【摘要】：背景與目的:腦梗死又稱(chēng)缺血性腦卒中,是指各種原因引起的腦局部血液供應(yīng)障礙,使局部腦組織發(fā)生不可逆損害,導(dǎo)致腦組織缺血、缺氧性壞死。世界衛(wèi)生組織調(diào)查結(jié)果顯示:我國(guó)腦梗死發(fā)病率不斷上升,已成為中老年人中最常見(jiàn)的疾病之一。第三次國(guó)民死因調(diào)查結(jié)果顯示,腦梗死已經(jīng)上升為中國(guó)第一位死因。隨著診療技術(shù)的不斷進(jìn)步,腦梗死的死亡率明顯下降,但腦梗死后常遺留有運(yùn)動(dòng)功能障礙,仍缺乏有效的治療措施。因此,對(duì)腦梗死的康復(fù)進(jìn)行必要的臨床研究,為其臨床治療尋找一個(gè)有效的方法,并制定針對(duì)性的預(yù)防措施,最大程度的恢復(fù)患者腦梗死后遺留的運(yùn)動(dòng)功能障礙,已成為當(dāng)今醫(yī)學(xué)界面臨的重大課題。重復(fù)經(jīng)顱磁刺激(repetitive transcranial magnetic stimulation,rTMS)是Barker教授在1985年報(bào)道的經(jīng)顱磁刺激的基礎(chǔ)上形成的一種神經(jīng)電生理技術(shù)。是一種將電磁脈沖信號(hào)透過(guò)顱骨傳送到大腦皮層,刺激特定腦區(qū)的神經(jīng),通過(guò)增加皮質(zhì)脊髓系統(tǒng)的興奮性,提高運(yùn)動(dòng)系統(tǒng)的反應(yīng)性,以達(dá)到治療的目的的技術(shù)。rTMS可以促進(jìn)受損的大腦皮質(zhì)區(qū)域性功能重建,提高康復(fù)治療的療效,具有無(wú)創(chuàng)、無(wú)痛、安全等優(yōu)勢(shì),且具有良好的時(shí)間分辨率和空間分辨率,更加容易被病人接受。近年來(lái),該方法被廣泛地應(yīng)用于腦梗死患者的康復(fù)治療中,為腦梗死患者運(yùn)動(dòng)功能障礙的康復(fù)開(kāi)辟了一個(gè)新領(lǐng)域,提供了新思路。本研究采用隨機(jī)、對(duì)照、盲法原則,主要觀察采用1Hz的重復(fù)經(jīng)顱磁刺激治療腦梗死患者運(yùn)動(dòng)功能障礙時(shí),試驗(yàn)組和對(duì)照組的上肢運(yùn)功功能、神經(jīng)功能和日常生活活動(dòng)能力的改善情況及差異。實(shí)驗(yàn)方法:選取2013年8月~2016年5月在我科入院的腦梗死伴上肢運(yùn)動(dòng)功能障礙的患者80例,并對(duì)患者進(jìn)行隨機(jī)分組,其中試驗(yàn)組(經(jīng)顱磁刺激組)40例,對(duì)照組(常規(guī)治療組)40例。80例患者均符合本研究的納入標(biāo)準(zhǔn),納入標(biāo)準(zhǔn):(1)初次、單側(cè)發(fā)病或者隨既往有發(fā)作但未遺留神經(jīng)功能障礙者;(2)生命體征平穩(wěn),意識(shí)清楚;(3)患者上肢Brunnstrom分級(jí)在I—III期;(4)年齡在20歲到75歲之間;(5)病程在4周之內(nèi);(6)給予經(jīng)顱磁刺激可以測(cè)出患側(cè)腦區(qū)運(yùn)動(dòng)誘發(fā)電位;(7)入選患者簽署知情同意書(shū)。排除標(biāo)準(zhǔn):(1)有嚴(yán)重的認(rèn)知障礙者;(2)有視、聽(tīng)言語(yǔ)障礙者;(3)存在骨關(guān)節(jié)、肌肉等運(yùn)動(dòng)系統(tǒng)疾病者;(4)患者有明顯的康復(fù)訓(xùn)練的禁忌癥(如嚴(yán)重的心臟病、新近發(fā)生的心肌梗塞、近期心絞痛發(fā)作未能良好控制的);(5)有明確的不能進(jìn)行rTMS的患者(如急性期的腦外傷、腦出血患者;癲癇病史或腦電圖檢查顯示有癲癇樣改變的患者);(6)病情不穩(wěn)定或者存在不可控制的健康因素;(7)存在嚴(yán)重的肌肉痙攣、震顫者;(8)同時(shí)參加其他試驗(yàn)或者是接受其他治療者。試驗(yàn)組中男27例,女13例,平均年齡(58.15±9.54),腦梗病灶側(cè)為左側(cè)24例,右側(cè)16例;平均病程(17.65±6.67)天;對(duì)照組中男23例,女17例,平均年齡(59.93±8.95),腦梗病灶側(cè)為左側(cè)26例,右側(cè)14例;平均病程(16.00±4.88)天。兩組一般資料無(wú)明顯差異(P0.05)。在患者生命體征平穩(wěn)后,試驗(yàn)組:給予1Hz的重復(fù)經(jīng)顱磁刺激,刺激作用于健側(cè)半球M1區(qū),刺激參數(shù):1Hz,強(qiáng)度為90%MT,25min/天,共1500脈沖,并配合常規(guī)藥物治療和康復(fù)訓(xùn)練。對(duì)照組:只采用常規(guī)的藥物治療和康復(fù)訓(xùn)練。常規(guī)的康復(fù)訓(xùn)練包括:(1)對(duì)于不能起床的患者行床邊的被動(dòng)肢體運(yùn)動(dòng)和良肢位的擺放,(2)進(jìn)入訓(xùn)練室后行運(yùn)動(dòng)療法、上肢作業(yè)療法、坐站訓(xùn)練、行走訓(xùn)練以及中頻電療。訓(xùn)練每日進(jìn)行一次。兩組患者治療均每天一次,每周5天,連續(xù)6周。分別在治療前、治療3周、治療結(jié)束后對(duì)患者進(jìn)行上肢簡(jiǎn)易Fuel-Meyer(FMA)運(yùn)動(dòng)功能評(píng)分、Barthel指數(shù)(BI)評(píng)分、神經(jīng)功能缺損評(píng)分的測(cè)定。實(shí)驗(yàn)結(jié)果:1.在治療3周后,與治療前相比較時(shí),經(jīng)顱磁刺激組的FMA評(píng)分與常規(guī)治療組的FMA評(píng)分均有一定程度提高;治療6周時(shí),經(jīng)顱磁刺激組的FMA評(píng)分與常規(guī)治療組的FMA評(píng)分均明顯提高,與治療前評(píng)分相比差異有統(tǒng)計(jì)學(xué)意義,且試驗(yàn)組評(píng)分更高,兩組之間差異有統(tǒng)計(jì)學(xué)意義。2.治療3周、6周后,兩組ADL評(píng)分均較治療前有升高,差異有統(tǒng)計(jì)學(xué)意義;試驗(yàn)組采用經(jīng)顱磁刺激在治療3周、6周后ADL評(píng)分與對(duì)照組相比較,ADL評(píng)分提高更明顯,差異有統(tǒng)計(jì)學(xué)意義。3.治療3周、6周后對(duì)兩組在兩個(gè)時(shí)間點(diǎn)NIHSS評(píng)分與治療前相比時(shí)有明顯下降,差異有統(tǒng)計(jì)學(xué)意義。經(jīng)顱磁刺激組與常規(guī)治療組比較,治療3周時(shí)組間差異有統(tǒng)計(jì)學(xué)意義(P=0.005),治療6周時(shí)差異有統(tǒng)計(jì)學(xué)意義(P=0.000)。4.兩組不良事件發(fā)生率均較低,組間差異無(wú)統(tǒng)計(jì)學(xué)意義。結(jié)論:本研究表明1Hz的r TMS刺激腦梗死患者健側(cè)大腦半球M1區(qū)可明顯提高患者的上肢運(yùn)動(dòng)功能,是一種治療腦梗死患者上肢運(yùn)動(dòng)功能障礙的有效方法,值得臨床借鑒和推廣。
