經顱直流電刺激合併神經肌肉電刺激對於中風病人大腦皮質興奮性的效應：經顱磁刺激初步研究

背景與目的：先前研究證實經顱直流電刺激(transcranial direct current stimulation, tDCS)與神經肌肉電刺激(neuromuscular electrical stimulation, NMES)於中風患者上肢功能恢復的效益，但同時合併兩種刺激對於大腦動作皮質興奮性的影響仍不清楚。本研究探討tDCS合併NMES對於大腦動作皮質興奮性變化的效應。方法：共徵召23位首次發病超過六個月缺血性中風患者，塊狀隨機分派至「tDCS合併NMES」、「tDCS合併假性NMES」或「假性tDCS合併假性NMES」三組。三組個案接受為期3週，每週5次，每天30分鐘，總共15次的介入治療。tDCS採雙極刺激模式，強度為2毫安培(mA)，兩個電極置放於雙側大腦主要動作皮質區。兩個NMES主動電極強度設定在10〜20mA，分別置於橈側伸腕肌和伸指總肌的運動點。使用經顱磁刺激評估第一次介入前後及治療15次結束後損傷大腦動作皮質興奮性改變情形。結果：共計有20位受試者完成實驗介入及評估，大腦運動皮質興奮性的變化於第一次介入前後即時效應和15次介入後之治療效應三組受試者之間皆沒有顯著變化差異。結論：初步研究結果尚無法支持tDCS合併NMES介入模式能夠有效增加損傷大腦動作皮質興奮性。未來的研究需要招募更多的受試者並探討最佳介入組合的模式。

關鍵字

中風；經顱直流電刺激；神經肌肉電刺激；經顱磁刺激；動作皮質

並列摘要

Background and purpose：Previous studies have demonstrated the transcranial direct current stimulation (tDCS) and neuromuscular electrical stimulation (NMES) intervention on motor recovery of upper extremity (UE) of stroke patients are evident, but changes of cortical excitability by combination of two neuromodulation instruments are still unknown. The aim of this study was to investigate the effects of tDCS combined with NMES on excitability of motor cortex in patients with stroke. Methods：Twenty three patients with first-ever ischemic stroke for more than six months were recruited and assigned into one of three groups (tDCS combined with NMES, tDCS combined with sham NMES, or sham tDCS combined with sham NMES) by block randomization. All participants received an intervention protocol with a total of 15 sessions for 3 weeks (5 times per week, 30 minutes daily). The tDCS intensity was set at 2mA with dual stimulation mode, the two electrodes were placed on the bilateral primary motor cortex. Two active electrodes of the NMES with intensity of 10 ~ 20mA were placed on the motor points of the extensor carpi radialis muscle and the extensor digitorum muscle. Transcranial magnetic stimulation was used to assess the changes in corticomotor excitability before and after the first and 15 interventions. Results：A total of twenty subjects completed the interventions and assessments. No significant changes in corticomotor excitability among three groups were found after the first and 15 interventions. Conclusion：Our preliminary findings did not support that the tDCS combined with NMES might increase effect in cortical excitability in lesioned hemisphere. Future studies need to recruit more subjects and identify the optimal settings of intervention mode.