重复经颅磁刺激联合认知训练对缺血性脑卒中患者淡漠的效果研究

doi:10.3761/j.issn.0254-1769.2023.03.004

摘要/Abstract

摘要：

目的探讨重复经颅磁刺激（repeat transcranial magnetic stimulation，rTMS）联合认知训练对缺血性脑卒中患者淡漠症状的影响。方法采用便利抽样法，选取2021年1月—12月在海口市某三级甲等医院神经内科、康复科住院的96例缺血性脑卒中伴淡漠的患者为研究对象。采用2 × 2析因试验设计，计算机随机分组，将研究对象分为r组、s组、联合组、对照组，每组24例。在对照组干预措施的基础上，r组行rTMS治疗，s组行卡片式Stroop范式认知训练，联合组行rTMS联合卡片式Stroop范式认知训练，对照组给予缺血性脑卒中常规治疗、康复及护理干预措施，干预周期均为15 d，使用淡漠评定量表-知情者版（Apathy Evaluation Scale-Informant，AES-I）评估干预后患者淡漠水平改善情况。结果 87例完成干预，4组基线均衡，差异无统计学意义（P>0.05）。rTMS对降低AES-I总分及各维度得分有主效应（P<0.001），卡片式Stroop范式认知训练对降低AES-I总分及兴趣、认知、行为维度得分有主效应（P<0.05），联合应用对改善AES-I总分及各维度得分无交互作用（P>0.05）。两两比较，3个试验组AES-I总分改善均好于对照组（P<0.05），改善效果从大到小为联合组、r组、s组，且联合组在兴趣、认知、行为维度比r组、s组改善效果更显著（P<0.05）。结论 rTMS与认知训练联合应用或单一训练均能降低卒中患者淡漠水平，联合应用效果更加明显，但rTMS与认知训练无交互作用，联合应用的效果可能仅为单一措施效果的叠加。

关键词: 淡漠, 卒中, 重复经颅磁刺激, 认知训练, 康复护理

Abstract:

Objective To explore the effects of repetitive transcranial magnetic stimulation（rTMS） combined with cognitive training on apathy symptoms in patients with apathy after ischemic stroke. Methods From January to December 2021，96 patients with ischemic stroke complicated with apathy in a tertiary A Hospital in Haikou City were randomly divided into a control group （n=24），r group （n=24），s group （n=24） and a combined group （n=24）. Using 2×2 factorial experimental design，the control group was given routine treatment，rehabilitation and nursing care. On the basis of interventions in the control group，the r group was treated with rTMS，and the s group was treated with card Stroop paradigm cognitive training，and the combined group was treated with rTMS combined with card Stroop paradigm cognitive training. The intervention cycle was 15 days. The apathy evaluation scale-informant（AES-I） was used to evaluate the improvement of apathy level. Results （1）87 patients completed the intervention，and there was no significant difference in baseline balance among the 4 groups（P>0.05）. （2）rTMS had a main effect on reducing the total score of AES-I and each dimension（P<0.001）. Card-based Stroop paradigm cognitive training had a main effect on reducing the total score of AES-I and the dimensions of interest，cognition and behavior（P<0.05）. Combined application had no interactive effect on improving apathy AES-I and all dimensions（P>0.05）.（3）The improvement of the total score of AES-I in the intervention groups were more effective than that in the control group（P<0.05），and the improvement effect was from large to small in the combined group，r group and s group，and the effect of the combined group was best in interest，cognition and behavior（P<0.05）. Conclusion rTMS combined with cognitive training or single training can reduce the level of apathy in PSA patients. The effect of combined application was most obvious，but there was no interaction between rTMS and cognitive training. The effect of combined application may only be the superposition of the effect of a single measure.

Key words: Apathy, Stroke, Repetitive Transcranial Magnetic Stimulation, Cognitive Training, Rehabilitation Nursing

谭绍英, 林晓丽, 刘赞, 王丹心, 吴尧, 王涛. 重复经颅磁刺激联合认知训练对缺血性脑卒中患者淡漠的效果研究[J]. 中华护理杂志, 2023, 58(3): 282-288.

