脳卒中後嚥下障害に対する低頻度反復性経頭蓋磁気刺激と集中的嚥下リハビリテーションの併用療法の経験

摘要

嚥下障害は脳卒中後にみられる後遺症の一つでrnある．脳卒中急性期には約55%の患者に嚥下障rn害がみられるとの報告もありその頻度は高い．rnまた嚥下障害の存在は脳卒中患者のADLrn（Activities of Daily Living）・QOL（Quality of rnLife）・生命予後に影響を与えるためその対応rnは大きな課題である．しかし，嚥下障害の治療とrnしてのリハビリテーション（以下リハ）の取り組rnみは比較的最近になってからのことであり，効果rnのある手法は限られているのが現状である．%The usefulness of repetitive transcranial magnetic stimulation (rTMS) for poststroke dysphagia has been reported. However, no report about combination therapy with rTMS and dysphagia rehabilitation has been published. In this study, combination therapy with rTMS and intensive dysphagia rehabilitation was performed in patients with poststroke dysphagia. The combination therapy was found to improve swallowing function. In a 76-year-old man with dysphagia after cerebral infarction in the territory of the right middle cerebral artery, the therapy was performed 6 months after stroke onset, when recovery had reached a plateau. The patient was admitted for 6 days according to the following protocol: on the scalp over the left cerebrum, 1-Hz rTMS was performed for 20 minutes twice a day where the maximum motor evoked potential of the bilateral elevator muscles of the hyoid bone was recorded, followed by direct and indirect swallowing training. Swallowing function was evaluated with fiberoptic endoscopy on the days of admission and discharge. Combination therapy for 6 days was completed without side effects or the deterioration of neurological symptoms. This therapy improved swallowing function, and single-photon emission computed tomography confirmed an improvement in cerebral blood flow. Simultaneously, oral intake function also improved. Combination therapy with low-frequency rTMS and intensive dysphagia rehabilitation could be safely performed, suggesting its usefulness for the treatment of poststroke dysphagia.