【作者】 郎建英；

【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】 目的探讨“靳三针”疗法、康复疗法、“靳三针”疗法结合康复疗法对缺血性中风后痉挛性偏瘫患者的神经功能、综合功能、运动功能和日常生活能力的影响,评价“靳三针”疗法对缺血性中风后痉挛性偏瘫的治疗作用,促进“靳三针”疗法治疗缺血性中风后痉挛性偏瘫的规范法,标准化,为进一步探讨治疗缺血性中风后痉挛性偏瘫的有效方法提供依据。方法1、病例选择：115例,符合诊断标准和纳入标准,发病在2周到6个月的缺血性中风后痉挛性瘫痪患者,随机分为“靳三针”疗法组36例、康复疗法组42例和“靳三针”疗法结合康复疗法组37例。三组病例入选时基线资料具有可比性(P>0.05)。2、基础治疗：三组患者的基础药物治疗均参照《中国脑血管病防治指南》(卫生部疾病控制司、中华医学会神经病学会,2005)的方案控制血压、血糖、调节血脂、给予阿斯匹林防止血小板聚集,给予胞二磷胆碱以营养神经,对症治疗、防治并发症等。3、治疗方法：“靳三针”组：取穴：颞三针、上肢挛三针、下肢挛三针。随症配穴：失语加舌三针；口角歪斜加口三针；腕关节严重痉挛加腕三针：踝关节内翻加踝三针；上下肢痉挛无法伸展加开三针；指趾浮肿加八邪、八风。辨证配穴：肝阳暴亢加太冲；风痰阻络加丰隆；气虚血瘀加健侧足三里；阴虚风动加太溪。所有穴位均规定具体的针刺方法、针刺深度、针刺角度、行针次数等参数。康复组：康复训练方案主要依据人民卫生出版社卫生部规划教材《康复医学》第三版制定。操作包括：缓解肌张力,坐位平衡训练,坐站转换,立位平衡训练,步行训练,上肢控制能力训练。“靳三针”结合康复组的治疗方案为“靳三针”治疗的同时配合康复训练。具体方法同上。4、疗程：各组疗程均为28天,针刺治疗和康复训练每周5次,休息2天再继续治疗,共治疗4周；常规基础药物治疗28天。5、疗效评定：对所有患者均于治疗前、治疗14天后、治疗28天后分别采用临床神经功能缺损程度评分量表(NDS)、功能综合评定量表(FCA)、四肢简化Fugl-Meyer运动功能评分量表、日常生活能力评分量表(Barthel指数)(ADL),分别评定其神经功能、综合功能、运动功能和日常生活能力,以此评价三种方法的治疗效果。结果1、神经功能缺损评分治疗前三组病例神经功能缺损评分(NDS)比较差别无统计学意义(P>0.05),经过14天治疗,三组神经功能缺损评分均较治疗前向康复方向变化(P<0.001),靳三针组、康复组、靳三针结合康复组的改变值均数分别为3.5、3.5、4.9,以靳三针结合康复组的改变值最大,但方差分析结果差异无统计学意义(P>0.05)。经过28天治疗,三组病例神经功能缺损评分均较治疗前进一步向康复方向改变(P<0.001),靳三针组、康复组、靳三针结合康复组三组改变值(差值均数分别为7.1、6.7、9.1)比较的方差分析结果差异有统计学意义(P<0.05)。经做两两比较(SNK法),靳三针结合康复组与单纯靳三针和单纯康复组之间比较差异有统计学意义(P<0.05)；虽然靳三针疗法的改变值均数大于康复疗法,但两组间比较差异无统计学意义。治疗14天后NDS疗效比较,三组改善程度依次为靳三针结合加康复组>单纯靳三针组>单纯康复组,但是秩和检验结果差别无统计学意义(P>0.05)。三组显效率依次为靳三针结合加康复组>单纯靳三针组>单纯康复组,但χ2检验结果差别无统计学意义(P>0.05)。治疗28天NDS疗效比较,三组改善程度依次为靳三针结合康复组>单纯靳三针组>单纯康复组,秩和检验结果差别有统计学意义,经两两比较,靳三针结合康复组与康复组比较差异有统计学意义(P<0.05),而靳三针结合康复组与单纯靳三针组比较差异无统计学意义(P>0.05),单纯靳三针组与康复组比较差别也无统计学意义(P>0.05)。三组显效率依次为靳三针结合康复组>靳三针组>康复组,χ2检验结果差别有统计学意义(P<0.02)。经两两比较,靳三针结合康复组与康复组比较差译有统计学意义(P<0.05),而与单纯靳三针组比较差异无统计学意义(P>0.05),单纯靳三针组与康复组比较差别也无统计学意义(P>0.05)。2、功能综合评分(FCA)治疗前三组病例功能综合评分比较差别无统计学意义(P>0.05),经过14天治疗,功能综合评分均较治疗前向康复方向有改变(P<0.001),靳三针组、康复组、靳三针结合康复组的三组改变值(差值均数分别为8.2、7.7、12.78)比较,方差分析结果差异有统计学意义(P<0.01)。经做两两比较(SNK法),靳三针结合康复组与单纯靳三针和康复组之间比较差异有统计学意义(P<0.05),而单纯靳三针与康复组之间比较差异无统计学意义(P>0.05)。经过28天治疗,三组病例功能综合评分均较治疗前进一步向康复方向有改变(P<0.001),靳三针组、康复组、靳三针结合康复组的三组改变值(差值均数分别为14.6、15.3、23.4)比较,方差分析结果差异有统计学意义(P<0.01)。经做两两比较(SNK法),靳三针结合康复组与单纯靳三针组和康复组之间比较差异有统计学意义(P<0.05),靳三针组与康复组比较差异无统计学意义(P>0.05)。3、四肢简化Fugl-Meyer评分(1)上肢治疗前三组病例上肢简化Fugl-Meyer评分比较差别无统计学意义(P>0.05),经过14天治疗,三组上肢简化Fugl-Meyer评分均较治疗前向康复方向改变(P<0.001),靳三针组、康复组、靳三针结合康复组的改变值均数分别为8.8、9.1、12.5,以靳三针结合康复组的改变值最大,但方差分析结果差异无统计学意义(P>0.05)。经过28天治疗,三组病例的简化Fugl-Meyer评分均较治疗前进一步向康复方向改变(P<0.001),靳三针组、康复组、靳三针结合康复组三组的改变值(差值均数分别为17.6、18.8、25.4)比较,方差分析结果差异有统计学意义(P<0.05)。经做两两比较(SNK法),靳三针结合康复组与单纯靳三针组和康复组之间比较差异有统计学意义(P<0.05),而单纯靳三针与康复组之间比较差异无统计学意义(P>0.05)。(2)下肢治疗前三组病例的下肢简化Fugl-Meyer评分比较差别无统计学意义(P>0.05),经过14天治疗,三组下肢简化Fugl-Meyer评分均较治疗前向康复方向改变(P<0.001),靳三针组、康复组、靳三针结合康复组的改变值均数分别为4.9、4.0、5.8,以靳三针结合康复组的改变值最大,但方差分析结果显示三组比较的差异无统计学意义(P>0.05)。经过28天治疗,三组病例简化Fugl-Meyer评分均较治疗前进一步向康复方向改变(P<0.001),三组的改变值均数分别为8.8、8.0、10.7,以靳三针结合康复组的改变值最大,但方差分析结果差异无统计学意义(P>0.05)。4、日常生活活动能力评分治疗前三组病例的日常生活能力评分比较差别无统计学意义(P>0.05),经过14天治疗,日常生活能力评分均较治疗前向康复方向改变(P<0.001),靳三针组、康复组、靳三针结合康复组改变值均数分别为12.2、13.0、16.5,以靳三针结合康复组的改变值最大,但方差分析结果显示三组比较差异无统计学意义(P>0.05)。经过28天治疗,三组病例的日常生活能力评分均较治疗前进一步向康复方向改变(P<0.001),靳三针组、康复组、靳三针结合康复组改变值均数分别为24.3、23.9、30.9,以靳三针结合康复组的改变值最大,但方差分析结果显示三组比较差异无统计学意义。结论靳三针疗法结合康复训练组在改善中风后痉挛性偏瘫的神经功能缺损、综合功能、上肢运动功能等方面的疗效优于单纯靳三针组和康复组,表明靳三针疗法与康复疗法的结合可以相互加强改善中风后痉挛性偏瘫患者神经功能、综合功能和上肢运动功能的作用。可以认为二者结合运用能够更好地促进缺血性中风偏瘫痉挛状态的改善,促进神经功能、综合功能和上肢运动功能的恢复。虽然靳三针结合康复组对日常生活能力的改善程度大于单纯靳三针组和康复组,但差异无统计学意义,但并不一定表明靳三针结合康复疗法改善日常生活能力方面不优于单纯靳三针疗法和康复疗法,也可能因为样本例数太少,统计学检验未能显示出客观的阳性结果。靳三针疗法结合康复疗法改善下肢运动功能和日常生活能力的作用是否优于单纯靳三针组和单纯康复组,有待于进一步大样本临床研究。虽然靳三针疗法对神经功能缺损、功能综合评分、下肢简化Fugl-Meyer评分改变程度大于康复疗法,但两组间未表现出统计学差异,是否靳三针疗法的治疗效果优于康复疗法,有待临床的大样本研究进一步验证。更多还原