TAN Shaoying, LIN Xiaoli, LIU Zan, WANG Danxin, WU Yao, WANG Tao. Effects of repetitive transcranial magnetic stimulation combined with cognitive training in patients with apathy after ischemic stroke[J]. Chinese Journal of Nursing, 2023, 58(3): 282-288.

图/表 3

表1 4组一般资料比较（n=87）

Table 1 Comparison of general data among 4 groups（n=87）

续表1 4组一般资料比较（n=87）

Table 1(Continued) Comparison of general data among 4 groups（n=87）

表2 4组淡漠评定量表-知情者版总分及各维度得分比较

Table 2 Comparison of total scores and dimensions of Apathy Evaluation Scale-Informant among 4 groups

参考文献 28

[1]	GBD Stroke Collaborators. and national burden of stroke and its risk factors,1990-2019:a systematic analysis for the Global Burden of Disease Study 2019[J]. Lancet Neurol, 2021, 20(10):795-820. DOI URL
[2]	Carnes-Vendrell A, Deus J, Molina-Seguin J, et al. Depression and apathy after transient ischemic attack or minor stroke:prevalence,evolution and predictors[J]. Sci Rep, 2019, 9(1):16248. DOI PMID
[3]	Zhao JY, Jin XL, Chen BX, et al. Apathy symptoms increase the risk of dementia conversion:a case-matching cohort study on patients with post-stroke mild cognitive impairment in China[J]. Psychogeriatrics, 2021, 21(2):149-157. DOI URL
[4]	Lopatkiewicz AM, Pera J, Slowik A, et al. Early apathetic,but not depressive,symptoms are associated with poor outcome after stroke[J]. Eur J Neurol, 2021, 28(6):1949-1957. DOI PMID
[5]	Sepehry AA, Sarai M, Hsiung GR. Pharmacological therapy for apathy in Alzheimer’s disease:a systematic review and meta-analysis[J]. Can J Neurol Sci, 2017, 44(3):267-275. DOI PMID
[6]	中国中医药信息学会抗衰老分会. 物理技术辅助脑卒中康复的临床指南[J]. 国际生物医学工程杂志, 2019, 42(2):100-108.
	China Information Association of Traditional Chinese Medicine. Clinical guidelines for physical technique-assisted rehabilitation of stroke[J]. Int J Biomed Eng, 2019, 42(2):100-108.
[7]	MacLeod CM. Half a century of research on the Stroop effect:an integrative review[J]. Psychol Bull, 1991, 109(2):163-203. DOI PMID
[8]	Tay J, Morris RG, Markus HS. Apathy after stroke:diagnosis,mechanisms,consequences,and treatment[J]. Int J Stroke, 2021, 16(5):510-518. DOI URL
[9]	Chen ZC, Lei X, Ding C, et al. The neural mechanisms of semantic and response conflicts:an fMRI study of practice-related effects in the Stroop task[J]. Neuroimage, 2013, 66:577-584. DOI URL
[10]	Turunen M, Hokkanen L, Bäckman L, et al. Computer-based cognitive training for older adults:determinants of adherence[J]. PLoS One, 2019, 14(7):e0219541. DOI URL
[11]	Nguyen JP, Suarez A, Kemoun G, et al. Repetitive transcranial magnetic stimulation combined with cognitive training for the treatment of Alzheimer’s disease[J]. Clin Neurophysiol, 2017, 47(1):47-53. DOI URL
[12]	中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组. 中国各类主要脑血管病诊断要点2019[J]. 中华神经科杂志, 2019(9):710-715.
	Chinese Society of Neurology,Chinese Stroke Society. Diagnostic criteria of cerebrovascular diseases in China(version 2019)[J]. Chin J Neurol, 2019(9):710-715.
[13]	Robert P, Lanctôt KL, Agüera-Ortiz L, et al. Is it time to revise the diagnostic criteria for apathy in brain disorders? The 2018 international consensus group[J]. Eur Psychiatry, 2018, 54:71-76. DOI URL
