低频重复经颅磁刺激联合重复外周磁刺激对脑卒中患者上肢功能和大脑皮层兴奋性影响的初步研究

关键词：脑卒中  上肢功能  痉挛  重复经颅磁刺激  重复外周磁刺激  功能性近红外光谱技术

Keywords:stroke  upper limb motor function  spasticity  repetitive transcranial magnetic stimulation  repetitive peripheral magnetic stimulation  functional near-infrared spectroscopy

摘要：

      摘要 目的：探讨低频重复经颅磁刺激（repetitive transcranial magnetic stimulation， rTMS）联合重复外周磁刺激（repetitive peripheral magnetic stimulation， rPMS）对脑卒中上肢功能及大脑皮层兴奋性的影响。 方法：纳入2021年11月至2022年11月在中山大学附属第三医院康复医学科收治的脑卒中上肢功能障碍患者35例，随机分为试验组（n=17）和对照组（n=18）。两组均接受2周常规治疗及健侧M1区低频rTMS，试验组在此基础上接受患侧上肢伸肘肌和伸腕肌rPMS，对照组接受伪rPMS。两组在治疗前、2周后接受Fugl-Meyer上肢运动部分（Fugl-Meyer assessment of the upper extremity， FMA-UE）、改良Ashworth（modified Ashworth scale， MAS）、改良Barthel指数（modified Bathel index， MBI）、静息运动阈值（rest motor threshold， rMT）评估；另采用功能性近红外光谱技术（functional near-infrared spectroscopy，fNIRS）检测23例患者双侧运动前区和辅助运动区（premotor and supplementary motor cortex， PMC-SMA）、感觉运动区（sensorimotor cortex， SMC）的氧合血红蛋白浓度变化（oxyhemoglobin concentration， △HbO2）。 结果：治疗后两组FMA-UE、MBI显著提高（P＜0.05），试验组FMA-UE改善程度、健侧半球M1区rMT显著高于对照组（P＜0.05）；试验组屈肘肌群MAS等级、患侧SMC区△HbO2显著改善（P＜0.05），FMA-UE改善值与健侧M1区rMT增加、患侧SMC区△HbO2存在显著的正相关关系（P＜0.05）。两组伸肘、屈腕肌群MAS等级、双侧PMC-SMA、健侧SMC区△HbO2组间、组内比较均无显著性差异（P＞0.05）。 结论：rTMS联合rPMS能改善脑卒中患者上肢功能和日常生活能力并调控大脑皮层兴奋性，且疗效优于单独rTMS，此可能与健侧M1区兴奋性降低及患侧SMC区激活有关。

Abstract:

      Abstract Objective： To investigate the effects of low-frequency repetitive transcranial magnetic stimulation （rTMS） combined with repetitive peripheral magnetic stimulation （rPMS） on upper limb function and cortical excitability of stroke. Method： Thirty-five patients with upper limb dysfunction in stroke admitted to the Department of Rehabilitation Medicine of the Third Affiliated Hospital of Sun Yat-sen University from November 2021 to November 2022 were selected. They were randomly divided into experimental group （n=17） and control group （n=17）. Both groups received conventional rehabilitation therapy and low-frequency rTMS. The experimental group received additional rPMS for the affected upper extremity extensors， while the control group received sham rPMS. Both groups received Fugl-Meyer assessment of the upper extremity （FMA-UE）， modified Ashworth scale （MAS）， modified Barthel index（MBI）， rest motor threshold （rMT）assessments. 23 patients underwent fNIRS to detect changes in oxyhemoglobin concentration （HbO2） in bilateral premotor and supplementary motor cortex （PMC-SMA） and sensorimotor cortex （SMC） before and after treatment. Result：FMA-UE and MBI were significantly improved in both groups （P<0.05）， and the improvement of FMA-UE and the rMT of unaffected M1 were significantly higher in the experimental group than in the control group after treatment（P<0.05）； the MAS grade of the flexor elbow group and △HbO2 of the affected SMC were significantly improved in the experimental group （P<0.05）， and the improvement of FMA-UE was correlated with the increase of the rMT of unaffected M1 and △HbO2 of the affected SMC （P<0.05）. There was no statistically significant difference for the MAS grade of elbow extension and wrist flexion muscle groups， △HbO2 of bilateral PMC-SMA area， and △HbO2 of unaffected SMC area （P>0.05）. Conclusion： The combination of rTMS and rPMS improved upper limb function and activities of daily living and modulated cortical excitability in stroke patients，This combination was more effective than rTMS alone, likely due to the reduced excitability of the unaffected M1 and the activation of the affected SMC.