Clinical observation on acupoint massage plus Vitalstim electrical stimulation for deglutition disorder after stroke

Tian Li(田莉), Nie Shao-tong (聶紹通),Lou Tian-xiao(樓天曉),Chen Huan (陳歡), Yuan Guang-hui(袁光輝)

1 Changsha Social Work College,Changsha 410000,China

2 Hunan Traditional Chinese Medical College,Zhuzhou 412000,China

3 Zhuzhou Central Hospital,Hunan Province,Zhuzhou 412000,China

Abstract

Keywords:Acupoint Pressure Therapy;Electric Stimulation Therapy;Electromyography;Poststroke Syndrome;Pseudobulbar Palsy; Deglutition Disorders

The incidence of deglutition disorder after stroke is 30%-65%[1-2],the incidence of aspiration in patients with deglutition disorder after stroke is 51%-73%[3-4],and deglutition disorder causes 72% of hospitalized aspiration pneumonia[5].Complications such as pneumonia will delay the recovery process of patients’swallowing function and even lead to death.Therefore,it is of great significance to take intervention as soon as possible.At present,the rehabilitation methods for deglutition disorder include oral sensory training,oral movement training,airway protection method,lowfrequency electrical stimulation,surface electromyographic biofeedback training,balloon dilatation,acupuncture treatment,application of ventilator swallowing and speaking valve[6].In this study,acupoint massage and Vitalstim electrical stimulation were adopted to treat patientswith deglutition disorder after stroke,and surface electromyography (SEMG)as an objective evaluation method,thus to provide reference for the selection of clinical treatment methods for patients with this disease.

1 Clinical Materials

1.1 Diagnostic criteria

1.1.1 Diagnostic criteria for stroke

The diagnostic criteria for stroke referred the Key Diagnostic Pointsfor Cerebrovascular Diseases[7].

1.1.2 Diagnostic criteria for deglutition disorder after stroke

The diagnostic criteria of Western medicine referred the definition of deglutition disorder after stroke in the Key Diagnostic Points for Cerebrovascular Diseases[7]and Chinese Expert Consensus on Deglutition and Nutrition Management of Stroke Patients(2013 Edition)[8]. The diagnosis of stroke was confirmed by cranial CT or MRI examination, and deglutition disorder,choking while drinking water and slurred speech or voice disorder were demonstrated.The diagnostic criteria of traditional Chinese medicine (TCM) referred theCriteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicine[9]and Standard for Diagnosis and Therapeutic Effect Evaluation of Stroke (Trial)[10]. The diagnosis was confirmed when the criteria for stroke disease in TCM were met, along with symptoms of deglutition disorder,choking while drinking water.

1.2 Inclusion criteria

Those who met the above diagnostic criteria,diagnosed with stroke by cranial CT or MRI examination,which was the first onset;screened as deglutition disorder by water swallowing test,incomplete loss of swallowing function,and no need to rely on nasal feeding; relatively stable vital signs,mini-mental state examination(MMSE)≥21 points,and could actively cooperate during rehabilitation training;aged between 41 and 70 years old;onset within 6 months;signed informed consent.

1.3 Exclusion criteria

Those with critical conditions;those with failure or bleeding tendency of important organs;those with severe cognitive impairment.

1.4 Dropout criteria

Those who were unwilling to continue the treatment;those with recurrent cerebrovascular diseases or aggravated condition during the study.

1.5 Statistical methods

The data was kept by a Microsoft Excel data sheet.The SPSS version 19.0 statistical software was adopted for data analysis.The measurement data in accordance with normal distribution were expressed as mean±standard deviation(±s),and compared by analysis of variance.Chi-square test was used to compare the rate.Rank-sum test was used to compare ranked count data between groups.P＜0.05 indicated statistical significance.

1.6 Generaldata

A totalof 60 inpatients with deglutition disorder after stroke who received treatment from the Department of Rehabilitation Medicine and Neurology of Zhuzhou Central Hospital,Hunan Province between February 2015 and September 2017 were recruited in the study.They were randomly divided into an electrical stimulation group,a massage group and an integrated group, with 20 cases in each group.No cases dropped out during treatment.There were no significant inter-group differences in gender,age and disease duration(allP＞0.05),indicating that the three groups were comparable(Table 1).

2 Therapeutic Methods

Patients in the three groups received the same basic treatment,including drug treatment and routine rehabilitation training for swallowing.

The drug treatment followed the routine treatment of cerebrovascular disease in the neurology department stipulated inChina Guidelines for Cerebrovascular Diseases Prevention and Treatment[11],such as control of blood pressure,blood lipid,blood glucose,and anti-platelet aggregation.

