| BackgroundStroke is the second leading cause of death and disability worldwide,with over 10 million new cases each year and high disability rate.After occurrence,it tends to cause cognitive impairment,severely affecting patient’s quality of life,their daily functioning and mental health,as well as increasing burden on family members and the society.Therefore,it is of great significance to study the pathogenesis of post-stroke cognitive impairment(PSCI)in depth and find new effective treatments,so as to promote the early recovery of PSCI patients’ cognitive functions and return them to their families and societies as soon as possible.At present,scalp acupuncture and intermittent theta burst stimulation(iTBS)have been widely used in clinical treatment of cognitive impairment caused by stroke,but their clinical efficacy and mechanisms of action are still not clear,which needs further research.Functional near-infrared spectroscopy(fNIRS)is a new type of brain functional imaging technology,which can be used to monitor the relative changes in cortical oxyhemoglobin(HbO2)concentration and interbrain functional connectivity.With the advantages of strong anti-interference,unlimited application scenarios and good mobility,it can be used to explore the specific neural mechanisms of scalp acupuncture combined with iTBS in treating cognitive impairment caused by stroke.ObjectiveThis study was to observe the efficacy and safety of scalp acupuncture combined with iTBS in cognitive rehabilitation of patients with post-stroke cognitive impairment no dementia(PSCIND).Based on fNIRS technology,the effect and mechanism of scalp acupuncture combined with iTBS on PSCIND were studied to provide theoretical basis and evidence-based medical evidence for clinical application of scalp acupuncture combined with iTBS on PSCIND.MethodsClinical study section:In this study,90 patients with PSCIND who were hospitalized in the Department of Rehabilitation Medicine and Neurology of Yuebei people’s hospital from July 2022 to July 2023 were selected to meet the diagnostic criteria and inclusion criteria.SPSS22.0 statistical software package was used to generate random numbers to obtain random grouping.Qualified subjects were randomly divided into scalp acupuncture group,iTBS group and combination group at a ratio of 1:1:1,with 30 cases in each group.All enrolled patients were given conventional drugs and conventional rehabilitation therapy.In the scalp acupuncture group,the Ezhongxian(MS1),Epangxian Ⅰ(MS2),Epangxian Ⅱ(MS3),Dingzhongxian(MS5),Nieqianxian(MS 10)and Niehouxian(MS 11)Of the affected side were used for acupuncture treatment,while in the iTBS group,the left dorsolateral prefrontal cortex(1-DLPFC)was used for iTBS treatment.The combination group was treated with acupuncture and iTBS.4 weeks is a course of treatment.Montreal cognitive assessment Scale(MoCA),mini-mental state examination(MMSE)and modified barthel index(MBI)were used to assess the patients’ cognitive function and ability to perform activities of daily living before and 4 weeks after treatment,respectively.Adverse events were observed and recorded in detail during the test.fNIRS study section:A total of 60 patients with PSCIND hospitalized in the Department of Rehabilitation Medicine and Neurology of Yuebei people’s hospital were included in the fNIRS study,and 20 patients were randomly selected from the scalp acupuncture group,iTBS group and combination group,respectively.The three groups underwent one fNIRS assessment before treatment,respectively.The assessment method adopted the recognized cognitive activation paradigm at home and abroad:verbal fluency test.The data was collected using Huichuang fNIRS system test(NirSmart,Danyang Huichuang Medical Equipment Company),and 48 channels(CH1-CH48)in frontotemporal lobe were selected.After the fNIRS assessment,the three groups were treated with the first scalp acupuncture treatment,iTBS treatment and scalp acupuncture combined with iTBS treatment,respectively,and the fNIRS assessment was performed again immediately after the treatment.The relative change values of oxygenated hemoglobin concentration and the changes of brain functional connectivity between brain regions were collected in the two assessments.ResultsClinical study section:This research included a total of 90 PSCIND patients,among