高低频重复经颅磁刺激治疗卒中后上肢痉挛的对照研究

目的 探讨高、低频重复经颅磁刺激（repetitive transcranial magnetic stimulation,rTMS）大脑初级运动皮层（M1区）治疗卒中后上肢痉挛的临床疗效及差异。      

经颅直流电刺激在卒中后吞咽障碍康复治疗中的应用研究进展

卒中后吞咽障碍可能是由吞咽皮质中枢、皮质下行纤维、延髓吞咽中枢及锥体外系损伤所致,目前尚无特异性治疗方法,临床干预以直接训练和间接训练等康复治疗为主.经颅直流电刺激(transcranial direct current stimulation,tDCS)是通过直流电刺激来改变神经可塑性和皮质兴奋性,以改善各种神经、精...     

重复经颅磁刺激治疗卒中后认知障碍的研究进展

认知障碍是卒中后常见并发症,严重影响患者康复进程及生活质量。重复经颅磁刺激（repetitive transcranial magnetic stimulation,rTMS）作为一种新型的非侵入性神经电生理技术,通过改变神经细胞动作电位影响脑内代谢和神经电活动,近年来逐渐被用于卒中后认知障碍的治疗。目前rTMS在卒中后执行功能、记忆功能、语言能力及视空间能力的康复应用中均取得了较为积极的疗效,且在指南推荐的治疗参数范围内操作基本是安全的,但仍缺乏大样本、多中心、高质量的随机对照试验进一步明确其最佳刺激参数与治疗效果。rTMS治疗卒中后认知障碍的研究仍处于探索阶段,未来有望进行更深入的机制研究,为rTMS治疗卒中后认知功能障碍提供更切实有力的依据。     

重复经颅磁刺激联合重复注射A型肉毒毒素对脑卒中后下肢肌肉痉挛状态的临床疗效和安全性研究

目的观察脑卒中后下肢肌肉痉挛患者行重复经颅磁刺激(rTMS)联合A型肉毒毒素(BTX-A)重复注射的治疗效果及安全性。方法选择2013年7月至2016年7月于本院康复科治疗的伴有下肢肌肉痉挛的脑卒中患者共96例,按照随机数字表法分为4组:A组,康复治疗;B组,rTMS+康复治疗;C组,重复注射BTX-A+康复治疗;D组,rTMS+重复注射BTX-A+康复治疗。治疗前及治疗后1、6和12个月对4组患者采用改良Ashworth痉挛量表(MAS)评定肌张力,Fugl-Meyer下肢运动功能量表(FMA)评定下肢运动功能,采用改良Barthel指数量表(MBI)评定患者日常生活能力,Berg平衡量表(BBS)评定患者平衡能力。并观察患者在治疗的过程中的不良反应情况。结果与治疗前相比,治疗后1、6、12个月,B、C、D组的MAS评分呈下降趋势,D组最为明显(P<0.05);4组患者治疗1个月后FMA评分、MBI评分、BBS评分均升高,治疗后6、12个月,A、B、C组的FMA评分、MBI评分、BBS评分有下降或回升,D组的评分都呈上升趋势,均高于其他3组(P<0.05);治疗过程中,4组均无严重不良反应情况发生。结论 rTMS联合重复注射A型肉毒毒素能够有效降低脑卒中后下肢肌肉痉挛患者的肌肉张力,提高患者的生活质量,治疗效果较为持久,无不良反应,有临床应用价值。     

肉毒杆菌毒素A在脑卒中后肢体痉挛中的应用

Ａ型肉毒毒素是近年来治疗脑卒中后肢体痉挛的一个新进展,国外已有多项试验证实了它的有效性及安全性,国内的研究也正在展开,本文综述了肉毒毒素的特点及其在脑卒中后肢体痉挛治疗的临床应用状况。     

