【作者】 杨爱国；

【导师】 罗才贵；

【作者基本信息】 成都中医药大学 ， 针灸推拿学， 2011， 博士

【摘要】 目的：建立适合于四川农村的神经根型颈椎病中医推拿适宜技术筛选指标体系,为基层中医推拿适宜技术的筛选提供决策依据；建立农村中医推拿适宜技术筛选模式,为基层中医适宜技术的筛选提供一套有效、可行的筛选方法；并通过临床疗效评价,从有效性及安全性指标验证所建立的筛选指标体系。方法：(1)通过文献优选法和德尔菲法,建立CSR推拿适宜技术筛选指标体系,通过秩和比法及百分权重法确定指标体系中各级指标的权重。(2)通过适宜技术需求调查,分析四川省基层对中医适宜技术的需求状况。(3)利用建立的中医推拿适宜技术筛选指标体系对初步确立的CSR推拿技术进行评价,筛选出适合在四川省基层推广应用的神经根型颈椎病推拿适宜技术。(4)通过多中心随机、阳性对照试验的研究方法,将288例神经根型颈椎病患者分为治疗组(推拿适宜技术)和对照组(牵引合手法),分别治疗两疗程(共12次),以症状体征、VAS、血液流变学、X线检查及生活质量指数为主要评价指标。结果：(1)建立了中医推拿适宜技术筛选指标体系：6个一级指标及其权重分别是：技术安全性(0.21)、技术有效性(0.18)、技术特性(0.15)、技术经济性(0.13)、技术可接受性(0.16)及技术满意度(0.17)；16个二级指标及权重分别是：不良反应强度(0.0285)、不良反应率(0.0931)、效果(0.09)、生存质量(0.0882)、技术需求性(0.0525)、技术可操作性(0.0495)、技术的成熟度(0.0465)、技术的运行成本(0.0338)、患者费用成本(0.0351)、患者时间成本(0.0312)、医务人员的时间成本(0.0299)、政府可接受性(0.0496)、推广单位可接受性(0.0528)、患者可接受性(0.0572)、患者对技术的满意(0.0867)、医务人员对技术的满意度(0.0833)。(2)筛选出仰卧拔伸手法治疗神经根型颈椎病技术为中医推拿适宜技术。(3)两组在两疗程后,对各症状均有明显改善,比较有统计学意义(P<0.05)。对于颈肩痛与麻木、上肢痛与麻木、椎间孔挤压试验、肌力、生活能力和颈椎活动功能,治疗组的积分变化明显高于对照组,有统计学意义(P<0.01)；对于手指疼痛、手的功能、腱反射及上肢感觉的变化,两组积分变化无明显差异,无统计学意义(P>0.05)。(4)治疗两疗程后两组症状总积分均有明显提高,与治疗前比较,均有显著差异,有统计学意义(P<0.01)；两组之间,在治疗后症状总积分比较有明显差异,有统计学意义(P<0.01),治疗组症状总积分高于对照组,说明治疗组两疗程后对症状积分的改善优于对照组。(5)两组对颈椎X线征象的变化,均有改善,改善生理曲度方面,两组有明显差异(p<0.01),对照组明显优于治疗组。而在椎体稳定性、椎间孔、椎间隙的改善方面,两组无明显差别(p>0.05)。但对于骨质增生方面,两组均无改善。(6)两组在治疗后,均对血液流变学有明显改善作用,有统计学意义(p<0.01),对于全血粘度30(1/s)的变化,两组对指标值的改变有明显差异,有统计学意义(p<0.01),对照组优于治疗组,对于全血粘度值200、5、1、血浆粘度值、血沉、红细胞聚集指数的变化,两组改变指标值无明显差异,无统计学意义(p>0.05),对于红细胞刚性指数的变化,两组指标值的变化有差异,有统计学意义(p<0.05),治疗组优于对照组。(7)两组在两疗程后,对生活质量均有明显的提高,统计学有显著差异(P<0.01)；治疗后两组间生活质量指数比较无明显差别(p>0.05),说明两组在生活质量的改善方面无明显差别。(8)治疗组临床疗效总有效率达93.38%,愈显率达61.76%。对照组总有效率为91.79%,愈显率为46.27%。两组总有效率无明显差异(p>0.05),愈显率有明显差异。结论：(1)本研究所建立的神经根型颈椎病推拿适宜技术筛选指标体系合理、可行,也可以作为中医适宜技术的筛选指标体系,能客观地对中医适宜技术进行评价。(2)国家推荐的中医适宜技术库不能满足当地实际需求,中医适宜技术需求调查可作为中医适宜技术筛选的基本依据。(3)仰卧拔伸法治疗神经根型颈椎病技术临床疗效显著,安全性高,符合适宜技术要求。更多还原

