党辉;李彩霞;吴清俊;陈国奇;杨菲菲;董虹;

• 1:儋州市人民医院

摘要(Abstract)：

目的 探讨重复经颅磁刺激（rTMS）结合穴位肌电生物反馈治疗（EMGBF）对脑卒中患者胫骨前肌形态结构与肌力的影响。方法 选取2019-06—2022-06收治于儋州市人民医院的180例脑卒中患者为研究对象，以随机数字表法将其分为常规组（CON组）、rTMS组、EMGBF组、r TMS+EMGBF组，每组45例。比较4组患者治疗前一般资料，采用超声技术测量并记录4组患者治疗前和治疗后（治疗4周后）的踝背屈肌力参数，静息和最大等长收缩状态时下胫骨前肌结构羽状角（PA）、肌肉厚度（MT）、肌纤维长度（FL）；采用FMA量表下肢（FMA-LE）评分、Berg平衡量表（BBS）和改良Barthel指数（MBI）评分评估患者治疗后的效果。随机行走模型比较4组患者上述指标的改善程度。记录患者治疗过程中不良反应发生情况。结果 治疗后CON组、rTMS组、EMGBF组和rTMS+EMGBF组患者踝背屈肌力、FMA-LE评分、BBS评分、MBI评分较治疗前均有明显改善（P<0.001）；静息和最大等长收缩状态下r TMS组、EMGBF组和rTMS+EMGBF组患者的PA、MT较治疗前均有明显改善（P<0.05）;rTMS+EMGBF组患者治疗后踝背屈肌力（31.43±5.07）N，静息状态和最大等长收缩状态下PA(11.32±1.02、11.42±1.05)°、MT(11.18±1.02、11.50±0.98)mm,FMA-LE评分（28.65±8.02）分，BBS评分（38.67±8.02）分、MBI评分（66.34±7.34）分较治疗前的改善程度明显优于其他3组（P<0.05）；随机行走模型评价各指标改善程度依次为rTMS+EMGBF组，rTMS组和EMGBF组，CON组。4组患者治疗期间均未出现明显的不良反应。结论 rTMS联合EMGBF治疗对脑卒中患者胫骨前肌和肌力的恢复具有显著疗效。

关键词(KeyWords)： 脑卒中颅磁刺激;穴位肌电生物反馈;胫骨前肌;肌力;随机行走模型

Abstract:

Keywords:

基金项目(Foundation): 2021年度海南省卫生健康行业科研项目（编号：21A200343）

作者(Authors): 党辉;李彩霞;吴清俊;陈国奇;杨菲菲;董虹;

