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。     

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、精神疾病的神经刺激治疗手段。近年来,研究者逐渐重视tDCS对大脑活动的调节作 用和生理效应,并对tDCS刺激神经网络的作用机制展开探索。本研究从tDCS的神经作用机制、刺激 参数以及刺激后效应等方面阐述tDCS的研究进展,以期为卒中后吞咽障碍患者寻找有效的康复方式, 并为未来的研究提供依据。     

经颅磁刺激治疗脑梗死的临床疗效观察

目的 观察经颅磁刺激（transcranial magnetic stimulation,TMS）对脑梗死患者的临床疗效。方法 符合病例入选标准的脑梗死患者60例,随机分为试验组及对照组,每组各30例,试验组及对照组均给予常规药物治疗,试验组在常规治疗基础上给予TMS治疗,疗程10 d,比较治疗前后患者的运动功能（Fugl-Meyer评分）、Barthel指数（Barthel index,BI）以及美国国立卫生研究院卒中量表（National Institutes of Health Stroke Scale,NIHSS）评分。结果 NIHSS评分：试验组由治疗前的6.57±2.66减少到治疗后4.01±2.83,对照组由6.29±3.00减少到5.10±2.43;Barthel指数：试验组由治疗前47.33±14.31增加到治疗后60.83±18.53,对照组由45.50±13.91增加到53.67±15.97;Fugl-Meyer评分：试验组由治疗前38.20±24.01增加到治疗后58.40±29.57,对照组由37.53±23.8增加到49.60±29.77,治疗前两组3项评分差异均无统计学意义,治疗后3项评分差异均有统计学意义（P分别为0.008、0.004和0.008）。结论 TMS对脑梗死患者肢体功能恢复有一定疗效,能提高患者的日常生活能力。     

F波、H反射在卒中后肢体痉挛疗效评估中的研究进展

卒中后肢体痉挛是上运动神经元损伤导致高级中枢失去对脊髓牵张反射的抑制,脊髓 反射性增高引起以牵张反射增强为特征的肌肉张力异常。肢体痉挛是卒中后常见并发症之一,严重影 响了卒中患者功能康复。近年来涌现出各类改善卒中后肢体痉挛的治疗方法,但其疗效评价标准不 一,其中以主观性量表评价为主。笔者搜集了近些年国内外卒中后肢体痉挛治疗的临床研究文献,发 现F波、H反射相关参数等客观评价指标被越来越多地与主观评价量表相结合,运用到各类临床研 究的疗效评价中。相对于H反射,F波具有更加灵敏的特点,能更好反映肢体肌张力的变化,常与改良 Ashworth痉挛量表一起作为缺血性卒中后肢体痉挛疗效的评价指标。     

重复经颅磁刺激治疗脑梗死后偏瘫的研究进展

脑梗死又称缺血性卒中,是全球致残率及致死率较高的疾病。尽管对脑梗死患者进行了全面的康复治疗,但大多数患者仍会遗留残疾,直接影响生活质量、日常生活能力,增加患者家庭和社会的经济负担。因此,促进脑梗死患者运动功能的恢复尤为重要,这需要在临床实践中有更多新的治疗选择。重复经颅磁刺激作为一个无痛、无创的治疗方法,已被证实可有效改善脑梗死后偏瘫肢体的运动功能,从而提高患者生活质量。目前,重复经颅磁刺激治疗的基础研究和临床研究都有了新进展,故此进行综述,以期对临床工作有一定帮助。     

重复经颅磁刺激治疗精神分裂症阴性症状的研究进展

<正>精神分裂症在一般人群中患病率约1%,是慢性、高致残性精神障碍[1]。人类对其病理生理机制仍缺乏实质性理解,仍无根本性防治手段[2]。临床表现上对以情感平淡、言语贫乏、意志缺乏等阴性症状为主要表现的精神分裂症患者的治疗难度更大,也是患者出现精神残疾的重要原因之一[3]。这对新型抗精神病药物的研发及新型治疗方法的开发提出了更大的挑战[4]。近年来,精神分裂症的非药物辅助治疗手段已崭露头角。越来越多的研究表明,     

