针刺对脑卒中后吞咽障碍治疗机制的研究
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摘要
吞咽障碍是脑卒中后常见的症状,对脑卒中的致残率及死亡率均有很大的影响,并可独立影响死亡率。有关吞咽障碍的治疗已成为现代医学研究的一个新热点。作为祖国医学的瑰宝,针刺治疗吞咽障碍显示出了独特的疗效。但是,由于它的治疗机理目前尚未明确,使得针刺治疗该症在理论上缺乏有效的说服力。本文从观察针刺治疗脑卒中后吞咽障碍的临床疗效入手,对比针刺前后吞咽功能评分的变化,探讨了临床相关因素在治疗本症中对疗效的影响;此外,运用电视透视(videofluorography,VFG)这一目前公认的评价吞咽障碍的金标准,评价了针刺治疗的疗效;利用功能性核磁共振成像(functional magnetic resonance imaging,fMRI)技术研究了生理状态下针刺对吞咽功能皮质中枢的影响,从生理角度揭示了针刺对大脑吞咽中枢的影响机制。结果显示,针刺治疗脑卒中后吞咽障碍具有起效快、疗效确切、安全等特点;应用电视透视检查评价吞咽功能障碍的患者,能够可靠发现吞咽障碍的病变部位所在,评价吞咽障碍的程度;从生理角度表明了,针刺能够激活吞咽皮质中枢的活动。针刺对脑卒中后吞咽障碍的治疗机制,可能是通过改善脑血流量的供应,从而弥补脑卒中所造成的吞咽中枢神经元的乏氧,促进神经元的新陈代谢,使吞咽反射的环路得到代偿或恢复这一途径而实现的。
Deglutition Disorders(DD)is a symptom evoked by many pathologicalcircumstances including stroke during swallowing. DD is frequently can be seenamong the stroke patients. The DD that comes from stroke characterized difficultyin the procedure of transmit bolus to stomach, including the oral stage, eg. chew-ing disorders, dyskinesia of tongue, and so on. It has been found that death rate ofstroke patients accompany DD is the 3 times than that of stroke patients withsimilar degree but deglutition function is normal, indicating DD is relevant tomutilation and death rate, and can effect death rate all alone. DD is concernedwith pulmonary infection, it can be inducing pneumonia, leading to deaquation,dystrophis, even threating to life because asphyxia, at the same time, DD made thequality of life decreased obviously, it depriving of foodintake-the basic physiolog-y requirement of human, hazardous the health of patients, bring severe economicsand society burden. As a tough problem of clinical therapy, therapeutics about DDhave become new hot spots of modern medicines. Status of this topic is: thera-peutic tools are arranged in recently years, clinicians are advancing with crocidis-mus, more focus concentrate on rehabilitate therapy, the rehabilitation of DD afterstroke has becaming one of important study topic of exterior and interior now-days.But rehabilitate research found that stroke patients accompany with DD
nearly 10% cannot fare by mouth after rehabilitation training, only 2/3 could be-come responders during chronic phase's training. Long-term nasogastric feedingduring compensation management bring patients enormous psychic-burden andinconvenient, result in gastric mucosal ulcer and hemorrhage, lead to some func-tions such as limbs movements could not recover, made the rehabilitation goal ofrecur society unable to come true. The therapeutic effect of acupuncture on DDafter stroke is remarkable, but its therapeutic machanism still unclear at present,and made acupuncture's therapeutic effect has insufficient valid persuasion inabstracto.This study is clinical research on acupuncture treatment of DD afterstroke, we made detail evaluation on therapeutic effect, approach the influence ofacupuncture on swallowing function through imageology technique, offer objec-tive evidence to acupuncture's clinical therapy. Both the broaden of research deckand the depth of the study level are all made great progress1.The study on clinical therapeutic effect of acupuncture treatment forDD after strokeStroke is one of the important cause of DD. According to statistics, there areabout 500 thousand per year kainogenesis stroke patients in America, about 40%complicating DD, 20% of the latter succumb to aspiration pneumonia. The deadthat because of chocking cough from DD overtopping 10 thousand in wholeAmerica per year. The morbidity and complication of our country's probablyclose to overseas reports. Among the many therapeutic methods, acupunctureshow remarkable therapeutic effects.Acupuncture and moxibustion is treasurs of Chinese traditional medicine, hascontributed greatly and positively, It is more and more welcomed by world'speople, it is the first traditional medicine that received by the world. As animportant supplement and substitution therapy, it has utend in 78 countries'
clinical working, more and more people pay close attention to the study of itsscience foundation.In this section, through clinical therapy, contrast acupuncture group andcontrol group, the difference is significantly, acupuncture group surpass controlgroup. Acupuncture treatment have significant therapeutic effect on DD patientsafter stroke. After statistical treatment, indicate sex, blood sugar, smoking,opportunity of cure are influenced the therapeutic effect of DD after stroke.Among them ,opportunity of cure have the most important effect, blood sugar isthe second, smoking and sex are the next. While age, urine specific gravity,profibrin, hematocrit, thrombocytocrit are no obviously influence found. Inclinical practice, we should pay more attention to these factors, so as to elevateclinical effect for these patients.2.Clinical research on the therapeutic mechanisms of acupuncture forDD after cerebral infarction applying videofluroscopy evaluation.]Deglutition is extremely complicated physiological reflexion course, it ishas been studied for a hundred years. In the earlier years, there were only someclinical observations, or some crude sruvey and delineation to draw assistancefrom some tools, such as stethophone, gastric tube, pressure balloon. In moderntimes, there are some methods that through anatomic structure to draw assistancefrom X-rays to study this topic, or through pressure meter to determin the pressurevariation of pharyngeal portion, or use electromyogram, or combined structureand functional determination. The videofluorographic swallowing study aslonamed dynamic visualization of pharyngeal, is a method to record the swallowingactivities of pharynx oralis when pharyngeal opacification with X-rays photo-graphic recording. It can be reveal the detail of quickly motions of pharyngeal,study the mechanism and reason of DD, and has been deemed “ideal method ”of
