【摘要】：目的通過對(duì)恢復(fù)期缺血性腦卒中后痙攣引起運(yùn)動(dòng)功能障礙的患者進(jìn)行低頻重復(fù)經(jīng)顱磁刺激(rTMS)聯(lián)合康復(fù)訓(xùn)練治療,運(yùn)用功能磁共振成像技術(shù)(fMRI)結(jié)合臨床行為學(xué)量表縱向觀察卒中患者康復(fù)治療前后大腦皮層功能的變化及痙攣引起肢體運(yùn)動(dòng)功能障礙改善情況,定性并定量分析大腦運(yùn)動(dòng)皮層激活重塑的動(dòng)態(tài)過程,旨在探討運(yùn)動(dòng)皮層代償、重組與肢體運(yùn)動(dòng)功能恢復(fù)間的關(guān)系,為低頻rTMS治療卒中后痙攣引起運(yùn)動(dòng)功能障礙的治療提供新的依據(jù)及探討其可能恢復(fù)機(jī)制。方法在福州總醫(yī)院康復(fù)理療科門診和神經(jīng)內(nèi)科病房招募符合納入標(biāo)準(zhǔn)和排除標(biāo)準(zhǔn)的50例患者,最終完成數(shù)據(jù)采集的共47例,采用隨機(jī)對(duì)照試驗(yàn)設(shè)計(jì),隨機(jī)分為治療組(1Hz rTMS+常規(guī)康復(fù)治療)24例,對(duì)照組(sham rTMS+常規(guī)康復(fù)治療)23例,通過每天1次,每周5天,持續(xù)8周的干預(yù)。兩組治療前、治療結(jié)束后分別進(jìn)行改良Ashworth量表(MAS),上肢Fugl-Meyer運(yùn)動(dòng)量表(FMA-UE),Barthel指數(shù)(BI)相關(guān)臨床行為學(xué)的評(píng)定,并在兩組中分別隨機(jī)抽取5例患者進(jìn)行fMRI檢查。觀察其治療前后大腦運(yùn)動(dòng)功能區(qū)激活區(qū)域與激活強(qiáng)度的改變。結(jié)果1.兩組患者治療前的一般臨床資料和FMA-UE、MAS、BI對(duì)比,差異無統(tǒng)計(jì)學(xué)意義(P0.05),隨機(jī)挑選的進(jìn)行fMRI檢查的患者治療前的一般臨床資料和臨床行為學(xué)資料對(duì)比,差異無統(tǒng)計(jì)學(xué)意義(P0.05)。2.康復(fù)干預(yù)后,兩組患者治療后的FMA-UE、MAS、BI均比治療前有不同程度的改善,差異有統(tǒng)計(jì)學(xué)意義(P0.05),且治療組效果優(yōu)于對(duì)照組。3.兩組接受fMRI檢查的患者,偏側(cè)化指數(shù)(LI)值均升高,差異有統(tǒng)計(jì)學(xué)意義(P0.01),治療組升高值大于對(duì)照組,治療組的LI升高值與MAS改善程度呈正相關(guān)(r=0.78,P0.05),對(duì)照組的LI升高值與MAS改善程度呈正相關(guān)(r=0.53,P0.05)。4.兩組接受fMRI檢查的患者的結(jié)果示,治療組激活區(qū)域有雙側(cè)大腦感覺運(yùn)動(dòng)區(qū)、輔助運(yùn)動(dòng)區(qū),患側(cè)初級(jí)運(yùn)動(dòng)區(qū),運(yùn)動(dòng)前區(qū),扣帶回,額中回,健側(cè)大腦頂下小葉,額下回;對(duì)照組激活區(qū)域有雙側(cè)感覺運(yùn)動(dòng)區(qū),輔助運(yùn)動(dòng)區(qū),初級(jí)運(yùn)動(dòng)區(qū),額下回,患側(cè)扣帶回,頂上小葉,健側(cè)丘腦,緣上回,顳下回。結(jié)論1.低頻rTMS結(jié)合康復(fù)訓(xùn)練及單純康復(fù)訓(xùn)練均可改善恢復(fù)期卒中患者痙攣引起的運(yùn)動(dòng)功能障礙,且低頻rTMS和康復(fù)訓(xùn)練有協(xié)同作用,能進(jìn)一步緩解痙攣,改善運(yùn)動(dòng)功能,提高日常生活能力。2.與運(yùn)動(dòng)功能相關(guān)的運(yùn)動(dòng)前區(qū)、輔助運(yùn)動(dòng)區(qū)和扣帶回不僅可以控制肌肉協(xié)調(diào)性和肌張力,還可促進(jìn)卒中后肢體痙攣患者痙攣的恢復(fù)。3.治療前后健患側(cè)大腦激活區(qū)的改變?yōu)樵缙诮?cè)激活為主,之后逐漸過渡到患側(cè)激活為主,符合該疾病的功能區(qū)重組的規(guī)律,這個(gè)過程中低頻rTMS和康復(fù)訓(xùn)練起到促進(jìn)的作用。4.低頻rTMS不僅明顯降低健側(cè)皮層興奮性,使患側(cè)皮層興奮性增強(qiáng),還可以加速大腦主要相關(guān)運(yùn)動(dòng)功能區(qū)由健側(cè)向患側(cè)的遷移,使運(yùn)動(dòng)功能改善,縮短康復(fù)周期。
[Abstract]:Objective to study the effects of low frequency repetitive transcranial magnetic stimulation (rTMS) combined with rehabilitation training in patients with motor dysfunction caused by spasticity after ischemic stroke in convalescence. Functional magnetic resonance imaging (fMRI) and clinical behavior scale were used to observe the changes of cerebral cortex function and the improvement of limb motor dysfunction caused by spasm before and after rehabilitation. The dynamic process of activation and remodeling of the motor cortex of the brain was analyzed qualitatively and quantitatively in order to explore the relationship between the compensation, recombination of motor cortex and the recovery of motor function of limbs. To provide a new basis for the treatment of motor dysfunction caused by post-stroke spasm with low frequency rTMS and to explore its possible recovery mechanism. Methods Fifty patients who met the standard of inclusion and exclusion were recruited from outpatient department of rehabilitation physiotherapy department and ward of neurology of Fuzhou General Hospital, and 47 cases of data were collected. A randomized controlled trial design was used. The patients were randomly divided into treatment group (1Hz rTMS routine rehabilitation group, 24 cases) and control group (sham rTMS routine