比較上肢痛覺溫度刺激和神經肌肉電刺激對於中風病人大腦皮質興奮性的即時效應: 經顱磁刺激先導型研究

背景與目的：許多研究證實痛覺冷熱溫度刺激和神經肌肉電刺激能夠促進中風病患上肢肢體動作功能的恢復。然而，目前沒有研究評估比較上述兩種物理因子刺激模式對於大腦動作皮質區產生效應的差異。本先導型研究目的探討比較痛覺冷熱溫度刺激與神經肌肉電刺激對於中風病患大腦皮質活化興奮性的即時效應。方法：於某大學附設醫院徵招首次發病六個月以上中風病患。每位受試者患側上肢分別接受單次30分鐘痛覺冷熱溫度刺激(熱痛: 46±1oC; 冷痛 7±1oC )及單次30分鐘的神經肌肉電刺激(頻率60赫茲、強度10~20毫安培，作用期/休息期：10秒/10秒)，採隨機方式來決定兩種不同介入的先後順序。兩種刺激介入前與介入後分別進行經顱磁刺激施測，記錄雙側大腦動作皮質的動作閾值、動作誘發電位與動作區域大小改變情況，做為評估比較大腦動作皮質興奮性變化的依據。結果：共計8位慢性中風病患完成這個實驗計畫。接受痛覺冷熱溫度刺激或神經肌肉電刺激介入後，於患側大腦動作皮質區皆發現動作閾值下降、動作誘發電位上升和動作皮質區域大小上升的情形；其中，在接受神經肌肉電刺激後，動作皮質區域大小從13.50±6.82上升到22.38±10.30(改變量8.88±1.48)有達到統計上顯著差異(p=0.01)。結論：比較神經肌肉電刺激和痛覺冷熱溫度刺激介入對於中風患側腦動作皮質即時活化程度並未達到顯著性差異；然而，神經肌肉電刺激介入前後對於患側大腦動作皮質活化區域有明顯變大。臨床意義：這個初步結果可以提供應用痛覺溫度刺激和神經肌肉電刺激介入臨床慢性期中風病患上肢動作恢復治療計劃的參考。

關鍵字

刺激；誘發電位；興奮性；中風

並列摘要

Background and Purpose: Several studies confirmed the effects of noxious thermal stimulation (NTS) and neuromuscular electrical stimulation (NMES) on functional recovery of upper extremity (UE) of stroke patients, but the comparison of effects on cortical excitability by the two physical agents was not yet evaluated. Therefore, this pilot study aims to explore the immediate effects between NTS and NMES on cortical excitability in patients with stroke. Methods: Subjects with first-stroke onset more than 6 months were recruited from the rehabilitation departments of a university hospital. The subjects received a 30-minute NTS intervention (hot-pain: 46±1oC; cold-pain 7±1oC) and a 30-minute NES (frequency: 60 Hz; intensity: 10~20mA; on/ off: 10sec/10sec) on affected UE with randomized sequences. Transcranial magnetic stimulation parameters including motor threshold (MT), motor evoked potential (MEP), and size of cortical motor output map (map size) from both hemispheres were assessed for the changes on cortical excitability before and after two separate NTS and NMES interventions. Results: A total of 8 chronic stroke patients completed this study. The MT decrease, MEP increase, and map size increase were found both receiving NTS and NMES interventions. The change of map size from 13.50 ± 6.82 to 22.38 ± 10.30 (number 8.88 ± 1.48) was significant (p=0.01) after NMES intervention. Conclusions: The finding of this study revealed no significant differences in the immediate effects between NTS and NMES intervention on cortical excitability. However, the increase of size of cortical motor output map in affected hemisphere after NMES intervention was significant. Clinical Relevance: This preliminary result can provide the reference of clinical use for NTS and NMES interventions on UE motor recovery in patients with chronic stroke.