To examine the effects and interaction of contralesional plantar peripheral electrical stimulation (PES) and posterior parietal cortex transcranial magnetic stimulation (PPC-TMS) on lower-limb motor function, balance, activities of daily living, and gait variables in patients with subacute post-stroke hemiparesis. This study used a prospective, randomized, double-blind 2 × 2 factorial trial design. A total of 151 patients with post-stroke hemiparesis (2 weeks to 6 months after onset) were enrolled and randomly assigned (1:1:1:1) to a double-sham control group, real PES group, real PPC-TMS group, or combined intervention group. All groups received the assigned intervention in addition to conventional rehabilitation: real PES was delivered to the plantar surface of the contralesional, non-paretic foot (i.e., the foot opposite to the paretic lower limb); real PPC-TMS targeted the contralesional posterior parietal cortex using an intermittent theta-burst stimulation (iTBS) protocol, 5 sessions/week for 4 weeks. The primary outcome was the post-intervention Fugl–Meyer Assessment for the Lower Extremity (FMA-LE) score (analyzed using a 2 × 2 factorial model with baseline FMA-LE as a covariate). Secondary outcomes included the Postural Assessment Scale for Stroke Patients (PASS), Berg Balance Scale (BBS), lower-limb–related Modified Barthel Index (MBI), and three-dimensional gait parameters. Baseline characteristics were comparable among the four groups. After the intervention, FMA-LE scores were 19.40 ± 3.21, 21.00 ± 3.10, 21.12 ± 3.16, and 25.60 ± 2.80, respectively. Compared with the control group, the real PES group, real PPC-TMS group, and combined group showed higher post-intervention FMA-LE scores by 1.60, 1.70, and 6.20 points, respectively (all P < 0.05). In the baseline-adjusted factorial model, the PES×PPC-TMS interaction was significant (P = 0.004). Regarding secondary outcomes, PASS, BBS, and lower-limb MBI improved versus control, with the combined group demonstrating the greatest overall gains. Three-dimensional gait analysis showed improvements in parameters including hip flexion, knee flexion, pelvic angles, and ankle joint angles, with evidence of interaction effects. Contralesional plantar PES combined with contralesional PPC-TMS significantly enhances lower-limb motor recovery of the affected side in patients with subacute post-stroke hemiparesis. The combined intervention exhibits synergistic benefits, providing preliminary clinical evidence supporting a “contralesional dual-pathway” stimulation strategy.

功能性近红外光谱技术(functional near-infrared spec-troscopy,fNIRS)是一种光学、无创的血流动力学神经成像技术,它可以通过将近红外光(650-950nm)照射入头部,测量出脑组织内氧合血红蛋白(oxygenated hemoglobin,HbO2)和脱氧血红蛋白(deoxyhemoglobin,Hb)的浓度变化,进而间接地测量出脑区兴奋性[1].fNIRS具有抗身体运动干扰能力强、便携不受环境限制等特点,因此研究者可以较容易地调整实验控制条件,以选择性观察大脑皮质区的兴奋情况.目前,fNIRS已经被证明是一种可靠的神经科学研究手段,国外大多数fNIRS研究都集中在认知心理行为、语言处理功能、脑功能重塑与运动学习等领域2-4].国内已有学者报道了fNIRS在社会认知神经科学以及语言言语科学中的应用[5-6]但尚缺少fNIRS应用于皮质感觉运动区的介绍.因此本文旨在对国内外针对感觉运动区皮质的近红外线成像研究进行梳理,为临床和科研中fNIRS的应用提供依据.

经颅磁刺激(TMS)是一种通过高强度脉冲磁场对中枢神经系统产生作用的治疗方法,可调节脑内代谢和神经电生理活动,从而在脑卒中运动、感觉和情绪等方面的功能障碍起调节作用.近年来国内外医疗研究机构采用TMS联合康复训练的方法对脑卒中患者进行治疗,积累了一定经验.检索2005-2020年万方、中国知网(CNKI)及PubMed数据库,以TMS、康复训练、脑卒中和运动功能为关键词,排除混有其他治疗方式、脑外伤及其他并发症的患者治疗研究,共检索到100篇文献(中文33篇,外文67篇).结果表明,TMS可通过高强度脉冲磁场对大脑中枢神经系统产生作用,调节脑内代谢和神经电生理活动;根据电磁感应原理,电流产生的磁场通过线圈作用于脑部运动皮质区,刺激大脑皮层使其兴奋,达到改善运动功能的效果;TMS可结合镜像疗法、虚拟现实疗法和康复机器人改善脑卒中患者的运动功能,有助于早期预测与评估脑卒中患者运动恢复情况,增强康复训练效果.

