【作者】 王冼生；

【导师】 庄礼兴；

【作者基本信息】 广州中医药大学 ， 针灸推拿学， 2011， 博士

【摘要】 研究目的颈性眩晕是因颈椎病导致椎基底动脉供血不足,引起延迟性短暂脑缺血而出现以眩晕为主要症状的临床综合征。其病因和发病机理、临床表现、诊断和治疗尚未形成统一认识。近年来,随着生活节奏加快及生活习惯的改变,颈椎病人逐年增多,且患者年龄呈现出低龄化趋势。正是由于颈性眩晕病因的不确定性和复杂性,给治疗带来了很大困难。鉴于颈性眩晕严重影响了患者的工作和生活以及病程长,治疗后容易复发的特点,而且近年来有不少报导,颈椎病患者总体心理健康状况较差,有较高的焦虑抑郁情绪及其他心理障碍发生率。我们认为临床治疗颈性眩晕的关键在于有效改善患者的临床症状,提高其生活质量及工作能力,降低复发率,改善心理健康。颈三针及四神针为靳瑞教授所倡导的靳三针之一,目的在于研究针灸配穴,加强针效,临床多用于治疗颈肩部、头部等疾病,疗效确切,也是治疗颈椎病常用穴。近年已有零星报导,颈三针加配穴治疗颈性眩晕疗效确切,而四神针为治脑病常用穴。近期也有四神针为主治疗心理疾病的报导,结合导师的经验,故我们对针刺颈三针加四神针治疗颈性眩晕的临床疗效进行探讨,以期对颈性眩晕的防治作出一些努力。本研究通过随机对照的临床研究方法,观察颈三针加四神针治疗颈性眩晕的临床疗效,并以临床常用的颈椎牵引加推拿按摩疗法作为对照组。采用颈性眩晕症状与功能评估量表、生存质量评定量表(SL-36)及症状自评量表(SCL-90)进行评分,及经颅彩色多普勒超声检查(TCD),检测椎—基底动脉的血流速度,客观评价临床疗效,从而探讨颈三针加四神针治疗颈性眩晕的临床价值。为提高患者生存质量,改善心理健康提供简便、安全、有效的治疗方法。研究方法一、分组将60例符合纳入标准的颈性眩晕患者按简单随机分组的方法分为颈三针加四神针组(治疗组)、颈椎牵引加推拿按摩组(对照组),每组30例。两组在基础治疗条件相同的情况下分别按以下方案进行治疗。治疗前及治疗后均采用颈性眩晕症状与功能评估量表、生存质量评定量表(SL-36)、症状自评量表(SCL-90)进行评分,根据评分判断临床疗效,并采用经颅彩色多普勒(TCD)比较两组椎-基底动脉收缩期及舒张期流速。在观察指标及疗效评定上采用盲法评价。二、治疗方案(一)颈三针加四神针组(治疗组)1.取穴主穴：四神针、颈三针(天柱、百劳、大杼)。辩证配穴风阳上扰：加行间、太冲、太溪；痰浊上蒙：加内关、中脘、丰隆；气血不足：加气海、血海、足三里；肝肾阴虚：加肝俞、肾俞、太溪。2.治疗频率和疗程：每天1次,10次为一疗程,每治疗5天后休息2天,共两个疗程。(二)颈椎牵引加推拿按摩组(对照组)推拿按摩治疗1.手法：采用椎旁或局部软组织放松手法。在患者双侧颈项部的胸锁乳突肌,斜方肌,颈椎横突前后结节,颈夹肌施用滚法,点按法,揉法,至局部热感为度。接着按揉风池、风府,肩井,肩外俞,天宗,等穴位,每穴各30秒,再在颈部两侧的肩胛提肌,斜方肌,头颈夹肌的压痛点,施以弹拔法,最后按揉颈肩部肌肉,拿肩井。2.治疗频率和疗程：每天1次,每次20min,10次为一疗程,每治疗5天后休息两天,共两个疗程。颈椎牵引治疗1.方法：使用张家港市永新医用设备制造有限公司生产的YXZ-O1豪华电脑颈椎牵引仪；患者采用坐式体位。采用坐式间歇颈椎牵引,牵引角度稍前倾15-30度左右(前屈位牵引),牵引重力为患者体重的10-30%,起始重量宜轻,逐日加重,以患者耐受为度,牵引过程中,充分注意患者的个体差异,密切观察牵引时患者的感受和反应,根据实际情况作必要的调整。2.治疗频率和疗程：同推拿按摩。研究结果1.本研究颈三针加四神针组和颈椎牵引加推拿按摩两组中医证型的构成比例无明显统计学差异(P>0.05),但本研究所纳入病人总的中医证型分布显示气血不足证型所占比例最大,其次为肝肾阴虚及痰浊上蒙证,再次为风阳上扰证,总体来看本病以虚为主,其中多表现为气血不足及肝肾阴虚,而实证以风阳上扰及痰浊为多,这和我们临床中所见是一致的。2.疗效分析结果显示在治疗2个疗程后,治疗组的30例患者中,治愈10例,显效11例,有效6例,无效3例总有效率90%,对照组的30例患者中,治愈7例,显效9例,有效6例,无效8例,总有效率73.33%。治愈率及总有效率方面,治疗组明显高于对照组(P<0.05)。提示两组治疗均有效,而治疗组疗效明显优于对照组。3.与治疗前相比,治疗组治疗后生存质量在：躯体功能(PF)、躯体角色(RP)、肌体疼痛(BP)、一般健康状况(GH)、社会功能(SF)等5个维度均有升高,差异有统计学意义(P<0.05)；对照组则仅有RP、BP两个维度上升高,差异有统计学意义(P<0.05)。生存质量在PF、GH、SF等3个维度的改善方面,治疗组优于对照组,差异有统计学意义(P<0.05)。说明在改善生存质量方面,治疗组优于对照组。4.在治疗前及治疗2个疗程后按颈性眩晕症状与功能评估表对两组进行评分。组内比较,治疗组与对照组治疗后评分明显高于治疗前(P<0.05),提示两组治疗对改善眩晕症状均有效。组间比较,治疗前两组眩晕量表评分差异无显著性(P>0.05),具有可比性；治疗后治疗组眩晕评分明显高于对照组,差异有统计学意义(P<0.05)。提示在改善眩晕症状方面,治疗组优于对照组。5.症状自评量表：在SCL-90各因子评分中,与治疗前比较,治疗组治疗后所有积分均下降,其中躯体化、焦虑、抑郁、精神病性等症状因子积分下降明显,治疗后与治疗前比较,差异有统计学意义(P<0.05)；对照组在各因子的改善方面不明显,与治疗前相比,仅在人际关系、抑郁、焦虑三个因子方面差异有统计学意义(P<0.05)。与对照组相比较,治疗组在躯体化、恐怖、精神病性及其他的症状评分方面明显降低,差异有统计学意义(P<0.05)；而在抑郁积分改善方面,对照组优于治疗组,但差异无统计学意义(P>0.05)。显示治疗组可明显降低患者躯体化、恐怖、精神病性及其他的症状评分。说明治疗后心理健康状况明显改善,且表现在多个维度方面。6.采用经颅彩色多普勒(TCD)比较两组椎-基底动脉收缩期及舒张期流速。治疗前,椎-基底动脉收缩期流速(基底动脉、右椎动脉及左椎动脉收缩期流速),治疗组与对照组无显著性差异(P>0.05)；治疗后治疗组基底动脉、右椎动脉及左椎动脉收缩期流速明显下降,差异有统计学意义(P<0.05)；而对照组则与治疗前相比无明显改变(P>0.05),治疗后治疗组基底动脉、右椎动脉及左椎动脉收缩期流速明显低于对照组；显示治疗组在改善右椎动脉及左椎动脉收缩期流速方面优于对照组,差异有统计学意义(P<0.05)。治疗前,椎-基底动脉舒张期流速(基底动脉、右椎动脉及左椎动脉),治疗组与对照组无显著性差异(P>0.05)：治疗后治疗组基底动脉、右椎动脉及左椎动脉舒张期流速明显下降,差异有统计学意义(P<0.05),而对照组则与治疗前相比无明显改变(P>0.05),与对照组比较,治疗组基底动脉、右椎动脉及左椎动脉舒张期流速明显低于对照组；显示治疗组在改善右椎动脉及左椎动脉舒张期流速方面优于对照组,差异有统计学意义(P<0.05)。而在基底动脉改善方面,两组无明显差异(P>0.05)。TCD显示治疗后治疗组右椎动脉及左椎动脉收缩期流速降低较对照组明显,右椎动脉及左椎动脉舒张期流速也低于对照组(在正常范围内),因血流速度下降是由于治疗后颈部病变得到一定程度的治疗,使因颈交感神经丛及椎动脉受影响而发生的血管痉挛得到缓解,使流速降低,故提示治疗组在改善血流速方面明显优于对照组。结论临床观察结果发现,颈三针加四神针治疗颈性眩晕在治愈率及总有效率、眩晕量表评分、症状自评量表、生存质量评定方面明显优于牵引加推拿按摩治疗对照组,而且观察到治疗组能降低右椎动脉及左椎动脉收缩期流速及舒张期流速,作用优于对照组,因而考虑治疗组疗效优于对照组是因为改善了椎动脉、基底动脉供血,增加脑血流量,减少脑血流阻力,改善迷路动脉及内耳的供血。更多还原