whom 1 was dropped from the scalp acupuncture group,2 were dropped from the iTBS group,and 2 were dropped from the combination group,all due to shortened hospital stay and insufficient treatment course.Eventually,85 PSCIND patients completed the trial,including 29 in the scalp acupuncture group,28 in the iTBS group,and 28 in the combination group.No significant differences were found in gender,age,years of education,disease course and other basic data of the three groups(P>0.05).Prior to treatment,no significant differences were found in MoCA scores,MMSE scores and MBI scores of the three groups(P>0.05).1.The changes of cognitive functionCompared with before treatment,the scores of MoCA and MMSE in the three groups after 4 weeks of treatment were higher than before treatment,with significant differences(P<0.01).After 4 weeks of treatment,there was no significant difference in MoCA and MMSE scores between the scalp acupuncture group and iTBS group(P>0.05),while the MoCA and MMSE scores of the combination group were significantly better than those of the scalp acupuncture group and iTBS group at the same time,with significant difference(P<0.05).2.The changes of ADLCompared with before treatment,the MBI score of the three groups after 4 weeks of treatment was higher than that before treatment,with significant difference(P<0.01).After 4 weeks of treatment,the MBI score of the combination group was better than that of the scalp acupuncture group and iTBS group at the same period,but there was no significant difference(P>0.05).3.SecurityThree patients from the iTBS group and combination group had slight headache when receiving the first iTBS treatment,which was tolerable.The headache symptom disappeared in the following treatments,and all the patients could persist for 4 weeks’treatment.No other adverse events occurred.Therefore,these three treatments gave reliable safety,and good compliance.fNIRS study section:A total of 60 patients with PSCIND hospitalized in Yuebei people’s hospital were included in the fNIRS study,and 20 patients were randomly selected from the scalp acupuncture group,iTBS group and combination group,respectively.Among them,2 case was dropped from in each group,respectively.All six cases were excluded from the study because they could not adhere to the completion of the fNIRS evaluation or could not cooperate with the evaluation.fNIRS assessment was completed in 54 PSCI patients,including 18 patients in the scalp acupuncture group,18 patients in the iTBS group and 18 patients in the combination group.There were no significant differences in the basic data of sex,age,years of education and course of disease between the three groups(P>0.05).Before fNIRS evaluation,there were no significant differences in MoCA score,MMSE score and MBI score between the three groups(P>0.05).1.The changes of cerebral cortex activation based on fNIRS techniqueThe scalp acupuncture group:Compared with before treatment,the relative change values of HbO2 concentration in channels 17(r-STC region),18(r-STC region),19(r-STC region)and 21(r-VLPFC region)in the scalp acupuncture group increased significantly after treatment,and there was a significant difference(P<0.05).The relative change values of HbO2 concentration in the other 44 channels did not increase significantly(P>0.05).iTBS group:Compared with before treatment,the relative change values of HbO2 concentration in channels 14(l-VLPFC region),21(r-VLPFC region),30(l-DLPFC region),36(l-SFC region),39(r-DLPFC region),40(r-DLPFC region)and 41(r-DLPFC region)in iTBS group increased significantly after treatment,and there was a significant difference(P<0.05).The relative change values of HbO2 concentration in the other 41 channels did not increase significantly(P>0.05).Combination group:Compared with before treatment,the relative change values of HbO2 concentration in channels 3(r-STC region),8(mPFC region),9(mPFC region),10(l-VLPFC region),14(l-VLPFC region),23(r-DLPFC region),24(r-DLPFC region),29(mPFC region),30(l-DLPFC region),39(r-DLPFC region),45(l-DLPFC region)and 47(l-DLPFC region)in combination group increased significantly after treatment,and there was a significant difference(P<0.05).The relative change values of HbO2 concentration in the other 36 channels did not increase significantly(P>0.05).Comparison between groups:There