【作者】 辛昕；

【导师】 庄礼兴；

【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：中风后肌张力增高是中风偏瘫患者常见的并发症,严重影响患者的肢体功能恢复及生活质量。本课题探讨经筋刺法、温针法及透刺法三种不同针刺法对中风后痉挛性偏瘫患者的神经功能缺损、肢体痉挛程度、运动功能和日常生活能力的影响,评价这三种疗法对中风后痉挛性偏瘫的作用优势,对中风后偏瘫痉挛状态的改善进行疗效评价及方案优化选择,以便为众多此类患者寻求更为有效、直接、肯定的治疗方法,并为临床针灸治疗中风后肌张力增高提供科学的依据。方法：1、病例选择：90例符合诊断标准和纳入标准的中风后肢体痉挛性瘫痪患者,随机分为经筋刺法组、温针组、透刺组各30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,对症治疗、防治并发症等。3、治疗方法：“经筋刺法组”取穴：以患侧肢体肩、肘、腕、掌指、髋、膝、踝等关节附近肌腱两侧的压痛点为主穴,以痛为腧；“温针法组”取穴：患侧上肢：肩髑、尺泽、手三里、合谷,患侧下肢：风市、足三里、阳陵泉、三阴交；“透刺法组”取穴：患侧上肢取穴为肩髑透臂臑、曲池透少海、外关透内关、合谷透后溪,患侧下肢取穴为伏兔透殷门、阴陵泉透阳陵泉、三阴交透悬钟、昆仑透太溪。每组穴位均按规定的具体针刺方法、针刺角度、针刺深度、行针次数等参数进行操作。4、疗程：每组每日操作一次,5天一疗程,休息2天后进行下一个疗程,共治疗3个疗程,共21天。常规基础药物治疗21天。5、疗效评定：对所有患者均于治疗前、后分别采用国家中医药管理局脑病急症协作组中风病诊断与疗效评定标准量表、临床神经功能缺损程度量表(NDS)、日常生活能力量表(ADL)、修改的Ashworth痉挛量表、临床痉挛指数CSI量表五方面对三种针刺法的治疗效果进行观察及分析评价。结果：1、国家中医药管理局脑病急症协作组中风病诊断与疗效评定标准量表评分(1)总分比较：组内比较：三组治疗前后比较(P<0.01),透刺组、经筋组及温针组均有较为显著的疗效。组间比较：经两两比较,透刺组与经筋刺组比较(P<0.01)、透刺组与温针组比较(P<0.05)、经筋组与温针组比较(P<0.05)说明三组治疗方法均能降低患者国家中医药局脑病急症诊疗标准量表总分值,三组病例的改善程度依次为：经筋组>温针组>透刺组。(2)程度比较：三组病例在治疗后程度方面比较显示,透刺组轻型的比例由73.3%增加到83.3%；经筋组轻型的比例由53.3%增加到100%；温针组轻型的比例由53.3%增加到76.7%。说明三组病例经治疗后程度均有好转,其中经筋组最为明显。(3)疗效比较：三组病例经治疗后,透刺组的有效率为70%,经筋组有效率为96.7%,温针组有效率为86.7%,三组改善程度依次为：经筋组>温针组>透刺组。2、临床神经功能缺损程度(NDS)量表评分(1)总分比较：组内比较：三组治疗前后比较(P<0.01),说明透刺组、经筋组及温针组均有较为显著的疗效。组间比较：经两两比较,透刺组与经筋刺组比较(P<0.01)、透刺组与温针组比较(P<0.05)、经筋组与温针组比较(P<0.05)说明三组治疗方法均能降低患者NDS总分值,三组病例的改善程度依次为：经筋组>温针组>透刺组。(2)各项目评分比较：言语方面在组内及组间比较(P>0.05)说明三组治疗无显著差异。面瘫方面组内治疗前后差值比较,经筋组和温针组(P<0.05)有一定改善效果；各组间比较(P>0.05)说明三组病例的改善程度在此方面没有显著差别。上肢肩关节肌力、手肌力组内治疗前后差值比较,三组在上肢肩关节肌力方面均有提高,且有统计学意义(P<0.01)；在手肌力方面,只有温针组与经筋组较治疗前有改善(P<0.01)；组间经两两比较,透刺组与经筋刺组比较(P<0.01)、透刺组与温针组比较(P<0.05)、经筋组与温针组比较(P<0.05)说明三组病例均可以改善上肢肩关节肌力,温针组与经筋组可以改善手肌力,三组病例的改善程度依次为：经筋组>温针组>透刺组。下肢肌力、步行能力三组组内治疗前后差值比较(P<0.01)差异均有统计学意义；组间经两两比较,透刺组与经筋刺组比较(P<0.01)、透刺组与温针组比较(P>0.05)、经筋组与温针组比较(P<0.05)说明三组病例均可以改善下肢肌力和步行能力,但以经筋组为最显著,温针组与透刺组无显著差别。3、日常生活活动能力(ADL)量表评分(1)总分比较：组内比较：三组病例经过治疗后,日常生活活动能力评分P值均小于0.05,说明三组病例均较治疗前有所改善,且以经筋组的改变值为最大。组间比较：治疗前后差值比较(P>0.05)三组差异无统计学意义；说明三组病例在日常生活活动能力评分总分方面的改善程度无显著性差异。(2)程度比较：三组病例在日常生活活动能力(ADL)量表缺陷程度比较方面,治疗前(P>0.05)三组间无统计学差异；治疗后(P>0.05)差异无统计学意义,说明三组在改善ADL缺陷程度方面无明显的差异。4、修改的Ashworth量表评分组内比较：三组病例修改的Ashworth量表评分治疗前后比较,经筋组和温针组(P<0.01)透刺组(P>0.05)说明经筋组及温针组均有改善上肢肢体痉挛的疗效。组间比较：透刺组与经筋组比较(P<0.05)、透刺组与温针组比较(P<0.01)、经筋组与温针组比较(P<0.05)说明三组治疗方法在改善上肢痉挛程度方面,改善程度依次为：温针组>经筋组>透刺组。5、临床痉挛指数CSI量表评分(1)总分比较：组内比较：三组病例临床痉挛指数CSI量表评分总分治疗前后比较(P<0.01)说明透刺组、经筋组及温针组治疗前后均有较为显著的疗效。组间比较：三组病例治疗前后差值比较(P<0.05)三组间存在差异；经两两比较,透刺组与经筋组比较(P<0.01)、透刺组与温针组比较(P<0.01)、经筋组与温针组比较(P<0.01)说明三组治疗方法均能改善下肢痉挛程度,三组病例的改善程度依次为：温针组>经筋组>透刺组。(2)各项目比较：组内比较：三组病例在腱反射、肌张力方面治疗前后比较(P<0.05)、在阵挛方面,温针组治疗前后(P<0.05)说明透刺组、经筋组及温针组均可以改善患者下肢腱反射、肌张力状况,此外,温针组还可以改善下肢阵挛情况。组间比较：在腱反射方面,经两两比较,透刺组与经筋组比较(P>0.05)、透刺组与温针组比较(P<0.01)、经筋组与温针组比较(P<0.01)说明三种方法在改善下肢腱反射中,温针组改善最为明显,经筋组与透刺组之间的差异无统计学意义。在肌张力方面,经两两比较,透刺组与经筋组比较(P<0.01)、透刺组与温针组比较(P<0.01)、经筋组与温针组比较(P<0.01)说明三种方法在改善下肢肌张力异常增高方面中,温针组优于经筋组,经筋组优于透刺组。在阵挛方面,治疗前后差值(P>0.05)说明三组病例在阵挛方面治疗无明显差异。结论：透刺组、温针组及经筋组在国家中医药管理局脑病急症协作组中风病诊断与疗效评定标准量表、临床神经功能缺损程度评分方面均有一定程度的好转,尤其在改善上肢肩关节肌力、下肢肌力和步行能力方面,三组均有良好的治疗效果,但以经筋组疗效最为显著。本研究中将上肢的痉挛程度评定采用修改的Ashworth评分,下肢的痉挛评定程度采用CSI量表评分。研究结果表明：经筋组及温针组均能较明显的改善上肢痉挛状态,其中以温针组改善最为明显。三组均能有效的改善下肢痉挛程度,尤其在腱反射和下肢肌张力方面,以温针组改善最为明显。更多还原