[14]	胡良平, 关雪. 两因素析因设计定量资料样本含量与检验效能估计[J]. 中华脑血管病杂志(电子版), 2012, 6(3):166-168.
	Hu LP, Guan X. Sample size and test efficiency estimation of quantitative data of two-factor factorial design[J]. Chin J Cere-brovasc Dis Electron Ed, 2012, 6(3):166-168.
[15]	Savulich G, Piercy T, Fox C, et al. Cognitive training using a novel memory game on an iPad in patients with amnestic mild cognitive impairment(aMCI)[J]. Int J Neuropsychophar-macol, 2017, 20(8):624-633.
[16]	Padala PR, Padala KP, Lensing SY, et al. Repetitive transcra-nial magnetic stimulation for apathy in mild cognitive im-pairment:a double-blind,randomized,sham-controlled,cross-over pilot study[J]. Psychiatry Res, 2018, 261:312-318. DOI URL
[17]	许毅, 李达, 谭立文, 等. 重复经颅磁刺激治疗专家共识[J]. 转化医学杂志, 2018, 7(1):4-9.
	Xu Y, Li D, Tan LW, et al. Chinese experts consensus on repetitive transcranial tagnetic stimulation[J]. Transl Med J, 2018, 7(1):4-9. DOI URL
[18]	常红, 乔雨晨. 认知训练护理门诊构建的专家共识[J]. 中华护理杂志, 2019, 54(10):1504-1508.
	Chang H, Qiao YC. Expert consensus on cognitive training nursing clinic[J]. Chin J Nurs, 2019, 54(10):1504-1508. DOI URL
[19]	Marin RS, Biedrzycki RC, Firinciogullari S. Reliability and validity of the Apathy Evaluation Scale[J]. Psychiatry Res, 1991, 38(2):143-162. DOI URL
[20]	李树亚, 李峥. 两种淡漠评定量表知情者版的汉化及效度信度检验[J]. 中国心理卫生杂志, 2018, 32(8):656-661.
	Li SY, Li Z. Validity and reliability of the Chinese version of the Lille Apathy Rating Scale-Informant and the Apathy Evaluation Scale-Informant[J]. Chin Ment Heal J, 2018, 32(8):656-661.
[21]	Sasaki N, Hara T, Yamada N, et al. The efficacy of high-frequency repetitive transcranial magnetic stimulation for improving apathy in chronic stroke patients[J]. Eur Neurol, 2017, 78(1/2):28-32. DOI URL
[22]	Tik M, Hoffmann A, Sladky R, et al. Towards understanding rTMS mechanism of action:stimulation of the DLPFC causes network-specific increase in functional connectivity[J]. Neuroimage, 2017, 162:289-296. DOI URL
[23]	Peng ZW, Zhou CH, Xue SS, et al. Mechanism of repetitive transcranial magnetic stimulation for depression[J]. Shanghai Arch Psychiatry, 2018, 30(2):84-92.
[24]	陈晓明, 朱慧慧, 卓惠洁. 1例蝴蝶状胼胝体胶质瘤全切术后并发精神淡漠患者的护理[J]. 中华护理杂志, 2018, 53(S1):100-102.
	Chen XM, Zhu HH, Zhuo HJ. Nursing care of a patient with mental apathy after total resection of a butterfly corpus callosum glioma[J]. Chin J Nurs, 2018, 53(S1):100-102.
[25]	Zhao X, Jia L. Training and transfer effects of interference control training in children and young adults[J]. Psychol Res, 2019, 83(7):1519-1530. DOI PMID
[26]	江思思, 沈利平, 阮恒芳, 等. 脑卒中患者家庭功能与健康行为的调查研究[J]. 中华护理杂志, 2014, 49(7):849-853.
	Jiang SS, Shen LP, Ruan HF, et al. Family function and health behaviors of stroke survivors[J]. Chin J Nurs, 2014, 49(7):849-853.
[27]	Zhang FX, Qin YY, Xie LF, et al. High-frequency repetitive transcranial magnetic stimulation combined with cognitive training improves cognitive function and cortical metabolic ratios in Alzheimer’s disease[J]. J Neural Transm(Vienna), 2019, 126(8):1081-1094.
[28]	Sathappan AV, Luber BM, Lisanby SH. The Dynamic Duo:combining noninvasive brain stimulation with cognitive interventions[J]. Prog Neuropsychopharmacol Biol Psychiatry, 2019, 89:347-360. DOI URL