放散式体外冲击波治疗脑卒中后小腿三头肌痉挛的疗效研究

目的:观察放散式体外冲击波(rESWT)对脑卒中后小腿三头肌痉挛的疗效.方法:22例脑卒中后小腿三头肌痉挛患者随机分为rESWT组和对照组,每组11例.rESWT组给予有效刺激1次,参数设置为压力强度100kPa,频率8Hz,冲击次数3000次.对照组仅给予安慰刺激1次.比较治疗前、治疗结束后即刻、治疗后1周、4周两组患者关节被动活动度(PROM)、改良Ashworth分级(MAS)及胫神经H反射的H波最大波幅和M波最大波幅比值(Hmax/Mmax值).结果:rESWT组治疗结束后即刻及治疗后1周、4周评估PROM及MAS,均优于治疗前,差异具有显著性意义(P＜0.05);治疗后1周、4周,rESWT组PROM及MAS均优于对照组,差异有显著性意义(P＜0.05).两组治疗前后Hmax/Mmax值比较,差异无显著性意义(P＞0.05).试验过程中两组患者均未发现任何不良反应.结论:放散式体外冲击波治疗可有效改善卒中后小腿三头肌痉挛.     

低频重复经颅磁刺激治疗脑卒中患者上肢痉挛的临床研究

目的:观察低频重复经颅磁刺激(rTMS)对脑卒中患者上肢痉挛状态、运动功能的治疗效果。方法:将脑卒中恢复期上肢痉挛的患者40例随机分为真刺激组及假刺激组各20例。所有患者给予常规物理治疗,真刺激组给予低频重复经颅磁刺激(1Hz),作用于非患侧大脑M1区上肢投射区。假刺激组给予假刺激,作用部位与真刺激组相同。于治疗开始前,治疗4周结束时及治疗结束后2周随访时进行评估。评估内容包括改良Ashworth痉挛评定(MAS)、上肢Fugl-Meyer运动功能评定(ULFMA)、Barthel指数(BI)、运动诱发电位(MEP)和上肢F波潜伏时及波幅。结果:治疗后及随访时,真刺激组腕屈及肘屈MAS评分均较治疗前及同时间点假刺激组显著降低(均P0.05),真刺激组ULFMA及BI评分较治疗前及同时间点假刺激组显著提高(均P0.05),假刺激组MAS、ULFMA及BI评分治疗前后差异均无统计学意义。治疗后及随访时,真刺激组MEP潜伏时较治疗前及假刺激组显著缩短,波幅提高(均P0.05),假刺激组治疗前后比较差异无统计学意义。治疗前后,F波在所有受试者均被引出,出波率100%。2组患者F波潜伏时、波幅组内及组间比较均无显著性差异。结论:低频重复经颅磁刺激可减轻脑卒中患者上肢痉挛,其作用机制可能与其提高了患侧大脑M1区上肢投射区的皮层兴奋性有关。     

