【摘要】：目的通過對恢復期缺血性腦卒中后痙攣引起運動功能障礙的患者進行低頻重復經顱磁刺激(rTMS)聯(lián)合康復訓練治療,運用功能磁共振成像技術(fMRI)結合臨床行為學量表縱向觀察卒中患者康復治療前后大腦皮層功能的變化及痙攣引起肢體運動功能障礙改善情況,定性并定量分析大腦運動皮層激活重塑的動態(tài)過程,旨在探討運動皮層代償、重組與肢體運動功能恢復間的關系,為低頻rTMS治療卒中后痙攣引起運動功能障礙的治療提供新的依據及探討其可能恢復機制。方法在福州總醫(yī)院康復理療科門診和神經內科病房招募符合納入標準和排除標準的50例患者,最終完成數(shù)據采集的共47例,采用隨機對照試驗設計,隨機分為治療組(1Hz rTMS+常規(guī)康復治療)24例,對照組(sham rTMS+常規(guī)康復治療)23例,通過每天1次,每周5天,持續(xù)8周的干預。兩組治療前、治療結束后分別進行改良Ashworth量表(MAS),上肢Fugl-Meyer運動量表(FMA-UE),Barthel指數(shù)(BI)相關臨床行為學的評定,并在兩組中分別隨機抽取5例患者進行fMRI檢查。觀察其治療前后大腦運動功能區(qū)激活區(qū)域與激活強度的改變。結果1.兩組患者治療前的一般臨床資料和FMA-UE、MAS、BI對比,差異無統(tǒng)計學意義(P0.05),隨機挑選的進行fMRI檢查的患者治療前的一般臨床資料和臨床行為學資料對比,差異無統(tǒng)計學意義(P0.05)。2.康復干預后,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)計學意義(P0.05),且治療組效果優(yōu)于對照組。3.兩組接受fMRI檢查的患者,偏側化指數(shù)(LI)值均升高,差異有統(tǒng)計學意義(P0.01),治療組升高值大于對照組,治療組的LI升高值與MAS改善程度呈正相關(r=0.78,P0.05),對照組的LI升高值與MAS改善程度呈正相關(r=0.53,P0.05)。4.兩組接受fMRI檢查的患者的結果示,治療組激活區(qū)域有雙側大腦感覺運動區(qū)、輔助運動區(qū),患側初級運動區(qū),運動前區(qū),扣帶回,額中回,健側大腦頂下小葉,額下回;對照組激活區(qū)域有雙側感覺運動區(qū),輔助運動區(qū),初級運動區(qū),額下回,患側扣帶回,頂上小葉,健側丘腦,緣上回,顳下回。結論1.低頻rTMS結合康復訓練及單純康復訓練均可改善恢復期卒中患者痙攣引起的運動功能障礙,且低頻rTMS和康復訓練有協(xié)同作用,能進一步緩解痙攣,改善運動功能,提高日常生活能力。2.與運動功能相關的運動前區(qū)、輔助運動區(qū)和扣帶回不僅可以控制肌肉協(xié)調性和肌張力,還可促進卒中后肢體痙攣患者痙攣的恢復。3.治療前后健患側大腦激活區(qū)的改變?yōu)樵缙诮燃せ顬橹?之后逐漸過渡到患側激活為主,符合該疾病的功能區(qū)重組的規(guī)律,這個過程中低頻rTMS和康復訓練起到促進的作用。4.低頻rTMS不僅明顯降低健側皮層興奮性,使患側皮層興奮性增強,還可以加速大腦主要相關運動功能區(qū)由健側向患側的遷移,使運動功能改善,縮短康復周期。
[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.
【學位授予單位】：福建中醫(yī)藥大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R743.3

【參考文獻】

相關期刊論文 前10條

1 賈杰;;“中樞-外周-中樞”閉環(huán)康復——腦卒中后手功能康復新理念[J];中國康復醫(yī)學雜志;2016年11期

2 吳海博;秦茵;;腦卒中后肢體痙攣性偏癱康復治療進展[J];按摩與康復醫(yī)學;2016年21期

3 李寧;滕飛;陳玉輝;聶志余;胡斌;陳曉宇;王戈鷹;靳令經;;缺血性卒中后痙攣發(fā)生情況及預測因素分析[J];中國卒中雜志;2016年06期

4 孫莉敏;吳毅;尹大志;范明霞;臧麗麗;胡永善;朱秉;徐一鳴;;運動想象訓練促進腦卒中患者上肢運動功能恢復的功能磁共振研究[J];中國康復醫(yī)學雜志;2015年12期

5 朱思憶;余茜;;BOLD-fMRI成像技術在腦梗死后腦功能重組及運動功能康復機制中的應用[J];中國康復醫(yī)學雜志;2015年07期

6 項文平;王寶軍;薛慧;安旭;張軍;龐江霞;;重復經顱磁刺激結合康復對腦卒中偏癱患者肩痛及上肢運動功能改善的臨床觀察[J];北京醫(yī)學;2015年05期

7 廖麟榮;廖曼霞;;腦卒中后肌肉特性變化研究進展[J];中國康復醫(yī)學雜志;2015年03期

8 徐光青;蘭月;趙江莉;何小飛;張群;張濤;黃東鋒;;A型肉毒毒素溶于利多卡因或生理鹽水治療腦卒中患者上肢痙攣的對照研究[J];中國康復醫(yī)學雜志;2015年03期

9 趙利娜;張志強;張立新;梁維娣;;1Hz重復經顱磁刺激對缺血性腦卒中后上肢運動功能的療效[J];中國康復理論與實踐;2015年02期

10 ;肉毒毒素治療成人肢體痙攣狀態(tài) 中國指南(2015)[J];中國康復醫(yī)學雜志;2015年01期

相關碩士學位論文 前1條

1 王敏銳;腦卒中者及正常人手足運動腦機制的fMRI研究[D];安徽醫(yī)科大學;2013年

，

本文編號：2274259