针灸治疗脑梗死恢复期吞咽障碍的临床研究

发布时间：2019-05-16 14:23

【摘要】：一、针灸治疗脑卒中后吞咽障碍的疗效研究随着当今社会的快速发展、生存环境以及人类疾病谱的变化以及社会老龄速度的加快,发病率日益上升的脑血管病(CVD),己超越癌症、心血管疾病,居危害世界人民生命安全的三大疾病之榜首,也是造成吞咽障碍的主要病因[1]。吞咽障碍是脑卒中患者最常见的并发症之一,28%—82%的脑卒中患者会发生吞咽障碍,吞咽障碍的发生提高了肺部感染、营养不良、再次中风及死亡的发生率,严重影响了患者的生存质量[2]。因此,对患者吞咽功能进行评定,并根据吞咽障碍的具体情况采取积极有效的康复治疗,对缩短病程、减轻患者及家庭社会的负担、提高患者的生存质量、降低死亡率等方面都有显著的影响。具有千百年历史的针灸疗法,作为中国传统医学的瑰宝,为人类的医疗保健做出了积极、巨大的贡献,在世界各地,越来越受到欢迎。针灸疗法也是被世界各国率先应用的祖国传统医学治疗方法。目前,在临床应用上,针灸疗法作为替代现代先进医学的治疗方法,已在世界多个国家实施,科学基础对针灸疗法的研究也越来越引起人们的重视。本研究通过临床治疗与观测,治疗组与对照组比较疗效差异显著,治疗组优于对照组。针刺治疗脑卒中后吞咽障碍有显著疗效,对提高这类病人的康复治疗率有显著的提高。经统计学分析表明,血糖、性别、吸烟饮酒史等相关因素对治疗脑卒中后吞咽障碍的疗效均有影响。其中,血糖影响最大,而年龄、饮酒史等对疗效无明显影响。因此在临床实践中,对血糖、吸烟、等因素宜引起重视,以便提高此类患者的临床疗效。二、电视透视系统评估针灸治疗脑卒中后吞咽障碍的临床研究吞咽是极其复杂生理反射的过程,脑卒中后吞咽障碍是常见合并症[3],是指固体或液体从口腔至胃的传递过程中出现运动障碍或传送延迟,主要发生于口、咽阶段。目前针对吞咽障碍的检查方法主要有:询问病史、口咽功能检查、洼田饮水试验、电视透视下吞咽能力检查(videofluoroscopic swallowing study,VFSS)等[4]。吞咽障碍的电视透视检查又称咽部动态造影,是指用X线录像记录吞咽造影时口咽部活动情况的方法。由于VFSS在诊断吞咽障碍方面可以提供更多的评价信息,准确区分误吸与穿透,区分否存在安静误吸等,故常被认为是诊断吞咽障碍的“金标准”[5],对脑卒中后患者吞咽功能的评价十分重要。针灸治疗脑卒中后吞咽障碍具有很好的效果,为了客观评价患者脑卒中后吞咽障碍程度及针刺治疗的疗效,我们运用电视透视检查的方式进行了实验。试验中,患者在电视透视下均有不同程度的吞咽障碍之异常表现,其中吞咽功能失代偿的有48例(82.8%),误吸及声门上穿透各20例,共40例(83.3%,有13例无呛咳表现的安静误吸病患,占误吸病患的27.1%)。经统计分析表明,电视透视检查可直观的分析针灸治疗脑卒中后吞咽障碍的能力,验证了该检查方法对评定脑梗死患者吞咽功能评定的有效性。吞咽障碍的重要威胁之一在于误吸。Mark等证实,VFSS不仅能客观直接地评价针刺治疗的疗效,准确发现吞咽中是否存在误吸,更可发现误吸的原因,它的评价推确率高于临床评价量表,尤其对隐匿性吸人的诊断有决定性意义[5],是脑卒中后吞咽障碍患者功能检查及疗效评估的有效方法。三、针灸与功能性核磁共振的成像脑功能磁共振成像(functional magnetic resonance imaging,fMRI),它是一种以脱氧血红蛋白的磁敏感效应为基础的磁共振成像技术。适宜的刺激可通过神经传入大脑引起相应脑区兴奋,兴奋脑区的代谢水平及局部血液流量均增加,后者的效应大于前者。故兴奋脑区的氧合血红蛋白含量增加,而在非兴奋脑区脱氧血红蛋白含量占优,脱氧血红蛋白具有顺磁性(可使组织的T1,T2及T2*时间缩短)。BOLD-fMRI检查采用EPI序列扫描(T2*WI),T2*时间缩短使非兴奋脑区组织的信号降低,反衬出相对高信号的兴奋脑区(T2*WI),经软件处理后使兴奋程度不同的脑区呈不同的颜色,从而直观显示脑功能的表现。BOLD法与其他脑功能成像手段相比具有较高的空间分辨率、较高的时间分辨率、无电磁辐射以及费用较低等优点。而且利用fMRI还可以进行反复多次、纵向和大样本的研究,为脑可塑性研究提供独特的方法,因而在对于认知功能、言语功能,运动、感觉功能等复杂的高级脑功能的研究中有其特殊价值,故在康复领域得到了广泛的应用。本试验结合现代神经解剖学理论,应用BOLD-fMRI技术观察针刺廉泉穴及双侧人迎穴前后所引起的脑吞咽功能区的活动和变化情况。试验中廉泉穴及双侧人迎穴所造成的信号改变,表明此区域的脑神经元参与有关吞咽活动。从我们的实验中,可以很直观地看到额叶、中央前回、中央后回、顶枕叶、外侧裂周围、基底节区的灰质核团、小脑上蚓部、小脑皮质、激活显著增强,而上述脑区与既往研究得出的吞咽皮质中枢相一致。同时试验中治疗组与对照组患者的吞咽皮质中枢均位于双侧半球,并且针刺后吞咽活动时皮质中枢脑区的激活明显增强、增多。表明针灸疗法是通过影响脑血流量、影响血氧含量变化来实现它的治疗作用。总之,针刺对脑卒中后吞咽障碍的治疗是有效的,疗效是确切的。
[Abstract]:1. The curative effect of acupuncture and moxibustion in the treatment of stroke after stroke is as follows: with the rapid development of the present society, the living environment and the change of the human disease spectrum and the acceleration of the social aging speed, the incidence of the cerebrovascular disease (CVD) with increasing incidence rate has exceeded the cancer and the cardiovascular disease, The top of the three major diseases that endanger the life safety of the world's people is also the main cause of swallowing disorder[1]. Dysphagia is one of the most common complications in stroke patients. In 28% and 82% of stroke patients, the incidence of dysphagia, malnutrition, stroke and death is increased, and the quality of life of patients is seriously affected[2]. Therefore, the swallowing function of the patient is evaluated, and active and effective rehabilitation therapy is taken according to the specific condition of the swallowing disorder, so that the disease course is shortened, the burden of the patient and the family society is reduced, the quality of the patient is improved, and the mortality rate is reduced. The acupuncture and moxibustion therapy with a history of thousands of years, as the treasure of Chinese traditional medicine, has made a positive and great