[Abstract]:BACKGROUND AND OBJECTIVE: Cerebral infarction, also known as ischemic stroke, refers to a variety of causes of local blood supply disorders in the brain, causing irreversible damage to local brain tissue, leading to cerebral ischemia, hypoxic necrosis. The World Health Organization survey results show that the incidence of cerebral infarction in China is rising, has become the most common disease in the elderly. The results of the third national death cause survey show that cerebral infarction has risen to be the first cause of death in China. With the continuous progress of diagnosis and treatment technology, the death rate of cerebral infarction has decreased significantly. However, motor dysfunction often remains after cerebral infarction, and effective treatment measures are still lacking. Therefore, it is necessary to carry out clinical research on the rehabilitation of cerebral infarction. To find an effective method for clinical treatment and formulate specific preventive measures to maximize the recovery of motor dysfunction after cerebral infarction has become a major issue facing the medical community. Repetitive transcranial magnetic stimulation (rTMS) was reported by Professor Barker in 1985. A neuroelectrophysiological technique based on magnetic stimulation of the skull is a technique that transmits electromagnetic pulse signals through the skull to the cerebral cortex to stimulate nerves in specific areas of the brain. It increases the excitability of the corticospinal system and the responsiveness of the motor system in order to achieve therapeutic purposes. rTMS can promote the damaged cerebral cortex. In recent years, this method has been widely used in the rehabilitation of patients with cerebral infarction and opened up a new way for the rehabilitation of motor dysfunction in patients with cerebral infarction. The purpose of this study was to observe the improvement and difference of motor function, neurological function and activities of daily living in the upper limbs of patients with cerebral infarction treated by 1 Hz repetitive transcranial magnetic stimulation. From May 2016 to May 2016, 80 patients with cerebral infarction accompanied by upper limb dyskinesia were randomly divided into two groups, 40 patients in the experimental group (transcranial magnetic stimulation group) and 40 patients in the control group (routine treatment group). All the 80 patients met the inclusion criteria of this study. The inclusion criteria were as follows: (1) Initial, unilateral onset or previous onset but not left behind. Patients with neurological impairment; (2) stable vital signs and clear consciousness; (3) Brunnstrom classification of upper limbs in I-III stage; (4) between 20 and 75 years of age; (5) course of disease within 4 weeks; (6) Transcranial magnetic stimulation can be given to detect the affected side of the brain motor evoked potential; (7) selected patients signed informed consent. Exclusive criteria: (1) serious cognition