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中华脑血管病杂志(电子版)

中华脑血管病杂志(电子版) ›› 2025, Vol. 19 ›› Issue (05) : 364 -374. doi: 10.3877/cma.j.issn.1673-9248.2025.05.002

论著

脑卒中偏瘫患者连续步行中骨盆不对称活动的动态分析
吴章薇1,2, 张通1,2,†(), 赵军1,2, 周昊2, 李冰洁2   
  1. 1　100068　北京，首都医科大学康复医学院
    2　100068　北京，中国康复研究中心北京博爱医院神经内科
  • 收稿日期:2025-06-24
  • 通信作者: 张通
  • 基金资助:
    国家重点研发计划项目(2023YFC3605200，2023YFC3605204)

Dynamic analysis of pelvic asymmetric activity during continuous walking in stroke patients with hemiplegia

Zhangwei Wu1,2, Tong Zhang1,2,†(), Jun Zhao1,2, Hao Zhou2, Bingjie Li2   

  1. 1 School of Rehabilitation Medicine, Capital Medical University, Beijing 100068, China
    2 Department of Neurology, Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing 100068, China
  • Received:2025-06-24
  • Corresponding author: Tong Zhang
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引用本文：

吴章薇, 张通, 赵军, 周昊, 李冰洁. 脑卒中偏瘫患者连续步行中骨盆不对称活动的动态分析[J/OL]. 中华脑血管病杂志(电子版), 2025, 19(05): 364-374.

Zhangwei Wu, Tong Zhang, Jun Zhao, Hao Zhou, Bingjie Li. Dynamic analysis of pelvic asymmetric activity during continuous walking in stroke patients with hemiplegia[J/OL]. Chinese Journal of Cerebrovascular Diseases(Electronic Edition), 2025, 19(05): 364-374.

目的

分析脑卒中患者骨盆偏瘫侧和非偏瘫侧之间的不对称性，并分析连续步行中骨盆偏瘫侧和非偏瘫侧不对称的渐进变化趋势。

方法

收集2020年10月至2022年9月中国康复研究中心北京博爱医院神经内科收治的脑卒中患者25例。入组患者接受三维步态分析，步态任务为连续步行最长距离。整个步行数据分为步行初期、步行中期、步行末期。弃去前3个步行周期，步行初期骨盆角度1（A1）为第4~6个步行周期的均值，步行末期A3为步行停止前3个步行周期的均值，步行中期A2为A1和A3中间的连续3个骨盆角度的均值；根据步行距离分为室内步行组（步行距离50~200 m）和室外步行组（步行距离>200 m）。分析骨盆三轴（X轴前倾/后倾，Y轴向上侧倾/向下侧倾，Z轴旋内/旋外）偏瘫侧和非偏瘫侧关节角度的差异；分析连续步行中骨盆三轴关节角度的渐进变化趋势；分析不同步行能力患者骨盆三轴关节角度渐进性变化趋势的差异。

结果

在整个步行周期中，骨盆偏瘫侧和非偏瘫侧的最大前倾（PTAmax；t=2.614，P=0.011）、最大向上侧倾（POAmax；Z=2.115，P=0.034）、步行初期骨盆前后倾斜活动范围（PTAROM1；t=2.829，P=0.009）、步行末期与步行初期骨盆前后倾斜活动范围差值（PTAROM3-1；t=3.263，P=0.003），组间差异均有统计学意义。在连续步行中，偏瘫侧PTAmax（F=3.295，P=0.046）和前后倾斜活动范围（PTAROM；F=4.374，P=0.018）均渐进增大，差异均有统计学意义；进一步分析发现，有统计学意义的渐进增大PTAmax体现在室内步行组（F=5.830，P=0.009）、PTAROM体现在室外步行组（F=3.500，P=0.046）。偏瘫侧骨盆最大旋内（PRAmax；F=3.306，P=0.046）及旋转活动范围（PRAROM；F=4.896，P=0.012）、非偏瘫侧PRAROM（F=4.454，P=0.017）均渐进减小，差异均有统计学意义；进一步分析发现，有统计学意义的渐进减少见于偏瘫侧PRAmax（F=3.484，P=0.048）室内步行组。

结论

脑卒中患者步行周期中骨盆偏瘫侧和非偏瘫侧前倾和侧倾存在不对称改变。在连续步行中，骨盆偏瘫侧前倾、前后倾斜范围、旋内均呈渐进变化，而非偏瘫侧骨盆未见对称性改变，且步行能力差的患者骨盆不对称改变更显著。

关键词: 脑卒中, 步态分析, 骨盆不对称, 康复
Objective

To analyze the asymmetry between the hemiplegic and non-hemiplegic sides of the pelvis in stroke patients and analyze the progressive changes in pelvic asymmetry during continuous walking.

