重復經顱磁刺激治療腦卒中后患者肢體運動功能障礙的系統評價_《中國循證醫學雜志》

作者：

王娟 ¹ , 朱芬 ¹ , 王樸 ² ,  廖維靖 ¹ , 郭毅 ³ , 李華鋼 ⁴

1. 武漢大學中南醫院康復醫學科（武漢 430071）；2. 四川大學華西醫院康復醫學科（成都 610041）；3. 武漢大學公共衛生學院流行病學教研室（武漢 430071）；4. 武漢大學中南醫院神經內科（武漢 430071;

關鍵詞：

重復經顱磁刺激腦卒中運動功能系統評價 Meta分析隨機對照試驗

DOI：

10.7507/1672-2531.20120228

視頻：

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摘要 全文 圖表 視頻 參考文獻 施引文獻 補充材料

目的　系統評價重復經顱磁刺激對腦卒中患者肢體運動功能障礙的療效。
方法　計算機檢索Cochrane 圖書館、MEDLINE、EMbase、CBM、CNKI和WanFang Data中關于重復經顱磁刺激改善腦卒中后患者肢體運動功能障礙的隨機對照試驗（RCT），同時追溯納入文獻的參考文獻。檢索時限均為從建庫至2012年1月。由兩名研究者按照納入與排除標準獨立進行文獻篩選、資料提取和質量評價后，采用RevMan 5.0.2軟件進行Meta分析，并使用GRADE系統評價證據質量。
結果　共納入11個RCT，376例患者。3個低質量RCT的Meta分析結果顯示，與常規康復治療相比，2～4周重復經顱磁刺激對腦卒中患者肢體運動功能障礙的療效更好，其差異有統計學意義［WMD=11.02，95%CI（2.56，19.47）］，其余8個研究僅作相應的描述性分析。
結論　重復經顱磁刺激對腦卒中患者的肢體運動功能障礙的治療效果尚不能確定。因此，在臨床上應用重復經顱磁刺激治療腦卒中患者運動功能障礙時仍需謹慎。

引用本文： 王娟,朱芬,王樸,廖維靖,郭毅,李華鋼. 重復經顱磁刺激治療腦卒中后患者肢體運動功能障礙的系統評價. 中國循證醫學雜志, 2012, 12(12): 1478-1488. doi: 10.7507/1672-2531.20120228 復制