重复经颅磁刺激对脊髓损伤大鼠痉挛状态及BDNF-TrkB信号通路的影响

摘要 目的：探讨重复经颅磁刺激（rTMS）对脊髓损伤（SCI）大鼠痉挛状态的影响,探讨rTMS对痉挛的作用与脑源性神经营养因子（BDNF）-酪氨酸激酶受体B（TrkB）信号通路的关系。 方法：研究分为A、B、C三部分。分别有18只、30只、15只雌性SD大鼠,共63只。A、B部分的大鼠均随机分为假手术组（Sham组）、SCI组和SCI+rTMS组。C部分的大鼠随机分为SCI组、SCI+rTMS组、SCI+rTMS+K252a组。SCI制模1周后对rTMS治疗组进行为期4周的干预。A部分每组大鼠干预前后使用H反射（Hmax/Mmax比值）评估大鼠后肢的痉挛状态,BBB评分连续每周评估运动功能。B部分在实验结束后采用Western Blot和免疫荧光检测各组大鼠皮质、脊髓损伤临近部位以及腰骶部BDNF、TrkB和KCC2的表达。C部分在SCI制模后1周,使用K252a阻断SCI+rTMS+K252a组的BDNF-TrkB信号通路,在4周rTMS治疗期间,用BBB评分评估大鼠后肢运动,实验结束后采用Western Blot检测KCC2的表达。 结果：①A部分：SCI后2—5周,SCI+rTMS组BBB评分明显大于SCI组（P＜0.05）。SCI后第5周,SCI+rTMS组痉挛大鼠Hmax/Mmax明显低于SCI组（P＜0.05）,两组大鼠RDD差异无显著性意义（P＞0.05）。②B部分：Western Blot和免疫荧光显示,SCI 5周后,SCI+rTMS组皮质部位、脊髓损伤临近部位以及腰骶部脊髓BDNF、TrkB和KCC2的表达量较SCI组均明显增加（P＜0.05）。③C部分：SCI后第2—5周,SCI+rTMS+K252a组BBB评分明显小于SCI+rTMS组（P＜0.05）。Western Blot显示,SCI后第5周,SCI+rTMS+K252a组各部位KCC2的表达量明显小于SCI+rTMS组（P＜0.05）。 结论：rTMS可改善SCI大鼠的痉挛状态和运动功能,该过程与BDNF、TrkB和KCC2含量增加有关,rTMS缓解SCI后痉挛的机制可能与BDNF-TrkB-KCC2信号通路相关。     

H反射在脑卒中后上肢偏瘫患者中的特征表现及分析

目的:通过研究脑卒中后上肢偏瘫患者H反射的特征表现,及其与偏瘫肢体肌张力的关系,探讨H反射在脑卒中后上肢偏瘫患者神经电生理评定中的应用价值。方法:选择符合本研究入选标准的脑卒中恢复期偏瘫患者42例。分别对患者双侧正中神经、尺神经、桡神经所支配的拇短展肌、小指展肌、指总伸肌进行H反射检查,并对患侧上肢给予改良Ashworth痉挛量表(MAS)评定,确定上述神经中哪些更容易引出H反射,并对其所引出的H反射结果及其与MAS的相关性进行比较和分析。结果:患者双侧正中神经、尺神经所支配的拇短展肌、小指展肌均较易引出H反射,引出率100%。桡神经所支配的指总伸肌不易(3例/42例,引出率7.14%)引出H反射。患侧正中神经和尺神经的H反射潜伏期分别为(25.89±3.66)ms、(25.71±3.26)ms;健侧正中神经和尺神经的H反射潜伏期分别为(26.60±3.11)ms、(26.44±2.87)ms。配对t检验分析,差异均有显著性意义(P<0.05);Hmax/Mmax比值均数用中位数表示,患侧正中神经和尺神经的Hmax/Mmax比值分别为0.185和0.217;健侧Hmax/Mmax比值分别为0.126和0.112,用Wilcoxon符号秩检验分析,患侧与健侧差异均有显著性意义(P<0.05)。用Kruskal-WallisH检验分析显示:患侧上肢正中神经、尺神经H反射潜伏期在MAS不同级别中没有差异,而Hmax/Mmax比值在MAS不同级别中有差异。Spearman秩相关检验结果显示:患侧上肢正中神经H反射潜伏期、Hmax/Mmax比值以及尺神经H反射潜伏期与MAS不相关;而患侧上肢尺神经Hmax/Mmax比值与MAS存在秩相关关系。结论:上肢H反射与MAS存在一定关系,其中Hmax/Mmax比值是评估下运动神经元兴奋性的较好指标,可以成为临床评价痉挛的客观神经电生理指标。     

