1、“通关利窍通关利窍”针刺法治疗针刺法治疗脑干梗死吞咽障碍的临床研究脑干梗死吞咽障碍的临床研究1研究背景研究背景BackgroundBackground is a common complication of cerebrovascular diseases，the rate of dysphagia due to stroke is 51-73%.It could bring about complications like aspiration pneumonia,insufficient intake of fluids and nutrients,asphyxia,hence affec
2、ting the patients quality of life。It is an important cause of death amongst stroke patients.1of46为脑血管疾病常为脑血管疾病常见并发症，见并发症，脑卒中急性期发生脑卒中急性期发生率为率为51-73%51-73%，可引发吸入性肺可引发吸入性肺炎、水分营养物质摄入障碍、炎、水分营养物质摄入障碍、窒息等并发症，严重影响患者窒息等并发症，严重影响患者生存质量，生存质量，是导致中风病患者是导致中风病患者死亡的重要原因之一死亡的重要原因之一。220052005年年中国脑血管病防治指南中国脑血管病防治指南 200
3、5 China Cerebrovascular Diseases Guidelines2005 China Cerebrovascular Diseases Guidelines吞咽障碍可分为真球麻痹、吞咽障碍可分为真球麻痹、假球麻痹，其中真球麻痹假球麻痹，其中真球麻痹主要为延髓疑核损伤，假主要为延髓疑核损伤，假球麻痹是由双侧皮质或皮球麻痹是由双侧皮质或皮质脑干束损伤造成，两者质脑干束损伤造成，两者统称为吞咽统称为吞咽困难困难。can be categorized into bulbar paralysis and pseudobulbar paralysis.Bulbar paralysis
4、 is due to lesions at the nucleus ambiguous of the medulla oblongata,while pseudobulbar paralysis is either due to lesions at the corticobulbar tracts or on both the cortical tracts.They were termed both conditions“dysphagia”.2of463真球麻痹真球麻痹VsVs假球麻痹假球麻痹Bulbar Paralysis Vs Pseudobulbar ParalysisBulbar
5、 Paralysis Vs Pseudobulbar Paralysis临床上临床上鉴别真鉴别真/假球麻痹假球麻痹多以疑多以疑核定位，疑核及疑核以下的部位病核定位，疑核及疑核以下的部位病损即下运动神经元病损为真球麻痹，损即下运动神经元病损为真球麻痹，疑核以上部位病损为假球麻痹。临疑核以上部位病损为假球麻痹。临床中由于影像学对于疑核定位尚存床中由于影像学对于疑核定位尚存在困难，无法清晰看到疑核受损情在困难，无法清晰看到疑核受损情况，因此将延髓部位存在病损的患况，因此将延髓部位存在病损的患者归入真球麻痹。者归入真球麻痹。Clinically,lesions at and below the nuc
6、leus that is lower motor neuron are referred to bulbar paralysis,while lesions above the nucleus are known as pseudobulbar paralysis.In radiography,the location of the nucleus remains unclear，therefore we broadened the scope,and classified lesions in the medulla oblongata under bulbar paralysis as w
7、ell.3of464大脑的供血系统大脑的供血系统Blood Supply of BrainBlood Supply of Brain4of465研究背景研究背景 Background Background5of46现代医学对于吞咽障碍现代医学对于吞咽障碍的治疗多以留置胃管技的治疗多以留置胃管技术改善患者营养摄入，术改善患者营养摄入，吞咽障碍已成为严重的吞咽障碍已成为严重的医疗和社会问题。医疗和社会问题。Modern medicine may attempt to improve nutrient intake via the insertion of the feeding tube,but
8、dysphagia remains a severe medical and social problem.6病案病案举隅举隅A MedicalA Medical RecordRecord马某 男 49岁 美国人主因“四肢瘫痪伴失语、吞咽障碍16个月”于2011年8月26日入院。患者于2008年和2010年两次患脑干梗死，予气管切开置管、胃壁造瘘及保守治疗，经治病情平稳，为进一步治疗收入我院。Martin Acierno,Male,49 years,American.The patient was admitted to hospital on 26 August 2011 due to qu
