【作者】 郑集诚；

【导师】 赖新生；

【作者基本信息】 广州中医药大学 ， 针灸推拿学， 2008， 博士

【摘要】 目的:本研究观察巨刺配以动气针法远道取穴治疗急性闭合性踝扭伤,既继承运用了古代九刺之一的巨刺法的左病取右,右病取左的思想,又融入了现代解剖学中“运动具有止痛作用”的理论,是古代中医与现代医学的完美结合。本研究首次选用外关透内关,后溪透合谷进行巨刺并配合动气针法治疗急性闭合性踝扭伤,旨在为临床治疗急性踝扭伤提供一种疗效确切、简便廉验的治疗方法。方法:依据《中医病证诊断疗效标准》(1994年)进行诊断。对符合纳入标准的病例分组方法,按损伤Ⅰ、Ⅱ度及病期急性期、亚急性期、恢复期进行分层,可得2×3=6层次,再将每层内的患者进行简单随机化分组。按每层的病例数从随机数字表任一行开始连续选取相应个数的随机数字,单数分至治疗组,双数分至对照组。治疗组:取穴对侧外关透内关、后溪透合谷。用3寸毫针,以后溪作进针点,沿第2、3、4、5掌骨掌侧面徐徐刺入,边捻转边进针,针用泻法,以捻转为主,辅以提插,直至合谷穴下,使2、3、4、5指及掌心均有明显的酸胀感。同样取患者外关进针,直刺至内关穴处。于进针得气后,在捻针的同时,令患者活动患踝,然后根据治疗效果决定出针和留针。留针期间,一面捻针,一面令患者继续不停活动患踝。对照组取穴—阿是穴、申脉、丘墟、解溪、照海、昆仑、太溪。均用泻法。每次留针30分钟。每天针刺一次,7天为1个疗程。分别于治疗前,治疗中(治疗第4日)、1疗程后对相关指标进行观察。筛选无开放性伤口,发病在2周内,以往患踝无扭伤史的患者,并排除中度损伤中不能行走者及严重损伤如血管神经韧带断裂,骨折需行外科骨科治疗者,对针刺治疗过敏或易晕针者,符合纳入标准但不合作者、持续治疗时间不足1周者,共收集急性闭合性踝扭伤病人64例。将其按损伤程度及疾病的分期进行分层随机,得治疗组32人和对照组32人。每天针刺一次,7天为1个疗程。治疗前、治疗中(第四天)及1疗程后对患者的关节疼痛、活动障碍、红热、肿胀、压痛等症状进行评分,对测评结果进行统计分析。采用李仲廉所著《临床疼痛治疗学》中疼痛视觉量表标准评价病情程度,根据依据国家中医药管理局《中医病证诊疗标准》以治疗前后疼痛、肿胀、活动度的评分,分别和总体计算改善率评定疗效。结果:采用t检验和卡方检验对表1数据进行分析,可知治疗前两组患者在性别、年龄、病程及病情、疾病分期等基线情况比较均无显著差异,具有可比性。治疗组与对照组总有效率均为100%,两组总有效例数分布不同,P＜0.05,治疗组的总有效例数主要集中于“治愈”,而对照组的总有效例数主要集中于“好转”,治疗组的治愈率高于对照组。分别对治疗组、对照组、合计组中的Ⅰ度损伤和Ⅱ度损伤的疗效分布情况进行X~2检验,结果三组的P值均＞0.05,表明各级病情程度与疗效无相关性。治疗组的Ⅰ度损伤治愈率(77.9%)大于对照组(63.2%),治疗组的Ⅱ度损伤治愈率(64.3%)大于对照组(58.3%),而对照组的Ⅰ度损伤好转率、Ⅱ度损伤好转率均大于治疗组(36.8%＞22.2%,41.7%＞35.7%)。临床观察结果显示,治疗组和对照组治疗后的评分总分值比治疗前均有显著性差异(P＜0.05),治疗组治疗前后的评分总差值与对照组治疗前后的评分总差值有显著性差异(P＜0.05)。分别对治疗组、对照组、合计组中的Ⅰ度损伤和Ⅱ度损伤的疗效分布情况进行X~2检验,结果三组的P值均＞0.05,表明各级病情程度与疗效无相关性。治疗组的Ⅰ度损伤治愈率(77.9%)大于对照组(63.2%),治疗组的Ⅱ度损伤治愈率(64.3%)大于对照组(58.3%),而对照组的Ⅰ度损伤好转率、Ⅱ度损伤好转率均大于治疗组(36.8%＞22.2%,41.7%＞35.7%)。对治疗组和对照组中急性期、亚急性期、恢复期的三组数据进行比较,得出不同病期对治疗前后症状评分变化值的影响不同(P＜0.05)。对不同时期的治疗组和对照组的各项指标进行t检验,两组的变化分值有显著差异(P＜0.05),治疗组比对照组的变化大。治疗组各项改善率均高于对照组。治疗组对各项症状的改善作用都可达到显效的标准,较为均衡,其中对活动障碍的改善程度较为突出。对照组对肿胀、压痛、疼痛这三个症状的改善作用相对其它症状好,其对各项症状及总体的改善作用只能达到有效的标准。对各项指标治疗中的治疗组和对照组评分,治疗后的治疗组和对照组评分进行比较,疗中关节肿胀度、压痛、关节障碍指数无差异(P＞0.05),其余均有显著差异。此外,两组在治疗7d后各项指标的分值较治疗4d时有明显改善。结论:用巨刺配以动气针法远道取穴治疗急性踝扭伤,在改善改善关节的活动障碍,关节疼痛、红肿、压痛方面有显著疗效,对于急性闭合性踝扭伤,针刺治疗介入越早,治疗效果越好。无论是轻度还是中度,无论是急性期还是亚急性期、恢复期的急性闭合性踝扭伤,巨刺配以动气针法均有较好疗效。巨刺配合动气疗法治疗急性闭合性踝扭伤,对关节活动障碍和关节疼痛的改善最为突出。而传统局部取穴对肿胀、疼痛、压痛的治疗效果相对其它两个症状的效果好。巨刺配合动气疗法治疗急性闭合性踝扭伤的即时止痛效果显著。在改善急性踝扭伤的关节疼痛、红热症状方面,巨刺配合动气疗法较传统针刺法的改善作用大且改善速度快,而在改善关节肿胀度、压痛、关节活动障碍方面,需随着时间的延长,4天以上才显示出比传统针刺法更优越的效果。更多还原

【Abstract】 Objective:This study was to observe the clinical efficacy of opposing needling plus moving Qi therapy on acute closed ankle sprain.To assure the reality and reliability of clinical data,a prospective randomized controlled trial was taken and acknowledged diagnosis and treatment standard was used.It offered not only high strength evidences of evidence-based medicine for opposing needling plus moving Qi therapy on acute closed ankle sprain,but also a simple,convenient,cheap and effective method of treatment on acute closed ankle sprain.Method:According to the Standard of the People’s Republic of China specification:the criteria for diagnosis and therapeutic effect evaluation of diseases and syndromes in traditional Chinese medicine（1994）,patients in 2 weeks after onset,with no open wound,no ankle sprain before,no disability to walk,no rupture of vascular,nerves,ligaments and no fractures which need orthopedic and surgical treatment,were selected.Besides,patients