基于吞咽皮质兴奋性探讨针刺及tDCS对卒中后吞咽障碍作用机制

发布时间：2018-02-11 16:00

  本文关键词： 吞咽障碍 非线性分析 经颅直流电刺激 针刺 皮质兴奋性　出处：《首都医科大学》2017年博士论文　论文类型：学位论文

【摘要】：目的:探讨脑电非线性分析(Nonlinear dynamics analysis,NDA)能否为中西医干预卒中后吞咽障碍患者吞咽皮质兴奋性改变提供客观的神经电生理分析手段,研究针刺疗法、经颅直流电刺激(Transcranial direct current stimulation,tDCS)干预卒中后吞咽障碍的恢复与吞咽皮质兴奋性变化的关联性及其作用机制。方法:第一部分采用A-B试验设计。A期干预措施是假经颅直流电刺激配合康复手法训练,B期的干预措施是阳极tDCS配合康复手法训练。A、B期治疗前后,利用吞咽失用量表(Swallowing apraxia scale,SAS)评估5例患者的吞咽功能。B期治疗前后利用脑电非线性指数近似熵(Approximate entropy,Ap En)对3例患者安静闭眼状态、反射性吞咽任务以及自主性吞咽任务下的吞咽皮质兴奋性进行分析;并选6例正常受试者作为对照组。第二部分采用随机对照试验设计:将符合纳入标准的40例卒中后吞咽障碍患者随机分入3个组:对照组、tDCS组和针刺组。对照组、tDCS组和针刺组的患者例数分别为14例、15例、11例。对照组采用常规的康复手法训练。tDCS组在常规的康复手法训练基础上,进行阳极tDCS治疗。针刺组在常规的康复手法训练的基础上,进行针刺治疗。治疗前、治疗1周后、治疗2周后分别利用吞咽障碍严重程度量表(Swallow severity scale,SSS)和改良吞咽障碍能力评价表(Modified Mann assessment of swallowing ability,MMASA)评估吞咽功能;治疗结束1个月随访,利用SSS量表进行吞咽功能评估。于治疗前、治疗2周后利用Ap En对17例半球卒中后吞咽障碍患者,其中对照组4例、tDCS组6例、针刺组7例安静闭眼状态和自主性吞咽任务下的吞咽皮质兴奋性进行分析。结果:第一部分A期治疗前后,5例患者吞咽功能评分无变化;B期治疗前后,患者SAS量表吞咽功能评分明显提高。脑电Ap En显示:正常对照组自主性吞咽时兴奋的脑区多于反射性吞咽时。阳极tDCS治疗前,3例患者反射性吞咽时的患侧中央-顶-颞区Ap En数值增高(P0.01),但自主性吞咽时所有检测脑区Ap En数值均无增高(P0.01)。经阳极tDCS治疗后,反射性吞咽和自主性吞咽时患侧或健侧半球均有更多脑区Ap En数值增高(P0.01)。第二部分吞咽功能评估:治疗前,对照组、tDCS组和针刺组的SSS评分和MMASA评分无差异(P0.05)。治疗1周后、2周后,3组患者的SSS评分及MMASA评分均明显增加(P0.05),但3组SSS评分及MMASA评分的组间比较无差异(P0.05)。1个月后随访,tDCS组与针刺组频数的比较无显著差异(P0.05),但tDCS组及针刺组均明显优于对照组,有显著性差异(P0.05)。脑电Ap En显示:治疗前,与安静闭眼状态相比,自主吞咽时对照组、tDCS组和针刺组的健侧中央区(C健侧)Ap En数值(分别是0.81±0.05,0.86±0.09和0.85±0.10)增加(P0.01)。治疗2周后,与安静闭眼状态相比,自主吞咽时对照组的健侧顶区(P_(健侧))Ap En数值(0.89±0.12)增加(P0.01);tDCS组的健侧中央区(C健侧)、健侧顶区(P_(健侧))和患侧中央区(C患侧)Ap En数值(分别是0.87±0.07,0.82±0.07和0.79±0.04)增加(P0.01);针刺组的健侧中央区(C健侧)和健侧额区(F健侧)Ap En数值(分别是0.80±0.06和0.79±0.07)增加(P0.01)。结论:脑电非线性分析可以作为中西医干预卒中后吞咽障碍患者吞咽皮质兴奋性变化的客观神经电生理分析手段。在康复手法训练基础上,配合针刺疗法或经颅直流电刺激更有助于卒中后吞咽障碍的远期恢复,其作用机制可能与吞咽皮质兴奋性的变化相关。
[Abstract]:Objective: to analyze the EEG nonlinear (Nonlinear dynamics analysis, NDA) to traditional Chinese medicine and Western medicine intervention after stroke patients with dysphagia swallowing cortical excitability changes provide neural electrophysiology objective analysis method, research on acupuncture therapy, transcranial direct current stimulation (Transcranial direct current stimulation, tDCS) and their correlation mechanism and recovery of swallowing cortex changes in the excitability of dysphagia after stroke intervention. Methods: in the first part of the A-B test design of.A period intervention is a sham transcranial direct current stimulation combined with rehabilitation training methods, B intervention combined with rehabilitation training methods is the anode tDCS.A, B before and after treatment, the dosage of Swallowing apraxia (loss of swallowing table scale. SAS) before and after.B treatment to assess swallowing function in 5 patients with EEG nonlinear indexes of approximate entropy (Approximate entropy, Ap En) in 3 patients with eyes closed. State analysis of swallowing cortical excitability reflex swallowing tasks and volitional swallowing task under the selection; and 6 normal subjects as control group. The second part of the design of randomized controlled trials: 40 patients met the inclusion criteria of stroke patients with dysphagia were randomly divided into 3 groups: control group, tDCS group and the acupuncture group. The control group, the number of patients with tDCS group and acupuncture group were 14 cases, 15 cases, 11 cases. The control group adopted the rehabilitation training methods in.TDCS group were in the rehabilitation training on the basis of conventional technique, the anodic tDCS treatment. The acupuncture group based on the conventional technique of complex training on the Kang. Acupuncture treatment. Before treatment, after 1 weeks of treatment, after 2 weeks of treatment respectively using the dysphagia severity scale (Swallow severity scale, SSS) and the improvement of dysphagia evaluation scale (Modified Mann assessment power of swallowing ability, MMASA) to assess swallowing function To the end of treatment; 1 months of follow-up, table to assess swallowing function by SSS. Before treatment, after 2 weeks of treatment with Ap En on 17 cases of patients with dysphagia after stroke hemisphere in 4 cases, the control group, 6 cases in tDCS group, acupuncture group, swallowing cortical excitability in 7 cases of peaceful state and autonomy the swallowing tasks were analyzed. Results: the first part of the A period before and after the treatment, 5 cases of patients with swallowing function score no change before and after B treatment, patients; SAS scale swallowing function score improved significantly. EEG Ap En showed: normal control group autonomy when swallowing excited brain areas than reflex swallowing. Anode before tDCS treatment, 3 cases of patients with swallowing reflex of the ipsilateral central parietal and temporal region of Ap En (P0.01), but the value increased autonomy when swallowing all detected brain Ap En values were not increased (P0.01). The anode of tDCS after treatment, swallowing reflex and self swallow ipsilateral or contralateral 鍗婄悆鍧囨湁鏇村�氳剳鍖篈p En鏁板，

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