脑梗死吞咽障碍针刺治疗方案的初步优选

Primary optimization of acupuncture program for dysphagia after cerebral infarction

目的:对脑梗死吞咽障碍针刺治疗方案进行初步优选。方法:以63例脑梗死假性延髓麻痹吞咽障碍患者为研究对象,以洼田饮水试验为观察指标,采用正交设计法,研究针刺时机(A因素:A1:1～10天,A2:11～20天,A3:21～40天),选穴配伍(B因素:B1:项部穴,B2:项部穴+舌咽部穴,B3:项部穴+舌咽部穴+辨证取穴),针刺深度(C因素:C1:浅刺,C2:中刺,C3:深刺),疗程(D因素:D1:2疗程,D2:4疗程,D3:6疗程)4因素3水平的不同搭配组合方案,对脑梗死假性延髓麻痹吞咽障碍患者的影响,初步确定脑梗死吞咽障碍针刺治疗优选方案。结果:正交设计法的直观分析显示,4因素3水平的最佳水平及搭配方案为A1(或A2)、B3、C3、D3,即在病程20天内,选用项部穴、舌咽部穴位,配合辨证取穴,采用深刺法,治疗6个疗程,对洼田饮水试验起最佳改善作用。4因素的作用主次比较(方差分析)显示:因素A、C为显著因素(P<0.05),因素B、D为不显著因素(P>0.05),说明针刺时机与针刺深度在获得临床疗效方面作用显著。显著因素A、C不同水平间的优劣比较(多重比较)显示:A1、A2显著优于A3(P<0.001),A1与A2比较差异无统计学意义(P>0.05);C3显著优于C2、C1(P<0.001,P<0.01),C2显著优于C1(P<0.05)。结论:对直观分析、方差分析、多重比较结论结合临床实际情况进行综合分析认为,对于所考察的4因素3水平而言,在病程1～20天内,采用项部穴为主,或结合舌咽部穴,或配合辨证取穴,行深刺法,治疗4～6个疗程,为脑梗死假性延髓麻痹吞咽障碍患者的针刺治疗优选方案。

Objective To optimize primarily acupuncture program for dysphagia after cerebral infarction. Methods Sixty-three patients with pseudobulbar palsy dysphasia after cerebral infarction were selected as the subjects. Water swallow test was adopted for observanon index. Orthogonal design was used to study the different combinations of treatment programs among four factors and three levels, named acupuncture opportunity （factor A： AI： 1-10 d. A2：11-20 d, A3.. 21-40 d）, point combination （factor B： BI： points in the neck, B2： points in the neck＋ points in the glossopharyngeal part, B3： points in the neck 7- points in the gtossopharyngeal part ＋ differentiating point）, needling depth （factor C： C1： shallow puncture, C2： moderate puncture, C3： deep puncture）, and treatment session （factor D： D1 .. 2 sessions. D2：4 sessions, D3.. 6 sessions）： as well as the influences on pseudobulbar palsy dysphagia after cerebral infarction so as to determine primarily the optimized acupunc- ture program for dysphagia after cerebral infarction. Results The direct analysis of orthogonal design indicated that the best level and the combination of four factors and three levels were Al（or A2）. B3, C3 and D3. It meant that for the patients less than 20 days for sickness, the points in the neck. points in the glossopharyngeal part and points selected according to syndrome differentiation were selected for deep puncture and the treatment lasted for 6 sessions. This program achieved the best improvement in water swallow test. The comparison between the prima- ry effect and secondary effect among four factors （variance analysis） showed that factor A and C were the signifi- cant factors （P〈0.05）, factor B and D were not significant （P〈0.05）. It was suggested that acupuncture oppor- tunity and needling depth played the significant roles in clinical efficacy. The comparison among different levels in terms of the significant factors A and C （multiple comparison） presented that A1 and A2 were superiorly signifi- cant than A3 （P〈0. 001）, A1 was not different m significance from A2 （P〈0. 05）. C3 was superiorly significantthan C2 and C1 （P〈0. 001 ,P〈0.01） and C2 was superiorly significant than C1 （P〈0.05）. Conclusion By the comprehensive summarization of direct analysis, variance analysis and multiple comparison combined with actual clinical situation, the optimal program of acupuncture treatment for pseudobulbar palsy dysphasia after cerebral in- farction is that in terms of the four factors and three levels, for the patients within I to 20 days for sickness, acu- puncture is applied to the points in the neck or combined with points in the glossopbaryngeal part or the points se letted according to syndrome differentiation, with deep puncture, for 4 to 6 sessions of treatment.