卒中后运动恢复的脑成像研究进展

近年来有研究从横向和纵向角度考察卒中后脑功能重组及其与运动恢复的关系.就脑卒中恢复的神经影像学研究进展进行综述,探讨损伤同侧及对侧半球在运动恢复中的作用.     

扩散张量成像评估脑卒中运动功能研究新进展

脑卒中后运动功能缺损是脑卒中致残的主要原因，在临床量表评估之外，运用影像学方法评估运动功能以早期预测临床结局，为康复干预提供依据正成为新兴的重要研究方向。本文从扩散张量成像（DTI）角度，围绕该技术在预测脑卒中后运动功能恢复、监测治疗反应及评估白质纤维束重塑等方面进行文献综述，旨在为临床合理应用该技术，指导临床工作提供理论依据。     

功能磁共振研究卒中后肢体运动功能重塑机制

脑卒中造成病灶对侧肢体运动功能障碍的恢复与脑可塑性和功能重组有关。在运动功能恢复过程中,大脑皮质有广泛区域参与神经重塑过程。血氧水平依赖功能磁共振成像对于脑卒中后运动功能恢复与脑功能重组之间关系的研究提供了有效平台。     

皮质脊髓束与脑卒中患者运动功能预后的相关研究进展

皮质脊髓束(CST)是重要的随意运动传导通路。CST损伤影响脑卒中患者运动功能,尤其是上肢运动功能恢复,并与患者长期运动功能预后相关。CST在脑卒中后可发生皮质水平和皮质下重塑,从而促进运动功能恢复。CST重塑机制复杂,需要进一步研究。     

利用静息态功能磁共振成像研究缺血性脑卒中患者康复治疗后运动功能网络连接的变化

目的利用静息态功能磁共振成像技术研究缺血性脑卒中患者康复治疗前后运动功能网络连接变化的特点。方法对2例符合亚急性缺血性脑卒中影像学诊断标准的患者在功能性电刺激康复治疗前后各进行一次静息态功能磁共振扫描,比较两次扫描的运动脑区功能连接的差异。结果康复后患者上肢运动功能改善;与康复治疗前相比,康复治疗后左侧和右侧的运动皮层功能连接均降低,左侧和右侧的运动皮层功能连接系数降低值与脑卒中患者上肢运动功能以及日常生活能力的改善程度相关。结论缺血性脑卒中患者上肢运动功能改善后,即康复后患侧脑区对健侧脑区依赖性减低,并且功能连接系数的降低与脑卒中患者上肢运动功能的改善相关。     

康复治疗对脑卒中后脑网络运动功能重塑的磁共振研究进展

随着脑卒中后运动功能障碍研究的不断深入,功能磁共振成像(fMRI)受到广泛关注。脑卒中后皮质下病灶影响附近或远端相关脑区,导致运动功能障碍。镜像神经元疗法、重复性经颅磁、经颅电刺激可通过无创方式激活大脑皮质相关区域,恢复大脑半球之间的平衡,对全脑网络环路有调节作用,但经颅电刺激缺乏A级证据。针灸虽能广泛调节全脑功能网络节点的拓扑结构,但由于针刺选穴、手法、时间、经络的差异,不能全面阐释针灸的治疗机制。康复治疗技术与神经影像学的结合成为脑卒中治疗研究的新方向。     

对脑卒中后运动功能恢复中双侧半球活动的研究

脑卒中后运动功能恢复的机制尚未完全阐明。研究表明脑卒中后功能的恢复与大脑可塑性有关,该文旨在阐述近年对一侧脑缺血后双侧大脑半球的活动的研究成果。     

执行功能对脑卒中后运动恢复的影响及其机制研究进展

执行功能是大脑的高级认知功能之一,脑卒中患者执行功能障碍的发生率较高。执行功能障碍是影响脑卒中后运动功能恢复的重要因素之一,可能涉及运动学习、姿势控制等。执行功能训练可以促进脑卒中患者运动功能的恢复,其机制与涉及多个脑区的脑功能网络有关。     

足部运动想像改善脑卒中偏瘫下肢运动功能的临床研究

目的 探讨运动想像对偏瘫患者下肢运动功能恢复的影响.方法 72例脑卒中偏瘫患者随机分为两组:治疗组37例,对照组135例.两组患者均进行常规康复训练,治疗组同时进行想像.实验前后分别采用Fugl-Meyer运动功能评定量表下肢部分和步态分析相关指标进行评定.结果 治疗组膝、踝和下肢运动功能评分高于对照组(P<0.05),步频和步速优于对照组(P<0.05).结论 在常规康复训练结合运动想像可以促进脑卒中偏瘫患者下肢运动功能恢复.     

