【作者】 卿鹏；

【导师】 柴铁劬；

【作者基本信息】 广州中医药大学 ， 针灸推拿学， 2012， 博士

【摘要】 目的：探讨巨刺法结合康复训练对缺血性脑卒中患者肢体功能的影响。同时,通过动物实验,探讨应用巨刺法结合康复训练对脑缺血再灌注损伤大鼠运动功能以及海马区和梗塞灶周围神经生长相关蛋白-43(GAP-43)和突触素(SYP)表达的影响。方法：本课题研究分为临床研究及动物实验研究两个方面：(1)临床研究将符合纳入标准的49例缺血性脑卒中患者随机分为两组,其中治疗组27例,对照组22例。治疗组应用巨刺法结合康复训练进行治疗,具体治疗方法如下：巨刺法：软瘫期选穴：头部取双侧颞三针,上肢取双侧肩髃、曲池、手三里、合谷；下肢取双侧髀关、梁丘、足三里、解溪；痉挛期选穴：头部取双侧颞三针,上肢取双侧肩髎、臑会、天井、外关、后溪；下肢取双侧居骼、殷门、阳陵泉、跗阳、解溪。康复训练法：弛缓阶段(Brunnstrom Ⅰ阶段)：体位摆放；被动运动；床上运动；桥式运动等；痉挛阶段(BrunnstromⅡ～Ⅲ阶段)：床上与床边训练；坐位训练；站立训练；平行杠内行走训练；步行训练等；分离阶段(BrunnstromⅣ～Ⅴ阶段)：行走训练；上肢功能训练。所有患者在按照上述不同训练方法进行肢体运动功能训练的同时,还按照不同患者的不同功能缺陷,进行日常生活活动能力的康复训练；口、面部、语言功能训练。对照组应用常规针刺法结合康复训练进行治疗,具体治疗方法如下：常规针刺法：软瘫期选穴：头部取病灶侧颞三针,上肢取瘫痪侧肩髃、曲池、手三里、合谷；下肢取瘫痪侧髀关、梁丘、足三里、解溪；痉挛瘫选穴：头部取病灶侧颞三针,上肢取瘫痪侧肩髎、臑会、天井、外关、后溪；下肢取瘫痪侧居髎、殷门、阳陵泉、跗阳、解溪。本组康复训练法同巨刺康复组。经过4周治疗后,评定各组患者神经功能缺损、运动功能、日常生活能力等方面的变化。(2)动物实验研究：采用线栓法栓塞实验大鼠大脑中动脉致局灶性脑缺血模型,造模成功后2h,拔除栓线,造成脑缺血再灌注损伤,将造模成功后的实验大鼠随机分组：模型组(9只)、康复组(8只)、常规针刺康复组(8只)、巨刺康复组(9只),增加一组空白对照组(6只),共5组。造模成功24h后,康复组开始进行滚笼、平衡木、转棒、网屏等训练；巨刺康复组开始给予巨刺针法,取穴百会、双侧曲池、足三里,同时又给予康复训练；常规针刺康复组给予常规针刺,取穴百会、瘫侧曲池、足三里,同时又给予康复训练,空白对照组及模型组不做任何干预。各组分别在造模后7d,14d时进行行为学评估综合评分,造模14d后,经灌注固定后断头取脑,用免疫组织化学方法检测海马区及缺血周围区神经生长相关蛋白-43(GAP-43)、突触素(SYP)表达。结果：(1)NDS评分两组患者治疗前后的比较,两组治疗后的NDS评分均显著低于治疗前的NDS评分,差异均有统计学(P<0.05),经治疗后两组病例的NDS评分相比,治疗组显著低于对照组,差异有统计学意义(P<O.05)。(2)MAS评分两组患者治疗前后的比较,两组治疗后的MAS评分均显著高于治疗前的MAS评分,差异均有统计学(P<0.05),经治疗后两组病例的MAS评分相比,治疗组显著高于对照组,差异有统计学意义(P<0.05)。(3)MBI评分两组患者治疗前后的比较,两组治疗后的MBI评分均显著高于治疗前的MBI评分,差异均有统计学(P<0.05),经治疗后两组病例的MBI评分相比,治疗组显著高于对照组,差异有统计学意义(P<0.05)。(4)实验大鼠神经行为学评分术后7d,巨刺康复组大鼠的神经行为学评分显著低于其余三组,差异有统计学意义(P<0.05),其余三组之间无明显差异(P>O.05)；术后14d,巨刺康复组大鼠的神经行为学评分显著低于其余三组,差异有统计学意义(P<O.05),常规针刺康复组大鼠的神经行为学评分显著低于康复组及模型组,差异有统计学意义(P<0.05),康复组及模型组相比较,差异无统计学意义(P>0.05)。(5)GAP-43阳性蛋白的表达与空白对照组相比较,模型组、巨刺康复组、常规针刺康复组、康复组大鼠脑组织GAP-43表达IOD值均明显增加,差异有统计学意义(P<0.05)；康复组与模型组相比较,两组大鼠脑组织GAP-43表达IOD值无明显差异,经统计学分析,差异无统计学意义(P>0.05)；常规针刺康复组与康复组及模型组相比较,常规针刺康复组大鼠脑组织GAP-43表达IOD值明显增加,差异有统计学意义(P<O.05)；巨刺康复组与常规针刺康复组与康复组及模型组相比较,巨刺康复组大鼠脑组织GAP-43表达IOD值明显增加,差异有统计学意义(P<0.05)。(6)SYP表达与空白对照组相比较,模型组、巨刺康复组、常规针刺康复组、康复组大鼠脑组织SYP表达IOD值均明显增加,差异有统计学意义(P<0.05)；康复组与模型组相比较,两组大鼠脑组织SYP表达IOD值无明显差异,经过统计学分析,差异无统计学意义(P>0.05)；常规针刺康复组与康复组及模型组相比较,常规针刺康复组大鼠脑组织SYP表达IOD值明显增加,差异有统计学意义(P<0.05)；巨刺康复组与常规针刺康复组与康复组及模型组相比较,巨刺康复组大鼠脑组织SYP表达IOD值明显增加,差异有统计学意义(P<0.05)。结论：(1)巨刺及常规针刺结合康复训练均能促进缺血性脑卒中患者运动功能、日常生活能力的改善,但巨刺法结合康复训练较常规针刺结合康复训练疗效更显著。(2)针刺治疗、康复训练均能在一定程度上促进MCAO大鼠神经功能的恢复,但是针刺结合康复训练较单纯康复训练疗效显著。而针刺方法上,巨刺法结合康复训练较常规针刺结合康复训练能更快更好地促进MCAO大鼠的恢复。模型组大鼠在造模后存在一定程度上的自然恢复。(3)针刺治疗、康复训练均能促进神经生长相关蛋白-43(GAP-43)及突触素(SYP)的表达,但针刺结合康复训练较单纯康复训练疗效显著,进一步促进了突触重建和突触联系。而在针刺方法上,巨刺法结合康复训练较常规针刺结合康复训练能更快更好地促进MCAO大鼠的中枢神经系统的重塑。更多还原

【Abstract】 ObjectiveTo observe the effects of opposing needling combined with rehabilitation training on the functional improvement of ischemic stroke patients. At the same time, by animal experiment study, To explore the effects of opposing needling combined with rehabilitation training on motor function and the expression of GAP-43, SYP in the hippocampus and around the cerebral infracted area of rats after cerebral ischemia damage.MethodsThis research is divided into two parts:clinical study and animal experimental study:(1) Clinical study49ischemic stroke patients were assigned to the treatment group and control group according to the principle of random, control and blindness. There were29patients in the treatment group and22patients in the control group.The treatment group received opposing needling combined with rehabilitation training, The specific treatment methods are as follows:opposing needling:Flaccid paralysis:the acup-points are the