复合电磁刺激联合下颌抗阻训练对卒中后吞咽障碍的效果

doi:10.3969/j.issn.1006-9771.2025.06.013

《中国康复理论与实践》 ›› 2025, Vol. 31 ›› Issue (6): 721-728.doi: 10.3969/j.issn.1006-9771.2025.06.013

复合电磁刺激联合下颌抗阻训练对卒中后吞咽障碍的效果

付国军¹, 余秀芳¹, 吕鑫¹, 吉璐¹, 刘华庆²()

1.宜宾市第一人民医院康复科，四川宜宾市 644000
2.重庆医科大学附属第三医院康复医学科，重庆市 401120

收稿日期:2024-12-24 修回日期:2025-05-15 出版日期:2025-06-25 发布日期:2025-06-16
通讯作者: 刘华庆(1989-)，女，汉族，重庆市人，主管护师，主要研究方向：神经康复护理。E-mail： 598969694@qq.com E-mail:598969694@qq.com
作者简介:付国军(1987-)，女，汉族，四川宜宾市人，主治医师，主要研究方向：吞咽障碍康复。
基金资助:
宜宾市科技局中医药研究课题(2023ZYY003)

Effect of composite electromagnetic stimulation combined with chin tuck against resistance on post-stroke patients with dysphagia

FU Guojun¹, YU Xiufang¹, LÜ Xin¹, JI Lu¹, LIU Huaqing²()

1. Department of Rehabilitation, the First Peoples' Hospital of Yibin, Yibin, Sichuan 644000, China
2. Department of Rehabilitation, the Affiliated Third Hospital of Chongqing Medical University, Chongqing 401120, China

Received:2024-12-24 Revised:2025-05-15 Published:2025-06-25 Online:2025-06-16
Contact: E-mail: 598969694@qq.com E-mail:598969694@qq.com
Supported by:
Traditional Chinese Medicine Research Project of Yibin Science and Technology Bureau(2023ZYY003)

摘要/Abstract

摘要：

目的探讨复合电刺激联合下颌抗阻训练(CTAR)对卒中后吞咽障碍的临床效果。

方法 2021年1月至2023年12月，宜宾市第一人民医院卒中后咽期吞咽障碍患者156例，随机分为CTAR组(n = 51)、神经肌肉电刺激(NMES)+重复经颅刺激(rTMS)组(n = 52)和联合组(n = 53)，在常规吞咽功能训练基础上分别给予CTAR、NMES+rTMS和NMES+rTMS+CTAR，共4周。比较治疗前后3组功能性经口摄食量表(FOIS)、标准吞咽功能量表(SSA)和吞咽困难生活质量量表(SWAL-QOL)评分、渗漏-误吸分级(PAS)评分、电视荧光吞咽造影检查(VFSS)(包括VFSS评分、咽运送时间、舌骨向上和向前位移)、颏下肌群和舌骨肌群平均肌电值(AMEG)。

结果 SSA、SWAL-QOL和两肌群AMEG的组内效应、组间效应和交互效应均显著(F > 6.611, P < 0.001)，FOIS、VFSS、咽运送时间、舌骨向上位移和舌骨向前位移的组内效应和交互效应显著(F > 3.451, P < 0.05)。事后检验显示，联合组咽运送时间短于NMES+rTMS组(P = 0.048)，舌骨向前位移明显高于CTAR组(P = 0.002)，AMEG显著高于CTAR组和NMES+rTMS组(P < 0.001)。治疗后3组PAS分级有显著性差异(H_c = 8.282, P = 0.016)，联合组最优。

结论 NMES+rTMS联合CTAR治疗卒中后吞咽障碍优于单一电磁刺激或CTAR。

关键词: 脑卒中, 吞咽障碍, 神经肌肉电刺激, 重复经颅刺激, 下颌抗阻训练

Abstract:

Objective To explore the effect of composite electromagnetic stimulation combined with chin tuck against resistance (CTAR) on post-stroke dysphagia.

Methods From January, 2021 to December, 2023, 156 post-stroke patients with pharyngeal dysphagia in the First People's Hospital of Yibin were randomly divided into CTAR group (n = 51), neuromuscular electrical stimulation (NMES)+repetitive transcranial magnetic stimulation (rTMS) group (n= 52) and combination group (n = 53). On the basis of routine swallowing function training, they received CTAR, NMES+rTMS and NMES+rTMS+CTAR, respectively, for four weeks. They were assessed with Functional Oral Intake Scale (FOIS), Standardized Swallowing Assessment (SSA), Swallowing-Quality of Life (SWAL-QOL), Rosenbek Penetration Aspiration Scale (PAS), video fluoroscopic swallowing study (VFSS) (including the score of VFSS, pharyngeal transit time, and upward and forward displacement of hyoid bone), average surface electromyography (AMEG) of submental and hyoid muscles, before and after treatment.

