1-石院士講稿“通關利竅”針刺法治療腦干梗死吞咽障礙的臨床研究(張部長改)

“通關利竅”針刺法治療腦干梗死吞咽障礙的臨床研究石學敏教授ShiXueminProf.

ClinicalResearchon“TongGuanLiQiao”AcupunctureTherapyfortheTreatmentofDysphagiaafterBrainstemStroke天津中醫(yī)藥大學第一附屬醫(yī)院FristTeachingHospital,TianjinUniversityofChineseMedicine2021/10/101研究背景BackgroundDysphagia

isacommoncomplicationofcerebrovasculardiseases，therateofdysphagiaduetostrokeis51-73%

.Itcouldbringaboutcomplicationslikeaspirationpneumonia,insufficientintakeoffluidsandnutrients,asphyxia,henceaffectingthepatient’squalityoflife。Itisanimportantcauseofdeathamongststrokepatients.

1of46吞咽障礙為腦血管疾病常見并發(fā)癥，腦卒中急性期發(fā)生率為51-73%，可引發(fā)吸入性肺炎、水分營養(yǎng)物質攝入障礙、窒息等并發(fā)癥，嚴重影響患者生存質量，是導致中風病患者死亡的重要原因之一

。2021/10/1022005年《中國腦血管病防治指南》

2005ChinaCerebrovascularDiseasesGuidelines吞咽障礙可分為真球麻痹、假球麻痹，其中真球麻痹主要為延髓疑核損傷，假球麻痹是由雙側皮質或皮質腦干束損傷造成，兩者統(tǒng)稱為吞咽困難。Dysphagia

canbecategorizedintobulbarparalysisandpseudobulbarparalysis.Bulbarparalysisisduetolesionsatthenucleusambiguousofthemedullaoblongata,whilepseudobulbarparalysisiseitherduetolesionsatthecorticobulbartractsoronboththecorticaltracts.Theyweretermedbothconditions“dysphagia”.2of462021/10/103真球麻痹Vs假球麻痹BulbarParalysisVsPseudobulbarParalysis臨床上鑒別真/假球麻痹多以疑核定位，疑核及疑核以下的部位病損即下運動神經(jīng)元病損為真球麻痹，疑核以上部位病損為假球麻痹。臨床中由于影像學對于疑核定位尚存在困難，無法清晰看到疑核受損情況，因此將延髓部位存在病損的患者歸入真球麻痹。Clinically,lesionsatandbelowthenucleusthatislowermotorneuronarereferredtobulbarparalysis,whilelesionsabovethenucleusareknownaspseudobulbarparalysis.Inradiography,thelocationofthenucleusremainsunclear，thereforewebroadenedthescope,andclassifiedlesionsinthemedullaoblongataunderbulbarparalysisaswell.3of462021/10/104大腦的供血系統(tǒng)BloodSupplyofBrain4of462021/10/105研究背景Background5of46現(xiàn)代醫(yī)學對于吞咽障礙的治療多以留置胃管技術改善患者營養(yǎng)攝入，吞咽障礙已成為嚴重的醫(yī)療和社會問題。

Modernmedicinemayattempttoimprovenutrientintakeviatheinsertionofthefeedingtube,butdysphagiaremainsaseveremedicalandsocialproblem.2021/10/106病案舉隅AMedical

