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1、吞咽障碍的神经肌肉电刺激治疗吞咽障碍的神经肌肉电刺激治疗 NEUROMUSCULAR ELECTRICAL STIMULATION THERAPY FOR DYSPHAGIA佛山市第一人民医院康复科 脑科康复医院 张盘德 2016.081内 容电极放置位置对疗效的影响低频电疗的概念低频电流和NMES的参数脑卒中后吞咽障碍吞咽障碍的 NMES治疗2佛山市第一人民医院佛山市第一人民医院 The First Peoples Hospital of FoshanThe First Peoples Hospital of Foshan百载医航百载医航Spanning a Century of Histo
2、rySpanning a Century of History百年医院发展历程 the Hospital, Spanning a Century of HistoryThe first president: Wenyon (18811893 )始建于1881年 Established in 1881 On October 14 1881 (the year Guangxu 7 of Qin Dynasty), London Missionary Society sent Charles Wenyon, a preacher as well as a doctor to Foshan desti
3、ned to spreading public health commonsense and saving the public. Under the name of Christian Society, he founded Guangji clinic in a big ware-store in Yinzuisha, Gangwalan near the railway station. It was the predecessor of Xundao hospital (the Methodist Missionary Hospital). 百年医院发展历程 the Hospital,
4、 Spanning a Century of History1959年,被评为全国12家办得最好的专医院之一in 1959, the hospital was evaluated to be one of the 12 best-managed regional hospitals. 1991年,成为卫生部审核的全国首批、全省首家三级甲等医院In 1991, Guangdong Provincial Public Health Department issued number 1 certificate of Grade A Hospital at Class to my hospital.2
5、012年,被誉为“中国医院现代化建设起点In 2012, It was known as “A New Starting Point of Chinese hospital Modernization Construction”国际救援网络亚洲国际紧急救援中心合作医院International rescue network Asia international cooperation hospital emergency center 2015年,成为广东省首家通过三甲复评的医院Tongji Rehabilitation HospitalRPrevention or retardation o
6、f disuse atrophy;Increasing local blood circulation;Muscle re-education;Immediate post-surgical stimulation of calf muscles to prevent venous thrombosis;Maintaining or increasing range of motion.37NMES与FES的关系范畴图 电刺激疗法 electric stimulation therapy低频电疗占电刺激的主要部分 Low frequency electric stimulation thera
7、py 在国外,NMES和TENS是应 用最多的低频电疗法FES属于NMES的一部分FESNMES低频电刺激电刺激38颈前吞咽肌肉浅层: 颈阔肌、胸锁乳突肌中层:舌骨上肌,舌骨下肌二腹肌,下颌舌骨肌颏舌骨肌,茎突舌骨肌肩胛舌骨肌,胸骨舌骨肌胸骨甲状肌,甲状舌骨肌深层: 椎前肌,前、中、后斜角肌吞咽障碍电刺激治疗文献回顾吞咽障碍电刺激治疗文献回顾1980s 吞咽肌电刺激开始应用;1996年, Freed 等详细描述了颈前肌肉电刺激改善吞咽障碍 的方法。2002年美国FDA批准了 VitalStim Therapy ,从此电刺激大 量应用于各种原因导致的吞咽障碍。但对疗效和治疗方法的争论也更加激烈。
8、Ludlow 等首先报道感觉阈强度的电刺激也能减少慢性吞咽 障碍病人的误吸率。40吞咽障碍电刺激治疗文献回顾电刺激的长期疗效一项有99个病例的对照研究:2年后, 89% 的电刺激组病 人吞咽功能明显改善,冰刺激组只有67%。 Freed ML . Respir Care. 2001; 46(5):466474. Park等对健康受试者电刺激舌骨下肌群同时用力吞咽, 每天刺激20min,2周后受试者舌骨上抬幅度明显增加, 前移幅度无明显变化。 Park JW. Dysphagia. 2009; 24(3):296301. 但另一项研究并没有发现电刺激后健康人颈前肌 群的肌电图改变。Kiger M
