1、神经肌肉电刺激在脑卒中的应用,燕铁斌 中山大学附属第二医院,内容,Dr.Y ,2,3,Introduction,Neuromuscular Electrical Stimulation (NES) refers to the electrical stimulation of an intact lower motor neuron (LMN) to activate paralyzed or paretic muscles. (Sheffler & Chae 2007)In the past decades, it has been increasingly applied to strok
2、e rehabilitationfunctional electrical stimulation (FES) transcutaneous electrical nerve stimulation (TENS)Liberson et al. reported the first clinical application of FES to a stroke patient in the early 1960sIn 1973, the first commercially available FES unit was used for treating hemiplegic patients.
3、 (Rebersek & Vodovnik 1973),Dr.Y ,4,Introduction,There was no study in the literature on the effectiveness of TENS in promoting motor recovery in stroke patients until the 1990sLevin and Hui-Chan (1992) found that repeated applications of TENS significantly decreased spasticity and increased maximal
4、 voluntary contraction of the ankle dorsiflexorsTekeoolu et al. (1998) also examined the effects of TENS on patients with chronic stroke and foundTENS significantly decreased the spasticity of the lower limb and increased the scores of Barthel Index,Dr.Y ,5,Limitations of Previous Studies,Glanz et a
5、l. (1996) and Chae and David (1999) critically reviewed studies on the efficacy of the NMES in treating hemiplegic patients between 1966 and 1999. They found8 single-blinded randomized controlled trialsonly one study used a placebo grouptreatment began from some 1.5-29.2 months after stroke Other ob
6、servationsNearly all the patients examined were at the chronic or a combination of acute and chronic stages that might not reveal the efficacy of early interventionMany study designs were not randomized controlled trials, without either a placebo or control groupThe intervals between assessments wer
7、e too long to delineate more specific changes with time,Dr.Y ,课题一神经肌肉电刺激治疗急性脑卒中下肢瘫痪:临床随机对照研究,Dr.Y ,6,研究目的 与单纯康复组比较，神经肌肉电刺激（FES/TENS）对急性脑卒中患者下肢功能恢复的影响,入选标准大脑中动脉系统初发脑卒中 年龄4584 岁 下肢中重度瘫痪坐位屈髋肌力0.05).,Dr.Y ,14,组一般资料 FES TENS 安慰组 对照组 TotalNumber of subjects 13 16 17 16 62Age (years) 68.2 7.7 68.3 10.2 73.
8、2 7.7 69.8 7.5 70.0 8.5Gender M / F 7 / 6 8 / 8 8 / 9 8 / 8 31/ 31Type of stroke I / H 12 / 1 14 / 2 15 / 2 15 / 2 55 / 7Paretic side L/ R 6 / 7 8 / 8 10 / 7 9 / 7 33 / 29BMI (kg/m2) 23.4 2.3 23.8 2.7 23.1 3.2 23.0 3.0 23.3 2.8AMT (score) 8.4 1.7 8.5 1.5 7.6 2.0 8.5 1.2 8.2 1.7CSS (score) 7.3 3.1 5.