examination of DD and “Gold standard” for diagnostic.The incidence rate of DD after stroke is highly, mainly occurred in oral orpharyngeal stage, clinician usually evaluate whether DD exist and how its extentbeing there by patients' signs and symptoms or clinical assessment measuringscale. However, abnormal of pharyngeal stage including silent aspiration cannotbe found through observing patients swallowing, and bedside examination cannotdistinguish penetrate and aspiration. For the pharynx oralis structure are better fitfor undertake radiologia assessment, When swallowing, combination of everyorgan could be seen in videofluoroscopic check, through it we can concludenormal swallow, describe the abnormal characteristic of oral pharynx swallow,discriminate aspiration and penetrate accuratly, find silence aspiratio, it is impo-tant for deglutition function assessment of stroke patients.In order to evaluate the patients' degree of DD after stroke and therapeuticeffect of acupuncture objectively, we use videofluoroscopy to carry out our study.Results show that palatum mobile downwards or tongue upwards to block oralpharynx aisle;Passavant tray increasing over extent eminence forward, sticking toemarcid palatum mobile, blocking nasal pharynx aisle;tongue larynx backward orposterior wall of pharynx antelocation;larynx ascend to superior position to com-pensate operculum laryngis inability declination;head anterior tilt to compensatecricopharynx insufficient patefaction during swallowing, et al, they all can befound in this study. There are 33 cases decompensation for swallowing function,display that different degree of aspiration, stagnation and nasal penetrate.Discovered that whether there are silence aspiration that cannot be find withclinical assessment. The results also show, epiglottic vallecula residual and sinuspiriformis residual appearance higher incidence rate, demonstration majoritypatients' swallowing act mismatch during pharynx phase. Videofluoroscopy can
assessment the therapeutic effect of acupuncture objectively, and its accurate ratiois higher than clinical assessment measuring scales. It is a modus operandi offunctional examination and therapeutic effect evaluation for those patients withDD after stroke.3.Study on influence of acupuncture on deglutation cortical areathrough brain functional magnetic resonance imaging.Functional magnetic resonance imaging is a imageology technique, it canmake functional localization for human brain through excellent space and timeresolution, it detecting the difference of MR signals that owing to different pro-portion of oxyhemoglobin/deoxyhemoglobin in regional flow of brain transac-tivation domain and untransactivation domain, reflexing the district area andfeature of brain metergasis, making real time functional imaging of brain. Atpresent, it has been used in localization of visual sensation, auditory sensation,motor cortex, also in study on acupuncture. Acupuncture has made extraordinarytherapeutic effects on deglutition disorders after stroke for a long time, but thereare major diverges in explaining acupuncture' mechanism using modern medicine.fMRI can observe the brain mantle nervous activities due to acupuncture directly,provide an available tool for study the mutual ralationship of acupuncture andcentral neural pathway. The present study has been carried out combined withmodern neuroanatomy theory, using BOLD-fMRI technique, observed the activityand variation of brain deglutition functional areas before and after acupuncturedlianquan (RN23) point. The results showed that when initiative deglutition thereare signals alteration in all the subjects because of increasing of oxygen meta-bolism appeared in posterior central gyrus, lateral of sulcus, wall of lobus tempo-ralis, grey matter of basal ganglia areas, hippocampus, dentate body of cerebellum,occipital cortex, et al, revealed cerebral nerves in these areas take participate in
activities about deglutition. From ours experiment, we can seen the signals rein-forcement in superior part directly. Contrast before acupuncture, after acupuncture,there are could been seen activation areas reinforcement significantly in frontallobe, anterior central gyrus, posterior central gyrus, wall of temporal lobe, body ofcorpus callosum, cortex of parietal lobe, sulcus periphery, insular cortex, greymatters of basal ganglia, hippocampus, cerebellum vermis superior, cerebellarcortex, dentate body of cerebellum, occipital cortex. At the same time, 13 normalsubjects' cortical area of deglutition are all located double latus hemisphere, whenswallowing after acupuncture, there are obviously reinforcement and increasingThe results showed, acupuncture could enhanced the active brain areas that relatedswallowing, sustain the regulation of acupuncture to deglutition function power-ful.In a word, the therapeutic effects of acupuncture to deglutition after stroke iseffectively and exactly.