Methods

A total of 25 stroke patients admitted to the Neurology Department of Beijing Bo'ai Hospital of China Rehabilitation Research Center, from October 2020 to September 2022 were enrolled. The enrolled patients underwent three-dimensional gait analysis, with the gait task being the maximum continuous walking distance. The entire gait cycle was divided into three phases: initial, middle, and terminal. The first three gait cycles were excluded. The pelvic angle (angle 1, A1) in the initial phase was the mean of the 4th to 6th gait cycles, while the terminal phase angle (A3) was the mean of the last three gait cycles before stopping. The middle phase angle (A2) was the mean of three consecutive pelvic angles between A1 and A3. Based on walking distance, patients were divided into an indoor walking group (50-200 m) and an outdoor walking group (>200 m). Differences in pelvic joint angles (X-axis: anterior/posterior tilt; Y-axis: up/down obliquity; Z-axis: internal/external rotation) between the hemiplegic and non-hemiplegic sides were analyzed. The progressive trends of pelvic joint angles during continuous walking were assessed, and differences in these trends between patients with varying walking abilities were examined.

Results

Significant differences were observed between the hemiplegic and non-hemiplegic sides in: maximum pelvis anterior tilt angles (PTAmax; t=2.614, P=0.011), maximum up obliquity angles (POAmax; Z=2.115, P=0.034), the range of motion (ROM) of pelvic tilt (PTAROM1) in the initial phase (t=2.829, P=0.009), the ROM of pelvic tilt between terminal and initial phases (PTAROM3-1; t=3.263, P=0.003). During continuous walking, the hemiplegic side showed statistically significant progressive increases in both PTAmax (F=3.295, P=0.046) and PTAROM (F=4.374, P=0.018). Further analysis revealed statistically significant progressive increases in PTAmax specifically in the indoor walking group (F=5.830, P=0.009), while significant progressive increases in PTAROM were observed in the outdoor walking group (F=3.500, P=0.046). The hemiplegic side demonstrated statistically significant progressive reductions in both maximum pelvic internal rotation (PRAmax; F=3.306, P=0.046) and the ROM of pelvic rotation (PRAROM; F=4.896, P=0.012), with the non-hemiplegic side also showing significant progressive decrease in PRAROM (F=4.454, P=0.017). Further analysis identified that the significant progressive reduction in hemiplegic-side PRAmax was particularly evident in the indoor walking group (F=3.484, P=0.048).

Conclusion

Stroke patients demonstrate asymmetric alterations in pelvic tilt and obliquity between the hemiplegic and non-hemiplegic sides during the entire gait cycle. During continuous walking, progressive changes occurre in pelvic anterior tilt, range of motion of pelvic tilt and internal rotation on the hemiplegic side, while the non-hemiplegic side showes no symmetrical changes. Patients with poor walking ability experience more significant changes in pelvic asymmetry during continuous walking.

