正念认知疗法结合重复经颅磁刺激在脑卒中后吞咽障碍康复训练中的应用

关键词：正念认知疗法  重复经颅磁刺激  康复训练  脑卒中后吞咽障碍  吞咽功能

Keywords:mindfulness cognitive therapy  repetitive transcranial magnetic stimulation  rehabilitation training  post-stroke dysphagia  swallowing function

摘要：

      摘要 目的：观察正念认知疗法结合重复经颅磁刺激（repetitive transcranial magnetic stimulation， rTMS）在脑卒中后吞咽障碍康复训练中的临床疗效。 方法：根据纳入标准选取93例患者，随机分为正念行为组、重复经颅磁刺激组、联合组各31例，三组均给予基础的康复治疗，正念行为组给予正念行为训练，rTMS组给予重复经颅磁刺激治疗，联合组给予正念行为训练和重复经颅磁刺激治疗。治疗4周前后采用下颌舌骨肌最大运动诱发电位（motor evoked potential， MEP）潜伏期和波幅测量、吞咽造影检查（videofluoroscopic swallowing study， VFSS）、匹兹堡睡眠质量指数量表（Pittsburgh sleep quality index， PSQI）评分、抑郁自评量表（depression self-assessment scales， SDS）评分、正念注意知觉量表（masognathic attention perception scale， MAAS）评分及神经损伤指标变化，评估患者的吞咽功能。 结果：三组治疗后下颌舌骨肌MEP潜伏期均较治疗前降低，下颌舌骨肌MEP波幅均较治疗前升高（P＜0.05）；rTMS组和联合组治疗后下颌舌骨肌MEP潜伏期低于正念行为组，下颌舌骨肌MEP波幅高于正念行为组，但rTMS组和联合组组间比较，无显著性差异（P＞0.05）。三组治疗后VFSS评分较治疗前升高（P＜0.05）；联合组治疗后VFSS评分高于正念行为组和rTMS组，同时rTMS组VFSS评分高于正念行为组（P＜0.05）。三组治疗后PSQI评分SDS评分均较治疗前降低，MAAS评分较治疗前升高（P＜0.05）；rTMS组和联合组治疗后MAAS评分高于正念行为组，且联合组MAAS评分高于其余两组，同时rTMS组MAAS评分低于正念行为组（P＜0.05）；联合组PSQI评分SDS评分低于其余两组（P＜0.05）。三组治疗后神经损伤指标比较，视锥蛋白样蛋白1（VILIP-1）、神经特异性烯醇化酶（neural specific enolase， NSE）均较治疗前降低，且联合组VILIP-1、NSE低于其余两组，rTMS组VILIP-1、NSE低于正念行为组（P＜0.05）。 结论：正念认知疗法结合重复经颅磁刺激可改善脑卒中后患者吞咽功能，临床疗效显著。

Abstract:

      Abstract Objective： To observe the clinical efficacy of mindfulness cognitive therapy combined with repetitive transcranial magnetic stimulation （rTMS） in the rehabilitation training of post-stroke dysphagia. Method： Ninety-three patients were selected according to the inclusion criteria and randomly divided into 31 cases each in the mindfulness thinking behavior group， the repetitive transcranial magnetic stimulation group and the combined group. All three groups were given basic rehabilitation treatment， mindfulness thinking behavior training in the mindfulness thinking behavior group， repetitive transcranial magnetic stimulation treatment in the rTMS group， and mindfulness thinking behavior training and repetitive transcranial magnetic stimulation treatment in the combined group. Before and after 4 weeks of treatment， maximal motor evoked potential （MEP） latency and wave amplitude measurements of the mandibuloglossus muscle， videofluoroscopic swallowing angiography （VFSS）， Pittsburgh sleep quality index （PSQI） scores， depression self-assessment scales （SDS） scores， masognathic attention perception scale （MAAS） scores， and changes in neurological injury indexes were used to assess the swallowing function of the patients. Result： The MEP latency of the mandibuloglossus muscle was lower than that before treatment in all three groups， and the MEP amplitude of the mandibuloglossus muscle was higher than that before treatment （P＜0.05）. The rTMS group and the combined group had a lower MEP latency than that of the orthostatic behavior group， and the MEP amplitude of the mandibuloglossus muscle was higher than that of the orthostatic behavior group， but there was no difference when comparing the rTMS group and the combined group with each other （P＞0.05）. The VFSS scores of the three groups were higher after treatment than before treatment （P＜0.05）； the VFSS scores of the combined group were higher than those of the orthostatic behavior group and the rTMS group after treatment， while the VFSS scores of the rTMS group were higher than those of the orthostatic behavior group （P＜0.05）. PSQI scores SDS scores were lower and MAAS scores were higher than before treatment in all three groups （P＜0.05）； MAAS scores were higher than those in the mindfulness thoughts behavior group in the rTMS group and the combined group， and MAAS scores were higher than those in the remaining two groups in the combined group， while MAAS scores were lower than those in the mindfulness thoughts behavior group in the rTMS group （P＜0.05）； PSQI scores SDS score was lower than the remaining two groups （P＜0.05）. Comparison of nerve damage indexes after treatment in the three groups， visinin like protein l （VILIP-1） and neural specific enolase （NSE） were lower than before treatment， and VILIP-1 and NSE in the combined group were lower than the remaining two groups， while VILIP-1 and NSE in the rTMS group were lower than those in the orthomolecular behaviours group （P＜0.05）. Conclusion： Mindfulness cognitive therapy combined with repetitive transcranial magnetic stimulation improves swallowing function in post-stroke patients with significant clinical efficacy.