Deglutition Disorders(DD)is a symptom evoked by many pathologicalcircumstances including stroke during swallowing. DD is frequently can be seenamong the stroke patients. The DD that comes from stroke characterized difficultyin the procedure of transmit bolus to stomach, including the oral stage, eg. chew-ing disorders, dyskinesia of tongue, and so on. It has been found that death rate ofstroke patients accompany DD is the 3 times than that of stroke patients withsimilar degree but deglutition function is normal, indicating DD is relevant tomutilation and death rate, and can effect death rate all alone. DD is concernedwith pulmonary infection, it can be inducing pneumonia, leading to deaquation,dystrophis, even threating to life because asphyxia, at the same time, DD made thequality of life decreased obviously, it depriving of foodintake-the basic physiolog-y requirement of human, hazardous the health of patients, bring severe economicsand society burden. As a tough problem of clinical therapy, therapeutics about DDhave become new hot spots of modern medicines. Status of this topic is: thera-peutic tools are arranged in recently years, clinicians are advancing with crocidis-mus, more focus concentrate on rehabilitate therapy, the rehabilitation of DD afterstroke has becaming one of important study topic of exterior and interior now-days.But rehabilitate research found that stroke patients accompany with DD
nearly 10% cannot fare by mouth after rehabilitation training, only 2/3 could be-come responders during chronic phase's training. Long-term nasogastric feedingduring compensation management bring patients enormous psychic-burden andinconvenient, result in gastric mucosal ulcer and hemorrhage, lead to some func-tions such as limbs movements could not recover, made the rehabilitation goal ofrecur society unable to come true. The therapeutic effect of acupuncture on DDafter stroke is remarkable, but its therapeutic machanism still unclear at present,and made acupuncture's therapeutic effect has insufficient valid persuasion inabstracto.This study is clinical research on acupuncture treatment of DD afterstroke, we made detail evaluation on therapeutic effect, approach the influence ofacupuncture on swallowing function through imageology technique, offer objec-tive evidence to acupuncture's clinical therapy. Both the broaden of research deckand the depth of the study level are all made great progress1.The study on clinical therapeutic effect of acupuncture treatment forDD after strokeStroke is one of the important cause of DD. According to statistics, there areabout 500 thousand per year kainogenesis stroke patients in America, about 40%complicating DD, 20% of the latter succumb to aspiration pneumonia. The deadthat because of chocking cough from DD overtopping 10 thousand in wholeAmerica per year. The morbidity and complication of our country's probablyclose to overseas reports. Among the many therapeutic methods, acupunctureshow remarkable therapeutic effects.Acupuncture and moxibustion is treasurs of Chinese traditional medicine, hascontributed greatly and positively, It is more and more welcomed by world'speople, it is the first traditional medicine that received by the world. As animportant supplement and substitution therapy, it has utend in 78 countries'
clinical working, more and more people pay close attention to the study of itsscience foundation.In this section, through clinical therapy, contrast acupuncture group andcontrol group, the difference is significantly, acupuncture group surpass controlgroup. Acupuncture treatment have significant therapeutic effect on DD patientsafter stroke. After statistical treatment, indicate sex, blood sugar, smoking,opportunity of cure are influenced the therapeutic effect of DD after stroke.Among them ,opportunity of cure have the most important effect, blood sugar isthe second, smoking and sex are the next. While age, urine specific gravity,profibrin, hematocrit, thrombocytocrit are no obviously influence found. Inclinical practice, we should pay more attention to these factors, so as to elevateclinical effect for these patients.2.Clinical research on the therapeutic mechanisms of acupuncture forDD after cerebral infarction applying videofluroscopy evaluation.]Deglutition is extremely complicated physiological reflexion course, it ishas been studied for a hundred years. In the earlier years, there were only someclinical observations, or some crude sruvey and delineation to draw assistancefrom some tools, such as stethophone, gastric tube, pressure balloon. In moderntimes, there are some methods that through anatomic structure to draw assistancefrom X-rays to study this topic, or through pressure meter to determin the pressurevariation of pharyngeal portion, or use electromyogram, or combined structureand functional determination. The videofluorographic swallowing study aslonamed dynamic visualization of pharyngeal, is a method to record the swallowingactivities of pharynx oralis when pharyngeal opacification with X-rays photo-graphic recording. It can be reveal the detail of quickly motions of pharyngeal,study the mechanism and reason of DD, and has been deemed “ideal method ”of