Record馬某男49歲美國人主因“四肢癱瘓伴失語、吞咽障礙16個月”于2011年8月26日入院。患者于2008年和2010年兩次患腦干梗死，予氣管切開置管、胃壁造瘺及保守治療，經(jīng)治病情平穩(wěn)，為進一步治療收入我院。MartinAcierno,Male,49years,American.Thepatientwasadmittedtohospitalon26August2011duetoquadriplegia,aphasiaanddysphagia.Hesufferedfrombrainsteminfarctionin2008and2010,andunderwenttrachealintubation,gastricintubationandotherconservativetreatment.Hisconditionstabilized,hencewasadmittedtoourhospitalforfurthertreatment.6of462021/10/107入院時AtAdmission7of46神情，精神弱，被動體位，構音不能，面部無表情，通過眼球移動表達是和否，吞咽障礙，氣切處置管，持續(xù)吸氧，痰涎壅盛，每日吸痰16次，胃壁造瘺，尿管通暢，二便失禁。Hismentalstatewaspoor,wasinapassiveposition,sufferedfromaphasiaandcouldonlycommunicateusingeyeballmovement.Hisheadcouldmoveslightly,butcouldnotopenhismouth.Hehaddysphasia,trachealintubation,requiredlongtermoxygeninspiration,hadexcessivesaliva,phlegmsuctioning16timesdaily,gastricintubation,hadclearurinarytube,urineandmotionincontinence.2021/10/108入院時AtAdmission8of46查體：四肢肌力0級，肌張力增高。雙側巴氏征（+）診斷：腦干梗死閉鎖綜合征高血壓病3級肺感染泌尿系感染胃壁造瘺術后氣管切開術后Physicalexamination:Levelofmusclestrength0,increasedmusclespasticity,bilateralBabinskisign(+).Diagnosis:CerebralInfarction,Locked-InSyndrome,Hypertension(Level3),trachealintubation,gastricintubation,urinaryinfection,lunginfection.2021/10/109治療Treatment9of46Treatment:

“TongGuanLiQiao”acupuncturetherapy,twicedaily。“通關利竅”針刺法治療

每天治療兩次2021/10/1010病情變化ConditionChangesTheurinetubewasremoved

ontheSECONDday

of

admission.Afteronemonth,hisfacialexpressionsimproved.Hisswallowingimproved,andcouldingest10mlofsemifluiddiet.Oxygeninspirationwasreducedfrom24hto12handphlegmsuctioningwasreducedtoonceevery2-3hours.Perspirationimproved,andhecouldsleepbetter,butstillhadincontinence.10of46入院后第2天拔掉尿管；住院1個月后面部表情基本正常，可口入10ml半流質飲食，吸氧時間由24小時減為12小時，吸痰次數(shù)減少為2~3小時一次。2021/10/1011治療結果ResultsAfterthreemonths,

hisspiritsandbodyconstitutionimproved.Hedidnotrequireoxygeninspiration,andhadbetterfacialexpressions.Hisswallowingabilityimprovedfurther,andcouldingest100ml

ofsemifluids.Hewasadmittedforatotalof178days,afterwhichhewasdischarged.11of住院3個月后，患者體質增強，無需吸氧，面部表情恢復正常，可發(fā)出低微聲音，每天可口入100ml半流質飲食。共住院治療178天，出院時可發(fā)出低微聲音，口入半流質飲食可滿足日常能量需要。46of2021/10/1012病案舉隅AMedical

Record患者杜某某，男，55歲，主因“右側肢體活動不遂伴失語、吞咽困難18天”住院。Thepatient,Mr.Du,male,55yearswasadmittedtohospitalduetodisabilityonhisright,difficultyinspeakingandswallowingfor18days.12of462021/10/1013入院時AtAdmission13of46入院時語言謇澀，持續(xù)右側肢體不遂，右上肢肌力0級，右下肢肌力2級，飲水咳嗆、吞咽困難，納食自胃管注入。Duringadmission,hisspeechwasslurred,hadcontinuousdisabilityonhisright,musclestrengthontherightarmwaslevel0,rightlegwaslevel2,experiencedcoughingwhendrinkingwater,difficultyinswallowing,andhadinsertionoffeedingtube.2021/10/1014治療Treatment14of46針刺治療（2次/日）上午“通關利竅”針刺治療：針刺內關、人中、三陰交、風池、完骨、翳風，咽后壁點刺，舌面點刺下午后顱凹排刺AcupunctureThrepy:Inthemorning“TongGuanLiQiao”acupuncturetherapy,inclusiveofNeiGuan(PC6),RenZhong(DU26),SanYinJiao(SP6),FengChi(GB20),WanGu(GB12),YiFeng(SJ17),prickingoftheposteriorpharyngealwallandtongueIntheafternoonLinedacupuncturetreatmentonthebackofhishead.

