重复经颅磁刺激改善脑卒中功能障碍的功能磁共振成像研究：Scoping综述

doi:10.3969/j.issn.1006-9771.2023.02.008

摘要/Abstract

摘要：

目的对重复经颅磁刺激(rTMS)改善脑卒中功能障碍的功能磁共振成像(fMRI)研究进行Scoping综述，了解rTMS作用的脑机制。方法检索建库至2022年6月1日PubMed、Web of Science、中国知网、万方数据库中有关rTMS改善脑卒中功能障碍的fMRI研究。采用物理治疗证据数据库(PEDro)量表对纳入文献进行质量评价。由2名研究人员筛选文献、整理资料并进行Scoping综述。结果最终纳入14篇文献，均为高质量或极高质量。纳入文献研究设计为临床随机对照试验。研究主要涉及rTMS对脑卒中后各种功能障碍，如偏瘫、失语、吞咽困难、认知损害、抑郁方面的治疗效果和fMRI变化。结论 rTMS可以改变脑卒中后大脑皮质的兴奋性和大脑区域之间有效连接，促进大脑功能重组，实现脑卒中后功能障碍的恢复。

关键词: 脑卒中, 功能障碍, 重复经颅磁刺激, 功能磁共振成像, Scoping综述

Abstract:

Objective To explore the brain mechanism of repetitive transcranial magnetic stimulation (rTMS) on dysfunction after stroke using functional magnetic resonance imaging (fMRI). Methods Literatures about the functional magnetic resonance imaging study about repetitive transcranial magnetic stimulation for dysfunction after stroke were retrieved in PubMed, Web of Science, CNKI and Wanfang data from establishment to June 1st, 2021. The quality of the literature was evaluated with Physiotherapy Evidence Database (PEDro) scale. Literature screening, and data extraction were performed by two researchers. Results A total of 14 randomized controlled trials were finally enrolled. They were of high or very high quality. They mainly involved the therapeutic effect and imaging mechanisms of rTMS on dysfunction after stroke. Conclusion rTMS could change the excitability of the cerebral cortex and the effective connections between brain regions after stroke, promote the reorganization of brain function, and achieve the recovery of post-stroke dysfunction.

Key words: stroke, dysfunction, repetitive transcranial magnetic stimulation, functional magnetic resonance imaging, scoping review

中图分类号:

R743.3

程斯曼, 辛榕, 赵燕, 刘庆余, 谢加乐, 刘鹏, 王朴. 重复经颅磁刺激改善脑卒中功能障碍的功能磁共振成像研究：Scoping综述[J]. 《中国康复理论与实践》, 2023, 29(2): 193-204.

CHENG Siman, XIN Rong, ZHAO Yan, LIU Qingyu, XIE Jiale, LIU Peng, WANG Pu. Functional magnetic resonance imaging study about repetitive transcranial magnetic stimulation for dysfunction after stroke: a scoping review[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2023, 29(2): 193-204.

图/表 4

图1

表1

纳入文献基本特征"