examination of DD and “Gold standard” for diagnostic.The incidence rate of DD after stroke is highly, mainly occurred in oral orpharyngeal stage, clinician usually evaluate whether DD exist and how its extentbeing there by patients' signs and symptoms or clinical assessment measuringscale. However, abnormal of pharyngeal stage including silent aspiration cannotbe found through observing patients swallowing, and bedside examination cannotdistinguish penetrate and aspiration. For the pharynx oralis structure are better fitfor undertake radiologia assessment, When swallowing, combination of everyorgan could be seen in videofluoroscopic check, through it we can concludenormal swallow, describe the abnormal characteristic of oral pharynx swallow,discriminate aspiration and penetrate accuratly, find silence aspiratio, it is impo-tant for deglutition function assessment of stroke patients.In order to evaluate the patients' degree of DD after stroke and therapeuticeffect of acupuncture objectively, we use videofluoroscopy to carry out our study.Results show that palatum mobile downwards or tongue upwards to block oralpharynx aisle;Passavant tray increasing over extent eminence forward, sticking toemarcid palatum mobile, blocking nasal pharynx aisle;tongue larynx backward orposterior wall of pharynx antelocation;larynx ascend to superior position to com-pensate operculum laryngis inability declination;head anterior tilt to compensatecricopharynx insufficient patefaction during swallowing, et al, they all can befound in this study. There are 33 cases decompensation for swallowing function,display that different degree of aspiration, stagnation and nasal penetrate.Discovered that whether there are silence aspiration that cannot be find withclinical assessment. The results also show, epiglottic vallecula residual and sinuspiriformis residual appearance higher incidence rate, demonstration majoritypatients' swallowing act mismatch during pharynx phase. Videofluoroscopy can
assessment the therapeutic effect of acupuncture objectively, and its accurate ratiois higher than clinical assessment measuring scales. It is a modus operandi offunctional examination and therapeutic effect evaluation for those patients withDD after stroke.3.Study on influence of acupuncture on deglutation cortical areathrough brain functional magnetic resonance imaging.Functional magnetic resonance imaging is a imageology technique, it canmake functional localization for human brain through excellent space and timeresolution, it detecting the difference of MR signals that owing to different pro-portion of oxyhemoglobin/deoxyhemoglobin in regional flow of brain transac-tivation domain and untransactivation domain, reflexing the district area andfeature of brain metergasis, making real time functional imaging of brain. Atpresent, it has been used in localization of visual sensation, auditory sensation,motor cortex, also in study on acupuncture. Acupuncture has made extraordinarytherapeutic effects on deglutition disorders after stroke for a long time, but thereare major diverges in explaining acupuncture' mechanism using modern medicine.fMRI can observe the brain mantle nervous activities due to acupuncture directly,provide an available tool for study the mutual ralationship of acupuncture andcentral neural pathway. The present study has been carried out combined withmodern neuroanatomy theory, using BOLD-fMRI technique, observed the activityand variation of brain deglutition functional areas before and after acupuncturedlianquan (RN23) point. The results showed that when initiative deglutition thereare signals alteration in all the subjects because of increasing of oxygen meta-bolism appeared in posterior central gyrus, lateral of sulcus, wall of lobus tempo-ralis, grey matter of basal ganglia areas, hippocampus, dentate body of cerebellum,occipital cortex, et al, revealed cerebral nerves in these areas take participate in
activities about deglutition. From ours experiment, we can seen the signals rein-forcement in superior part directly. Contrast before acupuncture, after acupuncture,there are could been seen activation areas reinforcement significantly in frontallobe, anterior central gyrus, posterior central gyrus, wall of temporal lobe, body ofcorpus callosum, cortex of parietal lobe, sulcus periphery, insular cortex, greymatters of basal ganglia, hippocampus, cerebellum vermis superior, cerebellarcortex, dentate body of cerebellum, occipital cortex. At the same time, 13 normalsubjects' cortical area of deglutition are all located double latus hemisphere, whenswallowing after acupuncture, there are obviously reinforcement and increasingThe results showed, acupuncture could enhanced the active brain areas that relatedswallowing, sustain the regulation of acupuncture to deglutition function power-ful.In a word, the therapeutic effects of acupuncture to deglutition after stroke iseffectively and exactly.
引文
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