconds Patient falls,can not cross legs or can only cross legs with double arm support Patient can only cross legs with single arm support Patient crosses legs without arm support but with clear trunk displacement Patient crosses legs with minimal trunk displacement Patient falls,can not abduct leg or can only abduct leg with double arm support Patient can only abductleg with singlearm support Patient abducts leg without arm support but with clear trunk displacement Patient abducts leg with minimal trunk displacement□1□1□2□2 4Starting position Patient crosses one leg over the other leg(assistance with one hand is allowed)'minimal'=small trunk movements without signs of imbalance of trunk during movement of leg'clear'=clear signs of imbalance i.e.lateral flexion or flexion of trunk□0□0□1□1□2□2□3□3 5Starting position Patient abducts one leg over 10 cm and returns to starting position(10 cm width=width of the knee)'minimal'=small trunk movements without signs of imbalance of trunk during movement of leg'clear'=clear signs of imbalance i.e.lateral flexion or flexion of trunk□0□0□1□1□2□2□3□3 Total static sitting balance /20

Dynamic Sitting Balance Item Bilat/Left Right 6a Selective movement control Testing procedure：Firstly,each item is verbally explained and demonstrated by the tester.Secondly,the item is demonstrated on the patient with manual guidance.Thirdly,the patient is asked to perform the expected movement under manual guidance of the tester.Then,the patient performs the item on its own in three attempts.Starting position：arms crossed over chest Patient is instructed to lean forward with a fixed trunk for approximately 45°and return to starting position normal righting reaction of the head i.e.limited head extension is not scored as a compensation Patient falls or can not reach target position Patient can lean forward If score=0,then item 6b=0□0□1 6b 7a Starting position：arms crossed over chest Patient is instructed to lean backward with a fixed trunk for approximately 45°and return to starting position normal righting reaction of the head i.e.limited head flexion is not scored as a compensation Patient compensates(1)increased head extension,(2)increased trunk flexion,(3)increased lumbar lordosis,(4)increased knee flexion,and(5)other Patient leans forward without compensations Patient falls or can not reach target position Patient can lean backward If score=0,then item 7b=0□0□1□0□1 7b □0 8a Starting position Patient is instructed to touch the table with the elbow at level of the femoral head(by shortening the ipsilateral side and lengthening the contralateral side)and return Patient compensates(1)increased head flexion,(2)increased trunk flexion,(3)increased knee extension,and(4)other Patient leans backward without compensations Patient falls or does not touch the table with the elbow Patient can touch the table with the elbow If score=0,then item 8b and 8c=0□1□0□1□0□1 8b □0□0 Patient demonstrates(1)no shortening/lengthening or(2)opposite shortening/lengthening Patient demonstrates expected shortening/lengthening If score=0,then item 8c=0 Patient compensates：(1)increased trunk flexion,(2)forwardor backward lean,(3)pelvic lift,and(4)other Patient touches the table without compensations Patient falls or can not lift the pelvis Patient can lift the pelvis If score=0,then item 9b and 9c=0□1□1 8c □0□0 9a Starting position Patient is instructed to lift the pelvis at one side and return to starting position.No lifting of the thigh is allowed.□1□0□1□1□0□1