1.	Warlow C, Van Gijn J, Sandercock P, et al. Stroke: practical management. 3Ed. UK: Blackwell Publishing, 2008: 5-76.
2.	吳兆蘇, 姚崇華, 趙冬. 我國人群腦卒中發病率、死亡率的流行病學研究. 中華流行病學雜志, 2003, 24(3): 236-239.
3.	World Health Organization.International classification of functioning, isability and health: ICF. Geneva: World Health Organization, 2001.
4.	Wade DT. Measurement in neurological rehabilitation. Curr Opin Neurol Neurosurg, 1992, 5(5): 682-686.
5.	Duncan PW, Zorowitz R, Bates B, et al. Management of Adult Stroke Rehabilitation Care: a clinical practice guideline. Stroke, 2005, 36(9): 100-143.
6.	Barker AT, Jalinous R, Freeston IL. Non-invasive magnetic stimulotion of human motor cortex. Lancet, 1985,1(8437): 1106-1107.
7.	Khedr EM, Ahmed MA, Fathy N, et al. Therapeutic trial of repetitive transcranial magnetic stimulation after acute ischemic stroke. Neurology, 2005, 65(3): 466-468.
8.	World Health Organisation. Cerebrovascular Disorders(Offset Publications). Geneva:World Health Organization, 1978.
9.	中華醫學會全國第4次腦血管病學術會議. 各類腦血管疾病診斷要點. 中華神經科雜志, 1996, 29(6): 379-381.
10.	Fugl-Meyer AR, Jaasko L, Leyman I, et al. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med, 1975, 7(1): 13-31.
11.	Wolf SL, Thompson PA, Morris DA, et al. The EXCITE trial: attributes of the Wolf Motor Function Test in patients with subacute stroke. Neurorehabil Neural Repair, 2005, 19(3): 194-205.
12.	Uswatte G, Taub E, Morris D, et al. Reliability and validity of the upper-extremity motor activity log-14 for measuring real-world arm use. Stroke, 2005, 36(11): 2493-2496.
13.	Wade DT. Measuring arm impairment and disability after stroke. Int Disabil Stud, 1989, 11(2): 89-92.
14.	Lindmark B, Hamrin E. Evaluation of functional capacity after stroke as a basis for active intervention. Validation of a modified chart for motor capacity assessment. Scand J Rehabil Med, 1988, 20(3): 111-115.
15.	Boissy P, Bourbonnais D, Carlotti MM, et al. Maximal grip force in chronic stroke subjects and its relationship to global upper extremity function. Clin Rehabil, 1999, 13(4): 354-362.
16.	Jebsen RH, Taylor N, Trieschmann RB, et al. An objective and standardized test of hand function. Arch Phys Med Rehabil, 1969, 50(6): 311-319.
17.	Bohannon RW, Melissa MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther, 1987, 67(2): 206-207.
18.	de Caneda MA, Fernandes JG, de Almeida AG, et al. Reliability of neurological assessment scales in patients with stroke. Arq Neuropsiquiatr, 2006, 64(3A): 690-697.
19.	Mansur CG, Fregni F, Boggio PS, et al. A sham stimulation-controlled trial of rTMS of the unaffected hemisphere in stroke patients. Neurology, 2005, 64(10): 1802-1804.
20.	Fregni F, Boggio PS, Mansur CG, et al. Transcranial direct current stimulation of the unaffected hemisphere in stroke patients. Neuroreport, 2005, 16(14): 1551-1555.
21.	Hamrin E, Wohlin AI. Evaluation of the functional capacity of stroke patients through an activity index. Scand J Rehabil Med, 1982, 14(3): 93-100.
22.	Atkins D, Best D, Briss PA, et al. Grading quality of evidence and strength of recommendations. BMJ (Clinical research ed.), 2004, 328(7454): 1490.
23.	Higgins JPT, Green S. Cochrance Handbook for Systematic Reviews of Interventions 4.2.6 2006: The Cochrane Collaboration.
24.	Fregni F, Boggio PS, Valle AC, et al. A sham-controlled trial of a 5-day course of repetitive transcranial magnetic stimulation of the unaffected hemisphere in stroke patients. Stroke, 2006, 37(8): 2115-2122.
25.	Malcolm MP, Triggs WJ, Light KE, et al. Repetitive transcranial magnetic stimulation as an adjunct to constraint-induced therapy: an exploratory randomized controlled trial. Am J Phys Med Rehabil, 2007, 86(9): 707-715.
26.	Takeuchi N, Tada T, Toshima M, et al. Inhibition of the unaffected motor cortex by 1 HZ repetitive transcranial magnetiv stimulation enhances motor performance and training effect paretic hand in patients with chronic stroke. J Rehabil Med, 2008, 40(4): 298-303.
27.	Khedr EM, Abedl-Fadeil MR, Farghali A, et al. Role of 1 and 3 Hz repetitive transcranial magnetic stimulation on motor function recovery after acute ischaemic stroke. Eur J Neurol, 2009, 16(12): 1323-1330.
28.	Khedr EM, Etraby AE, Hemeda M, et al. Long-term effect of repetitive transcranial magnetic stimulation on motor function recovery after acute ischemic stroke. Acta Neurol Scand, 2010, 121(1): 30-37.