目的 比较两种主动直腿抬高(ASLR)动作的募集程度,并探讨相关肌群的募集模式.方法 2018年6月至10月,选取11例健康受试者,记录动作A(连贯动作)和动作B(滞空10 s)单侧股直肌以及双侧腹直肌、腹外斜肌、腹内斜肌的表面肌电(sEMG)信号,并分析这些肌肉最大自主等长收缩(MVIC)时的募集程度(％MVIC).结果 在动作A中,同侧腹内斜肌和腹外斜肌募集程度大于对侧(t>2.549,P<0.05);在动作B中,同侧的腹内斜肌、腹外斜肌和腹直肌募集程度大于对侧(t>2.240,P<0.05);动作A时,双侧腹内斜肌和股直肌募集率更多(t>3.549,P<0.05).结论 两种ASLR动作都表现为同侧优势激活模式;在不同ASLR动作中,神经肌肉系统采取不同的运动控制策略.

目的 探讨主动直腿抬高(ASLR)动作相关核心肌群的募集模式.方法 12例健康在校大学生进行ASLR动作时,用表面肌电分析系统采集同侧股直肌以及双侧腹直肌、腹外斜肌、腹内斜肌、多裂肌的肌电信号,分析这些肌肉的最大自主等长收缩募集率(％MVIC).结果 在ASLR动作中,双侧腹直肌、多裂肌％MVIC比较无统计学差异(P>0.05),同侧腹内斜肌和腹外斜肌的％MVIC大于对侧[(4.50±2.24)％vs.(3.41±1.81)％ 和(3.98±2.64)％vs.(2.55±1.52)％](P<0.05).结论 正常人做ASLR动作时,同侧腹内斜肌和腹外斜肌表现为同侧优势模式,帮助建立骨盆稳定性,保证ASLR动作质量.

BACKGROUND:Contralaterally controlled functional electrical stimulation (CCFES) is an innovative method to improve upper extremity functions after stroke.OBJECTIVE:To compare the effects of CCFES versus neuromuscular electrical stimulation (NMES) on the upper extremity functions in patients with stroke.METHODS:Sixty patients with stroke were randomly assigned into CCFES group (n=30) or NMES group (n=30). All patients were also treated with conventional medical treatment and rehabilitation training. Patients in CCFES group received CCFES to the affected wrist extensors while the NMES group received NMES. The stimulus current was biphasic wave with a pulse duration of 200 μs and a frequency of 60 Hz. The electrical stimulation lasted for 20 min per session, 5 sessions per week for 3 weeks. The intensity of the CCFES was based on the electromyography (EMG) value of the unaffected side while the subjects voluntarily extended their unaffected wrist slightly (<10% range of motion, ROM), moderately (about 50% ROM) and completely (100% ROM). Fugl-Meyer assessment (FMA), motricity index (MI), the Hong Kong version of functional test for the hemiplegic upper extremity (FTHUE-HK) and active range of motion (AROM) of wrist extension were measured before and after 3 weeks of treatment.RESULTS:Compared with the baseline values, both groups showed significant improvements in all the measurements after treatment (p<0.05). Patients in CCFES group showed significantly higher upper extremity FMA, FTHUE-HK scores and AROM of wrist extension than those in NMES group (p<0.05).CONCLUSION:Compared with the conventional NMES, CCFES provides better recovery of upper extremity function in patients with stroke.

