目的 研究阳极经颅直流电刺激(atDCS)联合镜像疗法(MT)对脑卒中患者上肢功能恢复的影响.方法 2018年7月至2019年6月,在首都医科大学宣武医院康复医学科康复的脑卒中患者54例,随机数字表法分为A、B、C三组,每组18例.三组均接受神经内科常规药物治疗和康复训练.此外,A组接受MT 60 min;B组先行atDCS 20 min,再予MT 40 min;C组患者先行MT 40 min,再予atDCS 20 min;共4周.训练前后采用Fugl-Meyer评定量表上肢部分(FMA-UE)、上肢动作研究量表(ARAT)、运动功能评定量表(MAS)和改良Barthel指数(MBI)进行评定.结果 时间对FMA-UE评分(F=159.811,P<0.001)、ARAT评分(F=353.227,P<0.001)、MAS评分(F=513.494,P<0.001)和MBI评分(F=85.982,P<0.001)的主效应非常显著,治疗后3组各项评分均改善;组别对FMA-UE评分(F=12.502,P<0.001)、ARAT评分(F=20.095,P<0.001)、MAS评分(F=16.371,P<0.001)和MBI评分(F=11.882,P<0.001)的主效应非常显著;时间与组别对FMA-UE评分(F=37.659,P<0.001)、ARAT评分(F=78.681,P<0.001)、MAS评分(F=97.997,P<0.001)和MBI评分(F=48.015,P<0.001)的交互效应非常显著,B组明显优于A组和C组(P<0.01),A组和C组无显著性差异(P>0.05).结论 先行atDCS干预再予MT,对脑卒中患者上肢功能恢复更为有利.

Objective:To investigate any effect of combining mirror visual feedback (MVF) training with robot-assisted gait training (RGT) in promoting the recovery of lower limb motor function among stroke survivors.Methods:Sixty stroke survivors were randomly divided into a combined treatment group, an RGT group and a control group, each of 20. In addition to traditional rehabilitation, the RGT group received 30min of RGT 5 days a week for 4 weeks, while the combined treatment group underwent 30min of RGT and also 20min of MVF training with the same frequency and duration. Before and after the treatment, the lower extremities motor functioning and walking ability of all of the patients were assessed using the Fugl-Meyer Assessment for the lower extremities (FMA-LE), the Berg Balance Scale (BBS) and Functional Ambulation Categories (FAC).Results:There were no systematic differences in any of the measurements before the treatment. After the 4 weeks, however, the average FMA-LE, BBS and FAC scores of the combined treatment and RGT groups were significantly better than the control group′s averages, and those of the combined treatment group were significantly superior to the RGT group′s. All of the groups had, however, improved significantly compared with before the treatment.Conclusions:Robot-assisted gait training is more effective in enhancing the motor functioning of the lower extremities and walking ability when it is combined with MVF.

康复治疗技术专业学生的临床实习是康复治疗技术理论知识的临床实践过程,是从学生转变为合格康复治疗师的关键阶段,临床带教老师如何提高临床实践带教质量尤为重要.目前,以问题为基础的教学法(problem-based learning,PBL)是一种能够调动学生主动性而且从实际问题出发的教学理念,循证医学(evidence-based medicine,EBM)是科研实践和医学教学的基本方法,出发点是解决临床问题,强调临床研究证据,获取和分析信息,准确评估及使用基于循证的证据,增强临床治疗能力,反映出诊断和治疗模式的新变化.PBL和EBM的结合已被国内外医学院校广泛应用,并取得良好的效果[1].因此,在康复治疗实习生的临床实践教学中,需要不断探索教学改革与创新,利用PBL与EBM相结合的实习教学模式进行临床实践带教,评价教学效果.

目的:探讨运动想象疗法联合改良强制性运动疗法对脑卒中患者上肢运动功能的影响.方法:将首发脑卒中患者40例随机分为研究组和对照组,每组各20例.对所有患者进行常规康复训练和改良强制性运动疗法,前者2次/d,30min/次;后者1次/d,1h/次,均5d/周,共4周.研究组患者在此基础上,另外进行4周的运动想象疗法,20min/次,1次/d,5d/周.在入组时和治疗4周后进行功能评定,采用简化Fugl-Meyer运动功能量表上肢部分(FMA-UE)、上肢运动研究量表(ARAT)和改良Barthel指数量表(MBI)评价患者上肢运动功能和日常生活活动能力.结果:治疗4周后,2组患者FMA-UE评分、ARAT评分和MBI评分均较治疗前均明显提高(均P＜0.01),研究组患者上述评分均高于对照组(P＜0.01,0.05).结论:运动想象联合改良强制性运动疗法可以显著改善脑卒中患者的上肢和手运动功能、日常生活活动能力.

