急性缺血性脑卒中伴吞咽困难患者吞咽康复治疗的影响因素及其对预后的影响
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摘要
目的调查急性缺血性卒中伴吞咽困难的住院患者,并探索吞咽康复治疗的影响因素及其与预后的相关性。方法选取2012—2013年的1 581例多中心的缺血性卒中住院患者,吞咽困难的临床诊断由康复治疗师进行专业的床边吞咽评估得出。吞咽困难的康复治疗包括吞咽康复训练、电刺激或磁刺激,以及辅助治疗等。随访时间为12个月,终点事件包括全因死亡、卒中复发和功能预后不良。采用多因素Logistics回归模型对吞咽困难患者进行康复治疗的影响因素进行分析,采用Cox回归模型对吞咽困难患者进行康复治疗与预后的相关性进行分析。结果本研究共纳入1 581例伴吞咽困难的急性缺血性卒中患者,其中962例(60.8%)进行了吞咽康复治疗。进行吞咽康复治疗的影响因素包括:入院时较低的国立卫生研究院卒中量表评分、接受肢体康复治疗、深静脉血栓预防、颈动脉血管成像检查以及在年出院数较高的医院住院(均P<0.05)。与未进行吞咽康复治疗的患者相比,行吞咽康复治疗的患者12个月全因死亡风险较低[危险比(hazard ratio,HR):0.76;95%置信区间(confidence interval,CI):0.60～0.95],卒中复发比例较低[HR:0.73;95%CI:0.55～0.96],功能预后不良的比例较低(比值比:0.68;95%CI:0.50～0.93)(均P<0.05)。结论伴吞咽困难的急性缺血性卒中患者进行吞咽康复治疗的影响因素包括:入院时NIHSS评分,医院的年卒中出院人数,是否行肢体康复、深静脉血栓预防和颈动脉血管成像检查等。吞咽康复治疗可改善伴吞咽困难的急性缺血性卒中患者12个月的预后。
Objective To investigate the hospitalized patients with acute ischemic stroke with dysphagia,and to explore the influencing factors of swallowing rehabilitation therapy and its correlation with prognosis. Methods One thousand five hundred and eihtty-one patients were selected from a multi-center cohort of inpatients with ischemic stroke from 2012 to 2013.The clinical diagnosis of dysphagia was assessed by a professional bedside swallowing assessment conducted by a rehabilitation therapist.Rehabilitation therapy for dysphagia includes swallowing rehabilitation training,electrical or magnetic stimulation,and adjuvant therapy.The follow-up period was 12 months.Endpoint events included all-cause mortality,stroke recurrence and functional prognosis.Multivariate logistic regression model was used to analyze the influencing factors of rehabilitation treatment for dysphagia patients,and Cox regression model was used to analyze the correlation between rehabilitation treatment and prognosis for dysphagia patients. Results A total of 1 581 patients with acute ischemic stroke with dysphagia were enrolled in this study,of which 962(60.8%) underwent swallowing rehabil-itation therapy.Influencing factors for swallowing rehabilitation included lower NIH Stroke Scale score at admission,limb rehabilitation,prevention of deep vein thrombosis,carotid angiography and hospitalization in hospitals with higher annual discharge(P<0.05).Compared with patients without swallowing rehabilitation therapy,patients receiving swallowing rehabilitation therapy had lower risk of all-cause death(HR:0.76; 95%CI:0.60-0.95),low recurrence rate of stroke(HR:0.73; 95%CI:0.55-0.96),and low rate of poor functional prognosis.(ratio:0.68; 95% CI:0.50-0.93)(P<0.05). Conclusion The proportion of patients with acute ischemic stroke complicated with dysphagia receiving swallowing rehabilitation therapy is relatively low in China.The influencing factors of swallowing rehabilitation for patients with acute ischemic stroke with dysphagia include NIHSS at admission,the number of patients discharged from hospital after stroke,whether to perform limb rehabilitation,prevention of deep vein thrombosis and carotid angiography.Deglutition rehabilitation therapy can improve the 12-month prognosis of patients with acute ischemic stroke with dysphagia.
