重复经颅磁刺激治疗卒中后上肢痉挛性运动障碍的临床观察及纵向fMRI研究

发布时间：2018-10-16 11:47

【摘要】：目的通过对恢复期缺血性脑卒中后痉挛引起运动功能障碍的患者进行低频重复经颅磁刺激(rTMS)联合康复训练治疗,运用功能磁共振成像技术(fMRI)结合临床行为学量表纵向观察卒中患者康复治疗前后大脑皮层功能的变化及痉挛引起肢体运动功能障碍改善情况,定性并定量分析大脑运动皮层激活重塑的动态过程,旨在探讨运动皮层代偿、重组与肢体运动功能恢复间的关系,为低频rTMS治疗卒中后痉挛引起运动功能障碍的治疗提供新的依据及探讨其可能恢复机制。方法在福州总医院康复理疗科门诊和神经内科病房招募符合纳入标准和排除标准的50例患者,最终完成数据采集的共47例,采用随机对照试验设计,随机分为治疗组(1Hz rTMS+常规康复治疗)24例,对照组(sham rTMS+常规康复治疗)23例,通过每天1次,每周5天,持续8周的干预。两组治疗前、治疗结束后分别进行改良Ashworth量表(MAS),上肢Fugl-Meyer运动量表(FMA-UE),Barthel指数(BI)相关临床行为学的评定,并在两组中分别随机抽取5例患者进行fMRI检查。观察其治疗前后大脑运动功能区激活区域与激活强度的改变。结果1.两组患者治疗前的一般临床资料和FMA-UE、MAS、BI对比,差异无统计学意义(P0.05),随机挑选的进行fMRI检查的患者治疗前的一般临床资料和临床行为学资料对比,差异无统计学意义(P0.05)。2.康复干预后,两组患者治疗后的FMA-UE、MAS、BI均比治疗前有不同程度的改善,差异有统计学意义(P0.05),且治疗组效果优于对照组。3.两组接受fMRI检查的患者,偏侧化指数(LI)值均升高,差异有统计学意义(P0.01),治疗组升高值大于对照组,治疗组的LI升高值与MAS改善程度呈正相关(r=0.78,P0.05),对照组的LI升高值与MAS改善程度呈正相关(r=0.53,P0.05)。4.两组接受fMRI检查的患者的结果示,治疗组激活区域有双侧大脑感觉运动区、辅助运动区,患侧初级运动区,运动前区,扣带回,额中回,健侧大脑顶下小叶,额下回;对照组激活区域有双侧感觉运动区,辅助运动区,初级运动区,额下回,患侧扣带回,顶上小叶,健侧丘脑,缘上回,颞下回。结论1.低频rTMS结合康复训练及单纯康复训练均可改善恢复期卒中患者痉挛引起的运动功能障碍,且低频rTMS和康复训练有协同作用,能进一步缓解痉挛,改善运动功能,提高日常生活能力。2.与运动功能相关的运动前区、辅助运动区和扣带回不仅可以控制肌肉协调性和肌张力,还可促进卒中后肢体痉挛患者痉挛的恢复。3.治疗前后健患侧大脑激活区的改变为早期健侧激活为主,之后逐渐过渡到患侧激活为主,符合该疾病的功能区重组的规律,这个过程中低频rTMS和康复训练起到促进的作用。4.低频rTMS不仅明显降低健侧皮层兴奋性,使患侧皮层兴奋性增强,还可以加速大脑主要相关运动功能区由健侧向患侧的迁移,使运动功能改善,缩短康复周期。
[Abstract]:Objective to study the effects of low frequency repetitive transcranial magnetic stimulation (rTMS) combined with rehabilitation training in patients with motor dysfunction caused by spasticity after ischemic stroke in convalescence. Functional magnetic resonance imaging (fMRI) and clinical behavior scale were used to observe the changes of cerebral cortex function and the improvement of limb motor dysfunction caused by spasm before and after rehabilitation. The dynamic process of activation and remodeling of the motor cortex of the brain was analyzed qualitatively and quantitatively in order to explore the relationship between the compensation, recombination of motor cortex and the recovery of motor function of limbs. To provide a new basis for the treatment of motor dysfunction caused by post-stroke spasm with low frequency rTMS and to explore its possible recovery mechanism. Methods Fifty patients who met the standard of inclusion and exclusion were recruited from outpatient department of rehabilitation physiotherapy department and ward of neurology of Fuzhou General Hospital, and 47 cases of data were collected. A randomized controlled trial design was used. The patients were randomly divided into treatment group (1Hz rTMS routine rehabilitation group, 24 cases) and control group (sham rTMS routine rehabilitation treatment, 23 cases). The intervention was conducted once a day, 5 days a week, for 8 weeks. Before and after treatment, the modified Ashworth scale (MAS), upper limb Fugl-Meyer motor scale (FMA-UE), Barthel index (BI) was used to evaluate the clinical behavior, and 5 patients in the two groups were randomly selected for fMRI examination. To observe the changes of activation area and intensity of cerebral motor function area before and after treatment. Result 1. There was no significant difference in general clinical data and FMA-UE,MAS,BI between the two groups before treatment (P0.05), but there was no significant difference in general clinical data and clinical behavioral data before treatment in randomly selected patients with fMRI (P0.05). After rehabilitation intervention, the FMA-UE,MAS,BI of the two groups after treatment were improved to some extent, the difference was statistically significant (P0.05), and the effect of treatment group was better than that of control group. The hemiplegia index (LI) was significantly higher in the two groups with fMRI examination than that in the control group (P0.01), and the increased value in the treatment group was higher than that in the control group (P0.01). There was a positive correlation between the elevation of LI and the improvement of MAS in the treatment group (r = 0.78), and a positive correlation between the elevation of LI and the improvement of MAS in the control group (r = 0.53, P 0.05). 4. The results of fMRI examination showed that there were bilateral sensorimotor region, auxiliary motor area, primary motor area, premotor area, cingulate gyrus, middle frontal gyrus, inferior parietal lobule and inferior frontal gyrus in the treatment group. In the control group, there were bilateral sensorimotor region, auxiliary motor area, primary motor area, inferior frontal gyrus, cingulate gyrus, superior parietal lobule, healthy thalamus, supramarginal gyrus, subtemporal gyrus. Conclusion 1. Low frequency rTMS combined with rehabilitation training and rehabilitation training alone can improve motor dysfunction caused by spasticity in convalescent stroke patients, and low frequency rTMS and rehabilitation training have synergistic effects, which can further relieve spasm and improve motor function. Improving the ability of daily life. 2. The premotor area, auxiliary motor area and cingulate gyrus associated with motor function can not only control muscle coordination and muscle tension, but also promote the recovery of spasm in patients with limb spasm after stroke. 3. Before and after treatment, the changes of the brain activation areas in the diseased side were mainly the early activation of the healthy side, and then gradually transitioned to the activation of the affected side, which was in accordance with the law of the recombination of the functional regions of the disease, and the low frequency rTMS and rehabilitation training played a promoting role in the process. 4. Low frequency rTMS not only significantly reduced the excitability of the healthy cortex, enhanced the excitability of the affected cortex, but also accelerated the migration of the main motor functional areas from the healthy side to the affected side, improved the motor function and shortened the rehabilitation period.
【学位授予单位】：福建中医药大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R743.3

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