針灸治療腦梗死恢復(fù)期吞咽障礙的臨床研究
發(fā)布時(shí)間：2019-05-16 14:23
【摘要】：一、針灸治療腦卒中后吞咽障礙的療效研究隨著當(dāng)今社會(huì)的快速發(fā)展、生存環(huán)境以及人類疾病譜的變化以及社會(huì)老齡速度的加快,發(fā)病率日益上升的腦血管病(CVD),己超越癌癥、心血管疾病,居危害世界人民生命安全的三大疾病之榜首,也是造成吞咽障礙的主要病因[1]。吞咽障礙是腦卒中患者最常見的并發(fā)癥之一,28%—82%的腦卒中患者會(huì)發(fā)生吞咽障礙,吞咽障礙的發(fā)生提高了肺部感染、營(yíng)養(yǎng)不良、再次中風(fēng)及死亡的發(fā)生率,嚴(yán)重影響了患者的生存質(zhì)量[2]。因此,對(duì)患者吞咽功能進(jìn)行評(píng)定,并根據(jù)吞咽障礙的具體情況采取積極有效的康復(fù)治療,對(duì)縮短病程、減輕患者及家庭社會(huì)的負(fù)擔(dān)、提高患者的生存質(zhì)量、降低死亡率等方面都有顯著的影響。具有千百年歷史的針灸療法,作為中國(guó)傳統(tǒng)醫(yī)學(xué)的瑰寶,為人類的醫(yī)療保健做出了積極、巨大的貢獻(xiàn),在世界各地,越來越受到歡迎。針灸療法也是被世界各國(guó)率先應(yīng)用的祖國(guó)傳統(tǒng)醫(yī)學(xué)治療方法。目前,在臨床應(yīng)用上,針灸療法作為替代現(xiàn)代先進(jìn)醫(yī)學(xué)的治療方法,已在世界多個(gè)國(guó)家實(shí)施,科學(xué)基礎(chǔ)對(duì)針灸療法的研究也越來越引起人們的重視。本研究通過臨床治療與觀測(cè),治療組與對(duì)照組比較療效差異顯著,治療組優(yōu)于對(duì)照組。針刺治療腦卒中后吞咽障礙有顯著療效,對(duì)提高這類病人的康復(fù)治療率有顯著的提高。經(jīng)統(tǒng)計(jì)學(xué)分析表明,血糖、性別、吸煙飲酒史等相關(guān)因素對(duì)治療腦卒中后吞咽障礙的療效均有影響。其中,血糖影響最大,而年齡、飲酒史等對(duì)療效無明顯影響。因此在臨床實(shí)踐中,對(duì)血糖、吸煙、等因素宜引起重視,以便提高此類患者的臨床療效。二、電視透視系統(tǒng)評(píng)估針灸治療腦卒中后吞咽障礙的臨床研究吞咽是極其復(fù)雜生理反射的過程,腦卒中后吞咽障礙是常見合并癥[3],是指固體或液體從口腔至胃的傳遞過程中出現(xiàn)運(yùn)動(dòng)障礙或傳送延遲,主要發(fā)生于口、咽階段。目前針對(duì)吞咽障礙的檢查方法主要有:詢問病史、口咽功能檢查、洼田飲水試驗(yàn)、電視透視下吞咽能力檢查(videofluoroscopic swallowing study,VFSS)等[4]。吞咽障礙的電視透視檢查又稱咽部動(dòng)態(tài)造影,是指用X線錄像記錄吞咽造影時(shí)口咽部活動(dòng)情況的方法。由于VFSS在診斷吞咽障礙方面可以提供更多的評(píng)價(jià)信息,準(zhǔn)確區(qū)分誤吸與穿透,區(qū)分否存在安靜誤吸等,故常被認(rèn)為是診斷吞咽障礙的“金標(biāo)準(zhǔn)”[5],對(duì)腦卒中后患者吞咽功能的評(píng)價(jià)十分重要。針灸治療腦卒中后吞咽障礙具有很好的效果,為了客觀評(píng)價(jià)患者腦卒中后吞咽障礙程度及針刺治療的療效,我們運(yùn)用電視透視檢查的方式進(jìn)行了實(shí)驗(yàn)。試驗(yàn)中,患者在電視透視下均有不同程度的吞咽障礙之異常表現(xiàn),其中吞咽功能失代償?shù)挠?8例(82.8%),誤吸及聲門上穿透各20例,共40例(83.3%,有13例無嗆咳表現(xiàn)的安靜誤吸病患,占誤吸病患的27.1%)。經(jīng)統(tǒng)計(jì)分析表明,電視透視檢查可直觀的分析針灸治療腦卒中后吞咽障礙的能力,驗(yàn)證了該檢查方法對(duì)評(píng)定腦梗死患者吞咽功能評(píng)定的有效性。