非侵入性脑刺激技术可有效缓解卒中后疲劳症状:一项Meta分析

Non-invasive Brain Stimulation Techniques Can Effectively Relieve Post-stroke Fatigue:a Meta-analysis

背景疲劳是脑卒中患者常见的症状之一,国内外研究显示,疲劳症状严重影响脑卒中患者病情的恢复。非侵入性脑刺激技术可有效促进或抑制大脑皮质的兴奋性,加速神经可塑性,但其治疗疲劳症状的有效性和安全性并不明确。目的系统评价非侵入性脑刺激技术对卒中后疲劳患者的影响。方法检索PubMed、Web of Science、Embase、Cochrane Library、中国生物医学文献数据库(CBM)、中国知网、维普网和万方数据知识服务平台关于非侵入性脑刺激技术治疗卒中后疲劳患者的随机对照试验,试验组为经颅直流电刺激(tDCS)或重复经颅磁刺激(rTMS)治疗,对照组为常规康复训练,结局指标为疲劳严重程度量表(FSS)和简化运动功能量表(FMA)评分,检索时限为建库至2022年4月。由2名研究人员进行文献筛选、资料提取以及质量评价,采用RevMan 5.3软件进行Meta分析。采用GRADE证据分级系统对结局指标进行证据质量评价。结果共纳入5篇文献,331例研究对象,3篇为r TMS,2篇为tDCS。5篇文献质量均为B级。Meta分析结果显示,试验组FSS评分均低于对照组[SMD=-2.13,95%CI(-3.63,-0.63),P=0.005],FMA评分高于对照组[SMD=6.60,95%CI(4.33,8.87),P<0.00001]。敏感性分析结果显示结果稳健,Egger’s检验(t=-0.88,P=0.445)提示发表偏倚可能性较小。本研究共3个主要结局,分别为4周与8周的非侵入性脑刺激技术对卒中后疲劳患者FSS评分的影响和非侵入性脑刺激技术对卒中后疲劳患者FMA评分的影响,每个结局的GRADE系统推荐分级均为低级。结论非侵入性脑刺激技术对缓解卒中后疲劳患者疲劳症状疗效显著,同时可以促进患者运动能力的恢复。但结局指标依据GRADE系统推荐分级均为低级,样本量较少,未来还需开展高质量、大样本、多中心的随机对照试验进行验证。

Background Fatigue is one common symptom in stroke patients,which has been validated by studies to be negatively associated with the recovery of these patients.Non-invasive brain stimulation techniques can effectively promote or inhibit the excitability of cerebral cortex and accelerate neuroplasticity,but the efficacy and safety of the treatment for post-stroke fatigue are not clear.Objective To systematically evaluate the effects of non-invasive brain stimulation on post-stroke fatigue.Methods We searched randomized controlled trials(RCTs)of the efficacy of non-invasive brain stimulation techniques[transcranial direct current stimulation(tDCS)or repetitive transcranial magnetic stimulation(rTMS)](experimental group)compared with that of regular rehabilitation training(control group)in post-stroke fatigue in PubMed,Web of Science,Embase and the Cochrane Library,CBM,CNKI,VIP,Wanfang Data and other databases from database inception to April 2022.The reported outcomes were assessed using the Fatigue Severity Scale(FSS)and Fugl-Meyer Assessment(FMA)scale.Two researchers conducted literature screening,data extraction and quality evaluation.RevMan 5.3 was used for metaanalysis.GRADE was used to evaluate the quality of the evidence for reported outcomes.Results A total of five RCTs with 331subjects were included,among which three studied the efficacy of rTMS,and the other two studied the efficacy of tDCS.The methodological quality of all RCTs was categorized as grade B.Meta-analysis showed that the experimental group had lower mean FSS scores than the control group[SMD=-2.13,95%CI(-3.63,-0.63),P=0.005],and had higher FMA scores than the control group[SMD=6.60,95%CI(4.33,8.87),P<0.00001].Sensitivity analysis showed that the results were robust.Egger’s test suggested that there was little potential publication bias in this meta-analysis(t=-0.88,P=0.445).The quality of reported evidence regarding three primary outcomes,namely,FSS scores after a 4-week and 8-week non-invasive brain stimulation,and FMA score after non-invasive brain stimulation,was rated as"low"by the GRADE system.Conclusion Non-invasive brain stimulation techniques have been proven by included RCTs to be effective in relieving fatigue symptoms,and promoting the recovery of motor functions in patients with post-stroke fatigue.However,due to small sample size and low quality of the evidence about reported outcomes after treatment,the conclusion needs to be further verified by high-quality,largesample and multicenter RCTs.