Obstacles; (2) Visual and auditory speech disorders; (3) the presence of bone and joint, muscle and other motor system diseases; (4) patients with significant rehabilitation training contraindications (such as severe heart disease, recent myocardial infarction, recent angina attacks can not be well controlled); and (5) patients with a clear failure to carry out rTMS (such as acute brain trauma, brain injury) Hemorrhagic patients; epilepsy history or EEG examination showed epileptiform changes in patients; (6) unstable conditions or uncontrollable health factors; (7) severe muscle spasm, tremor; (8) attending other trials or receiving other treatment at the same time. There were 24 lesions on the left side and 16 lesions on the right side; the average course of disease was (17.65 + 6.67) days; 23 males and 17 females in the control group, with an average age of (59.93 + 8.95), 26 lesions on the left side and 14 lesions on the right side; and the average course of disease was (16.00 + 4.88) days. Magnetic stimulation, stimulation on the healthy hemisphere M1 area, stimulation parameters: 1 Hz, intensity of 90% MT, 25 min / day, a total of 1500 pulses, and with conventional drug treatment and rehabilitation training. Control group: only conventional drug treatment and rehabilitation training. Conventional rehabilitation training includes: (1) for patients unable to wake up passive limb movement and good limb position. After entering the training room, the patients were given exercise therapy, upper limb occupational therapy, sitting station training, walking training and intermediate frequency electrotherapy. Rthel index (BI) score and neurological deficit score were measured. Results: 1. After 3 weeks of treatment, compared with before treatment, the FMA score of the transcranial magnetic stimulation group and the conventional treatment group were improved to a certain extent. At 6 weeks of treatment, the FMA score of the transcranial magnetic stimulation group and the conventional treatment group were significantly improved, and the FMA score of the conventional treatment group was also improved. The ADL scores of the experimental group were higher than those of the control group. 2. After 3 weeks of treatment, the ADL scores of the two groups were higher than those before treatment, and the difference was statistically significant. There was significant difference in NIHSS score between the two groups at two time points after treatment. Compared with the conventional treatment group, there was significant difference in NIHSS score between the two groups at three weeks after treatment (P = 0.005), and there was significant difference at six weeks after treatment (P = 0.000). Conclusion: 1 Hz R TMS stimulation of M1 area of healthy hemisphere in patients with cerebral infarction can significantly improve the upper limb motor function, and is an effective method for the treatment of upper limb motor dysfunction in patients with cerebral infarction, which is worthy of clinical reference and promotion.
【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R743.3

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