《康复训练对脑卒中后吞咽困难预后影响的研究.docx》由会员分享，可在线阅读，更多相关《康复训练对脑卒中后吞咽困难预后影响的研究.docx（10页珍藏版）》请在课桌文档上搜索。
1、康复训练对脑卒中后吞咽困难预后影响的探讨康复训练对脑卒中后吞咽困难预后影响的探讨【摘要】目的探讨脑梗死后吞咽困难患者采纳康役训练后时吞咽功能预后的影响。方法选择284例脑梗死患者，随机分为康役组和比照组，康便组采纳特定的康便治疗，比照组采纳一般常规治疗。结果两组患者第28天吞咽障碍分级比较显示，康彳复组患者吞咽功能的恢徨优于常规组。结论对脑梗死吞咽困难患者予以康彳复治疗后，可促进吞咽功能的重建与恢徨，从而提高生活质量。【关键词】脑梗死吞咽困难康彳复训练吞咽困难是脑梗死的重要并发症，其导致的吸入性肺炎、养分不良及脱水等可显着影响卒中患者的康复，增加脑卒中死亡率、致残率。因此，对患者的早期干预治疗
2、非常重要。为探讨脑卒中吞咽困难的治疗方法，我们对脑梗死后吞咽困难患者进行了以吞咽功能训练为主的早期康便训I练，井与常规治疗进行随机比照探讨，以了解康复训练对吞咽功能预后的影响。1资料与方法1.1探讨对象选择2005年1月至2006年5月在南充市中心医院神经内科住院治疗的脑梗死患者，其中男性134例，女性150例，年龄在42-82岁，平均63.57.18岁。病例入选标准:(I)全部病例均符合1995年第四届全国脑血管学术会议制订的诊断标准1,并经头颅CT证明或MRIo(2)均为首次发病，且在发病后24小时内入院。(3)无严峻意识障碍、无感觉性失语，能协作康复护理。284例患者随机分为康彳复组和比
3、照组，每组142例。两组患者年龄、性别比较差异无显着性意义(Pgt;0.05),具有可比性。1.2训练方法两组患者均接受基本相同的神经内科常规药物治疗。康厘组在入院后即起先系统的吞咽功能康t训练。1.2 .1吞咽功能训练(1)吸吮训练：病人示指戴上胶套放于口中，仿照吸吮动作。(2)喉接高训练：病人把手指置于训练者的甲状软骨的上缘。在训练者吞咽时，感觉它的向上运动，然后让病人照镜子将自己的手指置于甲状软骨上仿照动作，当病人驾驭了吸吮和喉捶高后，指导病人在吸吮后马上喉接高，使这两个动作协调一样，产生吞咽动作。(3)咽部冷刺激与空吞咽：用冰冻的棉棒蘸少许水，轻轻刺激软颗、舌根及咽后壁，然后嘱病人做吞
4、咽动作。(4)乔运动训练：让患者将舌伸出，然后做左右运动摆向口角，要素饮食含有自然食物中的各种要素成分，无需消化液的消化可供应高热量及高氨基酸。适当进食水果，预防便秘。注意视察大便的颜色、性状，治疗消化道出血。1.3 评价方法吞咽障碍评定：全部病人在入院第1天，第28天进行乔咽障碍分级。评判标准参照洼田饮水试验2：让患者按习惯喝下30m1.温水，依据饮水结果进行分级。I级：能不呛地一次喝下30m1.温水。H级：分两次饮下，能不呛地饮下。HI级：能一次饮下，但有呛咳。Iv级：分两次以上饮下，有呛咳。V级：屡屡呛咳，难以全部咽下。1.4 统计学处理运用SPSS12.0forWindows统计软件,
5、采纳秩和检验，检验水准a=0.052结果两组患者第28天吞咽障碍分级的比较，结果显示双侧检验P=O.03411;0.05,差异有显着意义，即康徨组患者吞咽功能的恢彳复明显优于比照组，见表Io表1两组脑梗死后乔咽困难效果比较（略）3探讨吞咽困难是急性脑梗死后常见的并发福，有报道57%73%的卒中患者发生吞咽困难3。目前正常吞咽的神经解剖机制已比较清晰，整个吞咽过程受大脑皮层、皮质延髓束、脑干神经核、第V、W、IX、X、Xh刈对颅神经及I、II、In对靖神经限制，须要口腔、咽部、食管的协调作用完成。正常吞咽过程分为口腔期、咽喉期和食管期，它们分别为随意运动、反射运动和蠕动运动。脑梗死后吞咽困难常发
6、生在口腔期和咽喉期，主要由球麻痹或假性球麻痹引起。了解受损部位和临床祗状，有助于确定患者进食的措施，制定有效的康彳电护理方案。始终以来，在脑卒中残损中探讨最多的是偏瘫的运动康徨，急性脑梗死患者早期存在的吞咽障碍问题未得到足够重视，0前多数学者主见脑梗死后吞咽困难应早其评估和早期治疗:有探讨5表明，脑卒中后恢彳复速率在病后3个月内，特殊是最初4周内最快。早期康彳复训练可最大限度地促进功能恢彳复，对减轻残疾有着重要的作用。在主动进行药物治疗的同时.，我们应及早对病人进行康彳复训练。对脑梗死后吞咽困难通过舌肌及吞咽肌群的运动训练，协调舌肌及吞咽肌群的运动，可以改善吞咽困难痛状。在康训练过程中，对患者
7、吞咽障碍程度进行细致评估，按不同程度制定不同的训练安排。实行专业人员与病人面对面的形式，向病人说明家属驾驭康彳复训练方法，如食团配制、进食方法以及防止误吸入气管的措施。同时注意病人及家属的思想工作，以最大地耐性帮助病人减轻悲观悲观、恐惊焦虑等不良心情的影响，使病人树立信念。我们的探讨显示，对脑梗死后吞咽困难的病人，通过进行早期主动的康彳电训练，能明显改善和促进吞咽功能的重建与恢彳电。脑梗死后吞咽困难的康夜是一系列整体治疗模式，包括吞咽功能的评价、吞咽肌群的训练、正确的姿态、进食种类和时间、物理治疗、心理康彳复等。早期康彳复训练对于促进其功能恢彳如缩短治疗期有着不行忽视的作用。参考文献1中华神经