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。     

重复经颅磁刺激治疗脑卒中后下肢运动功能障碍的机制及应用研究进展

脑卒中后下肢运动功能恢复是脑卒中患者康复的重要目标之一。重复经颅磁刺激作为一种非入侵性脑刺激技术, 能够调控神经元兴奋性, 促进神经可塑性, 在神经康复领域存在巨大的潜力。既往其已广泛应用于治疗脑卒中后上肢和手运动功能障碍中, 而近期有研究表明其也能够改善脑卒中后下肢运动功能障碍。本文综述重复经颅磁刺激治疗脑卒中后下肢运动功能障碍的临床研究进展, 探讨脑卒中后运动功能障碍的机制假说及脑卒中后下肢运动功能重组的可能机制, 以期为未来的研究及临床应用提供新的思路。     

重复经颅磁刺激在帕金森抑郁中的应用研究进展

帕金森病是一种常见于中老年的慢性退行性病,抑郁症是帕金森患者中最常见的非运动症状,其极大程度上降低了患者的生活质量并给治疗带来困难.目前,帕金森抑郁的治疗仍以药物为主,但药物存在诸多不良反应.重复经颅磁刺激是一种新型的辅助治疗手段,帕金森病患者使用经颅磁刺激后临床症状有较好的改善,但目前对于最有效的刺激模式仍未有定论....     

Outcomes in spasticity after repetitive transcranial magnetic and transcranial direct current stimulations

Non-invasive brain stimulations mainly consist of repetitive transcranial magnetic stimulation and transcranial direct current stimulation. Repetitive transcranial magnetic stimulation exhib- its satisfactory outcomes in improving multiple sclerosis, stroke, spinal cord injury and cerebral palsy-induced spasticity. By contrast, transcranial direct current stimulation has only been studied in post-stroke spasticity. To better validate the efficacy of non-invasive brain stimulations in im- proving the spasticity post-stroke, more prospective cohort studies involving large sample sizes are needed.     

卒中早期康复研究进展

卒中具有高致残率的特点，70%～80%的患者存在卒中后功能障碍，康复是降低卒中后 功能障碍非常有效的方法。卒中后早期康复试验证据较少，卒中后开展康复的最佳时间仍然不确定。 尽管证据仍不充足，但是越来越多证据显示卒中后前2周内开展康复治疗是有益的。本文就卒中康复 相关机制及卒中后早期康复循证医学证据方面进行了综述。     

The effects of transcranial direct current stimulation on upper-limb function post-stroke: A meta-analysis of multiple-session studies

ObjectiveTo systematically review how patient characteristics and/or transcranial direct current stimulation (tDCS) parameters influence tDCS effectiveness in respect to upper limb function post-stroke.MethodsThree electronic databases were searched for sham-controlled randomised trials using the Fugl-Meyer Assessment for upper extremity as outcome measure. A meta-analysis and nine subgroup-analyses were performed to identify which tDCS parameters yielded the greatest impact on upper limb function recovery in stroke patients.ResultsEighteen high-quality studies (507 patients) were included. tDCS applied in a chronic stage yields greater results than tDCS applied in a (sub)acute stage. Additionally, patients with low baseline upper limb impairments seem to benefit more from tDCS than those with high baseline impairments. Regarding tDCS configuration, all stimulation types led to a significant improvement, but only tDCS applied during therapy, and not before therapy, yielded significant results. A positive dose–response relationship was identified for current/charge density and stimulation duration, but not for number of sessions.ConclusionOur results demonstrate that tDCS improves upper limb function post-stroke. However, its effectiveness depends on numerous factors. Especially chronic stroke patients improved, which is promising as they are typically least amenable to recovery.SignificanceThe current work highlights the importance of several patient-related and protocol-related factors regarding tDCS effectiveness.     

Recovery of motor disability and spasticity in post-stroke after repetitive transcranial magnetic stimulation (rTMS)

Lately it has been indicated that the stimulation of both sides of the motor cortices with different frequencies of rTMS can improve the behaviour of a paretic arm. We studied the effect of rTMS in severe cases of post-stroke after nearly 10 years. They had wide hemispheric lesion and their paresis had not changed for more than 5 years. The majority of patients could not move their fingers on the affected side. In our study we examined whether the active movement could be induced by rTMS even several years after stroke and which hemisphere (affected or unaffected) stimulated by rTMS would be the best location for attenuating the spasticity and for developing movement in the paretic arm.Sixty-four patients (more than 5 years after stroke in a stable state) were followed for 3 months. They were treated with rTMS with 1 Hz at 30% of 2.3 T 100 stimuli per session twice a day for a week. The area to be stimulated was chosen according to the evoked movement by TMS in the paretic arm. That way, four groups were created and compared. In group A, where both hemispheres were stimulated (because of the single stimulation of TMS could induce movement from both sides of hemispheres) the spasticity decreased but the movement could not be influenced. A highly significant improvement in spasticity, in movement induction and in the behaviour of paresis was observed in group B, where before treatment, there was no evoked movement in the paretic arm from stimulating either hemispheres of the brain. For treatment we stimulated the unaffected hemisphere from where the intact arm is moved (ipsilateral to the paretic side). In both groups C (contralateral hemisphere to the paretic arm) and D (ipsilaterally evoked movement in the paretic arm), the spasticity decreased during the first week, but the movement of the paretic arm improved only in group C.It seems that spasticity can be modified by the stimulation either the affected or the unaffected hemisphere, but the induction of movement can be achieved only by the stimulation of an intact motor pathway and its surrounding area (groups B and C). The improvement in paretic extremities can be achieved with rTMS even after years of stroke when the traditional rehabilitation has failed.     