吞咽障礙的重要威脅之一在于誤吸。Mark等證實(shí),VFSS不僅能客觀直接地評(píng)價(jià)針刺治療的療效,準(zhǔn)確發(fā)現(xiàn)吞咽中是否存在誤吸,更可發(fā)現(xiàn)誤吸的原因,它的評(píng)價(jià)推確率高于臨床評(píng)價(jià)量表,尤其對(duì)隱匿性吸人的診斷有決定性意義[5],是腦卒中后吞咽障礙患者功能檢查及療效評(píng)估的有效方法。三、針灸與功能性核磁共振的成像腦功能磁共振成像(functional magnetic resonance imaging,fMRI),它是一種以脫氧血紅蛋白的磁敏感效應(yīng)為基礎(chǔ)的磁共振成像技術(shù)。適宜的刺激可通過神經(jīng)傳入大腦引起相應(yīng)腦區(qū)興奮,興奮腦區(qū)的代謝水平及局部血液流量均增加,后者的效應(yīng)大于前者。故興奮腦區(qū)的氧合血紅蛋白含量增加,而在非興奮腦區(qū)脫氧血紅蛋白含量占優(yōu),脫氧血紅蛋白具有順磁性(可使組織的T1,T2及T2*時(shí)間縮短)。BOLD-fMRI檢查采用EPI序列掃描(T2*WI),T2*時(shí)間縮短使非興奮腦區(qū)組織的信號(hào)降低,反襯出相對(duì)高信號(hào)的興奮腦區(qū)(T2*WI),經(jīng)軟件處理后使興奮程度不同的腦區(qū)呈不同的顏色,從而直觀顯示腦功能的表現(xiàn)。BOLD法與其他腦功能成像手段相比具有較高的空間分辨率、較高的時(shí)間分辨率、無電磁輻射以及費(fèi)用較低等優(yōu)點(diǎn)。而且利用fMRI還可以進(jìn)行反復(fù)多次、縱向和大樣本的研究,為腦可塑性研究提供獨(dú)特的方法,因而在對(duì)于認(rèn)知功能、言語功能,運(yùn)動(dòng)、感覺功能等復(fù)雜的高級(jí)腦功能的研究中有其特殊價(jià)值,故在康復(fù)領(lǐng)域得到了廣泛的應(yīng)用。本試驗(yàn)結(jié)合現(xiàn)代神經(jīng)解剖學(xué)理論,應(yīng)用BOLD-fMRI技術(shù)觀察針刺廉泉穴及雙側(cè)人迎穴前后所引起的腦吞咽功能區(qū)的活動(dòng)和變化情況。試驗(yàn)中廉泉穴及雙側(cè)人迎穴所造成的信號(hào)改變,表明此區(qū)域的腦神經(jīng)元參與有關(guān)吞咽活動(dòng)。從我們的實(shí)驗(yàn)中,可以很直觀地看到額葉、中央前回、中央后回、頂枕葉、外側(cè)裂周圍、基底節(jié)區(qū)的灰質(zhì)核團(tuán)、小腦上蚓部、小腦皮質(zhì)、激活顯著增強(qiáng),而上述腦區(qū)與既往研究得出的吞咽皮質(zhì)中樞相一致。同時(shí)試驗(yàn)中治療組與對(duì)照組患者的吞咽皮質(zhì)中樞均位于雙側(cè)半球,并且針刺后吞咽活動(dòng)時(shí)皮質(zhì)中樞腦區(qū)的激活明顯增強(qiáng)、增多。表明針灸療法是通過影響腦血流量、影響血氧含量變化來實(shí)現(xiàn)它的治療作用�？傊�,針刺對(duì)腦卒中后吞咽障礙的治療是有效的,療效是確切的。
[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.
【學(xué)位授予單位】：廣西中醫(yī)藥大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2016
【分類號(hào)】：R246.6
本文編號(hào)：2478339
[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.
【學(xué)位授予單位】：廣西中醫(yī)藥大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2016
【分類號(hào)】：R246.6
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