参考文献(References)：

• [1]KESAV P,JOHN S,JOSHI P,et al.Cardiac Myxoma Embolization Causing Ischemic Stroke and Multiple Partially Thrombosed Cerebral Aneurysms[J].Stroke,2021,52(1):e10-e14.DOI:10.1161/STROKEAHA.120.031679.
• [2]WHITELEY W N,GUPTA A K,THOMAS G,et al.Long-Term Incidence of Stroke and Dementia in ASCOT[J].Stroke,2021,52(10):3088-3096.DOI:10.1161/STROKEAHA.120.033489.
• [3]PETERS S,CARCEL C,MILLETT E,et al.Sex differences in the association between major risk factors and the risk of stroke in the UK Biobank cohort study[J].Neurology,2020,95(20):2715-2726.DOI:10.1212/WNL.0000000000010982.
• [4]李宇辉，许超杰，罗焕，等.高盐饮食人群发生缺血性脑卒中风险的列线图模型[J].中国实用神经疾病杂志，2022,25(3):270-275.DOI:10.12083/SYSJ.220256.
• [5]连至炜，祝春素，刘远立.我国中老年人抑郁和脑卒中发病风险关系的队列研究[J].中国全科医学，2021,24(7):842-846.DOI:10.12114/j.issn.1007-9572.2020.00.405.
• [6]TUO Q Z,ZHANG S T,LEI P.Mechanisms of neuronal cell death in ischemic stroke and their therapeutic implications[J].Med Res Rev,2022,42(1):259-305.DOI:10.1002/med.21817.
• [7]AMA B,MAY A.Clinical perspectives on ischemic stroke[J].Exp Neurol,2021,338:113599.DOI:10.1016/j.expneurol.2021.113599.
• [8]WANG Q,MA N,WANG P,et al.Effects of eye-acupuncture combined with rehabilitation training for poststroke dyskinesia:A protocol for systematic review and meta-analysis[J].Medicine,2021,100(10):e25036.DOI:10.1097/MD.0000000000025036.
• [9]MASACHIKA N,TAMAKI I,KENJI H,et al.Effect of repetitive transcranial magnetic stimulation on the kynurenine pathway in stroke patients[J].Neuroreport,2020,31(9):629-636.DOI:10.1097/WNR.0000000000001438.
• [10]钱琪，龙诗琦，吕海东，等.重复经颅磁刺激对脑卒中患者神经功能恢复及运动诱发电位的影响[J].中国实用神经疾病杂志，2022,25(2):207-211.DOI:10.12083/SYSJ.2022.211961.
• [11]LUO Z,ZHOU Y,HE H,et al.Synergistic Effect of Combined Mirror Therapy on Upper Extremity in Patients With Stroke:ASystematic Review and Meta-Analysis[J].Front Neurol,2020,11:155.DOI:10.3389/fneur.2020.00155.
• [12]OLIVEIRA A,COSTA K,LUCENA G,et al.Comparing exercises with and without electromyographic biofeedback in subacromial pain syndrome:A randomized controlled trial[J].Clin Biomech,2022,93:105596.DOI:10.1016/j.clinbiomech.2022.105596.
• [13]ASTRID S D,CLEMMA M,DEAN S,et al.Comparing Vascular Brain Injury and Stroke by Cranial Magnetic Resonance Imaging,Physician-Adjudication,and Self-Report:Data from the Strong Heart Study[J].Neuroepidemiology,2021,55(5):398-406.DOI:10.1159/000517804.
• [14]TAKAHASHI Y,KAWAKAMI M,MIKKAMA R,et al.Relationship between spinal reflexes and leg motor function in sub-acute and chronic stroke patients[J].Clin Neurophysiol,2022,138:74-83.DOI:10.1016/j.clinph.2022.02.025.
• [15]EWA B,MVDA C,RT A,et al.Maximum weight-shifts in sitting in non-ambulatory people with stroke are related to trunk control and balance:a cross-sectional study[J].Gait Posture,2021,83:121-126.DOI:10.1016/j.gaitpost.2020.10.007.
• [16]GAO Y,WANG Y,LI D,et al.Disability assessment in stroke:Relationship among the pictorial-based Longshi Scale,the Barthel Index,and the modified Rankin Scale[J].Clin Rehabil,2021,35(4):606-613.DOI:10.1177/0269215520975922.
