低频重复经颅磁刺激联合任务导向性训练对痉挛型偏瘫脑瘫患儿下肢粗大运动及其步行功能的疗效分析

doi:10.11852/zgetbjzz2023-0103

摘要/Abstract

摘要： 目的探讨低频重复经颅磁刺激(rTMS)联合任务导向性训练(TOT)对痉挛型偏瘫脑瘫下肢粗大运动及步行功能的影响,为改善痉挛型偏瘫脑瘫运动功能提供新思路。方法选取2021年8月—2022年9月在西南医科大学附属医院康复医学科门诊和/或入院3~6岁痉挛型偏瘫脑瘫75例,按随机数字表法分为常规组(n=25)、TOT组(n=25)以及rTMS+TOT组(n=25)。三组均接受常规康复治疗,其中TOT组额外接受TOT,rTMS+TOT组额外接受低频rTMS联合TOT,三组均治疗6周。在治疗前后分别对三组患儿下肢腓肠肌肌张力采用改良Ashworth量表(MAS)、下肢运动及步行功能选取粗大运动功能测试量表-88项(GMFM-88)D区(站立)、E区(走跑跳)、足印分析法进行评定。结果治疗6周后,三组患儿各项评分均较治疗前有所提高,差异具有统计学意义(P<0.05);其中组间比较,rTMS+TOT组MAS评分(H=20.995)、GMFM-88项D区和E区评分(F=12.348、19.428)、跨步长(F=2.137)、步宽(F=12.160)以及1min步行距离(F=8.705)均优于常规组和TOT组,差异具有统计学意义(P<0.05)。结论低频rTMS联合任务导向性训练可改善痉挛型偏瘫脑瘫下肢腓肠肌肌张力、提高下肢粗大运动和步行功能,且效果优于单独任务导向性训练。

关键词: 低频重复经颅磁刺激, 任务导向性训练, 痉挛型偏瘫脑瘫, 下肢粗大运动, 步行功能

Abstract: Objective To analyze the effect of low frequency repetitive transcranial magnetic stimulation (rTMS) combined with task oriented training (TOT) on lower extremity gross motor and gait function of children with spastic hemiplegic cerebral palsy, in order to provide new ideas for improving the motor function of spastic hemiplegic cerebral palsy. Methods From August 2021 to September 2022, 75 children aged 3 - 6 years with spastic hemiplegic cerebral palsy were selected into this study from the Outpatient and Inpatient Departments of Rehabilitation Medicine in the Affiliated Southwest Medical University, and were randomly divided into routine group (n=25), TOT group (n=25) and rTMS+TOT group (n=25). Children in the three groups all received conventional rehabilitation. Additionally, children in TOT group received TOT, children in rTMS+TOT group received TOT combined with low frequency rTMS. Children in the three groups were assessed with Modified Ashworth Scale (MAS), D and E domains of Gross Motor Function Measure-88(GMFM-88) and footprint analysis before and after treatment. Results After 6-week intervention, scores of the above indicators in the three groups improved significantly than those before intervention (P<0.05). Intergroup comparison showed that performance of MAS (H=20.995), D and E domains of GMFM-88 (F=12.348, 19.428), turnover step length (F=2.137), step width (F=12.160) and 1 minute walk test (1MWT) distance assessment (F=8.705) were significantly better than those in TOT group and routine group (P<0.05). Conclusion Low frequency rTMS combined with TOT could decrease the gastrocnemius muscle tone and improve the lower extremity gross motor and gait function in children with spastic hemiplegic cerebral palsy, and the effect is better than TOT alone.

Key words: low frequency repetitive transcranial magnetic stimulation, task-oriented training, spastic hemiplegic cerebral palsy, lower extremity gross motor, gait function

中图分类号:

R742.3

张秋, 李卫平, 虞记华, 杜鑫萍, 凌运其, 胥方元. 低频重复经颅磁刺激联合任务导向性训练对痉挛型偏瘫脑瘫患儿下肢粗大运动及其步行功能的疗效分析[J]. 中国儿童保健杂志, 2023, 31(11): 1248-1253.

ZHANG Qiu, LI Weiping, YU Jihua, DU Xinping, LING Yunqi, XU Fangyuan. Therapeutic effect of low frequency repetitive transcranial magnetic stimulation combined with task oriented training on lower extremity gross motor function and gait function of children with spastic hemiplegic cerebral palsy[J]. Chinese Journal of Child Health Care, 2023, 31(11): 1248-1253.