目的 探讨经颅直流电刺激(tDCS)结合感觉训练对卒中偏身感觉障碍患者感觉功能及手功能的康复疗效.方法 回顾性连续纳入2019年7月至2020年1月在首都医科大学宣武医院康复医学科住院治疗的卒中偏身感觉障碍患者30例,均为初发卒中,病程3个月内.根据治疗方式的不同,将30例患者分为试验组和对照组,各15例.两组患者均接受常规药物治疗、偏瘫运动治疗及感觉功能训练,感觉训练2次/d,30 min/次,5 d/周.在感觉功能训练前,试验组另进行阳极tDCS治疗,对照组患者给予tDCS假刺激,即电刺激仪仅进行正常显示,无刺激电流输出;均2次/d,20 min/次,5 d/周.疗程均为2周.记录两组患者基线资料以及治疗前后的上肢感觉、上肢运动、日常生活能力评分[Fugl-Meyer运动功能(FMA)量表感觉、运动评分,改良Barthel指数(MBI)评分],并进行组间比较.基线资料包括性别、年龄、病程、卒中类型(脑梗死或脑出血)、病变部位(左半球、右半球).结果(1)两组患者性别、年龄、病程、病变性质和病变部位的差异均无统计学意义(均P>0.05).(2)两组患者治疗前后FMA感觉评分比较,组别及时间交互效应的差异有统计学意义(F=235.71,P<0.01).试验组治疗前和治疗后FMA感觉评分分别为(5.9±1.8)、(10.5±1.6)分,对照组治疗前后FMA感觉评分分别为(6.1±1.8)、(8.7±1.6)分.两组患者治疗前FMA感觉评分的差异无统计学意义(P=0.84);治疗2周后,试验组FMA量表上肢感觉评分高于对照组,组间差异有统计学意义(P<0.01).两组患者治疗后FMA感觉评分均高于本组治疗前,治疗前后的差异均有统计学意义(均P<0.01).(3)两组治疗前后FMA运动评分比较,组别及时间交互效应的差异有统计学意义(F=1713.93,P<0.01).试验组治疗前和治疗后FMA运动评分分别为(13±4)、(41±5)分,对照组治疗前后FMA运动评分分别为(14±4)、(36±3)分.两组患者治疗前FMA运动评分的差异无统计学意义(P=0.54);治疗2周后,试验组FMA运动评分优于对照组,组间差异有统计学意义(P<0.01).两组患者治疗后FMA运动评分均高于本组治疗前,治疗前后的差异均有统计学意义(均P<0.01).(4)两组患者治疗前后MBI评分比较,组别及时间交互效应的差异有统计学意义(F=412.33,P<0.01).试验组治疗前和治疗后MBI评分分别为(18±8)、(60±16)分,对照组治疗前后MBI评分分别为(15±6)、(44±8)分.两组患者治疗前MBI评分的差异无统计学意义(P=0.16);治疗后,试验组MBI评分高于对照组,组间差异有统计学意义(P<0.01).两组患者治疗后MBI评分均高于本组治疗前,治疗前后的差异均有统计学意义(均P<0.01).结论 经tDCS结合感觉训练可以改善卒中患者的感觉功能和偏瘫侧手功能,提高日常生活能力,但本研究结果有待于进一步验证.

目的:观察运动贴布(肌内效贴)联合神经肌肉电刺激对脑卒中后亚急性期患者足下垂所致步行障碍的临床疗效.方法:采用随机数字表法将符合纳入标准的60例脑卒中患者分为运动贴布组(KT组)、神经肌肉电刺激组(NMES组)、联合组,每组各20例.三组患者均接受常规康复训练(2次/d,40min/次),KT组在此基础上增加运动贴布治疗(1次/d);NMES组在此基础上增加神经肌肉电刺激治疗(1次/d,20min/次);联合组则在常规康复训练基础上接受运动贴布联合神经肌肉电刺激治疗.以上各组每周连续治疗5天,持续4周.于治疗结束前后分别采用主动关节活动度(AROM)、10m步行能力测试(10mWT)、起立-行走即时测试(TUGT)、生理耗能指数(PCI)对三组患者疗效进行评定.结果:三组患者在治疗前的各项评定指标比较均无显著性意义(P＞0.05).治疗后,三组患者各项评分均优于治疗前且各组内比较均有显著性意义(P＜0.01),其中,联合组各项评分均优于KT组和NMES组,组间比较有显著性意义(P＜0.01),KT组与NMES组各项指标组间比较无显著性意义(P＞0.05)结论:运动贴布联合神经肌肉电刺激应用到脑卒中后亚急性期足下垂的患者中能够改善足下垂、提高步行能力、优化步行功能.