Results The inter-group effect, intra-group effect and interaction effect were significant in SSA, SWAL-QOL and AMEG of the two muscles (F > 6.611, P < 0.001). The inter-group effect and interaction effect were significant in FOIS, VFSS, pharyngeal transit time, upward displacement of hyoid bone and forward displacement of hyoid bone (F > 3.451, P < 0.05). Pairwise comparison results showed that pharyngeal transit time was shorter in the combination group than in NMES+rTMS group (P = 0.048), forward displacement of hyoid bone was more in the combination group than in CTAR group (P = 0.002), and AMEG was higher in the combination group than in CTAR group and NMES+rTMS group (P < 0.001). There was significant difference in the score of PAS among three groups (H_c = 8.282, P= 0.016), and it was the best in the combination group.

Conclusion The combination of NMES+rTMS and CTAR is superior to single electromagnetic stimulation or CTAR in the treatment of post-stroke sysphagia.

Key words: stroke, dysphagia, neuromuscular electrical stimulation, repetitive transcranial magnetic stimulation, chin tuck against resistance

中图分类号:

R743.3

付国军, 余秀芳, 吕鑫, 吉璐, 刘华庆. 复合电磁刺激联合下颌抗阻训练对卒中后吞咽障碍的效果[J]. 《中国康复理论与实践》, 2025, 31(6): 721-728.

FU Guojun, YU Xiufang, LÜ Xin, JI Lu, LIU Huaqing. Effect of composite electromagnetic stimulation combined with chin tuck against resistance on post-stroke patients with dysphagia[J]. Chinese Journal of Rehabilitation Theory and Practice, 2025, 31(6): 721-728.

图/表 5

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组别	n	性别(男/女)/n	年龄/岁	病程/月	吞咽功能分级(Ⅲ/Ⅳ/Ⅴ级)/n
CTAR组	51	30/21	66.33±7.83	2.06±0.56	21/17/13
NMES+rTMS组	52	28/24	66.98±7.66	1.99±0.56	26/15/11
联合组	53	28/25	65.51±7.82	2.02±0.46	30/14/9
F/χ²值		0.429	0.473	0.231	2.582
P值		0.807	0.624	0.794	0.630

观察指标	组别	治疗前		治疗后
观察指标	组别	均值	标准差	均值	标准差
FOIS	CTAR组	33.45	5.80	28.14	4.55
	NMES+rTMS组	32.79	5.00	28.23	4.23
	联合组	33.75	5.67	25.85	4.40
SSA	CTAR组	3.08	1.15	4.41	1.08
	NMES+rTMS组	3.25	1.12	4.40	1.09
	联合组	3.15	1.08	5.06	1.01
SWAL-QOL	CTAR组	105.63	15.44	113.51	16.12
	NMES+rTMS组	107.17	18.75	114.27	17.93
	联合组	105.11	17.65	122.08	18.20
VFSS	CTAR组	3.69	1.24	5.27	1.18
	NMES+rTMS组	3.58	1.47	5.37	1.22
	联合组	3.66	1.44	6.00	1.16
咽运送时间/s	CTAR组	3.30	0.84	1.80	0.57
	NMES+rTMS组	3.38	0.92	1.75	0.54
	联合组	3.31	0.91	1.35	0.45
舌骨向上位移/cm	CTAR组	1.11	0.17	1.51	0.16
	NMES+rTMS组	1.17	0.28	1.59	0.27
	联合组	1.17	0.24	1.71	0.22
舌骨向前位移/cm	CTAR组	0.91	0.28	1.22	0.27
	NMES+rTMS组	0.97	0.25	1.26	0.28
	联合组	0.89	0.23	1.44	0.27
颏下肌群AMEG/μV	CTAR组	3.69	1.24	5.27	1.18
	NMES+rTMS组	3.58	1.47	5.37	1.22
	联合组	3.66	1.44	6.00	1.16
舌骨肌群AMEG/μV	CTAR组	3.79	1.40	5.39	1.29
	NMES+rTMS组	3.64	1.33	5.44	1.32
	联合组	3.67	1.42	6.07	1.24