9、adriplegia,aphasia and dysphagia.He suffered from brainstem infarction in 2008 and 2010,and underwent tracheal intubation,gastric intubation and other conservative treatment.His condition stabilized,hence was admitted to our hospital for further treatment.6of467入院时入院时At AdmissionAt Admission7of46神情，
10、精神弱，被动体位，神情，精神弱，被动体位，构音不能，面部无表情，通构音不能，面部无表情，通过眼球移动表达是和否，吞过眼球移动表达是和否，吞咽障碍，气切处置管，持续咽障碍，气切处置管，持续吸氧，痰涎壅盛，每日吸痰吸氧，痰涎壅盛，每日吸痰16次，胃壁造瘘，尿管通畅，次，胃壁造瘘，尿管通畅，二便失禁。二便失禁。His mental state was poor,was in a passive position,suffered from aphasia and could only communicate using eyeball movement.His head could move sli
11、ghtly,but could not open his mouth.He had dysphasia,tracheal intubation,required long term oxygen inspiration,had excessive saliva,phlegm suctioning 16 times daily,gastric intubation,had clear urinary tube,urine and motion incontinence.8入院时入院时At AdmissionAt Admission8of46查体：查体：四肢肌力四肢肌力0级，肌张力增高。级，肌张力
12、增高。双侧巴氏征双侧巴氏征（+）诊断：诊断：脑干梗死脑干梗死 闭锁综合征闭锁综合征 高血压病高血压病3级级 肺感染肺感染泌尿系感染泌尿系感染 胃壁造瘘术后胃壁造瘘术后 气管切开术后气管切开术后 Physical examination:Level of muscle strength 0,increased muscle spasticity,bilateral Babinski sign(+).Diagnosis:Cerebral Infarction,Locked-In Syndrome,Hypertension(Level 3),tracheal intubation,gastric i
13、ntubation,urinary infection,lung infection.9治疗治疗TreatmentTreatmentTreatment:“Tong Guan Li Qiao”acupuncture therapy,twice daily。“通关利窍通关利窍”针刺法治疗针刺法治疗 每天治疗两次每天治疗两次10病情变化病情变化Condition ChangesCondition ChangesThe urine tube was removed on the SECOND day of admission.After one month,his facial expressions
14、 improved.His swallowing improved,and could ingest 10 ml of semi fluid diet.Oxygen inspiration was reduced from 24 h to 12h and phlegm suctioning was reduced to once every 2-3 hours.Perspiration improved,and he could sleep better,but still had incontinence.10 of46入院后入院后拔掉尿管；拔掉尿管；住院住院面部表情基本面部表情基本正常，可
15、口入正常，可口入10ml半流质饮半流质饮食，吸氧时间由食，吸氧时间由24小时减为小时减为12小时，吸痰次数减少为小时，吸痰次数减少为23小时一次。小时一次。11治疗结果治疗结果ResultsResults,his spirits and body constitution his spirits and body constitution improved.He did not require improved.He did not require oxygen inspiration,and had better oxygen inspiration,and had better facia
16、l expressions.His swallowing facial expressions.His swallowing ability improved further,and ability improved further,and could ingest could ingest of semi fluids.of semi fluids.He was admitted for a total of 178 He was admitted for a total of 178 days,after which he was days,after which he was disch
17、arged.discharged.11 of住院住院，患者体质增强，无需吸氧，患者体质增强，无需吸氧，面部表情恢复正常，可发出面部表情恢复正常，可发出低微声音，每天可口入低微声音，每天可口入半流质饮食。共住院半流质饮食。共住院治疗治疗178天，出院时可发出低天，出院时可发出低微声音，口入半流质饮食可微声音，口入半流质饮食可满足日常能量需要。满足日常能量需要。46of12病案病案举隅举隅A MedicalA Medical RecordRecord患者杜某某，男，55岁，主因“右侧肢体活动不遂伴失语、吞咽困难18天”住院。The patient,Mr.Du,male,55 years was a