2021/10/1015治療結果ResultsAfter2weeksoftreatment,thepatientwasabletoingestlotusrootpaste,milk,coulddrinksmallsipsofwaterusingastraw,andcouldspeakclearerthanbefore.

Afterthe23rdday,thepatientcoulddrinkwaterwithoutcoughing,andcouldintakeasmuchas3000mlofwater.Hewasabletosatisfyhisdailyenergyrequirement,thereforeremovedhisfeedingtubethenextday.Hisdysphagiawasconsideredclinicallycured15of46治療2周后，患者可口入半流質飲食，構音較前清晰；治療第23天，患者可飲水，不嗆，口入量達3000ml，滿足日常能量需要，吞咽障礙臨床痊愈。2021/10/1016Howisthatpossible??如何治療的？針刺的方法是什么？2021/10/1017采用“通關利竅”針刺法

我們以通關利竅、滋補三陰為原則，嚴格規(guī)范取穴、針刺手法量學，治療吞咽障礙臨床療效顯著Usingtheprinciplesof“TongGuanLiQiao”acupuncturetherapyandnourishingthethreeyin,westandardizedtheprescriptionofacupuncturepoints,manipulationandquantification.Satisfactoryclinicalresultswereachieve.

2021/10/1018

內關NeiGuan,PC6人中RenZhong,DU26三陰交SanYinJiao,SP6風池FengChi,GB20完骨WanGu,GB12翳風Yifeng,SJ17咽后壁點刺Pricktheposteriorpharyngealwall針刺主穴TheMainPoints2021/10/1019操作方法

Manipulation內關Neiguan(PC6)

直刺0.5~1寸，采用提插捻轉瀉法，施手法1分鐘；FirstpuncturebilateralNeiguan(PC6)perpendicularlyfor0.5-1cun,usingcombinativereducingmethodoflifting-thrustingandtwirling-rotatingtheneedlefor1minute;19of242021/10/1020補法（左側順時針；右側逆時針）瀉法（左側逆時針；右側順時針）右左左右2021/10/1021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，至眼球濕潤或流淚為度；20of462021/10/1022三陰交Sanyinjiao(SP6)沿脛骨內側緣與皮膚呈45度角斜刺，進針1~1.5，用提插補法，使患側下肢抽動3次為度ThirdlypunctureSanyinjiao(SP6)obliquelyfor1-1.5cun,attheangleof45degreeswiththeskinsurfacealongtheposteriorborderofthemedialaspectofthetibia,withreinforcingmethodofliftingandthrustingtheneedletomaketheaffectedlowlimbhaveticforthreetimes.2021/10/10232021/10/1024風池、完骨、翳風Fengchi(GB20)Wangu(GB12)Yifeng(SJ17)針向結喉，進針1.5~2寸，施小幅度、高頻率捻轉補法1分鐘，以咽喉麻脹為宜；PunctureFengchi(GB20),Wangu(GB12)andYifeng(SJ17)inthedirectionofthelaryngealprotuberancefor2-2.5cun,withreinforcingmanipulationoftwirlingandrotatingtheneedleinhighfrequencyandsmallamplitudefor1minutetoeachacupoint.22of462021/10/1025咽后壁點刺prickatpharynxposteriorwall令患者張口，用壓舌板壓住舌體，清楚暴露咽后壁，用0.30×75mm長針點刺雙側咽后壁，每天一次Thepatientwastoldtoopenhismouth,andhistonguewaspresseddownusingaspatulatofullyexposetheposteriorpharyngealwall.Use0.30×75mmneedletoprickbothsidesoftheposteriorpharyngealwall

oncedaily..23of462021/10/1026取穴方義Explanation24of46123人中Renzhong三陰交SanYinJiao內關NeiGuan內關穴為八脈交會穴之一，通于陰維脈，屬手厥陰心包經(jīng)

