重复经颅磁刺激对脑梗死患者上肢运动功能障碍疗效的研究
发布时间：2018-08-25 10:55
【摘要】：背景与目的:脑梗死又称缺血性脑卒中,是指各种原因引起的脑局部血液供应障碍,使局部脑组织发生不可逆损害,导致脑组织缺血、缺氧性坏死。世界卫生组织调查结果显示:我国脑梗死发病率不断上升,已成为中老年人中最常见的疾病之一。第三次国民死因调查结果显示,脑梗死已经上升为中国第一位死因。随着诊疗技术的不断进步,脑梗死的死亡率明显下降,但脑梗死后常遗留有运动功能障碍,仍缺乏有效的治疗措施。因此,对脑梗死的康复进行必要的临床研究,为其临床治疗寻找一个有效的方法,并制定针对性的预防措施,最大程度的恢复患者脑梗死后遗留的运动功能障碍,已成为当今医学界面临的重大课题。重复经颅磁刺激(repetitive transcranial magnetic stimulation,rTMS)是Barker教授在1985年报道的经颅磁刺激的基础上形成的一种神经电生理技术。是一种将电磁脉冲信号透过颅骨传送到大脑皮层,刺激特定脑区的神经,通过增加皮质脊髓系统的兴奋性,提高运动系统的反应性,以达到治疗的目的的技术。rTMS可以促进受损的大脑皮质区域性功能重建,提高康复治疗的疗效,具有无创、无痛、安全等优势,且具有良好的时间分辨率和空间分辨率,更加容易被病人接受。近年来,该方法被广泛地应用于脑梗死患者的康复治疗中,为脑梗死患者运动功能障碍的康复开辟了一个新领域,提供了新思路。本研究采用随机、对照、盲法原则,主要观察采用1Hz的重复经颅磁刺激治疗脑梗死患者运动功能障碍时,试验组和对照组的上肢运功功能、神经功能和日常生活活动能力的改善情况及差异。实验方法:选取2013年8月~2016年5月在我科入院的脑梗死伴上肢运动功能障碍的患者80例,并对患者进行随机分组,其中试验组(经颅磁刺激组)40例,对照组(常规治疗组)40例。80例患者均符合本研究的纳入标准,纳入标准:(1)初次、单侧发病或者随既往有发作但未遗留神经功能障碍者;(2)生命体征平稳,意识清楚;(3)患者上肢Brunnstrom分级在I—III期;(4)年龄在20岁到75岁之间;(5)病程在4周之内;(6)给予经颅磁刺激可以测出患侧脑区运动诱发电位;(7)入选患者签署知情同意书。排除标准:(1)有严重的认知障碍者;(2)有视、听言语障碍者;(3)存在骨关节、肌肉等运动系统疾病者;(4)患者有明显的康复训练的禁忌症(如严重的心脏病、新近发生的心肌梗塞、近期心绞痛发作未能良好控制的);(5)有明确的不能进行rTMS的患者(如急性期的脑外伤、脑出血患者;癫痫病史或脑电图检查显示有癫痫样改变的患者);(6)病情不稳定或者存在不可控制的健康因素;(7)存在严重的肌肉痉挛、震颤者;(8)同时参加其他试验或者是接受其他治疗者。试验组中男27例,女13例,平均年龄(58.15±9.54),脑梗病灶侧为左侧24例,右侧16例;平均病程(17.65±6.67)天;对照组中男23例,女17例,平均年龄(59.93±8.95),脑梗病灶侧为左侧26例,右侧14例;平均病程(16.00±4.88)天。两组一般资料无明显差异(P0.05)。在患者生命体征平稳后,试验组:给予1Hz的重复经颅磁刺激,刺激作用于健侧半球M1区,刺激参数:1Hz,强度为90%MT,25min/天,共1500脉冲,并配合常规药物治疗和康复训练。对照组:只采用常规的药物治疗和康复训练。常规的康复训练包括:(1)对于不能起床的患者行床边的被动肢体运动和良肢位的摆放,(2)进入训练室后行运动疗法、上肢作业疗法、坐站训练、行走训练以及中频电疗。训练每日进行一次。两组患者治疗均每天一次,每周5天,连续6周。分别在治疗前、治疗3周、治疗结束后对患者进行上肢简易Fuel-Meyer(FMA)运动功能评分、Barthel指数(BI)评分、神经功能缺损评分的测定。实验结果:1.在治疗3周后,与治疗前相比较时,经颅磁刺激组的FMA评分与常规治疗组的FMA评分均有一定程度提高;治疗6周时,经颅磁刺激组的FMA评分与常规治疗组的FMA评分均明显提高,与治疗前评分相比差异有统计学意义,且试验组评分更高,两组之间差异有统计学意义。2.治疗3周、6周后,两组ADL评分均较治疗前有升高,差异有统计学意义;试验组采用经颅磁刺激在治疗3周、6周后ADL评分与对照组相比较,ADL评分提高更明显,差异有统计学意义。3.治疗3周、6周后对两组在两个时间点NIHSS评分与治疗前相比时有明显下降,差异有统计学意义。经颅磁刺激组与常规治疗组比较,治疗3周时组间差异有统计学意义(P=0.005),治疗6周时差异有统计学意义(P=0.000)。4.两组不良事件发生率均较低,组间差异无统计学意义。结论:本研究表明1Hz的r TMS刺激脑梗死患者健侧大脑半球M1区可明显提高患者的上肢运动功能,是一种治疗脑梗死患者上肢运动功能障碍的有效方法,值得临床借鉴和推广。
[Abstract]:BACKGROUND AND OBJECTIVE: Cerebral infarction, also known as ischemic stroke, refers to a variety of causes of local blood supply disorders in the brain, causing irreversible damage to local brain tissue, leading to cerebral ischemia, hypoxic necrosis. The World Health Organization survey results show that the incidence of cerebral infarction in China is rising, has become the most common disease in the elderly. The results of the third national death cause survey show that cerebral infarction has risen to be the first cause of death in China. With the continuous progress of diagnosis and treatment technology, the death rate of cerebral infarction has decreased significantly. However, motor dysfunction often remains after cerebral infarction, and effective treatment measures are still lacking. Therefore, it is necessary to carry out clinical research on the rehabilitation of cerebral infarction. To find an effective method for clinical treatment and formulate specific preventive measures to maximize the recovery of motor dysfunction after cerebral infarction has become a major issue facing the medical community. Repetitive transcranial magnetic stimulation (rTMS) was reported by Professor Barker in 1985. A neuroelectrophysiological technique based on magnetic stimulation of the skull is a technique that transmits electromagnetic pulse signals through the skull to the cerebral cortex to stimulate nerves in specific areas of the brain. It increases the excitability of the corticospinal