| Objective: Disturbance of consciousness refers to the patient’s ability to identify and detect the surrounding environment and their own state.With the rapid development of modern diagnosis and treatment level and the emergency medicine,especially the wide application of breathing machine,an increased survival rate of patients with severe craniocerebral injury,but even to survive,these patients may also experience the different levels of consciousness,such as predominantly awakening degree change consciousness: somnolence,spoor,coma,is given priority to with consciousness content change of consciousness: confusion,delirium,and some special type of disturbance of consciousness: vegetative state/unresponsive wakefulness syndrome(VS/UWS),minimally conscious state(MCS).Among them,coma,VS/UWS,MCS belong to disorders of consciousness(DOC).And study the DOC to promote wake is very popular.Current treatment clinically on DOC patients improved consciousness mainly includes drug(amantadine,thiazole),Hyperbaric oxygen(HBO)treatment,acupuncture and moxibustion,the Central thalamus deep brain stimulation(CT-DBS),Transcranial Magnetic stimulation(TMS),peripheral sensory stimulation to promote wake program,etc.Despite these methods,but they all has its advantages and disadvantage,so to seek a safe and effective method to improve the DOC patient’s state of consciousness is still a problem to be solved currently.How to effectively improve the DOC patients’ state of consciousness is still a problem to be solved currently.Transcranial direct current stimulation(t DCS),a non-invasive,emerging technique,is capable of modulating cortical neuronal activity through weak direct current(1~2m A),which can regulate cortical excitability via electrode on the scalp.TDCS works by adjusting the spontaneous neuron networkactivity.Such as stimulation in patients with primary cerebral cortex motor area(M1),which can effectively improve the motor function in patients with obstacles,and stimulate the prefrontal cortex,which can effectively improve patient swallowing dysfunction,etc.Although there is some evidence that t DCS can regulate brain function areas with movement,speech and swallowing dysfunction can be improved,but t DCS combined with conventional therapy on the clinical study of patients with disorders of consciousness are rarely reported at present.The purpose of this study is to explore the effect of t DCS combined with conventional rehabilitation therapy on patients with disturbance of consciousness,which can lay a good foundation for the clinical treatment of patients with disturbance of consciousness and provide a safe and effective clinical treatment.Methods: From April 2015 to December 2016,40 admitted patients who have a variety of reasons cause the loss of the awakening of degrees or content change of consciousness disorder patients in the second hospital of Hebei Medical University,were selected.Inclusion criteria consisted of the following:(1)(1)diagnosis was confirmed,according to diagnosis of vegetative state standards in 2011 by the Chinese medical association of hyperbaric oxygen on brain recovery of medical organization committee :1).The loss of cognitive function,unconscious activities,can’t execute instruction;2).Could automatically open or spurred him only;3).The sleep-wake cycle;4).Any purpose tracking eye movement;5).Can’t understand or to express language;6).Maintain spontaneous breathing and blood pressure;7).Basic save the hypothalamus and brainstem function.It includes physical exercise,eye movement,hearing,eating and emotional.Without any reaction to 0 points,stimulation reaction with flexion and extension,open eye with a voice alarm,can swallow,exciting performance,etc.In accordance with one of them named 1points.Stimulation can locate,have eye tracking,sound stimulation can locate,can perform simple command accidentally,can chew and perform simple command,for emotional language in tears or other excited expression,In accordance with one of them named 2points.Simple fiddling,fixed gazeobject or hand in order to take,can be repeated simple commands,be able to eat normally,the emotional language have complex reaction with one rated 3points;free movement and the complex of independent action,the enumeration object can identify and complete complex instruction,automatic feeding,normal emotional reaction with one awarded 4 points.Namely the PVS(Persistent vegetative state)score of 0,1 or 2 patients.(2)Glasgow coma scale has diagnositic evaluation under 8 scores;it includes eye opening,verbal response,motor response.Conform to(1)(2)in any one or all.