18、dmitted to hospital due to disability on his right,difficulty in speaking and swallowing for 18 days.12 of4613入院时入院时At AdmissionAt Admission13 of46入院时语言謇涩，持续右侧肢体不遂，右上肢肌力0级，右下肢肌力2级，饮水咳呛、吞咽困难，纳食自胃管注入。During admission,his speech was slurred,had continuous disability on his right,muscle strength on the
19、right arm was level 0,right leg was level 2,experienced coughing when drinking water,difficulty in swallowing,and had insertion of feeding tube.14治疗治疗TreatmentTreatment上午上午“通关利窍通关利窍”针刺治疗：针刺治疗：针刺内关、人中、三阴交、针刺内关、人中、三阴交、风池、完骨、翳风，咽后壁风池、完骨、翳风，咽后壁点刺，舌面点刺点刺，舌面点刺下午下午后颅凹排刺后颅凹排刺Acupuncture Threpy:In the mornin
20、g“Tong Guan Li Qiao”acupuncture therapy,inclusive of Nei Guan(PC6),Ren Zhong(DU26),San Yin Jiao(SP6),Feng Chi(GB20),Wan Gu(GB12),Yi Feng(SJ17),pricking of the posterior pharyngeal wall and tongueIn the afternoonLined acupuncture treatment on the back of his head.15治疗结果治疗结果ResultsResultsAfter 2 weeks
21、 of treatment,the patient was able to ingest lotus root paste,milk,could drink small sips of water using a straw,and could speak clearer than before.After the 23rd day,the patient could drink water without coughing,and could intake as much as 3000 ml of water.He was able to satisfy his daily energy
22、requirement,therefore removed his feeding tube the next day.His dysphagia was considered clinically cured 15 of46治疗2 周后周后，患者可口入半流质饮食，构音较前清晰；治疗第第23天天，患者可饮水，不呛，口入量达3000ml，满足日常能量需要，吞咽障碍临床痊愈。16How How is that possibleis that possible?17采用采用“通关利窍通关利窍”针刺法针刺法 我们以通关利窍、滋补三阴为原则，严格规范取穴、针刺手法量学，治疗吞咽障碍临床疗效显著 Usin
23、g the principles of“Tong Guan Li Qiao”acupuncture therapy and nourishing the three yin,we standardized the prescription of acupuncture points,manipulation and quantification.Satisfactory clinical results were achieve.18 内关Nei Guan,PC6人中Ren Zhong,DU26三阴交San Yin Jiao,SP6风池Feng Chi,GB20完骨Wan Gu,GB12翳风Y
24、ifeng,SJ17咽后壁点刺Prick the posterior pharyngeal wall针刺主穴针刺主穴The Main Points19操作方法操作方法 Manipulation内内 关关Neiguan(PC 6)直刺直刺0.50.51 1寸，采用提插捻转泻法，施手法寸，采用提插捻转泻法，施手法1 1分钟；分钟；First puncture bilateral Neiguan(PC 6)perpendicularly for 0.5-1 cun,using combinative reducing method of lifting-thrusting and twirling-
25、rotating the needle for 1 minute;19 of242021人人 中中Renzhong(DU 26)Secondly puncture Renzhong(DU 26)obliquely upwards to the nasal septum for 0.3-0.5 cun with heavy bird-pecking method until the patients eyeballs are moistened or tears flow down.向鼻中隔方向斜刺向鼻中隔方向斜刺0.30.30.50.5寸，行雀啄手法，寸，行雀啄手法，至眼球湿润或流泪为度；至眼