29.	Emara TH, Moustafa RR, ElNahas NM, et al. Repetitive transcranial magnetic stimulation at 1Hz and 5Hz produces sustained improvement in motor function and disability after ischaemic stroke. Eur J Neurol, 2010, 17(9): 1203-1209.
30.	Chang WH, Kim YH, Bang OY, et al. Long-term effects of rTMS on motor recovery in patients after Subacute Storke. J Rehabit Med, 2010, 42(8): 758-764.
31.	Conforto AB, Anjos SM, Saposnik G, et al. Transcranial magnetic stimulation in mild to severe hemiparesis early after stroke: a proof of principle and novel approach to improve motor function. J Neurol, 2012, 259(7): 1399-1405.
32.	池登科, 吳愛玲, 龔凌云, 等. 重復經顱磁刺激在卒中后運動功能康復中的作用. 中西醫結合心腦血管病雜志, 2008, 6(6): 743-744.
33.	饒江, 由麗, 邵偉波, 等. 重復經顱磁刺激對卒中后運動功能康復的臨床觀察. 中國民康醫學, 2010, 22(21): 2712-2713.
34.	吳小麗, 吳宏勝, 謝德豐, 等. 重復經顱磁刺激在腦梗塞運動功能康復中的作用. 海南醫學院學報, 2010, 16(6): 799-801.
35.	曾憲濤, 冷衛東, 李勝, 等. 如何正確理解及使用GRADE系統. 中國循證醫學雜志, 2011, 11(9): 985-990.
36.	Ziemann U. Improving disability in stroke with RTMS. Lancet Neurol, 2005, 4(8): 454-455.
37.	Nowak DA, Grefkes C, Dafotakis M, et al. Effects of low-frequency repetitive transcranial magnetic stimulation of the contralesional primary motor cortex on movement kinematics and neural activity in subcortical stroke. Arch Neurol, 2008, 65(6): 741-747.
38.	Takeuchi N, Chuma T, Matsuo Y, et al. Repetitive transcranial magnetic stimulation of contralesional primary motor cortex improves hand function after stroke. Stroke, 2005, 36(12): 2681-2686.
39.	Ward NS, Brown MM, Thompson AJ, et al. Neural correlates of outcome after stroke：across-sectional fMRI study. Brain, 2003, 126(Pt6): 1430-1448.
40.	Gorsler A, Bäumer T, Weiller C, et al. Interhemispheric effects of high and low frequency rTMS in healthy humans. Clin Neurophysiol, 2003, 114(10): 1800-1807.
41.	Gangitano M, Valero-Cabré A, Tormos JM, et al. Modulation of input-output curves by low and high frequency repetitive transcranial magnetic stimulation of the motor cortex. Clin Neurophysiol, 2002, 113(8): 1249-1257.
42.	Fitzgerald PB, Fountain S, Daskalakis ZJ. A comprehensive review of the effects of rTMS on motor cortical excitability and inhibition. Clin Neurophysiol, 2006, 117(12): 2584-2596.
43.	Wassermann EM, Lisanby SH. Therapeutic application of repetitive transeranial magnetic stimulation: a review. Clin Neurophysiol, 2001, 112(8): 1367-1377.
44.	Lazzaro VD, Dileone M, Profice P, et al. Direct demonstration that repetitive transcranial tmagnetic stimulation can enhance corticospinal excitability in stroke. Stroke, 2006, 37(11): 2850-2853.
45.	Huang YZ, Edwards MJ, Rounis E, et al. Theta burst stimulation of the human motor cortex. Neuron, 2005, 45(2): 201-206.
46.	Pascual-Leone A, Vails-Sole J, Wassermann EM, et al. Response to rapid-rate transcranial magnetite stimulation of the human motor cortex. Brain, 1994, 117(Pt4): 847-858.
47.	Chen R, Classen J, Gerloff C, et al. Depression of motor cortex excitability by low frequency transcranial magnetic stimulation. Neurology, 1997, 48(5): 1398-1403.
48.	Helmieh RC, Siebner HR, Bakker M, et al. Repetitive transcranial magnetic stimulation to improve mood and motor function in Parkinson’s disease. Neurol Sci, 2006, 248(2): 84-96.
49.	莊立. 重復經顱磁刺激改善缺血性腦卒中動功能的作用機制. 中國神經免疫學和神經病學雜志, 2009, 16(3): 213-216.
50.	Murase N, Duque J, Mazzocchio R, et al. Influence of interhemispheric interactions on motor function in chronic stroke. Ann Neurol, 2004, 55(3): 400-409.
51.	Khedr EM, Ahmed MA, Fathy N, et al. Therapeutic trial of repetitive transcranial magnetic stimulation after acute ischemic stroke. Neurology, 2005, 65(3): 466-468.
52.	Pal PK, Hanajirna R, Gmraj CA, et al. Effect of low-frequency repetitive transcranial magnetic stimulation on interhemispheric inhibition. J Neurophysiol, 2005, 94(3): 1668-1675.
53.	Jung SH, Shin JE, Jeong YS, et al. Changes in motor cortical excitability induced by high-frequency repetitive transcranial magnetic stimulation of different stimulation durations. Clin Neurophysiol, 2008, 119(1): 71-79.
54.	Küçükdeveci AA, Tennant A, Grimby G, et al. Strategies for assessment and outcome measurement in physical and rehabilitation medicine: an educational review. J Rehabil Med, 2011, 43(8): 661-672.
55.	Barak S, Duncan PW. Issues in Selecting Outcome Measures to Assess Functional Recovery After Stroke. NeuroRx, 2006, 3(4): 505-524.

