脑干卒中导致吞咽障碍的临床特征及康复

doi:10.3969/j.issn.1006-9771.2023.04.012

摘要/Abstract

摘要：

目的探讨脑干卒中吞咽障碍患者的临床特征、康复治疗效果及影响因素。
方法回顾性分析2018年4月至2021年12月北京博爱医院收治的脑干卒中后吞咽障碍的患者。收集患者性别、年龄、病程、治疗时间等一般资料，吞咽造影咽期结果，治疗前后才藤荣一吞咽障碍7级评价法(DSS)评分、Fugl-Meyer评定量表(FMA)评分、FMA-平衡功能评分、美国国立卫生研究院卒中量表中文版(NIHSS)评分、Barthel指数(BI)、简易精神状态检查(MMSE)评分，以及出院时是否经口进食。根据吞咽造影结果分为非环咽肌失弛缓组(对照组)和环咽肌失弛缓组(观察组)。
结果共纳入患者60例，对照组29例，观察组31例。观察组FMA评分、FMA-平衡功能评分、BI、MMSE评分均明显高于对照组(|t| > 3.281, P < 0.01)，NIHSS评分显著低于非失迟缓组(t = 4.390, P < 0.001)。治疗前，观察组DSS评分显著低于对照组(t = 5.785, P < 0.001)；治疗后，两组均显著提高(|t| > 5.387, P < 0.001)；两组间比较无显著性差异(t = 1.675, P = 0.099)，但观察组治疗前后差值明显大于对照组(t = -2.729, P = 0.008)。两组经口进食率无显著性差异(χ² = 2.742, P = 0.098)。对照组内，经口进食与鼻饲进食患者间，FMA-平衡功能评分、NIHSS评分、BI指数、入院时吞咽障碍严重程度评分有显著性差异(|t| > 2.429, P < 0.05)；观察组内，经口进食与鼻饲进食患者间，各因素无显著性差异(P > 0.05)。对照组内入院时DSS评分为能否经口进食的影响因素(OR = 3.947, 95%CI 1.361~11.450, P = 0.012)，观察组内无独立影响因素。
结论脑干卒中导致吞咽障碍患者中，出现环咽肌失弛缓患者吞咽障碍程度重，伴随障碍轻。脑干卒中吞咽障碍患者康复治疗有效，环咽肌失弛缓患者治疗效果总体好于非环咽肌失弛缓患者。非环咽肌失弛缓患者吞咽障碍预后与入院时吞咽障碍严重程度相关，环咽肌失弛缓患者预后与各临床因素无关。

关键词: 脑卒中, 吞咽障碍, 康复, 影响因素

Abstract:

Objective To investigate the clinical characteristics of dysphagia after brainstem stroke, and rehabilitation effect and influencial factors for it.
Methods A retrospectively analysis was conducted in patients who were diagnosed as dysphagia after brainstem stroke in the Beijing Bo'ai Hospital from April, 2018 to December, 2021. The following data were collected: the general information (gender, age, course of disease, and time of treatment), the result of videofluoroscopic swallowing study (VFSS), the Dysphagia Severity Scale (DSS) score before and after treatment, the scores of Fugl-Meyer Assessment (FMA), FMA-Balance (FMA-B), National Institutes of Health Stroke Scale (NIHSS) and Barthel index (BI), Mini-Mental State Examination (MMSE), and whether oral feeding. Based on the result of VFSS, all patients were divided into non-cricopharyngeal achalasia group (control group) and cricopharyngeal achalasia group (observation group).
Results A total of 60 patients were collected, with 29 in the control group and 31 in the observation group. The scores of FMA, FMA-B, BI and MMSE were higher (|t| > 3.281, P < 0.01), and the NIHSS score was lower (t = 4.390, P < 0.001) in the observation group than in the control group. Before treatment, the score of DSS was significantly lower in the observation group than in the control group (t = 5.785, P < 0.001); after treatment, the scores improved in both groups (|t| > 5.387, P < 0.001), and no significant difference was found between two groups (t = 1.675, P = 0.099); however, the d-value was more in the observation group than in the control group (t = -2.729, P = 0.008). There was no significant difference in the rate of oral feeding (χ² = 2.742, P = 0.098). In the control group, there were differences in the scores of NIHSS, FMA-B, BI and DSS between patients with oral feeding and those with nasal feeding (|t| > 2.429, P < 0.05); however, no significant difference was found in all factors in the observation group (P > 0.05). The DSS score was the influence factor of oral feeding in the control group (OR = 3.947, 95%CI 1.361 to 11.450, P = 0.012), and no influencing factor was found in the observation group.
Conclusion Among the patients with dysphagia after brainstem stroke, less accompanying disorders and more severe dysphagia were found in those with cricopharyngeal achalasia. All patients improved in dysphagia after treatment, and the rehabilitation effect of cricopharyngeal achalasia was better. The score of DSS relates with oral feeding in non-cricopharyngeal achalasia patients, and there was no specific influencing factor in cricopharyngeal achalasia patients.