system and the responsiveness of the motor system in order to achieve therapeutic purposes. rTMS can promote the damaged cerebral cortex. In recent years, this method has been widely used in the rehabilitation of patients with cerebral infarction and opened up a new way for the rehabilitation of motor dysfunction in patients with cerebral infarction. The purpose of this study was to observe the improvement and difference of motor function, neurological function and activities of daily living in the upper limbs of patients with cerebral infarction treated by 1 Hz repetitive transcranial magnetic stimulation. From May 2016 to May 2016, 80 patients with cerebral infarction accompanied by upper limb dyskinesia were randomly divided into two groups, 40 patients in the experimental group (transcranial magnetic stimulation group) and 40 patients in the control group (routine treatment group). All the 80 patients met the inclusion criteria of this study. The inclusion criteria were as follows: (1) Initial, unilateral onset or previous onset but not left behind. Patients with neurological impairment; (2) stable vital signs and clear consciousness; (3) Brunnstrom classification of upper limbs in I-III stage; (4) between 20 and 75 years of age; (5) course of disease within 4 weeks; (6) Transcranial magnetic stimulation can be given to detect the affected side of the brain motor evoked potential; (7) selected patients signed informed consent. Exclusive criteria: (1) serious cognition Obstacles; (2) Visual and auditory speech disorders; (3) the presence of bone and joint, muscle and other motor system diseases; (4) patients with significant rehabilitation training contraindications (such as severe heart disease, recent myocardial infarction, recent angina attacks can not be well controlled); and (5) patients with a clear failure to carry out rTMS (such as acute brain trauma, brain injury) Hemorrhagic patients; epilepsy history or EEG examination showed epileptiform changes in patients; (6) unstable conditions or uncontrollable health factors; (7) severe muscle spasm, tremor; (8) attending other trials or receiving other treatment at the same time. There were 24 lesions on the left side and 16 lesions on the right side; the average course of disease was (17.65 + 6.67) days; 23 males and 17 females in the control group, with an average age of (59.93 + 8.95), 26 lesions on the left side and 14 lesions on the right side; and the average course of disease was (16.00 + 4.88) days. Magnetic stimulation, stimulation on the healthy hemisphere M1 area, stimulation parameters: 1 Hz, intensity of 90% MT, 25 min / day, a total of 1500 pulses, and with conventional drug treatment and rehabilitation training. Control group: only conventional drug treatment and rehabilitation training. Conventional rehabilitation training includes: (1) for patients unable to wake up passive limb movement and good limb position. After entering the training room, the patients were given exercise therapy, upper limb occupational therapy, sitting station training, walking training and intermediate frequency electrotherapy. Rthel index (BI) score and neurological deficit score were measured. Results: 1. After 3 weeks of treatment, compared with before treatment, the FMA score of the transcranial magnetic stimulation group and the conventional treatment group were improved to a certain extent. At 6 weeks of treatment, the FMA score of the transcranial magnetic stimulation group and the conventional treatment group were significantly improved, and the FMA score of the conventional treatment group was also improved. The ADL scores of the experimental group were higher than those of the control group. 