经颅磁刺激在脑卒中后痉挛中的临床应用进展

Clinical application progress of transcranial magnetic stimulation in spasticity after stroke

脑卒中后痉挛(post-stroke spasticity,PSS)是卒中后常见的运动障碍表现形式之一,发生率高。主要表现为上肢屈肌群及下肢伸肌群肌张力增强。痉挛很大程度上影响日常生活能力,降低生活质量,故PSS的治疗尤为重要。PSS的治疗包括药物治疗、手法牵伸、神经阻滞疗法等,治疗方法均有其各自的优缺点,目前没有统一最优方案,以综合治疗为主。经颅磁刺激(TMS)治疗是一种非侵入性磁刺激技术,通过电磁感应原理,改变大脑皮层兴奋性,目前已广泛应用于神经系统疾病当中。经颅磁刺激治疗痉挛按治疗部位不同可分为应用于中枢及应用于外周。应用于中枢时,根据治疗模式的不同又分为低频重复经颅磁刺激(rTMS)、高频rTMS以及模式化TMS。研究大多采用1 Hz-rTMS作用于受累侧大脑半球,少量研究应用间歇性爆发性θ波刺激(iTBS)作用于受累侧大脑半球、10 Hz-rTMS作用于受累侧大脑半球。高频rTMS或iTBS作用于受累侧大脑半球,提高皮层兴奋性,加强上位中枢对脊髓运动神经元的控制,降低运动神经元的兴奋性和肌梭敏感性,改善痉挛症状。而低频rTMS作用于非受累侧大脑半球,降低非受累侧半球的兴奋性,减少非受累侧皮层对受累侧皮层的抑制作用,恢复双侧半球间的平衡,间接加强受累侧半球对脊髓运动神经元的控制。应用于外周目前的研究基本采用高频rTMS治疗。本综述旨在阐述经颅磁刺激在治疗脑卒中后痉挛方面的临床应用进展。

Post-stroke spasticity(PSS)is one of the common manifestations of dyspraxia after stroke,with a high incidence.The main clinical manifestation is the enhancement of the muscle tension of the flexor group of the upper limb and the extensor group of the lower limb.The treatment of PSS includes drug therapy,manual stretching,nerve block therapy,etc.The treatment methods have their own advantages and disadvantages.Currently,there is no unified treatment for PSS,which is mainly based on comprehensive treatment.Transcranial magnetic therapy(TMS)is a non-invasive magnetic stimulation technique based on electromagnetic induction which change the cortical excitability.It has been widely used in nervous system diseases.TMS can be applied to the central nervous system and the peripheral nervous system.When applied to the central nervous system,treatment modes include low-frequency rTMS,high-frequency rTMS,and patterned TMS.In most studies,1 Hz-rTMS was applied to the non-affected cerebral hemisphere.In a few studies,iTBS was applied to the affected cerebral hemisphere,and 10 Hz-rTMS was applied to the affected cerebral hemisphere.The application of high frequency rTMS and iTBS in the affected cerebral hemisphere can improve the cortical excitability,strengthen the control of the upper center on the spinal motor neurons,reduce the excitability and muscle spindle sensitivity of the motor neurons,and improve the symptoms of spasticity.Low-frequency rTMS are applied to the non-affected cerebral hemisphere to reduce the excitability of the non-affected cerebral hemisphere,reduce the inhibitory effect of the non-affected cerebral cortex on the affected cerebral cortex,restore the balance between the two hemispheres,and indirectly strengthen the control of the affected cerebral hemisphere on the spinal motor neurons.The current research applied to the periphery basically uses high-frequency rTMS treatment.The purpose of this review is to describe the clinical application progress of TMS in the treatment of spasticity after stroke.