观察指标		平方和	自由度	均方	F值	P值
FOIS	组内	167.200	1	167.200	488.987	< 0.001
	组间	52.315	153	0.342	0.462	0.741
	组内×组间	8.104	2	4.052	11.851	< 0.001
SSA	组内	2738.204	1	2738.204	451.368	< 0.001
	组间	928.168	153	6.066	6.611	< 0.001
	组内×组间	162.073	2	81.036	13.358	< 0.001
SWAL-QOL	组内	8839.644	1	8839.644	1175.172	< 0.001
	组间	1150.869	153	7.522	7.283	< 0.001
	组内×组间	1579.349	2	789.675	104.982	< 0.001
VFSS	组内	283.125	1	283.125	632.784	< 0.001
	组间	68.456	153	0.447	0.552	0.619
	组内×组间	7.915	2	3.958	8.845	< 0.001
咽运送时间	组内	224.922	1	224.922	450.070	< 0.001
	组间	76.462	153	0.500	0.571	0.637
	组内×组间	2.968	2	1.484	3.451	0.032
舌骨向上位移	组内	11.499	1	11.499	553.709	< 0.001
	组间	3.117	153	0.021	0.038	0.978
	组内×组间	1.051	2	0.526	25.304	< 0.001
舌骨向前位移	组内	16.222	1	16.222	771.908	<0.001
	组间	3.215	153	0.021	0.041	0.962
	组内×组间	0.297	2	0.148	7.059	0.001
颏下肌群AMEG	组内	1557454.790	1	1557454.790	1363.619	< 0.001
	组间	174748.642	153	1142.148	1078.892	< 0.001
	组内×组间	45649.087	2	22824.543	19.984	< 0.001
舌骨肌群AMEG	组内	1782893.626	1	1782893.626	1372.091	< 0.001
	组间	207311.947	153	1354.980	1102.778	< 0.001
	组内×组间	61292.772	2	30646.386	29.096	< 0.001

观察指标	组别	组别	平均差值	P值	95% CI
观察指标	组别	组别	平均差值	P值	上限	下限
FOIS	联合组	CTAR组	-0.359	0.127	0.082	-0.799
FOIS	联合组	NMES+rTMS组	-0.277	0.273	0.162	-0.715
SSA	联合组	CTAR组	0.992	0.451	3.035	-1.051
SSA	联合组	NMES+rTMS组	0.708	0.655	2.741	-1.325
SWAL-QOL	联合组	CTAR组	-4.026	0.389	3.550	-11.601
SWAL-QOL	联合组	NMES+rTMS组	-2.873	0.604	4.665	-10.411
VFSS	联合组	CTAR组	-0.350	0.241	0.178	-0.877
VFSS	联合组	NMES+rTMS组	-0.359	0.222	0.166	-0.884
咽运送时间	联合组	CTAR组	0.217	0.069	0.448	-0.014
咽运送时间	联合组	NMES+rTMS组	0.231	0.048	0.461	0.001
舌骨向上位移	联合组	CTAR组	-0.102	0.064	0.005	-0.208
舌骨向上位移	联合组	NMES+rTMS组	-0.051	0.455	0.055	-0.157
舌骨向前位移	联合组	CTAR组	-0.131	0.002	-0.042	-0.220
舌骨向前位移	联合组	NMES+rTMS组	-0.061	0.223	0.028	-0.149
颏下肌群AMEG	联合组	CTAR组	-0.727	< 0.001	-0.441	-1.006
颏下肌群AMEG	联合组	NMES+rTMS组	-0.633	< 0.001	-0.408	-0.978
舌骨肌群AMEG	联合组	CTAR组	-0.718	< 0.001	-0.456	-0.992
舌骨肌群AMEG	联合组	NMES+rTMS组	-0.631	< 0.001	-0.392	-0.963

复合电磁刺激联合下颌抗阻训练对卒中后吞咽障碍的效果

Effect of composite electromagnetic stimulation combined with chin tuck against resistance on post-stroke patients with dysphagia

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时间点	PAS分级	CTAR组(n = 51)	NMES+rTMS组(n = 52)	联合组(n = 53)	H_c值	P值
治疗前	正常	13	9	9	0.414	0.813
	渗漏	23	32	29
	误吸	15	11	15
治疗后	正常	20	18	32	8.282	0.016
	渗漏	28	31	20
	误吸	3	3	1

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