Objective To evaluate the effect of lumbar multifidus muscle training on muscle thickness.Methods The morphological changes in volunteers' lumbar multifidus muscles were observed in response to 11 kinds of training.Muscle thickness was measured at rest and during contraction using ultrasonography and two examiners.The rate of change in muscle thickness and the contraction rate were calculated.Results There was no significant difference in the contraction rates determined by the two examiners using ultrasound imaging.There was no significant difference in average contraction rate between the males and females.Pairwise,there was no significant difference among contralateral leg-raising,ipsilateral leg-raising,contralateral hand-raising,ipsilateral hand-raising and contralateral leg-lifting.Pairwise,there was no significant difference among ipsilateral leg-lifting and ipsilateral arm-lifting compared with contralateral leg-lifting,contralateral arm-lifting or contralaleral lower limb-lifting.There was no significant difference between contralateral arm-lifting and ipsilateral arm-lifting.There was no significant difference between ipsilateral arm-lifting with contralateral leg-lifting and contralateral arm-lifting with ipsilateral leg-lifting.Pairwise,there was a significant difference in lumbar multifidus muscle contraction rates among these actions.Conclusion Lumbar multifidus muscle training has various effects.Muscle thickness as measured using ultrasonography can provide a basis for formulating a rehabilitation training plan.

OBJECTIVE:To compare the effect of visual spatial training on the spatial attention to that on motor control and to correlate the improvement of spatial attention to motor control progress after visual spatial training in subjects with unilateral spatial neglect (USN).METHOD:9 cases with USN after right cerebral stroke were randomly divided into Conventional treatment group + visual spatial attention and Conventional treatment group. The Conventional treatment group + visual spatial attention received conventional rehabilitation therapy (physical and occupational therapy) and visual spatial attention training (optokinetic stimulation and right half-field eye patching). The Conventional treatment group was only treated with conventional rehabilitation training (physical and occupational therapy). All patients were assessed by behavioral inattention test (BIT), Fugl-Meyer Assessment of motor function (FMA), equilibrium coordination test (ECT) and non-equilibrium coordination test (NCT) before and after 4 weeks treatment.RESULT:Total scores in both groups (without visual spatial attention/with visual spatial attention) improved significantly (BIT: P=0.021/P=0.000, d=1.667/d=2.116, power=0.69/power=0.98, 95%CI[-0.8839,45.88]/95%CI=[16.96,92.64]; FMA: P=0.002/P=0.000, d=2.521/d=2.700, power=0.93/power=0.98, 95%CI[5.707,30.79]/95%CI=[16.06,53.94]; ECT: P=0.002/ P=0.000, d=2.031/d=1.354, power=0.90/power=0.17, 95%CI[3.380,42.61]/95%CI=[-1.478,39.08]; NCT: P=0.013/P=0.000, d=1.124/d=1.822, power=0.41/power=0.56, 95%CI[-7.980,37.48]/95%CI=[4.798,43.60],) after treatment. Among the 2 groups, the group with visual spatial attention significantly improved in BIT (P=0.003, d=3.103, power=1, 95%CI[15.68,48.92]), FMA of upper extremity (P=0.006, d=2.771, power=1, 95%CI[5.061,20.14]) and NCT (P=0.010, d=2.214, power=0.81-0.90, 95%CI[3.018,15.88]). Correlative analysis shows that the change of BIT scores is positively correlated to the change of FMA total score (r=0.77, P<;0.01), FMA of upper extremity (r=0.81, P<0.01), NCT (r=0.78, P<0.01).CONCLUSION:Four weeks visual spatial training could improve spatial attention as well as motor control functions in hemineglect patients. The improvement of motor function is positively correlated to the progresses of visual spatial functions after visual spatial attention training.

目的:从减轻脱位程度的角度观察两种贴扎方法对脑卒中患者肩关节半脱位的治疗效果.方法:选择10例具有肩关节半脱位的脑卒中患者,分别进行两种贴扎方法(方法一:肩部贴扎法；方法二:肩肘贴扎法)治疗,随即采用第二肩关节间隙X线测量法进行评估.结果:患者经过贴扎术治疗后,方法一无明显改善(P＞0.05)；方法二患者肩关节间隙显著缩小(P＜0.05),治疗前后关节间隙差值为7.80±2.97mm,两种方法治疗前后关节间隙差值有显著性差异(P＜0.05).结论:肩肘贴扎法对脑卒中患者的肩关节半脱位具有良好的即时疗效,可为早期的脑卒中患者纠正肩关节半脱位提供一种新的治疗方法.

