iTBS预激联合下肢外骨骼机器人训练对脑卒中患者下肢运动及脑功能的影响：一项fNIRS-三维步态多模态评估研究

关键词：间歇性Theta爆发式脉冲刺激  下肢外骨骼机器人  功能近红外光谱  三维步态分析  脑卒中

Keywords:intermittent theta burst stimulation  lower-limb exoskeleton robot  functional near-infrared spectroscopy  three-dimensional gait analysis  stroke

摘要：

      摘要 目的：探讨间歇性Theta爆发式脉冲刺激（iTBS）预激联合下肢外骨骼机器人训练改善脑卒中患者下肢运动功能的疗效及神经机制。 方法：将80例脑卒中后下肢运动功能障碍患者随机分为常规康复组（n=20）、iTBS组（n=20）、下肢机器人组（n=20）、iTBS+下肢机器人组（n=20）。4组均接受常规康复治疗，iTBS组、下肢机器人组分别叠加iTBS、下肢外骨骼机器人训练，iTBS+下肢机器人组则接受联合训练。治疗前后，进行Fugl-Meyer下肢运动功能评定量表（FMA-LE）、改良Barthel指数（MBI）、Berg平衡量表（BBS）、三维步态分析、功能近红外光谱（fNIRS）等评估。 结果：治疗前，4组一般资料及各项指标差异无显著性意义（P＞0.05）。①治疗后，4组FMA-LE、MBI、BBS评分均显著改善（P＜0.001），iTBS+下肢机器人组FMA-LE、MBI、BBS评分改善优于其他三组（P＜0.05）。②治疗后，4组步态参数均不同程度地改善（P＜0.05），iTBS+下肢机器人组时空、运动学参数改善优于其他三组（P＜0.05）。③治疗后，4组感兴趣区（ROI）间、ROI内功能连接（FC）显著增强（P＜0.05），iTBS+下肢机器人组在ROI间、ROI内FC增强均优于其他三组（P＜0.05）；iTBS+下肢机器人组双侧初级运动皮质（LM1/RM1）、双侧运动辅助区（LSMA/RSMA）、双侧前额叶皮质（LPFC/RPFC）、左侧枕叶（LOL）激活显著增强（P＜0.01），且LM1、LSMA、RSMA、LPFC、LOL激活强于其他三组（P＜0.05）。 结论：iTBS与下肢外骨骼机器人联合干预可通过增强运动皮质兴奋性、促进脑网络重组，发挥协同神经重塑效应，更有效地改善脑卒中患者的下肢运动功能与步态。

Abstract:

      Abstract Objective： To elucidate the therapeutic effects and neural mechanisms of a neuromodulatory priming strategy using intermittent theta burst stimulation （iTBS） combined with lower-limb exoskeleton robot training on functional recovery in stroke patients. Method： Eighty post-stroke patients with lower limb motor dysfunction were randomized into four groups （n=20 in each）： conventional rehabilitation（CR）， iTBS， lower limb robot（LLR）， and iTBS+LLR. All groups received conventional rehabilitation therapy. In addition， the iTBS and LLR groups received their respective interventions， while the combined group received both iTBS and robotic training. Outcome measures， including the Fugl-Meyer Assessment for Lower Extremity （FMA-LE）， Modified Barthel Index （MBI）， Berg Balance Scale （BBS）， 3D gait analysis， and fNIRS， were assessed before and after treatment. Result： There were no significant differences in baseline characteristics or outcome measures among the four groups （P>0.05）. Compared to baseline， all four groups exhibited statistically significant improvements in FMA-LE， MBI， and BBS scores following the intervention （P<0.001）. The iTBS+LLR group demonstrated superior outcomes in FMA-LE， MBI， and BBS scores compared to other groups （P<0.05）. Gait analysis indicated that all groups showed significant improvements in various gait parameters after treatment compared to pre-treatment values （P<0.05）. The iTBS+LLR group displayed more pronounced enhancements in temporal， spatial， and kinematic gait metrics than other groups （P<0.05）. At the neurophysiological level， functional connectivity（FC） within and between regions of interest （ROIs） significantly increased in all groups after treatment （P<0.05）. The iTBS+LLR group showed greater FC augmentation compared to other groups （P<0.05）. The iTBS+LLR group demonstrated broadened activation involving left and right primary motor cortex （LM1/RM1）， left and right supplementary motor area （LSMA/RSMA）， left and right prefrontal cortex （LPFC/RPFC）， and left occipital lobe （LOL） （P<0.01）. Intergroup comparisons confirmed that activation in LM1， LSMA， RSMA， LPFC， and LOL was significantly stronger in the combined group than in the other groups （P<0.05）. Conclusion： Priming iTBS combined with a lower limb exoskeleton robot results in greater improvements in motor function and gait in stroke patients than either intervention alone. These benefits may be associated with enhanced motor cortical excitability， strengthened functional connectivity, and facilitation of synergistic neuroplasticity within gait-control networks.