【Abstract】 ObjectiveHypermyotonia of flexors is a common complication in patients with hemiplegia after stroke and severely affects patients’recovery of neural and muscular functiona and reduces their quality of lives. The effects of musculature puncture therapy (MPT), needle warming therapy (NWT) and penetration needling therapy (PNT) on neurologic impairment, spasticity, motor function, activities of daily living (ADL) of spastic hemiplegia patients after stroke were observed. The research helps to evaluate the therapeutic effect of the three methods on spastic hemiplegia after stroke and provides the best treatment to patients with hemiplegia spasticity after stroke. It has good value of clinical application to effectively, directly and positively prevent the occurrence and aggravation of spasm. Moreover, the effective clinical therapy is a scientific proof for spastic hemiplegia after stroke.Methods1. Selection of subjects: ninety cases subjecting to diagnostic criteria and inclusion criteria of spastic hemiplegia after stroke were enrolled into the study. During the experiment, the patients were randomized into MPT group (N=30), NWT group (N=30) and PNT group (N=30). 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, and aspermin for preventing platelet aggregation. 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 in2005. If necessary, symptomatic treatment, and prevention and cure of complications were also carried out.3. Therapies:In MPT group, the main acupoints consisted of the pain points near patients’shoulder, elbow, wrist, hip, knee, metacarpophalangeal joint, ankle. In NWT group, there were four points in upper limbs, including qianyu, chize, shousanli,hegu and there were four points in lower limbs, including fengshi, zusanli, yanglingquan, sanyinjiao;In PNTgroup, we adopted penetrating from the point to point, including from jianyu to binao, from quchi to shaohai, from waiguan to neiguan, from hegu to houxi, from futu to yinmen, from yinlingquan to yanglingquan, from sanyinjiao to xuanzhong, from kunlun to taixi. The manipulation of all the acupoints was carried out subjecting to the specified requirement.4. Period of treatment:The period of treatment in the three groups lasted21days. Every group was performed5times a week, and continued after2-day break for3weeks. The basic drug treatment lasted21days in the three groups.5. Evaluation of therapeutic effect:Before treatment and after treatment, The changes of the five indexes were observed for the evaluation of the therapeutic effect, including Acute stroke diagnosis and curative effect evaluation criteria of State Administration of traditional Chinese medicine clinical neurologic impairment degree scale (NDS), modified Ashworth scale, clinical spasticity index(CSI), and activities of daily living (ADL) with Barthel’s index.Results1. Acute stroke diagnosis and curative effect evaluation criteria of State Administration of traditional Chinese medicine(1) Comparison of total score:Within every group, P<0.01, there was statistical significance and it showed that every group had good effect on treatment. Between groups, The differences of scores in the three groups were insignificant before treatment (P>0.05). The results of difference comparison after treatment showed that P was less than0.05between PNT group and NWT group, between MPT group and NWT group, moreover, P was less than0.01between PNT group and MPT group. It showed that every group reduced the total score on acute stroke diagnosis and curative effect evaluation criteria of State Administration of traditional Chinese medicine, and the therapeutic effect was best in the MPT group, and then came NWT group and PNT group. (2) Comparison of degree:After treatment, the light ratio increased from73.3%to83.3%in PNT group, from53.3%to100%in MPT group and from53.3%to76.7%in NWT group. It showed it help to improve the degree of disease for every group and the MPT group was the best among groups.