【作者】 杨海芳；

【导师】 刘茂才；

【作者基本信息】 广州中医药大学 ， 中医内科学， 2010， 博士

【摘要】 背景脑卒中所导致的吞咽障碍为功能性吞咽障碍。资料研究脑卒中患者吞咽障碍的发生率可达30%-65%,导致多种严重并发症,如吸人性肺炎、脱水、营养不良、支气管痉挛、气道阻塞以及出现社会隔绝、抑郁等负性社会心理,从而严重影响病人的身心健康。针对脑卒中后吞咽障碍不同的诊疗方案,改善患者预后,防止病情反弹是现在国内外研究的热点之一。近几年随着临床研究的深入,针刺加康复综合治疗脑卒中后吞咽障碍取得了良好的疗效。但由于诊断方法及评估方法的不标准、未采取随机双盲对照实验、样本量小及未进行随访等问题,使研究结果缺乏科学性及信度。目的通过电针联合康复训练治疗与已被公认存在确切疗效的单纯康复治疗对脑卒中后吞咽障碍的疗效进行比较,评价电针联合康复治疗对于脑卒中后吞咽障碍的疗效及安全性,试图初步研究电针治疗卒中后吞咽障碍的临床疗效以及可能的作用机制,并提供循证医学依据,为进一步深入研究做基础性探讨。方法用随机盲法对照试验的方法,3周电针联合康复训练(试验组)结束后与单纯康复训练(对照组)进行疗效比较,疗效评价标准为SSA评分及VFSS评分,并比较两种评价方法的相关性,及记录不良事件的发生。结果两组患者经治疗后,自身前后比较,SSA总分均降低而VFSS总分均提高,差异有统计学意义(P＜0.01)。试验组与对照组比较,SSA总分降低及VFSS总分升高差值试验组均高于对照组,差异有统计学意义(P<0.01)。VFSS评分中,两组患者经治疗后各阶段分值均有提高,差异有统计学意义(P＜0.05)。VFSS评分各阶段评分治疗前后差值比较,试验组差值高于对照组,差异有统计学意义(P<0.05)。将入选患者按头颅MR结果分为含有脑干组和不含脑干组两类患者。研究结果显示,治疗前两不同病灶分类组SSA评分及VFSS评分结果,含脑干损伤类患者较不含脑干损伤类患者的吞咽障碍总体情况严重,差异有统计学意义(P<0.01)。具体到吞咽障碍各期情况而言,含脑干损伤类患者口腔期障碍较不含脑干损伤类类患者轻,而咽期及误咽情况较重,差异有统计学意义(P<0.05)从疗效分析来看,从VFSS总分及SSA总分前后差值比较可以得出两类病灶损伤患者接受试验组治疗疗效均高于对照组,差异有统计学意义(P<0.01)。而从VFSS评分各阶段来看,两组治疗方法对于两类病灶损伤患者口腔期改善的疗效差异无统计学意义；而试验组相对于两类病灶损伤的患者咽期改善的疗效均好于对照组,差异有统计学意义(P＜0.01)；试验组对于含脑干损伤患者的误咽改善疗效好于对照组,差异有统计学意义(P＜0.05),而对于不含脑干病灶损伤患者的误咽改善两治疗组疗效差异无统计学意义。吞咽障碍评估方法SSA法及电视荧光透视VFSS评分呈负相关关系。研究过程中,除2例患者出现针刺后皮下瘀斑外,无其他不良事件发生。结论对于脑卒中后吞咽障碍,电针联合康复训练治疗组疗效优于单纯康复治疗组。吞咽障碍评估方法SSA法及电视荧光透视VFSS评分存在负相关关系。更多还原

【Abstract】 BackgroundDysphagia caused by stroke is a type of functional Dysphagia. Research shows that the occurrence of Dysphagia after stroke can reach 30% to 65% with serious complications such as aspiration pneumonia, dehydration, malnutrition, bronchiospasm, airway obstruction. The negative social psychology would also onset in the disease, like social isolation and depression. They would seriously affect the physical and mental health of the patients. Nowadays, the hot and focal points of study home and abroad have been the different treatment plan for Dysphagia in apoplexy, improvement of the prognosis and prevention of condition rebounding. With the help of the deep clinical research for the recent years, the combined treatment of acupuncture and rehabilitation training for Dysphagia in cerebral apoplexy has obtained satisfactory effect. But the research results lack scientificity and credibility because of the nonstandard diagnosis and assessment method, failure to adopt the randomized double-blind controlled experiment, small sample size and lacking follow-up studies.Object ivesCompare the three weeks’combined treatment of electro-acupuncture and rehabilitation training (experimental group) with simple rehabilitation training (control group)。Assess the efficacy and safety of the combined treatment of electro-acupuncture and rehabilitation on the Dysphagia patients after stroke. Try to initially investigate the possible mechanism of electro-acupuncture therapy on them, provid evidence-based medicine foundationand In clinical, and do some basis investigation for further studies.MethodsCompare the three weeks’combined treatment of electro-acupuncture and rehabilitation training (experimental group) with simple rehabilitation training (control group). Compare the correlation between the two assessment methods, SSA and VFSS, which are used for assessing efficacy, and record the adverse events.ResultsAfter the comparison of a patient before the treatment with himself after it, his total SSA score decreases, while his total VFSS score increase, whose differences are statistically significant (P<0.01). Comparing the experimental group with the control one, the decreases of the SSA and the increases of the VFSS in the test group are higher that those in the control one, whose differences are statistically significant. (P<0.01)In the VFSS score, patients’each stage values in both groups all increase after the treatment, whose differences are statistically significant. (P<0.05) Comparing the differences of the VFSS each stage scores before and after the treatment, those of the test group are higher than those of the control one, which is statistically significant. (P<0.05)The selected patients are divided into two groups:the group with brain stem injury and the group without brain stems injury, according to their cranial MR results. The research shows that the patients in the group with brain stems have more severe overall Dysphagia situations than those in the group without brain stems before the treatment according to their SSA and VFSS scores in both lesions, whose differences are statistically significant. (P<0.01) In terms of the concrete situation of each Dysphagia stage, the Dysphagia in The group with brain stems injury are less severe than that in The group without brain stems injury, while the Dysphagia period and the aspiration situation are more severe, whose differences are statistically significant. (P<0.05)From the perspective of the curative effect, the patients with two lesions in the experimental group have better effect than those in the control group, according to their VFSS and SSA scores, whose differences are statistically significant. (P<0.01) From that of each stage of the VFSS score, there is no statistical significance in the curative effect of oral improvement in the patients with two lesions in both groups. The curative effect of the pharyngeal improvement in the patients of the experimental group are better than that of the control group, whose differences are statistically significant. (P<0.01)The curative effect of the aspiration improvement in the patients with brain stems damaged in the experiemental group is better than that in the control group, whose differences are statistically significant. (P<0.05) But to the patients without the lesion of brain stem, there is no statistical significance in the aspiration improvement in both groups.The assessment method for Dysphagia, SSA, is highly related to the TV-fluoroscopy VFSS score by increasing with negative growth rate.During the researching process, no adverse events occur except that two patients are found subcutaneous ecchymosis after being acupunctured.ConclusionsIn terms of Dysphagia in celebral apoplexy, the effect of the combined treatment of electro-acupuncture and rehabilitation training group is better than that of the control group.The SSA for assessing Dysphagia is highly related to the TV-fluoroscopy VFSS score by increasing with negative growth rate.更多还原