9、 报道电刺激对恢复期中风病人的吞咽功能 的改善与常规吞咽训练比较无明显差异。4142 作者观察对象方法结果Bogaardt et al, 200925例MSEG: NMES at 30Hz, 200 s, Placement 1 ,20 minutes for 6 sessions (2 sessions/week) 20 swallows; 60 swallows/sessiona. Dysphagia Severity Scale 显著改善 p0.01 b. PAS 流质误 吸率显著改 善 (p0.01) c. 生活质量显著改善 (p=0.01)Gallas et al, 201011例中
10、风病人TES on submental area 5 sessions, 1h/day, 5s every minute, 80 Hz below motor threshold +Swallowinga. 流质和糊状食物SRT 降 低(p0.05) b. 减少食物残留(p0.05)Lim et al, 200936例中风病人EG: NMES(1hr, 5days/wk, low intensity: 7 mA, 80Hz, Placement 3) +Thermal Stimulation (5trials/week, 4 wks) CG: Thermal Stimulation (5 tr
11、ials/week, 4 wks)a. 电刺激组吞咽功能显著 改善,流质和半固体食物误 吸率显著降低; b. Change in PTT was greater for EG post treatment. c. 电刺激组6/12例,对照 组1/7例恢复经口进食; d. 舒适性无差异吞咽障碍电刺激治疗文献回顾43 作者观察对象方法结果Ryu et al, 200926例各种原因 的吞咽障碍病 人EG: NMES (30 mins, 80 Hz, 700 s placement 3B) plus 30 mins, therapeutic maneuvers CG: Sham TENS plus
12、therapeutic maneuvers and techniques 10 sessions of 30 mins for 5 days/week over 2 weeksFunctional dysphagia scale (FDS) 电刺激组改 善(p=0.04)Bulow et al, 200825例中风病人EG: 12例 NMES(Placement 3B, mean 13mA.) CG: 13 例常规手法治疗 15 therapy sessions of 60 mins over 3 weeks (5 days/week)2组没有显著差异Blumenfeld 80例各种原因 吞咽
13、障碍病人EG:40 例30 min NMES : 2 舌骨上, 80 Hz, 700us CG: 40例 : 30 min traditional therapya. NMES组吞咽功能改 善更好(p=0.002);治 疗次数更少(p=0.014); PTT改善更大。 b. 住院时间 没有显著差 异吞咽障碍电刺激治疗文献回顾44 作者观察对象方法结果Jaewon et al, 201128例脑外伤病 人电刺激组:舌骨上肌群, 60 Hz, 500s ,1s:1s 常规训练组 : 30min, 5d/wk,*4wksvideofluoroscopic dysphagia scale , ASHA
14、 level评分 2组无 显著差异,但ASHA评分 改善的病人数量电刺激 组更多吞咽障碍电刺激治疗文献回顾45p 2015年一项荟萃分析:22个研究,只有3个符合要求。73个脑卒中后吞咽障碍病例,平均年龄7211.8岁。治疗电刺激电流强度 16.86.6 mA治疗时间 2周吞咽障碍电刺激治疗文献回顾Compared with no/sham stimulation, PES was associated with lower PAS, 3.41.7 versus 4.11.7, (P= 0.02), lower DSRS(吞 咽障碍严重程度评分), 3.53.8 versus 4.94.4,
15、(P = 0.04). Length of stay in hospital tended to be shorter: 50.225.3 versus 71.260.4 days (P= 0.11). Functional outcome and death did not differ between treatment groups. Conclusions: PES was associated with less radiological aspiration and clinical dysphagia and possibly reduced length ofstay inho
16、spital across three small trials. 减少误吸,改善吞咽功能 ,可能降低住院日46吞咽障碍电刺激治疗文献回顾47PAS误吸评分吞咽障碍严重程度评分吞咽障碍电刺激治疗文献回顾48Kil-Byung Lim, Ann Rehabil Med, 2014;38(5):592-602 49吞咽障碍电刺激治疗文献回顾47例中风恢复期(3个月)吞咽障碍病人。分成3组:常规训练组:CDT, 4wksrTMS组:1 Hz, 20 min/d, 5 d/wk*2wksNMES组:VitalStim , 2通路,纵向排列, 300 s, 80 Hz, 30min/d, 5 d/wk*2wks50吞咽障碍电刺激治疗文献回顾51结论:NMES和rTMS都能促进吞咽功能早期恢复。L. ROFES Neurogastroenter