本文選題：電針 + 吞咽運(yùn)動(dòng)皮層��； 參考：《廣州中醫(yī)藥大學(xué)》2016年博士論文

【摘要】：背景：吞咽功能是人類最為基本和重要的生理活動(dòng)之一,其主要作用是將食物由口咽部傳遞至胃。在這一過程中,任一環(huán)節(jié)出現(xiàn)障礙,將會(huì)造成吞咽障礙,它是腦卒中的常見并發(fā)癥之一,給人類的健康帶來嚴(yán)重的危害。電針療法(簡稱電針)在治療腦卒中后吞咽障礙具有良好的臨床療效,但其生理和病理學(xué)機(jī)制的研究甚少。目的：觀察生理狀況下電針前經(jīng)顱磁刺激(Transcranial Magnetic Stimulation,TMS)以咽肌為靶肌的雙側(cè)吞咽運(yùn)動(dòng)皮層的最佳刺激點(diǎn)位置,以及電針前、不同電針參數(shù)干預(yù)任督脈經(jīng)穴后即刻,TMS雙側(cè)吞咽運(yùn)動(dòng)皮層所誘發(fā)咽肌的靜息運(yùn)動(dòng)閾值(Resting Motor Threshold,RMT)、運(yùn)動(dòng)誘發(fā)電位(Motor Evoked Potential,MEP)(波幅和潛伏期)的變化,探究電針對吞咽運(yùn)動(dòng)皮層興奮性的影響,從而明確吞咽運(yùn)動(dòng)皮層在電針激活咽皮質(zhì)延髓通路中的可能作用；并試圖探索其最佳電針參數(shù)方案；并觀察在最佳電針參數(shù)干預(yù)任督脈經(jīng)穴前提下,根據(jù)所誘發(fā)咽肌的MEP波幅的變化,分析電針對吞咽運(yùn)動(dòng)皮層的激活范圍與激活程度,進(jìn)而探究電針對吞咽運(yùn)動(dòng)皮層激活作用的影響。方法：從2014年8月至2015年12月期間,所有健康受試者均來自于廣州中醫(yī)藥大學(xué)的在讀學(xué)生,并通過廣東省中醫(yī)院倫理審查委員會(huì)的會(huì)議審查的批準(zhǔn)(批件號(hào)：B2014-017-01)。本研究的試驗(yàn)過程均在廣東省中醫(yī)院科學(xué)院中醫(yī)針灸重點(diǎn)實(shí)驗(yàn)室中完成。并簽署《健康受試者知情同意書》的受試者納入本研究,該研究共分為兩個(gè)試驗(yàn)階段進(jìn)行,均采用自身前后對照研究。第一個(gè)試驗(yàn)階段中,最終招募15例健康受試者參與第一個(gè)試驗(yàn)階段的研究；第二個(gè)試驗(yàn)階段中,在第一個(gè)試驗(yàn)階段的同一批健康受試者中,最終招募10例健康受試者參與第二個(gè)試驗(yàn)階段的研究。第一個(gè)試驗(yàn)階段的研究方法：采用韓式穴位神經(jīng)刺激儀(型號(hào)為HANS-200A)的不同電針參數(shù)即：電針頻率為2Hz和100Hz,時(shí)間為5min、15min、30min,強(qiáng)度均為健康受試者的最大耐受強(qiáng)度(2Hz時(shí)最大耐受強(qiáng)度為0.9mA-3mA;100Hz時(shí)最大耐受強(qiáng)度為0.9mA-2.5mA),波形均選用連續(xù)波,共六種電針參數(shù)(電針參數(shù)1為2Hz、5min;電針參數(shù)2為2Hz、15min;電針參數(shù)3為2Hz、30min;電針參數(shù)4為100Hz、5min;電針參數(shù)5為100Hz、15min;電針參數(shù)6為100Hz、30min)對健康受試者的任督脈經(jīng)穴-廉泉穴和風(fēng)府穴進(jìn)行電針干預(yù)。首先在電針前,運(yùn)用TMS雙側(cè)吞咽運(yùn)動(dòng)皮層,并記錄以咽肌為靶肌的雙側(cè)吞咽運(yùn)動(dòng)皮層的最佳刺激點(diǎn)位置,以及所誘發(fā)咽肌的RMT和MEP(波幅和潛伏期),然后隨機(jī)進(jìn)行上述六種電針參數(shù)干預(yù)健康受試者的任督脈經(jīng)穴-廉泉穴和風(fēng)府穴(每種電針參數(shù)干預(yù)之間的洗脫期為2天),并分別在每種電針參數(shù)干預(yù)后即刻,再運(yùn)用TMS雙側(cè)吞咽運(yùn)動(dòng)皮層,并記錄所誘發(fā)咽肌的RMT和MEP(波幅和潛伏期),均與電針前所誘發(fā)咽肌的RMT和MEP(波幅和潛伏期)進(jìn)行比較；并同時(shí)運(yùn)用TMS雙側(cè)手區(qū)運(yùn)動(dòng)皮層所誘發(fā)大魚際肌的RMT和MEP(波幅和潛伏期)作為對照。第二個(gè)試驗(yàn)階段的研究方法：在第一個(gè)試驗(yàn)階段的基礎(chǔ)上,從六種電針參數(shù)中獲得的最佳電針參數(shù)的前提下,繼續(xù)給予健康受試者的任督脈經(jīng)穴-廉泉穴和風(fēng)府穴進(jìn)行電針干預(yù),在電針前、電針后即刻,根據(jù)運(yùn)用TMS雙側(cè)吞咽運(yùn)動(dòng)皮層所誘發(fā)咽肌的MEP波幅的變化,分析電針對吞咽運(yùn)動(dòng)皮層的激活范圍與激活程度。