纳入文献	国家	受试者	n	干预措施	结局指标	fMRI显示结果	其他结局
Tosun等^[20](2017)	土耳其	偏瘫患者	9/7/9	假刺激+常规康复治疗/rTMS+NMES+常规康复治疗/常规康复治疗	FMA、BI、fMRI	rTMS干预后，在患手活动过程中患侧M1区激活增加明显，健侧M1区未见变化	rTMS组FMA评分显著高于假刺激组，运动功能明显改善
Gottlieb等^[21] (2021)	德国	偏瘫患者	14/14	假刺激+常规康复治疗/rTMS+常规康复治疗	FMA、fMRI	rTMS干预后左角回连接性增加	rTMS组FMA评分显著高于假刺激组，运动功能明显改善
Guo等^[22](2021)	中国	偏瘫患者	20/20/20	假刺激+常规康复治疗/1 Hz rTMS+常规康复治疗/10 Hz rTMS+常规康复治疗	FMA、BI、fMRI	低、高频rTMS组同侧M1和SMA与对侧PMA之间，对侧M1和对侧SMA之间，对侧SMA和同侧SMA之间的FC显著变化	rTMS组FMA评分、BI分数显著高于假刺激组，运动功能明显改善
Lee等^[23](2022)	中国	卒中后失语患者	13/13	假刺激+常规康复治疗/rTMS+常规康复治疗	CCAT、fMRI	rTMS组右颞上回、右前额叶背外侧回、岛叶皮质和尾状核的fALFF显著增加，右侧丘脑fALFF减少	rTMS组CCAT分数增高明显，言语功能改善明显
Bai等^[24](2022)	中国	卒中后失语患者	30/30	假刺激+言语训练/rTMS+言语训练	WAB、简式Token试验、fMRI	rTMS组右半球额叶多个脑区、右颞叶和右顶叶等脑区的fALFF值下降，左顶叶、左角回、左额叶、双侧边缘叶激活增加	rTMS干预后WAB、简式Token分数显著提高，语言能力改善
Szaflarski等^[25](2021)	美国	卒中后失语患者	9/9/9/9	3周假刺激/2周假刺激+1周真刺激/1周假刺激+2周真刺激/3周真刺激	WAB、BNT、SFT、COWAT、fMRI	rTMS组两侧半球都显示出更大的fMRI激活，左右侧IFG之间和双侧大脑半球脑区的连接性发生改变	rTMS干预后WAB、BNT分数改善明显，语言功能改善
Allendorfer等^[26](2021)	美国	卒中后失语患者	9/9/9/9	3周假刺激/2周假刺激+1周真刺激/1周假刺激+2周真刺激/3周真刺激	BNT、fMRI	rTMS组左侧视觉皮质包括左腹侧视觉流激活增加，双侧SMA激活减少，右前额叶和前岛叶区激活减少	rTMS干预后WAB、BNT分数改善明显，语言能力改善
陈栩铤等^[27](2021)	中国	卒中后吞咽困难患者	10/10	假刺激+常规康复治疗/rTMS+常规康复治疗	用进食评估问卷调查工具-10、吞咽功能性交流测试、改良曼恩吞咽能力评估量表、fMRI	rTMS组大脑顶叶、顶上小叶、BA7、BA40激活范围较组内治疗前和对照组治疗后均明显增大	治疗后，两组用进食评估问卷调查工具-10、吞咽功能性交流测试及改良曼恩吞咽能力评估评分均优于治疗前；rTMS组评分均优于假刺激组
焦勇钢等^[28](2020)	中国	卒中后吞咽困难患者	20/20	假刺激+常规康复治疗/rTMS+常规康复治疗	临床吞咽困难量表、吞咽困难预后和严重程度量表、fMRI	高频rTMS组ALFF增强的脑区包括双侧尾状核、双侧豆状核和双侧额上回	rTMS 组吞咽功能改善更明显
Yin等^[29](2020)	中国	卒中后认知损害患者	18/16	假刺激/rTMS	MoCA、RBMT、fMRI	rTMS组左内侧前额叶皮质ALFF增加以及右内侧前额叶皮质和右腹侧前扣带回FC增加	rTMS组认知功能改善更明显
罗红等^[30](2019)	中国	卒中后认知损害患者	15/15	认知康复训练/rTMS+认知康复训练	MoCA、MMSE、fMRI	rTMS组楔前叶、颞下回、额中回、IFG等FC增加，fALFF增高脑区主要有颞上回、IFG、海马旁回等，RoHo增高脑区主要有缘上回、楔前叶、扣带回等	rTMS组认知功能改善情况明显优于对照组
Li等^[31](2020)	中国	卒中后认知损害患者	15/15	假刺激+认知训练/rTMS+认知康复训练	MMSE、MoCA、fMRI	rTMS组颞上回、IFG和海马旁回fALFF值较高，颞中回、额中回和梭状回fALFF值较低。LDPFC与楔前叶、颞下回、额中下回和边缘回之间FC增加，与颞中回和丘脑之间的FC减少	两组认知均有改善，rTMS组较假刺激组改善明显
Li等^[32](2022)	中国	卒中后抑郁患者	16/16	假刺激+常规康复治疗/rTMS+常规康复治疗	汉密尔顿抑郁量表、fMRI	rTMS组ReHo 和 fALFF值较低的区域主要位于左半球。DMN内动态FC也产生显著变化	rTMS组汉密尔顿抑郁量表评分显著减少，抑郁症状改善明显
Eshel等^[33](2020)	美国	抑郁患者	13/20	假刺激+常规康复治疗/rTMS+常规康复治疗	汉密尔顿抑郁量表、EEG、fMRI	rTMS组DLPFC全脑连接性增加，并且诱导负性DLPFC-杏仁核连接性	rTMS干预后抑郁症状显著改善