目的:探讨早期康复训练对机械通气重症脑卒中患者功能改善的影响.方法:将50例带有机械通气的重症脑卒中患者按随机字数表法分为试验组和对照组,每组各25例.两组患者均接受神经科ICU常规药物治疗和常规护理,试验组在此基础上进行早期康复训练,包括肢体运动和呼吸训练,2次/d.比较两组患者治疗前后急性生理与慢性健康状况评分Ⅱ(acute physiology and chronic health evaluation,APACHEⅡ),以及呼吸机相关肺炎(ventilator associated pneumonia,VAP)发生率、撤机成功率、机械通气时间和ICU住院时间.结果:①治疗前两组患者APACHEⅡ评分比较,差异无显著性意义(P＞ 0.05);②治疗后,两组患者APACHEⅡ评分与治疗前比较均明显降低(P＜ 0.01),但组间差异无显著性意义(P＞0.05);③治疗后试验组VAP发生率明显低于对照组,而撤机成功率显著高于对照组,机械通气时间和ICU住院时间明显短于对照组(P＜0.05).结论:早期肢体运动和呼吸训练可以提高机械通气重症脑卒中患者的撤机成功率,降低VAP发生率,缩短机械通气时间和ICU住院时间.

目的:探讨运动想象联合优化运动技能训练对脑卒中患者上肢运动功能改善的影响.方法:将45例脑卒中患者按随机数字表分为联合组、运动想象组(MI)和优化运动技能组(OMP),每组各15例.三组患者均接受常规康复训练,30min/次,2次/d,5d/周,共4周.MI组常规康复训练的同时进行4周的运动想象疗法,20min/次,1次/d,5d/周;OMP组常规康复训练的同时进行4周的优化运动技能训练,20min/次,1次/d,5d/周;联合组则在常规康复训练的同时进行4周的运动想象疗法20min/次和优化运动技能训练20min/次,均1次/d,5d/周.于治疗前及治疗4周后对患者进行功能评定,采用简Fugl-Meyer运动功能评分(FMA)和手臂动作调查测试量表(ARAT)评价上肢运动功能;改良Barthel指数量表(MBI)评价日常生活活动能力,比较三组的疗效.结果:①治疗前,三组患者上肢FMA评分、ARAT评分和MBI评分无显著性差异(P＞0.05);治疗4周后,三组患者的上肢FMA评分、ARAT评分和MBI评分与治疗前比较均明显提高(P＜0.01).②治疗4周后联合组上肢FMA评分、ARAT评分和MBI评分均明显优于MI组和OMP组(P＜0.05);而MI组和OMP组之间评分的差异无显著性意义(P＞0.05).结论:在常规康复治疗的基础上,运动想象和优化运动技能训练均能提高脑卒中患者上肢运动功能和日常生活活动能力,两者联合治疗效果更加显著.

脑卒中因高死亡率、高致残率威胁着人们的生活[1],有研究表明,脑卒中后呼吸功能障碍是导致患者肺炎发生率升高、运动耐力下降、脑卒中再发风险增加甚至造成死亡的重要因素[2-41,然而,常规脑卒中康复仍较多地关注肢体功能障碍[5],忽视了呼吸功能的影响,本文就脑卒中后呼吸功能康复的研究进展进行综述,旨在提高临床重视程度的同时,为开展呼吸康复提供参考.

卒中后抑郁是卒中患者最常见的心理障碍,不仅严重影响患者的功能恢复、生活质量和回归社会的能力,还会增加卒中的复发率和病死率.近年来,已经有部分学者应用非侵入性脑刺激技术治疗卒中后抑郁,取得了一定的疗效.作者就目前非侵入性脑刺激技术在卒中后抑郁治疗中的研究进展进行综述.