Botulinum toxin type A for the treatment of the upper limb spasticity after stroke: a meta-analysis

Muscle over-activity is one of the cardinal features of spasticity and it is a common disability of stroke patients. In this group, spasticity is responsible for several limitations that interfere in their daily activities and quality of life. To treat spasticity, neurologists usually prescribe drugs as baclofen, tizanidine or benzodiazepines or even use definitive treatment as phenol or surgery. Authors suggest the use of botulinum toxin type A (BTX-A) for spasticity in the upper limbs after stroke, but there are few papers with adequate methodology supporting this idea. In this article we summarize the data of previous double-blind, randomised clinical trials to asses, with a meta-analysis, if BTX-A is an adequate treatment for spasticity due to stroke. The results show a statistical superiority of BTX-A ov%r placebo on reducing muscle tone by the Modified Ashworth Scale (WMD= 0.95 [0.74 to 1.17]) in patients with post-stroke upper limb spasticity.     

Facilitation of motor evoked potentials in ischemic stroke patients: prognostic value and neurophysiologic correlations

OBJECTIVE: To investigate the predictive value of paired transcranial magnetic stimulation (TMS) at rest in stroke patients in comparison with the predictive value derived from data obtained by single TMS during facilitation. METHODS: Fifty-six patients with a single ischemic lesion and no electromyographic responses from single TMS in the resting affected hand muscles participated in the study. TMS assessment was performed 32 days post-stroke. It consisted of a single stimulation at maximal output during facilitation (controlateral hand grip and elbow flexion) and a paired-pulse stimulation at rest with two stimuli at maximal output at interstimulus intervals ranging from 15 to 100 ms. Two blind clinical assessments using the 'motricity index' were carried out 26 and 76 days post-stroke. RESULTS: Thirty-seven percent of patients were responsive to single TMS during facilitation, had better clinical scores at both evaluations and better clinical recovery. Fifty-four percent of patients responded to paired TMS, had better clinical scores at the second evaluation and better clinical recovery. All patients who responded to the single stimulation paradigm also responded to the paired one. CONCLUSIONS: A positive correlation was found between the responsiveness to both the TMS paradigms (facilitation procedure and paired stimulation) and clinical recovery. This underlines the importance of facilitation during single TMS in stroke patients and suggests that paired TMS at rest might supplement this procedure in stroke studies.     

The use of tDCS and CVS as methods of non-invasive brain stimulation

Transcranial direct current stimulation (tDCS) and caloric vestibular stimulation (CVS) are safe methods for selectively modulating cortical excitability and activation, respectively, which have recently received increased interest regarding possible clinical applications. tDCS involves the application of low currents to the scalp via cathodal and anodal electrodes and has been shown to affect a range of motor, somatosensory, visual, affective and cognitive functions. Therapeutic effects have been demonstrated in clinical trials of tDCS for a variety of conditions including tinnitus, post-stroke motor deficits, fibromyalgia, depression, epilepsy and Parkinson's disease. Its effects can be modulated by combination with pharmacological treatment and it may influence the efficacy of other neurostimulatory techniques such as transcranial magnetic stimulation. CVS involves irrigating the auditory canal with cold water which induces a temperature gradient across the semicircular canals of the vestibular apparatus. This has been shown in functional brain-imaging studies to result in activation in several contralateral cortical and subcortical brain regions. CVS has also been shown to have effects on a wide range of visual and cognitive phenomena, as well as on post-stroke conditions, mania and chronic pain states. Both these techniques have been shown to modulate a range of brain functions, and display potential as clinical treatments. Importantly, they are both inexpensive relative to other brain stimulation techniques such as electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS).