功能性电刺激对脑卒中早期患者下肢运动功能及磁共振弥散张量成像的影响

Functional electrical stimulation based on a working pattern influences function of lower extremity in subjects with early stroke and effects on diffusion tensor imaging： a randomized controlled trial

目的 结合磁共振弥散张量成像（DTI）技术探讨基于人体行走模式的功能性电刺激（FES）改善脑卒中早期患者下肢运动功能的可能机制.方法 收集2012年8月至2013年9月广东省江门市中心医院神经内科住院的脑卒中患者,将符合入选标准的患者48例,按照年龄、性别、病程、Brunnstrom分期及脑卒中类型进行分层后,应用Minimize计算机软件随机分为四通道FES组（18例）、双通道FES组（15例）及安慰刺激组（15例）.3组患者常规治疗相同,四通道FES组采用基于正常行走模式设计的FES治疗仪治疗,刺激胫前肌、股四头肌内外侧头、腓肠肌及股二头肌;双通道FES组刺激胫前肌、腓骨长短肌;安慰刺激组电极放置与治疗组相同,但治疗时不予电流输出.3组患者在治疗开始前和治疗3周中的每周均进行Fugl-Meyer下肢运动功能（FMA）脑卒中患者姿势评定量表（PASS）、Brunel平衡量表（BBA）、Berg平衡量表（BBS）及改良Barthel指数（MBI）康复功能评定,部分患者在治疗前和治疗3周后给予DTI检查.结果 3组患者一般资料及治疗前各项评定结果差异无统计学意义.组内比较,治疗1周、2周和3周后,3组PASS、BBA、BBS、FMA及MBI评分与治疗前比较,差异均有统计学意义（均P＜0.05）;治疗3周后,四通道FES组和双通道FES组的患侧FA值与治疗前比较,差异有统计学意义（P＜0.05）.组间比较,治疗1周后,3组MBI评分组间比较,差异有统计学意义（P =0.037）,其中四通道组[（52±12）分]与安慰刺激组[（38±18）分]比较差异有统计学意义（P＜0.05）;治疗2周后,四通道FES组的PASS、MBI评分[（29±3）分、（73±13）分]分别与双通道FES组[（24±8）分、（60±17）分]比较,四通道FES组的PASS、BBA、BBS、FMA及MBI[（29±3）分、（8.3±2.4）分、（37±7）分、（22±5）分、（73±13）分]分别与安慰刺激组[（21±7）分、（6.2±3.1）分、（24±16）分、（15±8）分、（47±20）分]比较,双通道FES组的MBI[（60±17）分]与安慰刺激组[（47±20）分]比较,差异均有统计学意义（均P ＜0.05）;治疗3周后,四通道FES组的FMA[（25±5）分]与双通道FES组[（20±7）分]比较,有近似统计学意义（P=0.055）;四通道FES组的PASS、BBS、FMA及MBI[（31±3）分、（43±8）分、（25±5）分、（81±13）分]与安慰刺激组[（25±8）分、（29±17）分、（17±9）分、（54±25）分]比较,双通道FES组的MBI[（71±15）分]与安慰刺激组[（54±25）分]比较,差异有统计学意义（P＜0.05）.治疗3周后,3组患侧FA变化值明显升高,四通道FES组[（0.321±0.172）分]与安慰刺激组[（0.217±0.135）分]比较（P =0.020）,双通道FES组[（0.333±0.164）分]与安慰刺激组[（0.217±0.135）分]比较（P =0.049）,差异均有统计学意义.3组DTT结果显示,四通道FES组患侧纤维束明显增多,健侧纤维束改善不明显;双通道FES组和安慰刺激组改善不明显.结论 与传统的双通道FES相比,基于行走模式的FES疗效更显著,更有利于实现脑卒中后早期患者大脑结构和功能重组,促进运动功能恢复.

Objective To explore the possible mechanisms for improving lower extremity motor function in patients with early stroke through combining magnetic resonance diffusion tensor imaging （DTI） technology and functional electrical stimulation （FES） based on human walking patterns.Methods From August 2012 to September 2013,a total of 48 eligible patients were stratified according to age,gender,disease course,Brunnstrom staging and types of stroke.And the Minimize software was used to divided them randomly into four-channel FES group （n =18）,dual-channel FES group （n =15） and comfort stimulation group （n =15）.For all three groups,general medication and standard rehabilitation were provided.Based on normal walking pattern design of FES treatment,four-channel FES groups received the stimulations of quadriceps,hamstring,anterior tibialis and medial gastrocnemius.For the dual-channel FES group,the stimulations of tibialis anterior,peroneus longus and peroneus brevis muscles were applied.In comfort electrical stimulation group,the electrode positions were identical to the stimulation group,but there was no current output during stimulation.Before and after 3-week treatment,three groups received weekly rehabilitation evaluations of Fugl-Meyer assessment （FMA）,posture assessment of stroke scale （PASS）,Brunel balance assessment （BBA）,Berg balance scale （BBS） and modified Barthel index （MBI）.Before and after treatment,DTI examination was performed for some patients.Results Among three groups,general patient profiles and pre-treatment evaluations showed no significant difference.For intra-group comparisons versus pre-treatment,at week 1,2 and 3,the scores of PASS,BBA,BBS,FMA and MBI had statistically significant differences （P ＜ 0.05） ; At week 3 post-treatment,when four-channel and doublechannel FES groups were compared versus pre-treatment,the scores of ipsilateral FA had statistically significant differences （P ＜ 0.05）.At week 1 post-treatment,MBI had statistically significant difference among 3 groups （P =0.037）.As compared with placebo,four-channel group had statistically significant difference [（52 ± 12） vs （38 ± 18）,P ＜0.05] ; At week 2 post-treatment,the scores of PASS and MBI were （29 ±3,73 ± 13） in four-channel FES group versus （24 ±8,60 ± 17） in dual-channel FES group.And the scores of PASS,BBA,BBS,FMA and MBI were （9 ± 3,8.3 ± 2.4,37 ± 7,22 ± 5,73 ± 13） in four-channel FES group versus （21 ± 7,6.2 ± 3.1,24 ± 16,15 ± 8,47 ± 20） in comfort electrical stimulation group.When dual-channel FES and comfort stimulation groups were compared,MBI had significant statistical difference [（60 ± 17） vs （47 ± 20）,P ＜ 0.05].At week 3 post-treatment,fourchannel and dual-channel FES groups were compared,there was also statistical significance in FMA [（25 ± 5） vs （20 ± 7）,P =0.055].The scores of PASS,BBS,FMA and MBI were （31 ± 3,43 ± 8,25 ± 5,81 ± 13） in four-channel FES group versus （25 ± 8,29 ± 17,17 ± 9,54 ± 25） in comfort stimulation group respectively.When dual-channel FES and comfort stimulation groups were compared,the scores of MBI were （71 ± 15） and （54 ± 25） respectively.And the difference was statistically significant （P ＜0.05）.At week 3 post-treatment,the scores of FA significantly increased [four-channel FES group （0.321 ± 0.172） vs comfort stimulation group （0.217 ± 0.135） （P =0.020）].When dual-channel FES group （0.333 ±0.164） and comfort stimulation group （0.217 ±0.135） （P =0.049） were compared,the differences were statistically significant.DTI showed that four-channel FES group increased significantly,but contralateral fiber bundle was not obvious.And the improvements of dual-channel FES and comfort stimulation groups were insignificant.Conclusion Compared with traditional dual-channel FES,functional electrical stimulation based on human walking patterns is more efficacious.And it helps to restore brain structure and function and promote motor function recovery in patients with early stroke.