脑卒中后吞咽障碍的评价及康复治疗

华中科技大学博士学位论文脑卒中后吞咽障碍的评价及康复治疗姓名：夏文广申请学位级别：博士专业：神经病学指导教师：朱遂强2011-04脑卒中后吞咽障碍的评价及康复治疗　中文摘要　第一部分吞咽障碍评价标准评定脑卒中后吞咽障碍患者的信度和效度研究目的探讨吞咽障碍评价标准评定脑卒中后吞咽障碍患者吞咽功能的信度和效度。

方法采用洼田饮水试验筛查出128名脑卒中后吞咽障碍患者，并根据吞咽障碍严重程度分为轻、中、重度，利用吞咽障碍评价标准和电视透视吞咽造影检查（VFSS）同时对其吞咽功能进行评价，后者为效度标准。

采用Spearman相关分析进行信度和效标效度评价。

结果吞咽障碍评价标准评分与VFSS结果具有显著相关性(r=0.84, p＜0.01)；吞咽障碍评价标准在同一评定者及不同评定者间均有良好的信度；可对吞咽障碍患者是否发生误吸和住院期间是否发生肺炎进行预测。

结论吞咽障碍评价标准适用于脑卒中后患者的吞咽功能评价，是一种简单、方便、安全、有效的评估工具。

关键词脑卒中；吞咽障碍；吞咽障碍评价标准；信度；效度第二部分针刺联合康复训练对脑卒中后吞咽障碍的影响目的探讨综合康复治疗对脑卒中后吞咽障碍患者吞咽功能恢复的影响。

方法 120例脑卒中后伴吞咽功能障碍的患者随机分成2组，对照组：进行摄食-吞咽障碍的康复训练；实验组：进行摄食-吞咽障碍的康复训练与针刺治疗。

分别于治疗前、治疗后1、2、3、4周时利用标准吞咽功能评估（SSA）进行吞咽功能床旁评估，在治疗前及治疗4周后利用电视透视吞咽功能检查（VFSS）进行吞咽功能仪器评估，同时评价其日常生活活动能力及生存质量。

结果治疗前、治疗后1、2、3、4周各时间点实验组与对照组的SSA评分比较，在治疗前及治疗1周时实验组与对照组之间差异无统计学意义，而在治疗后第2、3、4周，实验组明显高于对照组（均p＜0.05）；实验组与对照组的吞咽功能、日常生活活动能力及生存质量方面在治疗前后进行比较，实验组各方面在治疗后均较对照组改善显著，差异有统计学意义；同时吞咽功能改善的程度与日常生活活动能力、生存质量的改善程度之间均具有显著相关性；实验组治疗满意度与对照组比较，差异有统计学意义。

结论综合康复治疗有助于吞咽功能、日常生活活动能力及生存质量的恢复。

关键词吞咽障碍；摄食-吞咽训练；针刺；脑卒中第三部分 VitalStim 电刺激及吞咽训练对脑卒中后吞咽障碍影响目的探讨VitalStim 电刺激及吞咽训练对脑卒中后吞咽障碍患者吞咽功能恢复的影响。

方法 120例脑卒中后伴吞咽功能障碍的患者随机分成3组，即训练组：常规吞咽障碍的康复训练；电刺激组：VitalStim电刺激治疗；实验组：VitalStim电刺激治疗配合常规的吞咽训练，分别于治疗前、治疗后检测吞咽肌群的表面肌电信号（sEMG），利用标准吞咽功能评估（SSA）和电视透视吞咽功能检查（VFSS）评价其吞咽功能，利用吞咽障碍特异性生活质量量表（SWAL-QOL)对其生存质量进行评定。

将124例脑卒中后不同程度的吞咽障碍的患者进行吞咽功能、神经功能缺损程度、抑郁程度及生存质量的评价后，给与常规吞咽训练后，治疗4周后对以上指标进行再次评估，并将吞咽障碍的严重程度与神经功能缺损程度、抑郁程度及生存质量进行相关性分析。

