目的 观察低频重复经颅磁刺激(rTMS)联合任务导向性镜像疗法(TOMT)对脑梗死患者上肢运动功能障碍的影响。方法 2017年1月至2018年1月,住院脑梗死患者90例随机分为对照组(n = 30)、镜像组(n = 30)和联合组(n = 30)。3组均接受常规药物治疗和上肢功能训练,镜像组增加任务导向性镜像疗法,联合组在镜像组的基础上增加非受累侧M1区1 Hz rTMS。治疗前和治疗4周后,测量患侧脑区运动诱发电位皮质潜伏期(CL)、中枢运动传导时间(CMCT),采用Fugl-Meyer评定量表上肢部分(FMA-UE)和改良Barthel指数(MBI)进行评定。结果 治疗后,3组患者各项指标均较治疗前改善(t > 2.983, P < 0.05),联合组和镜像组优于对照组(P < 0.05),联合组优于镜像组(P < 0.05)。结论 任务导向性镜像疗法可以改善脑梗死患者患侧大脑皮质兴奋性和上肢运动功能;联合低频rTMS效果更佳。
Objective To investigate the effects of low-frequency repetitive transcranial magnetic stimulation (rTMS) combined with task-oriented mirror therapy (MT) on upper limbs function in patients with cerebral infarction. Methods From January, 2017 to January, 2018, 90 patients with cerebral infarction were randomly divided into control group (n = 30), MT group (n = 30), and rTMS+MT group (n = 30). All the patients received routine medicine and rehabilitation training. Moreover, MT group received task-oriented mirror therapy, and rTMS+MT group received 1 Hz rTMS over the M1 area of the unaffected hemisphere followed by task-oriented mirror therapy. Before and after four weeks of treatment, their motor evoked potential cortical latency (CL) and central motor conduction time (CMCT) in affected brain areas were measured, and they were assessed with Fugl-Meyer Assessment-upper extremities (FMA-UE) and modified Barthel Index (MBI). Results CL, CMCT, FMA-UE and MBI improved significantly in all the groups after treatment (t > 2.983, P < 0.05), and it was the best in MT+rTMS group, and then the MT group and the control group (P < 0.05). Conclusion Task-oriented mirror therapy could improve the excitability of cerebral cortex of the affected brain and promote the recovery of upper limbs motor function, which is even more effective combined with 1 Hz rTMS.
[1] Wolf SL, Winstein CJ, Miller JP, et al.Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial[J]. JAMA, 2006, 296(17): 2095-2104.
[2] Roger VL, Go AS, Lloyd-Jones DM, et al.Heart Disease and Stroke Statistics–2012 update: a report from the American Heart Association[J]. Circulation, 2012, 125: e2-e220.
[3] 赵利娜,张志强,张立新,等. 1Hz重复经颅磁刺激对缺血性脑卒中后上肢运动功能的疗效[J]. 中国康复理论与实践, 2015, 21(2): 216-219.
[4] 白钟飞,张子未,王惠芳,等. 镜像疗法改善脑卒中后上肢运动功能和日常生活活动的Meta分析[J]. 中国康复理论与实践, 2016, 22(12): 1384-1394.
[5] Paik YR, Kim SK, Lee JS, et al.Simple and task-oriented mirror therapy for upper extremity function in stroke patients: a pilot study[J]. Hong Kong J Occup Ther, 2014, 24(1): 6-12.
[6] Matz K, Brainin M.Neurostimulation in ischemic stroke—down with the healthy hemisphere[J]. Eur J Neurol, 2009, 16(12): 1253-1254.
[7] 全国第四届脑血管病学术会议. 各类脑血管疾病诊断要点[J]. 中华神经科杂志, 1996, 29(6): 379-380.
[8] 王玉龙. 康复功能评定学[M]. 北京:人民卫生出版社, 2008: 164-168.