(3) Comparison of curative effect:the total effects were70%,96.7%and86.7%in PNT group, MPT group and NWT group respectively. The differences in the three groups were significant (P<0.05) after treatment and the therapeutic effect was best in the MPT group, and then came NWT group and PNT group.2.Scores of neurologic impairment (NDS)(1) Comparison of total score:Within every group,(P<0.01) there was statistical significance and it showed that every group had good effect on treatment. Between groups, The results of difference comparison showed that P was less than0.05between PNT group and NWT group, between MPT group and NWT group, moreover, P was less than0.01between PNT group and MPT group. It showed that every group reduced the total score of NDS and the therapeutic effect was best in the MPT group, and then came NWT group and PNT group.(2) Comparison of different symptoms:For comparison of speech within every group and between groups, P was larger than0.05and it meant that there was no statistical significance. It showed that every group had not significance difference on treatment.For comparison of facial paralysis within every group,(P<0.05) there was statistical significance in MPT and NWT groups. Between groups, The differences of scores in the three groups were insignificant (P>0.05). The results shows that there is no significance difference among three groups.For comparison of muscle strengths of shoulder and hand within every group, P was less than0.01in the muscle strengths of shoulder in every group and in the muscle strengths of hand in NWT and MPT groups. Between groups, The results of difference comparison showed that P was less than0.05between PNT group and NWT group, between MPT group and NWT group, moreover, and P was less than0.01between PNT group and MPT group. It showed that every group improved the muscle strengths of shoulder and MPT and NWT groups improved the muscle strengths of hand too. The therapeutic effect was best in the MPT group, and then came NWT group and PNT group.For comparison of muscle strengths of lower limbs and walking ability within every group, P was less than0.01in the muscle strengths of lower limbs and walking ability in every group. Between groups, The results of difference comparison showed that P was less than0.05between PNT group and NWT group, between MPT group and NWT group, moreover, P was less than0.01between PNT group and MPT group. It showed that every group improved the muscle strengths of lower limbs and walking ability. The therapeutic effect was best in the MPT group, and there is no significant difference between NWT group and PNT group.3. Activities of daily living (ADL) with Barthel’s index.(1) Comparison of total score:Within every group,(P<0.05) there was statistical significance and it showed that every group had good effect on treatment. Between groups, The differences of scores in the three groups were insignificant (P>0.05) after treatment and and it shows that there has no significant difference on three groups.