Page 101 - 2023-08-中国全科医学

·998· http: //www.chinagp.net E-mail: zgqkyx@chinagp.net.cn March 2023, Vol.26 No.8

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Corresponding authors：TAN Jie，Associate professor，Master supervisor；E-mail：86869454@qq.com
ZHAO Ning，Associate chief physician，Master supervisor；E-mail：298360561@qq.com
【Abstract】 Background Upper limb motor dysfunction is a common complication after stroke that seriously affects
daily living skills of patients. As a common neuroelectrohysiological technique，repetitive transcranial magnetic stimulation
（rTMS） has a good effect on post-stroke upper limb motor dysfunction. However，there is still no practice-based evidence on
the selection of modalities of rTMS. Objective To evaluate the clinical efficacy of four rTMS modalities in post-stroke upper limb
motor dysfunction by a network meta-analysis. Methods Randomized controlled trials（RCTs） about rTMS for treating upper
limb motor dysfunction after stroke were searched with subject words combined with free words as searching terms in PubMed，
Embase，Cochrane Library，Web of Science，CBM，CNKI，Wanfang Data，and VIP from inception to February 2022，
supplemented by references from retrospective meta-analysis. Two researchers performed literature screening，data extraction，
and quality evaluation separately. RevMan 5.0 and Stata 16.0 were used for statistical analysis. Results A total of 17 RCTs with
790 cases were included. Six interventions were involved：high frequency-rTMS（HF-rTMS），low frequency-rTMS（LF-rTMS），
intermittent theta burst stimulation（iTBS），continuous theta burst stimulation（cTBS），sham stimulation and conventional
therapy. Network meta-analysis results showed that HF-rTMS and LF-rTMS had better effects on increasing the FMA-UE
score than sham stimulation and conventional therapy（P<0.05）. cTBS increased the FMA-UE score more significantly than
conventional therapy（P<0.05）. LF-rTMS increased the MBI and BI scores more notably than sham stimulation and conventional
therapy（P<0.05）. HF-rTMS and LF-rTMS reduced the MEP latency more significantly than sham stimulation（P<0.05）. The
SUCRA ranking of the six interventions in terms of increasing the FMA-UE score showed the following：LF-rTMS（79.9%）
>cTBS（75.3%）>HF-rTMS（71.1%）>iTBS（45.8%）>sham stimulation（20.2%）>conventional therapy（7.7%）. The
SUCRA ranking of decreasing the MAS score revealed the following：iTBS（77.0%）>LF-rTMS（64.1%）>cTBS（61.0%）
>HF-rTMS（38.0%）>sham stimulation（30.6%）>conventional therapy（29.2%）. The SUCRA ranking of increasing the
MBI and BI scores showed the following：LF-rTMS（96.4%）>iTBS（74.9%）>HF-rTMS（38.6%）>sham stimulation
（30.7%）>conventional therapy（9.4%）. The SUCRA ranking of reducing the MEP latency showed the following：HF-rTMS
（80.0%）>LF-rTMS（78.9%）>conventional therapy（58.8%）>iTBS（24.9%）>sham stimulation（7.5%）. Conclusion
The available evidence indicates that，among four modalities producing better effects than sham stimulation and conventional
therapy，namely LF-rTMS，HF-rTMS，iTBS，and cTBS，LF-rTMS was superior to the other three in improving upper limb
motor function and daily living skills of stroke patients，iTBS performed best in decreasing upper limb muscle tension，and HF-
rTMS did best in intervening the corticospinal excitability.
【Key words】 Stroke；Repetitive transcranial magnetic stimulation；Theta burst stimulation；Upper limb motor
dysfunction；Network meta-analysis；Randomized controlled trials

脑卒中又名脑血管意外，是由于脑内血管堵塞或破 的文献，比较具有共同特征的多种干预措施，按照结局
裂等多种原因引起的局限性或全脑功能障碍。中国每 指标进行分析排序，获得改善疾病相关症状的最佳干预
年新增脑卒中患者约 200 万 ［1］ ，其中 55%~75% 的患 方案，为临床实践提供依据 ［6］ 。因此，本研究采用网
者存在不同程度的上肢运动功能障碍，具体表现为上 状 Meta 分析，比较 rTMS 的 4 种干预模式对脑卒中后上
肢肌力下降、肌张力增高、关节挛缩、皮质脊髓兴奋 肢运动功能障碍患者上肢运动功能、上肢肌张力、日常
性改变等，严重影响了患者日常生活能力 ［2-3］ 。重复 生活能力及皮质脊髓兴奋性的影响，为临床 rTMS 模式
经颅磁刺激（repetitive transcranial magnetic stimulation， 的选择提供循证依据。
rTMS）作为近年来治疗脑卒中后上肢运动功能障碍常 1 资料与方法
见的神经电生理技术，具有无痛无创、安全可靠、操作 1.1 文献纳入和排除标准
简便等特点，已在临床中取得较好的疗效 ［4］ 。目前临 1.1.1 文献纳入标准 （1）研究设计类型：随机对照
床上治疗脑卒中后上肢运动功能障碍的 rTMS 模式主要 试 验（randomized controlled trial，RCT）。（2） 研 究
有 4 种：高频 rTMS（high frequency-rTMS，HF-rTMS） 对象：最小年龄或平均年龄≥ 50 岁，经《中国各类主
（>1 Hz）、低频 rTMS（low frequency-rTMS，LF-rTMS） 要脑血管病诊断要点 2019》 ［7］ 确诊为脑卒中且伴有
（ ≤ 1 Hz）、 间 断 性 theta 节 律 刺 激（intermittent 上肢运动功能障碍的住院患者。（3）干预措施：HF-
theta burst stimulation，iTBS）、连续性 theta 节律刺激 rTMS、LF-rTMS、iTBS、cTBS 与假刺激的比较、与常
（continuous theta burst stimulation，cTBS） ［5］ 。网状 规疗法的比较或 4 种 rTMS 模式之间的相互比较。（4）
Meta 分析通过归纳总结相关的文献，排除不符合标准 结局指标：Fugl-Meyer 运动评分量表上肢部分（Fugl-