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重复经颅磁刺激联合机器人辅助步态训练对缺血性卒中患者下肢功能的影响OA北大核心CSTPCD

Effect of repetitive transcranial magnetic stimulation combined with robot-assisted gait training on lower limb motor function in ischemic stroke patients

中文摘要英文摘要

目的 探讨重复经颅磁刺激(rTMS)联合机器人辅助步态训练(RAGT)对缺血性卒中患者下肢运动功能、平衡功能、步行功能的影响.方法 前瞻性连续纳入2022年12月至2023年9月在南通市第一人民医院康复医学科就诊的缺血性卒中患者,按照随机数字表法,将符合纳排标准的患者分为对照组、rTMS组、RAGT组和联合组,每组各21例.4组患者在病情平稳后接受常规康复治疗,包括肌力训练、转移训练、坐站平衡训练、步行训练以及日常活动能力训练,物理因子治疗等,1次/d,5 d/周,持续3周.rTMS组患者在常规康复治疗的基础上给予rTMS,每个脉冲频率1 Hz/s,持续12s,间隔2s,共 1 200个脉冲,累计1 400s;1 400s/次,1次/d,5d/周,持续3周.RAGT组患者在常规康复治疗的基础上给予RAGT,30 min/次,1次/d,5d/周,持续3周.联合组在常规康复治疗基础上,rTMS治疗结束后立即接受RAGT治疗,方法与单用rTMS或RAGT相同.分别采用Fugl-Meyer下肢运动功能评定(FMA-LE)量表、Berg平衡量表(BBS)、运动范围测试、Holden步行功能分级评价4组患者治疗前后的下肢运动功能、平衡功能、运动范围和步行功能.结果 (1)4组患者性别、年龄、病灶侧别、病程、患侧下肢Brunnstrom分期的组间差异均无统计学意义(均P>0.05).(2)对照组、rTMS组、RAGT组和联合组治疗前FMA-LE量表评分分别为(14.4±2.9)、(13.6±3.0)、(13.5±2.8)、(14.3±3.0)分,对照组、rTMS 组、RAGT 组和联合组治疗后 FMA-LE 评分分别为(20.4±2.4)、(23.1±3.1)、(22.8±2.4)、(27.1±3.4)分,4 组患者 FMA-LE 量表评分时间主效应、组别主效应和组别与时间的交互效应的差异均有统计学意义(F值分别为1 083.102、6.535、23.522,均P<0.01);与本组治疗前比较,4组患者治疗后FMA-LE量表评分均升高(均P<0.05);治疗后rTMS组、RAGT组和联合组FMA-LE量表评分均高于对照组,联合组评分高于rTMS组和RAGT组(均P<0.05).(3)对照组、rTMS组、RAGT组和联合组治疗前BBS评分分别为(25±5)、(25±6)、(25±6)、(26±6)分,对照组、rTMS组、RAGT组和联合组治疗后BBS评分分别为(30±5)、(34±6)、(35±6)、(43±6)分,4组患者BBS评分时间主效应、组别主效应和时间与组别的交互效应的差异均有统计学意义(F值分别为1 057.204、6.377、59.140,均P<0.01);与本组治疗前比较,4组治疗后BBS评分均升高(均P<0.05);治疗后rTMS组、RAGT组和联合组评分均高于对照组,联合组评分高于rTMS组和RAGT组(均P<0.05).(4)对照组、rTMS组、RAGT组和联合组治疗前前后向运动范围测试评分分别为(7.3±0.8)、(7.4±0.8)、(7.4±0.8)、(7.6±0.7)分,治疗后前后向运动范围测试评分分别为(8.8±0.7)、(9.3±0.7)、(9.4±0.7)、(9.9±0.6)分;治疗前左右向运动范围测试评分分别为(7.1±0.7)、(7.2±0.8)、(7.2±0.8)、(7.3±0.7)分,治疗后左右向运动范围测试评分分别为(8.3±0.8)、(8.9±0.9)、(9.0±0.9)、(9.7±0.8)分;4组前后向、左右向运动范围测试评分时间主效应、组别主效应和组别与时间的交互效应均有统计学意义(前后向:F 值分别为 818.773、3.834、6.075,左右向:F 值分别为 1 935.147、3.114、40.516;均 P<0.05);与本组治疗前比较,4组治疗后前后向、左右向运动范围测试评分均升高(均P<0.05);治疗后rTMS组、RAGT组和联合组评分均高于对照组,联合组评分高于rTMS组和RAGT组(均P<0.05).(5)rTMS 和时间(OR=1.948,95%CI:1.465~2.590)、RAGT 和时间(OR=2.043,95%CI:1.529~2.728)、联合组和时间(OR=4.376,95%CI:3.116~6.146)交互效应的差异均有统计学意义(均P<0.01);以治疗前分级作为参照,4组患者治疗后Holden步行功能分级提高,差异有统计学意义(OR=1.948,95%CI:1.592~2.383,P<0.01);以对照组为参照,rTMS 组、RAGT 组和联合组患者Holden步行功能分级的差异均无统计学意义(均P>0.05).结论 rTMS联合RAGT可改善缺血性卒中患者下肢运动功能、平衡功能及步行功能恢复.