1. Warlow C, Van Gijn J, Sandercock P, et al. Stroke: practical management. 3Ed. UK: Blackwell Publishing, 2008: 5-76.
2. 吳兆蘇, 姚崇華, 趙冬. 我國人群腦卒中發病率、死亡率的流行病學研究. 中華流行病學雜志, 2003, 24(3): 236-239.
3. World Health Organization.International classification of functioning, isability and health: ICF. Geneva: World Health Organization, 2001.
4. Wade DT. Measurement in neurological rehabilitation. Curr Opin Neurol Neurosurg, 1992, 5(5): 682-686.
5. Duncan PW, Zorowitz R, Bates B, et al. Management of Adult Stroke Rehabilitation Care: a clinical practice guideline. Stroke, 2005, 36(9): 100-143.
6. Barker AT, Jalinous R, Freeston IL. Non-invasive magnetic stimulotion of human motor cortex. Lancet, 1985,1(8437): 1106-1107.
7. Khedr EM, Ahmed MA, Fathy N, et al. Therapeutic trial of repetitive transcranial magnetic stimulation after acute ischemic stroke. Neurology, 2005, 65(3): 466-468.
8. World Health Organisation. Cerebrovascular Disorders(Offset Publications). Geneva:World Health Organization, 1978.
9. 中華醫學會全國第4次腦血管病學術會議. 各類腦血管疾病診斷要點. 中華神經科雜志, 1996, 29(6): 379-381.
10. Fugl-Meyer AR, Jaasko L, Leyman I, et al. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med, 1975, 7(1): 13-31.
11. Wolf SL, Thompson PA, Morris DA, et al. The EXCITE trial: attributes of the Wolf Motor Function Test in patients with subacute stroke. Neurorehabil Neural Repair, 2005, 19(3): 194-205.
12. Uswatte G, Taub E, Morris D, et al. Reliability and validity of the upper-extremity motor activity log-14 for measuring real-world arm use. Stroke, 2005, 36(11): 2493-2496.
13. Wade DT. Measuring arm impairment and disability after stroke. Int Disabil Stud, 1989, 11(2): 89-92.
14. Lindmark B, Hamrin E. Evaluation of functional capacity after stroke as a basis for active intervention. Validation of a modified chart for motor capacity assessment. Scand J Rehabil Med, 1988, 20(3): 111-115.
15. Boissy P, Bourbonnais D, Carlotti MM, et al. Maximal grip force in chronic stroke subjects and its relationship to global upper extremity function. Clin Rehabil, 1999, 13(4): 354-362.
16. Jebsen RH, Taylor N, Trieschmann RB, et al. An objective and standardized test of hand function. Arch Phys Med Rehabil, 1969, 50(6): 311-319.
17. Bohannon RW, Melissa MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther, 1987, 67(2): 206-207.
18. de Caneda MA, Fernandes JG, de Almeida AG, et al. Reliability of neurological assessment scales in patients with stroke. Arq Neuropsiquiatr, 2006, 64(3A): 690-697.
19. Mansur CG, Fregni F, Boggio PS, et al. A sham stimulation-controlled trial of rTMS of the unaffected hemisphere in stroke patients. Neurology, 2005, 64(10): 1802-1804.
20. Fregni F, Boggio PS, Mansur CG, et al. Transcranial direct current stimulation of the unaffected hemisphere in stroke patients. Neuroreport, 2005, 16(14): 1551-1555.
21. Hamrin E, Wohlin AI. Evaluation of the functional capacity of stroke patients through an activity index. Scand J Rehabil Med, 1982, 14(3): 93-100.