9、3 2.1 5.4 2.6 6.9 3.0 6.2 2.9LOS at acute hospital (day) 5.7 5.0 6.3 4.0 7.1 3.4 7.0 3.3 6.8 3.5Initial intervention from onset (day) 8.7 5.8 8.6 4.3 9.9 2.7 9.1 3.3 9.2 3.5,结果,Dr.Y ,15,FES TENS 安慰组 对照组 W0 (分) 7.4 3.1 5.3 2.4 5.5 2.6 6.9 3.0 W1 (分) 8.6 3.0 5.6 2.4 7.3 2.4 8.1 2.8 (W1-W0)/W0 (%) 16.3
10、 86.8 5.7 35.3 33.0 52.6 17.4 58.4 W2 (分) 8.8 2.7 6.6 2.4 7.9 2.5 9.3 2.2 (W2-W0)/W0 (%) 18.8 92.2 24.5 51.2 44.0 72.5 34.7 67.5 W3 (分) 9.6 2.5 7.2 1.6 8.1 2.8 10.1 1.8 (W3-W0)/W0 (%) 29.2 35.3 36.7 66.1 47.3 93.9* 46.2 71.3 *WFU (分) 10.4 1.9 7.7 2.0 8.8 2.5 10.8 1.4 (WFU-W0)/W0 (%) 40.3 93.5 45.3 8
11、7.3 59.7 93.3 56.3 71.4 *与FES组比较， P 0.05。,结果,治疗前后各组痉挛评定比较,结果,Dr.Y ,16,治疗前后患侧踝关节最大等长收缩是踝背伸力矩增加 (%) * P 0.05, * P 0.01 ，与FES组比较.,结果,Dr.Y ,17,3周治疗对增强踝背伸时胫前肌最大收缩力(积分肌电图)的影响, * P0.05, * P0.01,与FES组比较,结果,Dr.Y ,18,治疗前后患侧踝背伸肌群协同收缩率比较（sEMG）* P0.05， * P0.05).,Dr.Y ,26,2组一般资料比较,结果,治疗组:TENS治疗前（左）,后（右）rCBF变化,患者，
12、女，55，左顶叶脑梗死,结果,患者，女，71岁，右基底节脑梗死,对照组:治疗前（左）,后（右）rCBF变化,Dr.Y ,27,治疗前后放射性计数均值比较,结果,注：组内治疗前后比较, P0.01;治疗组治疗后与对照组比较, P0.05.,Dr.Y ,28,治疗前后半定量值比较,结果,半定量值=病灶计数值/病灶之镜像计数值100% 组内治疗前后比较, P0.05; 治疗组治疗后与对照组比较, P0.01.,Dr.Y ,29,治疗前后不对称指数值比较,结果,注: 不对称指数值（健侧计数值-患侧计数值）/健侧计数值100% 组内治疗前后比较, P0.05; 治疗组治疗后与对照组比较 P0.01.,D
13、r.Y ,30,课题三经皮电神经刺激对急性脑卒中患者提干诱发电位的影响,研究目的观察经皮电神经刺激脑组织急性期患者患侧肢体学位对提干诱发电位的影响,31,对象,2组患者一般资料,入选对象和筛选对象标准同课题一和课题二. 分层后患者被随机分为 TENS 组和安慰TEN组,32,方法,采用Synergy T-EP EMG/EP Monitoring Systems (Oxford Instruments Medical, Inc).患者在检查室接受45min TENS 或安慰TENS治疗前后，分别接受1次SEP检查分别分析N9和 N20的潜伏期和波幅,结果,注：经t检验，p0.05,提示有显著性差
14、异,34,Dr.Y ,治疗前，2组患侧与健侧比较，患侧的N9和N20振幅降低，潜伏期缩短，差异有显著性（ * Po.o5）,治疗前2组健侧和患侧SEP组内比较,治疗后，2组患侧SEP值组间比较,*注：经两独立样本T检验，P0.05,35,* p0.05,TENS 组,安慰TENS组,N9 振幅 N20 振幅 N9 潜伏期 N20 潜伏期,* P0.05， 2组之间比较,治疗后2组SEP变化% 比较,36,Dr.Y ,变化率 % = (治疗后治疗前) SEP值 / 治疗前 SEP值， * po.o5，2组之间比较,课题四功能性电 刺激对脑卒中早期患者脑可塑性影响的功能性磁共振观察,目的观察FES