Table 1. Comparison of the general data among the three groups

Routine rehabilitation training for swallowing function included the following four categories.

Oral sensory stimulation: Asked the patient to take a sitting or semi-sitting position, and ice cotton stick or ice lemon cotton stick was used for ice or acid sensation stimulation.The stimulation sites were palatolingual arch,both sides of the soft palate, tongue root and posterior pharyngeal wall, and each site was stimulated 3-5 times.

Oral movement training: Passive, active and againstresistance movements with the mouth in closing and opening states, as well as extending the tongue in all directions. Each movement was repeated 3-5 times.

Chin tucking against resistance (CTAR)[12]: Asked the patient to take a sitting position, and placed the small ball between the chin and the suprasternal fossa. Asked the patient to draw his chin downward and inward to squeeze the ball. Isometric contraction was maintained for 1 min, followed by a 1-minute interval, and isotonic contraction was performed 30 times. This training was practiced for 3 times each morning, noon and evening.

Ingestion training:Swallowing angiography was adopted to determine the most suitable food consistency, properties and the amount of a mouthful.Chose an half lying or sitting position for eating, e.g. an half lying position with neck, slight forward flexion and a pillow under the hemiplegic shoulder. Selected food that was not easy to fall apart with even density. Made sure that each bite was swallowed before the next. Paid attention to the cleaning of oral secretions before and after eating.

2.1 Integrated group

2.1.1 Acupoint massage

Acupoints: Three acupoints on the face [Jiache (ST 6),Xiaguan (ST 7) and Chengjiang (CV 24)]; six acupoints on the neck [Lianquan(CV 23),Renying (ST 9),Tiantu(CV 22), Yamen (GV 15), Dazhui (GV 14) and Fengchi(GB 20)].

Methods:The location of acupoints referred theNomenclature and Location of Acupuncture Points(GB/T 12346-2006)[13].The patient took a supine position.Manipulations mainly included finger digital An-pressing,An-pressing,Rou-kneading and Tuipushing. The first step was to massage the three points on the face. The operator gently used the side of the middle finger and ring finger of both hands to push straight from Jiache(ST 6)to Xiaguan(ST 7)for 20-30 times.The operator Rou-kneaded and Anpressed the three points on the face with his thumb,two times of Rou-kneading and one An-pressing, each point for 10-20 times,until the patient felt sore and heavy.Then were the six points on the neck.The operator gently used the side of the two thumbs to push straight from Lianquan (CV 23) to Tiantu (CV 22)for 20-30 times,until the skin around the acupoints turned red. The operator digital An-pressed Lianquan(CV 23),Renying (ST 9) and Tiantu(CV 22) with his thumb for 10-20 times per acupoint, until the patient felt sore and heavy.The operator Rou-kneaded Lianquan (CV 23),Renying (ST 9) and Tiantu (CV 22)with his thumb for 10-20 times per acupoint.The operator Rou-kneaded Yamen (GV 15) to Dazhui (GV 14)for 10-20 times with the four fingers except the thumb.The operator Rou-kneaded Yamen(GV 15),Dazhui(GV 14) and Fengchi (GB 20) with his middle finger, each point for 10-20 times,until the patient felt sore and heavy. This treatment was given once a day for 6 d as a course, with a rest of 1 d between two courses and for 4 courses in total.

2.1.2 Vitalstim electrical stimulation

The skin was degreased first.The location and treatment mode of the surface electrode were selected based on the swallowing assessment results,the patient's tolerance as well as his disease condition. For patients with deglutition disorder of oral phase, the channel electrodes were placed at the body surface projection position of the buccal branch of facial nerve.For patients with deglutition disorder of pharyngeal phase, the channel electrodes were placed along the anterior midline, with one on the hyoid bone and the other on the cricoid cartilage. Treatment parameters:bidirectional square wave,wave width 600-700 μs,frequency 30-80 Hz, amplitude 0-25 mA, dual-channel and dual-output electrodes were adopted.This treatment was given once a day for 30 min each time and 6 d as a course, with a rest of 1 d between two courses and for 4 courses in total.

2.2 Massage group

Patients in this group received the same acupoint massage treatment as in the integrated group, with the same acupoints, manipulations and treatment courses.

2.3 Electricalstimulation group

Patients in this group received the same electrical stimulation treatment as in the integrated group,with the same stimulation sites,parameters and treatment courses.