脑卒中后偏瘫患者下肢H反射的特征表现

目的:通过研究脑卒中后偏瘫患者下肢H反射的特征表现及其与偏瘫下肢肢体功能评定的关系,探讨H反射在脑卒中后偏瘫患者神经电生理评定中的应用价值。方法:选择脑卒中恢复期偏瘫患者40例,分别对患者双侧胫神经和腓总神经所支配的腓肠肌和胫骨前肌进行H反射检查,并对患侧下肢给予临床痉挛指数(CSI)评定。计算胫神经和腓总神经H反射的引出率,并对其所引出的H反射结果以及与CSI的相关性进行比较和分析。结果:患者双侧胫神经所支配的腓肠肌H反射引出率100%,胫骨前肌H反射引出率为10%。患侧胫神经H反射潜伏期平均为(30.09±1.87)ms;非患侧胫神经H反射潜伏期平均为(31.99±2.31)ms。患侧胫神经Hmax/Mmax比值均数中位数平均为0.476;非患侧胫神经Hmax/Mmax比值平均为0.189。患侧与非患侧相比,患侧H反射潜伏期缩短,Hmax/Mmax比值增大,且差异有显著性意义(P<0.05)。将患侧下肢胫神经H反射潜伏期分别与CSI进行Spearman秩相关检验,结果显示患侧下肢胫神经H反射潜伏期与CSI不相关,而患侧下肢胫神经Hmax/Mmax比值与CSI存在秩相关关系。结论:用H反射来评价脑卒中后偏瘫患者患侧痉挛的存在和严重程度,比CSI量表更客观、量化。其中Hmax/Mmax比值是评估下运动神经元兴奋性的较好指标。     

用H反射和M波评价恢复期偏瘫患者运动神经元群的兴奋性

用H反射和M波的发展斜率比较偏瘫患者恢复期痉挛侧和未受累侧运动神经元群的兴奋性。记录 15例偏瘫患者双侧比目鱼肌的H反射和M波 ,计算其阈值和最大值 (Hth、Hmax、Mth、Mmax) ,并运用线性回归计算其发展斜率 (Hslp和Mslp)。比较偏瘫患者两侧Hmax/Mmax、Hth/Mth和Hslp/Mslp ,及其与Brunnstrom分期的关系。偏瘫患者痉挛侧Hslp/Mslp明显高于未受累侧(P =0 .0 2 1) ,且与Brunnstrom分期相关性好。Hslp/Mslp是评价恢复期偏瘫患者痉挛侧运动神经元群兴奋性的很好的指标。     

不同输出压力体外冲击波对脑卒中后小腿三头肌痉挛的影响

目的观察不同输出压力体外冲击波治疗(ESWT)对脑卒中患者小腿三头肌痉挛的疗效差异及可能的电生理机制。方法 2015年1月至2017年12月,脑卒中后偏瘫侧小腿三头肌痉挛住院患者90例,随机分为对照组、治疗组1和治疗组2,各30例。3组均予基础和常规康复治疗,两个治疗组在此基础上增加ESWT治疗,输出压力分别为1.5 bar和2.0 bar,共4周。治疗前后采用踝关节综合痉挛量表(CSS)、踝关节被动活动度(PROM)、10米步行时间(10MWT)和神经电生理(H反射潜伏期、Hmax/Mmax)进行评定。两个治疗组在每次ESWT治疗结束后,采用视觉模拟评分(VAS)评估治疗时疼痛。结果治疗后,3组患者CSS评分、PROM和10MWT均较治疗前显著改善(t 7.261, P 0.001),两个治疗组CSS评分和10MWT均低于对照组(P 0.05),治疗组2 10MWT低于治疗组1 (P 0.05)。治疗后,两个治疗组H反射潜伏期显著延长(t 15.025, P 0.001),Hmax/Mmax均显著下降(t 14.850, P 0.001),治疗组1 H反射潜伏期长于对照组(P 0.01)。两个治疗组VAS评分无显著性差异(t=0.735, P 0.05)。结论 2.0 bar和1.5 bar ESWT均可有效改善脑卒中后小腿三头肌痉挛,提高步行功能,2.0 bar较1.5 bar对步行功能的改善更大。其电生理机制尚需进一步研究。     