同時(shí)仍與運(yùn)用TMS雙側(cè)手區(qū)運(yùn)動(dòng)皮層所誘發(fā)大魚際肌的MEP波幅的變化作為對照。結(jié)果：1.一般資料：健康受試者年齡在19-23歲之間；男性9例、女性6例；右利手13例,左利手2例；身高、體重、BMI指數(shù)均在正常范圍內(nèi)；生命體征平穩(wěn)；洼田飲水試驗(yàn)均為Ⅰ級(jí)；簡易智能狀態(tài)評分均為30分；鼻孔至食管上段擴(kuò)約肌的距離為18-21厘米之間。2.雙側(cè)吞咽運(yùn)動(dòng)皮層的最佳刺激點(diǎn)位置驗(yàn)證：本研究與經(jīng)典文獻(xiàn)中TMS以咽肌為靶肌的雙側(cè)吞咽運(yùn)動(dòng)皮層的最佳刺激點(diǎn)位置進(jìn)行比較,結(jié)果表明,以咽肌為靶肌的雙側(cè)吞咽運(yùn)動(dòng)皮層的最佳刺激點(diǎn)的橫、縱坐標(biāo)位置與經(jīng)典文獻(xiàn)中報(bào)道的橫、縱坐標(biāo)位置不存在統(tǒng)計(jì)學(xué)差異(P0.05)。3.電針任督脈經(jīng)穴對咽肌的RMT的影響：六種不同電針參數(shù)分別進(jìn)行干預(yù)后,TMS雙側(cè)吞咽運(yùn)動(dòng)皮層所誘發(fā)咽肌的RMT,均與雙側(cè)電針前的RMT進(jìn)行比較,在電針參數(shù)2和電針參數(shù)5干預(yù)后,雙側(cè)吞咽運(yùn)動(dòng)皮層所誘發(fā)咽肌的RMT均較雙側(cè)電針前RMT降低,差異均具有統(tǒng)計(jì)學(xué)意義(P0.01或P0.05)。六種不同電針參數(shù)干預(yù)后,TMS左側(cè)吞咽運(yùn)動(dòng)皮層所誘發(fā)咽肌的RMT變化率之間比較,差異均無統(tǒng)計(jì)學(xué)意義(P0.05)；TMS右側(cè)吞咽運(yùn)動(dòng)皮層所誘發(fā)咽肌的RMT變化率之間比較,差異均無統(tǒng)計(jì)學(xué)意義(P0.05)；且其左、右兩側(cè)的RMT變化率進(jìn)行比較,差異無統(tǒng)計(jì)學(xué)意義(P0.05)。并以電針前后,TMS雙側(cè)手區(qū)運(yùn)動(dòng)皮層所誘發(fā)大魚際肌的RMT和RMT變化率作為對照,后者電針前后的RMT未有明顯變化,差異均無統(tǒng)計(jì)學(xué)意義(P0.05)；電針前后其左、右兩側(cè)的RMT變化率進(jìn)行比較,差異無統(tǒng)計(jì)學(xué)意義(P0.05)。4.電針任督脈經(jīng)穴對咽肌的MEP波幅的影響：六種不同電針參數(shù)分別進(jìn)行干預(yù)后,TMS雙側(cè)吞咽運(yùn)動(dòng)皮層所誘發(fā)咽肌的MEP波幅,均與雙側(cè)電針前的MEP波幅進(jìn)行比較,六種電針參數(shù)干預(yù)后,雙側(cè)吞咽運(yùn)動(dòng)皮層所誘發(fā)咽肌的MEP波幅均較雙側(cè)電針前MEP波幅增大,差異均具有統(tǒng)計(jì)學(xué)意義(P0.01)。TMS雙側(cè)吞咽運(yùn)動(dòng)皮層所誘發(fā)咽肌的MEP波幅變化率比較,唯有在電針參數(shù)2(即2Hz、15min、健康受試者最大耐受強(qiáng)度)干預(yù)后,雙側(cè)MEP波幅變化率最大,差異均具有統(tǒng)計(jì)學(xué)意義(P0.05)；且其左、右兩側(cè)的MEP波幅變化率進(jìn)行比較,差異無統(tǒng)計(jì)學(xué)意義(P0.05)。并以電針前后,TMS雙側(cè)手區(qū)運(yùn)動(dòng)皮層所誘發(fā)大魚際肌的MEP波幅和MEP波幅變化率作為對照,后者電針前后的MEP波幅未有明顯變化,差異均無統(tǒng)計(jì)學(xué)意義(P0.05)；電針前后其左、右兩側(cè)的MEP波幅變化率進(jìn)行比較,差異無統(tǒng)計(jì)學(xué)意義(P0.05)。5.電針任督脈經(jīng)穴對咽肌的MEP潛伏期的影響：六種不同電針參數(shù)分別進(jìn)行干預(yù)后,TMS雙側(cè)吞咽運(yùn)動(dòng)皮層所誘發(fā)咽肌的MEP潛伏期均與雙側(cè)電針前的MEP潛伏期進(jìn)行比較,未有明顯變化,差異均無統(tǒng)計(jì)學(xué)意義(P0.05)。并以電針前后TMS雙側(cè)手區(qū)運(yùn)動(dòng)皮層所誘發(fā)大魚際肌的MEP潛伏期作為對照,后者電針前后的MEP潛伏期未有明顯變化,差異均無統(tǒng)計(jì)學(xué)意義(P0.05)。從而,無須再對咽肌和大魚際肌的MEP潛伏期進(jìn)行變化率之間的計(jì)算與比較。6.最佳電針參數(shù)干預(yù)任督脈經(jīng)穴對吞咽運(yùn)動(dòng)皮層的激活范圍的影響：由第一個(gè)試驗(yàn)階段獲得的最佳電針參數(shù)干預(yù)下,TMS以咽肌為靶肌的雙側(cè)吞咽運(yùn)動(dòng)皮層的激活個(gè)數(shù)較雙側(cè)電針前激活個(gè)數(shù)增加,差異均具有統(tǒng)計(jì)學(xué)意義(P0.05)。