反复经颅磁刺激联合动作观察训练治疗儿童痉挛性脑瘫
Summary
痉挛型脑瘫（SCP）患儿因脑皮层运动区域损伤，出现肢体痉挛、运动障碍、姿势异常等症状，导致无法正常站立和行走。因此，缓解SCP患儿肢体痉挛和增强粗大运动功能已成为重要的治疗目标。
Abstract
本研究介绍了一项使用 2 x 2 因子设计的随机对照试验的结果，比较了重复经颅磁刺激 （rTMS） 和动作观察训练 （AOT） 干预方法对痉挛性脑瘫 （SCP） 儿童痉挛状态、平衡功能和运动功能的影响。该研究旨在调查两种干预措施的组合是否比单独治疗或传统治疗产生更大的改善。
本研究对象患儿按照随机数表随机分为常规组、rTMS组、AOT组、联合干预组4组。四组患儿均接受常规康复治疗，在此基础上给予不同治疗方案的康复治疗方案。常规组无其他治疗，rTMS组接受rTMS，AOT组接受AOT，联合干预组接受rTMS和AOT联合干预。他们每周接受 5 天的培训，持续 12 周。在训练计划开始时和完成 12 周的治疗时评估了痉挛、平衡功能、步行能力和粗大运动功能评分的变化。
共有 64 名患有 SCP 的儿童完成了这项研究，并对他们的结果进行了分析。实验组总粗大运动功能效率为87.50%，明显高于常规组的25.00%、rTMS组的62.50%和AOT组的68.75%。初步结果表明，rTMS和AOT联合干预能有效改善儿童的平衡功能和运动功能，且联合干预的治疗效果优于常规治疗、rTMS或AOT单独使用。最后，明确了联合干预的临床疗效和最佳治疗参数，为治疗师为SCP患儿进行下肢功能康复提供临床依据。
Introduction
脑性瘫痪1 型 （CP） 是儿童中最常见的致残性疾病之一，是一组由发育中的胎儿和婴儿非进行性脑损伤引起的持续性综合征，包括中枢性运动障碍、姿势异常和行动不便。目前，全球约有1700万儿童患有脑瘫2，其中中国的病例超过500万。在各种形式的脑瘫中，痉挛性脑瘫（SCP）约占80%3。患有SCP的儿童患有脑损伤，导致肌肉痉挛、感觉功能下降、肌肉协调受损和平衡能力下降，所有这些都阻碍了独立行走和日常活动。目前用于增强SCP儿童粗大运动功能的康复措施包括核心稳定性训练4、任务导向训练5、约束诱导运动疗法6和镜像视觉反馈疗法7等活动。这些措施可以通过改善外周器官的功能，自下而上调节和重塑中枢神经系统，从而改善儿童的临床症状。
经颅磁刺激 （TMS）8,9 是一种无痛、非侵入性且安全的治疗方法。rTMS是指在发出单一命令后，以相等的时间间隔连续释放刺激，这是常规重复刺激模式之一。它基于电磁感应和电磁转换的原理，通过刺激线圈施加瞬态电流，形成脉冲磁场穿透颅骨，产生感应电流，刺激神经元，触发一系列生理生化反应。rTMS 已被应用于神经系统疾病的监测、评估和治疗，为探索大脑的结构和功能提供了一种新的方法10。现有研究11,12 表明 rTMS 对脑瘫儿童的肢体痉挛和运动功能具有不同的治疗效果。此外，rTMS治疗结合其他康复技术的效果更为明显。
AOT 是一种利用镜像神经元系统 （MNS） 建立运动学习和记忆的康复方法13,14。AOT的本质是让观察者仔细观察视频中的动作，然后尽力模仿他们所观察到的。观察过程可能会触发称为 MNS 的神经网络中的激活，类似于当一个人亲自参与执行这些动作时发生的激活15，这为 AOT 提供了神经生理学基础。AOT 已显示出在改善运动障碍患者的运动技能方面取得成功，在脑瘫患者的中风恢复和上肢运动功能恢复方面产生了积极成果16,17。
我们之前的研究发现，基于镜像神经元系统的AOT可以有效提高脑瘫儿童的平衡和行走能力18。此外，研究19 表明，rTMS可以改善SCP患儿的肌肉痉挛、运动和步态，但应用于脑瘫患儿的rTMS治疗标准尚未统一，探索rTMS不同参数对CP患儿的影响，提供个性化、精准的治疗标准是一个亟待解决的问题。我们相信，将rTMS与AOT相结合有潜力发展成为一种有价值的脑瘫神经康复物理治疗策略。rTMS 和 AOT 都刺激了 SCP20 儿童的大脑皮层，从而有助于粗大运动功能的发育。本研究旨在了解rTMS和AOT的联合治疗是否比常规治疗或单独使用rTMS或AOT能取得更大的协同效应。
Protocol
本研究严格按照国家人体实验标准进行，临床研究经湘雅博爱康复医院伦理协会批准（伦理批准文号：20211223）。儿童的监护人同意参加该培训项目，并签署了知情同意书。2022年2月至2022年12月，在中南大学湘雅博爱康复医院和湘雅医院招募了患有SCP的儿童。 1.实验前的准备工作 为确保学习结果的准确性，应为康复治疗师提供相关培训，并提前评估他们的?…
Representative Results
本文介绍了64例SCP患儿（补充表S1 和 补充文件1）的结果，他们按照数字表法随机分为4组，给予不同的康复措施，为期12周。在整个过程中，参与的儿童均未出现头痛、头晕、癫痫发作等不良反应。 四组儿童的人口统计数据如 表1所示。治疗前，脑瘫的性别比、年龄、痉挛性类别、GMFCS、GDDS发育商数（GDDS DQ）、辅助器具（踝足矫形器或助?…
Discussion
对于患有SCP的儿童，γ和α神经元的活动增加会导致皮质脊髓束输入受到抑制，从而导致肌肉紧张增加，称为痉挛。由于肢体痉挛会显著影响SCP患儿下肢运动功能的发展，因此减少痉挛是重要的训练目标之一。目前，采用逐步治疗策略来缓解痉挛状态，包括康复护理、物理治疗、骨科支具应用、肉毒杆菌毒素注射27、药物治疗和手术干预28。在这项研究中，使用?…
Disclosures
The authors have nothing to disclose.
Acknowledgements
这项研究得到了湘雅博爱康复医院的资助。
Materials
| K6 multimedia scene interactive training system | Hunan Le Jiekang technology Co., LTD | Program implementation | |
| KLW-SLL type spa machine for children | Nanjing Kanglongwei Technology Industrial Co., LTD | Conventional therapy | |
| Pulse magnetic field stimulator model YRD CCY-II | Shenzhen Yingzhi technology Co., LTD | Program implementation | |
| SPSS26 software | IBM | Statistic analysis |
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Cite This Article
Fan, T., Wei, H., Dai, J., You, G., Lu, Z. Repeated Transcranial Magnetic Stimulation Combined with Action Observation Training in Children with Spastic Cerebral Palsy. J. Vis. Exp. (210), e66013, doi:10.3791/66013 (2024).