3 Observation of Clinical Efficacy

3.1 Observed items

3.1.1 Score of Fujishima Ichiro food intake level scale(FILS)

Before treatment and after 4 treatment courses,FILS was scored[14], between 1 and 10 grades from severe deglutition disorder to normal swallowing function,and the corresponding score was between 1 and 10 points.1-3 points suggested severe disorder, in which patients were unable to eat orally;4-6 points suggested moderate disorder,in which patients could eat orally,but supplementary nutrition was needed;7-9 points suggested mild disorder,in which patients could take enough nutrition orally;10 points suggested normal swallowing function.

3.1.2 SEMG

SEMG was adopted to quantitatively analyze the swallowing muscle function.The patient underwent SEMG examination before and after treatment.The examination environment should be quiet. Exposed the skin above the patient’s neck,and used 75% alcohol to wipe the surface of electrodes to enhance their electrical conductivity.Took the left side as an example,stuck the recording electrodes under zygomatic arch,about 3 cm from earlobe (masseter muscle),and recording electrodes were 15-20 mm away from the reference electrodes.Asked the patient to swallow 15-20 mL purified water at one time as quickly as possible.If choking cough occurred,the measurement stopped and restarted after 20 min.The recruitment pattern of the patient's swallowing process was intercepted,and the totalduration(swallowing duration)and the maximal amplitude height of the recruitment potential generated during muscle contraction were measured.Both the left and right sides needed to be tested,and the average value of the two testswas taken as the evaluation result.

3.2 Efficacy evaluation criteria

Markedly effective:After treatment,swallowing function was significantly improved,and the FILS score was 9-10 points,or 5-7 points higher than that before treatment.

Effective: After treatment,swallowing function was improved,and the FILS score was2-4 pointshigher than that before treatment.

Failure: After treatment, swallowing function did not change significantly, and the FILS score increased by less than 2 points.

3.3 Results

3.3.1 Comparison of the efficacy

The total effective rate in the integrated group was 95.0%, versus 60.0% in the massage group, and 70.0%in the electrical stimulation group. The total effective rate in the integrated group was significantly higher than that in the other two groups (P＜0.05), and there was no significant difference between the massage group and the electrical stimulation group(P＞0.05).Please check Table 2 for details.

Table 2. Comparison of the efficacy among the three groups(case)

3.3.2 Comparison of the FILS score

Before treatment,there was no significant intergroup difference in the FILS score (P＞0.05), indicating that the three groups were comparable. After 4 courses of treatment, the FILS scores in the three groups all increased significantly (allP＜0.05).The score in the integrated group was higher than that in the massage group and the electrical stimulation group(P＜0.05).There was no significant difference between the massage group and the electrical stimulation group(P＞0.05). This suggested that all the three treatment methods could improve the FILS score, and the effect of the integrated treatment was better than that of the two treatment methods used alone.Please check Table 3 for details.And the effect of the integrated treatment was better than that of the two treatment methods used alone.After 4 courses of treatment,the maximal amplitudes of the recruitment potentials of masseter muscles in the three groups increased when the masseter muscles contracted vigorously,showing intra-group statistical significance(allP＜0.05).The maximal amplitude in the integrated group was higher than that in the massage group and the electrical stimulation group(bothP＜0.05),but there was no significant difference between the massage group and the electrical stimulation group(P＞0.05).This suggested that all the three treatment methods could enhance the masseter muscle and increase the discharge of muscle fibers,and the effect of the integrated treatment was better than that of the two treatment methods used alone.Please check Table 4 for details.

Table 3. Comparison of the FILS score among the three groups ( ±s, point)

Table 3. Comparison of the FILS score among the three groups ( ±s, point)

Note:Compared with that before treatment in the same group,1) P＜0.05;compared with the integrated group after treatment,2) P＜0.05

Group n Before treatment After treatment Integrated 20 3.38±0.57 7.69±0.641)Massage 20 3.32±0.58 6.25±0.521)2)Electrical stimulation 20 3.35±0.55 6.33±0.761)2)

3.3.3 Comparison of the changes in the curves of masseter muscle group in SEMG

Before treatment,there were no significant differences among the three groups in the swallowing duration and maximal amplitude of masseter muscle group(allP＞0.05), indicating that the three groupswere comparable.After 4 courses of treatment,the swallowing duration of masseter muscle group in the 3 groups was shortened,showing intra-group statistical significance(allP＜0.05).The swallowing duration in the integrated group was shorter than that in the massage group and the electrical stimulation group(bothP＜0.05).There was no significant difference between the massage group and the electrical stimulation group(P＞0.05).This suggested that all the three treatment methods could improve the coordination and flexibility of masseter muscle group,and shorten swallowing time.