• [17]ZHU Y,ZHAO Y,LU Y,et al.The association between plasma soluble triggering receptor expressed on myeloid cells 2 and cognitive impairment after acute ischemic stroke[J].J Affect Disord,2022,299:287-293.DOI:10.1016/j.jad.2021.12.011.
• [18]WANG F,ZHANG D,HU S,et al.Brunnstrom Stage Automatic Evaluation for Stroke Patients by Using Multi-Channel s EMG[J].Ann Int Conf IEEE Eng Med Biol Soc,2020:3763-3766.DOI:10.1109/EMBC44109.2020.9175285.
• [19]郭景鹏，谢兰军，钱令涛，等.神经内镜辅助下经胼胝体入路治疗脑室出血的临床疗效分析[J].中华神经医学杂志，2021,20(9):941-944.DOI:10.3760/cma.j.cn115354-20201126-00923.
• [20]邵真，周停，陈文莉，等.脑卒中患者上肢运动神经元功能状态及与运动功能相关性研究[J].华西医学，2021,36(5):595-599.DOI:10.7507/1002-0179.202102045.
• [21]王顺达，刘振国，高珩，等.LF-rTMS刺激健侧大脑半球M1区对老年缺血性脑卒中偏瘫病人上肢运动功能康复效果的影响[J].中西医结合心脑血管病杂志，2020,18(19):3290-3292.DOI:10.12102/j.issn.1672-1349.2020.19.037.
• [22]杨阳，胡利杰，邹丽丽，等.重复经颅磁刺激联合肌电生物反馈对脑卒中患者上肢功能恢复的影响[J].中华物理医学与康复杂志，2020,42(05):415-418.DOI:10.3760/cma.j.issn.0254-1424.2020.05.008
• [23]陈国茜，陈泽华，叶翔凌，等.基于肌肉功能和质量探讨肌肉与膝骨关节炎关系的研究进展[J].中华物理医学与康复杂志，2022,44(5):471-475.DOI:10.3760/cma.j.issn.0254-1424.2022.05.020.
• [24]VAZ L,ALMEIDA J,FROES K,et al.Effects of inspiratory muscle training on walking capacity of individuals after stroke:Adouble-blind randomized trial[J].Clin Rehabil,2021,35(9):1247-1256.DOI:10.1177/0269215521999591.
• [25]KOVACIKOVA Z,SARVESTAN J,NEUMANNOVA K,et al.Balance control during stair descent on compliant surface is associated with knee flexor and ankle plantar flexor strength in older adults[J].J Biomech,2020,111:110013.DOI:10.1016/j.jbiomech.2020.110013.
• [26]AQUINO M,RESENDE R A,KIRKWOOD R N,et al.Spatial-temporal parameters,pelvic and lower limb movements during gait in individuals with reduced passive ankle dorsiflexion[J].Gait Posture,2022,93:32-38.DOI:10.1016/j.gaitpost.2022.01.010.
• [27]刘晶，修忠标，林巧璇，等.膝骨关节炎患者股直肌超声形态特征分析[J].中国康复医学杂志，2022,37(3):311-315.DOI:10.3969/j.issn.1001-1242.2022.03.004.
• [28]SARI A,ESME M,AYCICEK G S,et al.Evaluating Skeletal Muscle Mass With Ultrasound In Patients With Systemic Sclerosis[J].Nutrition,2020:110999.DOI:10.1016/j.nut.2020.110999.
• [29]王晨，王人卫，杨坚，等.核心稳定性训练结合常规康复治疗对脑卒中偏瘫患者躯干肌肉厚度，活动度的meta分析[J].中国康复医学杂志，2019,34(9):1065-1070.DOI:10.3969/j.issn.1001-1242.2019.09.011.
• [30]HINKS A,DAVIDSON B,AKAGI R,et al.Influence of isometric training at short and long muscle tendon unit lengths on the history dependence of force[J].Scand J Med Sci Sports,2020,31(2):325-338.DOI:10.1111/sms.13842.
• [31]刘美快，徐乐义，李海燕，等.肌电生物反馈疗法改善脑卒中患者腓肠肌形态结构的超声研究[J].中国康复医学杂志，2020,35(7):847-850.DOI:CNKI:SUN:ZGKF.0.2020-07-015.
• [32]蒋自牧，梁嘉辉，黎建乐，等.脑卒中后瘫痪肢体肌肉萎缩和失神经支配研究进展[J].中华神经科杂志，2020,53(12):1063-1067.DOI:10.3760/cma.j.cn113694-20200325-00207.
• [33]刘美快，徐乐义，李海燕，等.镜像疗法对脑卒中患者运动功能和平衡功能以及胫骨前肌形态结构的影响[J].中华物理医学与康复杂志，2020,42(5):419-423.DOI:10.3760/cma.j.issn.0254-1424.2020.05.009.
• [34]黄华垚，杜厚伟，陈超，等.低频r TMS联合FES治疗对亚急性期缺血性脑卒中患者下肢痉挛及运动功能的康复作用[J].心血管康复医学杂志，2019,28(02):134-138.DOI:10.3969/j.issn.1008-0074.2019.02.02.
• [35]MP A,MZ B,SJ A.The effects of transcranial direct current stimulation on corticospinal and cortico-cortical excitability and response variability:Conventional versus high-definition montages[J].Neurosci Res,2021,166:12-25.DOI:10.1016/j.neures.2020.06.002.
