“通关利窍”针刺法治疗脑干梗死吞咽障碍的临床研究.ppt

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ShiXueminProf ClinicalResearchon TongGuanLiQiao AcupunctureTherapyfortheTreatmentofDysphagiaafterBrainstemStroke 天津中医药大学第一附属医院FristTeachingHospital TianjinUniversityofChineseMedicine 研究背景 Background Dysphagiaisacommoncomplicationofcerebrovasculardiseases therateofdysphagiaduetostrokeis51 73 Itcouldbringaboutcomplicationslikeaspirationpneumonia insufficientintakeoffluidsandnutrients asphyxia henceaffectingthepatient squalityoflife Itisanimportantcauseofdeathamongststrokepatients 1 of 46 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 2005ChinaCerebrovascularDiseasesGuidelines 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 Dysphagiacanbecategorizedintobulbarparalysisandpseudobulbarparalysis Bulbarparalysisisduetolesionsatthenucleusambiguousofthemedullaoblongata whilepseudobulbarparalysisiseitherduetolesionsatthecorticobulbartractsoronboththecorticaltracts Theyweretermedbothconditions dysphagia 2 of 46 真球麻痹Vs假球麻痹 BulbarParalysisVsPseudobulbarParalysis 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 lesionsatandbelowthenucleusthatislowermotorneuronarereferredtobulbarparalysis whilelesionsabovethenucleusareknownaspseudobulbarparalysis Inradiography thelocationofthenucleusremainsunclear thereforewebroadenedthescope andclassifiedlesionsinthemedullaoblongataunderbulbarparalysisaswell 3 of 46 大脑的供血系统BloodSupplyofBrain 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 Modernmedicinemayattempttoimprovenutrientintakeviatheinsertionofthefeedingtube butdysphagiaremainsaseveremedicalandsocialproblem 病案举隅 AMedicalRecord 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 MartinAcierno Male 49years American Thepatientwasadmittedtohospitalon26August2011duetoquadriplegia aphasiaanddysphagia Hesufferedfrombrainsteminfarctionin2008and2010 andunderwenttrachealintubation gastricintubationandotherconservativetreatment Hisconditionstabilized hencewasadmittedtoourhospitalforfurthertreatment 6 of 46 入院时 AtAdmission 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 Hismentalstatewaspoor wasinapassiveposition sufferedfromaphasiaandcouldonlycommunicateusingeyeballmovement Hisheadcouldmoveslightly butcouldnotopenhismouth Hehaddysphasia trachealintubation requiredlongtermoxygeninspiration hadexcessivesaliva phlegmsuctioning16timesdaily gastricintubation hadclearurinarytube urineandmotionincontinence 入院时 AtAdmission 8 of 46 查体 四肢肌力0级 肌张力增高 双侧巴氏征 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 Physicalexamination Levelofmusclestrength0 increasedmusclespasticity bilateralBabinskisign Diagnosis CerebralInfarction Locked InSyndrome Hypertension Level3 trachealintubation gastricintubation urinaryinfection lunginfection 治疗 Treatment Treatment TongGuanLiQiao acupuncturetherapy twicedaily 通关利窍 针刺法治疗每天治疗两次 病情变化 ConditionChanges TheurinetubewasremovedontheSECONDdayofadmission Afteronemonth hisfacialexpressionsimproved Hisswallowingimproved andcouldingest10mlofsemifluiddiet Oxygeninspirationwasreducedfrom24hto12handphlegmsuctioningwasreducedtoonceevery2 3hours Perspirationimproved andhecouldsleepbetter butstillhadincontinence 