(2) Comparison of degree:Before treatment,(P>0.05) there was no statistical significance on three groups. After treatment, The differences of degree in the three groups were insignificant (P>0.05) and it showed that there had no significant difference in three groups.4. modified Ashworth scale.Within every group:P were less than0.01in MPT and NWT groups. Additionally, P were larger than0.05in PNT group.It showed that MPT and NWT groups had good effect on improvement spasticity of the upper limbsBetween groups, The results of difference comparison showed that P was less than0.05between PNT group and MPT group, between MPT group and NWT group, moreover, P was less than0.01between PNT group and NWT group. It showed that every group improved the spasticity of the upper limbs. The therapeutic effect was best in the NWT group, and then came MPT group and PNT group.5. clinical spasticity index(CSI)(1) Comparison of total score:Within every group:P were less than0.01in three groups. It showed that every group had good effect on improvement spasticity of the lower limbsBetween groups:The differences of scores in the three groups were statistical significant (P<0.05). The results of difference comparison showed that P was less than0.01between PNT group and MPT group, between MPT group and NWT group and between PNT group and NWT group. It showed that every group improved the spasticity of the lower limbs. The therapeutic effect was best in the NWT group, and then came MPT group and PNT group.(2)Comparison of different symptoms:Within every group:P were less than0.05in three groups for the tendon reflex and muscle tone of the lower limbs, and P were less than0.05in NWT group for clonus of the lower limbs. It showed that every group had good effect on the tendon reflex and muscle tone of the lower limbs and NWT group had good effect on clonus of the lower limbs.Between groups:For comparison of the tendon reflex, P was larger than0.05between PNT and MPT group, moreover P was less than0.01between MPT and NWT group and between PNT and NWT group.It showed that every group improved the tendon reflex of the lower limbs. The therapeutic effect was best in the NWT group, and there was no significance difference between PNT and MPT groupFor comparison of the muscle tone, P was less than0.01among three groups. It showed that every group improves the muscle tone of the lower limbs. The therapeutic effect was best in the NWT group, and there was no significance difference between PNT and MPT group. The therapeutic effect was best in the NWT group, and then came MPT group and PNT group.For comparison of the clonus, between groups, the differences of scores in the three groups were insignificant (P>0.05) after treatment and it showed that there had no significant difference in three groups for the clonus of the lower limbs.ConclusionThe effects of musculature puncture therapy (MPT), needle warming therapy (NWT), penetration needling therapy(PNT) on acute stroke diagnosis and curative effect evaluation criteria of State Administration of traditional Chinese medicine and clinical neurologic impairment degree scale (NDS) were remarkable, especially for muscle strengths of shoulder, muscle strengths of lower limbs and walking ability. Additionally, musculature puncture therapy was the best on these ways.The research adopted the modified Ashworth scale to observe the spasticity of the upper limbs and adopted the clinical spasticity index (CSI) to observe the spasticity of the lower limbs. The MPT and NWT groups improved obviously the spasticity of the upper limbs and every group improved obviously the spasticity of the lower limbs, especially the tendon reflex and the muscle tone. Additionally, needle warming therapy was the best on these ways.更多还原