本文關(guān)鍵詞： 吞咽障礙 非線性分析 經(jīng)顱直流電刺激 針刺 皮質(zhì)興奮性　出處：《首都醫(yī)科大學(xué)》2017年博士論文　論文類(lèi)型：學(xué)位論文

【摘要】：目的:探討腦電非線性分析(Nonlinear dynamics analysis,NDA)能否為中西醫(yī)干預(yù)卒中后吞咽障礙患者吞咽皮質(zhì)興奮性改變提供客觀的神經(jīng)電生理分析手段,研究針刺療法、經(jīng)顱直流電刺激(Transcranial direct current stimulation,tDCS)干預(yù)卒中后吞咽障礙的恢復(fù)與吞咽皮質(zhì)興奮性變化的關(guān)聯(lián)性及其作用機(jī)制。方法:第一部分采用A-B試驗(yàn)設(shè)計(jì)。A期干預(yù)措施是假經(jīng)顱直流電刺激配合康復(fù)手法訓(xùn)練,B期的干預(yù)措施是陽(yáng)極tDCS配合康復(fù)手法訓(xùn)練。A、B期治療前后,利用吞咽失用量表(Swallowing apraxia scale,SAS)評(píng)估5例患者的吞咽功能。B期治療前后利用腦電非線性指數(shù)近似熵(Approximate entropy,Ap En)對(duì)3例患者安靜閉眼狀態(tài)、反射性吞咽任務(wù)以及自主性吞咽任務(wù)下的吞咽皮質(zhì)興奮性進(jìn)行分析;并選6例正常受試者作為對(duì)照組。第二部分采用隨機(jī)對(duì)照試驗(yàn)設(shè)計(jì):將符合納入標(biāo)準(zhǔn)的40例卒中后吞咽障礙患者隨機(jī)分入3個(gè)組:對(duì)照組、tDCS組和針刺組。對(duì)照組、tDCS組和針刺組的患者例數(shù)分別為14例、15例、11例。對(duì)照組采用常規(guī)的康復(fù)手法訓(xùn)練。tDCS組在常規(guī)的康復(fù)手法訓(xùn)練基礎(chǔ)上,進(jìn)行陽(yáng)極tDCS治療。針刺組在常規(guī)的康復(fù)手法訓(xùn)練的基礎(chǔ)上,進(jìn)行針刺治療。治療前、治療1周后、治療2周后分別利用吞咽障礙嚴(yán)重程度量表(Swallow severity scale,SSS)和改良吞咽障礙能力評(píng)價(jià)表(Modified Mann assessment of swallowing ability,MMASA)評(píng)估吞咽功能;治療結(jié)束1個(gè)月隨訪,利用SSS量表進(jìn)行吞咽功能評(píng)估。于治療前、治療2周后利用Ap En對(duì)17例半球卒中后吞咽障礙患者,其中對(duì)照組4例、tDCS組6例、針刺組7例安靜閉眼狀態(tài)和自主性吞咽任務(wù)下的吞咽皮質(zhì)興奮性進(jìn)行分析。結(jié)果:第一部分A期治療前后,5例患者吞咽功能評(píng)分無(wú)變化;B期治療前后,患者SAS量表吞咽功能評(píng)分明顯提高。腦電Ap En顯示:正常對(duì)照組自主性吞咽時(shí)興奮的腦區(qū)多于反射性吞咽時(shí)。陽(yáng)極tDCS治療前,3例患者反射性吞咽時(shí)的患側(cè)中央-頂-顳區(qū)Ap En數(shù)值增高(P0.01),但自主性吞咽時(shí)所有檢測(cè)腦區(qū)Ap En數(shù)值均無(wú)增高(P0.01)。經(jīng)陽(yáng)極tDCS治療后,反射性吞咽和自主性吞咽時(shí)患側(cè)或健側(cè)半球均有更多腦區(qū)Ap En數(shù)值增高(P0.01)。第二部分吞咽功能評(píng)估:治療前,對(duì)照組、tDCS組和針刺組的SSS評(píng)分和MMASA評(píng)分無(wú)差異(P0.05)。治療1周后、2周后,3組患者的SSS評(píng)分及MMASA評(píng)分均明顯增加(P0.05),但3組SSS評(píng)分及MMASA評(píng)分的組間比較無(wú)差異(P0.05)。1個(gè)月后隨訪,tDCS組與針刺組頻數(shù)的比較無(wú)顯著差異(P0.05),但tDCS組及針刺組均明顯優(yōu)于對(duì)照組,有顯著性差異(P0.05)。腦電Ap En顯示:治療前,與安靜閉眼狀態(tài)相比,自主吞咽時(shí)對(duì)照組、tDCS組和針刺組的健側(cè)中央?yún)^(qū)(C健側(cè))Ap En數(shù)值(分別是0.81±0.05,0.86±0.09和0.85±0.10)增加(P0.01)。治療2周后,與安靜閉眼狀態(tài)相比,自主吞咽時(shí)對(duì)照組的健側(cè)頂區(qū)(P_(健側(cè)))Ap En數(shù)值(0.89±0.12)增加(P0.01);tDCS組的健側(cè)中央?yún)^(qū)(C健側(cè))、健側(cè)頂區(qū)(P_(健側(cè)))和患側(cè)中央?yún)^(qū)(C患側(cè))Ap En數(shù)值(分別是0.87±0.07,0.82±0.07和0.79±0.04)增加(P0.01);針刺組的健側(cè)中央?yún)^(qū)(C健側(cè))和健側(cè)額區(qū)(F健側(cè))Ap En數(shù)值(分別是0.80±0.06和0.79±0.07)增加(P0.01)。結(jié)論:腦電非線性分析可以作為中西醫(yī)干預(yù)卒中后吞咽障礙患者吞咽皮質(zhì)興奮性變化的客觀神經(jīng)電生理分析手段。在康復(fù)手法訓(xùn)練基礎(chǔ)上,配合針刺療法或經(jīng)顱直流電刺激更有助于卒中后吞咽障礙的遠(yuǎn)期恢復(fù),其作用機(jī)制可能與吞咽皮質(zhì)興奮性的變化相關(guān)。
[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鑴戝尯Ap En鏁板，

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