之絡穴，有養(yǎng)心安神、疏通氣血之功。Calmthemind,improvethecirculationofqiandblood.人中為督脈與手足陽明經(jīng)之會穴，督脈起于胞中，上行人腦達巔，故瀉人中可調督脈，開竅啟閉可健腦寧神。針刺可刺激穴周的面神經(jīng)、三叉神經(jīng)分支，激活了三叉神經(jīng)-腦血管系統(tǒng)，可達到興奮腦神經(jīng)元，改善腦血流的作用。

RegulatetheDumeridian,openorifices,

nourishthebrainandcalmthemind.足三陰之經(jīng)脈或挾舌本，或絡于舌本，或連舌本，散舌下;

補其三陰可達補益肝腎，健脾利濕之功。Nourishthekidneys,liver,spleenandcleardampness.2021/10/1027取穴方義Explanation25of46123風池、完骨、翳風FengChi，WanGuandYiFeng咽后壁點刺Pricktheposteriorpharyngealwall風池FengChi風池穴乃治風要穴，為足少陽與陰維之會，歸屬膽經(jīng)，

可條達陽經(jīng)之氣，潛陽熄風，活血化瘀，清頭利竅。Calmwind,suppressyang,improvebloodcirculationandclearthehead.風池、完骨、翳風穴共為少陽之脈，具有通利樞紐之功，

三穴合用可達養(yǎng)腦髓、通腦竅、利機關的作用。Threepointstogethercannourishthebrainmatter,openbrainorifices,andregulateqi.配合咽后壁點刺局部取穴，諸穴合用可調神導氣、平衡陰

陽，通關利竅的作用。Allpointstogethermayregulateqiandthemind,balanceyinandyang,andunblockanyobstruction.2021/10/1028研究方案

Researchprograms

我們以臨床實踐為基礎，以醒腦開竅為原則，在取穴、配方、針刺手法及其量學方面做了嚴格規(guī)范，臨床療效顯著。臨床資料

ClinicalData26of46療效評定

AssessmentofResults治療結果

ResultsofTreatment治療方法

TreatmentMethod2021/10/1029

臨床資料ClinicDate27of46排除標準

診斷及納入標準一般資料GeneralDataExclusionCriteriaDiagnosisandInclusionCriteria2021/10/1030

一般資料GeneralDate28of46Diagram腦干梗死吞咽障礙患者64例64postbrainsteminfarctiondysphagiapatientswerescreened

年齡平均63.86±9.49歲averageageofthepatientswas63.86±9.49years

病程平均23.89±20.71天averagecourseofdiseasewas23.89±20.71days2021/10/1031診斷及納入標準DiagnosisandInclusionCriteria29of462021/10/1032

排除標準

30of46DiagramExclusionCriteria①Otherdiseasesthatmightcausedysphagia;②Poorconsciousness,psychologicalproblemsandhavedifficultycomplyingwiththedoctor;③Suffersfromotherprimarydiseaseslikeliver,kidneyandendocrinedisorders①運動神經(jīng)元性疾病導致的吞咽障礙；②神志不清，有精神癥狀不能配合治療者；③合并有肝腎、造血系統(tǒng)、內分泌系統(tǒng)等嚴重原發(fā)病及精神疾患者；2021/10/1033

治療方法TreatmentMethod2of6治療周期均為28天采用“通關利竅”針刺法Performthe“TongGuanLiQiao”acupuncturetherapy.