Objective To investigate the hospitalized patients with acute ischemic stroke with dysphagia,and to explore the influencing factors of swallowing rehabilitation therapy and its correlation with prognosis. Methods One thousand five hundred and eihtty-one patients were selected from a multi-center cohort of inpatients with ischemic stroke from 2012 to 2013.The clinical diagnosis of dysphagia was assessed by a professional bedside swallowing assessment conducted by a rehabilitation therapist.Rehabilitation therapy for dysphagia includes swallowing rehabilitation training,electrical or magnetic stimulation,and adjuvant therapy.The follow-up period was 12 months.Endpoint events included all-cause mortality,stroke recurrence and functional prognosis.Multivariate logistic regression model was used to analyze the influencing factors of rehabilitation treatment for dysphagia patients,and Cox regression model was used to analyze the correlation between rehabilitation treatment and prognosis for dysphagia patients. Results A total of 1 581 patients with acute ischemic stroke with dysphagia were enrolled in this study,of which 962(60.8%) underwent swallowing rehabil-itation therapy.Influencing factors for swallowing rehabilitation included lower NIH Stroke Scale score at admission,limb rehabilitation,prevention of deep vein thrombosis,carotid angiography and hospitalization in hospitals with higher annual discharge(P<0.05).Compared with patients without swallowing rehabilitation therapy,patients receiving swallowing rehabilitation therapy had lower risk of all-cause death(HR:0.76; 95%CI:0.60-0.95),low recurrence rate of stroke(HR:0.73; 95%CI:0.55-0.96),and low rate of poor functional prognosis.(ratio:0.68; 95% CI:0.50-0.93)(P<0.05). Conclusion The proportion of patients with acute ischemic stroke complicated with dysphagia receiving swallowing rehabilitation therapy is relatively low in China.The influencing factors of swallowing rehabilitation for patients with acute ischemic stroke with dysphagia include NIHSS at admission,the number of patients discharged from hospital after stroke,whether to perform limb rehabilitation,prevention of deep vein thrombosis and carotid angiography.Deglutition rehabilitation therapy can improve the 12-month prognosis of patients with acute ischemic stroke with dysphagia.
引文
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[26] Wang Y,Li Z,Zhao X,et al.Effect of a Multifaceted Quality Improvement Intervention on Hospital Personnel Adherence to Performance Measures in Patients With Acute Ischemic Stroke in China:A Randomized Clinical Trial[J].JAMA.2018,320:245-254
[27] Foley N,Teasell R,Salter K,et al.Dysphagia treatment post stroke:A systematic review of randomised controlled trials[J].Age Ageing,2008,37:258-264
[28] Perry L,Love C P.Screening for dysphagia and aspiration in acute stroke:A systematic review[J].Dysphagia,2001,16:7-18
[29] Martino R,Martin R E,Black S.Dysphagia after stroke and its management[J].CMAJ,2012,184:1127-1128
[30] Geeganage C,Beavan J,Ellender S,et al.Interventions for dysphagia and nutritional support in acute and subacute stroke[J].Cochrane Database Syst Rev,2012,10:323
[31] Wang C,Rao K,Wu S,et al.Health care in china:Improvement,challenges,and reform[J].Chest,2013,143:524-531
[32] Bettger J P,Li Z,Xian Y,et al.Assessment and provision of rehabilitation among patients hospitalized with acute ischemic stroke in china:Findings from the china national stroke registry ii[J].Int J Stroke,2017,12:254-263
[33] Huang K L,Liu T Y,Huang Y C,et al.Functional outcome in acute stroke patients with oropharyngeal dysphagia after swallowing therapy[J].J Stroke Cerebrovasc Dis,2014,23:2547-2553
[34] McMicken B L,Muzzy C L.Prognostic indicators of functional outcomes in first time documented acute stroke patients following standard dysphagia treatment[J].Disabil Rehabil,2009,31:2196-2203
[35] Schepp S K,Tirschwell D L,Miller R M,et al.Swallowing screens after acute stroke:A systematic review[J].Stroke,2012,43:869-871
[2] Meng N H,Wang T G,Lien I N.Dysphagia in patients with brainstem stroke:Incidence and outcome[J].Am J Phys Med Rehabil,2000,79:170-175
[3] Ramsey DJ,Smithard DG.Kalra L.Early assessment of dysphagia and aspiration risk in acute stroke patients[J].Stroke,2003,34:1252—1257
[4] Smithard D G,O′Neill P A,Parks C,et al.Complications and outcome after acute stroke.Does dysphagia matter?[J].Stroke,1996,27:1200-1204
[5] Mann G,Hankey G J,Cameron D.Swallowing disorders following acute stroke:Prevalence and diagnostic accuracy[J].Cerebrovasc Dis,2000,10:380-386
[6] Paciaroni M,Mazzotta G,Corea F,et al.Dysphagia following stroke[J].Eur Neurol,2004,51:162-167
