【作者】 Marmori F.；

【导师】 赵吉平；

【作者基本信息】 北京中医药大学 ， 针灸推拿学， 2012， 博士

【摘要】 支气管哮喘是内科临床上的常见病之一,属肺系疑难病症。支气管哮喘也是一种与心理社会因素关系密切的慢性疾病。目前,在针灸临床,哮喘发作期多采用单纯针灸疗法,并取得一定疗效,但重症仍依靠西医常规治疗。哮喘缓解期多选用灸法、穴位敷贴、穴位注射等,对减缓哮喘发作有积极的治疗意义。对针灸作用机制的研究,主要是集中在改善肺通气功能,提高机体免疫力等方面,作用机制复杂,仍有许多问题亟待解决。目前尚无根治哮喘的方法,控制哮喘复发,提高患者的生命质量是主要目标任务。本课题也是基于此目的,拟观察针刺调神治疗支气管哮喘慢性持续期作用的疗效,并初步探讨其作用机制。目的：通过针灸治疗,初步观察针刺调神治疗慢性持续期支气管哮喘的临床疗效,并初步探讨本法治疗哮喘的作用机制。方法：分组：将试验病例随机分为治疗组(常规取穴加调神腧穴)和对照组(常规取穴)每组各30例。选穴：主穴：对照组：肺俞、定喘、膻中、列缺、尺泽、合谷。治疗组：在对照组取穴的基础上,加百会、印堂、内关、太冲。配穴：脾虚证加脾俞；肾虚证加肾俞；鼻塞流鼻涕加迎香；咳嗽痰多加丰隆；喘甚加天突。针刺操作：两组患者治疗均以主穴为主,酌加配穴。患者先行仰卧位,针刺胸前部腧穴,得气后行平补平泻手法10秒,留针15分钟。留针过程中,行针1次,每次提插捻转约10秒钟,以促使再次得气或使针感得到加强。然后行腑卧位,针刺背部脊柱两侧腧穴,其它操作同上观察指标：1.情绪状态指标：用焦虑自评量表(self- rating anxiety scale, SAS)和抑郁自评量表(selfrating depression scale、SDS)两项评价哮喘患者治疗前后的情绪状态。2.生命质量测评：采用支气管哮喘生命质量调查问卷(asthma quality of life questionnaire, AQLQ)评价哮喘患者治疗前后的生命质量变化；3.哮喘症状评价：采用哮喘日记表,评价夜间症状和白天症状的状况。4.哮喘相关量表：用哮喘控制测试(sthma control test, ACT)观察哮喘控制情况。5.肺功能检测：用第一秒用力呼气容积(forced expiratory volume in one second, FEV1)和FEV1/FVC (forced vital capacity,用力肺活量)观察哮喘患者治疗前后肺功能变化。结果：1.两组患者情绪状态(SAS、SDS)积分比较：(1)两组全部患者,组间及各组治疗前后SAS、SDS积分比较：经3个月治疗后,治疗组SAS和SDS分值均显著下降(P<0.05),对照组仅SDS分值明显下降(P<0.05)；治疗后,两组间SAS分值和SDS分值均有明显差异(P<0.05),治疗组SAS分值和SDS分值下降幅度较对照组为显著。结果表明,治疗组患者的焦虑程度较治疗前明显减轻,对照组无明显变化；两组穴方均可改善患者抑郁症状,但治疗组在改善焦虑抑郁程度方面明显优于对照组。(2)两组有焦虑抑郁状态(SAS积分>45或SDS积分>50)的患者,组间及各组治疗前后SAS和SDS积分比较：针刺治疗3个疗程后,治疗组SAS分值和SDS分值均明显下降(P<0.05)；对照组SAS分值无明显变化(P>0.05),SDS分值明显下降(P<0.05)；治疗后两组间SAS分值、SDS分值均有显著性差异(P<0.05),治疗组下降显著。结果提示,治疗组患者的焦虑程度明显减轻,对照组焦虑程度无明显改变,两种穴方均可使患者抑郁症状改善,说明治疗组在改善SAS分值和SDS分值方面优于对照组,且改善焦虑抑郁程度较对照组明显。2.两组患者生命质量积分比较：(1)两组全部患者,组间及各组治疗前后AQLQ积分比较：经3个疗程治疗后,与本组治疗前比较,治疗组在改善AQLQ总分、活动受限(A分)、症状影响(B分)、情感功能(C分)及环境刺激(D分)均有统计学差异(P<0.05),积分明显上升。对照组总分和A分、B分、C分组积分明显上升(P<0.05)。治疗组A分明显高于对照组。结果提示,两组患者治疗后的生命质量整体状况都有改善,治疗组在改善活动受限方面优于对照组。(2)两组有焦虑抑郁状态患者,组间及各组治疗前后AQLQ积分变化比较：经3个疗程治疗后,与本组治疗前比较,两组治疗后AQLQ积分均明显升高(P<0.05),说明两组焦虑抑郁状态患者治疗后生命质量整体状况都有改善。进一步评价AQLQ各个能区,结果提示：与本组治疗前比较,治疗组A分、B分、C分、D分积分均明显上升(P<0.05),表明有精神障碍状态患者治疗后的活动受限、症状影响、情感功能和环境刺激方面都有改善；对照组的A分、B分、D分积分均上升(P<0.05),C分无明显变化(P>0.05),提示有精神状态患者治疗后除情感功能无明显改善外其余均有提高。治疗后两组差值比较AQLQ总分、A分、B分、C分均有统计学差异(P<0.05),D分积分差值无统计学意义(P>0.05),说明治疗组在改善活动受限、症状影响、情感功能方面优于对照组。3.两组患者临床症状(白天和夜间症状日记)积分比较：(1)两组全部患者,组间及各组治疗前后日记症状积分比较：针刺治疗3个疗程后,患者治疗前后白天和夜间症状积分变化显示,与治疗前相比,治疗后两组患者白天和夜间症状积分都明显下降(均P<0.05),两组间白天和夜间症状积分均无明显差异(P>0.05)。提示治疗组与对照组穴方都能明显改善和哮喘有关的白天和夜间症状。(2)两组有焦虑抑郁状态的患者,组间及各组治疗前后日记症状积分比较：针刺治疗3个疗程后,治疗组治疗后较治疗前白天和夜间症状积分均明显下降,(P<0.05)；对照组治疗后白天和夜间症状积分均无明显下降,(P>0.05)；治疗后,组间比较,治疗组积分较对照组明显下降(P<0.05)。4.哮喘控制测评：采用ACT哮喘控制测量表测评,治疗3个疗程后,两组全部患者,治疗前后ACT积分均明显的升高(P<0.05)。表明两组穴位都有控制哮喘症状的疗效；对两组患者中有精神障碍状态者治疗前后的积分进行比较,治疗组在改善ACT积分方面优于对照组。5.两组患者肺功能变化比较：(1)两组全部患者,组间及各组治疗前后肺功能变化比较：针刺治疗3个疗程后,与本组治疗前比较,两组患者的肺功能指标FEV1&、FEV1/FVC%均明显升高(均P<0.05)；治疗后两组间比较,FEV1%、FEV1/FVC%及治疗前后组内差值无明显差异(P>0.05)。结果说明,两组穴方均能明显改善哮喘患者的肺功能。(2)两组有焦虑抑郁状态患者,组间及各组治疗前后肺功能变化比较：针刺治疗3个疗程后,与本组治疗前比较,两组患者的肺功能指标FEV1%、FEV1/FVC%均明显升高(均P<0.05)；治疗后两组间FEV1%、FEV1/FVC%及治疗前后组内差值均无明显差异(P>0.05)。结果表明,伴有焦虑抑郁状态的两组哮喘患者,经针刺治疗后,肺通气功能均明显改善,但两组之间肺通气功能的改善无明显差异。结论：1.针刺调神能够改善有焦虑抑郁状态哮喘患者的焦虑和抑郁症状,对照组穴方仅能改善有抑郁状态患者的抑郁症状。提示有焦虑抑郁状态哮喘患者加用调神穴位进行治疗,能够明显减少焦虑和抑郁的症状,获到最佳的疗效。2.针灸调神治疗能够改善有精神障碍状态的哮喘患者活动受限,症状影响,情感功能,环境刺激状况,提高哮喘患者整体生命质量；在改善活动受限、症状影响、情感功能方面较常规针刺治疗有一定的优势。3.针刺调神能够减轻有精神障碍状态哮喘患者的白天症状和夜间症状,针刺调神较常规针刺治疗在减轻有精神障碍状态哮喘患者的白天症状和夜间症状方面具有明显的疗效优势。4.针灸调神和常规治疗均能改善哮喘患者和有精神障碍状态哮喘控制的疗效,但在有精神障碍状态患者当中治疗组穴方的哮喘控制优于对照组。哮喘患者哮喘控制情况均得到改善,并且与肺功能检测结果有较好的相关性。5.针灸调神和常规针刺治疗均能改善哮喘患者和有精神障碍状态的哮喘患者的肺通气功能,减少气道阻力。两种穴方在改善肺通气功能方面无明显差异。更多还原