Objective: To observe the performance of different sensory modalities and spatial frames of reference in a patient with massive right cerebral infarction and the effects after the behavioral treatment and transcranial magnetic stimulation (TMS). Methods: The line cancellation, letter cancellation, star cancellation and line bisection test in the Behavioral Inattention Test (BIT), as well as the copying test of left-right parallel graphics were used. The unilateral spatial neglect examination was also conducted for the auditory modality (both ears hearing the twist with fingers) and tactile modality (left and right hand fingers being touched) at the same time. Conventional behavior and low-frequency TMS stimulating left posterior parietal lobe were used for the treatment of unilateral spatial neglect for two weeks. Results: Circled digit oneThe patients line cancellation, letter cancellation and star cancellation tests before treatment all showed that the numbers of completing cancellation in the left space were lower than those in the right space. There was significant difference (P < 0.01). The line bisection test also showed that the marked midpoint obviously turned to the right. Circled digit twoThe graphic copy showed that the patient not only neglected the stimulation (objects) in the left space, but also neglected left half of the stimulation (objects) in the right space. Circled digit threeThe auditory and tactile modality tests also showed that detection capabilities of the auditory and tactile stimulation in the left space were significantly lower than those in the right space. There was significant difference (P < 0.01). Circled digit fourThe cancellation test and graphic copy of the patient were improved after two-week treatment, (P < 0.05, P < 0.01). Conclusion: The large cerebral infarction of right hemispher may result in unilateral spatial neglect in different sensory modalities and spatial frames of reference. Two weeks of behavioral and low-frequency TMS therapy are effective for improving the unilateral spatial neglect symptom.

Objective:To study the effects of functional electrical stimulation(FES) combined with rehabilitation therapy on function and activities of stroke patients.Methods:Thirty stroke patients were divided into FES group and control group(n=15 each).Both groups took the same regular rehabilitation training.FES group received FES and walking training with gait appliance additionally.Before and after 4 weeks,strength of ankle dorsiflexion muscle,timed up-and-go test(TUG),10-m walking test,and Barthel index were assessed.Results:After 4 weeks of training,the strength of ankle dorsiflexion muscle,10-m walking speed and Barthel index scores in both two groups were increased as compared with those pretreatment,more significantly in FES group than in control group(P0.01,0.05).TUG time in both two groups was shortened as compared with pretreatment,more significantly in FES group than in control group(P0.01,0.05).Conclusion:FES combined with rehabilitation therapy can improve strength of ankle dorsiflexion muscle,lower limb functions,and ability of activities of daily living.

Objective To evaluate the reliability of measuring multidus muscles with ultrasonography in different postures in rehabilitative ultrasound imaging.Methods The thickness of bilateral lumbar multifidus muscles was measured using ultrasonography by two examiners in 20 healthy volunteers at rest and 5 contraction states.The thinckness variation of multifidus muscles was compared.Results The results measured by two examiners were similar with high reliability(P>0.05).Among 6 postures,the thinckness variation was the greatest in "superman" posture [(25.75±7.46)%] and was the least in the posture of liftting the limbs up on the same side(P<0.05).Conclusion Ultrasonography shows good reliability in measuring the multifidus muscles.

Objective:To investigate the interventional effect of distraction and slide stretching with the traditional method on the patients with dysfunction of elbow joint as combination of physical modalities,physical therapy and massage is a conventional method for the treatment of elbow joint dysfunction.Methods:One hundred and ten patients with elbow joint dysfunction hospitalized in the department of rehabilitation medicine,the First Affiliated Hospital of Nanjing Medical University from January 2009 to December 2011 were randomly divided into the sliding traction group(n=55) and control group(n=55).Patients received one hour therapy including physical modalities,physical therapy and massage one after another everyday as one session.Patients in the distraction and slide stretching group received the same therapy as in the control group,adding elbow joint distraction and slide stretching in each session.included:① slide stretching of humeroulnar articulation,②slide stretching of humeroradial articulation,③ distraction of humeroulnar articulation ④slide stretching of radioulnar articulation.In both groups,ten treatment sessions added up to one course,and all the patients were treated for four courses.ROM and Barthel index of the elbow joint were evaluated before and after treatment.Results:All patients were involved in the result analysis.①after 4-courses treatment,scores on ROM and Barthel index of the elbow joint were improved obviously in the two groups(P0.05).② The scores on ROM and Barthel index of the elbow joint were significantly higher in the distraction and slide stretching group than in the control group(P0.05).Conclusion:The elbow jiont distraction and slide stretching can improve the motor function of elbow joint,and thus can improve the range of motion of elbow joint.

