應用呼氣肌力量訓練於腦中風吞嚥困難病人之成效：系統性文獻回顧暨統合分析

目的：吞嚥困難是腦中風病人常見的合併症，並使腦中風病人面臨更高的肺炎發生率及死亡風險。呼氣肌力量訓練為增加呼氣肌肌肉力量之訓練方式，研究發現除可增加咳嗽、清除呼吸道能力外，對於改善吞嚥困難症狀亦有效益，目前已廣泛應用於神經疾患病人。然而，目前的研究對應用呼氣肌力量訓練於腦中風吞嚥困難病人之成效尚未明瞭，本研究以系統性文獻回顧暨統合分析方式，探討呼吸肌力量訓練對腦中風吞嚥困難病人之成效。方法：本研究架構遵循 PRISMA 聲明，並將研究計畫書註冊於 PROSPERO 資料庫，註冊日期為 2020 年 9 月 25 日，註冊編號為 CRD42020195829。於研究開始進行至 2020 年 10 月 23 日結束，搜尋 Cochrane Library 之子資料庫 The Cochrane Central Register of Controlled Trails (CENTRAL)、PubMed、EMBASE、CINAHL and Medline（EBSCO 系統）、Web of Science (WOS)等資料庫，並以手動搜尋方式檢索納入文獻之參考資料與研討會摘要。納入研究類型為應用呼氣肌力量訓練於腦中風吞嚥困難病人成效之隨機分派試驗 (Randomized control trial, RCT)。納入文獻以考科藍組織之「Cochrane handbook for systematic reviews of interventions」中建議的風險偏差評估工具第二版(RoB 2.0)來鑑別文獻品質。並使用考科藍組織發行之 RevMan 5.4.1 版軟體進行資料分析。結果：文獻檢索結果共找到 55 篇文獻，最終納入 5 篇文獻進行分析討論，其中 3 篇文獻有報告吞嚥困難嚴重度之結果指標，2 篇有報告呼吸肌肌肉力量之結果指標。統合分析結果於食物滲入／吸入量表 (Penetration-Aspiration Scale, PAS)及最大呼氣壓力(Maximal Expiratory Pressure, MEP)有顯著改善(PAS: MD = -0.88，95%信賴區間 = -1.41～ -0.36，P = .001；MEP: MD = 18.21，95%信賴區間 = 10.69～25.74, P < .00001)，於功能性由口進食量表(Functional Oral Intake Scale, FOIS) 及最大吸氣壓力(Maximal Inspiratory Pressure, MIP)之成效未達顯著 (FOIS: MD = 0.44，95%信賴區間 = -0.47～1.36，P = .34；MIP: MD = 25.37，95%信賴區間 = -1.50～52.25, P = .06)。結論：呼氣肌力量訓練可增加呼氣肌肌肉力量並改善吞嚥困難嚴重程度，建議腦中風後 3-7 週的吞嚥困難病人，可開始接受呼氣肌力量訓練以改善吞嚥困難。建議未來可探討呼氣肌力量訓練之劑量成效(Dose Response)，以擬定提出呼氣肌力量訓練之執行標準。

關鍵字

腦中風；吞嚥困難；呼氣肌力量訓練；統合分析

並列摘要

Purpose: Dysphagia is common after stroke and increases a patient's risks of pneumonia, disability, and death. Expiratory muscle strength training (EMST) can improve the patient's respiratory muscle strength and was recently conducted as a new rehabilitation for dysphagia.This study aims to investigate the effects of EMST in stroke patients with dysphagia. Method: A systematic review and meta-analysis were performed by searching the databases of the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, Web of Science (WOS), CINAHL, and Medline (EBSCO) from their inception to October 23, 2020. We searched the reference list of all selected studies and the abstracts presented at the seminar/conference. These studies were selected to identify randomized controlled trials of EMST in stroke patients with dysphagia. The quality of each included randomized controlled trials was assessed using version 2 of the Cochrane risk-of-bias tool, as recommended in the Cochrane Handbook for Systematic Reviews of Interventions. Data were analyzed using the Cochrane Collaboration's RevMan 5.4.1. Results: Five studies were included in this meta-analysis: Three studies reported the dysphagia severity, and two studies reported respiratory muscle strength. Compared with the control groups, EMST in stroke patients with dysphagia significantly reduced the penetration-aspiration scores (MD = -0.88, 95% confidence interval = -1.41 to -0.36, P = .001) and increased maximal expiratory pressure (MD = 18.21, 95% confidence interval = 10.69 to 25.74, P < .00001) but did not increase the Functional Oral Intake Scale (MD = 0.44, 95% confidence interval = -0.47 to 1.36, P = .34) and maximal inspiratory pressure (MD = 25.37, 95% confidence interval = -1.50 to 52.25, P = .06). Conclusion: EMST can improve swallowing function and expiratory muscle strength in stroke patients with dysphagia. Stroke patients with dysphagia 3–7 weeks after stroke should consider receiving EMST. Future research should explore the training dose-response relationship of EMST and appropriate measurement indicators of dysphagia.