【作者】 罗清源；

【导师】 原林；

【作者基本信息】 南方医科大学 ， 中西结合， 2011， 博士

【摘要】 背景坐骨神经是人体全身最大的神经,坐骨神经痛(Sciatica)是指坐骨神经由于其自身或者其周围结构病变引起的坐骨神经通路及其分布区域放射性疼痛综合征。坐骨神经痛根据其病因可分为原发性坐骨神经痛和继发性坐骨神经痛,继发性坐骨神经痛又可分为根性坐骨神经痛和干性坐骨神经痛。其中根性坐骨神经痛较多见,常由于腰椎间盘突出、腰椎结核、畸形、椎管内肿瘤及腰椎管狭窄等导致,主要表现为阵发性或者持续性疼痛,夜间尤甚,疼痛部位多为腰部、臀部、大腿后侧、小腿后外侧和足外侧,咳嗽、喷嚏或者用力时疼痛可加剧。屈髋屈膝或者向健侧卧位可缓解疼痛,直腿抬高试验阳性。祖国医学将坐骨神经痛归为“痹证”范畴,其病理机制是以肾虚为本,外邪侵袭或跌仆闪挫为标,导致经脉拘急,气血运行不畅,经络不通,不通则痛,甚至影响肢体运动功能。本病发病年龄以中老男性为主,病变部位一般以足太阳经、足少阳经者居多,多单侧发病,亦可双侧发病。劳累及受凉后容易诱发本病,病情较重者患者往往难以忍受,严重影响人们的生活和工作。坐骨神经痛目前治疗上国内外尚无公认的、有效的方法。西医治疗方面的进展较为缓慢。一般以急性期卧床休息,针对病因治疗,如腰椎间盘突出症患者可卧床休息及手术治疗。常给予止痛剂以缓解症状为主,同时辅助应用镇静剂、血管扩张药及维生素B1、B2等,也可应用肾上腺皮质激素,但常因副作用大而难以持久,疗效不甚满意。随着祖国医学尤其是针灸推拿的不断发展,对坐骨神经痛治疗的也越来越受到重视。许多学者通过研究表明：针灸推拿可以提高机体痛闽、改善微循环、消除神经的炎症反应、影响镇痛传导通路及递质的释放等。目前已有许多学者利用不同的针灸推拿方法治疗坐骨神经痛,并取得了一定的疗效。因此,针灸推拿疗法治疗坐骨神经痛疗效确切,是治疗该病的理想方法。近年来,原林教授提出的“筋膜学理论”认为：人体是由遍布全身的非特异性结缔组织(筋膜)支架构成的支持与储备系统和被该支架支持和包绕的各种功能细胞构成的功能系统共同组成。其中人体遍布全身的结缔组织支架构成了中医经络的解剖学基础,“穴位”是指富含能产生较强生物信息的神经感受器和活性细胞的结缔组织聚集处,对穴位进行行针操作时能够产生较强的生物学信息。因此,全身各处“穴位”和“非穴位”只有产生生物信息量的不同而没有质的差异,即全身各部都是穴位。通过对“穴位”的刺激可刺激支持与储备系统中的筋膜组织产生较强的生物学信息,而且刺激越强所产生的生物学信息越丰富,激发人体的机能调节(组织细胞的活性)和生命调节(组织细胞的修复和再生)功能,最终可促使功能系统的修复。因此,“筋膜学理论”认为通过对支持与储备系统中的筋膜结缔组织高强度的刺激可促使机体功能的自我修复。“筋出槽,骨错缝”是中医特有的名词,它既属于病名,又属于病机变化,在历史文献中并非罕见,但由于比较散在,而未引起重视。从现代医学知识角度来解释和论证骨错缝,一般认为“骨错缝”可分为两种情况,一是指骨关节之间,由于不同的损失,使正常的解剖结构发生了微小错缝。这种改变的半脱位很轻,所以在线摄片上目前还不能得到反映。但解剖结构病理改变以后,影响到生理机能,故出现肿胀疼痛；二是比较严重的,骨缝发生参差不齐或半脱位,在线摄片上可以显示,肿胀疼痛也比较显著。“筋出槽”是指受损伤时,肌键等软组织发生滑脱或解剖位置有变化,从而影响活动功能,甚者出现较剧烈的疼痛,影响正常的工作和生活。“骨错缝”“筋出槽”两者之间有密切关联的,“筋出槽”的损伤可使骨缝处于交锁错位,反过来骨缝错位也可使筋损伤,所以《医宗金鉴》对于“骨错缝”的治疗,首先要用治筋肉损伤的按摩法,筋舒后骨节就能够合缝。本课题即是基于“筋膜学理论”的理论指导,并结合“骨错缝、筋出槽”的治疗理念,提出了一种系统的标准化的治疗坐骨神经痛的新方法,并称之为“新易筋疗法”,即首先通过跨关节的最大角度的牵拉、拔伸和旋转刺激关节囊及囊内的深感觉感受器,然后再通过传统针刺和浮针等方法给予病变部位周围的肌间隔筋膜结缔组织及皮神经高强度的刺激,最后再通过手法复位使“骨复位,筋归槽”。为了观察新易筋疗法治疗坐骨神经痛的临床疗效,本课题首先从对新易筋疗法治疗坐骨神经痛的可能机制进行了理论研究,然后通过设计随机对照实验进行临床研究,以寻求一种新的有效的方法治疗坐骨神经痛。目的本研究通过简单随机对照临床研究,与单纯传统针刺疗法比较,观察新易筋疗法治疗根性坐骨神经痛的临床疗效和安全性,并进行客观的疗效评价,以寻求一种新的治疗坐骨神经痛的有效的方法。方法选取香港日光诊疗中心符合纳入标准的根性坐骨神经痛患者100例,按照简单随机对照原则分为治疗组和对照组,每组各50例。治疗组给予新易筋疗法治疗：(1)手法治疗：患者俯卧位,医生站于患侧。将一只手按于患者腰骶部,另一只手握住患肢踝关节内侧,向后屈膝90°,先将髋关节内收外旋后最大角度拔伸、牵拉并旋转三周,同时伴有膝关节的旋外和膝关节的伸直。再由髋关节外展内旋最大角度拔伸、牵拉并旋转三周,同时伴有膝关节的旋内和膝关节的伸直。然后将放置于腰骶部的手移置于臀大肌下缘,以同样的方法用力最大角度拔伸、牵拉和旋转髋关节和膝关节三周。屈髋屈膝900,一只手放置于膝关节内侧,另一只手握住内踝。先由旋内至旋外,再由旋外至旋内最大角度拔伸、牵拉并旋转髋三周。(2)传统针刺：针刺部位为双侧肾俞、气海俞、大肠俞和关元俞及附近阿是穴(即压痛点)；患侧秩边、承扶及两旁各1.5cm的阿是穴、委中和阳陵泉。常规消毒后,持一次性直径为0.30mm,长度为40mm的毫针针刺,施以捻转手法使其得气后,再施以平补平泻手法使局部产生酸麻重胀的针感,保留15-30min。(3)浮针：针刺部位为髂后上嵴与坐骨结节连线的中点(相当于环跳穴)。常规消毒后持一次性5mL注射器针头朝向坐骨神经主干走行方向呈迅速平刺入皮下,然后左右晃动针体数下至病人最大忍受程度,留针15-20min,每隔5-10min晃动针体一至两次。(4)手法治疗：患者侧卧位,医生站于患者背侧。患肢屈髋屈膝90°,一只手用力按住患者髋关节,另一只手抱着患者的膝关节,先髋关节内旋最大角度拔伸、牵拉和旋转三周,再将髋关节外旋最大角度拔伸、牵拉和旋转三周。治疗1次休息2天,3次为1个疗程。对照组采用单纯传统针刺治疗,选穴和治疗方法同上。两组随访3个月后进行疗效评价,并采用视觉模拟评分表(Visual Analog Scale, VAS)、汉化Oswestry功能障碍指数(CODI)表及巴氏日常生活功能量表(Barthel Index, BI)对患者治疗前、治疗后疼痛及生活行为功能障碍进行客观评价。结果1、治疗组和对照组的年龄、性别及治疗前视觉模拟评分、Oswestry功能障碍指数评分和巴氏日常生活功能量表评分均无统计学差异(P>0.05),两组具有可比性。2、随访结束后,治疗组和对照组视觉模拟评分均显著低于治疗前(P<0.01),而且治疗组治疗后评分及治疗前后评分差均明显优于对照组(P<0.01)。3、随访结束后,治疗组和对照组汉化Oswestry功能障碍指数评分均显著低于治疗前(P<0.01),并且治疗组治疗后评分及治疗前后评分差均明显优于对照组(P<0.01)。4、随访结束后,治疗组和对照组巴氏日常生活功能量表评分均显著高于治疗前(P<0.01),并且治疗组治疗后评分及治疗前后评分差均明显优于对照组(P<0.01)。5、随访结束后,治疗组的临床治愈率为36%明显高于对照组治愈率4%,总有效率治疗组为96%亦明显优于对照组70%。治疗组和对照组的疗效具有显著性差异(P<0.01),治疗组明显优于对照组。结论通过对新易筋疗法治疗根性坐骨神经痛的临床疗效的客观评价,本研究表明：新易筋疗法治疗根性坐骨神经痛明显减轻了患者的疼痛症状从而改善了其他症状并提高了患者的生活行为能力,其疗效明显优于单纯的传统针刺疗法。新易筋疗法操作简单,疗效迅速,疗程短,是一种有效的治疗根性坐骨神经痛的方法。更多还原