Objective To investigate the effects of slide stretching on rehabilitation of knee joint after trauma.Methods Seventy patients with knee joint dysfunction after trauma were equally randomized into two groups.The patients in group C received conventional therapy including physical modalities,physical therapy and massage(once a day,10 days a cycle for 4 cycles) and those in group A were treated with additional patellofemoral joints slide stretching for 20 min ones in every 10 days.The range of motion(ROM) of the knee joint was measured.The function of the knee joint was evaluated with HSSscore before and after treatment.Results After treated for 4-cycles,ROM and HSS scores were increased(P0.05).The scores of ROM and HSS of traumatic knee joints were significantly higher in group A than those in group C(115.2±14.7) degrees vs.(90.3±12.6) degrees and(83.7±14.4) points vs.(60.8±11.6) points(P0.05).Conclusion Additional use of patellofemoral joints slide stretching can effectively promote the rehabilitation of knee joint after trauma.

目的观察改良膝关节松动术治疗创伤后膝关节功能障碍的疗效。方法选取膝关节创伤后功能障碍患者90例,分成对照组和松动组,每组患者45例。对照组行中药熏蒸、运动疗法及中医推拿综合治疗。松动组在对照组治疗方法的基础上增加改良的膝关节松动术。2组患者均于治疗前及治疗6个疗程后采用膝关节评定量表进行评定,量表主要包括评定膝关节功能的膝评定量表、评定患者步行和上下楼能力的功能量表,基本分都是100分,每部分都设定有减分的评定参数。结果治疗6个疗程后,2组患者膝关节功能及步行、上、下楼评分与治疗前比较,差异均有统计学意义(P<0.05);松动组与对照组治疗6个疗程后的膝关节功能及步行上、下楼评分相比较,差异亦有统计学意义(P<0.05)。结论改良膝关节松动术能有效地改善关节活动范围和膝关节运动功能。

脑卒中患者的行走训练往往需先进行长时间的直立训练和下肢肌力训练,再进行独立站立和平衡训练,完成上述训练后方可进行行走训练,而且一般需要2-3人搀扶.这样的训练耗时长,效率低,加重治疗师工作负担.

目的:观察综合手法治疗对肩关节功能障碍的疗效.方法:肩关节创伤后功能障碍患者90例,随机分为2组各45例,均行物理因子治疗及运动疗法,观察组在此基础上增加推拿及肩关节松动技术.结果:治疗2个月后,2组肩关节活动度(ROM)值均较治疗前明显提高(P<0.01);2组间比较,观察组提高更显著(P<0.01).结论:配合推拿及肩关节松动术对肩关节功能障碍的康复有显著促进效益.

目的:观察关节持续被动活动(CPM)治疗骨折后肘关节功能障碍的效果。方法:63例骨折后肘关节功能障碍患者分为CPM组33例和对照组30例,均采用常规康复治疗。CPM组加用CPM。结果:治疗2个月后,CPM组患者肘关节活动范围及有效率均明显优于对照组(P<0.05)。结论:CPM能显著提高骨折后肘关节功能障碍的疗效。

Objective:To investigate the effects of reinforced STS training on the function of the paretic lower limb and ADL in patients with hemiplegia after stroke.Methods:Forty hemiplegia patients were randomly divided into the reinforced STS training group and the control group.All patients were regularly treated with physical training.The patients in the reinforced STS training group were administered with sit-to-stand function training in addition to the above interventions.The evaluation was done pre-treatment and 1,3 and 6 months post-treatment.The Fugl-Meyer assessment (FMA) and the Modified Barthel Index (MBI) were used to assess the function of the paretic lower limb and ADL.Results:FMA-L and MBI of both groups were extremely increased (P0.01) after the treatment.At 1st and 3rd month after stroke,the lower limb motor function in the reinforced STS training group was significantly improved as compared with that in the control group (P0.05).At 3rd month after stroke,the ADL in the reinforced group was significantly improved as compared with that in the control group (P0.05).Conclusion:The reinforced STS training can significantly improve the motor function of the paretic lower limb and ADL of stroke patients.

1 病例资料 病史:患者男性,60岁,因"双下肢麻木、疼痛、活动不利3月余"于2004年7月8日人院.患者2003年9月份体检时发现"糖尿病",住院治疗后发现血白细胞总数升高,经进一步检查确诊为"急性淋巴细胞性白血病",住血液科行定期化疗,至今已6个疗程.