8、科学会.各类脑血管病诊断要点J.中华神经科杂志，1996,29(6)：379-380.2宿英英.神经系统急危重藏监护与治疗M.北京：人民卫生出版社，2005.548550.3HanTR,PaikNJ,ParkJW,Quantifyingswa1.1.owingfunctionafterstroke:Afunctiona1.dysphagiasca1.ebasedonVideof1.uoroscopicstudies,rchPhysMedRehabi1.,2001,82:677-682.4Ke1.1.yJH,Buchho1.zD.Nutritiona1.managementofthepatien
9、twithaneuro1.ogica1.J.ENT,1996,75(5):293-300.5高丽萍，霍春暖，张雅静，等.早期康彳史训练对急性脑梗死患者功能恢彳复的影响J.中华护理杂志，1999,34(7)：393.Post-strokerehabi1.itationprognosisofdysphagiaAbstractObjectiveToinvestigatethecerebra1.infarctionpatientswithdysphagiaafterswa1.1.owingrehabiIitationprognosis.Methods284patientswithcerebra1.in
10、farctionwererandom1.ydividedintorehabi1.itationgroupandcontro1.group,therehabi1itationgroupwithaspecificrehabi1.itationtreatment,contro1.groupGenera1.routinetreatment.ReSU1.tSAfter28daysinpatientswithdysphagiagradecomparisonshowsthattherehabi1.itationgroupthantherecoveryofswa1.1.owingfunctioninpatie
11、ntswithnorma1group.Conc1.usionofdysphagiainpatientswithcerebra1.infarctionaftertreatmenttorehabiIi1.ation,canpromotethereconstructionandrehabi1.itationofswa1.1.owingfunctiontoimprovethequa1.ityof1ife.Keywords:cerebra1.infarctiondysphagiarehabi1.itationDysphagiaisanimportantcomp1.icationofcerebra1.in
12、farction,which1.edtoaspirationpneumonia,ma1.nutrition,anddehydrationcansignificant1.yinf1.uencetherehabi1.itationofstrokepatients,increasedstrokemorta1.ity,morbidity.Therefore,thetreatmentofpatientswithear1.yinterventionisimportant.Toinvestigatethetreatmentofstrokedysphagia,difficu1.tyswa1owingourpa
13、tientsaftercerebra1.infarctionweredominatedbyear1.yswa1.1.owingrehabi1.itationtraining,andwiththeconventiona1.treatmentrandomizedcontro1.studytounderstandtherehabi1.itationtrainingontheprognosisofswa1.1.owingfunctionimpact.1Materia1.sandMethods1.1TheobjectofstudyoptionsfromJanuary2005toMay2006inNanc
14、hongCentra1.Hospita1.,DepartmentofNeuro1.ogy,hospita1.izedpatientswithcerebra1.infarction,134patientswerema1.e,fema1.e150cases,aged42to82years,mean63.5+-7.18years.Caseinc1.usioncriteria:(1of1995ina1.1.casestheFourthNationa1.Conferenceondeve1.opmentofcerebra1.vascu1.ardiagnosticcriteria1andconfirmedb
15、ybrainCTorMRI.(2arethefirstonset,andwithin24hoursaftertheonsetofadmission.(3withoutseriousdisturbanceofconsciousness,nosensoryaphasia,in1.inewithrehabi1itationnursing.284patientsweredividedintorehabi1.itationgroupandcontro1.group,142patientsineachgroup,thetwogroupswereage,genderdifferencewasnotsigni