15、对脑可塑性影响的功能性磁共振研究,Dr.Y ,37,第一部分：健康年轻志愿者初步报告第二部分：脑卒中患者与同年龄组的健康老人 正在进行,38,对象与方法,4位右利手的健康年轻志愿者男性2人,女性2, 23-32 岁,39,FES 治疗仪, Pulsecure-pro KR-7, 日本,初步结果,FES诱发出的伸腕肌群与大脑对侧运动皮层的兴奋性相关,Dr.Y ,40,41,An fMRI risk map. A 24 years male. The fMRI activation areas are visualized as yellow and red areas after repeate
16、d wrist extension induced by FES within the 1.5 T MRI.,我们研究的结论,神经肌肉电刺激，包括FES和TENS较之安慰电刺激组和标准对照组，能促进初发脑卒中患者更早、更快的运动功能恢复FES的作用比 TENS的作用出现早，效果强 (课题一),Dr.Y ,42,我们研究的结论,可能的机制增加脑卒中患者患侧和健侧脑局部血流量rCBF (课题二) 增加神经原的兴奋性,表现为SEP的潜伏期缩短、振幅增加 (课题三) 增加健康年轻者脑的血氧水平，fMRI表现 也许可以激活脑卒中患者脑细胞 的活性，促进功能重组 (课题四),Dr.Y ,43,近几年我科发
17、表的与神经肌肉电刺激方面有关的论文,YAN T, HUI-CHAN CWY , LI LSW Functional electrical stimulation improves knee joint proprioception in subjects with acute stroke: A randomized control trial. the 4th World Congress of the ISPRM, June 9-14, 2007 Seoul Korea, keynote speaker Wei N, Yan T, Hui-Chan C.W.Y Effects of Tra
18、nscutaneous Electrical Nerve Stimulation (TENS) on Sometosensory Evoked Potential (SEP) of Strokes Subjects: A pilot Study. 5th Pan Pacific Rehabilitation Conference, 2006, Aug Hong Kong （Best Poster）Yan T, Hui-Chan CWY, Li LSW. Functional electrical stimulation improves motor recovery of the lower
19、extremity and walking ability of subjects with first acute stroke: a randomized, placebo-controlled Trial. Stroke, 2005,36: 80-85. 燕铁斌，Hui-Chan CWY.经皮穴位电刺激对急性脑卒中偏瘫患者踝关节肌张力及协同收缩率的影响. 中华物理医学与康复杂志，2007,29:25-28.魏妮，燕铁斌，Hui-Chan CWY，陈月桂. 经皮穴位电神经刺激不同部位对脑卒中患者体感诱发电位的影响. 中华物理医学与康复杂志，2007,29:29-32.郭友华，燕铁斌, Hu
20、i-Chan CWY.经皮电神经刺激对脑卒中患者脑局部血流量的影响.中华物理医学与康复杂志，2005，27：507509燕铁斌等.盆底肌肉电刺激治疗脊髓损伤后尿失禁疗效观察初报.中华物理医学与康复杂志,2005:27:286-288 郭友华，燕铁斌，Hui-Chan CWY .低频电刺激治疗脑卒中偏瘫的临床研究进展.中华物理医学与康复杂志，2005，27：507509.郭友华，燕铁斌，Hui-Chan CWY.低频电刺激治疗脑卒中偏瘫的神经机制研究进展.中国康复医学杂志，2005，20：156-158. 燕铁斌，郭友华，卢献平等. 经皮电刺激对脑卒中患者脑局部血流量的影响初报.中国康复医学杂志，2004，19：499-501. 燕铁斌，Hui-Chan.踝背伸和跖屈肌群的最大等长收缩：脑卒中急性期患者与同龄健康老人表面肌电图对照研究. 中华物理医学与康复杂志,2003，25：212-215.燕铁斌.神经肌肉电刺激及其在痉挛性瘫痪治疗中的临床应用.中国康复理论与实践.2003,9:155-158燕铁斌.经皮神经电刺激在脑卒中康复治疗中的应用.中国康复理论与实践，2002，8，140-141.,44,Dr.Y ,THANK YOU!,Dr.Y ,45,
