肉毒毒素联合针灸治疗脑梗死后上肢局部肌痉挛的疗效观察及fMRI研究

Effects of botulinum toxin A combined with acupuncture for muscle spasm after stroke and fMRI

目的:观察肉毒毒素注射结合针灸疗法对脑梗死上肢局部肌痉挛患者疗效以及治疗前后上肢运动的fMRI变化,并分析其机制。方法:脑梗死后上肢局部肌痉挛患者60例,随机分为3组各20例,A组采用A型肉毒毒素注射配合针灸以及康复训练,B组采用肉毒毒素注射及常规康复训练,C组则仅予以常规康复训练。治疗前后采用改良Ashworth评分、Wolf运动功能评定、Fugl-Meyer上肢功能评分,并结合超声观察引起上肢屈肌痉挛肌肉的长度、厚度的变化,以及上肢运动的fMRI变化。结果:治疗3周后,3组患者Fugl-Meyer上肢功能评分及Wolf运动功能评定评分均较治疗前明显提高(P<0.05),且A组更高于B、C组(P<0.05)、B组更高于C组(P<0.05);3组改良Ashworth分级和Wolf评定时间评分均较治疗前明显下降(P<0.05),且A组更低于B、C组(P<0.05)、B组更低于C组(P<0.05)。A、B组患者在静息时肱二头肌长度均较治疗前及C组明显增加(P<0.05),并接近正常人的肌长度;C组治疗前后肱二头肌长度比较差异无统计学意义;3组患者在静息时的肌纤维厚度、最大等长收缩的肌纤维长度和厚度治疗前后比较差异无统计学意义。A、B组患者肱二头肌屈伸肌力均较治疗前及C组明显增加(P<0.05),C组治疗前后比较差异无统计学意义。A、B组患者SM1区激活面积及激活强度均较治疗前增大(P<0.05),2组SMA区和小脑激活区域治疗前后比较差异无统计学意义。结论:A型肉毒毒素联合针灸疗法可以较好的缓解脑梗死后上肢局部肌痉挛,增加上肢活动的灵活性,以及患者的日常生活功能。

Objective： To study the effect of botulinum toxin type A combined with acupuncture for muscle spasm after stroke and fMRI. Methods： Sixty patients with muscle spasm were randomly divided into three groups. Group A was given botulinum toxin type A combined with acupuncture, group B botulinum toxin type A alone, and group C conventional therapy. Fugl-Meyer, Wolf motor function test （WMFT）, modified ashworth scale, length and thickness of musculus biceps brachii through ultrasound, and changes of the fMRI before and after the treatment were recorded respectively. Results： Scores of Fugl-Meyer, WMFT and modified ashworth scale in three groups after treatment were significantly increased as compared with those at 3rd week before treatment （P〈0. 05）. The scores of Fugl-Meyer, WMFT and modified ashworth scale in group A were significantly higher than those of the remaining two groups after treatment （P〈0.05）, and those in group B were significantly higher than in group C after treatment （P〈0. 05）. Length and thickness of musculus biceps braehii in groups A and B were significantly increased before treatment as compared with those after treatment （P〈0. 05）. Thickness of musculus biceps brachii in quiescent condition and maximal isometric contraction showed no significant difference after treatment among the three groups （P〉0. 05）. Flexor muscle strength of the biceps brachii in groups A and B after treatment were significantly increased as compared with those in group C and before treatment （P〈0. 05）. SM1 activation areas and activation intensity were increased after treatment in groups A and B as compared with those before treatment, and there was no significant difference in SMA and cerebellum in groups A and B before and after treatment. Conclusion： The treatment of botulinum toxin type A combined with acupuncture can alleviate the muscle spasm of the upper limbs, and improve the motor function of the upper limbs and the activities of daily living after stroke.