参考文献

[1] Vitrikas K, Dalton H, Breish D. Cerebral palsy: An overview[J]. Am Fam Physician, 2020, 101(4):213-220.
[2] 李晓捷, 邱洪斌, 姜志梅,等. 中国十二省市小儿脑性瘫痪流行病学特征[J]. 中华实用儿科临床杂志, 2018, 33(5):378-383.
Li XJ, Qiu HB, Jiang ZM, et al. Epidemiological characteristics of cerebral palsy in twelve province in China[J]. Appl Clin Pediatr, 2018,33(5): 378-383. (in Chinese)
[3] 唐久来, 秦炯, 邹丽萍, 等. 中国脑性瘫痪康复指南(2015):第一部分[J]. 中国康复医学杂志, 2015,30(7): 747-754.
Tang JL, Qin J, Zhou LP, et al. Chinese rehabilitation guidelines for cerebral palsy(2015): Part 1[J]. Chin J Rehabil Med, 2015, 30(7): 747-754. (in Chinese)
[4] Palmer JA, Wheaton LA, Gray WA, et al. Role of interhemispheric cortical interactions in poststroke motor function[J]. Neurorehabil Neural Repair, 2019, 33(9):762-774.
[5] Cunningham DA, Knutson JS, Sankarasubramanian V, et al. Bilateral contralaterally controlled functional electrical stimulation reveals new insights into the interhemispheric competition model in chronic stroke[J]. Neurorehabil Neural Repair, 2019, 33(9):707-717.
[6] Yuan X, Yang Y, Cao N, et al. Promotion of poststroke motor-function recovery with repetitive transcranial magnetic stimulation by regulating the interhemispheric imbalance[J]. Brain Sci, 2020, 10(9):648-652.
[7] 张新恒, 王德强, 毕锋莉, 等. 重复经颅磁刺激治疗痉挛型脑瘫儿童运动功能障碍的研究进展[J]. 中华物理医学与康复杂志, 2021, 43(3):273-275.
Zhang XH, Wang DQ, Bi FL, et al. Research progress on repetitive transcranial magnetic stimulation for the treatment of motor dysfunction in children with spastic cerebral palsy[J].Chin J Phys Med Rehabil, 2021, 43(3):273-275. (in Chinese)
[8] Novak I, Morgan C, Fahey M, et al. State of the evidence traffic lights 2019: systematic review of interventions for preventing and treating children with cerebral palsy[J]. Curr Neurol Neurosci Rep, 2020, 20(2): 3-24.
[9] 张文娟, 陈蓓蓓, 沈晨曦, 等. 国际临床神经电生理联盟脑电图电极安放标准指南(2017)解读[J]. 中华神经科杂志, 2018, 51(10):854-856.
Zhang WJ, Chen PP, Shen CX, et al. The interpretation of the international federation of clinical neurophysiology electroencephalography electrode array standards (2017)[J]. Chin J Neurol, 2018, 51(10):854-856. (in Chinese)
[10] 吴跃迪, 李放, 熊莉. 改良Ashworth量表及改良Tardieu量表应用于卒中患者屈肘肌评估的信度比较[J].中国康复医学杂志, 2013, 28(12):1151-1152.
Wu YD, Li F, Xiong L.Comparison of reliability between the modified Ashworth Scale and the modified Tardieu Scale in evaluating the elbow flexor muscle in stroke patients[J]. Chin J Rehabil Med, 2013, 28(12):1151-1152. (in Chinese)
[11] 刘鹏, 黄东锋, 江沁, 等. 脑瘫患儿粗大运动功能测量量表的标准化研究[J]. 中国康复医学杂志, 2004,19(3):10-13.
Liu P, Hang DF, Jiang Q, et al. Validity of reliability of the gross motor functional measure in children with cerebral palsy[J]. Chin J Rehabil Med, 2004,19(3):10-13. (in Chinese)
[12] 孙爱萍, 毕胜, 赵海红, 等. 痉挛型脑瘫患儿个体化康复治疗前后步态特征分析[J].中国康复, 2020, 35(6):317-320.
Sun AP, Bi S, Zhao HH, et al. Gait characteristics and walking ability before and after individualized treatment of children with spastic cerebral palsy[J]. Chin Rehabil, 2020, 35(6):317-320. (in Chinese)
[13] 中国康复医学会儿童康复专业委员会, 中国残疾人康复协会小儿脑性瘫痪康复专业委员会, 中国医师协会康复医师分会儿童康复专业委员会, 等. 中国脑性瘫痪康复指南(2022)第四章:康复治疗(上)[J]. 中华实用儿科临床杂志, 2022, 37(16):1201-1229.
