目的：探讨肌电图导引下局部肌内注射A型肉毒毒素治疗脑卒中后肢体痉挛的疗效。

方法：研究对象为96例脑卒中后痉挛性偏瘫患者，按照痉挛程度较为严重的上肢或下肢的Fugl-Meyer评定（Fugl-Meyer Assessment，FMA）量表评分结果，分为上肢A组（26例，≥51分）、B组（21例，34～50分）和C组（9例，≤33分）以及下肢A组（25例，≥23分）、B组（12例，17～22分）和C组（3例，≤16分）。在肌电图导引下确定治疗靶肌肉，进行局部肌内注射A型肉毒毒素治疗（1次多点注射，每一例患者的总注射剂量≤400 U），并配合肢体功能训练。在治疗后1个月、3个月和6个月，采用改良Ashworth量表、FMA量表、改良Barthel指数、世界卫生组织生存质量测定量表、抑郁自评量表、焦虑自评量表和肌电图评估疗效。

结果：治疗后1个月、3个月和6个月，上肢A组FAM量表评分分别为60.35士1.51、62.35士3.01和64.10士2.56，B组FAM量表评分分别为39.10士2.23、42.12士2.34和43.09士1.89；下肢A组FAM量表评分分别为33.16士1.06、33.45士2.14和33.89士2.08，B组FAM量表评分分别为20.95士3.75、23.45士2.20和24.12士1.97。治疗后A组和B组的FAM量表评分均较治疗前明显改善（P＜0.05），但C组治疗前后FAM量表评分的差异无统计学意义（P＞0.05）。治疗后1个月，A组、B组和C组的总显效率和总有效率差异均有统计学意义（P＜0.05）；治疗后3个月和6个月，A组、B组和C组的总显效率和总有效率差异均无统计学意义（P＞0.05）。96例患者治疗后1个月、3个月和6个月的改良Barthel指数评分均较治疗前无显著改善（P＞0.05）；除环境评分以外，世界卫生组织生存质量测定量表的生理、心理和社会关系评分均较治疗前显著增加（P＜0.05）；抑郁自评量表评分和焦虑自评量表评分均较治疗前显著下降（P＜0.05）；A组和B组静息时自发电位活动均较治疗前明显减少，但C组的静息时自发电位活动较治疗前无明显变化。

结论：局部肌内注射A型肉毒毒素治疗脑卒中后肢体痉挛的疗效显著；配合有效的康复训练，可以迅速缓解或消除肌肉痉挛，并能改善生活质量和不良情绪。

Objective: To investigate the efficacy of local intramuscular injection of botulinum toxin A (BTX-A) guided by electromyography (EMG) in the treatment of limb spasm after stroke.

Methods: The subjects were 96 patients with spastic hemiplegia after stroke. According to the results of the Fugl-Meyer Assessment (FMA) scale of upper limbs or lower limbs with severer spasticity, these 96 patients were divided into upper limbs group A (n = 26, score ≥51), group B (n = 21, score 34-50) and group C (n = 9, score ≤33), and lower limbs group A (n = 25, score ≥23), group B (n = 12, score 17-22) and group C (n = 3, score ≤16). Local intramuscular injection of BTX-A (a multi-point injection, the total dose of each patient ≤400 U) was performed under the guidance of EMG, and combined with limb function training. One month, three months and six months after treatment, the efficacy was evaluated by Modified Ashworth Scale, FMA scale, Modified Barthel Index, World Health Organization Quality of Life Assessment Instrument, Self-rating Depression Scale, Self-rating Anxiety Scale and EMG.

Results: One month, three months and six months after treatment, the FAM scale scores of upper limbs groups A and B were 60.35±1.51, 62.35±3.01 and 64.10±2.56, and 39.10±2.23, 42.12±2.34 and 43.09±1.89, respectively; the FAM scale scores of lower limbs groups A and B were 33.16±1.06, 33.45±2.14 and 33.89±2.08, and 20.95±3.75, 23.45±2.20 and 24.12±1.89, respectively. The scores of FAM scale in group A and group B were significantly improved after treatment (P < 0.05), but there was no significant difference in the score of FAM scale in group C after treatment as compared with that before treatment (P > 0.05). One month after treatment, there were significant differences in total marked efficiency and total effective rate among group A, group B and group C (P < 0.05), but there were no significant differences in total marked efficiency and total effective rate among group A, group B and group C after 3 months and 6 months of treatment (P > 0.05). The Modified Barthel Index scores of 96 patients at 1, 3 and 6 months after treatment were not significantly improved compared with those before treatment (P > 0.05); besides environmental score, the physiological, psychological and social relationship scores of the World Health Organization Quality of Life Assessment Instrument were significantly increased compared with those before treatment (P < 0.05); the scores of Self-rating Depression Scale and Self-rating Anxiety Scale were significantly decreased compared with those before treatment (P < 0.05). The activities of spontaneous potential at rest in group A and group B were significantly lower than those before treatment, but there was no significant change in group C compared with that before treatment. 

Conclusion: Local intramuscular injection of BTX-A has a remarkable effect on limb spasm after stroke. Combined with effective rehabilitation training, muscle spasm can be quickly alleviated or eliminated, and the quality of life and the mood can be improved.