22. Atkins D, Best D, Briss PA, et al. Grading quality of evidence and strength of recommendations. BMJ (Clinical research ed.), 2004, 328(7454): 1490.
23. Higgins JPT, Green S. Cochrance Handbook for Systematic Reviews of Interventions 4.2.6 2006: The Cochrane Collaboration.
24. Fregni F, Boggio PS, Valle AC, et al. A sham-controlled trial of a 5-day course of repetitive transcranial magnetic stimulation of the unaffected hemisphere in stroke patients. Stroke, 2006, 37(8): 2115-2122.
25. Malcolm MP, Triggs WJ, Light KE, et al. Repetitive transcranial magnetic stimulation as an adjunct to constraint-induced therapy: an exploratory randomized controlled trial. Am J Phys Med Rehabil, 2007, 86(9): 707-715.
26. Takeuchi N, Tada T, Toshima M, et al. Inhibition of the unaffected motor cortex by 1 HZ repetitive transcranial magnetiv stimulation enhances motor performance and training effect paretic hand in patients with chronic stroke. J Rehabil Med, 2008, 40(4): 298-303.
27. Khedr EM, Abedl-Fadeil MR, Farghali A, et al. Role of 1 and 3 Hz repetitive transcranial magnetic stimulation on motor function recovery after acute ischaemic stroke. Eur J Neurol, 2009, 16(12): 1323-1330.
28. Khedr EM, Etraby AE, Hemeda M, et al. Long-term effect of repetitive transcranial magnetic stimulation on motor function recovery after acute ischemic stroke. Acta Neurol Scand, 2010, 121(1): 30-37.
29. Emara TH, Moustafa RR, ElNahas NM, et al. Repetitive transcranial magnetic stimulation at 1Hz and 5Hz produces sustained improvement in motor function and disability after ischaemic stroke. Eur J Neurol, 2010, 17(9): 1203-1209.
30. Chang WH, Kim YH, Bang OY, et al. Long-term effects of rTMS on motor recovery in patients after Subacute Storke. J Rehabit Med, 2010, 42(8): 758-764.
31. Conforto AB, Anjos SM, Saposnik G, et al. Transcranial magnetic stimulation in mild to severe hemiparesis early after stroke: a proof of principle and novel approach to improve motor function. J Neurol, 2012, 259(7): 1399-1405.
32. 池登科, 吳愛玲, 龔凌云, 等. 重復經顱磁刺激在卒中后運動功能康復中的作用. 中西醫結合心腦血管病雜志, 2008, 6(6): 743-744.
33. 饒江, 由麗, 邵偉波, 等. 重復經顱磁刺激對卒中后運動功能康復的臨床觀察. 中國民康醫學, 2010, 22(21): 2712-2713.
34. 吳小麗, 吳宏勝, 謝德豐, 等. 重復經顱磁刺激在腦梗塞運動功能康復中的作用. 海南醫學院學報, 2010, 16(6): 799-801.
35. 曾憲濤, 冷衛東, 李勝, 等. 如何正確理解及使用GRADE系統. 中國循證醫學雜志, 2011, 11(9): 985-990.
36. Ziemann U. Improving disability in stroke with RTMS. Lancet Neurol, 2005, 4(8): 454-455.
37. Nowak DA, Grefkes C, Dafotakis M, et al. Effects of low-frequency repetitive transcranial magnetic stimulation of the contralesional primary motor cortex on movement kinematics and neural activity in subcortical stroke. Arch Neurol, 2008, 65(6): 741-747.
38. Takeuchi N, Chuma T, Matsuo Y, et al. Repetitive transcranial magnetic stimulation of contralesional primary motor cortex improves hand function after stroke. Stroke, 2005, 36(12): 2681-2686.
39. Ward NS, Brown MM, Thompson AJ, et al. Neural correlates of outcome after stroke：across-sectional fMRI study. Brain, 2003, 126(Pt6): 1430-1448.