脑卒中后患者出现不同的并发症,比较常见的有肩关节半脱位、上肢痉挛和单侧忽略,对脑卒中患者的功能恢复造成了很大影响.临床上采用不同的治疗方法,本文主要介绍上肢康复机器人的分类和临床应用,以探讨上肢康复机器人对脑卒中并发症的康复效果,并对上肢康复机器人的发展进行小结.

Objective To investigate the effect of cathodal transcranial direct current stimulation (ctDCS)on upper limb motor function in patients with stroke. Methods From July 2016 to February 2017,45 patients with first-ever stroke hemiplegia treated with rehabilitation at the Department of Rehabilitation Medicine,Xuanwu Hospital,Capital Medical University were enrolled prospectively. Their course of disease was 1 -6 months. They were randomly divided into a 1. 0 mA group,a 2. 0 mA group,and a control group (n =15 in each group)according to the random number table. The 3 groups of patients received traditional rehabilitation training,2 times a day,once for 45 min,5 days a week for 2 weeks. On this basis,the 1. 0 mA group and 2. 0 mA group were treated with 1. 0 mA and 2. 0 mA ctDCS for two weeks,once a day,once for 20 min,5 days a week at the same time,while the control group was only treated with sham stimulation. The upper limb function was evaluated before treatment and 2 weeks after treatment. Fugl-Meyer Assessment (FMA)score and Action Research Arm Test (ARAT)were used to assess the upper limb motor function. The modified Barthel index (MBI)was used to evaluate the activities of daily living. Paired t test was used to compare before and after treatment in the groups. Single factor analysis of variance was used to compare between the groups. Results (1)There were no significant differences in the upper limb FMA score, ARAT score,and MBI score before treatment among the three groups of patients (all P >0. 05). Two weeks after treatment,the upper limb FMA score,ARAT score,and MBI score of the patients in the 3 groups were significantly improved compared with those in the same groups before treatment. The differences in the 1. 0 mA group were 12 ±3,10 ±2,and 22 ±9,respectively,those in the 2. 0 mA group were 12 ±3,10 ±3, and 20 ±6,respectively,and those in the control group were 9 ±3,7 ±3,and 18 ±7,respectively in control group (all P <0. 01). (2)Two weeks after treatment,the upper limb FMA scores and ARAT scores in the 1. 0 mA group and 2. 0 mA group were superior to the control group (the FMA scores all P < 0. 01 and ARAT scores all P <0. 05),while there was no significant difference in scores between the 1. 0 mA group and 2. 0 mA group (P > 0. 05). The were no significant differences in the MBI scores among the three groups (P >0. 05). Conclusion Cathodal transcranial direct current stimulation may have a trend of improving the upper limb motor function and promote the improvement of activity of daily living in patients with stroke,however,there was no significant difference in treatment effect of ctDCS intensity between the 1. 0 mA and 2. 0 mA treatment.

Objective To investigate the effect of transcranial direct current stimulation combined with motor relearning program on the recovery of upper limb motor function after stroke.Methods From September 2015 to June 2016,40 patients with first-ever stroke received rehabilitation therapy at the Department of Rehabilitation Medicine,Xuanwu Hospital,Capital Medical University were enrolled prospectively.Their course of disease was 1 to 6 months.They were divided into either a combined treatment group or a control group according to the odd and even numbers in hospital (n =20 in each group).The patients of both groups received traditional rehabilitation training and motor relearning program for upper lindb recovery,2 times a day,once for 30 min,5 days a week for 6 weeks.The combined treatment group was also given transcranial direct current stimulation,2 times a day,once for 20 min,5 days a week,while the control group was only treated with sham stimulation treatment.The patients were assessed before treatment and at 6 weeks after treatment.Fugl-Meyer Assessment (FMA) scores and Action Research Arm Test (ARAT) were used to assess upper limb motor function.The modified Barthel index (MBI) was used to evaluate the activities of daily living.Results There was no significant difference in the observation indices before treatment between the 2 groups (P ＞ 0.05).Six weeks after treatment,the differences of the upper limb FMA score and ARAT score before treatment were superior to the control group,they were 13 ± 3,10 ± 3 and 10 ± 2,8 ± 2,respectively (t =3.503 and 3.244 respectively,all P ＜ 0.01).There was no significant difference in the MBI score between the 2 groups (P ＞ 0.05).Conclusion Transcranial direct current stimulation combined with motor relearning program may effectively improve the upper limb motor function in patients with stroke and promote the improvement of the activities of daily living.

