经颅直流电刺激联合虚拟现实康复机器人对脑梗死后上肢功能影响的临床研究

A clinical research of transcranial direct current stimulation combined with virtual reality on upper limb function in patients with ischemic stroke

目的探讨经颅直流电刺激(tDCS)联合虚拟现实上肢康复机器人技术对脑梗死后上肢运动功能恢复的作用。方法前瞻性连续纳入2021年6月至2022年6月在常州市德安医院康复中心的脑梗死住院患者44例,按区块随机法随机分为试验组和对照组,根据纳入与排除标准,两组各排除2例,最终每组纳入20例。两组患者均接受基础药物治疗和常规康复治疗,在此基础上试验组采用tDCS联合虚拟现实上肢康复机器人技术同步干预,对照组则采用tDCS伪刺激联合虚拟现实上肢康复机器人技术同步干预,两组同步干预频次为1次/d,20 min/次,5 d/周,持续3周。分别于治疗前和治疗3周后采用Fugl-Meyer上肢运动功能量表(FMA-UL)、手臂动作调查测试(ARAT)评定偏瘫侧上肢功能,并采用改良Barthel指数(MBI)评定日常生活活动能力(ADL)。结果(1)两组患者性别、年龄、病程及偏瘫侧的差异均无统计学意义(均P>0.05)。(2)治疗前,试验组和对照组FMA-UL评分分别为(32±15)、(33±17)分;治疗3周后,试验组和对照组FMA-UL评分分别为(48±15)、(38±18)分。治疗前后两组FMA-UL评分比较,组别及时间交互效应差异具有统计学意义(F=22.24,P<0.01),时间主效应差异具有统计学意义(P<0.01),组别主效应差异无统计学意义(P>0.05)。两组患者治疗前,组间FMA-UL评分的差异无统计学意义(P>0.05);治疗3周后,两组FMA-UL评分均优于本组治疗前,且差异均具有统计学意义(均P<0.01)。(3)治疗前,试验组和对照组ARAT评分分别为(3.7±2.2)、(3.8±2.6)分;治疗3周后,试验组和对照组ARAT评分分别为(5.4±2.1)、(4.4±2.6)分。治疗前后两组ARAT评分比较,组别及时间交互效应差异具有统计学意义(F=10.984,P<0.01),时间主效应差异具有统计学意义(P<0.01),组别主效应差异无统计学意义(P>0.05)。两组患者治疗前,组间ARAT评分的差异无统计学意义(P>0.05);治疗3周后,两组ARAT评分均优于本组治疗前,且差异均具有统计学意义(均P<0.01)。(4)治疗前,试验组和对照组MBI评分分别为(72±14)、(69±23)分;治疗3周后,试验组和对照组MBI评分分别为(84±13)、(79±22)分。治疗前后两组MBI评分比较,组别及时间交互效应差异无统计学意义(F=0.56,P>0.05),时间主效应差异有统计学意义(P<0.01),组别主效应差异无统计学意义(P>0.05)。两组患者治疗前,MBI组间差异无统计学意义(P>0.05);治疗3周后,两组MBI评分均优于本组治疗前,且差异均具有统计学意义(均P<0.01)。(5)两组治疗前后FMA-UL、ARAT、MBI评分差值比较,结果显示,试验组治疗前后FMA-UL、ARAT评分的差值优于对照组[FMA-UL评分:15.00(9.00,21.00)分比4.50(1.25,8.00)分,Z=-3.996;ARAT评分:12.00(5.00,23.00)分比4.00(0.50,6.00)分,Z=82.50;均P<0.01];MBI评分治疗前后差值的组间差异无统计学意义(P>0.05)。结论tDCS联合虚拟现实上肢康复机器人技术可提高亚急性期脑梗死患者的偏瘫上肢运动功能的改善程度,但在改善ADL方面未显现出明显的优势。