【Abstract】 Objective:Establish a index system which was suitable for rural Chinese medicine appropriate technology—cervical spondylotic radiculopathy massage technique for screening grass-roots, and provide decision-making basis of Chinese massage screening of appropriate technology; Establishing a rural Chinese mode of appropriate technology screening of appropriate technology grass-roots TCM screening and providing a set of effective and feasible method of selecting, and also establishing screening verified index system by the efficacy and safety of index from the evaluation of clinical curative effect.Methods:(1)The establishment of the system of screening index was based on the research of literature and the Delphi method. The CSR and percent-weight method were used to calculate the weight-value of the indexes. (2) This study aims to analyze the technical demand through the baseline survey of appropriate technology. (3) Using the screening of the establishment of index system of appropriate technology for preliminary evaluation, screen appropriate technology for cervical spondylotic radiculopathy and the optimum appropriate technology application of TCM grass-roots appropriate technology in Sichuan province. (4)Methods of Positive control test and randomized controlled trial were adapted in the research; 288 cases of nerve root type cervical spondylosis were divided into treatment group (manipulation of appropriate technology) and control group (traction combined approach), respectively, the two treatment courses (12 times) to symptoms and signs, VAS, blood rheology; X-ray examination and quality of life index for the main index. Evaluate clinical curative effect of appropriate technology of cervical spondylosis of nerve root type by multicenter, randomized methods.Results:(1) The system of screening index included 6 primary and the weight-values of the primary indexes which were as follows:the effectiveness(0.21), the security(0.18), the characteristics(0.15), the economy(0.13), the social suitability(0.16) and the degree of satisfaction(0.17). Besides, the 16 secondary indexes were also screened the adverse reaction intensity (0.0285), the adverse reaction rate (0.0931) and the effect (0.09), the quality of life (0.0882), the technology requirement(0.0525), the technical operability (0.0495), the technology maturity (0.0465), the technology operating costs (cost 0.0338), the economic cost of patients (0.0351), the time costs of patients (0.0312), the time costs of medical staff time(0.0299), and the government acceptance (0.0496), the promotion of unit acceptability (0.0528), the patients acceptability (0.0572). the technical satisfaction for patients (0.0867), medical personnel of technology satisfaction (0.0833). (2) Screening supine hand pull method as a appropriated technology to treat the cervical spondylotic radiculopathy technology. (3) After two courses of treatment, two groups in two treatment of various symptoms were significantly improvement, they had statistical difference (P< 0.05). For neck shoulder pain and numbness, upper limb pain and numbness, intervertebral foramen extrusion test, muscle, the ability of living and cervical activities, the integral function, treatment group marked change than control group, and they had significant statistical difference (P< 0.01); For pain of fingers, the function of hand,tendinous reflex and upper limbs feeling changes, two groups of integral change was not statistical difference (P> 0.05). (4) After two courses of treatment two total score of symptoms were obviously improved, compared with before treatment, it had significant statistical difference(P< 0.01); after total score more obvious symptoms, two groups had statistical significant difference (P< 0.01); the treatment group improve than control group; in the symptoms that total scores. (5) Two groups of cervical X line were signs of change and in improving the physiological curvature two groups had significant statistical difference (p< 0.01), the control group was obviously better than the treatment group. And in the vertebral stability, the intervertebral foramen and vertebral clearance improvement had not statistical difference (p> 0.05). But in bone hyperplasia, both groups had not improvement.(6) After treatment two groups of blood rheology, all had obvious improvement and they had significant statistical difference (p< 0.01), for whole blood viscosity 30 (1/s), two groups had significant statistical difference (p< 0.01);for worth 200,5,1, plasma viscosity value, ESR,two group had not statistical difference(p> 0.05), for red rigid index two groups had significant statistical difference (p< 0.05).(7) After two groups treating, quality of life, were obviously increased, it had statistical significant difference (P< 0.01); the two groups quality of life had not significant difference (p> 0.05). (8)The total effectiveness and markedly effective rate of using supine hand pull appropriate technology to treat cervical spondylotic radiculopathy was 61.76%and 93.38%. The control group was 91.79%,46.27%. The total effectiveness between two groups had no significant difference (p> 0.05), and there was obvious difference about the markedly effective rate. Conclusion:(1) The screening index system established in the study about the appropriate massage technology of cervical spondylosis of nerve root type was reasonable practicable and also can be used for screening index system of TCM appropriate technology and evaluate the appropriate technology objectively. (2) Skill base of Chinese medicine appropriate technology recommended by national cannot satisfy the local actual requirement. The investigation of TCM appropriate technology can use for the basic foundation of appropriate technology screening. (3) The method of using supine hand pull method to treat cervical spondylotic radiculopathy technology was effective, safe and accorded with appropriate technical requirements.更多还原