【Abstract】 Bronchial asthma, a refractory respiratory condition, is prevalent among internal medicine diseases. It is a chronic condition closely related to psychosocial effects. While acupuncture treatment on asthma onset is effective, severe attack requires conventional medical management. During remission periods, different acupuncture technics can be applied such as: moxibustion, topical application on acupuncture points and acupuncture point injection. Research about the mechanism of acupuncture in ventilation improvement and immune system strengthening is complex and there are remaining problems that need to be solved. In absence of a complete cure, the present goals of asthma treatment are asthma relapse control and life quality improvement. The present research objective is the observation of the mechanism of mind regulating in the acupuncture treatment of persistent chronic bronchial asthma.Objective:observation of the mind regulating method in the acupuncture treatment of persistent chronic bronchial asthma was implemented in order to obtain a comprehensive evaluation of its mechanism and efficacy.Methods:Subjects were randomly distributed in the treatment group (selection of points for the mind regulation in addition to points for standard asthma treatment) and in the control group (selection of points for standard asthma treatment) with 30 subjects in every group. Point selection criteria:main prescription points for the control group were BL13 Feishu, EX-B1 Dingchuan, CV17 Shanzhong, LU7 Lieque, LU5 Chize and LI4 HeGu. As for the treatment group GV20 BaiHui, EX-HN3 YinTang, PC6 Neiguan and LR3 TaiChong were added to the points prescribed in the control group main prescription. For each group associated points were added:BL20 Pishu (for spleen deficiency pattern), BL23 Shenshu (for kidneys deficiency pattern). LI20 Yingxiang in case of nasal obstruction or rhinorrhea, ST40 Fenglong in case of cough with expectoration, Tian Tu in case of severe dyspnea. Needling techniques:in both groups the points belonging to the main prescription were used systematically, as for the associated points they were selected according to the symptomatology. Points located on the thoracic area were inserted first with the patient lying supine. After the Qi response was obtained on the acupuncture point, a neutral stimulation was applied on each point for about 10 seconds and thereafter the needles were left in situ for 15 minutes. During that interval each needle was manipulated once, combining rotating with the thrusting and pulling technique for about 10 seconds on each point in order to strengthen the Qi response and increase the needle sensation. Afterwards the operation was repeated again for the points located on the dorsal area, following the same protocol as above. Indicators:1) Emotional state indicators:Zung Self-Rating Anxiety Scale (SAS) and Zung Self-Rating Depression Scale (SDS) were used to evaluate the asthmatic patient emotional condition before and after treatment.2) Life quality evaluation:The Asthma Quality of Life Questionnaire (AQLQ) was used to evaluate the asthma patient quality of life before and after treatment.3) Asthma symptoms:the asthma diary was used to evaluate night and day time asthma symptoms.4) Assessment tables:Asthma Control Test (ACT) was used to evaluate the state of asthma control.5) Pulmonary function testing:forced expiratory volume in one second (FEV1) and the ratio of FEV1 to the forced vital capacity (FEV1/FVC) were used to evaluate the pulmonary function before and after treatment.Results:1.Comparing emotional states:1) comparing global level of anxiety with SAS scores in both groups after 3 month of treatment. In the treatment group both SAS and SDS showed an evident drop in scores (P<0.05), as for the control group there was an evident drop in SDS scores (P<0.05). Comparing SAS and SDS scores, between the two groups, showed a significant difference (P<0.05) and both SAS and SDS drop in scores were more evident in the treatment group. The results indicate that there is an evident improvement in the level of anxiety for the patient in the treatment group which is not the case for the control group. Point from both prescriptions can improve depressive symptoms, but the effectiveness in reducing anxiety and depression is superior in the treatment group.2) Comparing patients with anxiety and depression disorders in both groups (SAS积分>45、SDS积分>50) showed a drop in SAS and SDS scores for asthmatic patients with mental disorder