temporal3-needle, Jianyu, Quchi, Shousanli, Hegu, Biguan, Liangqiu, Zusanli, Jiexi on both sides; Spastic paralysis:the acup-points are the temporal3-needle, Jianniao, Naohui, Tianjing, Waiguan, Houxi, Juniao, Yinmen, Yanglingquan, Fuyang, Jiexi on both sides.The rules of rehabilitation:Relaxation phase (Brunnstrom I phase): Keeping normal limbs in good position, Passive movement, Moving on the bed, Bridge-style movement, and so on. Spasticity phase (BrunnstromⅡ-Ⅲ phase): activities on bed and bedside, training on sitting position. training on stand position, walk training and walk inside parallel bars. Separation phase (BrunnstromⅣ-Ⅴphase):Walk training and upper limb function training. All patients in accordance with the different training methods for extremity motor function in training, at the same time, also in accordance with the different patients with different functional defects, to carry out activities of daily living ability, mouth rehabilitation training; language training.The control group received routine needling combined with rehabilitation training, routine needling:Flaccid paralysis:the acup-points are the temporal3-needle, Jianyu, Quchi, Shousanli, Hegu, Biguan, Liangqiu, Zusanli, Jiexi in their paralyzed part of the bodies. Spastic paralysis:the acup-points are the temporal3-needle, Jianniao, Naohui, Tianjing, Waiguan, Houxi, Juniao, Yinmen, Yanglingquan, Fuyang, Jiexi in the paralyzed part of the bodies. The rules of rehabilitation are the same as the treatment group.After4weeks of treatment, all of the patients were evaluated through the Neurologic Deficit Scale (NDS), Motor Assessment Scale (MAS), Modified Barthel Index (MBI).(2) Animal experimental studyEstablishing the animal model of focal cerebral ischemia by using suture method in mature SD rats,2hours later, the thread was withdrawn to resume perfusion, and resulted in cerebral ischemia reperfusion injury. All MCAO models were randomly divided into4groups:model group (n=9), rehabilitation group (n=8), routine needling combined with rehabilitation group (n=8), opposing needling combine with rehabilitation group (n=9). The rats of rehabilitation group were received motor training programs, including balancing, grasping, rotating and walking exercise. The rats of opposing needling combine with rehabilitation group were received motor training programs and opposing needling, the main points were Baihui, Quchi, Zusanli on the both sides. The rats of routine needling combined with rehabilitation group were received motor training programs and routine needling, the main points were Baihui, Quchi and Zusanli in the paralyzed part of the bodies. The behavioral tests of every group were evaluated at the7th,14th day after operation. The animals were decapitated14th day after operation, and immunohistochemistry staining method was used to detect the immune positive expression of Growth Associated Protein43(GAP-43) and Synaptophysin(SYP) of peri-ischemia cortex and hippocampal.Results(1) NDSAfter4weeks therapies, compared with scores before the treatment, there were significant differences in NDS in two group (P＜0.05). After treatment, there were significant difference between treatment group and control group (P＜0.05)(2) MASAfter4weeks therapies, compared with scores before the treatment, there were significant differences in MAS in two group (P＜0.05). After treatment, there were significant difference between treatment group and control group (P＜0.05)(3) MBIAfter4weeks therapies, compared with scores