[9] 殷稚飞,沈滢,孟殿怀,等. 不同频率低频重复经颅磁刺激对脑梗死患者上肢功能的影响[J]. 中华物理医学与康复杂志, 2014, 36(8): 596-601.
[10] 马玉娟,黄杰,方征宇,等. 高频重复经颅磁刺激对脑梗死大鼠运动诱发电位皮质潜伏时和中枢运动传导时间的影响[J]. 中国康复医学杂志, 2011, 26(10): 898-902.
[11] Chen R, Cros D, Curra A, et al.The clinical diagnostic utility of transcranial magnetic stimulation: Report of an IFCN committee[J]. Clin Neurophysiol, 2008, 119(3): 504-532.
[12] 王峻瑶,黄真. 镜像视觉反馈及其在康复医学中的应用进展[J]. 中华物理医学与康复杂志, 2012, 34(1): 70-73.
[13] Rizzolatti G, Fabbri-Destro M, Cattaneo L.Mirror neurons and their clinical relevance[J]. Nat Clin Pract Neuro, 2009, 5(1): 24-34.
[14] Garrison KA, Winstein CJ, Azizzadeh L.The mirror neuron system: a neural substrate for methods in stroke rehabilitation[J]. Neurorehabil Neural Repair, 2010, 24(5): 404-412.
[15] Michielsen ME, Smits M, Ribbers GM, et al.The neuronal correlates of mirror therapy: an fMRI study on mirror induced visual illusions in patients with stroke[J]. J Neurol Neurosurg Psychiatry, 2011, 82(4): 393-398.
[16] Nojima I, Mima T, Koganemaru S, et al.Human motor plasticity induced by mirror visual feedback[J]. J Neurosci, 2012, 32(4): 1293-1300.
[17] Carrico C, Chelette KC, Westgate PM, et al.Nerve stimulation enhances task-oriented training in chronic, severe motor deficit after stroke[J]. Stroke, 2016, 47(7): 1879-1884.
[18] 郭丽云,田泽丽,王潞萍,等. 任务导向性训练结合肌力训练对脑卒中后遗症期偏瘫患者运动功能的影响[J]. 中国康复医学杂志, 2013, 28(7): 642-644.
[19] 金俏,吴世政,任晵晶,等. 重复经颅磁刺激偶联功能性电刺激对脑梗死患者运动功能恢复的影响[J]. 中华物理医学与康复杂志, 2017, 39(10): 747-749.
[20] 杨露,盛扬,谢亮,等. 重复经颅磁刺激联合康复训练对脑卒中患者步行功能的影响[J]. 中华物理医学与康复杂志, 2016, 38(12): 907-909.
[21] Kakuda W, Abo MG, Kaito N, et al.Low-frequency rTMS with language therapy over a 3-month period for sensory-dominant aphasia: case series of two post-stroke Japanese patients[J]. Brain Inj, 2010, 24(9): 1113-1117.
[22] Corti M, Patten C, Triggs W.Repetitive transcranial magnetic stimulation of motor cortex after stroke: a focused review[J]. Am J Phys Med Rehabil, 2012, 91(3): 254-270.
[23] 殷稚飞,沈滢,戴文骏,等. 低频重复经颅磁刺激在脑卒中后上肢运动功能康复中的研究和应用[J]. 中华物理医学与康复杂志, 2014, 36(6): 486-489.
[24] Conchou F, Loubinoux I, Castel-Lacanal E, et al.Neural substrates of low-frequency repetitive transcranial magnetic stimulation during movement in healthy subjects and acute stroke patients. A PET study[J]. Brain Mapp, 2009, 30(8): 2542-2557.
[25] 孙玮,赵晨光,牟翔,等. 低频重复经颅磁刺激治疗脑卒中患者上肢痉挛的临床研究[J]. 中国康复, 2017, 32(2): 102-105.
[26] 张洪翠,丁大君,刘志华,等. 镜像疗法对偏瘫患者上肢功能康复疗效的观察[J]. 中国卒中杂志, 2011, 6(5): 381-387.