TMS以咽肌為靶肌的雙側(cè)吞咽運(yùn)動(dòng)皮層的激活個(gè)數(shù)變化率進(jìn)行比較,其左、右兩側(cè)的激活個(gè)數(shù)變化率差異無統(tǒng)計(jì)學(xué)意義(P0.05)。并以電針前后TMS以大魚際肌為靶肌的雙側(cè)手區(qū)運(yùn)動(dòng)皮層的激活個(gè)數(shù)和激活個(gè)數(shù)變化率作為對照,后者電針前后的激活個(gè)數(shù)未有明顯變化,差異均無統(tǒng)計(jì)學(xué)意義(P0.05)。電針前后其左、右兩側(cè)的激活個(gè)數(shù)變化率進(jìn)行比較,差異無統(tǒng)計(jì)學(xué)意義(P0.05)。7.最佳電針參數(shù)干預(yù)任督脈經(jīng)穴對吞咽運(yùn)動(dòng)皮層的激活程度的影響：由第一個(gè)試驗(yàn)階段獲得的最佳電針參數(shù)干預(yù)下,將健康受試者電針前后TMS以咽肌為靶肌的雙側(cè)吞咽運(yùn)動(dòng)皮層所激活的相同位點(diǎn)的激活程度進(jìn)行比較,以咽肌為靶肌的雙側(cè)吞咽運(yùn)動(dòng)皮層各點(diǎn)激活程度較雙側(cè)電針前激活程度增強(qiáng),差異均具有統(tǒng)計(jì)學(xué)意義(P0.01)。TMS以咽肌為靶肌的雙側(cè)吞咽運(yùn)動(dòng)皮層所激活的相同位點(diǎn)的激活程度變化率進(jìn)行比較,其左、右兩側(cè)的激活程度變化率差異均無統(tǒng)計(jì)學(xué)意義(P0.05)。并以電針前后TMS以大魚際肌為靶肌的雙側(cè)手區(qū)運(yùn)動(dòng)皮層所激活的相同位點(diǎn)的激活程度和激活程度變化率作為對照,后者電針前后的激活程度未有明顯變化,差異均無統(tǒng)計(jì)學(xué)意義(P0.05)。電針前后其左、右兩側(cè)的激活程度變化率進(jìn)行比較,差異均無統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論：1.TMS健康受試者的雙側(cè)吞咽運(yùn)動(dòng)皮層,與經(jīng)典文獻(xiàn)當(dāng)中歐洲人群的最佳刺激點(diǎn)位置相比,亞洲人群和歐洲人群的最佳刺激點(diǎn)的位置基本一致,可推斷生理狀況下TMS人類的雙側(cè)吞咽運(yùn)動(dòng)皮層的最佳刺激點(diǎn)不存在人種差異,但此結(jié)論應(yīng)擴(kuò)大樣本量進(jìn)一步證實(shí)。2.采用頻率為2Hz和100Hz,時(shí)間5min、15min、30min,強(qiáng)度均為健康受試者的最大耐受強(qiáng)度,這六種不同電針參數(shù)干預(yù)任督脈經(jīng)穴-“廉泉穴”和“風(fēng)府穴”后,均可促進(jìn)雙側(cè)吞咽運(yùn)動(dòng)皮層的興奮性,進(jìn)而增強(qiáng)咽皮質(zhì)延髓通路下行傳導(dǎo)的興奮性。其中,2Hz、15min、健康受試者最大耐受強(qiáng)度為六種不同電針參數(shù)中最佳的電針參數(shù)方案。3.在六種不同電針參數(shù)干預(yù)任督脈經(jīng)穴-“廉泉穴”、“風(fēng)府穴”后,對健康受試者的雙側(cè)吞咽運(yùn)動(dòng)皮層興奮性具有促進(jìn)作用,并以大魚際肌為靶肌的手區(qū)運(yùn)動(dòng)皮層興奮性相比,后者的皮層興奮性未有明顯變化,可提示生理狀況下電針任督脈經(jīng)穴對促進(jìn)雙側(cè)吞咽運(yùn)動(dòng)皮層的興奮性存在一定的特異性。4.在最佳電針參數(shù)干預(yù)任督脈經(jīng)穴-“廉泉穴”、“風(fēng)府穴”后,可增大健康受試者的雙側(cè)吞咽運(yùn)動(dòng)皮層的激活范圍以及增強(qiáng)其激活程度,并以大魚際肌為靶肌的手區(qū)運(yùn)動(dòng)皮層的激活范圍和激活程度相比,后者的激活范圍和激活程度未有明顯變化,可表明生理狀況下電針任督脈經(jīng)穴對雙側(cè)吞咽運(yùn)動(dòng)皮層具有特異性的激活作用,并且此激活作用的機(jī)制可能與大腦可塑性有一定的聯(lián)系,具體可能與突觸的短期可塑性當(dāng)中的短時(shí)程增強(qiáng)(Short-term Potentiation,STP)作用或長期可塑性當(dāng)中的長時(shí)程增強(qiáng)(Long-term Potentiation,LTP)作用有關(guān)。
[Abstract]:Background : The swallowing function is one of the most basic and important physiological activities of human . The main function is to transfer food from oropharynx to stomach . In this process , it is one of the most common complications of stroke . It is one of the most common complications of stroke .
