【摘要】：背景： 痙攣性斜頸(cervical dystonia, CD)是局灶性肌張力障礙的常見類型,主要臨床表現(xiàn)為頸部肌肉的異常收縮導致了頭頸部的姿勢異常和／或運動增多。而感覺詭計(sensory trick, ST)現(xiàn)象是其經(jīng)典的臨床特征之一。感覺詭計是指患者可以通過一些特定的動作,暫時減輕斜頸的姿勢和運動異常。根據(jù)感覺詭計是否需要用力,可將其分為“經(jīng)典型”感覺詭計(classical sensory trick, CST)和“用力型”感覺詭計(forcible sensory trick, FST)。感覺詭計的方向與頭偏轉(zhuǎn)的方向之間是否有關(guān)仍存在爭議。感覺詭計的有效程度、作用時間長短究竟與哪些因素相關(guān)；CST與FST的作用機制是否相同；FST是否僅僅通過對抗異常運動發(fā)揮作用；這些問題都沒有定論。感覺詭計的機制仍是不解之謎。除感覺詭計現(xiàn)象外,還有許多證據(jù)表明局灶性肌張力障礙的患者存在感覺系統(tǒng)的異常,如時間辨別覺與空間辨別覺的異常。這些異常與感覺詭計的有效性之間是否相關(guān)也尚無定論。 目的： 本研究通過調(diào)查痙攣性斜頸患者中感覺詭計的臨床特征及其相關(guān)因素,著重對比“經(jīng)典型”感覺詭計與“用力型”感覺詭計,結(jié)合感覺詭計與空間辨別覺之間關(guān)系的研究,探究感覺詭計的作用機制。 方法： 對北京協(xié)和醫(yī)院神經(jīng)科運動障礙專病門診的痙攣性斜頸患者進行標準問卷調(diào)查與臨床評估,具體包括患者的一般情況、起病年齡、病程長短、病情加重緩解因素和感覺詭計詳細情況。使用TSUI評分評估患者的斜頸嚴重程度。 使用J.V.P Domes套件測定痙攣性斜頸患者與健康受試者的觸覺空間辨別覺閾值(Spatial Discrimination Threshold,SDT)。對比健康受試者、感覺詭計使癥狀完全緩解的CD患者、感覺詭計使癥狀部分緩解的CD患者以及感覺詭計無效的CD患者之間的SDT是否不同。 所有數(shù)據(jù)均錄入SPSS22.0中進行統(tǒng)計分析。 結(jié)果： 在納入研究的240名痙攣性斜頸患者中,有75%的患者在接受調(diào)查時存在感覺詭計。感覺詭計常見的形式較為多樣,多數(shù)表現(xiàn)為手觸摸頭頸部的某一部位。一個患者可有多種感覺詭計。多數(shù)患者認為感覺詭計對癥狀的緩解不如肉毒毒素。與FST組相比,CST組的患者年齡較小、起病年齡較小、病程較短、TSUI評分較低,且CST組的患者感覺詭計效果更好、持續(xù)時間更長(p0.05), CST組患者的感覺詭計有效程度和持續(xù)時間均與TSUI評分相關(guān)(p0.05)。FST組患者中,多數(shù)患者(55.5%)為頭偏轉(zhuǎn)同側(cè)的感覺詭計更為有效。但CST組與FST組均有部分患者雙側(cè)感覺詭計有效程度相等(分別為39.2%和11.1%),CST組雙雙側(cè)感覺詭計有效程度相等的患者比例更高(p0.05)�？拷挥|摸、想象、雙手伸直上舉這3個動作在FST組的患者中有效率均顯著低于CST組患者(p0.05)。健康受試者與CD患者之間以及感覺詭計效果不同的CD患者之間未發(fā)現(xiàn)SDT存在顯著性差異(p0.05)。 結(jié)論： 絕大多數(shù)痙攣性斜頸的患者在病程中會出現(xiàn)感覺詭計。與FST的患者相比,CST的患者斜頸程度較輕,感覺詭計更為有效,持續(xù)的時間也更長。FST并非單純通過對抗異常運動來緩解癥狀,但與CST相比,FST更依賴于觸覺刺激。感覺詭計的機制十分復雜,它的作用可能分為兩個階段：①使頭從姿勢異�；謴偷秸�,②維持頭部的正常姿勢。FST與CST的不同之處可能在于,在斜頸程度較重的患者中,需要施加力量即使用FST使頭恢復到正位。而在維持頭部位置正常的過程中,FST與CST的機制是類似的。除了觸覺刺激外,本體感覺刺激、運動覺刺激、溫度覺刺激、視覺聽覺刺激甚至想象感覺詭計均可使某些肌張力障礙的患者癥狀減輕。感覺詭計可能是通過多種感覺刺激的整合,改變了大腦皮層的激活模式,降低了異常的皮層內(nèi)易化,從而使癥狀暫時緩解。感覺詭計對肌張力障礙的治療有一定的指導意義,但仍需要進一步的研究以證實。
[Abstract]:Background:
Spastic torticollis (CD) is a common type of focal dystonia. The main clinical manifestation is abnormal contraction of cervical muscles, which results in abnormal head and neck posture and/or increased movement. Sensory trick (ST) is one of the classical clinical features of CD. Sensory trick refers to the ability of a patient to pass through a single sensory trick. Certain movements temporarily relieve the posture and movement abnormalities of the torticollis. According to whether sensory cunning requires exertion, it can be divided into classical sensory trick (CST) and forcible sensory trick (FST). Whether the direction of sensory cunning is related to the direction of head deflection remains. There are controversies about the effectiveness and duration of sensory cunning; whether CST and FST work in the same way; whether FST only works against abnormal movements; and whether these questions are not conclusive. There are sensory abnormalities in patients with focal dystonia, such as temporal and spatial abnormalities. Whether these abnormalities are related to the effectiveness of sensory cunning is not conclusive.
Objective:
By investigating the clinical features and related factors of sensory cunning in patients with spastic torticollis, this study compared the classical sensory cunning with the forced sensory cunning, and explored the mechanism of sensory cunning combined with the relationship between sensory cunning and spatial discrimination.