[7] Falsetti P,Acciai C,Palilla R,et al.Oropharyngeal dysphagia after stroke:Incidence,diagnosis,and clinical predictors in patients admitted to a neurorehabilitation unit[J].J Stroke Cerebrovasc Dis,2009,18:329-335
[8] Schmidt J,Holas M,Halvorson K,et al.Videofluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke[J].Dysphagia,1994,9:7-11
[9] Martino R,Foley N,Bhogal S,et a1.Dysphagia after stmke:incidence diagnosis.and pulmonary complications[J].Stroke,2005,36:2756-2763
[10] Yeh SJ,Huang KY,Wang TG,et al.Dysphagia screening decreases pneumonia in acute stroke patients admitted to the stroke intensive care unit[J].J Neurol Sci,2011,306:38-41
[11] Corrigan ML,Escuro AA,Celestin J,et al.Nutrition in the stroke patient[J].Nutr Clin Pract,2011,26:242-252
[12] Langdon P C,Lee A H,Binns C W.Dysphagia in acute ischaemic stroke:Severity,recovery and relationship to stroke subtype[J].J Clin Neurosci,2007,14:630-634
[13] Bakhtiyari J,Sarraf P,Nakhostin-Ansari N,et al.Effects of early intervention of swallowing therapy on recovery from dysphagia following stroke[J].Iran J Neurol,2015,14:119-124
[14] National Stroke Foundation.Clinical Guidelines for Acute Stroke Management[M].Melbourme:National Stroke Foundation,2007
[15] Intercollegiate Stroke Working Party.National Clinical Guideline for Stroke,3rd edn[M].London:Royal College of Physicians,2008
[16] Chinese expert group on swallowing disorders and nutrition management.Chinese expert consensus on swallowing disorders and nutritional management of stroke patients[M].2013
[17] Kasprisin A T,Clumeck H,Nino-Murcia M.Efficacy of rehabilitative management of dysphagia[J].Dysphagia,1989,4:48-52
[18] Sukthankar S M,Reddy N P,Canilang E P,et al.Design and development of portable biofeedback systems for use in oral dysphagia rehabilitation[J].Med Eng Phys,1994,16:430-435
[19] Rosenbek J C,Robbins J,Fishback B,et al.Effects of thermal application on dysphagia after strok[J].J Speech Hear Res,1991,34:1257-1268
[20] DePippo K L,Holas M A,Reding M J,et al.Dysphagia therapy following stroke:A controlled trial[J].Neurology,1994,44:1655-1660
[21] Carnaby G,Hankey G J,Pizzi J.Behavioural intervention for dysphagia in acute stroke:A randomised controlled trial[J].Lancet Neurol,2006,5:31-37
[22] Latorre J G S,Flanagan S,Phipps M S,et al.Quality improvement in neurology:Stroke and stroke rehabilitation quality measurement set update[J].Neurology,2017,89:1619-1626
[23] Wang Y,Cui L,Ji X,et al.The china national stroke registry for patients with acute cerebrovascular events:Design,rationale,and baseline patient characteristics[J].Int J Stroke,2011,6:355-361
[24] Stroke.Recommendations on stroke prevention,diagnosis,and therapy.Report of the who task force on stroke and other cerebrovascular disorders[J].Stroke,1989,20:1407-1431
[25] Crary M A,Carnaby G D,LaGorio L A,et al.Functional and physiological outcomes from an exercise-based dysphagia therapy:A pilot investigation of the mcneill dysphagia therapy program[J].Arch Phys Med Rehabil,2012,93:1173-1178
[26] Wang Y,Li Z,Zhao X,et al.Effect of a Multifaceted Quality Improvement Intervention on Hospital Personnel Adherence to Performance Measures in Patients With Acute Ischemic Stroke in China:A Randomized Clinical Trial[J].JAMA.2018,320:245-254
[27] Foley N,Teasell R,Salter K,et al.Dysphagia treatment post stroke:A systematic review of randomised controlled trials[J].Age Ageing,2008,37:258-264
[28] Perry L,Love C P.Screening for dysphagia and aspiration in acute stroke:A systematic review[J].Dysphagia,2001,16:7-18
[29] Martino R,Martin R E,Black S.Dysphagia after stroke and its management[J].CMAJ,2012,184:1127-1128
[30] Geeganage C,Beavan J,Ellender S,et al.Interventions for dysphagia and nutritional support in acute and subacute stroke[J].Cochrane Database Syst Rev,2012,10:323
[31] Wang C,Rao K,Wu S,et al.Health care in china:Improvement,challenges,and reform[J].Chest,2013,143:524-531
[32] Bettger J P,Li Z,Xian Y,et al.Assessment and provision of rehabilitation among patients hospitalized with acute ischemic stroke in china:Findings from the china national stroke registry ii[J].Int J Stroke,2017,12:254-263
[33] Huang K L,Liu T Y,Huang Y C,et al.Functional outcome in acute stroke patients with oropharyngeal dysphagia after swallowing therapy[J].J Stroke Cerebrovasc Dis,2014,23:2547-2553
[34] McMicken B L,Muzzy C L.Prognostic indicators of functional outcomes in first time documented acute stroke patients following standard dysphagia treatment[J].Disabil Rehabil,2009,31:2196-2203
[35] Schepp S K,Tirschwell D L,Miller R M,et al.Swallowing screens after acute stroke:A systematic review[J].Stroke,2012,43:869-871