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1、,“通关利窍”针刺法治疗 脑干梗死吞咽障碍的临床研究,石学敏 教授 Shi Xuemin Prof.,Clinical Research on “Tong Guan Li Qiao” Acupuncture Therapy for the Treatment of Dysphagia after Brainstem Stroke,天津中医药大学第一附属医院 Frist Teaching Hospital, Tianjin University of Chinese Medicine,研究背景,Background,Dysphagia is a common complication of ce
2、rebrovascular 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 affecting the patients quality of life。It is an important cause of death amongst stroke patients.,1,of,46,
3、吞咽障碍为脑血管疾病常见并发症，脑卒中急性期发生率为51-73%，可引发吸入性肺炎、水分营养物质摄入障碍、窒息等并发症，严重影响患者生存质量，是导致中风病患者死亡的重要原因之一 。,2005年 中国脑血管病防治指南,2005 China Cerebrovascular Diseases Guidelines,吞咽障碍可分为真球麻痹、假球麻痹，其中真球麻痹主要为延髓疑核损伤，假球麻痹是由双侧皮质或皮质脑干束损伤造成，两者统称为吞咽困难。,Dysphagia can be categorized into bulbar paralysis and pseudobulbar paralysis. B
4、ulbar paralysis 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”.,2,of,46,真球麻痹Vs假球麻痹,Bulbar Paralysis Vs Pseudobulbar Par
5、alysis,临床上鉴别真/假球麻痹多以疑核定位，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，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者归入真球麻痹。,Clinically, lesions at and below the nucleus that is lower motor neuron are referred to bulbar paralysis, while lesions above the nucleus are known as pseudobulbar paralysis. In r
6、adiography, the location of the nucleus remains unclear，therefore we broadened the scope, and classified lesions in the medulla oblongata under bulbar paralysis as well.,3,of,46,大脑的供血系统 Blood Supply of Brain,4,of,46,研究背景,Background,5,of,46,现代医学对于吞咽障碍的治疗多以留置胃管技术改善患者营养摄入，吞咽障碍已成为严重的医疗和社会问题。,Modern medi
7、cine may attempt to improve nutrient intake via the insertion of the feeding tube, but dysphagia remains a severe medical and social problem.,病案举隅,A Medical Record,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 year
8、s, American. The patient was admitted to hospital on 26 August 2011 due to quadriplegia, 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
9、 to our hospital for further treatment.,6,of,46,入院时,At Admission,7,of,46,神情，精神弱，被动体位，构音不能，面部无表情，通过眼球移动表达是和否，吞咽障碍，气切处置管，持续吸氧，痰涎壅盛，每日吸痰16次，胃壁造瘘，尿管通畅，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
10、slightly, 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.,入院时,At Admission,8,of,46,查体： 四肢肌力0级，肌张力增高。 双侧巴氏征（+
11、） 诊断： 脑干梗死 闭锁综合征 高血压病3级 肺感染 泌尿系感染 胃壁造瘘术后 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 intubation, urinary infection, lung in
12、fection.,治疗,Treatment,Treatment: “Tong Guan Li Qiao” acupuncture therapy , twice daily。,“通关利窍”针刺法治疗 每天治疗两次,病情变化,Condition Changes,The urine tube was removed on the SECOND day of admission. After one month, his facial expressions improved. His swallowing improved, and could ingest 10 ml of semi fluid
13、 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,of,46,入院后第2天拔掉尿管； 住院1个月后面部表情基本正常，可口入10ml半流质饮食，吸氧时间由24小时减为12小时，吸痰次数减少为23小时一次。,治疗结果,Results,After three mon
14、ths, his spirits and body constitution improved. He did not require oxygen inspiration, and had better facial expressions. His swallowing ability improved further, and could ingest 100 ml of semi fluids. He was admitted for a total of 178 days, after which he was discharged.,11,of,住院3个月后， 患者体质增强，无需吸
15、氧，面部表情恢复正常，可发出低微声音，每天可口入100ml半流质饮食。共住院治疗178天，出院时可发出低微声音，口入半流质饮食可满足日常能量需要。,病案举隅,A Medical Record,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 admitted to hospital due to disability on his right, difficulty in speaking and swallowing for 18 days.,12,of,46,入院时,At Admi
16、ssion,13,of,46,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 right arm was level 0, right leg was level 2, experienced coughing when drinking water, difficulty in swallowing, and had insertion of feeding tube.,治疗,Treatment,针刺治疗 （2次/日） 上午 “通关利窍”针刺治疗： 针刺内关、人中、三阴交、风池、完骨、翳风，咽后壁点刺，舌面点刺 下午 后颅凹排刺,Acupuncture Threpy: In the morning “Tong Guan Li Qiao” acupuncture therapy, in