Thecourseoftreatment

was28days.2021/10/1034療效評定AssessmentofResults32of46評定吞咽功能

assessthepatients’

swallowingability洼田飲水試驗Kubotawatertest藤島一郎吞咽療效評價標準

FujishimaIchiroratingscale標準吞咽功能評價量表（SSA）

StandardSwallowingAssessmentBarthel生活指數(shù)BarthelIndex評價生活質量assessstandardofliving2021/10/1035治療結果

ResultsofTreatment采用洼田飲水試驗進行療效比較，治療前后評分具有顯著性差異，說明通關利竅針刺法在改善吞咽功能方面效果顯著。ComparisonofResultsforBulbarParalysis/BrainstemInfarction/CombinedInfarction，thereweresignificantdifferencesbetweenthescoresofKubotawatertestbeforeandaftertreatment.Thisshowsthat“TongGuanLiQiao”acupuncturetherapyiseffectiveinimprovingswallowingability.33of462021/10/1036洼田飲水試驗Kubotawatertest34of46Diagram延髓梗死患者治療前洼田飲水評分較高、病情較重，但治療前后評分改善程度明顯，表現(xiàn)出了更好的療效趨勢。

Comparisonamongthegroupsshowedthatinbrainsteminfarctionpatients,theKubotaWaterTestresultswerehigher,andtheirconditionweremoreseriousbeforetreatment,butaftertreatment,theyshowedabettertrendinrecovery.2021/10/1037洼田飲水試驗Kubotawatertest35of46Diagram結合患者影像學結果進行分析，延髓梗塞組病變部位在延髓，導致舌咽神經(jīng)、舌下神經(jīng)缺血缺氧，導致吞咽障礙的發(fā)生，通過針刺可有效地改善腦循環(huán)，快速建立代償機制，取得臨床療效。Withreferencetotheirradiographicreports,thelesionsofthesepatientsareatthemedullaoblongata,henceoftenpressagainsttheglossopharyngealnerveandhypoglossalnerve,causingdysphagia.

Acupuncturecaneffectivelyimprovethebraincirculation,swiftlysetupcompensatorymechanismsandachieveclinicalresults.2021/10/1038治療結果

Resultsoftreatment36of46采用藤島一郎試驗進行療效比較，治療前后評分具有顯著性差異，說明通關利竅針刺法在改善吞咽功能方面效果顯著。ComparisonofResultsforBulbarParalysis/BrainstemInfarction/CombinedInfarction，thereweresignificantdifferencesbetweenthescoresofFujishimaIchiroratingbeforeandaftertreatment.Thisshowsthat“TongGuanLiQiao”acupuncturetherapyiseffectiveinimprovingswallowingability.2021/10/1039治療結果

ResultsofTreatment37of46采用吞咽功能評價量表（SSA）進行療效比較，治療前后評分具有顯著性差異，有效的改善了患者吞咽功能，加速了患者生活能力的恢復，有助于提高患者生活質量。ComparisonofResultsforBulbarParalysis/BrainstemInfarction/CombinedInfarction，thereweresignificantdifferencesbetweentheSSAscoresbeforeandaftertreatment.Thistherapycaneffectivelyimprovetheswallowingabilityofpatients,andhastentherecoveryoftheirstandardofliving.2021/10/1040治療結果

ResultsofTreatment38of46采用Barthel生活指數(shù)進行療效比較，治療前后評分具有顯著性差異，有效的改善了患者吞咽功能，加速了患者生活能力的恢復，有助于提高患者生活質量。ComparisonofResultsforBulbarParalysis/BrainstemInfarction/CombinedInfarction，thereweresignificantdifferencesbetweentheBarthelscoresscoresbeforeandaftertreatment.Thistherapycaneffectivelyimprovetheswallowingabilityofpatients,andhastentherecoveryoftheirstandardofliving.2021/10/1041療效判定標準AssessmentofResults39of462021/10/1042治療結果

ResultsofTreatment40of46真球麻痹/腦干梗死/合并部位洼田飲水試驗療效比較組別（例數(shù)）Group（No.）有效率

RateofEfficacy延髓梗死（22）MedullaOblongata（22）

95.86%中腦、腦橋等部位梗死（16）Midbrain,Pons（16）93.75%腦干合并基底節(jié)、皮層等部位梗死（26）BrainstemwithBasalGanglia,Cortex（26）88.46%2021/10/1043治療結果