26、球湿润或流泪为度；20 of4622三三 阴阴 交交Sanyinjiao(SP 6)沿胫骨内侧缘与皮肤呈沿胫骨内侧缘与皮肤呈4545度角斜刺，进针度角斜刺，进针1 11.51.5，用，用提插补法，使患侧下肢抽动提插补法，使患侧下肢抽动3 3次为度次为度Thirdly puncture Sanyinjiao(SP 6)obliquely for 1-1.5 cun,at the angle of 45 degrees with the skin surface along the posterior border of the medial aspect of the tibia,with re
27、inforcing method of lifting and thrusting the needle to make the affected low limb have tic for three times.2324风池、完骨、翳风风池、完骨、翳风Fengchi(GB 20)Wangu(GB 12)Yifeng(SJ 17)针向结喉，进针针向结喉，进针1.51.52 2寸，施小幅度、高频率捻转补法寸，施小幅度、高频率捻转补法1 1分钟，以咽喉麻胀为宜；分钟，以咽喉麻胀为宜；Puncture Fengchi(GB 20),Wangu(GB 12)and Yifeng(SJ 17)in t
28、he direction of the laryngeal protuberance for 2-2.5 cun,with reinforcing manipulation of twirling and rotating the needle in high frequency and small amplitude for 1 minute to each acupoint.22 of4625咽后壁点刺咽后壁点刺prick at pharynx posterior wall 令患者张口，用压舌板压住舌体，清楚暴露咽后壁，令患者张口，用压舌板压住舌体，清楚暴露咽后壁，用用0.3075mm长针
29、点刺双侧咽后壁，每天一次长针点刺双侧咽后壁，每天一次The patient was told to open his mouth,and his tongue was pressed downusing a spatula to fully expose the posterior pharyngeal wall.Use 0.3075 mm needle to prick both sides of the posterior pharyngeal wall once daily.23 of4626取穴方义取穴方义ExplanationExplanation24 of46123人中Ren zh
30、ong三阴交San Yin Jiao内关 Nei Guanl内关穴为八脉交会穴之一，通于阴维脉，属手厥阴心包经 之络穴，有养心安神、疏通气血之功。Calm the mind,improve the circulation of qi and blood.l人中为督脉与手足阳明经之会穴，督脉起于胞中，上行人脑达巅，故泻人中可调督脉，开窍启闭可健脑宁神。针刺可刺激穴周的面神经、三叉神经分支，激活了三叉神经-脑血管系统，可达到兴奋脑神经元，改善脑血流的作用。l Regulate the Du meridian,open orifices,nourish the brain and calm the
31、mind.l足三阴之经脉或挟舌本，或络于舌本，或连舌本，散舌下;补其三阴可达补益肝肾，健脾利湿之功。lNourish the kidneys,liver,spleen and clear dampness.27取穴方义取穴方义ExplanationExplanation25 of46123风池、完骨、翳风Feng Chi，Wan Gu and Yi Feng 咽咽后壁点刺Prick the posterior pharyngeal wall风池Feng Chil风池穴乃治风要穴，为足少阳与阴维之会，归属胆经，可条达阳经之气，潜阳熄风，活血化瘀，清头利窍。lCalm wind,suppress
32、yang,improve blood circulation and clear the head.l风池、完骨、翳风穴共为少阳之脉，具有通利枢纽之功，三穴合用可达养脑髓、通脑窍、利机关的作用。l Three points together can nourish the brain matter,open brain orifices,and regulate qi.l配合咽后壁点刺局部取穴，诸穴合用可调神导气、平衡阴 阳，通关利窍的作用。lAll points together may regulate qi and the mind,balance yin and yang,and un
33、block any obstruction.28研究方案研究方案 Research programsResearch programs我们以临床实践为基础，以醒脑开窍为原则，在取穴、我们以临床实践为基础，以醒脑开窍为原则，在取穴、配方、针刺手法及其量学方面做了严格规范，临床疗效显著配方、针刺手法及其量学方面做了严格规范，临床疗效显著。临床资料临床资料 Clinical DataClinical Data26 of46疗效评定疗效评定 Assessment of ResultsAssessment of Results治疗结果治疗结果 Results of TreatmentResults of