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2 3小时一次 治疗结果 Results Afterthreemonths hisspiritsandbodyconstitutionimproved Hedidnotrequireoxygeninspiration andhadbetterfacialexpressions Hisswallowingabilityimprovedfurther andcouldingest100mlofsemifluids Hewasadmittedforatotalof178days afterwhichhewasdischarged 11 of 住院3个月后 患者体质增强 无需吸氧 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 AMedicalRecord 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 Thepatient Mr Du male 55yearswasadmittedtohospitalduetodisabilityonhisright difficultyinspeakingandswallowingfor18days 12 of 46 入院时 AtAdmission 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 Duringadmission hisspeechwasslurred hadcontinuousdisabilityonhisright musclestrengthontherightarmwaslevel0 rightlegwaslevel2 experiencedcoughingwhendrinkingwater difficultyinswallowing andhadinsertionoffeedingtube 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 AcupunctureThrepy Inthemorning TongGuanLiQiao acupuncturetherapy inclusiveofNeiGuan PC6 RenZhong DU26 SanYinJiao SP6 FengChi GB20 WanGu GB12 YiFeng SJ17 prickingoftheposteriorpharyngealwallandtongueIntheafternoonLinedacupuncturetreatmentonthebackofhishead 治疗结果 Results After2weeksoftreatment thepatientwasabletoingestlotusrootpaste milk coulddrinksmallsipsofwaterusingastraw andcouldspeakclearerthanbefore Afterthe23rdday thepatientcoulddrinkwaterwithoutcoughing andcouldintakeasmuchas3000mlofwater Hewasabletosatisfyhisdailyenergyrequirement thereforeremovedhisfeedingtubethenextday Hisdysphagiawasconsideredclinicallycured 15 of 46 治疗2周后 患者可口入半流质饮食 构音较前清晰 治疗第23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 Howisthatpossible 如何治疗的 针刺的方法是什么 采用 通关利窍 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 Usingtheprinciplesof TongGuanLiQiao acupuncturetherapyandnourishingthethreeyin westandardizedtheprescriptionofacupuncturepoints manipulationandquantification Satisfactoryclinicalresultswereachieve 内关NeiGuan PC6 人中RenZhong DU26 三阴交SanYinJiao SP6 风池FengChi GB20 完骨WanGu GB12 翳风Yifeng SJ17 咽后壁点刺Pricktheposteriorpharyngealwall 针刺主穴TheMainPoints 操作方法Manipulation 内关Neiguan PC6 直刺0 5 1寸 采用提插捻转泻法 施手法1分钟 FirstpuncturebilateralNeiguan PC6 perpendicularlyfor0 5 1cun usingcombinativereducingmethodoflifting thrustingandtwirling rotatingtheneedlefor1minute 补法 左侧顺时针 右侧逆时针 泻法 左侧逆时针 右侧顺时针 右 左 左 右 人中Renzhong DU26 SecondlypunctureRenzhong DU26 obliquelyupwardstothenasalseptumfor0 3 0 5cunwithheavybird peckingmethoduntilthepatient seyeballsaremoistenedortearsflowdown 向鼻中隔方向斜刺0 3 0 5寸 行雀啄手法 至眼球湿润或流泪为度 三阴交Sanyinjiao SP6 沿胫骨内侧缘与皮肤呈45度角斜刺 进针1 1 5 用提插补法 使患侧下肢抽动3次为度ThirdlypunctureSanyinjiao SP6 obliquelyfor1 1 5cun attheangleof45degreeswiththeskinsurfacealongtheposteriorborderofthemedialaspectofthetibia withreinforcingmethodofliftingandthrustingtheneedletomaketheaffectedlowlimbhaveticforthreetimes 风池 完骨 翳风Fengchi GB20 Wangu GB12 Yifeng SJ17 针向结喉 进针1 5 2寸 施小幅度 高频率捻转补法1分钟 以咽喉麻胀为宜 PunctureFengchi GB20 Wangu GB12 andYifeng SJ17 inthedirectionofthelaryngealprotuberancefor2 2 5cun withreinforcingmanipulationoftwirlingandrotatingtheneedleinhighfrequencyandsmallamplitudefor1minutetoeachacupoint 咽后壁点刺prickatpharynxposteriorwall 令患者张口 用压舌板压住舌体 清楚暴露咽后壁 用0 