【Abstract】 BackgroundSciatic nerve is the human body’s largest nerve. Sciatica is a radiated pain syndrome of sciatic nervous pathway and its distribution area caused by sciatic nerve disease or surrounding structure disorder. According to its etiopathogenisis, Sciatica can be divided to primary and secondary sciatica. Secondary sciatica can be divided to radicular sciatica and dry Sciatica. Radicular sciatica is more frequently seen due to lumbar disc protrusion, lumbar disc protrusion and abnormal, intraspinal tumor and Lumbar spinal stenosis. It mainly display as paroxysmal or persistent pain, worse at night, and mainly at waist, hips, back of the thigh, calf and foot lateral posterolateral. Coughing, sneezing or exertion can exacerbate the pain. Knee or hip flexion can mitigate the pain. Straight leg raising test is positive. Traditional Chinese medicine classified it as "Arthralgia" category. The pathological mechanism is based on kidney-oriented, evils invasion or sprain or servant as the standard, leading to meridians Juji, blood runs sluggish, meridian unreasonable, pain and even affect motor function. This disease most often occurs in old man and diseased region mainly at foot-taiyang and foot-shaoyin. It may be unilateral or bilateral and be induced by tired and cold. Heavier patients are often unbearable and the qualities of life are affected severely.Currently there is no generally accepted and effective treatment at home and abroad with sciatica. Western medical therapies make slow progress, which advocate repose on bed and aimed at pathogeny cure, for example that lumbar disc protrusion patients should be in bed and accepted operative treatment. Patients often given painkillers to alleviate the symptoms and take sedative, angiotenic, Vitamin B1 and B2 at the same time. Adrenal cortical hormone also could be used, but it has created a considerable side effect.Along with the development of traditional Chinese medicine, especially acupuncture, treatments of sciatica have arosen increasing attention. Dozens of studies have shown that acupuncture could increase pain threshold, improve microcirculation, eliminate inflammatory reaction of nerve, effect signaling pathway of analgesia and release of transmittance. Many scholars have gained curative effects though different acupuncture and manipulation methods on sciatica. Therefore, acupuncture and manipulation method has curative effects and is an ideal method.Recently, L. Yuan had put forward a new hypothesis, fasciology hypothesis. In fasciology, the human body is classified into two major systems. One is the supporting-storing system, which is consisted of is constituted of undifferentiated cells from the network of unspecialized connective tissues (fascia network). The other one is the functional system, which is consisted of differentiated