Key words: stroke, dysphagia, rehabilitation, influencing factor

中图分类号:

R743.3

高飞, 刘丽旭, 袁永学. 脑干卒中导致吞咽障碍的临床特征及康复[J]. 《中国康复理论与实践》, 2023, 29(4): 465-471.

GAO Fei, LIU Lixu, YUAN Yongxue. Clinical characteristics and rehabilitation of dysphagia after brainstem stroke[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2023, 29(4): 465-471.

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组别	n	性别(男/女)/n	年龄/岁	病程/d	治疗时间/d
对照组	29	22/7	61.86±14.01	68.66±63.67	52.21±28.58
观察组	31	25/6	55.23±10.99	43.23±43.67	46.94±25.10
t/χ²值		0.653	2.048	1.814	0.760
P值		0.758	0.045	0.075	0.450

组别	n	FMA评分	FMA-平衡功能评分	NIHSS评分	BI评分	MMSE评分
对照组	29	50.48±32.30	5.38±4.45	7.86±5.01	40.00±23.19	20.14±10.25
观察组	31	91.52±15.99	9.68±3.12	3.55±2.13	67.42±19.27	26.90±4.33
t值		-6.298	-4.352	4.390	-4.994	-3.281
P值		< 0.001	< 0.001	< 0.001	< 0.001	0.002

项目	经口	鼻饲	t/χ²值	P值
性别(男/女)/n	15/6	7/1	0.817	0.635
年龄/岁	60.00±14.42	66.75±12.41	-1.167	0.253
病程/d	59.57±54.80	92.50±82.11	-1.258	0.219
MMSE评分	23.14±7.20	12.25±13.19	2.210	0.050
FMA评分	57.05±28.40	33.25±37.41	1.848	0.076
FMA-平衡功能评分	6.52±4.24	2.38±3.70	2.432	0.022
NIHSS评分	6.14±2.52	12.38±7.09	-2.429	0.043
BI评分	46.43±21.34	23.13±19.99	2.671	0.013
入院时DSS评分	3.95±1.40	2.00±1.07	3.563	0.001
治疗时间/d	45.86±25.91	68.89±30.19	-2.045	0.051

项目	经口	鼻饲	t/χ²值	P值
性别(男/女)/n	11/5	14/1	2.998	0.172
年龄/岁	53.70±12.16	56.87±9.75	-0.800	0.430
病程/d	46.63±49.90	39.60±37.31	0.442	0.662
MMSE评分	26.94±4.28	27.07±4.46	0.050	0.961
FMA评分	88.70±21.74	94.53±4.81	-1.017	0.317
FMA-平衡功能评分	9.69±3.03	9.67±3.33	0.018	0.986
NIHSS评分	3.63±2.42	3.47±1.85	0.204	0.840
BI评分	69.70±15.76	65.00±22.76	0.670	0.508
入院时DSS评分	1.69±0.48	1.73±0.46	-0.272	0.787
治疗时间/d	55.06±25.86	38.27±21.85	1.947	0.061