30 75mm长针点刺双侧咽后壁 每天一次Thepatientwastoldtoopenhismouth andhistonguewaspresseddownusingaspatulatofullyexposetheposteriorpharyngealwall Use0 30 75mmneedletoprickbothsidesoftheposteriorpharyngealwalloncedaily 取穴方义 Explanation 24 of 46 人中Renzhong 三阴交SanYinJiao 内关NeiGuan 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 Calmthemind improvethecirculationofqiandblood 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 RegulatetheDumeridian openorifices nourishthebrainandcalmthemind 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 Nourishthekidneys liver spleenandcleardampness 取穴方义 Explanation 25 of 46 风池 完骨 翳风FengChi WanGuandYiFeng 咽后壁点刺Pricktheposteriorpharyngealwall 风池FengChi 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 Calmwind suppressyang improvebloodcirculationandclearthehead 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 Threepointstogethercannourishthebrainmatter openbrainorifices andregulateqi 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 Allpointstogethermayregulateqiandthemind balanceyinandyang andunblockanyobstruction 研究方案 Researchprograms 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 临床资料ClinicalData 26 of 46 疗效评定AssessmentofResults 治疗结果ResultsofTreatment 治疗方法TreatmentMethod 临床资料 ClinicDate 27 of 46 DiagnosisandInclusionCriteria 一般资料 GeneralDate 28 of 46 Diagram 诊断及纳入标准 DiagnosisandInclusionCriteria 29 of 46 排除标准 30 of 46 Diagram ExclusionCriteria Otherdiseasesthatmightcausedysphagia Poorconsciousness psychologicalproblemsandhavedifficultycomplyingwiththedoctor Suffersfromotherprimarydiseaseslikeliver kidneyandendocrinedisorders 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 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 治疗方法 TreatmentMethod 2 of 6 Performthe TongGuanLiQiao acupuncturetherapy Thecourseoftreatmentwas28days 疗效评定 AssessmentofResults 32 of 46 评定吞咽功能assessthepatients swallowingability 洼田饮水试验Kubotawatertest藤岛一郎吞咽疗效评价标准FujishimaIchiroratingscale标准吞咽功能评价量表 SSA StandardSwallowingAssessment Barthel生活指数BarthelIndex 评价生活质量assessstandardofliving 治疗结果 ResultsofTreatment 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 ComparisonofResultsforBulbarParalysis BrainstemInfarction CombinedInfarction thereweresignificantdifferencesbetweenthescoresofKubotawatertestbeforeandaftertreatment Thisshowsthat TongGuanLiQiao acupuncturetherapyiseffectiveinimprovingswallowingability 33 of 46 洼田饮水试验 Kubotawatertest 34 of 46 Diagram 延髓梗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 Comparisonamongthegroupsshowedthatinbrainsteminfarctionpatients theKubotaWaterTestresultswerehigher andtheirconditionweremoreseriousbeforetreatment butaftertreatment theyshowedabettertrendinrecovery 洼田饮水试验 Kubotawatertest 35 of 46 Diagram 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 Withreferencetotheirradiographicreports thelesionsofthesepatientsareatthemedullaoblongata henceoftenpressagainsttheglossopharyngealnerveandhypoglossalnerve causingdysphagia Acupuncturecaneffectivelyimprovethebraincirculation swiftlysetupcompensatorymechanismsandachieveclinicalresults 治疗结果 Resultsoftreatment 36 of 46 采用藤岛一郎试验进行疗效比较 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 