and attempts to explore its optimal parameters scheme ;
From August 2014 to December 2015 , all healthy subjects came from the students of Guangzhou University of Traditional Chinese Medicine and approved by the meeting of the Ethics Review Committee of the Central Hospital of Guangdong Province ( lot number : B2014 - 017 - 01 ) . The study was completed in the Chinese Academy of Traditional Chinese Medicine Acupuncture and Moxibustion Key Laboratory of the Chinese Academy of Sciences in Guangdong Province . Subjects who signed the Informed Consent Form for Healthy Subjects were enrolled in the study . The study was conducted in two trial stages , both in the first trial phase , and in the first trial phase , 15 healthy subjects were enrolled in the first trial phase .
In the second trial phase , 10 healthy subjects were enrolled in the study of the second trial phase in the same group of healthy subjects in the first trial phase . The first trial phase consisted of two different electroacupuncture parameters : the frequency of the electroacupuncture was 2 Hz and 100 Hz , the maximum tolerance intensity was 0.9 mA - 2 . 5mA at 100 Hz ; the electroacupuncture parameters were 2 Hz , 15 min ; the electroacupuncture parameters 6 were 100 Hz and 30 min . The RMT and MEP ( amplitude and latency ) of the evoked pharyngeal muscle were recorded , which were compared with RMT and MEP ( amplitude and latency ) of pharyngeal muscle induced before electroacupuncture .
On the base of the first experiment stage , the authors continued to give the acupuncture intervention of the acupuncture point of the healthy subjects on the basis of the first test phase , and then , on the basis of the optimal electroacupuncture parameters obtained from the six kinds of electroacupuncture parameters , the activation range and the activation degree of the pharyngeal muscle were analyzed .
There were 9 males and 6 females .
Right hand 13 cases , left hand 2 cases ;
Height , weight and BMI were within the normal range ;
The vital signs are stable ;
The drinking water test in depression is Grade 鈪，

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