2. After 3 weeks of treatment, the ADL scores of the two groups were higher than those before treatment, and the difference was statistically significant. There was significant difference in NIHSS score between the two groups at two time points after treatment. Compared with the conventional treatment group, there was significant difference in NIHSS score between the two groups at three weeks after treatment (P = 0.005), and there was significant difference at six weeks after treatment (P = 0.000). Conclusion: 1 Hz R TMS stimulation of M1 area of healthy hemisphere in patients with cerebral infarction can significantly improve the upper limb motor function, and is an effective method for the treatment of upper limb motor dysfunction in patients with cerebral infarction, which is worthy of clinical reference and promotion.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R743.3
[Abstract]:BACKGROUND AND OBJECTIVE: Cerebral infarction, also known as ischemic stroke, refers to a variety of causes of local blood supply disorders in the brain, causing irreversible damage to local brain tissue, leading to cerebral ischemia, hypoxic necrosis. The World Health Organization survey results show that the incidence of cerebral infarction in China is rising, has become the most common disease in the elderly. The results of the third national death cause survey show that cerebral infarction has risen to be the first cause of death in China. With the continuous progress of diagnosis and treatment technology, the death rate of cerebral infarction has decreased significantly. However, motor dysfunction often remains after cerebral infarction, and effective treatment measures are still lacking. Therefore, it is necessary to carry out clinical research on the rehabilitation of cerebral infarction. To find an effective method for clinical treatment and formulate specific preventive measures to maximize the recovery of motor dysfunction after cerebral infarction has become a major issue facing the medical community. Repetitive transcranial magnetic stimulation (rTMS) was reported by Professor Barker in 1985. A neuroelectrophysiological technique based on magnetic stimulation of the skull is a technique that transmits electromagnetic pulse signals through the skull to the cerebral cortex to stimulate nerves in specific areas of the brain. It increases the excitability of the corticospinal system and the responsiveness of the motor system in order to achieve therapeutic purposes. rTMS can promote the damaged cerebral cortex. In recent years, this method has been widely used in the rehabilitation of patients with cerebral infarction and opened up a new way for the rehabilitation of motor dysfunction in patients with cerebral infarction. The purpose of this study was to observe the improvement and difference of motor function, neurological function and activities of daily living in the upper limbs of patients with cerebral infarction treated by 1 Hz repetitive transcranial magnetic stimulation. From May 2016 to May 2016, 80 patients with cerebral infarction accompanied by upper limb dyskinesia were randomly divided into two groups, 40 patients in the experimental group (transcranial magnetic stimulation group) and 40 patients in the control group (routine treatment group). All the 80 patients met the inclusion criteria of this study. The inclusion criteria were as follows: (1) Initial, unilateral onset or previous onset but not left