脑卒中患者运动功能恢复预测的研究进展

脑卒中是成人残疾的常见原因, 脑卒中后独立生活能力在很大程度上取决于运动障碍的治疗和运动功能的恢复。运动功能恢复的准确预测不仅能够帮助患者确立切合实际的目标, 并且有助于康复团队对患者进行分层并制定个性化的康复方案, 更有效地利用医疗资源。本文对目前常用的脑卒中后运动功能恢复的预测因素及其应用进行综述。     

早期康复介入对急性脑卒中重度偏瘫患者运动功能恢复的影响

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An update on predicting motor recovery after stroke

Being able to predict an individual's potential for recovery of motor function after stroke may facilitate the use of more effective targeted rehabilitation strategies, and management of patient expectations and goals. This review summarises developments since 2010 of approaches based on clinical, neurophysiological and neuroimaging measures for predicting individual patients’ potential for upper limb recovery. Clinical assessments alone have low prognostic accuracy. Transcranial magnetic stimulation can be used to assess the functional integrity of the corticomotor pathway, and has some predictive value but is not superior when used in isolation due to its low negative predictive value. Neuroimaging measures can be used to assess the structural integrity of descending white matter tracts. Recent studies indicate that the integrity of corticospinal and alternate motor tracts in both hemispheres may be useful predictors of motor recovery after stroke. The PREP algorithm is currently the only sequential algorithm that combines clinical, neurophysiological and neuroimaging measures at the sub-acute stage to predict the potential for subsequent recovery of upper limb function. Future research could determine if a similar algorithmic approach may be useful for predicting the recovery of gait after stroke.     

Repetitive transcranial magnetic stimulation of motor cortex after stroke: a focused review

Repetitive Transcranial Magnetic Stimulation (rTMS) is known to modulate cortical excitability and has thus been suggested to be a therapeutic approach for improving the efficacy of rehabilitation for motor recovery after stroke. In addition to producing effects on cortical excitability, stroke may affect the balance of transcallosal inhibitory pathways between motor primary areas in both hemispheres: the affected hemisphere (AH) may be disrupted not only by the infarct itself but also by the resulting asymmetric inhibition from the unaffected hemisphere, further reducing the excitability of the AH. Conceptually, therefore, rTMS could be used therapeutically to restore the balance of interhemispheric inhibition after stroke. rTMS has been used in two ways: low-frequency stimulation (≤1 Hz) to the motor cortex of the unaffected hemisphere to reduce the excitability of the contralesional hemisphere or high-frequency stimulation (>1 Hz) to the motor cortex of the AH to increase excitability of the ipsilesional hemisphere. The purpose of this systematic review is to collate evidence regarding the safety and efficacy of high-frequency rTMS to the motor cortex of the AH. The studies included investigated the concurrent effects of rTMS on the excitability of corticospinal pathways and upper-limb motor function in adults after stroke. This review suggests that rTMS applied to the AH is a safe technique and could be considered an effective approach for modulating brain function and contributing to motor recovery after stroke. Although the studies included in this review provide important information, double-blinded, sham-controlled Phase II and Phase III clinical trials with larger sample sizes are needed to validate this novel therapeutic approach.     

Motor recovery after stroke: a systematic review of the literature

OBJECTIVE: To collect and integrate existing data concerning the occurrence, extent, time course, and prognostic determinants of motor recovery after stroke using a systematic methodologic approach. DATA SOURCES: A computer-aided search in bibliographic databases was done of longitudinal cohort studies, original prognostic studies, and randomized controlled trials published in the period 1966 to November 2001, which was expanded by references from retrieved articles and narrative reviews. STUDY SELECTION: After a preliminary screening, internal, external, and statistical validity was assessed by a priori methodologic criteria, with special emphasis on the internal validity. DATA EXTRACTION: The studies finally selected were discussed, based on the quantitative analysis of the outcome measures and prognostic determinants. Meta-analysis was pursued, but was not possible because of substantial heterogeneity. DATA SYNTHESIS: The search resulted in 174 potentially relevant studies, of which 80 passed the preliminary screening and were subjected to further methodologic assessment; 14 studies were finally selected. Approximately 65% of the hospitalized stroke survivors with initial motor deficits of the lower extremity showed some degree of motor recovery. In the case of paralysis, complete motor recovery occurred in less than 15% of the patients, both for the upper and lower extremities. Hospitalized patients with small lacunar strokes showed relatively good motor recovery. The recovery period in patients with severe stroke was twice as long as in patients with mild stroke. The initial grade of paresis was the most important predictor for motor recovery (odds ratios [OR], >4). Objective analysis of the motor pathways by motor-evoked potentials (MEPs) showed even higher ORs (ORs, >20). CONCLUSIONS: Our knowledge of motor recovery after stroke in more accurate, quantitative, and qualitive terms is still limited. Nevertheless, our data synthesis and quantitative analysis comprises data from many methodologically robust studies, which may support the clinician in the management of stroke patients. With respect to early prognosis of motor recovery, our review confirms clinical experience that the initial grade of paresis (as measured on admission in the hospital) is the most important predictor, although the accuracy of prediction rapidly improves during the first few days after stroke. Initial paralysis implies the worst prognosis for subsequent motor recovery. Remarkably, the prognostic accuracy of MEPs appears much higher than that of clinical examination for different subgroups of patients.     