结果 3组患者sEMG、SSA、VFSS及生存质量在治疗前、后进行比较，差异有显著性变化；经过4周的治疗后，实验组与训练组和电刺激组在sEMG、SSA、VFSS及生存质量方面比较，差异有统计学意义，而训练组和电刺激组比较未见明显差异，无统计学意义。

常规的吞咽训练能明显改善轻度和重度吞咽障碍患者的吞咽功能，其治疗有效率达到93.1０％和88.0０％，但对重度吞咽障碍患者，影响不明显，VFSS评分与治疗前比较，差异无统计学意义，P>0.05。

吞咽障碍的严重程度与神经功能缺损程度无明显相关性，与抑郁程度有弱相关性，与生存质量有高度相关性。

结论 VitalStim 电刺激及吞咽训练有助于患者吞咽功能的恢复。

仅采用常规康复训练时，重度吞咽障碍患者吞咽功能的恢复较难。

关键词吞咽障碍；VitalStim电刺激；吞咽训练；脑卒中Assessment and T reatment Rehabilitation ofDysphagia Post StrokeAbstractPart one The validity and reliability of Tengdao’s swallowing evaluation for stroke patients with dysphagiaObjective To study the validity and reliability of Tengdao’s swallowing standard for stroke patients with dysphagia.Methods A t otal of 128 patients with poststroke dysphagia took swallowing test and then were divided into three sub-groups. Their scores on Tengdao’s evaluation and their fluoroscopy results were analyzed using Spearman’s correlation cofficient. Intra-class cofficients(ICCs) were used to exaine the intra-reter and inter-rater reliability of Tengdao’s evaluation.Results Tengdao’s evaluation possessed good validity and reliability. There was a high correlation between the scores of Tengdao’s evaluation and fluoroscopy results.Conclusions Tengdao’s evaluation is valid, reliable, simple and safe. It can be used in the clinic to evaluate the stroke patients with dysphagia.Key words Stroke; Dysphagia; Tengdao’s swallowing evaluation; Reliability; ValidityPart two Combination of Feeding-swallowing Training and Acupuncture: an Effective Rehabilitation Method ofDysphagia Post StrokeObjective To assess the effects of feeding-swallowing training combined with acupuncture on the swallow function improvement of patients with dysphagia following stroke.Methods One hundred and twenty patients with dysphagia after stroke were randomly divided into experimental group (n=60) and control group (n=60). The patients in experimental group were subjected to feeding-swallowing training and acupuncture treatment, while those in control group received feeding-swallowing training alone. SSA, VFSS, MBI and SWAL-QOL were used to assess the swallow function and life quality of patients in two groups before and at the week 1, 2, 3, 4 after treatment.Results There was no significant difference in SSA scores between two groups before and one week after treatment. Compared with those before treatment, the VFSS, MBI and SWAL-QOL scores at the fourth week after treatment were significantly increased and the SSA scores were significantly decreased in both groups (p<0.05). The VFSS, MBI and SWAL-QOL scores of patients in experimental group were significantly higher and the SSA scores were significantly lower than those in control group. The SSA score was negatively correlated with VFSS, MBI and SWAL-QOL scores and the satisfactory score of patients in experimental group was significantly higher than that in control group.Conclusion Feeding-swallowing training combined with acupuncture was abetter rehabilitation treatment for patients with swallowing disorders after stroke than conventional feeding-swallowing training alone.Key words dysphagia; feeding-swallowing training; acupuncture; strokePart three VitalStim Therapy Coupled with Swallowing Training: an Effective Rehabilitation Method of Dysphagia PostStrokeObjective To investigate the effects of VitalStim therapy coupled with conventional swallowing training on recovery of post-stroke dysphagiaMethods a total of 120 patients with