【Abstract】 Objectives:This paper studies the therapeutic effectiveness of combined acupuncture at "Cervical Three Points" and "Four Gods Points" on relieving cervical vertigo, based on random case-control study samples and compares that to the control group in which conventional practice of cervical traction and naprapathy are performed. Clinical efficacy is determined through objective scoring of 3 assessment surveys:the "cervical vertigo symptoms and functional assessment survey", the "quality of life assessment survey (SL-36) " and the "self-assessment of symptoms survey (SCL-90) ". In addition, the maximum systolic and minimum diastolic blood flow velocities were measured at the cervical and basilar arteries as an indicator of therapeutic efficacy. The results are evaluated and used to determine whether the use of "Cervical Three Points" and "Four Gods Points" should be advocated as treatment of choice for patients with cervical vertigo, based on its effectiveness, safety, and potential ability of improving quality of life.Methods:1. SAMPLING60 patients with cervical vertigo were randomly selected during the period of March 2009 to February 2010. Under the same basic treatment conditions, the patients were then divided into 2 groups of 30 people each. The control group is treated using cervical traction and naprapathy method while the trial group is treated using combined "Cervical Three Points" with "Four Gods Points" acupuncture.Scoring based on the three surveys:the "cervical vertigo symptoms and functional assessment survey", the "quality of life assessment survey (SL-36)" and the "self-assessment of symptoms survey (SCL-90)" were collected both prior to and after treatment. Blind evulation was performed and the clinical efficacy of each treatment were investigated based on the results. In addition, the velocities of vertebral arterial systole and diastole were measured and compared between the two groups through the use of transcranial Doppler.2. TREATMENT PLANa. Combined "Cervical Three Points" and "Four Gods Points" acupuncture (Trial group)i. Placement of points Major points:"Four Gods Points", "Cervical Three Points" (Tian Zhu、Bailao、Da Zhu). Placement of points based on diagnosis:modified according to the symptoms of CV.ii. Treatment regimen Two courses. A course is defined by once daily treatment for five consecutive days, followed by a rest period of two days, and start of another five-day treatment.b. Cervical traction with naprapathy (Control group) Naprapathy treatment:i. Method Relaxation therapy on paravertebral or focal soft tissue. Focus on Sternocleidomastoid on either sides of the neck, the Trapezius, transverse processes of cervical vertebrae and the Splenius. Techniques include rolling, point pressuring and rubbing until heat is generated on the target areas. Acupressure is then applied to five points:Fengchih, Fengfu, Chienching, Chienwaishu, Tientsung, for 30 seconds each. After that, plucking of pain-pressure points on the Trapezius, Splenius and Levator Scapulae is followed by gentle massage of the muscles on neck and shoulders.ii. Treatment regimenTwo courses. A course is defined by daily treatment of 20 minutes each for 10 consecutive days. Cervical traction treatment: i. Method Assisted with medical equipment:computerized cervical traction apparatus. Treatment perform in sitting position. Traction is carried out intermittently at an angle of 15 to 30 degrees to the front. Traction force is approximately 10 to 30% of patient’s body weight, with small initial force and increasing gradually over the days of the course. Extend of traction is primarily based on patient’s tolerance to the force applied. Throughout the