34、 Treatment治疗方法治疗方法 Treatment MethodTreatment Method29 临床资料临床资料Clinic DateClinic Date27 of46排除标准 诊断及纳入标准一般资料General DataExclusion CriteriaDiagnosis and Inclusion Criteria30 一般资料一般资料General DateGeneral Date28 of46脑干梗死吞咽障碍患者脑干梗死吞咽障碍患者64例例64 post brainstem infarction dysphagiapatients were screened年龄平均年
35、龄平均63.869.49岁岁average age of the patients was 63.869.49 years病程平均病程平均23.8920.71天天average course of disease was23.8920.71 days 31诊断及纳入标准诊断及纳入标准Diagnosis and Inclusion Criteria29 of4632 排除标准排除标准 30 of46Exclusion Criteria Other diseases that might cause dysphagia;Poor consciousness,psychological proble
36、ms and have difficulty complying with the doctor;Suffers from other primary diseases like liver,kidney and endocrine disorders 运动神经元性疾病导致的吞咽障碍；运动神经元性疾病导致的吞咽障碍；神志不清，有精神症状不能配合治疗者；神志不清，有精神症状不能配合治疗者；合并有肝肾、造血系统、内分泌系统等严重原合并有肝肾、造血系统、内分泌系统等严重原 发病及精神疾患者；发病及精神疾患者；33 治疗方法治疗方法Treatment MethodTreatment Method2of
37、6 治疗周期均为治疗周期均为28天天采用采用“通关利窍通关利窍”针刺法针刺法Perform the“Tong Guan Li Qiao”acupuncture therapy.The course of treatment was 28 days.34 疗效评定疗效评定Assessment of ResultsAssessment of Results32 of46评定吞咽功能评定吞咽功能 assess the patients swallowing ability洼田饮水试验洼田饮水试验 Kubota water test藤岛一郎吞咽疗效评价标准藤岛一郎吞咽疗效评价标准 Fujishima
38、Ichiro rating scale标准吞咽功能评价量表（标准吞咽功能评价量表（SSA）Standard Swallowing AssessmentBarthelBarthel生活指数生活指数Barthel Index评价生活质量评价生活质量assess standard of living35治疗结果治疗结果 Results of TreatmentResults of Treatment采用洼田饮水试验进行疗效比较，治疗前后评分具有显著性差异，说明通关利窍针刺法在改善吞咽功能方面效果显著。Comparison of Results for Bulbar Paralysis/Brainst
39、em Infarction/Combined Infarction，there were significant differences between the scores of Kubota water test before and after treatment.This shows that“Tong Guan Li Qiao”acupuncture therapy is effective in improving swallowing ability.33 of4636洼田饮水试验洼田饮水试验Kubota water testKubota water test34 of46延髓梗
40、死患者治疗前洼田饮水评分较高、病情较重，但治疗前后评分改善程度明显，表现出了更好的疗效趋势。Comparison among the groups showed that in brainstem infarction patients,the Kubota Water Test results were higher,and their condition were more serious before treatment,but after treatment,they showed a better trend in recovery.37洼田饮水试验洼田饮水试验Kubota wate
41、r testKubota water test35 of46结合患者影像学结果进行分析，延髓梗塞组病变部位在延髓，导致舌咽神经、舌下神经缺血缺氧，导致吞咽障碍的发生，通过针刺可有效地改善脑循环，快速建立代偿机制，取得临床疗效。With reference to their radiographic reports,the lesions of these patients are at the medulla oblongata,hence often press against the glossopharyngeal nerve and hypoglossal nerve,causing
42、dysphagia.Acupuncture can effectively improve the brain circulation,swiftly set up compensatory mechanisms and achieve clinical results.38治疗结果治疗结果 Results of Results of t treatmentreatment36 of46采用藤岛一郎试验进行疗效采用藤岛一郎试验进行疗效比较，治疗前后评分具有显著比较，治疗前后评分具有显著性差异，说明通关利窍针刺法性差异，说明通关利窍针刺法在改善吞咽功能方面效果显著。在改善吞咽功能方面效果显著。C