Objective To investigate the effect of transcranial direct current stimulation(tDCS)combined with virtual reality(VR)-based upper limb rehabilitation robot on the recovery of upper limb motor function after ischemic stroke.Methods A total of 44 inpatients in the Rehabilitation Center of Changzhou Dean Hospital from June 2021 to June 2022 were prospectively enrolled.According to the block random method,they were randomly divided into the experimental group and the control group,with 4 cases falling off during the treatment(2 cases in the experimental group and 2 cases in the control group).There were 20 patients in each group left eventually.All patients in both groups received basic drug therapy and conventional rehabilitation therapy.In addition,the experimental group received synchronous intervention of tDCS combined with VR-based upper limb rehabilitation robot,while the control group received synchronous intervention of sham tDCS combined with VR-based upper limb rehabilitation robot.The frequency of synchronous intervention in two groups was 20 min/d,5 d/week,lasting for 3 weeks.We evaluated the motor function of the paretic upper limb by Fugl-Meyer assessment upper limb scale(FMA-UL),action research arm test(ARAT)and the activities of daily life(ADL)by modified Barthel index(MBI)before and after the intervention respectively.Results(1)There were no significant differences in sex,age,course of disease,and hemiplegic side between the two groups(all P>0.05).(2)Before treatment,FMA-UL scores of the experimental group and the control group were(32±15)and(33±17),respectively.After 3 weeks of treatment,the FMA-UL scores of the experimental group and the control group were(48±15)and(38±18),respectively.Comparing the FMA-UL scores of the two groups before and after treatment,the difference in the interaction effect of group and time was statistically significant(F=22.24,P<0.01).The difference in the main effect of time was statistically significant(P<0.01),and the difference in the main effect of group was not statistically significant(P>0.05).Before treatment,there was no significant difference in FMA-UL scores between the two groups(P>0.05).After 3 weeks of treatment,the FMA-UL scores of the two groups were better than those before treatment in the same group,and the differences were statistically significant(both P<0.01).(3)Before treatment,ARAT scores of the experimental group and the control group were(3.7±2.2)and(3.8±2.6),respectively.After 3 weeks of treatment,ARAT scores of the experimental group and the control group were(5.4±2.1)and(4.4±2.6),respectively.Comparing the ARAT scores of the two groups before and after treatment,the difference in the interaction effect of group and time was statistically significant(F=10.984,P<0.01).The difference in the main effect of time was statistically significant(P<0.01),and the difference in the main effect of group was not statistically significant(P>0.05).Before treatment,there was no significant difference in ARAT scores between the two groups(P>0.05).After 3 weeks of treatment,the ARAT scores of the two groups were better than those before treatment in the same group,and the differences were statistically significant(both P<0.01).(4)Before treatment,the MBI scores of the experimental group and the control group were(72±14)and(69±23)points,respectively.After 3 weeks of treatment,the MBI scores of the experimental group and the control group were(84±13)and(79±22)points,respectively.Comparing the MBI scores of the two groups before and after treatment,there was no significant difference in the interaction effect of group and time(F=0.56,P>0.05).The main effect of time was significant(P<0.01),and the main effect of group was not significant(P>0.05).Before treatment,there was no significant difference between the MBI scores in the two groups(P>0.05).After 3 weeks of treatment,the MBI scores in the two groups were better than those before treatment in the same group,and the differences were statistically significant(both P<0.01).(5)The comparison of the differences in three outcomes before and after treatment between the two groups showed that the differences of FMA-UL and ARAT in the experimental group were significantly better than those in the control group(FMA-UL scores:15.00[9.00,21.00]vs.4.50[1.25,8.00],Z=-3.996;ARAT scores:12.00[5.00,23.00]vs.4.00[0.50,6.00],Z=82.50;both P<0.01).There was no statistically significant difference in difference of MBI scores between the two groups(P>0.05).Conclusions The tDCS combined with VR-based upper limb rehabilitation robot can increase the degree of improvement of hemiplegic upper limb motor function in subacute stroke patients.However,there was no obvious advantage in improving ADL.