（优质课件）讲稿 “通关利窍”针刺法治疗脑干梗死吞咽障碍的临床研究

1、“通关利窍”针刺法治疗 脑干梗死吞咽障碍的临床研究,1,研究背景,Background,Dysphagia 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 affecting the patients

2、 quality of life。It is an important cause of death amongst stroke patients.,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 。,2,2005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

3、吞咽困难。,Dysphagia can be categorized into bulbar paralysis and pseudobulbar paralysis. Bulbar 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 terme

4、d both conditions “dysphagia”.,2,of,46,3,真球麻痹Vs假球麻痹,Bulbar Paralysis Vs Pseudobulbar Paralysis,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 bul

5、bar 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 well.,3,of,46,4,大脑的供血系统 Blood Supply of Brain,4,

6、of,46,5,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 medicine may attempt to improve nutrient intake via the insertion of the feeding tube, but dysphagia remains a severe medical and social problem.,6,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2

7、6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 quadriplegia, aphasia and dysphagia. He suffered from brainstem infarction in 2008 and 2010, and underwent tracheal intubation, gas

8、tric intubation and other conservative treatment. His condition stabilized, hence was admitted to our hospital for further treatment.,6,of,46,7,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 positio

9、n, suffered from aphasia and could only communicate using eyeball movement. His head could move 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

10、 urinary tube, urine and motion incontinence.,8,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（+） 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 Syn

11、drome, Hypertension (Level 3), tracheal intubation, gastric intubation, urinary infection, lung infection.,9,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,10,病情变化,Condition Changes,The urine tube was removed on the SECOND day of admission. After on

12、e month, his facial expressions 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,of

13、,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。,11,治疗结果,Results,After three months, 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 sem

14、i 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。,12,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 hos

15、pital due to disability on his right, difficulty in speaking and swallowing for 18 days.,12,of,46,13,入院时,At Admission,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 le

16、vel 0, right leg was level 2, experienced coughing when drinking water, difficulty in swallowing, and had insertion of feeding tube.,14,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, inclusi

17、ve 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 tongue In the afternoon Lined acupuncture treatment on the back of his head.,15,治疗结果,Results,After 2 weeks of treatment, the patient was able to in

18、gest 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 requirement, therefore removed hi

19、s feeding tube the next day. His dysphagia was considered clinically cured,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 。,16,How is that possible?,如何治疗的？ 针刺的方法是什么？,17,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,Using the principles of “Tong Guan Li Qiao

20、” 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 Yifeng, SJ17,咽后壁点

21、刺 Prick the posterior pharyngeal wall,针刺主穴 The Main Points,19,操作方法 Manipulation,内 关 Neiguan (PC 6),直刺0.51寸，采用提插捻转泻法，施手法1分钟；,First puncture bilateral Neiguan(PC 6) perpendicularly for 0.5-1 cun, using combinative reducing method of lifting-thrusting and twirling-rotating the needle for 1 minute;,20,补

22、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,21,人 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0.30.5寸，行雀啄手法，至眼球湿润或流泪为度；,22,三 阴 交 Sanyinjiao (S

23、P 6),沿胫骨内侧缘与皮肤呈45度角斜刺，进针11.5，用提插补法，使患侧下肢抽动3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 reinforcing method of lifting and thrusting the needle to make the affected lo

24、w limb have tic for three times.,23,24,风池、完骨、翳风 Fengchi(GB 20) Wangu(GB 12) Yifeng(SJ 17),针向结喉，进针1.52寸，施小幅度、高频率捻转补法1分钟，以咽喉麻胀为宜；,Puncture Fengchi(GB 20),Wangu(GB 12) and Yifeng(SJ 17) in the direction of the laryngeal protuberance for 2-2.5 cun, with reinforcing manipulation of twirling and rotating

25、the needle in high frequency and small amplitude for 1 minute to each acupoint.,25,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， 用0.3075mm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 down using a spatula to fully expose the posterior pharyngeal wa

26、ll.Use 0.3075 mm needle to prick both sides of the posterior pharyngeal wall once daily.,26,取穴方义,Explanation,24,of,46,人中 Ren zhong,三阴交 San Yin Jiao,内关 Nei Guan,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.,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

27、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。 Regulate the Du meridian, open orifices, nourish the brain and calm the mind.,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。 Nourish the kidneys, liver, spleen and clear dampness.,27,取穴方义,Explanation,25,of,46,风池、完骨、翳风Feng Chi ， Wan Gu an

28、d Yi Feng,咽后壁点刺 Prick the posterior pharyngeal wall,风池 Feng Chi,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。 Calm wind, suppress yang, improve blood circulation and clear the head.,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。 Three points together can nourish the brain matter, open brain orif