behind. Patients with neurological impairment; (2) stable vital signs and clear consciousness; (3) Brunnstrom classification of upper limbs in I-III stage; (4) between 20 and 75 years of age; (5) course of disease within 4 weeks; (6) Transcranial magnetic stimulation can be given to detect the affected side of the brain motor evoked potential; (7) selected patients signed informed consent. Exclusive criteria: (1) serious cognition Obstacles; (2) Visual and auditory speech disorders; (3) the presence of bone and joint, muscle and other motor system diseases; (4) patients with significant rehabilitation training contraindications (such as severe heart disease, recent myocardial infarction, recent angina attacks can not be well controlled); and (5) patients with a clear failure to carry out rTMS (such as acute brain trauma, brain injury) Hemorrhagic patients; epilepsy history or EEG examination showed epileptiform changes in patients; (6) unstable conditions or uncontrollable health factors; (7) severe muscle spasm, tremor; (8) attending other trials or receiving other treatment at the same time. There were 24 lesions on the left side and 16 lesions on the right side; the average course of disease was (17.65 + 6.67) days; 23 males and 17 females in the control group, with an average age of (59.93 + 8.95), 26 lesions on the left side and 14 lesions on the right side; and the average course of disease was (16.00 + 4.88) days. Magnetic stimulation, stimulation on the healthy hemisphere M1 area, stimulation parameters: 1 Hz, intensity of 90% MT, 25 min / day, a total of 1500 pulses, and with conventional drug treatment and rehabilitation training. Control group: only conventional drug treatment and rehabilitation training. Conventional rehabilitation training includes: (1) for patients unable to wake up passive limb movement and good limb position. After entering the training room, the patients were given exercise therapy, upper limb occupational therapy, sitting station training, walking training and intermediate frequency electrotherapy. Rthel index (BI) score and neurological deficit score were measured. Results: 1. After 3 weeks of treatment, compared with before treatment, the FMA score of the transcranial magnetic stimulation group and the conventional treatment group were improved to a certain extent. At 6 weeks of treatment, the FMA score of the transcranial magnetic stimulation group and the conventional treatment group were significantly improved, and the FMA score of the conventional treatment group was also improved. The ADL scores of the experimental group were higher than those of the control group. 2. After 3 weeks of treatment, the ADL scores of the two groups were higher than those before treatment, and the difference was statistically significant. There was significant difference in NIHSS score between the two groups at two time points after treatment. Compared with the conventional treatment group, there was significant difference in NIHSS score between the two groups at three weeks after treatment (P = 0.005), and there was significant difference at six weeks after treatment (P = 0.000). Conclusion: 1 Hz R TMS stimulation of M1 area of healthy hemisphere in patients with cerebral infarction can significantly improve the upper limb motor function, and is an effective method for the treatment of upper limb motor dysfunction in patients with cerebral infarction, which is worthy of clinical reference and promotion.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R743.3
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