post-stroke dysphagia were randomly and evenly divided into three group : conventional swallowing therapy group , VitalStim therapy group, and VitalStim therapy plus conventional swallowing therapy group ,Prior to an after the treatment,signals of surface electromyography (sEMG) of swallowing muscles were detected, swallowing function was evaluated by using the Standardized Swallowing Assessment(SSA) and Videofluoroscopic Swallowing Study(VFSS) tests, and swallowing-related quality of life (SWAL-QOL) was evaluated using the SWAL-QOL questionnaire. Water Swallowing Test (WST) was used to identify the presence of dysphagia and 124 stroke patients with dysphagia were divided into mild dysphagia group (n=58), moderate dysphagia group (n=50) and severe dysphagia group (n=16) according to the WST. VFSS, NIHSS, HAMD and SWAL-QOL questionnaire were used to assess the swallow function, neural function, metal status and life quality of patients respectively before and after4-week rehabilitation training. The scores of VFSS, NIHSS, HAMD and SWAL-QOL of three groups were compared and analyzed.Results There were significant differences in sEMG value, SSA, VFSS, and SWAL-QOL scores in each group between prior to and after treatment. After 4-week treatment, sEMG value, SSA, VFSS and SWAL-QOL scores in each group between prior to and after treatment. After 4-week treatment, sEMG value, SSA, VFSS and SWAL-QOL scores were significantly greater in the VitalStim therapy plus conventional swallowing therapy group than in the conventional swallowing training group and VitalStim therapy group, but no significant difference existed between conventional swallowing therapy and VitalStim therapy groups. Before rehabilitation training, there was no statistic difference in scores of NIHSS, HAMD and SWAL-QOL among three groups. After r ehabilitation training, the scores of VFSS increased and the scores of NIHSS, HAMD and SWAL-QOL decreased in mild or moderate dysphagia group but only the scores of NIHSS decreased in severe dysphagia group. VFSS scores negatively correlated with HAMD and SWAL-QOL scores, but did not correlate with NIHSS scores.Conclusion It was concluded that VitalStim therapy coupled with conventional swallowing training was conducive to recovery of post-stroke dysphagia. Dysphagia was common in stroke patients and rehabilitation training could improve the swallow function, thus improving depression and life quality of patients with mild or moderate dysphagia but not with severe dysphagia.Key words dysphagia; VitalStim therapy; swallowing therapy; stroke英文缩写及对照表　effortful swallow 强力吞咽纤维内镜吞咽功能评估ＦＥＥＳｆｉｂｅｒｏｐｔｉｃｅｎｄｏｓｃｏｐｉｃ　ｅｘａｍｉｎａｔｉｏｎ ｏｆ　ｓｗａｌｌｏｗｉｎｇfMRI functional Magnetic Resonance Imaging 功能性磁共振成像HAMD the Hamiltion rating scale for depression Hamilton 抑郁量表ICC intraclass correlation coefficient 组内信度mandelsohn maneuver 门德尔松动作MBI modified Barthel index 改良Barthel 指数NMES Neuromuscular Electrical Stimulation 神经肌肉电刺激NIHSS The National Institutes of Health Stroke Scale 美国国立卫生院卒中量表Peak maximum amplitude 最大波幅值PSD post-stroke dysphagia 脑卒中后吞咽障碍ｐｕｌｓｅ　ｏｘｉｍｅｔｒｙ脉冲血氧定量法sEMG Surface Electromyography 表面肌电信号ＳＳＡｔｈｅ　Ｓｔａｎｄａｒｄｉｚｅｄ　Ｓｗａｌｌｏｗｉｎｇ　Ａｓｓｅｓｓｍｅｎｔ标准吞咽功能评分SWAL-QOL Swallowing-Related Quality of Life 吞咽障碍特异性生活质量量表swallow maneuver 空咽练习super- supraglottic swallow 上声门上吞咽supraglottic swallow 声门上吞咽TOR-BSST The Toronto Bedside Swallowing Screening Test 多伦多吞咽筛查工具ＶＦＳＳvideofloroscopic swallowing study 电视透视吞咽造影检查独创性声明　本人郑重声明，本学位论文是本人在导师指导下进行的研究工作及取得的研究成果的总结。