(2)disease because of injury or trauma;(3)age between 18 to 80 years old;(4)first-ever disease of consciousness;(5)agreed and signed the informed consent to treatment.Subjects were excluded for:(1)unstable vital signs;(2)late malignant tumor or nearly six months had tumor radiation and chemotherapy;(3)heart rate by more than 70% of the age allowed maximum heart rate,on the basis of resting heart rate﹥20%,﹤40times/min or﹥130times/min;(4)oxygen saturation ﹤ 88%;(5)systolic blood pressure ﹥ 180 mm Hg or orthostatic hypotension,mean arterial pressure﹤65mm Hg or﹥110mm Hg;(6)the patient and family don’t agree.Contraindications:(1)the use of implantable electronic devices,such as cardiac pacemaker;(2)intracranial patients with metallic implant device;(3)fever,electrolyte disorder or not stable vital signs;(4)pregnant woman and children;(5)local skin damage or inflammation patients;(6)patients with bleeding tendency;(7)patients with increased intracranial pressure;(8)patients with severe heart disease or other medical conditions;(9)patients with acute large area cerebral infarction;(10)patients with epilepsy and taking drugs which can cause epilepsy;(11)treatment area have patients implanted devices with metal parts;(12)stimulate regional hyperalgesia.The final will be included in the study 38 patients were randomly divided into experimental group and control group,experimental group of 19 patients,14 were male,5 were female;aged 18~74 years old,average age(42.68±14.81)years;10 cases of traumatic brain injury,2 cases of cerebral hemorrhage after cardiopulmonary resuscitation in 2 cases,2 cases hypoxic ischemic encephalopathy,2 cases of CO poisoning,1 cases oforganophosphorus poisoning;duration was 2~66 days,average 21.21days;19cases in the control group,11 cases were male,8 were female;aged 24~79years old,average age(45.37 ± 13.04);6 cases of traumatic brain injury,cerebral hemorrhage in 4 cases,hypoxic ischemic encephalopathy,after cardiopulmonary resuscitation in 3 cases,2 cases of encephalitis;duration was2~65 days,average 22.68days;two groups were comparable,there was no significant difference(P > 0.05).The control group was treated with conventional rehabilitation methods,such as hyperbaric oxygen,cerebellar fastigial nucleus stimulation,electrical stimulation of limbs,lower limb intelligent rehabilitation training system and so on.Hyperbaric oxygen pressure is generally used 1.8~2.0ATA,pressure time and decompression time 25 min,adjusting the mask to absorb pure oxygen time is 30min×2,during the suction air 10 min,or pure oxygen 20min× 3,suction cabin air 5min.Fastigial nucleus stimulation: the crescent shaped electrodes affixed to the patients after ear,improve the brain in patients with posterior circulation,stimulus intensity reference normal tolerance,about15 m A,stimulation time 30min/times;electrical stimulation of limb:conventional 4cm×4cm square electrodes affixed to the body of patients with radial extensor muscle of wrist and anterior tibial muscles.The stimulus intensity for maximum muscle contraction and the patient had no expression of pain is appropriate,limbs had no obvious activity in patients with limb limb stimulation,hemiplegia patients with ipsilateral limb stimulation,in order to achieve the purpose of passive activities,time is 30min/ times lower limb rehabilitation training system;intelligent motion mode using passive mode,time is 30min/ times all methods of rehabilitation;1 times / day,6 times per week,30 times for a course of treatment,treatment and rest for 5~7 days.The experimental group in the conventional treatment based on t DCS treatment,t DCS anodal stimulation at the sites of the left dorsolateral prefrontal cortex(Dorsolateral prefrontal,cortex,DLPFC),the reference electrode is located on the right orbital margin or right shoulder,the stimulation intensity is 1~2m A,the initial measurement of 1m A combined with the specific situation graduallyincreased to the maximum dose of 2.0m A,stimulation time 20min/ times.1times / day,6 times per week,20 times for a course of treatment,20 days rest between treatments.Curative effect evaluation method: scale assessment with a Glasgow coma scale or PVS rating scale,nerve electrophysiology evaluate electroencephalogram(EEG),Brainstem auditory evoked potential(BAEP),Upper sense evoked potential(USEP).According to Hockaday(1965)EEG consciousness EEG standard: basic rhythms of α rhythm,close to the normal grade I,3 score;θrhythm,accompanied by a δ wave II score was 2;δ wave,no other rhythmic activity in grade III,1 score;brain the basic electrical rhythm disappeared,nearly flat wave,as class IV,0 score.BAEP according to the standard of Greenbery: normal grade I,grade 3;I-V wave can be seen clearly,but the latency and amplitude decreased to the second level,rated 2 points;of the latency and amplitude of each wave of more than normal,or a differentiation is not clear positive wave III,as of 1 points;it is difficult to distinguish the waveform or only wave I exist as class IV,0 score.USEP according to the standard of Greenbery: normal grade I,3 score;lack of waveform components after 50 ms latency was prolonged and the amplitude decreased to the second level,2 score;only P15 and N20,the lack of waveform components after 20 ms III,rated 1 points;each wave disappeared or only P15 grade,0 score.All patients were evaluated by a fixed physician before and after 1~2 treatment all of the patients before treatment and after treatment to evaluate the above respectively.The clinical curative effect evaluation: the basic cure,patients with clear signs and symptoms disappeared,GCS