ComparisonofResultsforBulbarParalysis BrainstemInfarction CombinedInfarction thereweresignificantdifferencesbetweenthescoresofFujishimaIchiroratingbeforeandaftertreatment Thisshowsthat TongGuanLiQiao acupuncturetherapyiseffectiveinimprovingswallowingability 治疗结果 ResultsofTreatment 37 of 46 采用吞咽功能评价量表 SSA 进行疗效比较 治疗前后评分具有显著性差异 有效的改善了患者吞咽功能 加速了患者生活能力的恢复 有助于提高患者生活质量 ComparisonofResultsforBulbarParalysis BrainstemInfarction CombinedInfarction thereweresignificantdifferencesbetweentheSSAscoresbeforeandaftertreatment Thistherapycaneffectivelyimprovetheswallowingabilityofpatients andhastentherecoveryoftheirstandardofliving 治疗结果 ResultsofTreatment 38 of 46 采用Barthel生活指数进行疗效比较 治疗前后评分具有显著性差异 有效的改善了患者吞咽功能 加速了患者生活能力的恢复 有助于提高患者生活质量 ComparisonofResultsforBulbarParalysis BrainstemInfarction CombinedInfarction thereweresignificantdifferencesbetweentheBarthelscoresscoresbeforeandaftertreatment Thistherapycaneffectivelyimprovetheswallowingabilityofpatients andhastentherecoveryoftheirstandardofliving 疗效判定标准 AssessmentofResults 39 of 46 治愈 显效 有效 无效 治疗结果 ResultsofTreatment 40 of 46 治疗结果 ResultsofTreatment 41 of 46 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 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 Thetotalefficacyrateoftreatingdysphagiaaftermedullaoblongatainfarctionwas95 86 the64patientsshowedmarkedimprovementintheirswallowingabilityandqualityoflife showingthatthisacupuncturemethodiseffectiveintreatingdysphagiacausedbypoststrokebulbarparalysis 治疗结果 ResultsofTreatment 42 of 46 Thisstudyhasshownthattheefficacyrateforcombinedinfarctionwaslowestwithpoorprognosis 本疗法对单纯真球麻痹疗效显著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 Ourtreatmentforpseudobulbarparalysisiseffective 数据分析 DataAnalyze 43 of 46 吞咽困难复发率低 患者很少有舌肌震颤 舌肌萎缩症状 Raisingthedifficultlyofbuildingcollateralcirculation thustheprognosiswasthepoorest 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Improvepoststrokedysphagiaandbloodoxygensaturationlevels 随访 临床研究 44 of 46 实验观察 Thisacupuncturetherapycansignificantlyimprovebloodcirculation bloodrheology rheoencephalogram hencepromotingcranialbloodsupply therecoveryofcentralnervoussystem thuspromotingtherecoveryofthiscondition Therecoveryofthefunctionofneuraltissueisrelatedtothecranialbloodcirculation laboratoryresearch DataAnalyze 数据分析 1999年第8期于 中国针灸 发表 针刺治疗假性延髓麻痹325例临床和机理研究 结论 Conclusion 45 of 46 通关利窍 针刺法治疗脑干梗死吞咽障碍疗效明显 可有效改善患者生活质量 TongGuanLiQiao acupuncturetreatmentfordysphagiaduetobrainstemstrokehasreceivedsatisfactoryresults andcanimprovethepatient squalityoflife 机理研究紧扣中风病的治疗难点及突破点 聚焦在神经与血管的再生 研究针刺手段促进损伤后脑循环重建及神经细胞再生的作用 从形态学 生物化学 中枢神经机制 分子生物学等方面开展了二十余项基础实验 Definesthemechanismresearchandtreatmentofapoplexy focusingonnerveandbreakthroughofbloodvessels Researchmethodstopromotetheheadinjuryacupunctureandnervecellsregenerationcycle fromthemorphology biochemistry molecularbiology centralnervousmechanismformorethantwentyexperiments 针刺治疗缺血性中风病的机理研究ThemechanismresearchofAcupuncturetreatmentischemicstroke 形态学研究 证明针刺可促进侧枝循环建立Morphologyresearchthatacupuncturecanpromotecollateralcirculation 梗塞半球脑表面缺血区Cerebralinfarctionhemispheresurfaceischemia 阻断大脑中动脉后 大脑表面缺血区所见 Blockaftermiddlecerebralarterysurfacearea thebrainischemia 缺血后自身代