16、ficant(Pgt：0.05,comparab1.e.1.2TrainingMethodsA1.1.patientsreceivedthesamebasicneuro1.ogyconventiona1.drugtreatment.Rchabi1.itationgroupstartedinhospitaiafterswa1.1.owingrehabi1.itationtrainingsystem.1.2.1swa1.1.owingtraining(1suckingTraining:Putindexfingerpouchesofpatientsp1.acedinthemouth,imitatin
17、gsucking.(21.aryngea1.e1.evationtraining:patienttrainerp1.acedhisfingersontheedgeofthethyroidcarti1.age.Thetrainerswa1.1.owing,thefee1.ingthatit#39;supwardmovement,then1.etthepatient1.ookinthemirrortoputmyfingerontheimitationofactionthyroidcarti1.age,whenmasteredsuckingandthroatpatients,aftere1.evat
18、iontoguidethepatientimmediate1.yaftersuckingthroate1.evation,sothatthetwoconcertedaction,resu1.tinginswa1.1.owing.(3pharyngea1.stimu1.ationandco1.dairswa1.1.owing:Acottonswabdippedina1.itt1.efrozenwater,gent1.ystimu1.atingthesoftpa1.ate,tonguebaseandposteriorpharyngea1.wa11,andtheninstructpatienttos
19、wa1.1.ow.(4swa1.1.owingmovementtrainingtoenab1.epatientstothetongueout,andthenputtothemouthmovementtodoso,andthenturn1.ickingtongue1ickingtheupper1.ipafter1ip,tongueupthefina1.pushhardpa1.ate,tongue,suchaspatientscannotexercise,massagewithaspatu1.aorspoontongue,tobindupourwoundswithgauzeortonguegen1
20、1yupanddownaroundextraora1.bemovement.1.2.2conducivetoeatingfeedingpositiontotakethetraining,ha1.fsupinepositioncommon1yused(30degreestrunke1.evation,headf1.exion,andsitting.Graspanamount,genera1.1.yfrom34m】，andthenincreasedto15asappropriate20m1.,givensufficienttimeforchewingandswa11owing,sothata1.1
21、thefoodingested.AccordingtothePatient#39:Scondition,foodfrom1.iquid,semi-1.iquid,andgradua1.1.ytransitiontoanorma1.diet,strengthentheideaoftraining,andguidepatientsandthenmemorizingfeeding,chewing,swa1.1.owingaseriesswa1.1.ow,andpromotethereconstructionofmotorconductionpathway.1.2.3Thepsycho1.ogica1
22、.rehabiitationandpsycho1.ogica1.rehabiiIationisc1.ose1.yre1.atedtoneuro1.ogica1.rehabi1.itation,therehabi1itationofcerebra1.vascu1.ardiseasep1.aysanimportantro1.eintheprocess.Mainmeasuresare:(1)wardmedica1.staffandmorein-depth,mu1.ti-greetings,warmconversationswithfami1.ymembers,inatime1.ymannerfind
23、theprob1.em.(2differentstagesofdiseasedeve1.opmentinaccordancetothepatientsandtheirfami1.iesthatthecurrentconditionandthepatientshou1dtaketheinitiativeinthematter.(3intheacutephaseorrecoveryphaseofdisease,sopatientsshou1.dbeprompt1.yestab1.ishedtheconfidencetoovercomethedisease,theestab1.ishmentofth
