不同模式经颅磁刺激在脑卒中后吞咽障碍的康复研究进展

Advance in Different Modes of Transcranial Magnetic Stimulation in Rehabilitation of Dysphagia after Stroke

吞咽障碍是脑卒中后最常见的功能障碍之一,其发生率可达30%~50%,并引起营养不良、误吸性肺炎等并发症,严重者可危及生命。脑卒中后吞咽障碍的发生涉及多个脑功能区和神经网络,一般认为,脑卒中后吞咽障碍与大脑皮层、皮层下结构以及脑干吞咽中枢相关病损有关,不同病损部位导致吞咽障碍的机制和临床表现存在明显差异。对其发生机制的了解有助于临床上制定更为针对性、个体化的康复治疗手段,这对于患者的预后有着重要的影响。除了目前临床上常用的吞咽运动感觉训练、外周神经肌肉电刺激、针灸、姿势训练、饮食调整等传统吞咽治疗方案,考虑到神经修复机制可能参与恢复过程,近年来人们对中枢神经调控治疗吞咽功能障碍的研究越来越感兴趣。经颅磁刺激作为一种无创性神经调控技术,利用变化的磁场产生感应电场,改变大脑皮质神经细胞的动作电位,即通过调节大脑皮层兴奋性达到神经调控的目的。随着研究的深入,不同的脉冲刺激模式逐渐被开发并被实验性地应用于脑卒中后吞咽障碍的治疗。重复经颅磁刺激(rTMS)是指在选定大脑区域给予重复、连续、强度不变的刺激;Theta爆发式磁刺激(TBS)则是在rTMS的基础上加入丛状节律式刺激,刺激强度更低,刺激时间更短;而成对关联刺激(PAS)是将中枢TMS与外周神经电刺激按一定时间间隔相结合,成对激活大脑网络,每种治疗模式具有各自不同的特点。从吞咽障碍机制的科学研究、经颅磁刺激的相关机制和临床治疗研究3个方面综述了不同刺激模式在健康人和脑卒中后吞咽障碍患者中的应用,分析目前该领域的研究进展和局限性,为脑卒中后吞咽障碍的临床研究与治疗提供新思路。

Dysphagia is one of the most common functional disorders after stroke,with an incidence of up to 30%-50%,resulting in malnutrition and aspiration pneumonia,which could be life-threatening.The pathogenic mechanism of dysphagia after stroke involves multiple brain functional areas and neural networks.It is generally believed that dysphagia after stroke is related to the lesions of cerebral cortex,subcortical structures and brainstem swallowing center.There are significant differences in the mechanism and clinical manifestations of dysphagia caused by different lesion sites.Understanding the mechanism is conducive to the development of more targeted and individualized rehabilitation therapy in clinical practice,which has an important impact on the prognosis of patients.Except for the traditional swallowing treatment programs commonly used,such as swallowing motion-sensory training,peripheral neuromuscular electrical stimulation,acupuncture,postural training,and dietary adjustment,people have become more and more interested in central nervous regulation in the treatment of swallowing dysfunction.Transcranial Magnetic Stimulation(TMS),as a non-invasive neuroregulation technique,achieves the purpose of neuroregulation by regulating the excitability of the cerebral cortex.With the development of research,different pulse stimulation patterns have been developed and experimentally applied in the treatment of post-stroke dysphagia.Repetitive transcranial magnetic stimulation(rTMS)is a repeated,continuous and constant intensity stimulation of selected brain regions.Theta burst stimulation(TBS)is based on rTMS with the addition of cluster rhythmic stimulation,which has lower stimulus intensity and shorter stimulus duration.Paired associative stimulation(PAS)combines central TMS with peripheral electrical stimulation at certain intervals to activate brain networks in pairs.Each mode of treatment has its own characteristics.This article reviews the application of different stimulation modes in healthy people and patients with dysphagia after stroke,analyzes the current research progress and limitations in this field,and provides a new idea for the clinical research and treatment of deglutition disorder after stroke from three points.