40. Gorsler A, Bäumer T, Weiller C, et al. Interhemispheric effects of high and low frequency rTMS in healthy humans. Clin Neurophysiol, 2003, 114(10): 1800-1807.
41. Gangitano M, Valero-Cabré A, Tormos JM, et al. Modulation of input-output curves by low and high frequency repetitive transcranial magnetic stimulation of the motor cortex. Clin Neurophysiol, 2002, 113(8): 1249-1257.
42. Fitzgerald PB, Fountain S, Daskalakis ZJ. A comprehensive review of the effects of rTMS on motor cortical excitability and inhibition. Clin Neurophysiol, 2006, 117(12): 2584-2596.
43. Wassermann EM, Lisanby SH. Therapeutic application of repetitive transeranial magnetic stimulation: a review. Clin Neurophysiol, 2001, 112(8): 1367-1377.
44. Lazzaro VD, Dileone M, Profice P, et al. Direct demonstration that repetitive transcranial tmagnetic stimulation can enhance corticospinal excitability in stroke. Stroke, 2006, 37(11): 2850-2853.
45. Huang YZ, Edwards MJ, Rounis E, et al. Theta burst stimulation of the human motor cortex. Neuron, 2005, 45(2): 201-206.
46. Pascual-Leone A, Vails-Sole J, Wassermann EM, et al. Response to rapid-rate transcranial magnetite stimulation of the human motor cortex. Brain, 1994, 117(Pt4): 847-858.
47. Chen R, Classen J, Gerloff C, et al. Depression of motor cortex excitability by low frequency transcranial magnetic stimulation. Neurology, 1997, 48(5): 1398-1403.
48. Helmieh RC, Siebner HR, Bakker M, et al. Repetitive transcranial magnetic stimulation to improve mood and motor function in Parkinson’s disease. Neurol Sci, 2006, 248(2): 84-96.
49. 莊立. 重復經顱磁刺激改善缺血性腦卒中動功能的作用機制. 中國神經免疫學和神經病學雜志, 2009, 16(3): 213-216.
50. Murase N, Duque J, Mazzocchio R, et al. Influence of interhemispheric interactions on motor function in chronic stroke. Ann Neurol, 2004, 55(3): 400-409.
51. Khedr EM, Ahmed MA, Fathy N, et al. Therapeutic trial of repetitive transcranial magnetic stimulation after acute ischemic stroke. Neurology, 2005, 65(3): 466-468.
52. Pal PK, Hanajirna R, Gmraj CA, et al. Effect of low-frequency repetitive transcranial magnetic stimulation on interhemispheric inhibition. J Neurophysiol, 2005, 94(3): 1668-1675.
53. Jung SH, Shin JE, Jeong YS, et al. Changes in motor cortical excitability induced by high-frequency repetitive transcranial magnetic stimulation of different stimulation durations. Clin Neurophysiol, 2008, 119(1): 71-79.
54. Küçükdeveci AA, Tennant A, Grimby G, et al. Strategies for assessment and outcome measurement in physical and rehabilitation medicine: an educational review. J Rehabil Med, 2011, 43(8): 661-672.
55. Barak S, Duncan PW. Issues in Selecting Outcome Measures to Assess Functional Recovery After Stroke. NeuroRx, 2006, 3(4): 505-524.

《中國循證醫學雜志》

重復經顱磁刺激治療腦卒中后患者肢體運動功能障礙的系統評價

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《中國循證醫學雜志》

重復經顱磁刺激治療腦卒中后患者肢體運動功能障礙的系統評價

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