经颅直流电刺激前扣带回对卒中后无动性缄默症的疗效观察

Clinical observation of transcranial direct current stimulation over anterior cingulate cortex on post-stroke akinetic mutism

目的观察经颅直流电刺激前扣带回对卒中后无动性缄默症的应用疗效。方法回顾性连续纳入2016年7月至2021年9月在首都医科大学宣武医院康复医学科收治的18例卒中后无动性缄默症患者,均为首次卒中发病。根据治疗方式的不同,将18例卒中后无动性缄默症患者分为观察组和对照组,每组各9例。两组均接受常规康复治疗,包括视、听、触、嗅和味觉的多重感官刺激,同时给予言语训练、关节活动度训练及神经肌肉电刺激;观察组则在常规康复治疗基础上接受经颅直流电刺激治疗,阳极刺激部位为前扣带回,参考电极则置于前后矢状线枕点。两组治疗频次为2次/d,30 min/次,每周连续5 d,治疗总时间为2周。收集并对比分析两组患者的基线资料(年龄、卒中类型、性别、病程)和疗效指标[改良昏迷恢复量表(CRS-R)、行为反应量表评分]。结果(1)两组患者年龄、性别、卒中类型、病程的差异均无统计学意义(均P>0.05)。(2)CRS-R评分显示,观察组治疗前及治疗后分别为(7.89±2.67)、(15.44±3.94)分,对照组治疗前及治疗后分别为(8.11±2.37)、(9.33±2.87)分。两组患者治疗前后CRS-R评分比较,观察组与对照组的组间及时间的交互效应差异有统计学意义(F=80.72,P<0.01)。观察组与对照组的组间主效应差异有统计学意义(F=4.56,P=0.04),治疗前,组间CRS-R评分的差异无统计学意义(P=0.85);治疗后,观察组CRS-R评分较对照组提高,组间差异有统计学意义(P<0.01)。不同时间点的时间主效应差异有统计学意义(F=14.14,P<0.01),两组治疗后的CRS-R评分较治疗前均有提高,差异均有统计学意义(均P<0.05)。(3)行为反应量表总分显示,观察组治疗前及治疗后分别为(6.89±4.26)、(26.22±8.82)分,对照组治疗前及治疗后分别为(7.56±4.61)、(9.44±4.95)分。两组治疗前后行为反应量表总分比较,观察组与对照组的组间及时间交互效应差异有统计学意义(F=91.72,P<0.01)。观察组与对照组的组间主效应差异有统计学意义(F=9.35,P<0.01),治疗前,行为反应量表总分的组间差异无统计学意义(P=0.75);治疗后,观察组行为反应量表总分较对照组提高,组间差异有统计学(P<0.01)。不同时间点的时间主效应差异有统计学意义(F=25.22,P<0.01),两组治疗后的行为反应量表总分较治疗前均提高,治疗前后差异均有统计学意义(均P<0.01)。(4)行为反应量表的行为部分评分显示,观察组治疗前及治疗后分别为(5.31±3.24)、(15.56±5.68)分,对照组治疗前及治疗后分别为(6.12±3.35)、(6.89±3.69)分。两组治疗前后行为反应量表中的行为部分评分比较,观察组与对照组的组间及时间交互效应差异有统计学意义(F=87.33,P<0.01)。观察组与对照组的组间主效应差异有统计学意义(F=4.33,P=0.043),治疗前,行为部分评分的组间差异无统计学意义(P=0.81);治疗后,观察组行为部分评分较对照组提高,组间差异有统计学意义(P<0.01)。不同时间点的时间主效应差异有统计学意义(F=14.73,P<0.01),观察组治疗后行为部分评分较治疗前提高,治疗前后差异有统计学意义(P<0.01);对照组治疗前后行为部分评分的差异无统计学意义(P=0.28)。(5)行为反应量表的交流部分评分显示,观察组治疗前及治疗后分别为(1.33±1.23)、(11.78±3.31)分,对照组治疗前及治疗后分别为(1.11±1.05)、(2.56±2.01)分。两组治疗前后行为反应量表中的交流部分评分比较,观察组与对照组的组间及时间交互效应差异有统计学意义(F=45.00,P<0.01)。观察组与对照组的组间主效应差异有统计学意义(F=16.67,P<0.01),治疗前,交流部分评分的组间差异无统计学意义(P=0.72);治疗后,观察组的交流部分评分较对照组提高,组间差异有统计学意义(P<0.01)。不同时间点的时间主效应差异有统计学意义(F=28.84,P<0.01),观察组治疗后交流部分评分较治疗前提高,治疗前后差异有统计学意义(P<0.01);对照组治疗前后交流部分评分的差异无统计学意义(P=0.20)。结论应用阳极经颅直流电刺激前扣带回可能有助于改善卒中后无动性缄默症患者的功能表现,提高其行为反应和交流能力,对卒中后无动性缄默症的治疗而言,经颅直流电刺激可能具有一定的优势,但本研究结果有待于大样本数据及多中心研究结果进一步证实。