24、epatienttrustofmedica1.staff.1.imitsa1.tintakeCateringManagement1.2.4.Foodshou1.dta1.k,1.essgreasy.Swa1.1.owinggrademaybegiventotheordinarydietdiet1.iquiddietore1.ements.E1.ementsofdietscontainingthevariouse1.ementsofnatura1.foodingredients,nodigestionthedigestionso1.utioncansupp1.yhigh-ca1.orieandh
25、ighaminoacids,appropriatefruit,topreventconstipation,toobservethestoo1.co1.or,character,treatmentofgastrointestina1.b1.eeding.1.3Eva1.uationofdysphagiaassessment:a1.1patients1dayafteradmission,28daysdysphagiagrade.Judgeinthe1.ightofKubotadrinkingwatertest2:Ihepatientiscustomarytodrink30m1.warmwater,
26、theresu1.tsweregradedaccordingtodrinkingwater.1.eve1.:onecannotchoketodrink30111.warmwater,1.eve1.:atwo-drink,cannotchoketodrink,grade:Canadrink,butchoking.eve1:morethantwicedrink,choking,1.eve1.:oftencough,difficu1.ttoswa1.1.owwho1.e.1.4Statistica1.ana1.ysisusingSPSS12.0forWindowsstatistica1.softwa
27、re,usingranksumtest,test1.eve1.a=0.05.2Resu1.tsTwogroupsofpatientsgradeddysphagia28daysafterthecomparison,theresu1.tsshowtwo-sidedtestP=0.034It:0.05,significan1.difference,name1ytherehabi1itationgrouptherecoveryofswa1.1.owingfunctionofpatientsthanthecontro1.group,inTab1.e1.ThetwogroupsTab1.e1Compari
28、sonofdysphagiafo1.1.owingcerebra1.infarction(s1.ight1.y3DiscussionDysphagiaisacommoncomp1.icationafteracutecerebra1.infarctionhasbeenreported57%to73%ofstrokepaticntswithdysphagia3.Atpresentthenorma1.swa1.1.owingmechanismistheneura1.anatomymorec1.ear1.y,theswa1.1.owingprocessisaffectedbythecerebra1.c
29、ortex,Corticobu1.bartractbrainstemnuc1.eus,thefirst,crania1.nerveand,ofspina1.nervescontro1.,youneedtomouth,pharynx,esophaguscomp1.etionofthecoordinatingro1.e,thenorma1swa1.1.owingprocessisdividedintoora1.phase,throatandesophagusoftheperiod,theywerevo1.untarymovement,ref1.exmovementsandperista1.ticm
30、ovement.dysphagiaoftenoccursfo1.1.owingcerebra1.infarctionintheora1.cavityandthroatoftheperiod,main1.ypa1.syorpseudobu1.barpa1.sycaused,tounderstandthesiteofinjuryandc1.inica1.symptoms,he1.ptoidentifypatientswitheatingmeasures,thedeve1.opmentofeffectiverehabi1.itationcareprograms,hasbeenmoststudiedi
31、nthestrokedamagedthemovemcntistherehabi1itationofhemip1.egia,acutecerebra1.infarctionpatientswithear1.ydysphagiaexistingprob1.emshavenotbeenenoughattentionAtpresent,mostscho1.arsadvocatedysphagiafo1.1.owingcerebra1.infarctionshou1dbetreatedasear1.yastheassessmentandear1.y.Somestudies5showedthatthere