functional cells and is enclosed by the supporting-storing system. Connective tissues that link all parts of the body compose the anatomical basis of meridian. Acupuncture point means a place that rich in nerve receptor with intense bioinformation and connective tissue of competent cell. Therefore, acupuncture point and un-acupuncture point only differ at quantitative of bioinformation, but not qualitative, which means that acupuncture point filled our whole body. Though stimulating the acupuncture point, fascia tissue could generate intense bioinformation in the supporting-storing system, and stimulate the function regulation (activity of tissue and cells) and life regulation (repair and regenerate of tissue and cells) of body, finally promoting repair the function system. So fasciology hypothesis thought that though high-intensity stimulating fascia tissue in the supporting-storing system could promote repairing of body function."Bars the groove, bone staggered joint" is a kind of special name called in TCM. It is the name of disease, but also the pathomechanisms, and was not uncommon historical documents. But it did not get enough regards due to relatively scattered. From the angle of modern medicine, bone staggered joint generally divided into two cases. One is different losses between joints induce the normal anatomical structure form a small staggered joint. The other serious one is that suture is Uneven or subluxation, which can be displayed in X-ray and pain are more obvious. "Bars the groove" means when injury, tendon and other soft tissue slippage, or changes in the anatomical location, which affects mobility, even appear more intense pain and affect the normal work and life. It has close relationship between "Bars the groove" and "bone staggered joint". Injury by "Bars the groove" can induce interlocking suture dislocation of bone suture. Dislocation of bone suture can also induce tendon injury. So treatment on "bone staggered joint" in Golden Mirror of Medicine thought that massage treatment should be first used to cure muscle injury.This topic is based on the theory of fasciology hypothesis, along with the treatment concept of "Bars the groove, bone staggered joint". We raised a new, systemic and standardized method to cure sciatica, which called the new Yi-Jin therapy. First, through the cross-joint the maximum angle traction, pulling and rotating to stimulate joint capsule and the capsule of the deep sensory receptors, then through traditional methods such as acupuncture and floating needles to give the lesion of connective tissue around the muscle and fascia interval high-intensity stimulation of cutaneous nerve. Finally, use the manual reduction to "Bone reduction, Return slot bars".To observe the clinical effect of the new Yi-Jin therapy with sciatica, our topic made theory research on the mechanism of the new Yi-Jin therapy with sciatica, then made clinical research though designing randomized controlled experiment, and to explore a new effective method to cure sciatica.ObjectiveIn this study, a simple randomized controlled clinical