was no significant difference in the relative change values of HbO2 concentration in all channels of the three groups before treatment(P>0.05).After treatment,the relative changes of HbO2 concentration in 7 channels(channels 3,6,8,14,29,38 and 47)of the three groups had significant differences(P<0.05),while the relative changes of HbO2 concentration in the other 41 channels had no statistical significance(P>0.05).After multiple comparisons,there was no statistical significance in the relative change of HbO2 concentration between the scalp acupuncture group and iTBS group(P>0.05).Compared with the scalp acupuncture group,the relative changes of HbO2 concentration in channel 3(r-STC region),channel 6(r-VLPFC region),channel 8(mPFC region),channel 29(l-VLPFC region)and channel 47(l-DLPFC region)in combination group was significantly increased(P<0.05).Compared with iTBS group,the relative changes of HbO2 concentration in channel 3(r-STC region),channel 6(r-VLPFC region),channel 8(mPFC region),channel 14(l-VLPFC region),channel 38(r-SFC region)and channel 47(l-DLPFC region)in combination group increased significantly.There were significant differences(P<0.05).2.The changes of functional connectivity of the brain based on fNIRS technologyScalp acupuncture group:Compared with before treatment,functional connectivity between mPFC region and r-SFC region,mPFC region and r-STC region was enhanced in scalp acupuncture group after treatment,and there were significant differences(P<0.05).iTBS group:Compared with before treatment,functional connectivity between the r-VLPFC region and the l-SFC region in iTBS group was enhanced after treatment,and there were significant differences(P<0.05).Combination group:Compared with before treatment,functional connectivity between the l-VLPFC region and mPFC region,l-VLPFC region and l-SFC region,l-VLPFC region and l-DLPFC region,l-DLPFC region and l-STC region,l-DLPFC region and r-VLPFC region,r-VLPFC region and l-SFC region,r-VLPFC region and r-SFC region,r-DLPFC region and r-STC region in combination group was enhanced after treatment,and there were significant differences(P<0.05).Pairwise comparison:There was no statistical significance in brain functional connectivity between the three groups before treatment(P>0.05).After treatment,compared with iTBS group,the brain functional connectivity between r-VLPFC region and l-SFC region was stronger in combination group,with statistical significance(P<0.05).Compared with iTBS group,the brain functional connectivity between l-VLPFC region and r-SFC region was stronger in scalp acupuncture group,with statistical significance(P<0.05).There was no significant difference in brain functional connectivity between the scalp acupuncture group and combination group after treatment(P>0.05).Conclusions1.Scalp acupuncture combined with iTBS therapy is clinically superior in improving cognitive function outcomes of PSCIND patients than either scalp acupuncture alone or iTBS alone.2.Scalp acupuncture therapy,iTBS therapy and scalp acupuncture combined with iTBS can significantly activate the frontal temporal cortex of the brain,and the activation modes of the three therapies are different.Compared with scalp acupuncture and iTBS therapy,scalp acupuncture combined with iTBS therapy activate more channels,and the activation is more significant in the r-STC region,r-VLPFC region,mPFC region,l-VLPFC region,r-SFC region and l-DLPFC region.3.Scalp acupuncture therapy,iTBS therapy,and scalp acupuncture combined with iTBS can enhance functional connectivity between ROI in patients with PSCIND.Scalp acupuncture therapy and scalp acupuncture combined with iTBS appeare to be more effective than iTBS in modulating cognition-related ROI connectivity.4.Scalp acupuncture combined with iTBS therapy can improve cognitive function in PSCIND patients,and the clinical efficacy is superior to scalp acupuncture therapy and iTBS therapy alone.The mechanism of scalp acupuncture combined with iTBS therapy in the treatment of PSCIND may be as follows:activation of cognition-related brain functional areas and enhancement of cognition-related ROI connectivity,and improvement of cognitive function by improving local cerebral blood flow,promoting nerve repair and brain function remodeling. |
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