通关利窍针法结合低频重复经颅磁刺激对脑卒中后吞咽障碍的观察

Observation on the combination of Tongguan Liqiao acupuncture and low-frequency repetitive transcranial magnetic stimulation for post-stroke dysphagia

摘要

目的 探讨通关利窍针法结合低频重复经颅磁刺激对脑卒中后吞咽障碍患者吞咽功能及吞咽相关肌群运动功能的协同作用。 方法 选取2024年1月—2025年11月收治的85例脑卒中后吞咽障碍患者，按随机数字表法分为观察组（42例）与对照组（43例）。2组均接受常规吞咽康复训练，对照组加用低频重复经颅磁刺激，观察组在此基础上联合通关利窍针法，连续治疗4周。治疗前后采用标准吞咽功能评定量表（SSA）及Gugging吞咽功能评估表（GUSS）评估吞咽功能；通过肌电图诱发电位仪检测舌骨上下肌群吞咽时程及最大波幅，结合改良曼恩吞咽能力评估表（MASA）评估肌群运动功能；采用生存质量量表评估生活质量变化。 结果 治疗后2组SSA评分均显著降低，GUSS评分升高（P＜0.05），且观察组吞咽功能改善优于对照组（P＜0.05）；观察组MASA评分高于对照组（P＜0.05），舌骨上下肌群吞咽时程更短、最大波幅更高（P＜0.05）；2组生存质量量表评分均下降，观察组降幅更显著（P＜0.05）；观察组总有效率高于对照组（P＜0.05）。 结论 通关利窍针法联合低频重复经颅磁刺激可有效改善脑卒中后吞咽障碍患者吞咽功能及吞咽相关肌群运动协调性，提升生活质量。

Abstract

Objective To explore the synergistic effect of Tongguan Liqiao acupuncture combined with low-frequency repetitive transcranial magnetic stimulation (rTMS) on swallowing function and related muscle group motor function in post-stroke dysphagia patients. Methods 85 post-stroke dysphagia patients admitted from January 2024 to November 2025 were selected and randomly divided into the observation group (n = 42) and the control group (n = 43) according to random number table method. Both groups received conventional swallowing rehabilitation. Additionally, the control group received low-frequency rTMS, while the observation group combined this with Tongguan Liqiao acupuncture for 4 weeks. Swallowing function was assessed using the Standardized Swallowing Assessment (SSA) and Gugging Swallowing Screen (GUSS) scales. Electromyography-evoked potential instrument was used to detect the swallowing duration and maximum amplitude of suprahyoid and infrahyoid muscle groups, combined with the modified Mann Assessment of Swallowing Ability (MASA) to evaluate muscle group motor function; Quality of life was measured using quality of life scales. Results After treatment, SSA scores of both groups decreased significantly while GUSS scores increased (P<0.05), with the observation group showing superior swallowing function improvement compared to the control group (P<0.05). The observation group showed higher MASA scores than the control group (P<0.05), with shorter swallowing duration and greater maximum amplitude in the suprahyoid and infrahyoid muscle groups (P<0.05). The quality of life scale scores decreased in both groups, with a more significant reduction in the observation group (P<0.05). The total effective rate of the observation group was higher than that of the control group (P<0.05). Conclusion Tongguan Liqiao acupuncture combined with low-frequency rTMS can effectively improve swallowing function and motor coordination of swallowing-related muscle groups in patients with post-stroke dysphagia, thereby enhancing their quality of life.

关键词

脑卒中 / 吞咽障碍 / 针刺 / 低频重复经颅磁刺激

Key words

stroke / dysphagia / acupuncture / low-frequency repetitive transcranial magnetic stimulation

脑卒中是临床常见病，常并发卒中后吞咽障碍（post-stroke dysphagia，PSD）。相关研究^[1]发现，脑卒中急性期吞咽障碍患病率在42%左右，在高龄患者中发病率可高达39.4%。常可导致误吸、电解质紊乱、吸入性肺炎等，还会增加营养不良风险，进而降低患者的生存质量，甚至可危及患者的生命^[2]。临床多以吞咽功能训练为常规康复手段，虽有疗效，但因病情严重程度、年龄、意识水平、康复小组协作能力、患者及家属承担能力等差异，部分患者吞咽功能恢复进程缓慢^[3]。非侵入性脑刺激（non-invasive brain stimulation，NIBS）技术是一种新兴的神经调控技术，可通过调节大脑皮层兴奋性以改善吞咽功能。重复经颅磁刺激（repeated transcranial magnetic stimulation，rTMS）因其耐受性较高、副作用少，故而得到广泛应用^[4]。在中医领域，PSD并无明确病名，归纳于“喉痹”“喑痱”等范畴，针刺作为有效治疗手段，因证据等级较高，已成为国内权威指南推荐治疗手段之一^[5]。通关利窍针法前期研究表明，对PSD具有良好的治疗效果^[6]。主要作用为醒脑、通络、利窍，但结合低频rTMS应用能否产生增效作用，尤其对吞咽相关肌群的神经肌肉控制功能有何影响，尚待深入研究。基于此问题，研究拟通过观察分析通关利窍针法结合低频rTMS治疗PSD的效果，探索针对PSD更为优化的中西医结合干预方案。

1 资料与方法

1.1 一般资料

全部病例来源于2024年1月－2025年11月天津康复疗养中心中医针灸康复科收治住院的PSD患者，共计85例。采用随机数字表法分为对照组和观察组，其中对照组43例，观察组42例。由于依从性不足，对照组2例患者和观察组1例患者未能完成全部治疗，予以剔除，最后2组均纳入41例患者。对照组男23例，女18例；年龄47～66岁，平均年龄（59.79±6.27）岁；病程39～55 d，平均病程（45.29±6.75）d；致病原因中脑梗死与脑出血分别为21例、20例；洼田式饮水试验分级为Ⅲ级26例、Ⅳ级15例。治疗组男25例，女16例；年龄43～68岁，平均年龄（60.12±6.33