表1

表2

纳入文献rTMS处方"

纳入文献	频率	强度	序列	总脉冲	刺激部位	持续时间	假rTMS设置
Tosun等^[20](2017)	1 Hz	90% rMT	未描述	每天1 200脉冲	健侧M1	每天1次，每周5 d，2周	旋转刺激线圈90°垂直于头皮
Gottlieb等^[21] (2021)	1 Hz	100% rMT	未描述	每天1 200脉冲	健侧M1	每天1次，每周5 d，2周	旋转刺激线圈90°垂直于头皮
Guo等^[22](2021)	1 Hz/10 Hz	90% rMT	30	每天900脉冲/1 500脉冲	健侧M1/患侧M1	每天1次，每周5 d，1周	假线圈
Lee等^[23](2022)	1 Hz	90% rMT	未描述	未描述	患侧三角部	每天1次，每周5 d，2周	假线圈
Bai等^[24](2022)	1 Hz	80% rMT	100	每天1 000脉冲	右侧IFG	每天1次，每周5 d，4周	旋转刺激线圈90°垂直于头皮
Szaflarski等^[25](2021)	50 Hz	80% AMT	未描述	每天600脉冲	左侧IFG	每天1次，每周5 d，3周	未描述
Allendorfer等^[26](2021)	50 Hz	80% AMT	未描述	每天600脉冲	左侧IFG	每天1次，每周5 d，3周	未描述
陈栩铤等^[27](2021)	5 Hz	80% rMT	未描述	每天1 000脉冲	健侧大脑半球舌骨上肌群皮质对应区	每天1次，每周6 d，2周	旋转刺激线圈90°垂直于头皮
焦勇钢等^[28](2020)	3 Hz	80% rMT	未描述	未描述	双侧咽部运动皮质	每天1次，每周5 d，2周	未描述
Yin等^[29](2020)	10 Hz	80% rMT	40	每天2 000脉冲	左侧DLPFC	每天1次，每周5 d，4周	旋转刺激线圈90°垂直于头皮
罗红等^[30](2019)	5 Hz	80%~120% MT	未描述	每天1 050脉冲	左侧DLPFC	每天1次，每周5 d，3周	未描述
Li等^[31](2020)	5 Hz	100% MT	50	每天2 000脉冲	左侧DLPFC	每天1次，每周5 d，4周	旋转刺激线圈90°垂直于头皮
Li等^[32](2022)	5 Hz	90% rMT	50	每天2 000脉冲	左侧DLPFC	每天1次，每周6 d，4周	旋转刺激线圈90°垂直于头皮
Eshel等^[33](2020)	10 Hz	未描述	未描述	每天2 000脉冲	左侧DLPFC	每天1次，每周5 d，4周	旋转刺激线圈90°垂直于头皮

表2

表3

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纳入文献	条目1	条目2	条目3	条目4	条目5	条目7	条目8	条目9	条目10	条目11	总分	文献质量
Tosun等^[20](2017)	√	√	√	√	√	√	√	√	√	√	9	极高
Gottlieb等^[21] (2021)	√	√	√	√	√	√	√	√	√	√	9	极高
Guo等^[22](2021)	√			√	√		√	√	√	√	6	高
Lee等^[23](2022)	√	√	√	√	√	√	√	√	√	√	9	极高
Bai等^[24](2022)	√	√		√			√	√	√	√	6	高
Szaflarski等^[25](2021)	√	√	√	√		√		√	√	√	7	高
Allendorfer等^[26](2021)	√	√	√	√		√		√	√	√	7	高
陈栩铤等^[27](2021)	√	√		√			√	√	√	√	6	高
焦勇钢等^[28](2020)	√	√		√			√	√	√	√	6	高
Yin等^[29](2020)	√	√		√	√	√	√	√	√	√	8	高
罗红等^[30](2019)	√	√		√		√	√	√	√	√	7	高
Li等^[31](2020)	√	√	√	√	√	√	√	√	√	√	9	极高
Li等^[32](2022)	√	√	√	√	√	√	√	√	√	√	9	极高
Eshel等^[33](2020)	√	√	√	√	√		√	√	√	√	8	高