咽部电刺激治疗脑卒中后吞咽障碍的Meta分析

doi:10.3969/j.issn.1006-9771.2020.11.006

摘要/Abstract

摘要：

目的综合评价咽部电刺激治疗脑卒中后吞咽障碍的疗效。方法计算机检索Cochrane Library、Embase、EBSCO、PubMed、Web of Science、中国生物医学文献数据库、维普信息资源系统、中国知网和万方医学数据库中咽部电刺激治疗脑卒中后吞咽障碍的随机对照试验(RCT),检索时限为建库到2020年6月,进行文献质量评价,采用RevMan 5.3 软件进行Meta分析。结果共纳入5项RCT研究,包括325例患者。咽部电刺激在吞咽障碍严重程度评定量表评分(SMD = -0.27, 95%CI -0.53~-0.01, P = 0.04)和拔管率(RR = 4.69, 95%CI 2.02~10.87,P < 0.001)方面有效,但在功能性经口摄食量表评分(SMD = 0.24,95%CI -0.32~0.79, P = 0.40)、渗漏-误吸量表评分(MD = -0.18, 95%CI -0.74~0.39, P = 0.54)和住院时间(SMD = -0.16, 95%CI -0.42~0.11, P = 0.25)方面与对照治疗无显著性差异。结论咽部电刺激能改善卒中后吞咽障碍患者的吞咽功能,提高鼻饲拔管率,但在经口摄食、减少误吸和住院时间方面尚需进一步研究。

关键词: 脑卒中, 吞咽障碍, 咽部电刺激, Meta分析

Abstract:

Objective To evaluate the effect of pharyngeal electrical stimulation (PES) on post-stroke dysphagia.Methods Randomized controlled trial (RCT) about pharyngeal electrical stimulation for dysphagia after stroke were searched in Coehrane Library, Embase, EBSCO, PubMed, Web of Science, CBM, VIP, CNKI and Wanfang Data until June, 2020. The literature quality was evaluated, and the data were analyzed with RevMan 5.3.Results Five RCTs were returned, including 325 patients. PES was more effective in improvement of Dysphagia Severity Rating Scale scores (SMD = -0.27, 95%CI -0.53 to -0.01, P = 0.04) and decannulation rate (RR = 4.69, 95%CI 2.02 to 10.87,P < 0.001); however, there was no significant difference in Functional Oral Intake Scale scores (SMD = 0.24, 95%CI -0.32 to 0.79, P = 0.40), Penetration-Aspiration Scale scores (MD = -0.18, 95%CI -0.74 to 0.39, P = 0.54) and length of stay (SMD = -0.16, 95%CI -0.42 to 0.11, P = 0.25) between PES and control.Conclusion Pharyngeal electrical stimulation can improve the swallowing function and enhance decannulation rate for post-stroke dysphagia, while it is uncertain for functional oral intake, risk of aspiration and length of stay.

Key words: stroke, dysphagia, pharyngeal electrical stimulation, meta analysis

中图分类号:

R743.3

肖荟芳,王冉冉,王德强. 咽部电刺激治疗脑卒中后吞咽障碍的Meta分析[J]. 《中国康复理论与实践》, 2020, 26(11): 1280-1286.

XIAO Hui-fang,WANG Ran-ran,WANG De-qiang. Pharyngeal Electrical Stimulation for Post-stroke Dysphagia: A Meta-analysis[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2020, 26(11): 1280-1286.