Objective To investigate the effects of repetitive transcranial magnetic stimulation(rTMS)combined with robot-assisted gait training(RAGT)on motor,balance,and walking function of lower limb in patients with ischemic stroke.Methods Ischemic stroke patients admitted to the Department of Rehabilitation Medicine,Nantong First People's Hospital were prospectively included from December 2022 to September 2023.According to random number table method,patients meeting the inclusion and exclusion criteria were divided into the control group,rTMS group,RAGT group,and combination group,with 21 cases in each group.The 4 groups of ischemic stroke patients received routine rehabilitation therapy after the condition stabilized,including muscle strength training,transfer training,sit-stand balance training,walking training,daily activity ability training,physical factor therapy,once a day,5 days a week,lasting for 3 weeks.Patients in rTMS group were given rTMS on the basis of routine rehabilitation therapy,with each pulse frequency of 1 Hz/s,lasting for 12 s,with a 2 s interval,totaling 1 200 pulses and 1 400 s in accumulation;1 400 s per session,once a day,5 days a week,lasting for 3 weeks.Patients in RAGT group were given RAGT on the basis of routine rehabilitation therapy,30 min per session,once a day,5 days a week,lasting for 3 weeks.On the basis of routine rehabilitation therapy,the combination group were received RAGT immediately after rTMS treatment,using the same methods as single rTMS or RAGT.The lower limb motor function,balance function,range of motion,and walking function of the four groups of patients were assessed before and after treatment using the Fugl-Meyer assessment for lower extremity(FMA-LE),Berg balance scale(BBS),range of motion,and the Holden walking ability grading.Results(1)There were no statistically significant differences in terms of sex,age,lesion site,course of disease,and Brunnstrom stage of the affected lower limb among the four groups(all P>0.05).(2)Before treatment,the FMA-LE scores for the control group,rTMS group,RAGT group,and combined group were(14.4±2.9),(13.6±3.0),(13.5±2.8),and(14.3±3.0)points,respectively.After treatment,the FMA-LE scores for the control group,rTMS group,RAGT group,and combined group were(20.4±2.4),(23.1±3.1),(22.8±2.4),and(27.1±3.4)points,respectively.There were statistically significant differences in the main effects of time,group,and the interaction effect of group and time for FMA-LE scores among the four groups(F values were 1 083.102,6.535,23.522,respectively;all P<0.01).Compared to before treatment,FMA-LE scores in 4 groups were increased after treatment(all P<0.05).After treatment,the FMA-LE scores of the rTMS group,RAGT group,and combined group were higher than those of the control group,and the combined group had higher scores than the rTMS group and RAGT group(all P<0.05).(3)Before treatment,the BBS scores for the control group,rTMS group,RAGT group,and combined group were(25±5),(25±6),(25± 6),and(26±6)points,respectively.After treatment,the BBS scores for the control group,rTMS group,RAGT group,and combined group were(30±5),(34±6),(35±6),and(43±6)points,respectively.There were statistically significant differences in the main effects of time,group,and the interaction effect of time and group for BBS scores among the four groups(F values were 1 057.204,6.377,59.140,respectively;all P<0.01).Compared to those before treatment,BBS scores in 4 groups were increased after treatment(all P<0.05).After treatment,the BBS scores of the rTMS group,RAGT group,and combined group were higher than those of the control group,and the combined group had higher scores than the rTMS group and RAGT group(all P<0.05).(4)Before treatment,the anteroposterior range of motion scores for the control group,rTMS group,RAGT group,and combined group were(7.3±0.8),(7.4±0.8),(7.4±0.8),and(7.6±0.7)points,respectively.After treatment,the anteroposterior range of motion scores were(8.8±0.7),(9.3±0.7),(9.4±0.7),and(9.9±0.6)points,respectively.Before treatment,the left-right range of motion scores for the control group,rTMS group,RAGT group,and combined group were(7.1±0.7),(7.2±0.8),(7.2±0.8),and(7.3±0.7)points,respectively.After treatment,they were(8.3±0.8),(8.9±0.9),(9.0±0.9),and(9.7±0.8)points,respectively.There were statistically significant differences in the main effects of time,group,and the interaction effect of group and time for both anteroposterior and left-right range of motion scores among the four groups(anteroposterior:F values were 818.773,3.834,6.075,respectively;left-right:F values were 1 935.147,3.114,40.516,respectively;all P<0.05).Compared to before treatment,anteroposterior and left-right range of motion scores in 4 groups were increased after treatment(all P<0.05).After treatment,the rTMS group,RAGT group,and combined group had higher scores than the control group,with the combination group had higher scores than the rTMS group and RAGT group(all P<0.05).(5)rTMS and time(OR,1.948,95%CI 1.465-2.590),RAGT and time(OR,2.043,95%CI 1.529-2.728),and the interaction effect of the combination group and time(OR,4.376,95%CI 3.116-6.146)all showed statistically significant differences(all P<0.01).Compared to the baseline grading before treatment,all four groups of patients showed an improvement in Holden walking grading after treatment,with statistically significant differences(OR,1.948,95%CI 1.592-2.383,P<0.01).Using the control group as a reference,there was no significant difference in the main effect of Holden walking ability grading among rTMS group,RAGT group and combined group(all P>0.05).Conclusion The combination of rTMS and RAGT can significantly improve the recovery of lower limb motor function,balance function,and walking ability in patients with ischemic stroke.

吉桧媛;朱冬燕;王梁;曹月姣;徐倩;韩珍真;高静;卢红建;陈伟观

226000 江苏省南通市第一人民医院康复医学科

经颅磁刺激机器人辅助步态训练卒中下肢

Robot-assisted gait trainingTranscranial magnetic stimulationStrokeLower limb

《中国脑血管病杂志》 2024 (004)

227-235 / 9

南通市民生科技计划项目(HS2022001);南通市卫生健康委科研项目(QNZ2023025)

10.3969/j.issn.1672-5921.2024.04.002

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