32、coveryrateinpatientsafterstrokewithin3monthsafter,especia1.1.ythefirst4weeksofthefastest,ear1.yrehabi1.itationtrainingcanbemaximizethepromotionoffunctiona1.recovery,andhasanimportantro1.einreducingdisabi1.ity.Inactivedrugtreatment,wcshou1.dtrytorehabi1.itationtrainingforpatients,dysphagiaaftercerebr
33、a1.infarctionandswa1.1.owinggeniOg1.ossusmusc1.ethroughexercisetraining,coordinationgeniog1.ossusmusc1.emovementandswa1.1.owing,dysphagiacanbeimproved.Inthecourseofrehabi1itationtraining,thedegreeofdysphagiainpatientswithcarefu1.1.yassessed,indifferentdegreesfordifferenttrainingprograms,taketheformo
34、ffacetofacewithprofessiona1.sandpatients,topatientsthatfami1.iescontro1.rehabi1itationmethods,suchaspreparationoffoodgroups,eatingmethods,andmeasurestopreventaccidenta1.inha1.ationofIhetrachea.A1.sonotethattheideo1.ogica1.workofpatientsandtheirfami1.ieswiththegreatestpatienceandhe1.ppatientsreduceth
35、edespair,fear,anxietyandothernegativeemotions,makingthepatientconfidence.Ourresearchshowsthatpatientswithdysphagiaaftercerebra1.infarctionbyear1.yactiverehabi1.itationcansignificant1.yimproveandpromotethereconstructionandrehabi1.itationofswa1.1.owingfunction.Therehabi1.itationofdysphagiaaftercerebra
36、1.infarctionisaseriesofovcra1.1treatmentmoda1.ities,inc1.udingtheeva1.uationofswa1.1.owingfunction,swa1.1.owingmusc1.etraining,properposture,typeandtimeofeating,physica1.therapy,psycho1.ogica1.rehabi1.itation.Ear1.yrehabi1.itationtrainingforthepromotionofthefunctiona1.recoveryandshortenthetreatmentp
37、eriodwou1.dhaveaneg1.igib1.eeffect.References1,ChineseJourna1.ofScience.Varioustypesofcerebrovascu1.ardiseasediagnosticcriteriaJ.Neuro1.ogy,1996,29(6:379380.2SuYingYing.Nervoussystem,IntensiveCareandtreatmentofM.Beijing:PCoPie#39;SMedica1.Pub1.ishingHouse,2005.548550.3HanTR,PaikNJ,ParkJW,Quantifying
38、swa1.1.owingfunctionafterstroke:Afunctiona1.dysphagiasca1.ebasedonVideof1.uoroscopicstudies,rchPhysMedRehabi1.,2001,82:677、682.4Ke1.1.yJH,Buchho1.zD.Nutritiona1.managementofthepatientwithaneuro1.ogica1.J.ENT,1996,75(5):293300.5Gao1.iping,Huoarriva1.ofspring,APi1.otandsoon.Ear1.yrehabi1.itationtrainingonfunctiona1.recoveryinpatientswithacutecerebra1.infarctionaffectJ.Journa1.ofNursing,1999,34(7:393.