基于H反射通路探究大鼠慢性肌筋膜疼痛触发点的发病机制

目的:基于H反射探究大鼠慢性肌筋膜疼痛触发点(myofascial trigger points,MTrPs)的发病机制。方法:16只7周龄雄性SD大鼠随机分为实验组和对照组,实验组采取对腓肠肌定点钝性打击结合离心运动的模式进行连续8周造模。造模结束后两组均正常饲养4周。12周结束后,检测MTrPs造模成功指标(即紧张带、局部抽搐反应和自发肌电活动),并在此基础上进行H反射的诱发实验,采集引发H波的阈值、Mmax、Hmax、M波和H波潜伏期、Hmax/Mmax等。结果:与非MTrPs相比,MTrPs处诱发的H反射Mmax(4.28±1.27 mV)较低,Hmax(1.01±0.34 mV)较高,H波潜伏期(4.60±0.89 ms)较短,Hmax/Mmax比值(0.21±0.19)较大(P<0.05)。结论:H反射与慢性MTrPs形成的病理生理机制有关,MTrPs大鼠脊髓中枢可能存在高度致敏,Iα类传入神经兴奋性较高,肌梭敏感性可能也较高。     

脊髓损伤患者下肢胫神经H反射和F波的临床观察

目的：观察脊髓损伤(SCI)患者不同时期下肢胫神经H反射和F波的变化与临床神经体征之问的关系及电生理评定方面的意义。方法：对同一时期在我科住院的24例SCI患者进行双下肢胫神经H反射和F波检查．同时采用Ashworth痉挛评定方法评定及记录患肢肌张力、腱反射等。观察H反射和F波的特征表现与临床体征之间的关系。结果：SCI患者临床不同时期，下肢H反射和F波的表现不同．H反射和F波的表现特征受神经体征严重程度的影响。结论：H反射和F波有可能做为临床评定痉挛的客观电生理指标，它优于主观的Ashworth等痉挛评定方法．但尚需通过临床观察来完善这一指标的评定标准。     

高频重复经颅磁刺激结合外周磁刺激 治疗脑卒中后肌痉挛的临床研究

目的：观察高频重复经颅磁刺激（HF-rTMS）结合外周磁刺激治疗脑卒中后肌痉挛的临床效果。方 法：卒中患者120例随机分为联合组、rTMS组和对照组,每组40例。在脑卒中后二级预防用药治疗及常规 康复训练治疗基础上,联合组加用HF-rTMS和外周磁刺激,rTMS仅加用HF-rTMS,对照组不给予磁刺激。 于治疗前、治疗4周后检测患者患侧拇短展肌运动诱发电位（MEP）潜伏期及脑皮质到脊髓α前角运动神经 元的传导时间（CMCT）;采用改良Ashworth痉挛量表（MAS）和下肢痉挛指数（CSI）评定肢体痉挛情况,采 用上肢Fugl-Meyer运动量表（FMA）和改良Barthel指数（MBI）评定肢体运动功能。结果：3组治疗前的屈腕 MAS、CSI指数、上肢FMA评分、MBI评分、MEP潜伏期和CMCT差异无统计学意义（P＞0.05）。经4周治 疗后,各组患者上肢FMA评分、MBI评分均较治疗前明显升高（P＜0.05）,屈腕MAS、CSI指数均较治疗前 明显降低（P＜0.05）;rTMS组和联合组MEP潜伏期和CMCT均较治疗前缩短（P＜0.05）。联合组对以上指 标的改善作用最强,治疗效果最佳,rTMS次之,均明显优于对照组（P＜0.05）。治疗期间无诱发癫痫病例发 生。结论：HF-rTMS结合外周磁刺激比单用HF- rTMS治疗脑卒中后肌痉挛的效果更好,可减轻上肢屈肘 肌和下肢痉挛指数,改善患者运动功能及活动能力,缩短MEP潜伏期和CMCT,且安全性高。     