contribution to the health care of human beings, and has become more and more popular in all parts of the world. The acupuncture and moxibustion therapy is also a traditional Chinese medicine treatment method which is the first to be applied by the countries in the world. At present, in the clinical application, the acupuncture and moxibustion therapy has been implemented in many countries in the world as an alternative to the modern advanced medicine, and the scientific base has attracted more and more attention to the research of acupuncture and moxibustion therapy. The curative effect of the treatment group and the control group was significant, and the treatment group was better than that of the control group. The effect of acupuncture on the dysphagia after stroke has a significant effect on the improvement of the recovery treatment rate of such patients. The statistics show that the related factors such as blood sugar, sex, smoking history and other related factors have an effect on the curative effect of the dysphagia after stroke. Among them, the influence of blood sugar is the most, and the age, the history of drinking and so on have no obvious effect on the curative effect. Therefore, in clinical practice, attention should be paid to the factors such as blood sugar, smoking, and so on, in order to improve the clinical curative effect of such patients. 2. The clinical study on the assessment of the dysphagia after stroke by the television perspective system is a process of extremely complex physiological reflex. The dysphagia after stroke is a common complication[3], which means the movement of the solid or liquid from the oral cavity to the stomach or the transmission delay, It mainly occurs in the mouth and the pharynx stage. At present, the method of examination for dysphagia mainly includes: asking for medical history, oropharyngeal function examination, drinking water test in low-lying field, and video of swallowing ability examination (VFSS), etc.[4]. The fluoroscopy of the swallowing disorder, also known as the pharynx dynamic contrast, is a method to record the oropharyngeal activity of the oropharynx with the X-ray video recording. Because VFSS can provide more evaluation information in the diagnosis of dysphagia, it is often considered to be the "gold standard" of diagnosis and swallowing disorder[5], and it is very important to evaluate the swallowing function of patients after stroke. Acupuncture and moxibustion have a good effect in the treatment of post-stroke dysphagia. In order to evaluate the degree of dysphagia after stroke and the curative effect of acupuncture treatment, we use the way of fluoroscopy. In the test, the patients had a different degree of swallowing disorder in the perspective of the television, including 48 (82.8%) of the decompensation of the swallowing function,20 cases of misabsorption and the penetration of the supraglottic door,40 (83.3%) and 13 non-cough-free patients with no cough. (27.1% of the patients with missuction). The statistical analysis shows that the ability of acupuncture to treat the dysphagia after stroke can be directly analyzed by the fluoroscopy, and the effectiveness of this method in the evaluation of the swallowing function of the patients with cerebral infarction is verified. One of the important threats to the swallowing disorder is the aspiration. Mark et al. confirmed that the VFSS not only can objectively and directly evaluate the curative effect of the acupuncture treatment, but also can accurately find the cause of the misabsorption in the swallowing, and can find the cause of the aspiration, and the evaluation accuracy rate is higher than that of the clinical evaluation scale, in particular, the diagnosis of the occult will be of a decisive significance[5], It is an effective method for functional examination and curative effect evaluation of patients with dysphagia after stroke. 