小脑与卒中后运动学习关系的研究进展

运动学习强调引导患者主动练习缺失的运动功能,获得尽可能接近正常的运动技能,这 种学习过程由小脑和大脑皮层的共同作用来完成。卒中后的功能恢复是运动再学习的过程,康复锻 炼的一个重要机制是基于细胞可塑性的运动学习,而小脑在运动学习过程中发挥着不可替代的作用。 神经生理学研究表明,小脑中参与运动学习最主要的细胞是浦肯野细胞和颗粒细胞。小脑-皮质通 路涉及运动控制和运动学习,使得小脑成为神经调节和治疗卒中后运动障碍的重要靶点。本文就小 脑运动学习的细胞机制和针对小脑的刺激技术对卒中后运动功能恢复的作用进行综述。     

重复经颅磁刺激和θ节律刺激治疗卒中后忽视的Meta分析

目的系统评价重复经颅磁刺激(repetitive transcranial magnetic stimulation,rTMS)和θ节律刺激(theta burst stimulation,TBS)治疗卒中后忽视的疗效和安全性。方法通过计算机检索、手工检索方法,全面收集rTMS和TBS治疗卒中后忽视的随机对照试验(randomized controlled trial,RCT)和非随机对照试验,按Cochrane协作网系统评价的方法进行评价。结果共纳入3个试验(69例患者),包括2个随机双盲假刺激对照试验和1个非随机假刺激对照试验。3个试验采用不同的量表的评价治疗期末忽视改善,Meta分析结果显示:上述刺激对卒中后忽视的改善程度优于对照组,差异有统计学意义[SMD=-2.61,95%CI(-4.70,-0.52),P=0.01];其中2个试验采用TBS治疗卒中后忽视(42例),Meta分析结果显示:TBS组优于对照组,但差异无统计学意义[SMD=-2.53,95%CI(-5.96,0.90),P=0.15];纳入的所有试验中,均未报道治疗过程中的严重不良反应,1个试验报到了治疗过程中不良反应,主要是发生在治疗过程中的一过性头痛,2组差异无统计学意义[RR=5.0,95%CI(0.27,93.55),P=0.28];1个试验报道了治疗期末生活质量的改善,结果显示:治疗组优于对照组,差异有统计学意义[MD=12.50,95%CI(4.98,20.02),P=0.001]。无临床试验评价进行长期的随访结果。结论本系统评价结果提示rTMS和TBS能有效改善治疗前后的忽视状况和生活质量,且不良反应小,未见严重不良反应。但纳入文献的研究样本量较小,缺乏长期随访结果,有待进一步多中心大样本随机对照研究。     

高频重复经颅磁刺激治疗卒中后抑郁的临床研究

运用高频重复经颅磁刺激（rTMS）技术探索卒中后抑郁（PSD）新的治疗方法，我们进行了以下研究。     

阳极经颅直流电刺激联合多奈哌齐治疗卒中后认知障碍的疗效观察

目的 探讨阳极经颅直流电刺激(transcranial direct current stimulation,tDCS)联合多奈哌齐治疗卒中后认知障碍(post-stroke cognitive impairment,PSCI)的临床疗效.方法 前瞻性连续纳入2019年10月-2020年9月在河南大学附属南石医院康复医...     

Effectiveness of Botulinum Toxin for Lower Limbs Spasticity after Stroke: A Systematic Review and Meta-Analysis

Objectives: To evaluate current evidence of the effectiveness of botulinum toxin (BTX) injection for lower limbs spasticity after stroke.

Methods: Ovid MEDLINE(R) In-Process and Other Non-Indexed Citations,Ovid MEDLINE(R), Ovid EMBASE, Web of Science, and PubMed (NLM) from database were searched inception through Week 23, 2015. Randomized controlled trials (RCTs) comparing the clinical efficacy of BTX injection to placebo or conventional therapy on lower limbs spasticity after stroke were included. We constructed random effects models and calculated mean difference (MD) or standardized mean difference (SMD) for continuous outcomes.