【Abstract】 Objective The effects of Jin’s three-needle therapy (JTNT), rehabilitation therapy (RT), Jin’s three-needle therapy combined with rehabilitation therapy on neurologic impairment, comprehensive function, activities of daily living (ADL) of spastic hemiplegia patients after ischemic stroke were observed for the evaluation of the therapeutic effect of Jin’s three-needle therapy. Thereby, the standardization of effective therapy for spastic hemiplegia after ischemic stroke is explored.Methods1 Selection of subjects:One hundred and fifteen cases subjecting to diagnostic criteria and inclusion criteria of spastic hemiplegia after ischemic stroke were enrolled into the study. The patients had a course of disease from 2 weeks to 6 months. During the experiment, the patients were randomized into JTNT group (N=36), RT group (N=42) and combination group (N=37). The baseline was similar in the three groups (P>0.05).2 Basic treatment:The drug treatment included drugs for controlling blood pressure and blood sugar, drugs for regulating blood lipid, aspermin for preventing platelet aggregation, and citicoline for nourishing nerves. The drug treatment followed China Guideline for Prevention and Cure of Cerebrovascular Disease issued by Disease Control Department of Ministry of Public Health, and Chinese Medical Association Neurology Association in 2005. If necessary, symptomatic treatment, and prevention and cure of complications were also carried out.3 Therapies:In JTNT group, the main acupoints for Jin’s three-needle therapy consisted of Niesanzhen (temporal three needles), Sishenzhen (four needles around Baihui), Luansanzhen (spasm three needles) in the upper limbs, (?)ans(?)zhen in the lower limbs, and coordination of acupoints included Shesanzhen (tongue three needles) for aphasia, Kousanzhen (mouth three needles) for distortion of commissure, Wansanzhen (wrist three needles) for severe spasm in wrist joint, Huaisanzhen (ankle three needles) for ankle joint inversion, Kaisanzhen (extension three needles) for extremities spasm, Baxie and Bafen for edema in digits. On the basis of syndrome differentiation, the following acupoints were selected when necessary:Taichong for sudden hyperactivity of liver yang, Fenglong for wind-phlegm blocking collaterals, Zusanli in the uninjured side for Qi deficiency and blood stasis, and Taixi for wind stirring due to yin deficiency. The manipulation of all the acupoints was carried out subjecting to the specified requirement. In RT group, the patients received rehabilitation therapy based on the method described in the third edition of Rehabilitation Medicine published by People’s Health Publishing House. The rehabilitation training included relief of muscular tension, balance of sitting position, transition of sitting position and standing position, balance of erect position, walking training, and control of upper extremity. In the combination group, treatment included JTNT and RT.4 Period of treatment:The period of treatment in the three groups lasted 28 days. Acupuncture and rehabilitation were performed 5 times a week, and continued after 2-day break for 4 weeks. The basic drug treatment lasted 28 days in the three groups.5 Evaluation of therapeutic effect:Before treatment,14 and 28 days after treatment, neurologic