【作者】 朱虹；

【导师】 陈先文；

【作者基本信息】 安徽医科大学 ， 神经病学， 2025， 硕士

【摘要】 目的观察重复经颅磁刺激(r TMS)对帕金森病冻结步态的改善作用,分析其治疗前后皮层兴奋性的改变,探讨其作用机制。对象和方法纳入原发性帕金森伴冻结步态(PD-FOG)患者54例,不伴冻结步态(NO-FOG PD)患者30例,健康对照(HC)30例。将PD-FOG随机分为真刺激组(n=28)、假刺激组两组(n=26)。收集被试人口学和临床资料,采用运动障碍病学会帕金森病综合评定量表第二、三部分(MDS-UPDRSⅡ、Ⅲ)、H-Y分期、新冻结步态问卷量表(NFOGQ)、Tinetti平衡与步态量表、简易精神状态检查量表(MMSE)、汉密尔顿焦虑量表(HAMA)、汉密尔顿抑郁量(HAMD)表的评估被试运动症状和认知情绪障碍症状。采用经颅磁刺激(TMS)及运动诱发电位记录治疗前后皮层兴奋性指标:静息运动阈值(RMT)、皮质静默期(CSP)、短间隔皮质内抑制(SICI)、长间隔皮质内抑制(LICI)和皮质内易化(ICF)、刺激反应曲线(I/O curve)。比较PD-FOG、NO-FOG PD和HC组皮层兴奋性差异。PD-FOG真刺激组给于高频r TMS治疗,刺激靶点为双侧大脑半球M1区的腿部运动区(M1-LL),刺激频率10HZ,刺激强度为引起下肢运动的最小阈值强度,每日一次,每次20min,连续14天。对假刺激组给与r TMS假刺激,线圈垂直放置于双侧M1-LL,在刺激过程中,注意确保线圈位置固定不变,刺激参数与真刺激组相同,用连续刺激模式,每日一次,每次20分钟,连续14天。比较两组PD-FOG患者r TMS治疗前后临床症状和皮层兴奋性的变化。结果1、三组间在年龄、性别、体重、身高、受教育程度、认知功能和情绪状态上大致相当(P>0.05)。PD-FOG组与NO-FOG PD组表现出相匹配的H/Y分期、左旋多巴等效剂量(LEDD)、MDS-UPDRS II、MDS-UPDRS III评分。PD-FOG患者的Tinetti平衡、步态评分明显低于NO-FOG PD患者(P均<0.0001)。与NO-FOG组和健康对照相比,PD-FOG患者的SICI(ISI:2ms、4ms)、LICI(ISI:100ms)均显著减弱,但ICF三组间无统计学差异。2、PD-FOG真刺激组治疗前后,其日常生活能力,运动症状、冻结步态的严重程度及抑郁、焦虑情况均得到明显改善(P<0.05),而假刺激组治疗前后的量表评分无明显统计学差异(P>0.05)。r TMS真刺激组治疗后SICI(ISI:2ms、4ms)和LICI(ISI:100ms)较治疗前均显著的增强,但ICF在治疗前后无显著变化;假刺激组治疗前后SICI、LICI及ICF无显著改变。结论帕金森病伴冻结步态患者皮层内抑制活动减弱。双侧M1区高频r TMS治疗,可改善PD患者的冻结步态、整体运动功能以及抑郁和焦虑症状,并可逆转皮层内抑制减弱。更多还原

【Abstract】 ObjectivesTo observe the effect of repetitive transcranial magnetic stimulation(r TMS)on frozen gait in Parkinson’s disease,analyze the changes of cortical excitability before and after treatment,and explore the mechanism of action.Subjects and MethodsWe included 54 patients with PD with frozen gait(PD-FOG),30 patients without frozen gait(NO-FOG PD),and 30 healthy controls(HC).PD-FOG was randomly divided into two groups:true stimulus group(n=28)and false stimulus group(n=26).Demographic and clinical data were collected.Parts II and III(MDS-UPDRS II and III),H-Y staging,NFOGQ,Tinetti Balance and Gait Scale,MMSE,HAMA,and HA were used MD)table was used to assess motor symptoms and cognitive-emotional disorder symptoms.Transcranial magnetic stimulation(TMS)and motor evoked potential were used to record cortical excitability before and after treatment,including resting motor threshold(RMT),cortical quiet period(CSP),short-septal cortical inhibition(SICI),long-septal cortical inhibition(LICI),intracortical facilitation(ICF),and stimulation-response curve(I/O curve).The cortical excitability of PD-FOG,NO-FOG PD and HC groups was compared.The PD-FOG true stimulation group was given high-frequency r TMS treatment,the stimulation target was the leg motor area(M1-LL)in the M1 region of the bilateral cerebral hemisphere,the stimulation frequency was 10HZ,and the stimulation intensity was the minimum threshold intensity causing lower limb movement,once a day,20minutes each time,for 14 consecutive days.The false stimulation group was given r TMS false stimulation,and the coil was placed vertically on both sides of M1-LL.During the stimulation process,attention was paid to ensure that the coil position was fixed and the stimulation parameters were the same as those of the true stimulation group.The continuous stimulation mode was used once a day for 20 minutes each time for 14 consecutive days.The clinical symptoms and cortical excitability of two groups of PD-FOG patients were compared before and after r TMS treatment.Result1.Age,sex,weight,height,education level,cognitive function and emotional state were roughly similar among the three groups(P>0.05).The H/Y staging,LEvodopa equivalent dose(LEDD),MDS-UPDRS II and MDS-UPDRS III scores were matched between PD-FOG and NO-FOG PD groups.The Tinetti balance and gait scores of PD-FOG patients were significantly lower than those of NO-FOG PD patients(P<0.0001).Compared with the No-FOG group and healthy controls,SICI(ISI:2ms,4ms)and LICI(ISI:100ms)in PD-FOG patients were significantly decreased,but there was NO statistical difference in ICF among the three groups.2.Daily living ability,motor symptoms,severity of frozen gait,depression and anxiety were significantly improved in the PD-FOG true stimulation group before and after treatment(P<0.05),while there was no significant difference in the scale scores of the false stimulation group before and after treatment(P>0.05).After treatment,SICI(ISI:2ms,4ms)and LICI(ISI:100ms)were significantly increased in r TMS true stimulation group,but ICF had no significant change before and after treatment.There were no significant changes in SICI,LICI and ICF in sham stimulation group before and after treatment.ConclusionReduced cortical inhibitory activity in patients with Parkinson’s disease and frozen gait.Bilateral M1 high-frequency r TMS treatment improves frozen gait,overall motor function,and symptoms of depression and anxiety in PD patients,and reverses reduced intracortex inhibition.更多还原