Ambulatório de Neuromodulação da Divisão de Fisioterapia do Instituto Central do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Brazil; Department of Neurology, Hospital das Clínicas, School of Medicine, University of São Paulo, Brazil.
Ambulatório de Neuromodulação da Divisão de Fisioterapia do Instituto Central do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Brazil; Universidade Nove de Julho, Brazil.
J Clin Neurosci. 2020 Jun;76:208-210. doi: 10.1016/j.jocn.2020.04.025. Epub 2020 Apr 10.
Dystonia is a disabling movement disorder characterized by co-contraction of antagonist and agonist muscles, leading to abnormal sustained postures and impaired motor control. Cervical Dystonia (CD) and Hand Focal Dystonia (HFD) have been the most common forms of focal dystonia (FD). Do Non-Invasive Brain Neuromodulation (NIBS) such as Transcranial Direct Current Stimulation (tDCS) and repetitive Transcranial Magnetic Stimulation (rTMS) modulate the excitability of the connections between the motor cortical areas and may represent a therapeutic alternative for focal dystonia? Herein, we reported three cases of focal dystonia, two of them with cervical dystonia (CD) and one with hand focal dystonia (HFD), treated with NIBS combined to kinesiotherapy. The patients were daily submitted to 15 sessions of NIBS combined simultaneously with kinesiotherapy. CD patients were treated with tDCS (2 mA, 20 min, over the primary motor cortex), and HFD patient with rTMS (1 Hz, 1200 pulses, 80% of resting motor threshold, over the premotor cortex). For the CD patient's assessment, the Modified Toronto Scale for Cervical Dystonia Assessment (MTS), quiet balance test, and visual postural assessment were applied to observe the therapeutic effects. Quality handwriting analysis, tremor acceleration amplitudes, and the Wrinter's Cramp Rating Scale (WCRS) were used to assess the NIBS effect on HFD symptoms. Patients were evaluated before (pretest), immediately after (posttest), and three months after treatment (retention). NIBS associated with kinesiotherapy produced a long-term improvement of dystonia symptoms in all three patients. rTMS and tDCS associated with kinesiotherapy showed to be useful and safe to relief the dystonia symptoms in individuals with different types of focal dystonia with distinct functional disorders. SIGNIFICANCE: The combined use of these intervention strategies seems to optimize and anticipate satisfactory clinical results in these neurological conditions, characterized by its difficult clinical management.
肌张力障碍是一种致残的运动障碍，其特征为拮抗肌和主动肌的共同收缩，导致异常的持续姿势和运动控制受损。颈肌张力障碍（CD）和手部局灶性肌张力障碍（HFD）是最常见的局灶性肌张力障碍（FD）形式。非侵入性脑神经调节（NIBS），如经颅直流电刺激（tDCS）和重复经颅磁刺激（rTMS），是否调节运动皮质区之间连接的兴奋性，并可能成为局灶性肌张力障碍的治疗选择？在此，我们报告了三例局灶性肌张力障碍患者，其中两例为颈肌张力障碍（CD），一例为手部局灶性肌张力障碍（HFD），采用 NIBS 联合运动疗法治疗。患者每天接受 15 次 NIBS 联合运动疗法。CD 患者接受 tDCS（2 mA，20 分钟，在初级运动皮质上）治疗，HFD 患者接受 rTMS（1 Hz，1200 个脉冲，80%静息运动阈值，在运动前皮质上）治疗。对 CD 患者的评估采用改良多伦多颈部肌张力障碍评估量表（MTS）、安静平衡测试和视觉姿势评估来观察治疗效果。使用手写质量分析、震颤加速度幅度和 Winter 痉挛分级量表（WCRS）评估 NIBS 对 HFD 症状的影响。在治疗前（前测）、治疗后即刻（后测）和治疗后 3 个月（保留）对患者进行评估。NIBS 联合运动疗法使所有 3 例患者的肌张力障碍症状均得到长期改善。rTMS 和 tDCS 联合运动疗法在不同类型的局灶性肌张力障碍中均显示出有用性和安全性，这些患者具有不同的功能障碍。意义：这些干预策略的联合使用似乎可以优化和预测这些具有难以临床管理的神经疾病的满意临床结果。