Method:
Standard questionnaire survey and clinical evaluation were conducted on the patients with spastic torticollis in the neurological department of Peking Union Medical College Hospital, including general condition, age of onset, duration of illness, remission factors of aggravation and sensory trickery.
Spatial Discrimination Threshold (SDT) was measured in spastic torticollis patients and healthy volunteers using the J.V.P Domes suite. Compared with healthy volunteers, the SDT between CD patients with complete remission of symptoms by sensory cunning, CD patients with partial remission of symptoms by sensory cunning and CD patients with ineffective sensory cunning were It's not different.
All data were entered in SPSS22.0 for statistical analysis.
Result:
Of the 240 patients with spastic torticollis included in the study, 75% had sensory cunning at the time of the study. Sensory cunning was more common in a variety of forms, mostly by touching a part of the head and neck. One patient could have multiple sensory cunning. Most patients thought sensory cunning was less effective than botulinum toxin in relieving symptoms. Compared with group T, CST patients were younger, younger onset age, shorter course of disease, lower TSUI score, and CST patients felt better trickery effect, longer duration (p0.05). The efficacy and duration of sensory trickery in CST patients were correlated with TSUI score (p0.05). Most patients (55.5%) in FST group were head deflection ipsilateral. Sensory cunning was more effective. However, some patients in CST and FST groups had the same degree of efficacy in bilateral sensory cunning (39.2% and 11.1% respectively). The proportion of patients in CST group with the same degree of efficacy in bilateral sensory cunning was higher (p0.05). The efficiency of the three movements in FST group was significantly lower than that in CST group. There was no significant difference in SDT between healthy subjects and CD patients or between CD patients with different sensory cunning effects (p0.05).
Conclusion:
The vast majority of patients with spastic torticollis develop sensory cunning during the course of their illness. CST patients have less torticollis, more effective sensory cunning, and longer duration than FST patients. FST does not relieve symptoms simply by confronting abnormal movements, but is more dependent on tactile stimuli than CST. The difference between FST and CST may be that, in patients with severe torticollis, a force is needed to restore the head to its normal position, while in the process of maintaining normal head position, FST and CST are required. In addition to tactile stimuli, proprioceptive stimuli, motor stimuli, thermosensory stimuli, visual and auditory stimuli, and even imaginative sensory cunning can alleviate symptoms in some patients with dystonia. Sensory cunning may change the activation pattern of the cerebral cortex and reduce abnormal cortex through the integration of multiple sensory stimuli. Sensory cunning has a guiding role in the treatment of dystonia, but further research is needed to confirm it.
【學位授予單位】：北京協(xié)和醫(yī)學院
【學位級別】：博士
【學位授予年份】：2014
【分類號】：R746

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本文編號：2182215