rehabilitation treatment, 23 cases). The intervention was conducted once a day, 5 days a week, for 8 weeks. Before and after treatment, the modified Ashworth scale (MAS), upper limb Fugl-Meyer motor scale (FMA-UE), Barthel index (BI) was used to evaluate the clinical behavior, and 5 patients in the two groups were randomly selected for fMRI examination. To observe the changes of activation area and intensity of cerebral motor function area before and after treatment. Result 1. There was no significant difference in general clinical data and FMA-UE,MAS,BI between the two groups before treatment (P0.05), but there was no significant difference in general clinical data and clinical behavioral data before treatment in randomly selected patients with fMRI (P0.05). After rehabilitation intervention, the FMA-UE,MAS,BI of the two groups after treatment were improved to some extent, the difference was statistically significant (P0.05), and the effect of treatment group was better than that of control group. The hemiplegia index (LI) was significantly higher in the two groups with fMRI examination than that in the control group (P0.01), and the increased value in the treatment group was higher than that in the control group (P0.01). There was a positive correlation between the elevation of LI and the improvement of MAS in the treatment group (r = 0.78), and a positive correlation between the elevation of LI and the improvement of MAS in the control group (r = 0.53, P 0.05). 4. The results of fMRI examination showed that there were bilateral sensorimotor region, auxiliary motor area, primary motor area, premotor area, cingulate gyrus, middle frontal gyrus, inferior parietal lobule and inferior frontal gyrus in the treatment group. In the control group, there were bilateral sensorimotor region, auxiliary motor area, primary motor area, inferior frontal gyrus, cingulate gyrus, superior parietal lobule, healthy thalamus, supramarginal gyrus, subtemporal gyrus. Conclusion 1. Low frequency rTMS combined with rehabilitation training and rehabilitation training alone can improve motor dysfunction caused by spasticity in convalescent stroke patients, and low frequency rTMS and rehabilitation training have synergistic effects, which can further relieve spasm and improve motor function. Improving the ability of daily life. 2. The premotor area, auxiliary motor area and cingulate gyrus associated with motor function can not only control muscle coordination and muscle tension, but also promote the recovery of spasm in patients with limb spasm after stroke. 3. Before and after treatment, the changes of the brain activation areas in the diseased side were mainly the early activation of the healthy side, and then gradually transitioned to the activation of the affected side, which was in accordance with the law of the recombination of the functional regions of the disease, and the low frequency rTMS and rehabilitation training played a promoting role in the process. 4. Low frequency rTMS not only significantly reduced the excitability of the healthy cortex, enhanced the excitability of the affected cortex, but also accelerated the migration of the main motor functional areas from the healthy side to the affected side, improved the motor function and shortened the rehabilitation period.
【學(xué)位授予單位】：福建中醫(yī)藥大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R743.3

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