ResultsofTreatment41of46本試驗本研究治療延髓梗死患者總有效率95.86%，64例患者治療后，吞咽功能及生活質量均得到顯著提高，提示本針法治療腦卒中后延髓麻痹吞咽障礙療效顯著。Thetotalefficacyrateoftreatingdysphagiaaftermedullaoblongatainfarctionwas95.86%,the64patientsshowedmarkedimprovementintheirswallowingabilityandqualityoflife,showingthatthisacupuncturemethodiseffectiveintreatingdysphagiacausedbypoststrokebulbarparalysis.2021/10/1044治療結果

ResultsofTreatment42of46

Thisstudyhasshownthattheefficacyrateforcombinedinfarctionwaslowest

withpoorprognosis

本療法對單純真球麻痹療效顯著真球麻痹并發(fā)其他多部位梗死的患者治療有效率相對較低。Ourtreatmentforpseudobulbarparalysisiseffective2021/10/1045數(shù)據(jù)分析DataAnalyze43of46吞咽困難復發(fā)率低，患者很少有舌肌震顫、舌肌萎縮癥狀。Raisingthedifficultlyofbuildingcollateralcirculation,thustheprognosiswasthepoorest.

有效改善腦卒中后吞咽障礙患者吞咽功能及血氧飽和度水平

Improvepoststrokedysphagiaand

bloodoxygensaturationlevels.

隨訪臨床研究2021/10/104644of46顯著改善中風性假性延髓麻痹患者的血循環(huán)、血流變學、腦血流圖和顱底動脈血流狀況，增加腦血流量，改善病損腦組織的血氧供應，促進中樞神經(jīng)功能的恢復實驗觀察

Thisacupuncturetherapycansignificantlyimprovebloodcirculation,bloodrheology,rheoencephalogram,hencepromotingcranialbloodsupply,therecoveryofcentralnervoussystem,thuspromotingtherecoveryofthiscondition.Therecoveryofthefunctionofneuraltissueisrelatedtothecranialbloodcirculation.laboratoryresearchDataAnalyze數(shù)據(jù)分析1999年第8期于《中國針灸》發(fā)表“針刺治療假性延髓麻痹325例臨床和機理研究”2021/10/1047結論Conclusion45of46“通關利竅”針刺法治療腦干梗死吞咽障礙療效明顯，可有效改善患者生活質量?！癟ongGuanLiQiao”acupuncturetreatmentfordysphagiaduetobrainstemstrokehasreceivedsatisfactoryresults,andcanimprovethepatient'squalityoflife.2021/10/1048機理研究緊扣中風病的治療難點及突破點，聚焦在神經(jīng)與血管的再生。研究針刺手段促進損傷后腦循環(huán)重建及神經(jīng)細胞再生的作用，從形態(tài)學、生物化學、中樞神經(jīng)機制、分子生物學等方面開展了二十余項基礎實驗。Definesthemechanismresearchandtreatmentofapoplexy,focusingonnerveandbreakthroughofbloodvessels.Researchmethodstopromotetheheadinjuryacupunctureandnervecellsregenerationcycle,fromthemorphology,biochemistry,molecularbiology,centralnervousmechanismformorethantwentyexperiments.針刺治療缺血性中風病的機理研究

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mechanismresearchofAcupuncturetreatmentischemicstroke2021/10/1049形態(tài)學研究，證明針刺可促進側枝循環(huán)建立Morphologyresearchthatacupuncturecanpromotecollateralcirculation梗塞半球腦表面缺血區(qū)Cerebralinfarctionhemispheresurfaceischemia阻斷大腦中動脈后，大腦表面缺血區(qū)所見：Blockaftermiddlecerebralarterysurfacearea,thebrainischemia缺血后自身代償情況After