图/表 10

图1

表1

图2

图3

表2

图4

图5

图6

图7

图8

参考文献 23

[1]	Guyomard V, Fulcher R A, Redmayne O, et al. Effect of dysphasia and dysphagia on inpatient mortality and hospital length of stay: a database study[J]. J Am Geriatr Soc, 2009, 57(11):2101-2106. doi: 10.1111/jgs.2009.57.issue-11
[2]	Bonilha H S, Simpson A N, Ellis C, et al. The one-year attributable cost of post-stroke dysphagia[J]. Dysphagia, 2014, 29(5):545-552. doi: 10.1007/s00455-014-9543-8
[3]	王嘉楠, 徐铃琪, 项雨晴, 等. 无创性神经刺激技术治疗脑卒中后吞咽障碍的临床研究进展[J]. 临床神经外科杂志, 2018, 15(1):77-80.
	Wang J N, Xu L Q, Xiang Y Q, et al. Clinical research progress of non-invasive neurostimulation technique in the treatment of dysphagia after stroke[J]. J Clin Neurosurg, 2018, 15(1):77-80.
[4]	闫思念, 吴毅. 非侵入性脑刺激技术对脑卒中导致的吞咽障碍康复治疗研究进展[J]. 中国康复医学杂志, 2019, 34(11):1374-1377.
	Yan S N, Wu Y. Research progress of non-invasive brain stimulation technology in rehabilitation treatment of dysphagia caused by stroke[J]. Chin J Rehabil Med, 2019, 34(11):1374-1377.
[5]	Restivo D A, Hamdy S. Pharyngeal electrical stimulation device for the treatment of neurogenic dysphagia: technology update[J]. Med Devices (Auckl), 2018, 11:21-26.
[6]	Fraser C, Power M, Hamdy S, et al. Driving plasticity in human adult motor cortex is associated with improved motor function after brain injury[J]. Neuron, 2002, 34(5):831-840. pmid: 12062028
[7]	Jayasekeran V, Singh S, Tyrrell P, et al. Adjunctive functional pharyngeal electrical stimulation reverses swallowing disability after brain lesions[J]. Gastroenterology, 2010, 138(5):1737-1746. doi: 10.1053/j.gastro.2010.01.052 pmid: 20138037
[8]	中华神经科学会, 中华神经外科学会. 各类脑血管疾病诊断要点[J]. 中华神经科杂志, 1996, 29(6):379-380.
	Chinese Society of Neurology, Chinese Neurosurgical Society. Diagnosis of Cerebral Vascular Diseases[J]. Chin J Neurol, 1996, 29(6):379-380.
[9]	Higgins J P, Green S. Cochrane Handbook for Systematic Reviews of Interventions [DB/OL]. ( 2015- 04- 05). http://handbook.cochrane.org.
[10]	Bhogal S K, Teasell R W, Foley N C, et al. The PEDro scale provides a more comprehensive measure of methodological quality than the Jadad scale in stroke rehabilitation literature[J]. J Clin Epidemiol, 2005, 58(7):668-673. doi: 10.1016/j.jclinepi.2005.01.002
[11]	杨声坪, 闫先侠, 刘建强, 等. 随机对照试验质量评价标准的比较分析[J]. 循证医学, 2010, 10(6):369-373.
	Yang S P, Yan X X, Liu J Q, et al. Comparative analysis of quality evaluation standards of randomized controlled trials[J]. J Evidence-Based Med, 2010, 10(6):369-373.
[12]	Vasant D, Michou E, Tyrrell P, et al. OC-063 pharyngeal electrical stimulation (PES) in dysphagia post-acute stroke: a double- blind, randomised trial[J]. Gut, 2014, 63(1):A31. doi: 10.1136/gutjnl-2014-307263.5
[13]	Suntrup S, Marian T, Schröder J B, et al. Electrical pharyngeal stimulation for dysphagia treatment in tracheotomized stroke patients: a randomized controlled trial[J]. Intensive Care Med, 2015, 41(9):1629-1637. doi: 10.1007/s00134-015-3897-8 pmid: 26077087
[14]	Bath P M, Scutt P, Love J, et al. Pharyngeal electrical stimulation for treatment of dysphagia in subacute stroke: a randomized controlled trial[J]. Stroke, 2016, 47(6):1562-1570. doi: 10.1161/STROKEAHA.115.012455
[15]	Dziewas R, Stellato R, van der Tweel I, et al. Pharyngeal electrical stimulation for early decannulation in tracheotomised patients with neurogenic dysphagia after stroke (PHAST-TRAC): a prospective, single-blinded, randomised trial[J]. Lancet Neurol, 2018, 17(10):849-859. doi: S1474-4422(18)30255-2 pmid: 30170898
[16]	韩瑞. 脑卒中后吞咽障碍的研究进展[J]. 安徽医学, 2009, 30(12):1381-1386.
	Han R. Research progress of dysphagia after stroke[J]. Anhui Med J, 2009, 30(12):1381-1386.
[17]	Scutt P, Lee H S, Hamdy S, et al. Pharyngeal electrical stimulation for treatment of poststroke dysphagia: individual patient data meta-analysis of randomised controlled trials[J]. Stroke Res Treat, 2015, 2015:429053.
[18]	杨云梅. 老年吸入性肺炎的诊断与处理[J]. 中华危重症医学杂志(电子版), 2010, 3(3):150-158.
	Yang Y M. Diagnosis and treatment of aspiration pneumonia in the elderly[J]. Chin J Crit Care Med (Electronic Edition), 2010, 3(3):150-158.
[19]	宗敏茹, 庞灵, 郑兰娥, 等. 间歇性管饲结合吞咽训练对脑卒中吞咽障碍患者的影响[J]. 中华物理医学与康复杂志, 2017, 39(12):932-933.
	Zong M R, Pang L, Zheng L E, et al. The effect of intermittent tube feeding combined with swallowing training on stroke patients with dysphagia[J]. Chin J Phys Med Rehabil, 2017, 39(12):932-933.
[20]	Falsetti P, Acciai C, Palilla R, et al. Oropharyngeal dysphagia after stroke: incidence, diagnosis, and clinical predictors in patients admitted to a neurorehabilitation unit[J]. J Stroke Cerebrovasc Dis, 2009, 18(5):329-335. doi: 10.1016/j.jstrokecerebrovasdis.2009.01.009
[21]	Kim Y K, Lee S H, Lee J W. Effect of vallecular ballooning in stroke patients with dysphagia[J]. Ann Rehabil Med, 2017, 41(2):231-238. doi: 10.5535/arm.2017.41.2.231
[22]	Huang K L, Liu T Y, Huang Y C, et al. Functional outcome in acute stroke patients with oropharyngeal dysphagia after swallowing therapy[J]. J Stroke Cerebrovasc Dis, 2014, 23(10):2547-2553. doi: 10.1016/j.jstrokecerebrovasdis.2014.05.031
[23]	朱亚芳, 张晓梅, 肖瑞, 等. 经口摄食功能评估量表与洼田饮水试验应用于急性脑卒中患者中的信效度研究[J]. 中国全科医学, 2018, 21(3):318-321, 329.
	Zhu Y F, Zhang X M, Xiao R, et al. Reliability and validity of the FOIS versus water swallow test in patients with acute stroke[J]. Chin Gener Prac, 2018, 21(3):318-321, 329.