Objective To observe the effect of transcranial direct current stimulation(tDCS)of anterior cingulate cortex on post-stroke akinetic mutism(AM).Methods The study retrospectively included 18 stroke patients who were treated in the Department of Rehabilitation Medicine of Xuanwu Hospital,Capital Medical University from July 2016 to September 2021.All patients had the onset of stroke for the first time.According to treatment methods,they were divided into observation group and control group,with 9 cases in each group.Both groups were received routine rehabilitation,including multi-sensory stimulation of sight,hearing,touch,smell and taste,speech training,range of motion training and neuromuscular electrical stimulation.The observation group were received tDCS on the basis of routine rehabilitation therapy,with the anodic stimulation site was located at the anterior cingulate cortex and the reference electrode was placed at the occipital point of the anterior and posterior sagittal lines.Both groups received routine rehabilitation treatment(2 times/d,30 min/time,5 consecutive days a week for 2 weeks).Baseline data(age,stroke type,gender and course of disease)and outcome measures(modified Coma Recovery Scale[CRS-R]and behavioral response scale scores)in both groups were collected and compared.Results(1)There was no statistically significant difference in age,stroke type,gender and course of disease between the two groups(all P>0.05).(2)The CRS-R scores before and after treatment were(7.89±2.67)and(15.44±3.94)in the observation group and(8.11±2.37)and(9.33±2.87)in the control group,respectively.There were significant differences in the interaction of group and time when comparing the CRS-R scores before and after treatment between the two groups(F=80.72,P<0.01).There was statistically significant difference in the main effect between the observation group and the control group(F=4.56,P=0.04).There was no significant difference between the CRS-R scores between the two groups before treatment(P=0.85);after treatment,the CRS-R scores of the observation group were higher than those of the control group with a significant difference(P<0.01).There were statistically significant differences in the main effect of time at different time points(F=14.14,P<0.01),and the CRS-R scores of both groups were improved after treatment compared with those before treatment with statistically significant differences(all P<0.05).(3)The total scores of behavioral response scale before and after treatment in the observation group were(6.89±4.26)and(26.22±8.82),respectively,while the total scores of behavioral response scale before and after treatment in the control group were(7.56±4.61)and(9.44±4.95),respectively.There were significant differences in the interaction of group and time when comparing the total scores of behavioral response scales before and after treatment between the two groups(F=91.72,P<0.01).There was statistically significant difference in the main effect between the observation group and the control group(F=9.35,P<0.01).There was no significant difference in the total scores of the behavioral response scale between the two groups before treatment(P=0.75);after treatment,the total scores of the behavioral response scale in the observation group were higher than those in the control group,and there was a significant difference between the groups(P<0.01).There were statistically significant differences in the main effect of time at different time points(F=25.22,P<0.01).The total scores of behavioral response scale in both groups were significantly improved after treatment compared with those before treatment(both P<0.01).(4)The behavioral component scores before and after treatment were(5.31±3.24)and(15.56±5.68)in the observation group and(6.12±3.35)and(6.89±3.69)in the control group,respectively.There were significant differences in the interaction of group and time in the behavioral component scores of the behavioral response scale before and after treatment between the two groups(F=87.33,P<0.01).The main effect between the observation group and the control group was statistically significant(F=4.33,P=0.043).There was no significant difference in the behavioral component scores of the two groups before treatment(P=0.81);after treatment,the behavioral component scores of the observation group were higher than those of the control group,and there was a significant difference between the groups(P<0.01).The time main effect at different time points had statistical significance(F=14.73,P<0.01).The behavioral part scores of the intervention group improved after treatment compared with those before treatment,and the difference was significant(P<0.01);there was no significant difference between the pre-and post-treatment behavioral component scores in the control group(P=0.28).(5)The pre-treatment and post-treatment communication section scores were(1.33±1.23)and(11.78±3.31)in the observation group,respectively,and the pre-treatment and post-treatment communication section scores were(1.11±1.05)and(2.56±2.01)in the control group,respectively.There were significant differences in the group and time interactions of the scores of the communication part of the behavioral response scale before and after treatment in the two groups(F=45.00,P<0.01).The main effect between the observation group and the control group was statistically significant(F=16.67,P<0.01).There was no significant difference between the communication part scores of the two groups before treatment(P=0.72);after treatment,the communication part scores of the observation group were higher than those of the control group with a significant difference(P<0.01).The main effect of time at different time points had statistical significance(F=28.84,P<0.01).After treatment,the communication part score of the observation group improved compared with that before treatment,with a significant difference(P<0.01);there was no significant difference between the pre-and post-treatment communication part score of the control group(P=0.20).Conclusions The tDCS of anterior cingulate cortex can improve the functional performance,behavior and communication ability of patients with post-stroke AM.The results of this study need to be further confirmed by multiple-center studies with large sample size.