Results: One thousand three hundred and forty-three records were identified and among them 7 articles (603 patients) were eligible for the final analysis. A statistically significant decrease in muscle tone was observed at week 4 and 12 after injection (Subgroup analysis, SMD = 0.85, 95% CI: 0.2–1.5; p = 0.001; I² = 81% and SMD = 0.42, 95% CI: 0.07–0.77; p = 0.02; I² = 45%, respectively). Patients who received in BTX therapy were likely to have significant increased Fugl-Meyer score than control group with MD = 3.19 (95% CI: 0.22–6.16, p = 0.04, I² = 96%). There was no difference in gait speed between two groups during whole follow-up period.

Conclusion: BTX showed more persistent clinical benefits in lower limbs spasticity and Fugl-Meyer score than placebo in patients after stroke. These results suggest that BTX could be a useful and safety strategy for the treatment of lower limbs spasticity after stroke. Further investigation is required to determine the effectiveness of BTX injection for stroke patients with optimal timing and dose of intervention.     

Modification of altered ankle motor control after stroke using focal application of botulinum toxin type A

Study design

Blinded, placebo-controlled, prospective clinical trial.

Purpose

To examine the effects of botulinum toxin type A (BTX-A) injections into plantar flexor muscles in stroke patients with equinovarus gait.

Subjects

15 post-stroke and 10 matched neurologically intact subjects.

Methods

Modified Ashworth Scale (MAS) and Fugl–Meyer assessment of physical function scale scores along with surface EMG collected before and up to 12 weeks after BTX-A injections to plantar flexor muscle motor points in stroke subjects. Saline placebo injections were performed in a subset of stroke subject group.

Results

MAS scores were decreased at 4, 8 and 12 weeks but F–M scores did not improve until 12 weeks post injection. Multi-muscle EMG patterns showed the return of volitional dorsiflexor activity in 11 and a decrease of antagonistic and distant coactivation in all but one of the 15.

Conclusions

BTX-A is effective in reducing antagonistic and distant muscle activation that impedes volitional dorsiflexion.     

A型肉毒毒素治疗卒中患者痉挛性足下垂和足内翻的研究

目的探讨A型肉毒毒素治疗卒中后患者痉挛性足下垂及足内翻的效果及对步行功能的改善。方法35例卒中后痉挛性足下垂及足内翻患者,随机分为BTX2A注射结合物理治疗组(17例)和单纯物理治疗组(18例)。治疗组应用下肢肌肉局部注射国产A型肉毒毒素治疗,每个患者每次选择3~5块肌肉,每块肌肉总的注射剂量为50~100IU。对照组仅接受康复治疗。所有患者在注射前,注射后2周、1个月、3个月改良Ashworth量表(MAS)评定肌张力变化,按粗大运动功能量表(GMFM)中的D和E两项及步行速度评价步行能力。结果MAS评分治疗后2周、1个月、3个月组间差异均有统计学意义(P<0.05)。GMFM评分治疗后1、3个月组间差异均有统计学意义(P<0.05)。步行速度治疗后1、3个月组间差异均有统计学意义(P<0.05)。结论研究发现下肢肌肉局部注射A型肉毒毒素结合康复治疗可以更好减轻脑卒中患者的肌张力,改善患者的痉挛步态。     

Immediate and Late Modulation of Interhemipheric Imbalance With Bilateral Transcranial Direct Current Stimulation in Acute Stroke