Key words: Stroke, Gait analysis, Pelvic asymmetry, Rehabilitation
表1 室内步行组和室外步行组基线资料比较
基线资料 室内步行组（n=12） 室外步行组（n=13） 统计值 P值
年龄（岁，
）		 51.83±10.80 49.46±13.67 t=0.479 0.637
性别[例（%）] - 0.096*
男 12（100.00） 9（69.23）
女 0（0） 4（30.77）
身高（cm，
）		 171.33±6.64 167.23±6.44 t=1.568 0.131
体质量（kg，
）		 76.67±14.71 72.00±10.20 t=0.928 0.363
病程（d，
）		 48.08±21.26 35.85±16.38 t=1.620 0.119
卒中类型[例（%）] χ2=0.811 0.368
出血 1（8.33） 4（30.77）
梗死 11（91.67） 9（69.23）
偏瘫侧[例（%）] - 0.322*
左 3（25.00） 8（61.54）
右 9（75.00） 5（38.46）
步行速度（m/s，
）		 0.28±0.17 0.56±0.21 t=3.787 0.001
表2 偏瘫侧和非偏瘫侧骨盆三轴最大角度比较（°）
项目 例数 PTAmax（
）		 POAmax[M（QR）] PRAmax[M（QR）]
偏瘫侧 25 31.19±0.674 4.78（3.33，6.74） 4.25（1.53，6.79）
非偏瘫侧 25 31.55±0.696 4.54（1.77，5.93） 4.54（1.77，5.93）
统计值 t=2.614 Z=2.115 Z=1.241
P值 0.011 0.034 0.215
表3 偏瘫侧和非偏瘫侧骨盆三轴活动范围比较（°，
）
项目 例数 PTAROM1 POAROM1 PRAROM1
偏瘫侧 25 4.27±0.37 8.65±0.82 9.43±0.75
非偏瘫侧 25 4.91±0.43 8.19±0.74 9.72±0.70
t值 2.829 1.599 0.666
P值 0.009 0.123 0.512
表4 偏瘫侧和非偏瘫侧骨盆三轴活动范围差值比较（°，
）
项目 例数 PTAROM3-1 POAROM3-1 PRAROM3-1
偏瘫侧 25 0.50±0.15 −0.36±0.44 −1.58±0.51
非偏瘫侧 25 −0.53±0.31 0.08±0.46 −1.71±0.45
t值 3.263 0.922 0.246
P值 0.003 0.366 0.808
表5 骨盆X轴和Z轴各组不同步行时期各指标的描述统计结果（°，
）
变量 组别 侧别 步行初期 步行中期 步行晚期 F值 P值
PTAmax 分组前 偏瘫侧 30.70±1.21 31.38±1.20 31.41±1.17 3.295 0.046
非偏瘫侧 31.34±1.26 31.65±1.27 31.55±1.16 0.432 0.652
室内步行组 偏瘫侧 29.39±1.98 30.99±1.89 30.81±1.68 5.830 0.009
非偏瘫侧 29.91±1.20 31.10±1.91 30.72±1.58 2.073 0.150
室外步行组 偏瘫侧 32.01±1.43 31.78±1.51 32.01±1.64 0.257 0.655
非偏瘫侧 32.77±1.56 32.20±1.70 32.39±1.68 1.351 0.278
PTAROM 分组前 偏瘫侧 4.25±0.36 4.63±0.42 4.75±0.40 4.374 0.018
非偏瘫侧 4.90±0.44 5.00±0.49 4.35±0.38 2.070 0.138
室内步行组 偏瘫侧 3.81±0.52 4.25±0.61 4.16±0.64 1.813 0.187
非偏瘫侧 4.51±0.63 4.38±0.70 3.67±0.55 1.666 0.212
室外步行组 偏瘫侧 4.69±0.48 5.01±0.59 5.34±0.51 3.500 0.046
非偏瘫侧 5.28±0.60 5.62±0.68 5.03±0.52 0.785 0.467
PRAmax 分组前 偏瘫侧 4.81±0.86 4.53±0.88 3.87±0.89 3.306 0.046
非偏瘫侧 4.75±1.13 4.98±1.11 4.46±1.18 0.267 0.767
室内步行组 偏瘫侧 5.123±1.45 4.77±1.38 3.95±1.45 3.484 0.048
非偏瘫侧 4.70±2.12 4.86±1.68 4.25±2.15 0.358 0.703
室外步行组 偏瘫侧 4.49±0.98 4.28±1.11 3.79±1.08 0.765 0.477
非偏瘫侧 4.79±0.95 5.11±1.48 4.67±1.11 0.074 0.825
PRAROM 分组前 偏瘫侧 9.44±0.77 8.92±0.52 7.84±0.50 4.896 0.012
非偏瘫侧 9.72±0.71 9.32±0.80 8.01±0.63 4.454 0.017
室内步行组 偏瘫侧 9.66±1.11 8.89±0.76 7.47±0.72 2.674 0.091