3. The imaging brain functional magnetic resonance imaging (fMRI) of acupuncture and functional nuclear magnetic resonance is a kind of magnetic resonance imaging technology based on the magnetic sensitive effect of deoxygenated hemoglobin. The appropriate stimulation can cause the brain region to be excited by the nerve, and the metabolic level and local blood flow in the excited brain region increase, and the effect of the latter is larger than that of the former. Therefore, the content of oxygenated hemoglobin in the excited brain region is increased, and the content of deoxygenated hemoglobin in the non-excited brain region is dominant, and the deoxygenated hemoglobin has paramagnetism (the time of T1, T2 and T2 * of the tissue can be shortened). BOLD-fMRI was used to scan (T2 * WI), T2 * time to decrease the signal of non-excited brain region, and to reverse the high-signal excitation brain region (T2 * WI). The BOLD method has the advantages of high spatial resolution, high time resolution, no electromagnetic radiation and low cost compared with other brain function imaging methods. and the fMRI can also be used for researching the repeated multiple times, the longitudinal and the large samples, and provides a unique method for the research of the brain plasticity, so that the fMRI has special value in the research of the complex advanced brain functions such as the cognitive function, the speech function, the motion, the sensory function and the like, So that the invention has wide application in the field of rehabilitation. Combined with the modern neuroanatomy theory, the activity and the change of the brain-swallowing function area caused by the acupuncture, the Lianquan point and the two-sided human-facing point were observed by using the BOLD-fMRI technique. The changes of the signal caused by the Lianquan point in the trial and the two-sided man-ying point indicated that the brain neurons of this region were involved in the swallowing activity. In our experiments, the frontal lobe, the central back, the central back, the occipital lobe, the lateral fissure, the nucleus of the gray matter in the basal ganglia, the vermis of the cerebellum, the cortex of the cerebellum, and the activation were significantly enhanced, and the brain regions were consistent with the center of the swallowing cortex from the previous study. At the same time, the center of the swallowing cortex in both the treatment group and the control group was located in the bilateral hemisphere, and the activation of the cortex of the cortex in the event of swallowing after acupuncture increased significantly. It is indicated that the acupuncture and moxibustion therapy can affect the blood flow of the brain and influence the change of the blood oxygen content to realize its therapeutic effect. In conclusion, the treatment of dysphagia after stroke is effective and the curative effect is exact.
【学位授予单位】：广西中医药大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R246.6

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