BackgroundSignificant changes in neurophysiological and clinical outcomes in chronic stroke had been reported after tDCS; but there is a paucity of data in acute stroke.ObjectiveWe aimed to evaluate whether a tDCS-induced modulation of primary motor cortex excitability in patients with acute stroke enhances motor recovery associated with rehabilitation and induces differential neuroplasticity.MethodsWe conducted two experiments in acute stroke patients. In experiment 1 (14 patients), we tested the immediate effects of bilateral tDCS alone as compared to sham tDCS on recovery. Experiment 2 (20 patients) was designed to assess effects of bilateral tDCS delivered together with constraint-induced movement therapy (CIMT). In this experiment, we included a longer follow-up (3 months) and measured, in addition to the same clinical outcomes of experiment 1, changes of motor cortex excitability and the amount of promoted LTP-like activity.ResultsDespite the expected improvement at 1 week, none of the clinical measures showed any different modulation in dependence of CIMT and tDCS. On the neurophysiological assessments, on the other hand, the Real_tDCS group, compared to Sham_tDCS group, showed a reduction of inter-hemispheric imbalance when considering the differences of motor evoked potential between both 3-month and 1 week follow up (P = 0.007) and three month and baseline (P = 0.015).ConclusionsDespite the lack of additional clinical changes, real bilateral tDCS, together with CIMT, significantly reduces inter-hemispheric imbalance between affected and unaffected hemispheres. These findings may shed light on plasticity changes in acute stroke and its potential impact in chronic phases.     

Overview of botulinum toxin as a treatment for spasticity in stroke patients

Spasticity after the occurrence of stroke induces limb deformity, functional disability and/or pain in patients, which limits their activities of daily living and deteriorates their quality of life. Botulinum toxin (BTX) has recently been reported as an efficacious therapeutic agent for the treatment of spasticity. Systematic review and meta-analysis studies have demonstrated that BTX therapy after stroke reduces spasticity and increases physical activity capacity and performance levels. Moreover, BTX can be used as an adjuvant in physiotherapy. Several studies have confirmed that the combination of BTX therapy and physiotherapy improves motor recovery. However, to date, only a few such combination studies have been conducted and their findings are considered preliminary and controversial. Therefore, future studies are required to determine the appropriate combination of treatment methods that will aid motor recovery.     

Brain Stimulation: New Vistas for the Exploration and Treatment of Tinnitus

Aims : Tinnitus, the perception of sounds or noise in the absence of auditory stimuli, is a frequent and often severely disabling symptom of different disorders of the auditory system. Attempts to develop evidence‐based therapies have been thwarted by a poor understanding of the underlying pathophysiology. However, recent work points toward a pivotal role of maladaptive cortical reorganization in the generation and perpetuation of tinnitus. Changes in the representation of sounds, abnormalities of oscillatory activity, and hyperactivity in higher order areas of auditory processing have been linked with the perception of tinnitus. Brain stimulation techniques have entered the field and have opened exciting new perspectives for the modulation of dysfunctional brain activity. In this review, a comprehensive overview on the use of brain‐stimulation techniques in the exploration and experimental treatment of tinnitus is provided. Discussions : Noninvasive and invasive brain stimulation techniques, for example, transcranial magnetic stimulation (TMS), direct current stimulation (tDCS), and direct electrical cortical stimulation gave rise to a new line of investigation in tinnitus research. First, it has been shown that focal interference with presumably pathological cortical function can reduce tinnitus at least transiently. Second, the reduction of tinnitus‐associated enhancement of cortical activity by neuronavigated TMS has been demonstrated to ameliorate tinnitus. Third, preliminary data suggest that repeated application of TMS or continuous cortical stimulation may lead to a longer lasting suppression of tinnitus. Conclusions : These proof of principle studies point toward a new option for the investigation and neurophysiology based treatment of tinnitus. Based on these findings, larger scale randomized clinical trials are needed to explore the efficacy of different brain stimulation techniques and parameters as well as the optimal target sites and treatment schedules. Particularly, a careful evaluation of clinical relevance under consideration of an adequate sham control and attention to possible unwanted side effects of these new interventions are indispensable.     

卒中后口咽吞咽困难的治疗

卒中患者吞咽困难的患病率正在逐渐增加,目前对吞咽困难的管理多采用多学科的管理方法。但是,在临床上普遍使用的治疗方法均缺乏证据基础,需要随机试验来证实其效果。这篇综述主要关注卒中后的口咽吞咽困