非偏瘫侧 9.87±1.03 8.92±1.16 8.08±0.91 3.084 0.066
室外步行组 偏瘫侧 9.21±1.06 8.95±0.73 8.25±0.69 2.462 0.107
非偏瘫侧 9.58±0.99 9.71±1.11 7.94±0.87 2.200 0.133
POAmax 分组前 偏瘫侧 5.20±0.62 4.86±0.63 4.88±0.67 1.143 0.314
非偏瘫侧 3.43±0.69 3.69±0.66 3.72±0.75 0.722 0.491
室内步行组 偏瘫侧 5.11±0.92 4.90±0.87 4.70±0.90 0.562 0.578
非偏瘫侧 2.98±1.13 3.58±1.16 3.47±1.20 1.755 0.196
室外步行组 偏瘫侧 5.30±0.84 4.81±0.91 5.06±0.98 1.008 0.354
非偏瘫侧 3.88±0.81 3.79±0.70 4.00±0.91 0.104 0.902
POAROM 分组前 偏瘫侧 8.63±0.83 8.09±0.84 8.27±0.84 1.055 0.356
非偏瘫侧 8.17±0.74 8.86±0.85 8.27±0.85 1.337 0.273
室内步行组 偏瘫侧 8.15±1.13 7.83±0.98 7.70±0.99 0.406 0.671
非偏瘫侧 7.68±0.97 8.44±1.04 8.01±1.10 0.746 0.486
室外步行组 偏瘫侧 9.10±1.22 8.35±1.34 8.84±1.33 0.994 0.385
非偏瘫侧 8.67±1.12 9.27±1.30 8.53±1.29 0.735 0.490
表6 骨盆X轴和Z轴各指标的重复测量方差分析结果
变量 侧别 变异来源 SS df MS F值 P值
PTAmax 偏瘫侧 组内 8.084 2.000 4.042 3.295 0.046
组间 44.341 1.000 44.341 0.425 0.521
组内*组间 11.473 2.000 5.737 4.677 0.014
非偏瘫侧 组内 1.245 2.000 0.623 0.432 0.652
组间 66.146 1.000 66.146 0.598 0.447
组内*组间 10.042 1.476 6.803 3.481 0.055
PTAROM 偏瘫侧 组内 3.357 2.000 1.679 4.374 0.018
组间 16.542 1.000 16.542 1.479 0.236
组内*组间 0.550 2.000 0.275 0.676 0.514
非偏瘫侧 组内 6.014 2.000 3.007 2.070 0.138
组间 23.474 1.000 23.474 2.071 0.164
组内*组间 1.244 2.000 0.622 0.428 0.654
PRAmax 偏瘫侧 组内 11.533 2.000 5.767 3.306 0.046
组间 3.494 1.000 3.494 0.064 0.802
组内*组间 0.730 2.000 0.365 0.209 0.812
非偏瘫侧 组内 3.389 2.000 1.695 0.267 0.767
组间 1.186 1.000 1.186 0.014 0.907
组内*组间 0.350 2.000 0.175 0.028 0.973
PRAROM 偏瘫侧 组内 33.309 2.000 16.654 4.896 0.012
组间 0.225 1.000 0.225 0.011 0.918
组内*组间 4.284 2.000 2.142 0.630 0.537
非偏瘫侧 组内 40.073 2.000 20.037 4.454 0.017
组间 0.274 1.000 0.274 0.009 0.924
组内*组间 4.305 2.000 2.153 0.479 0.623
POAmax 偏瘫侧 组内 1.876 1.405 1.335 1.143 0.314
组间 0.451 1.000 0.451 0.016 0.902
组内*组间 0.630 1.405 0.448 0.383 0.611
非偏瘫侧 组内 1.261 2.000 0.631 0.722 0.491
组间 5.405 1.000 5.405 0.155 0.697
组内*组间 1.503 1.936 0.776 0.860 0.427
POAROM 偏瘫侧 组内 3.782 2.000 1.891 1.055 0.356
组间 14.151 1.000 14.151 0.288 0.597
组内*组间 1.301 2.000 0.650 0.363 0.698
非偏瘫侧 组内 6.808 2.000 3.404 1.337 0.273
组间 11.352 1.000 11.352 0.253 0.620
组内*组间 0.679 2.000 0.339 0.133 0.876
表7 骨盆X轴和Z轴各指标组内重复测量方差分析结果
变量 侧别 组别 SS df MS F值 P值
PTAmax 偏瘫侧 室内步行组 18.375 2.000 9.187 5.830 0.009
室外步行组 0.466 1.161 0.402 0.257 0.655