before the treatment, there were significant differences in MBI in two group (P＜0.05). After treatment, there were significant difference between treatment group and control group (P＜0.05)(4) The scores of neuroethology assessment7th day after operation, there were significant difference between opposing needling combine with rehabilitation group and the other three groups (P＜0.05).14th day after operation, there were significant difference between opposing needling combine with rehabilitation group and the other three groups (P＜0.05). Compared rehabilitation group with routine needling combined with rehabilitation group, there were significant difference between the two groups (P＜0.05)(5) The immune positive expression of GAP-43Compared with the blank group, the immune positive expression of GAP-43of the four experiment groups was obviously increased. Compared model group with rehabilitation group, there were no significant difference between the two groups (P>0.05). Compared routine needling combined with rehabilitation group with routine model group and rehabilitation group, there were significant difference between the two groups (P＜0.05). Compared with model group, rehabilitation group and routine needling combined with rehabilitation group, the immune positive expression of GAP-43of the opposing needling combine with rehabilitation group was obviously increased (P＜0.05)(6) The immune positive expression of SYPCompared with the blank group, the immune positive expression of SYP of the four experiment groups was obviously increased. Compared model group with rehabilitation group, there were no significant difference between the two groups (P>0.05). Compared routine needling combined with rehabilitation group with routine model group and rehabilitation group, there were significant difference between the two groups (P＜0.05). Compared with model group, rehabilitation group and routine needling combined with rehabilitation group, the immune positive expression of SYP of the opposing needling combine with rehabilitation group was obviously increased (P<0.05)Conclusion(1) The therapies of routine needling combined with rehabilitation and opposing needling combine with rehabilitation are can promote the motor function of patients with ischemic stroke, improve the activities of daily living. The efficacy of opposing needling combine with rehabilitation is more significant than the efficacy of routine needling combined with rehabilitation.(2) Acupuncture therapy, rehabilitation training can promote the recovery of neural function of the animal model of focal cerebral ischemia in some extent. But the acupuncture combined with rehabilitation is much more effective than simple rehabilitation training. About the acupuncture methods, The efficacy of opposing needling combine with rehabilitation is more significant than the efficacy of routine needling combined with rehabilitation. There is some spontaneous recovery in those rats of model group.(3) Acupuncture therapy, rehabilitation training can promote the immune positive expression of SYP.of the animal model of focal cerebral ischemia in some extent. But the acupuncture combined with rehabilitation is much more effective than simple rehabilitation training, acupuncture can promote the rebuilding of synapses and synaptic connections obviously. About the acupuncture methods, The efficacy of opposing needling combine with rehabilitation is more significant than the efficacy of routine needling combined with rehabilitation.更多还原