impairment was evaluated with clinical neurologic impairment degree scale (NDS), comprehensive function with Functional Capacity Assessments (FCA), motor function of four limbs with simplified Fugl-Meyer Motor Scale, and activities of daily living (ADL) with Barthel’s index. The changes of the four indexes were observed for the evaluation of the therapeutic effect.Results1 Scores of neurologic impairmentThe differences of NDS scores in the three groups were insignificant (P>0.05) before treatment. After treatment for 14 days, NDS scores were improved in the three groups (P<0.001 compared with those before treatment). The improvement of NDS scores in the combination group was the best, the difference of NDS scores being 3.5,3.5 and 4.9 in JTNT group, RT group and the combination group, respectively. However, the difference of NDS scores was insignificant between the three groups (P=0.077)After treatment for 28 days, NDS scores were improved in the three groups (P<0.001 compared with those before treatment). The difference of NDS scores was 7.1,6.7 and 9.1 in JTNT group, RT group and the combination group, respectively, and the difference of NDS scores was significant between the three groups (P=0.026). The results of differences between groups compared with SNK method showed that the improvement of NDS score in the combination group differed from that in JTNT group and RT group (P<0.05), but the difference between JTNT group and RT group was insignificant.After treatment for 14 days, the therapeutic effect on NDS was best in the combination group, and then came JTNT group and RT group, the difference being insignificant (P>0.05). So did the remarkable rate on NDS in the three groups (P>0.05)After treatment for 28 days, the therapeutic effect on NDS was best in the combination group, and then came JTNT group and RT group. The result of rank sum test showed statistical differences. The results of difference between groups showed that the combination group had better effect than that in RT group (P<0.05). However, the difference between the combination group and JTNT group was insignificant (P>0.05), so did the difference between JTNT group and RT group (P>0.05). The remarkable effective rate was the best in the combination group, better in JTNT group and good in RT group, the difference being significant (P=0.02). The remarkable effective rate in the combination group differed from that in RT group (P<0.05) while did not differ from JTNT group (P> 0.05). The difference between JTNT group and RT group was insignificant (P>0.05)2 Functional comprehensive assessment (FCA)The differences of FCA scores in the three groups were insignificant before treatment (P>0.05). After treatment for 14 days, FCA scores were improved (P<0.001), and the improvement value was 8.2,7.7 and 12.78 in JTNT group, RT group and combination group, respectively (P=0.007). The results of difference comparison between groups showed that FCA scores in the combination group differed from those in JTNT group and RT group (P<0.05), but the difference between JTNT group and RT group was insignificant. After treatment for 28 days, FCA scores were improved in the three groups (P<0.001), and the improvement value was 14.6,15.3,23.4 in JTNT group, RT group and combination group, respectively (P=0.002). The results of difference comparison between groups showed that FCA scores in the combination group differed from those in JTNT group and RT group (P<0.05), but the difference of the improvement of FCA scores between JTNT group and RT group was insignificant.3 Scores of simplified Fugl-Meyer assessment (FMA)(1) Upper limbsFMA scores in upper limbs of the three group were insignificant before treatment (P>0.05).After treatment for 14 days, FMA scores in upper limbs of the three group were improved (P<0.001), and the improvement value was 8.8,9.1,12.5 in JTNT group, RT group and combination group, respectively, the difference between the three groups being insignificant (P=0.139).After treatment for 28 days, FMA scores in upper limbs were improved in the three groups (P<0.001 compared with those before treatment), and the improvement value was 17.6,18.8,25.4 in JTNT group, RT group and combination group, respectively (P=0.011). The results of difference comparison between groups showed that FMA scores in upper limbs in the combination group differed from those in JTNT group and RT group (P<0.05), but the difference between JTNT group and RT group was insignificant.(2) Lower limbsFMA scores in lower limbs of the three group were insignificant before treatment (P>0.05).After treatment for 14 days, FMA scores in lower limbs of the three group were improved (P<0.001), and the improvement value was 4.9,4.0,5.8 in JTNT group, RT group and combination group, respectively, the difference between the three groups being insignificant (P=0.17).After treatment for 28 days, FMA scores in lower limbs of the three group were improved (P<0.001 compared with those before treatment), and the improvement value was 8.8,8.0,10.7 in JTNT group, RT group and combination group, respectively, the difference between the three groups being insignificant (P=0.10).4 Scores of ADLScores of ADL in the three groups were insignificant before treatment (P>0.05). After treatment for 14 days, ADL scores were improved in the three groups (P<0.001 compared with those before treatment), and the improvement value was 12.2,13.0,16.5 in JTNT group, RT group and combination group, respectively, the difference between the three groups being insignificant (P=0.22)After treatment for 28 days, ADL scores were improved in the three groups (P<0.001 compared with those before treatment), and the improvement value was 24.3,23.9,30.9 in JTNT group, RT group and combination group, respectively, the difference between the three groups being insignificant.ConclusionJin’s three-needle therapy combined with rehabilitation therapy shows better effect on neurologic impairment, comprehensive function, upper limb motor function of spastic hemiplegia patients after ischemic stroke than Jin’s three-needle therapy or rehabilitation therapy alone, indicating that the combination of Jin’s three-needle therapy and rehabilitation therapy has synergistic effect on promoting the improvement of comprehensive function. Jin’s three-needle therapy combined with rehabilitation therapy can relieve the spasticity, and promote neurologic function and limbs motor function.The improvement of ADL scores in the combination group is superior to that in JTNT group and RT group, but the differences were insignificant, which may result from the small sample, and need further large-sample research.Jin’s three-needle therapy exerts better effect on neurologic impairment, comprehensive function, and lower limbs FMA scores than rehabilitation therapy, but the differences were insignificant, which need further verification by large-sample research.更多还原