• [36]YANG K,XI X,WANG T,et al.Effects of transcranial direct current stimulation on brain network connectivity and complexity in motor imagery[J].Neurosci Lett,2021,757:135968.DOI:10.1016/j.neulet.2021.135968.
• [37]陈利强，王花明，原永康.核心稳定性训练结合肌电生物反馈对脑卒中偏瘫患者下肢运动及平衡功能的疗效观察[J].中国药物与临床，2020,20(1):106-108.DOI:10.11655/zgywylc2020.01.044.
• [38]何玲燕，吴月峰，王雪飞，等.穴位肌电生物反馈治疗脑卒中偏瘫后踝关节活动障碍的临床疗效观察[J].中国康复医学杂志，2020,35(11):1342-1345.DOI:10.3969/j.issn.1001-1242.2020.11.012.
• [39]靳静娜，王会琴，廖文清，等.r TMS联合运动训练对运动皮质功能影响的研究[J].生物医学工程与临床，2020,24(1):1-6.DOI:10.13339/j.cnki.sglc.20200107.001.
• [40]李杰，李海燕，林祖琛，等.本体感觉神经肌肉促进术结合重复性经颅磁刺激治疗改善脑卒中偏瘫患者上肢功能的短期疗效[J].江苏医药，2022,48(2):161-164.DOI:10.19460/j.cnki.0253-3685.2022.02.015.
• [41]SMITH M C,STINEAR C M.Transcranial magnetic stimulation(TMS)in stroke:Ready for clinical practice?[J].J Clin Neurosci,2016,31:10-14.DOI:10.1016/j.jocn.2016.01.034.
• [42]DIONíSIO A,DUARTE I C,PATRíCIO M,et al.The Use of Repetitive Transcranial Magnetic Stimulation for Stroke Rehabilitation:A Systematic Review[J].J Stroke Cerebrovasc Dis,2018,27(1):1-31.DOI:10.1016/j.jstrokecerebrovasdis.2017.09.008.
• [43]LEóN RUIZ M,RODRíGUEZ SARASA M L,SANJUáN RO-DRíGUEZ L,et al.Current evidence on transcranial magnetic stimulation and its potential usefulness in post-stroke neurorehabilitation:Opening new doors to the treatment of cerebrovascular disease[J].Neurologia(Engl Ed),2018,33(7):459-472.DOI:10.1016/j.nrl.2016.03.008.
• [44]ZONG X,LI Y,LIU C,et al.Theta-burst transcranial magnetic stimulation promotes stroke recovery by vascular protection and neovascularization[J].Theranostics,2020,10(26):12090-12110.DOI:10.7150/thno.51573.
• [45]KIM W J,ROSSELIN C,AMATYA B,et al.Repetitive transcranial magnetic stimulation for management of post-stroke impairments:An overview of systematic reviews[J].J Rehabil Med,2020,52(2):jrm00015.DOI:10.2340/16501977-2637.
• [46]XU P,HUANG Y,WANG J,et al.Repetitive transcranial magnetic stimulation as an alternative therapy for stroke with spasticity:a systematic review and meta-analysis[J].J Neurol,2021,268(11):4013-4022.DOI:10.1007/s00415-020-10058-4.
• [47]LEFAUCHEUR J P,ANDRé-OBADIA N,ANTAL A,et al.Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (r TMS)[J].Clin Neurophysiol,2014,125(11):2150-2206.DOI:10.1016/j.clinph.2014.05.021.25034472.
• [48]HERNANDEZ-PAVON J C,HARVEY R L.Noninvasive Transcranial Magnetic Brain Stimulation in Stroke[J].Phys Med Rehabil Clin N Am,2019,30(2):319-335.DOI:10.1016/j.pmr.2018.12.010.
• [49]Karatzetzou S,Tsiptsios D,Terzoudi A,et al.Transcranial magnetic stimulation implementation on stroke prognosis[J].Neurol Sci,2022,43(2):873-888.DOI:10.1007/s10072-021-05791-1.
• [50]HORDACRE B,COMACCHIO K,WILLIAMS L,et al.Repetitive transcranial magnetic stimulation for post-stroke depression:a randomised trial with neurophysiological insight[J].J Neurol,2021,268(4):1474-1484.DOI:10.1007/s00415-020-10315-6.
• [51]VABALAITE B,PETRUSEVICIENE L,SAVICKAS R,et al.Effects of High-Frequency(HF)Repetitive Transcranial Magnetic Stimulation (r TMS) on Upper Extremity Motor Function in Stroke Patients:A Systematic Review[J].Medicina(Kaunas),2021,57(11):1215.DOI:10.3390/medicina57111215.