43、omparison of Results for Bulbar Paralysis/Brainstem Infarction/Combined Infarction，there were significant differences between the scores of Fujishima Ichiro rating before and after treatment.This shows that“Tong Guan Li Qiao”acupuncture therapy is effective in improving swallowing ability.39治疗结果治疗结果
44、 Results of TreatmentResults of Treatment37 of46采用吞咽功能评价量表（采用吞咽功能评价量表（SSA）进行）进行疗效比较，治疗前后评分具有显著性差疗效比较，治疗前后评分具有显著性差异，有效的改善了患者异，有效的改善了患者，加，加速了患者生活能力的恢复，有助于提高速了患者生活能力的恢复，有助于提高患者生活质量。患者生活质量。Comparison of Results for Bulbar Paralysis/Brainstem Infarction/Combined Infarction，there were significant differen
45、ces between the SSA scores before and after treatment.This therapy can effectively improve the swallowing ability of patients,and hasten the recovery of their standard of living.40治疗结果治疗结果 Results of TreatmentResults of Treatment38 of46采用采用Barthel生活指数进行疗效比较，生活指数进行疗效比较，治疗前后评分具有显著性差异，有治疗前后评分具有显著性差异，有效
46、的改善了患者效的改善了患者，加速了，加速了患者生活能力的恢复，有助于提高患者生活能力的恢复，有助于提高患者生活质量。患者生活质量。Comparison of Results for Bulbar Paralysis/Brainstem Infarction/Combined Infarction，there were significant differences between the Barthel scores scores before and after treatment.This therapy can effectively improve the swallowing abi
47、lity of patients,and hasten the recovery of their standard of living.41 疗效判定标准疗效判定标准Assessment of ResultsAssessment of Results39 of46治愈治愈显效显效有效有效无效无效42治疗结果治疗结果 Results of TreatmentResults of Treatment40 of4643治疗结果治疗结果 Results of TreatmentResults of Treatment41 of46l本试验本研究治疗延髓梗死患者总有效率95.86%，64例患者治疗后，
48、吞咽功能及生活质量均得到显著提高，提示本针法治疗脑卒中后延髓麻痹吞咽障碍疗效显著。lThe total efficacy rate of treating dysphagia after medulla oblongata infarction was 95.86%,the 64 patients showed marked improvement in their swallowing ability and quality of life,showing that this acupuncture method is effective in treating dysphagia caus
49、ed by post stroke bulbar paralysis.44治疗结果治疗结果 Results of TreatmentResults of Treatment42 of46l This study has shown that the efficacy rate forcombined infarction was lowest with poor prognosis l 本疗法对单纯真球麻痹疗效显著l真球麻痹并发其他多部位梗死的患者治疗有效率相对较低。l Our treatment for pseudobulbar paralysis is effective45数据分析数据分
50、析Data AnalyzeData Analyze43 of46吞咽困难复发率低，患者很少有舌吞咽困难复发率低，患者很少有舌肌震颤、舌肌萎缩症状。肌震颤、舌肌萎缩症状。Raising the difficultly of building collateral circulation,thus the prognosis was the poorest.有效改善脑卒中后吞咽障碍患者有效改善脑卒中后吞咽障碍患者 吞咽功能及血氧饱和度水平吞咽功能及血氧饱和度水平 Improve post stroke dysphagia and blood oxygen saturation levels.随访随