Chinese Association of Rehabilitation Medicine Pediatric Rehabilitation Committee, Chinese Association of Rehabilitation of Disabled Persons Rehabilitation Committee for cerebral palsy, Chinese Medical Doctor Association Pediatric Rehabilitation Committee, et al. Chinese rehabilitation guidelines for cerebral palsy (2022) part 4: Rehabilitation treatment(Ⅰ)[J]. Chin J Appl Clin Pediatr, 2022, 37(16):1201-1229. (in Chinese)
[14] Sah AK, Balaji GK, Agrahara S. Effects of Task-oriented activities based on neurodevelopmental therapy principles on trunk control, balance, and gross motor function in children with spastic diplegic cerebral palsy: A single-blinded randomized clinical trial[J]. J Pediatr Neurosci, 2019, 14(3):120-126.
[15] 付蕊,徐桂芝,朱海军,等.经颅磁刺激对学习记忆及大脑神经突触可塑性影响的研究进展[J].生物医学工程学杂志,2021,38(4):783-789.
Fu R, Xu GZ, Zhu HJ, et al. Research progress on the effect of transcranial magnetic stimulation on learning, memory and plasticity of brain synaptic[J].Journal of Biomedical Engineering,2021, 38(4):783-789.
[16] 吴野, 巩尊科, 李新剑, 等. 不同模式经颅磁刺激对痉挛型偏瘫脑性瘫痪患儿上肢运动功能的影响[J]. 中国康复医学杂志, 2019, 34(11):1368-1370.
Wu Y, Gong ZK, Li XJ, et al.The effect of upper limb motor function on different modes of transcranial magnetic stimulation for children with spastic hemiplegia cerebral palsy[J]. Chin J Rehabil Med, 2019, 34(11):1368-1370. (in Chinese)
[17] 冯枫.重复经颅磁刺激联合常规促醒在颅脑损伤后意识障碍患者治疗中的临床应用研究[J].陕西医学杂志,2020,49(4):442-445.
Feng F.The role of repetitive transcranial magnetic stimulation combined with conventional wake-up therapy in the treatment of patients with disturbance of consciousness after craniocerebral injury[J].Shaanxi Medical Journal,2020,49(4):442-445.
[18] Parvin S, Shahrokhi A, Tafakhori A, et al. Therapeutic effects of repetitive transcranial magnetic stimulation on corticospinal tract activities and neuromuscular properties in children with cerebral palsy[J]. Annu Int Conf IEEE Eng Med Biol Soc, 2018, 2018(1):2218-2221.
[19] Rajak BL, Gupta M, Bhatia D, et al. Increasing number of therapy sessions of repetitive transcranial magnetic stimulation improves motor development by reducing muscle spasticity in cerebral palsychildren[J]. Ann Indian Acad Neurol, 2019, 22(3): 302-307.
[20] 袁海斌, 成莲英, 尹飞, 等. 不同类型脑性瘫痪患儿脑脊液氨基酸变化[J]. 中国当代儿科杂志, 2008, 10(4):475-477.
Yuan HB, Cheng LY, Yin F, et al. Levels of amino acids in cerebral spinal fluid in children with cerebral palsy[J].Chin J Contemp Pediatr, 2008, 10(4):475-477. (in Chinese)
[21] 梁亚利, 张静, 廖瑞松, 等. 痉挛型偏瘫脑性瘫痪患儿的步态分析[J]. 中华物理医学与康复杂志, 2017, 39(6):450-452.
Liang YL, Zhang J, Liao RS, et al. The gait analysis of children with spastic hemiplegia cerebral palsy[J]. Chin J Phys Med Rehabil, 2017, 39(6):450-452. (in Chinese)
[22] 李海峰, 尹宏伟, 邹艳, 等. 重复经颅磁刺激对痉挛偏瘫型脑瘫患儿肢体运动功能的影响[J]. 中华物理医学与康复杂志, 2016, 38(6):433-435.
Li HF, Yin HW, Zhou Y, et al. The effect of repeated transcranial magnetic stimulation on limb motor function in children with spastic hemiplegia cerebral palsy[J]. Chin J Phys Med Rehabil, 2016, 38(6):433-435. (in Chinese)
[23] 靳静娜, 王会琴, 廖文清, 等. rTMS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.
Jin JN, Wang HQ, Liao WQ, et al. Effect of rTMS combined with motor training on function of motor cortex[J]. BME＆Clin Med, 2020, 24(1):1-6. (in Chinese)