非偏瘫侧 室内步行组 8.826 2.000 4.413 2.073 0.150
室外步行组 2.195 2.000 1.098 1.351 0.278
PTAROM 偏瘫侧 室内步行组 1.293 2.000 0.647 1.813 0.187
室外步行组 2.669 2.000 1.334 3.500 0.046
非偏瘫侧 室内步行组 4.898 2.000 2.449 1.666 0.212
室外步行组 2.254 2.000 1.127 0.785 0.467
PRAmax 偏瘫侧 室内步行组 8.687 2.000 4.343 3.484 0.048
室外步行组 3.364 2.000 1.682 0.765 0.477
非偏瘫侧 室内步行组 2.352 2.000 1.176 0.358 0.703
室外步行组 1.347 1.155 1.166 0.074 0.825
PRAROM 偏瘫侧 室内步行组 29.484 2.000 14.742 2.674 0.091
室外步行组 7.218 2.000 3.609 2.462 0.107
非偏瘫侧 室内步行组 19.299 2.000 9.65 3.084 0.066
室外步行组 25.32 2.000 12.66 2.200 0.133
POAmax 偏瘫侧 室内步行组 1.005 2.000 0.502 0.562 0.578
室外步行组 1.522 1.313 1.159 1.008 0.354
非偏瘫侧 室内步行组 2.460 2.000 1.230 1.755 0.196
室外步行组 0.214 2.000 0.107 0.104 0.902
POAROM 偏瘫侧 室内步行组 1.318 2.000 0.659 0.406 0.671
室外步行组 3.866 2.000 1.933 0.994 0.385
非偏瘫侧 室内步行组 3.484 2.000 1.742 0.746 0.486
室外步行组 4.024 2.000 2.012 0.735 0.490
表8 骨盆X轴和Z轴各指标的事后LSD差异检验结果
指标 组别 对比组 平均值差（I-J） P值 95%CI
上限 下限
PTAmax 分组前 PTAmax1 vs PTAmax2 −0.683 0.019 −1.244 −0.123
PTAmax1 vs PTAmax3 −0.710 0.076 −1.500 0.081
PTAmax2 vs PTAmax3 −0.027 0.924 −0.595 0.541
室内步行组 PTAmax1 vs PTAmax2 −1.597 0.007 −2.655 −0.540
PTAmax1 vs PTAmax3 −1.418 0.031 −2.682 −0.153
PTAmax2 vs PTAmax3 0.180 0.713 −0.868 1.228
室外步行组 PTAmax1 vs PTAmax2 0.231 0.416 −0.366 0.827
PTAmax1 vs PTAmax3 −0.002 0.996 −1.109 1.104
PTAmax2 vs PTAmax3 −0.233 0.441 −0.870 0.404
PTAROM 分组前 PTAROM1 vs PTAROM2 −0.377 0.073 −0.792 0.038
PTAROM1 vs PTAROM3 −0.497 0.004 −0.817 −0.178
PTAROM2 vs PTAROM3 −0.120 0.452 −0.445 0.205
室内步行组 PTAROM1 vs PTAROM2 −0.437 0.140 −1.044 0.169
PTAROM1 vs PTAROM3 −0.353 0.157 −0.866 0.159
PTAROM2 vs PTAROM3 0.084 0.709 −0.400 0.568
室外步行组 PTAROM1 vs PTAROM2 −0.316 0.297 −0.948 0.316
PTAROM1 vs PTAROM3 −0.641 0.009 −1.087 −0.195
PTAROM2 vs PTAROM3 −0.325 0.172 −0.811 0.162
PRAmax 分组前 PRAmax1 vs PRAmax2 0.281 0.360 −0.342 0.904
PRAmax1 vs PRAmax3 0.937 0.021 0.155 1.718
PRAmax2 vs PRAmax3 0.656 0.142 −0.236 1.548
室内步行组 PRAmax1 vs PRAmax2 0.356 0.220 −0.247 0.958
PRAmax1 vs PRAmax3 1.173 0.032 0.122 2.224
PRAmax2 vs PRAmax3 0.817 0.177 −0.428 2.063
室外步行组 PRAmax1 vs PRAmax2 0.206 0.699 −0.926 1.339
PRAmax1 vs PRAmax3 0.700 0.248 −0.556 1.956
PRAmax2 vs PRAmax3 0.494 0.457 −0.906 1.894
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