29、ices, and regulate qi.,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。 All points together may regulate qi and the mind, balance yin and yang, and unblock any obstruction.,28,研究方案,Research programs,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 Clinical Data,26,of,46,疗效评定 Assessment of Results,治疗结果 R

30、esults of Treatment,治疗方法 Treatment Method,29,临床资料,Clinic Date,27,of,46,Diagnosis and Inclusion Criteria,30,一般资料,General Date,28,of,46,Diagram,31,诊断及纳入标准,Diagnosis and Inclusion Criteria,29,of,46,32,排除标准,30,of,46,Diagram,Exclusion Criteria, Other diseases that might cause dysphagia; Poor consciousnes

31、s, psychological problems 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； 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；,33,治疗方法,Treatment Method,2,of,6,Perform the “Tong Guan Li Qiao” acupuncture ther

32、apy.,The course of treatment was 28 days.,34,疗效评定,Assessment of Results,32,of,46,评定吞咽功能 assess the patients swallowing ability,洼田饮水试验 Kubota water test 藤岛一郎吞咽疗效评价标准 Fujishima Ichiro rating scale 标准吞咽功能评价量表（SSA） Standard Swallowing Assessment,Barthel生活指数 Barthel Index,评价生活质量 assess standard of living

33、,35,治疗结果,Results 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/ Brainstem Infarction/Combined Infarction，there were significant differences between the scores of Kubota water test before and after treatment. This shows that “Tong Guan Li

34、 Qiao” acupuncture therapy is effective in improving swallowing ability.,33,of,46,36,洼田饮水试验,Kubota water test,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。,Comparison among the groups showed that in brainstem infarction patients, the Kubota Water Test results were higher, and th

35、eir condition were more serious before treatment, but after treatment, they showed a better trend in recovery.,37,洼田饮水试验,Kubota water test,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。,With reference to their radiographic reports, the lesions of

36、 these patients are at the medulla oblongata, hence often press against the glossopharyngeal nerve and hypoglossal nerve, causing dysphagia. Acupuncture can effectively improve the brain circulation, swiftly set up compensatory mechanisms and achieve clinical results.,38,治疗结果,Results of treatment,36

37、,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。 Comparison 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” acupunctur

38、e therapy is effective in improving swallowing ability.,39,治疗结果,Results of Treatment,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。,Comparison of Results for Bulbar Paralysis/ Brainstem Infarction/Combined Infarction，there were significant differences between the

39、 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,Results of Treatment,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。,Comparison of Results f

40、or 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 ability of patients, and hasten the recovery of their standard of living.,41,疗效判定标准,Asses

41、sment of Results,39,of,46,治愈,显效,有效,无效,42,治疗结果,Results of Treatment,40,of,46,43,治疗结果,Results of Treatment,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。,The total efficacy rate of treating dysphagia after medulla oblongata infarction was 95.86%, the 64 patients s

42、howed marked improvement in their swallowing ability and quality of life, showing that this acupuncture method is effective in treating dysphagia caused by post stroke bulbar paralysis.,44,治疗结果,Results of Treatment,42,of,46,This study has shown that the efficacy rate forcombined infarction was lowes

43、t with poor prognosis,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。,Our treatment for pseudobulbar paralysis is effective,45,数据分析,Data Analyze,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。 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 吞咽功能及血氧饱和度水平 I

44、mprove post stroke dysphagia and blood oxygen saturation levels.,随访,临床研究,46,44,of,46,实验 观察,This acupuncture therapy can significantly improve blood circulation, blood rheology, rheoencephalogram, hence promoting cranial blood supply, the recovery of central nervous system,thus promoting the recovery

45、 of this condition. The recovery of the function of neural tissue is related to the cranial blood circulation.,laboratory research,Data Analyze,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”,47,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。,“Tong Guan Li Qiao” acupuncture treatment for d

46、ysphagia due to brainstem stroke has received satisfactory results, and can improve the patients quality of life.,48,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。Defines the mechanism research and treatment of apoplexy, focusing on nerve and breakthr

47、ough of blood vessels. Research methods to promote the head injury acupuncture and nerve cells regeneration cycle, from the morphology, biochemistry, molecular biology, central nervous mechanism for more than twenty experiments.,针刺治疗缺血性中风病的机理研究The mechanism research of Acupuncture treatment ischemic stroke,49,形态学研究，证明针刺可促进侧枝循环建立 Morphology research that acupuncture can promote collateral circulation,梗塞半球 脑表面缺血区 Cerebral infarction hemisphere surface ischemia,阻断大脑中动脉后，大脑表面缺血区所见： Block after middle cerebral artery surface area, the brain ischem