经颅直流电刺激协同下肢康复治疗在脑卒中偏瘫下肢康复中的应用进展

Application Progress of Transcranial Direct Current Stimulation Combined with Limb Therapy in Rehabilitation of Lower Limbs after Stroke

下肢运动功能障碍是脑卒中患者最常见和最迫切需要解决的问题之一,即使早期、规范介入康复治疗,仍有许多患者在发病6个月后还不能恢复行走功能或遗留严重异常步态,对患者的日常活动和自理能力造成巨大影响,给社会和家庭带来沉重经济负担。下肢运动功能障碍的康复治疗技术包括神经调控、头针等以大脑为靶点的中枢干预技术,以及协同功能性电刺激(FES)、机器人辅助步态训练(RAGT)等以肢体为靶点的外周干预技术。虽然中枢干预与外周干预刺激靶点不同,但是治疗目的一致。为了提高治疗效果,有研究发现将有效的中枢干预技术与外周干预技术联合应用比单一中枢或外周治疗的效果更好。国内学者将这种模式称为"脑-肢协同调控治疗技术",该技术根据协同部位不同可分为脑-上肢协同治疗模式和脑-下肢协同治疗模式;根据协同顺序的不同,又可分为脑-肢体同步治疗模式和脑-肢体非同步治疗模式,其中非同步治疗模式又可分为先大脑刺激后肢体刺激模式和先肢体刺激后大脑刺激模式。目前,脑-肢协同调控治疗技术在临床中被普遍应用和研究。由于经颅直流电刺激(tDCS)治疗安全性高、设备携带方便、后延效应时间长等优势,被广泛与下肢康复治疗技术协同应用。但由于参与协同的下肢康复技术种类不同以及协同治疗顺序的不一致,tDCS协同下肢康复治疗的效果存在较大差异。本文就国内外近年来不同治疗参数的经颅直流电刺激协同不同的下肢康复治疗技术及不同脑-肢体协同治疗顺序,在脑卒中偏瘫下肢康复中的应用模式作一综述,并探讨影响协同治疗效果的因素及可能有效的协同治疗模式,旨在为脑卒中后下肢功能障碍的研究和治疗提供新思路。

Motor dysfunction of lower extremities is one of the most common and urgent problems to be solved in patients with stroke.Even if early and standardized rehabilitation therapy,there are still many patients who cannot restore their walking function or have serious abnormal gait after 6 months of onset.It has a great impact on their daily activities and self-care ability,and brings a heavy economic burden to the society and family financial situation.Rehabilitation interventions for motor dysfunction of lower extremities include central intervention techniques and peripheral intervention techniques.Central intervention technology stimulates the brain,such as neuroregulation and scalp acupuncture,while peripheral intervention technology stimulates limbs,such as functional electrical stimulation(FES)and robot-assisted gait training(RAGT).Although the two technologies have different stimulation targets,the same purpose,previous studies found that the treatment effect was better when combined application of effective central intervention technology with peripheral intervention technology.It is called"brain-limb coordinated regulation therapy technology",which can be divided into brain-upper-limb coordinated therapy mode and brain-lower-limb coordinated therapy mode according to different coordinated parts.The technology can be divided into synchronous brain-limb coordination therapy mode and asynchronous brain-limb coordination therapy mode according to the different coordination sequence.The asynchronous mode can be further divided into the mode of stimulating the brain first and then the limbs,and the mode of stimulating the limbs first and then the brain.At present,this technique is widely used in clinical research.Transcranial direct current stimulation(tDCS)is widely used in combination with lower limb rehabilitation therapy because of its advantages such as high safety,easy to carry equipment and long delayed effect time.However,the therapeutic effect of this kind of synergistic therapy is quite different,due to the different lower limb rehabilitation techniques and different sequence involved in the synergistic therapy.This article reviews the application progress of tDCS with different treatment parameters combined with different lower limb rehabilitation techniques and different cooperative treatment sequence in stroke,and discusses the factors which affect the effect of cooperative treatment and the possible effective cooperative treatment mode,in order to provide new ideas for the treatment of lower limb dysfunction after stroke.