脑-机接口（brain-computer interface，BCI）技术是近年来迅速发展的一种电脑通讯系统［1］，其特点是不依赖于大脑、周围神经、肌肉和骨骼这一人体正常的传导输出通路，而是将获取的大脑电活动信号经过外源输出设备评价分析或补充修正后，转变为相应指令并显示成人们预期的行为活动，从而实现人体大脑与外部环境之间的交互作用［2］。更简单地说，BCI可以定义为一种“新型大脑信号传输系统”。目前，其在生物医学工程、康复医学、保健医学和传媒娱乐等领域具有广阔的发展空间［3］。卒中发病后在急性期进行康复训练，部分患者可自行恢复且效果良好，而在后遗症期传统康复训练效果则不明显［4］，患者自行恢复能力显著降低，尤其是上肢运动功能、手功能恢复等问题。因此，研究寻找新的治疗方法对改善患者功能和提高生活质量均至关重要。笔者就BCI技术在卒中康复中的研究进展综述如下。

Objective To investigate the effect of transcranial magnetic stimulation on unilateral spatial neglect and motor functions rehabilitation in patients with stroke.Methods A total of 30 post-stroke patients with unilateral spatial neglect were divided into either a repetitive transcranial magnetic stimulation(rTMS) group(n=15) or a control group(n=15) according to a random number table.The patients of rTMS group were treated with behavioral training methods(including visual scanning training,trunk rotation training,and cross-promote training,once for 15 min,twice a day;the conventional training once for 30 min,twice a day) and rTMS(the frequency of stimulation 0.5 Hz,an intensity of 90% of resting motor threshold,once for 15 min,twice a day),all for 2 weeks.The patients of the control group were treated with the behavior training only.The patients in both groups were evaluated with the line bisection test,line cancellation test,clock drawing test,simple Fugl-Meyer motor function assessment,and modified Barthel index before and after treatment.Results ①After treatment,the median line bisection test scores(median,range) in the rTMS group and the control group were 8.17(0-48.31) and 31.75(0-86.96) respectively;the median line cancellation test scores in the 2 groups were 0.005(0-0.333) and 1.333(0-5.667) respectively;the median clock drawing test scores in the 2 groups were 0(0-1) and 1(0-2) respectively.There were significant differences in each index score between the two groups(all P0.05).②After treatment,the median simple Fugl-Meyer motor function test scores in the rTMS group and the control group were 36(24-94) and 21(6-63) respectively.There was significant difference between the 2 groups(P=0.001);the median modified Barthel index scores in both groups were 45(30-65) and 40(10-60) respectively.There was significant difference between the two groups(P0.001).ConclusionTranscranial magnetic stimulation has significant effect on the unilateral spatial neglect in patients with stroke.Ipsilateral unilateral spatial neglect recovery after stroke contributes to the rehabilitation of motor function of the patients.

<正>视觉空间忽略(visual spatial neglect,VSN)是指卒中后对来自病灶对侧空间的刺激不能正确注意、搜索、反应、定位或报告,患者不能注意到来自患侧的视觉、听觉或触觉等刺激[1]。VSN是一种神经性功能障碍综合症,多发生在右侧大脑半球受损后,因为右侧大脑半球对注意的支配起主要作用,其主要发病机制一般认为是由于半球间竞争导致的,当一

目的 观察行为学疗法联合重复经颅磁刺激治疗脑卒中后偏侧空间忽略的临床疗效.方法 采用随机数字表法将30例脑卒中后偏侧空间忽略患者分为实验组和对照组,2组患者均给予行为学治疗,包括视觉扫描训练、躯干旋转训练、交叉促进训练及常规康复训练等,实验组在此基础上辅以重复经颅磁刺激治疗(磁刺激频率0.5 Hz,磁刺激强度为静息运动阈值的90％水平,每次治疗15 min,每日治疗2次).于治疗前、治疗2周后采用直线二等分试验、线段划消试验、画钟试验、简式Fugl-Meyer运动功能评分、改良Barthel指数评分对2组患者进行疗效评定.结果 治疗前2组患者直线二等分试验、线段划消试验、画钟试验、简式Fugl-Meyer运动功能评分及改良Barthel指数评分组间差异均无统计学意义(P＞0.05).分别经2周治疗后,发现实验组上述指标改善幅度均显著优于对照组水平(均P＜0.05).结论 联合行为学疗法及重复经颅磁刺激治疗脑卒中后偏侧空间忽略具有协同疗效,能进一步改善脑卒中患者偏侧空间忽略,提高肢体功能及日常生活活动能力.