who were allergy to acupuncture or easy to be faint during acupuncture,who are accordance with the inclusion criteria but non-cooperation and whose continuous treatment was less than a week were eliminated.64 acute ankle sprain patients were collected and divided into 2 groups stratified randomly based on their conditions and stages.Each group has 32 patients.The treatment group received opposing needling plus moving Qi therapy.The points on the healthy side were taken,included Waiguan-through-Neiguan and Houxi-through-Hegu.A 3 cun long needle was inserted into Houxi point,then punctured slowly through the palm side of the 2^ndto 5^thmetacarpals until it reached Hegu point.During puncturing,reducing manipulation in which twirling is the major while lifting and thrusting is subsidiary method,was done till the patients felt strongly sour and distend in the palm and the 2^ndto 5^thfingers. The same method was used to puncture Waiguan straightly through Neiguan.After needle insertion and obtaining of needle sensation,let patients exercised the wound ankles while twirling needle.Whether withdrawing the needle immediately or bow long the needle should be retained were based on therapeutic effects.The control group received traditional acupuncture therapy.The points taken are as follow:Ashi point,Shenmai,Qiuxu,Jiexi,Zhaohai,Kunlun, Taixi.Both the treatment group and control group have one 30 minutes treatment a day,7 day for a course.Each patient was evaluated by scoring the clinical symptoms like pain,tumidity,red,fever,tenderness and hypo activity of the ankle before,in the middle（the 14th）and after treatment.All the scores were statistical analyzed.Results:It was found that the total scores in both two groups have a great different after treatment（P＜0.05）.However,the score in treatment group improved more than that in the control group.This indicates that both therapies are useful but opposing needling plus moving Qi therapy is more effective.The improvement rate of each symptom in the treatment group is higher than that in the control group.In the treatment group every symptom improvement rate reaches the effectual criteria,among them the hypo activity of ankle relived most greatly.On the whole,the efficacy of opposing needling plus moving Qi therapy is equilibrium.In the control group,the improvement rates in such symptoms as tumidity,tenderness and pain were relatively greater than others.There was no difference in effect distribution betweenⅠ°andⅡ°patients in the two groups（P＞0.05）.This hinted that there was no relation between condition and effect.Both cure rates ofⅠ°andⅡ°patients in the treatment group were higher than those in the control group.This showed that opposing needling plus moving Qi therapy was more effective in eitherⅠ°orⅡ°patients.Each symptom scores had greatly changed in the two groups in different stages（P＜0.05）.The change in treatment group was greater than that in control group.So in every stage opposing needling plus moving Qi therapy is better than traditional acupuncture therapy.The change in each stage was also different（P＜0.05）:that in the acute stage was biggest,followed by that in the sub acute stage and then the recovery stage.It showed that the earlier the