belonging to the treatment group (P<0.05). There was no evident drop in the SAS scores in the control group (P>0.05) but the SDS scores did drop significantly (P<0.05). There was a significant difference in SAS and SDS drops after treatment between the two groups (P<0.05), the treatment group showed a significant drop in scores. This indicates that for the patients in the treatment group the anxiety level was reduced significantly, as for the control group there was no significant reduction. Both group point prescription can improve depressive symptoms.This result indicates that the treatment group does have a major improvement in SAS and SDS scores compared to the control group with a higher improvement of the levels of anxiety and depression.2. Evaluating quality of life:1) comparing AQLQ scores within every group after three treatment periods showed an improvement in both groups for overall AQLQ scoring. The treatment group in its AQLQ sub groups:activity reduction (subgroup A), symptoms influence (subgroup B), emotional function (subgroup C) and environment stimuli (subgroup D) showed a significant score increase after treatment (P<0.05). The control group AQLQ subgroups A, B and C showed a significant score increase after treatment (P<0.05). Results were higher in A subgroup with the treatment group compared to the control group. This indicates an improvement of life quality after treatment in both the treatment group and control group patients and that the treatment group had a superior efficacy in improving patient movement limitations compared to the control group.2) comparing AQLQ scores in patients with mental disorders (SDS>50 or SAS>45) in every group showed a rise in overall AQLQ scoring after three treatment periods within either the treatment group and the control group (P<0.05). This indicates an improvement of life quality, in patient with mental disorders, after treatment in both the treatment group and control group. As for evaluating AQLQ subgroups within the treatment and control group, scoring rose significantly (P<0.05) for A, B, C and D subgroup in the treatment group indicating an improvement in movement limitation, symptom influence, emotional function and environment stimuli in patients with mental disorders. As for the control group there was a significant score rise in subgroup A. B and D (P<0.05) with no significant score rise in the C subgroup (P>0.05). This indicates that there was an improvement in all areas, for patients with mental disorders, except for emotional function area. Comparing the difference between the two groups after treatment showed that there was a significant difference for overall scoring as well as A, B and C subgroups (P<0.05), as for D subgroup there was no significant difference (P>0.05) which indicates that the treatment group has major efficacy in improving the patient movement limitation, symptoms influence and emotional function compared to the control group.3. Comparing clinical symptoms:1) comparing night time and day time overall symptoms scores in both groups. Comparing the results before and after a 3 month treatment course, scores dropped significantly in both the treatment group and the control group (P<0.05), there was no significant difference in night time and day time symptom scoring between the two groups (P>0.05). This indicates that both group point prescription can improve significantly asthma related night time or day time symptoms.2) Comparing scores changes in patients with anxiety and depression disorders in both groups (SAS>45、SDS>50) before and after treatment. The treatment group showed an evident drop in scores in night time and day time symptoms after treatment (P<0.05), among the patients with mental disorders, which was not the case with the control group (P>0.05). Comparing the results between the two groups after treatment showed an evident major drop of scores in the treatment group compared to the control group. 