重复经颅磁刺激联合疗法在脑卒中后 吞咽障碍康复中应用的研究进展

Research Progress on the Application of Repetitive Transcranial Magnetic Stimulation Combined Therapy in the Rehabilitation of Dysphagia after Stroke

摘要: 脑卒中后吞咽障碍是脑卒中最常见的严重并发症之一，急性期发病率达46.3%，恢复期高达56.9%，可显著增加患者误吸、营养不良、吸入性肺炎等不良事件风险，严重阻碍康复进程、降低患者生活质量。重复经颅磁刺激(rTMS)作为非侵入性神经调控技术，可通过调节吞咽相关大脑皮质兴奋性改善吞咽功能，但单一应用疗效有限。近年来，rTMS联合多种干预手段的治疗模式成为该领域研究热点，核心联合方案可分为四大类：rTMS联合外周神经肌肉刺激、rTMS联合传统康复训练与物理治疗、rTMS联合中医特色疗法、rTMS联合感觉刺激疗法，各类方案均通过“中枢–外周协同调控”“神经调控 + 功能强化”“中西医疗法优势互补”等核心机制实现疗效提升。本文系统梳理近年相关临床与基础研究，对不同rTMS联合疗法的作用机制、临床疗效、研究进展进行全面综述，同时对纳入研究的方法学质量进行系统评价，基于证据强度对比不同联合方案的疗效差异，分析当前研究核心局限，并提出未来研究的具体方向，为脑卒中后吞咽障碍的临床康复方案优化与研究设计提供循证参考。

Abstract: Post-stroke dysphagia is one of the most common and severe complications of stroke, with an incidence of 46.3% in the acute phase and up to 56.9% in the recovery phase. It significantly elevates the risks of adverse events such as aspiration, malnutrition, and aspiration pneumonia, severely hindering the rehabilitation process and reducing patients’ quality of life. Repetitive transcranial magnetic stimulation (rTMS), as a non-invasive neuromodulation technique, can improve swallowing function by regulating the excitability of the cerebral cortex related to swallowing, but its efficacy is limited when used alone. In recent years, the combined therapy of rTMS with various interventions has become a research hotspot in this field. The main combined strategies fall into four categories: rTMS combined with peripheral neuromuscular stimulation, rTMS combined with conventional rehabilitation training and physical therapy, rTMS combined with traditional Chinese medicine characteristic therapies, and rTMS combined with sensory stimulation therapy. All these protocols achieve enhanced therapeutic effects through core mechanisms including central-peripheral synergistic regulation, neuromodulation plus functional reinforcement, and complementary advantages of traditional Chinese and Western medicine. This paper systematically reviews recent clinical and basic studies, comprehensively summarizes the mechanisms, clinical efficacy and research progress of different rTMS combined therapies, systematically evaluates the methodological quality of included studies, compares the efficacy of different combination regimens based on evidence strength, analyzes the key limitations of current research, and proposes specific directions for future research, so as to provide evidence-based references for optimizing clinical rehabilitation protocols and research design of post-stroke dysphagia.