續(xù)表

Dynamic Sitting Balance Item Selective movement control Testing procedure：Firstly,each item is verbally explained and demonstrated by the tester.Secondly,the item is demonstrated on the patient with manual guidance.Thirdly,the patient is asked to perform the expected movement under manual guidance of the tester.Then,the patient performs the item on its own in three attempts.Bilat/Left Right 9b □0□1□0□1 9c□2□0□2□0□1 10a Starting position：arms crossed over chest Patient is instructed to rotate the upper trunk three times with head fixated in starting position.The movement is initiated from the shoulder girdle.□1□0□1□2 10b 11a Starting position：arms crossed over chest Patient is instructed to rotate the upper trunk three times with head fixated in starting position.The movement is initiated from the shoulder girdle.□0□1□0□1□2 11b 12a Starting position：arms crossed over chest Patient is instructed to shuffle the pelvis three times in a forward direction and return backwards in three times to the starting position Shuffle movement=combination of lateral flexion and rotation with the pelvis,alternated left and right□1□2□0□1□2 12b Patient demonstrates no shortening/lengthening Patient demonstrates partially expected shortening/lengthening(partial=short and/or small ROM)Patient demonstrates expected shortening/lengthening If score=0,then item 9c=0 Patient compensates：(1)contralateral head flexion,(2)marked lateral trunk displacement,and(3)other Patient lifts the pelvis without compensations Patient(1)falls,(2)can not rotate the upper trunk i.e.patient can not perform the rotation movement,even not with the entire trunk,or(3)demonstrates no selective rotation of the upper trunk(en bloc)Patient demonstrates partial selective rotation of the upper trunk(partial=asymmetrical,small ROM,more shoulders than trunk)Patient demonstrates expected selective rotation of the upper trunk If score=0,then item 10b=0 Patient rotates the upper trunk with head rotation Patient rotates the upper trunk without head rotation Patient(1)falls,(2)can not rotate the lower trunk i.e.patient can not perform the rotation movement,even not with the entire trunk,or(3)demonstrates no selective rotation of the lower trunk(en bloc)Patient demonstrates partial selective rotation of the lower trunk(partial=asymmetrical,small ROM,additional movement of upper trunk)Patient demonstrates expected selective rotation of the lower trunk If score=0,then item 11b=0 Patient compensates with pelvic tilt Patient rotates the lower trunk without compensations Patient falls or can not shuffle the pelvisin forward and backward direction i.e.no displacement of the body in either direction Patient can partially shuffle the pelvis(partial=with mainly lateral flexion and little rotation;small ROM;takes a lot of effort)Patient can shuffle the pelvis by use of both lateral flexion and rotation in one direction and partially in the other direction Patient can shuffle the pelvis by use of both lateral flexion and rotation in both directions If score=0,then item 12b=0 Patient compensates with excessive trunk displacement Patient shuffles pelvis without compensations Total selective movement control□3□1□2/28

注：TCMS英文版已獲原作者Lieve Heyrman許可：(Iam very pleased with your interest in the TCMSand your initiative to translate it into Chinese.Therefore,Igive you the permission to use the TCMSand to start up the translation process of the TCMS.Iwish you the best with your work on this.)

Item 13 Dynamic reaching(equilibrium reactions)Testing procedure：Each item is verbally explained by the tester and then performed three times by the patient.Starting position：arms straight forward Patient isinstructed to reach forward with both arm straight to target at eye level positioned at a distance,corresponding with the forearm length and return to starting position Bilat/Left□0□1 Right□0□1 Patient falls or can not reach target Patient reaches target,but has difficulties in performance.Difficulties are：(1)takes a lot of effort i.e.slow and with difficulty or(2)usessome support of hand when approaching the starting position Patient reaches target and returns to starting position without difficulties Patient falls or can not reach target Patient reaches target,but has difficulties in performance.Difficulties are：(1)takes a lot of effort i.e.slow and with difficulty or(2)usessome support of hand when approaching the starting position Patient reaches target and returns to starting position without difficulties Patient falls or can not reach target Patient reaches target,but has difficulty in performance.Difficulties are：(1)takes a lot of effort i.e.slow and with difficulty or(2)usessome support of hand when approaching the starting position Patient reaches target and returns to starting position without difficulties□2□2 14Starting position：one arm straight sideward and other hand on leg Patient isinstructed to reach sideward with one arm straight to target at eye level positioned at a distance,corresponding with the forearm length and return to starting position□0□1□0□1□2□2 15Starting position：one arm straight sideward and other hand on leg Patient isinstructed to reach across the midline with one arm(reach to the opposite side)and return to starting position.The target ispositioned at eye level at a distance corresponding with half the forearm length of the reaching arm.□0□1□0□1□2□2 Total dynamic reaching Total TCMSscore/10/58