study, compared with traditional acupuncture therapy, was designed to observe the objective clinical efficacy and safety of the new Yi-Jin therapy on root sciatica, to seek a new effective treatment method of root sciatica. MethodsAccording to the inclusive criteria,100 cases were chosen from HONGKONG sunlight treatment centre.100 cases were randomly divided into a treatment group (n=50) and a control group(n=50) by a simple randomized principle.The treatment group was treatment with the new Yi-jin therapy, and the control group was treatment with the traditional acupuncture therapy. Both of them selected the same acupuncture points and the same period of treatment. After one time of therapy, the patient had a rest for two days. Three times were a period of treatment.After 3 months of follow-up, both of the two groups were done by the efficacy evaluation from two aspects:one was the pain of the patient by using the visual analogue scale (Visual Analog Scale, VAS), Chinese Oswestry Disability Index (CODI) and Barthel Index (BI) before and after the treatment; the other one was the behavior and conduct disorders by an objective evaluation.Results1. There was no statistically different in age, gender, pre-treatment visual analog scale, Chinese Oswestry Disability Index score and Barthel Index scores between the treatment group and the control groups (P> 0.05). The two groups were comparable.2. Follow-up after the end of the treatment group and the control group, visual analogue scale were significantly lower than before treatment (P<0.01), and the score difference of the treatment group before and after treatment were significantly more advantage than the control group (P<0.01).3 After follow-up, Chinese Oswestry Disability Index score in the treatment group and the control group were both significantly lower than before treatment (P<0.01), and the scores difference before and after treatment in the treatment group were significantly more advantage than the control group (P<0.01).4. Barthel Index scores of the treatment group and the control group were significantly higher than before treatment (P<0.01), and the scores difference before and after treatment in the treatment group were significantly more advantage than the control group (P<0.01).5. The clinical cure rate in the treatment group (36%) was significantly higher than the control group (4%). The total effective rate (96%) in the treatment group was significantly higher than the control group (70%). The treatment group and control group were significant differences in efficacy (P<0.01), and the treatment group was significantly better than the control group.ConclusionBy the objective evaluation of the new Yi-Jin therapy on the clinical efficacy of root sciatica, this study showed that:the new Yi-Jin therapy could greatly improve the symptoms of sciatica, and enhance the capacity of life of the patients. Its efficacy was better than traditional acupuncture. The new Yi-Jin therapy is a new effective treatment method on root sciatica due to the simple operation, rapid effect and a short course.更多还原