Table 4.Comparison of SEMG curves of masseter muscle group( ±s)

Table 4.Comparison of SEMG curves of masseter muscle group( ±s)

Note:Compared with that before treatment in the same group,1) P＜0.05;compared with the integrated group after treatment,2) P＜0.05

Group n Swallowing duration (s)Maximal amplitude (mⅤ)Before treatment After treatment Beforetreatment After treatment Integrated 20 3.861±0.335 3.172±0.3271)0.297±0.051 0.407±0.0421) Massage 20 3.876±0.283 3.527±0.3131)2)0.305±0.044 0.362±0.0531)2) Electrical stimulation 20 3.866±0.356 3.530±0.3471)2)0.301±0.054 0.332±0.0211)2)

4 Discussion

Acupoint stimulation is a common method to treat deglutition disorder after stroke nowadays.Qin L,et al[15]believe that deep needling at Lianquan (CV 23)and Yifeng (TE 17) can improve cervical nerve regulation,vascular nutrition and lymphatic circulation in patients with deglutition disorder after stroke. Zhang LZ,et al[16]found that needling at Lianquan (CV 23) and Fengfu(GV 16) can affect the discharge of swallowing-related neurons in nucleus tractus solitarius,thus inducing swallowing movement. The research results of Yuan Y,et al[17]suggested that stimulating deep sensation of the tongue and pharynx through deep needling at Tiantu (CV 22) can promote the recovery of swallowing muscle strength and central nervous system pathway.Some studies have also shown that repeated massage of lips, tongues and cheeks can effectively enhance the coordination of oral movements[18]; stimulation signals of massage are repeatedly transmitted to the cerebral cortex, thus improving swallowing function[19].

The 9 acupoints selected in this study all function as regulating the swallowing function.Jiache(ST 6),Xiaguan (ST 7) and Chengjiang (CV 24) benefit the oral function.Renying (ST 9)is the crossing point of the Stomach Meridian and the Gallbladder Meridian.Renying (ST 9) and Lianquan(GV 23) are commonly used to treat deglutition disorder. Together with Tiantu(CV 22),these three acupoints can unblock the meridians and benefit the pharynx[17,20]. Yamen (GV 15),the crossing point of the Governor Vessel and the Yang Link Vessel, can treat the loss of voice. Fengchi (GB 20)has the function of calming the liver and extinguishing the wind,as well as unblocking the collaterals and opening the orifices[21].Dazhui(GV 14), the crossing point of the Governor Vessel and the yang meridians,can invigorate yang qi and regulate qi and blood.

Vitalstim electrical stimulation is one of the most popular methods to treat deglutition disorder in recent years. Some studies have shown that Vitalstim electrical stimulation can regulate muscle excitability,improve muscle strength of the swallowing muscle group and improve swallowing function by affecting motor fibers of medulla oblongata peripheral nerve[22].Many research results have shown that Vitalstim electrical stimulation therapy is more effective than routine swallowing function rehabilitation training[23].

The results of this study showed that acupoint stimulation,Vitalstim electrical stimulation and their integrated application can improve swallowing function in patients with deglutition disorder after stroke, and the effect of the integration of the two methods should be better than that of the two methods used alone.

SEMG, as a safe, simple and affordable evaluation method,is mostly adopted for early screening and evaluation of deglutition disorder[24].It is attracting increasing attention at home and abroad as it can reflect the function of the swallowing muscle group.In recent years,more and more studies have taken SEMG asan objective indicator to evaluate the clinical efficacy of Vitalstim in treating deglutition disorder after stroke[25-26].The results of SEMG examination in this study showed that after treatment,the swallowing durations of masseter muscle group in patients of the three groups were shortened,and the maximal amplitudes of muscle contraction were increased. This showed that acupoint stimulation,Vitalstim electrical stimulation and their integrated application can improve the flexibility and coordination of masseter muscle,enhance the muscle strength,and thusimprove swallowing function.The effect of the integration of the two methods was better than that of the two methods used alone.

Acupoint massage is a non-invasive treatment,and it is safe and easy to operate.It can stimulate alarger area than acupuncture treatment,and the fear of patients for needling can be avoided,so that the method should be popularized and applied in clinicalpractice.

Conflict of Interest

The authors declare that there is no potential conflict of interest in thisarticle.

Acknowledgments

This work was supported by Project of Hunan Province Administration of Traditional Chinese Medicine (湖南省中醫(yī)藥管理局課題,No.2015136).

Statement of Informed Consent

Informed consent was obtained from all individual participants.

Received:20 December 2019/Accepted:20 February 2020