acupuncture therapy was used,the better the result was. The scores on the 7^thday showed more improvement than that on the 4^thday in both groups.This indicated that there was a relationship between treatment course and effect.There was significant difference in symptoms between two groups on the 4^thday except tumidity,tenderness and hypo activity of ankle （P＞0.05）.There was also significant difference in each symptom between two groups after treatment.This hinted that the two therapies were in different speeds while improving different symptoms.To relieve the pain,red and fever of ankle,opposing needling plus moving Qi therapy has faster and better effect. While to relieve the tumidity,tenderness and hypo activity of ankle,there was no much difference between the two therapies in the first four days,but as time passed,opposing needling plus moving Qi therapy showed more effective.Conclusion:Opposing needling plus moving Qi therapy has significant effect in curing acute closed ankle sprain,especially in relieving hypo activity, pain,red,tumidity and tender.It not only inherits the idea of opposing needling,one of the nine needling in ancient," using points on the left side to cure diseases on the right,vice versa",but also absorbs the theory of modern anatomy "exercise can relieve pain".It’ s a perfect combination of traditional Chinese medicine and modern medicine.Since in the acute stage of ankle sprain,local pain,swelling and blood stasis are obvious,needling local point will probably make the patient feel more painful.If the manipulation is unsuitable,it may cause unnecessary wound or secondary infection.Using opposing needling plus moving Qi therapy to treat acute closed ankle sprain can avoid the shortage of needling local points.What’ s more, patients can actively exercise their wound ankle while needling.This helps to dreg qi and blood in the meridians and finally to relieve pain.So opposing needling plus moving Qi therapy is a simple,convenient,cheap and effective method of treatment on acute closed ankle sprain and has great value of clinical application.To cure acute closed ankle sprain,the earlier the acupuncture is used, the better the effect is.Opposing needling plus moving Qi therapy is effective in bothⅠ°andⅡ°patients.So does in acute stage,subacute stage and recovery stage.The relieving effect in hypo activity and pain is most significant.While traditional acupuncture therapy showed relatively better effect in treating tumidity,pain and tenderness than the other two symptoms. Opposing needling plus moving Qi therapy has great immediate analgesic effect. To relieve the pain,red and fever of ankle,opposing needling plus moving Qi therapy has faster and better effect.While to relieve the tumidity, tenderness and hypo activity of ankle,there was no much difference between the two therapies in the first four days,but as time passed,opposing needling plus moving Qi therapy showed a better result.To assure the reality and reliability of clinical data,a prospective randomized controlled trial was taken and acknowledged diagnosis and treatment standard was used in this study.It offers evidence-based medicine for opposing needling plus moving Qi therapy on acute closed ankle sprain.更多还原