Exercise-mediated locomotor recovery and lower-limb neuroplasticity after stroke

Assumptions that motor recovery plateaus within months after stroke are being challenged by advances in novel motor-learning-based rehabilitation therapies. The use of lower-limb treadmill (TM) exercise has been effective in improving hemiparetic gait function. In this review, we provide a rationale for treadmill exercise as stimulus for locomotor relearning after stroke. Recent studies using neuroimaging and neurophysiological measures demonstrate central nervous system (CNS) influences on lower-limb motor control and gait. As with studies of upper limbs, evidence shows that rapid transient CNS plasticity can be elicited in the lower limb. Such effects observed after short-term paretic leg exercises suggest potential mechanisms for motor learning with TM exercise. Initial intervention studies provide evidence that long-term TM exercise can mediate CNS plasticity, which is associated with improved gait function. Critical needs are to determine the optimal timing and intensities of TM therapy to maximize plasticity and learning effects.     

卒中后运动皮层功能重组的BOLD-fMRI研究进展

卒中后患者运动功能的自行恢复与神经可塑性及运动皮层功能重组有关。以BOLD-fMRI为主的功能磁共振技术在卒中后运动皮层功能重组研究中的作用日益显著。本文就卒中后神经可塑性和运动皮层功能重组机制、BOLD-fM-RI在卒中后运动皮层功能重组研究中的进展予以综述。     

Non-invasive brain stimulation (NIBS) and motor recovery after stroke

Recovery of motor function after stroke occurs largely on the basis of a sustained capacity of the adult brain for plastic changes. This brain plasticity has been validated by functional imaging and electrophysiological studies. Various concepts of how to enhance beneficial plasticity and in turn improve functional recovery are emerging based on the concept of functional interhemispheric balance between the two motor cortices. Besides conventional rehabilitation interventions and the most recent neuropharmacological approaches, non-invasive brain stimulation (NIBS) has recently been proposed as an add-on method to promote motor function recovery after stroke. Several methods can be used based either on transcranial magnetic stimulation (repetitive mode: rTMS, TBS) via a coil, or small electric current via larges electrodes placed on the scalp, (transcranial direct current stimulation tDCS). Depending on the different electrophysiological parameters of stimulation used, NIBS can induce a transient modulation of the excitability of the stimulated motor cortex (facilitation or inhibition) via a probable LTP-LTD-like mechanism. Several small studies have shown feasible and positive treatment effects for most of these strategies and their potential clinical relevance to help restoring the disruption of interhemispheric imbalance after stroke. Results of these studies are encouraging but many questions remain unsolved: what are the optimal stimulation parameters? What is the best NIBS intervention? Which cortex, injured or intact, should be stimulated? What is the best window of intervention? Is there a special subgroup of stroke patients who could strongly benefit from these interventions? Finally is it possible to boost NIBS treatment effect by motor training of the paretic hand or by additional neuropharmacological interventions? There is clearly a need for large-scale, controlled, multicenter trials to answer these questions before proposing their routine use in the management of stroke patients.     

综合康复治疗对脑卒中恢复期偏瘫患者的影响

目的探讨综合康复治疗对脑卒中恢复期偏瘫患者生活能力的影响。方法对83例首发脑卒中,在恢复期(发病3个月以上)接受综合性康复治疗的偏瘫患者进行康复前后患肢运动功能及日常生活活动功能(ADL)比较。结果经综合康复治疗后,患者患肢Brunnstrom分级和ADL分值与治疗前比较均有非常显著性差异(P<0.01)。结论综合性康复治疗可以显著改善恢复期脑卒中偏瘫患者患肢功能,提高其生活质量。