低频重复经颅磁刺激联合MOTOmed智能运动训练系统对脑卒中偏瘫患者上肢痉挛的影响

目的:探讨低频重复经颅磁刺激(rTMS)联合MOTOmed智能运动训练系统对脑卒中偏瘫患者上肢痉挛和运动功能的影响.方法:将90例脑卒中恢复期偏瘫患者随机分为联合治疗组、rTMS治疗组和伪rTMS治疗组,每组各30例.伪rTMS治疗组患者在常规康复治疗基础上辅以rTMS假刺激治疗,rTMS治疗组患者在常规康复治疗基础上...     

Enhanced stretch reflex excitability of the soleus muscle in persons with incomplete rather than complete chronic spinal cord injury

OBJECTIVE: To compare excitabilities of spinal stretch reflex among clinically complete spinal cord injury (SCI), incomplete SCI, elderly healthy, and young healthy subjects. DESIGN: Case comparison. SETTING: Research laboratory. PARTICIPANTS: Volunteer sample of 12 complete SCI, 10 incomplete SCI, 10 elderly, and 11 young subjects. INTERVENTION: Mechanically induced stretch reflex, H-reflex, and M response in electromyographic activity of the soleus muscle were recorded in all subjects. MAIN OUTCOME MEASURES: Absolute peak-to-peak stretch reflex amplitude and maximum H-reflex (Hmax), and those values relative to the maximum M response (Mmax) amplitude (relative peak-to-peak stretch reflex amplitude) and H/M ratio. RESULTS: Both the absolute and relative peak-to-peak stretch reflex amplitudes showed the greatest values in incomplete SCI among the 4 groups. Although absolute and relative peak-to-peak stretch reflex amplitudes of the incomplete SCI group were greater than those of the complete SCI group, the H/M ratios of both groups were comparable, and were greater than those of the younger and elderly groups. CONCLUSIONS: The results suggest that the greater absolute and relative peak-to-peak stretch reflex amplitudes of incomplete SCI were mostly due to the greater maximum motor potential (Mmax), while the elevated spinal motoneuronal excitability shown by the increased H/M ratio was maintained in the chronic stage after both complete and incomplete SCIs.     

胫神经局部振动对脑卒中患者小腿三头肌痉挛的影响及神经生理机制研究

目的:观察胫神经局部振动治疗对脑卒中患者小腿三头肌痉挛及神经电生理功能的影响。方法:选取脑卒中后偏瘫下肢功能障碍患者60例,按随机数字表法将其分为治疗组和对照组,每组30例。2组均给予常规康复训练,治疗组在此基础上增加局部振动治疗。治疗前、后,采用改良Ashworth量表(MAS)、Clonus阵挛分级法分别评价2组患...     

颈胸髓损伤患者H反射测定值与痉挛的关系研究

目的探讨完全性颈胸髓损伤后H反射相关值的变化及其定量评价痉挛的程度。方法对13例健康成人(对照组)和30例脊髓损伤患者(亚急性期18例,慢性期12例)进行两次比目鱼肌H反射测定,两次之间相隔1个月,对患者同时运用改良Ashworth肌张力评定分级进行痉挛评估。结果通过比目鱼肌H反射检测,各阶段脊髓损伤患者H_max/M_max比、最大H波波幅无显著性差异(P>0.05),但波幅均较健康成人明显减小(P<0.01)。脊髓损伤亚急性期痉挛程度与最大H波波幅、H_max/M_max比均呈quadratic关系(P<0.05),慢性期后两者间呈线性关系(P<0.05)。结论脊髓损伤后比目鱼肌H_max/M_max比与痉挛有密切的关系,但它们之间的定量关系还需要更大样本来证实。     

Changes in motoneuron excitability in hemiplegic subjects after passive exercise when using a robotic arm