score,PVS score,15 points,8 points.The obvious effective: symptoms significantly improved,GCS score,PVS score of 12 points,5~8 points.The effective: symptoms improved,GCS score > 9,PVS improved 2~4 points.The invalid: no improvement in symptoms and signs,GCS score and PVS score without increasing or decreasing.In this study,the treatment time was 10~45 days,the average treatmenttime(21.87 ± 1.44)days.All patients were evaluated by a physician before and after treatment.Adverse events: In the process of patients,the presence of severe adverse reactions were observed.Such as secondary cerebral hemorrhage,epilepsy,etc.Statistical analysis: the results were analyzed by SPSS21.0 software.The measurement data were expressed by the mean and standard deviation(?x±s),the first test data normality and homogeneity of variance,if in line with the application of t test were compared between the two groups,if it does not meet the normal analysis and homogeneity of variance using non parametric test.Test level alpha =0.05,P < 0.05 was considered statistically significant.Results:1 The influence of t DCS functional recovery in patients with disturbance of consciousness1.1 Glasgow scoresThe experimental group before treatment GCS overall score(6.33±1.23)and the control group before treatment GCS score was(5.43 ± 1.90),the two groups before treatment had no significant difference(P > 0.05),the test group after treatment the score was(12.44 ± 2.51),the control group after treatment the score was(10.43 ± 1.90),the two groups before and after treatment,scores improved,there were significant differences(P< 0.05);while the experimental group after treatment,GCS score better than the control group(P < 0.05).1.2 PVS scoresThe experimental group before treatment PVS overall score(4.20 ± 0.63)and the control group before treatment PVS score was(4.25 ± 0.62),the two groups before treatment had no significant difference(P > 0.05),the test group after treatment the score was(13.10 ± 3.78),the control group after treatment the score was(9.75 ± 2.49),the two groups before and after treatment,scores improved,there were significant differences(P< 0.05);while the experimental group after treatment,PVS score better than the control group(P < 0.05).1.3 EEGThe experimental group before treatment,the overall score(1.32 ± 0.58),the control group before treatment score was(1.11 ± 0.81),the two groups before treatment had no significant difference(P > 0.05),the test group after treatment the score was(2.26 ± 0.65),the control group after treatment the score was(1.53 ± 0.77),two group after treatment compared with before treatment scores improved,there were significant differences(P < 0.05);while the experimental group after treatment,EEG score better than the control group(P < 0.05).1.4 BAEPThe experimental group before treatment,the overall score(0.95 ± 0.23),the control group before treatment score was(0.79 ± 0.42),the two groups before treatment had no significant difference(P > 0.05),the test group after treatment the score was(2.00 ± 0.67),the control group after treatment the score was(1.32 ± 0.48),two group after treatment compared with before treatment scores improved,there were significant differences(P < 0.05);while the experimental group after treatment,BAEP score better than the control group(P < 0.05).1.5 USEPThe experimental group before treatment,the overall score(0.79 ± 0.42),the control group before treatment score was(0.79 ± 0.42),the two groups before treatment had no significant difference(P > 0.05),the test group after treatment the score was(1.84 ± 0.77),the control group after treatment the score was(1.32 ± 0.48),two group after treatment compared with before treatment scores improved,there were significant differences(P < 0.05);while the experimental group after treatment,USEP score better than the control group(P < 0.05).1.6 Curative effect evaluationIn this study,19 cases of patients in the experimental group of patients with severe mental disorders,of which 8 patients were basically cured,effective significantly in 7 cases,effective in 2 cases,and the effective rate was 89.47% in all the cases,The control group of 19 cases of patients with severe disorder of consciousness,in which a total of 3 cases were cured,effective significantly in 5 cases,effective in 8 cases,the total effective rate was 84.21%,and the promotion rate was 5.26%.Two groups of control P <0.05.2 Adverse reactionThis study has not been appeared serious adverse reactions such as secondary cerebral hemorrhage,seizure in patients.Conclusions:This study through randomized study showed that treatment based on routine rehabilitation,after an average treatment time(21.87 ± 1.44)days after t DCS treatment,patients with severe disturbance of consciousness in the observed indicators scores increased significantly,the clinical effective rate was 89.47%,and the t DCS is safe and convenient,less side effect.Due to the observation of fewer cases in this study,the treatment time is affected by the bed turnover,the long-term efficacy and the adjustment of treatment dose need further study. |