course, attention should be paid on patient’s response to treatment and adjustments should be made accordingly.ii. Treatment regimen Single course. A course is defined by 10 treatments of 20 minutes each, performed every other day.Results:1. Sample population. There is no statistical significance in the initial symptom differences presented in the two groups of patients selected to perform the two treatments. That is, the patients were randomly selected, all their symptoms of cervical vertigo are similar and possible errors due to selection bias can be ruled out. However, looking at the patients as a whole, patients with poor circulating blood volume take up the highest percentage, followed by those with poor liver and kidney functions and then those with turbid phlegm. This clinical observation agrees with the physiopathology of the condition.2. Treatment efficacy. Analysis of treatment result shows after two treatment courses, the trial group has 10 patients with the condition cured,11 patients with significant improvement,6 patients with improvement and 3 patients with no effects. Overall efficacy is 90%. In contrast, the control group has 7 cases of cure,9 cases of significant improvement,6 cases of improvement and 8 cases of no improvement. Overall efficacy is 73.33%. On the aspects of cured population and overall efficacy, the trial group has a more superior result compared to that of the control group. However, the difference is of no statistical difference suggesting that both treatment are effective with higher treatment efficacy being the trial treatment.3. Assessment of quality of life. When compared to the data collected prior to treatment, there is improvement in all 5 aspects of quality of life (PF, RP, PB, GH, SF) in the trail group after treatment, which is of statistical significance (with P< 0.05). On the contrary, the control group showed improvement in only two aspects of quality of life (RP, BP) which is again of statistical significance (with P< 0.05). The other three aspects of quality of life (PF, GH, SF) has higher improvement in the trial group and the finding is of statistical significance. Therefore, it illustrates that trial group provides a better improvement in quality of life than the control group.4. Assessment of cervical vertigo symptoms and cervical functions in the two groups before and after two treatment courses. Comparisons were made within the group, which showed that significant improvement were noted following treatment (with P< 0.05). Hence, both treatment were effective. Comparing trial group with control group, there was no significant difference in survey result prior to treatment, making the results valid for comparison. Following treatment, trial group has a significant improvement on vertigo symptoms with compared to the control group (P< 0.05). This shows that trial group is more effective in improving vertigo symptoms compared to the control group.5. Self-assessment of symptoms. According to the assessment result of different components of the survey SCL-90, trial group has an overall decrease in scores after the treatment. In particular, there were obvious decrease in points related to somatization, anxiety, depression, psychotic symptoms following treatment, and the result is of clinical significance (P< 0.05). On the other hand, there is less significant improvement following the control treatment. Statistical significance was only observed in three areas:interpersonal relationships, depression and anxiety. When comparing