研究	国家					对照组				结局指标
研究	国家	n	男/女(n)	年龄 (岁)	干预措施	n	男/女(n)	年龄 (岁)	干预措施	结局指标
Jayasekeran等(2010)^[7]	英国	16	10/6	75±2.7	PES(5 Hz,14.4 mA,10 min)	12	9/3	74±2.3	假刺激	PAS,DSRS,住院时间
Bath等 (2016)^[14]	德国	87	48/39	74.0±9.9	PES(5 Hz,14.8 mA,10 min)+常规治疗	75	46/29	74.9±12.6	假刺激+常规治疗	DSRS,PAS,住院时间
Vasant等 (2014)^[12]	英国	18	11/7	71	PES(5 Hz,75%最大耐受强度,10 min)	18	10/8	71	假刺激	PAS,DSRS,住院时间
Suntrup等 (2015)^[13]	德国	20	9/11	63.0±14.5	PES(5 Hz,10 min)	10	6/4	66.7±14.5	假刺激	拔管率,住院时间
Dziewa等 (2018)^[15]	德国	35	24/11	61.7±13.0	PES(5 Hz,10 min)	34	20/14	66.8±10.3	假刺激(5 Hz,10 min)	拔管率,DSRS,FOIS

研究	条目1	条目2	条目3	条目4	条目5	条目6	条目7	条目8	条目9	条目10	条目11	总分	等级
Jayasekeran等(2010)^[7]	1	1	1	1	0	0	1	0	0	1	1	7	中
Bath等(2016)^[14]	1	1	0	1	1	1	1	0	1	1	1	9	高
Vasant等(2014)^[12]	1	1	1	0	1	1	1	0	1	1	1	9	高
Suntrup等(2015)^[13]	1	1	0	1	0	0	0	1	0	1	1	6	中
Dziewa等(2018)^[15]	1	1	0	1	0	0	1	1	0	1	1	7	中