OBJECTIVE: To test the hypothesis that motoneuron excitability in stroke subjects is influenced by peripheral sensory input through passive exercise to the hemiplegic upper extremity. DESIGN: Case-control prospective study. SETTING: Physical medicine and rehabilitation inpatient and outpatient clinic at a tertiary Veterans Affairs medical center. PARTICIPANTS: Nineteen hemiplegic adult subjects with a history of a cerebrovascular event. INTERVENTION: A standardized passive exercise program was performed on the right upper extremity by using a robotic arm. Nerve conduction study of the median nerve was obtained before and after the exercise. Maximum onset and peak amplitudes of the Hoffmann reflex (Hmax) and motor response (Mmax) wave were recorded. MAIN OUTCOME MEASURES: Hmax, Mmax, and Hmax/Mmax ratio. RESULTS: Immediately after passive exercise, there was no significant alteration in the Hmax (P=.94), Mmax (P=.60), or Hmax/Mmax ratio (P=.53) as compared with pre-exercise evoked responses. CONCLUSIONS: Peripheral proprioceptive input with passive exercise does not cause appreciable change in the Hmax/Mmax ratio, suggesting that motoneuron excitability of the affected upper extremity in stroke subjects is not influenced by passive robotic intervention.     

Acute effects of whole-body vibration on spinal excitability level and ankle plantar flexion spasticity in post-stroke individuals: A randomized controlled trial

IntroductionThis study aimed to evaluate the acute effects (up to 30 min) of whole-body vibration (WBV) on spinal excitability level and ankle plantar flexion spasticity in chronic stroke subjects.MethodsTwenty-one subjects (age 30–70 years old) with chronic stroke and ankle plantar flexion spasticity were randomly assigned to the vibration group (VG, n = 11) or the control group (CG, n = 10). Subjects in the VG underwent 10 minutes of WBV with a frequency of 35 Hz and amplitude of 2 mm. Subjects in the CG remained on the platform for 10 min without receiving vibratory stimulus. The spinal excitability level was estimated by the Hmax/Mmax ratio extracted from the H-reflex with simple stimulus examination. The value of the second/first wave ratio (H2/H1 ratio) at the peak of the first facilitation was also considered through the recovery curve with double stimulation. Spasticity was estimated by the Modified Ashworth Scale (MAS) and global perception of change. All outcomes were assessed before and at 10, 20, and 30 min after the WBV, except for MAS, which was evaluated only 10 min after WBV.ResultsNo between-group differences were found in either the spinal excitability level or plantar flexor spasticity at the three evaluated moments after WBV.ConclusionThese results suggest that WBV does not reduce spinal excitability level or spasticity of the plantar flexor muscles in chronic stroke patients in the first 30 min after vibratory stimulus.     

Comparison of three methods for recording tibial H reflex: a clinical note.

Recording the tibial H reflex from the calf is routine in clinical electromyography. Two widely used methods are Hugon's and Braddom and Johnson's. Both methods produce an H wave with an initial positive deflection. Another method, the "half and half" method, generates an H wave with an initial negative deflection. To compare these methods, H-reflex responses were recorded in the right calf of 20 normal adults with each method using identical amplifier and stimulator settings. Stimulus current was increased by increments of 0.5-1.0 mA until the H reflex and motor (M) wave responses reached maximum amplitudes (Hmax, Mmax). H wave to M wave (H/M) amplitude ratios were calculated. The half-and-half method produced greatest Hmax, Mmax, and H/M ratio. Wave form configuration for the half-and-half method was biphasic with an initial negative deflection; it was triphasic with an initial positive deflection with the other methods. The shapes of M and H waves were similar in two methods but dissimilar in one. Because of the greater amplitude and the initial negative deflection, the H wave may be easier to detect with the half-and-half method and may present a latency that is more easily determined. For these reasons, the half-and-half method is recommended for measuring amplitude and latency in clinical settings.