to the control group, the trial group has significantly lower scores in aspects of somatization, phobia, psychosis and other symptoms which is of statistical significance (P< 0.05). Only in the aspect of depression did the control group achieve better improvement than the trial group, however, the difference is of no statistical significance. Summing up, the trial treatment provides positive effects on reducing symptoms such as somatization, phobia, psychotic behaviours, and provides the patient with better psychological health in various aspects post treatment.6. Maximum systolic and minimum diastolic blood flow velocity in both left and right cervical arteries and basilar artery. There is no difference of statistical significance among maximum systolic velocities of blood flow in basilar, left and right cervical arteries of trial and control groups prior to treatment (P< 0.05). After treatment, the maximum blood flow velocity is significantly lower in the trial group compared to the control group. When compared to the pre-treatment value, the maximum blood flow velocity has lowered significantly in the trial group (P< 0.05). Whereas in the control group, little difference can be observed post treatment. Overall, there is significant improvement in lowering the maximum systolic blood flow velocity in basilar, left and right cervical arteries in trial group comparing to control group.Likewise, there is no difference of statistical significance among minimum diastolic velocities of blood flow in basilar, left and right cervical arteries of trial and control groups prior to treatment (P< 0.05). Post treatment, the minimum blood flow velocity is significantly lower in the trial group compared to the control group. When compared to the pre-treatment value, the minimum diastolic blood flow velocity has lowered significantly in the trial group (P< 0.05). Whereas in the control group, little difference can be observed post treatment. Overall, there is significant improvement in lowering the minimum diastolic blood flow velocity in left and right cervical arteries in trial group comparing to control group. However, improvement is similar for both groups in basilar artery.In the trial group, the lowering of maximum systolic blood flow velocity is more obvious than the control group. The same applies for the minimum diastolic blood flow velocity in the trial group. This implies that the reduction of blood flow is due to relieve of neck pathology post treatment, in particular the vascular spasms caused by stimulated cervical sensory nerves and vertebral arteries.Conclusion:It is found in this study that the combined acupuncture at " Cervical Three Points " and "Four Gods Points" has a more superior therapeutic efficacy than the traditional treatment method of cervical traction and naprapathy on relieving cervical vertigo. This conclusion is based on investigations on cure rate, treatment efficacy and the three assessment surveys:the "cervical vertigo symptoms and functional assessment survey", the "quality of life assessment survey (SL-36)" and the "self-assessment of symptoms survey (SCL-90)". In addition, the trial group with combined acupuncture displayed a lowered maximum systolic and minimum diastolic blood flow velocity in both left and right cervical arteries. Hence improving blood supply to the brain via vertebral and basilar arteries with the reduction of cerebral blood flow resistance. Improvement of blood supply can also be seen in the inner ear labyrinth artery.更多还原