不同模式小脑θ爆发刺激联合皮层磁刺激治疗脑卒中后上肢痉挛的疗效观察

关键词：脑卒中  上肢  痉挛  经颅磁刺激  小脑

Keywords:stroke  upper limb  spasticity  transcranial magnetic stimulation  cerebellum

摘要：

      摘要 目的：探讨不同模式小脑θ爆发刺激联合健侧大脑皮层1Hz重复经颅磁刺激对脑卒中偏瘫患者上肢痉挛的影响。 方法：选择2023年11月—2024年11月在复旦大学附属金山医院收治并符合纳排标准的脑卒中恢复期患者60例，随机分入对照组（n=20）、iTBS组（n=20）、cTBS组（n=20）。3组均给予内科治疗和常规康复治疗，在此基础上，对照组给予健侧大脑皮层1Hz重复经颅磁刺激和随机的空载小脑TBS治疗，iTBS组给予健侧大脑皮层1Hz重复经颅磁刺激和小脑iTBS治疗，cTBS组给予健侧大脑皮层1Hz重复经颅磁刺激和小脑cTBS治疗。在治疗前和治疗4周后，采用改良Ashworth痉挛量表（MAS）评估患者患侧上肢肌张力，Fugl-Meyer上肢运动功能评定量表（FMA-UE）评估患者患侧上肢运动能力，经颅磁刺激仪器测定患侧皮层的运动诱发电位（MEP）波幅及中枢运动传导时间（CMCT）。 结果：治疗前，3组患者的MAS评分、FMA-UE评分、MEP波幅、CMCT值均无显著性差异（P＞0.05）；经4周治疗后，3组患者的MAS评分显著降低（|t|>5.101，P＜0.001）、FMA-UE评分（|t|>4.621，P＜0.001）、MEP波幅均显著提高（|t|>3.530，P＜0.05），CMCT值均显著缩短（|t|>4.969，P＜0.001）；进一步两两比较发现：与对照组相比较，治疗后其余2组MAS评分降低，FMA-UE评分、MEP波幅提高及CMCT值缩短更显著（P＜0.05）；治疗后，iTBS组与cTBS组的MAS评分、FMA-UE评分、MEP波幅、CMCT值均无显著性差异（P＞0.05）。 结论：不同模式小脑θ爆发刺激联合健侧大脑皮层1Hz重复经颅磁刺激均有助于减轻脑卒中患者偏瘫上肢痉挛状态，促进上肢运动功能恢复。

Abstract:

      Abstract Objective： To discuss the impact of different modes of cerebellar theta burst stimulation combined with 1Hz repetitive transcranial magnetic stimulation of the contralateral cerebral cortex on upper limb spasticity in stroke hemiplegic patients. Method： Sixty stroke patients in the recovery stage， who were admitted to Jinshan Hospital affiliated with Fudan University between Nov. 2023 and Nov. 2024 and met the predefined inclusion and exclusion criteria， were selected. These patients were then randomly allocated to three groups： the control group （n=20）， the iTBS group（n=20）， and the cTBS group（n=20）. All three groups received conventional medical therapy and routine rehabilitation regimens. Additionally， the control group was administered 1Hz repetitive transcranial magnetic stimulation（rTMS） on the contralesional cerebral cortex， along with random sham transcranial magnetic stimulation（TBS） of the cerebellum. The iTBS group was subjected to 1Hz rTMS on the contralesional cerebral cortex， combined with intermittent theta-burst stimulation （iTBS） of the cerebellum. Similarly， the cTBS group received 1Hz rTMS on the contralesional cerebral cortex， in conjunction with continuous theta-burst stimulation（cTBS） of the cerebellum. Prior to treatment initiation and four weeks post-treatment， the Modified Ashworth Scale（MAS） was applied to assess the muscle tone of the affected upper limb. The Fugl-Meyer Assessment for Upper Extremity（FMA-UE） was utilized to evaluate the motor function of the affected upper limb. Moreover， a transcranial magnetic stimulation device was employed to measure the motor evoked potential （MEP） amplitude and central motor conduction time（CMCT） of the affected cerebral cortex. Result：No statistically significant differences were observed among the three groups in terms of MAS scores， FMA-UE scores， MEP amplitudes， and CMCT values prior to the treatment（P＞0.05）. After four weeks of treatment， a significant decrease in MAS scores was observed in all three groups（|t|>5.101，P＜0.001）. Simultaneously， significant increases in FMA-UE scores（|t|>4.621，P＜0.001）and MEP amplitudes（|t|>3.530，P＜0.05）， as well as a significant shortening of CMCT values（|t|>4.969，P＜0.001） were detected. Further pairwise comparisons indicated that， compared with the control group， the other two groups showed more significant decreases in MAS scores， more substantial increases in FMA-UE scores and MEP amplitudes， and more pronounced shortening of CMCT values post-treatment（P＜0.05）. After treatment， no statistically significant differences were found between the iTBS group and the cTBS group in MAS scores， FMA-UE scores， MEP amplitudes， and CMCT values （P＞0.05）. Conclusion： Both different modes of cerebellar theta-burst stimulation combined with 1Hz repetitive transcranial magnetic stimulation on the contralateral cerebral cortex are helpful in alleviating the spasticity of the hemiplegic upper limb in stroke patients and promoting the recovery of upper limb motor function.