4. Asthma control evaluation:Asthma Control Test was used to evaluate overall score changes in each group. After three treatment periods there was a significant rise in ACT scores in both the treatment group and the control group (P<0.05) which indicates that prescription points from both groups have a positive effect in the control of asthma symptoms. As for patients with mental disorders, both groups also showed evident rise in overall scores after treatment (P<0.05) with a higher scoring in the control group compared to the control group.5. Comparing pulmonary function:1) comparing pulmonary function changes in every group before and after treatment showed that, after three treatment periods, there was an index increase in pulmonary function FEV1%,FEV1/FVC% in both the treatment group and the control group (P<0.05). Comparing pulmonary function results after treatment between the treatment group and the control group as well as the difference in each group before and after the treatment, did not show any significant difference (P>0.05). This indicates that acupuncture points from both groups can improve asthmatic patient’s pulmonary function.2) Pulmonary function index FEV1%, FEV1/FVC% showed significant increase after treatment (P<0.05), within each group, in patients with mental disorders (SDS>50 or SAS>45) in the treatment group as well as the control group. Comparing FEV1%,FEV1/FVC% after treatment, between the two groups, as well as the difference in each group before and after the treatment did not show any significant difference (P>0.05). This result indicates that there is a significant improvement in pulmonary ventilation, in asthmatic patients with mental disorders (SDS>50 or SAS>45), after acupuncture treatment with points from both groups and that the difference in pulmonary ventilation improvement between the two groups is not significant.Discussion:1. Acupuncture treatment with the method of regulating the mind can improve anxiety and depression symptoms in patients suffering from anxiety and depression condition, but acupuncture points belonging to the control group can only improve depression symptoms in depressed patients. This indicates that there is a major efficacy in improving anxiety and depression symptoms, in asthmatic patients suffering from anxiety and depression condition, when applying the mind regulating method in acupuncture treatment.2. The acupuncture method of regulating the mind can improve the movement limitations, the symptoms influence, the emotional function and environment stimuli in the asthmatic patients with mental disorders, thus improving his overall quality of life. Major efficacy in improving movement limitations, symptoms influence and emotional function was shown when applying the mind regulating points compared to the standard asthma group of points.3. The acupuncture method of regulating the mind is efficient in reducing night time and day time symptoms in patients with mental disorders. Using the acupuncture method of regulating the mind has a major efficacy, compared to the standard asthma acupuncture treatment, in reducing day time and night time symptoms in patients with mental disorders.4. The acupuncture method of regulating the mind and the standard asthma acupuncture treatment both can improve asthma control levels in asthmatic patients whether they suffer from mental disorders or not, but the improvement is more evident in patients with mental disorders when using points from the treatment group. The improvement of asthma control was correlated with the improvement of the pulmonary function.5. The acupuncture method of regulating the mind and the standard asthma acupuncture treatment both can improve the ventilatory function and reduce airway resistance in overall patients and patients with mental disorders. In fact, there was no significant difference in ventilatory function improvement when selecting points from these two different prescriptions.更多还原