【作者】 徐厚平；

【导师】 王小云；

【作者基本信息】 广州中医药大学 ， 中医妇科学， 2009， 博士

【摘要】 研究背景亚健康状态是指人的机体虽然检查无明显疾病,但呈现出疲劳,活力、反应能力和适应力减退,创造能力较弱,自我有种种不适的症状的一种生理状态。失眠是亚健康状态最为常见的证候,亚健康状态失眠是指与现代生活方式相关的原因所引起的睡眠节律(生物钟)的紊乱而致经常不易入睡,或睡后易醒,或早醒的一种状态,是大脑机能平衡失调引起的功能性疾患。中医认为人的睡眠过程是五脏六腑功能协调,气血畅达、营卫交会的结果,其中尤与心、肝、脾、肾关系密切。失眠的发生系机体内伤七情、外感六淫、饮食不节、年迈病后或者禀赋不足等多种原因,引起脏腑机能失调,营卫失和,阳不入阴所导致。失眠在我国的发生率达29.9%。临床上失眠的治疗方法多种多样,概括起来主要有镇静催眠药物治疗、中医辨证论治、非药物治疗等。据调查,普通人群对失眠采取的对策有:服安眠药33.4%,看医师22.3%,喝中药14.5%,喝酒13.1%等等,对失眠治疗的总体满意度只有45.9%。从目前治疗失眠的现状来看,许多问题尚待解决。失眠治疗的目标首先是建立良好的睡眠卫生习惯和正确的睡眠认知功能,教育患者学会控制与纠正各种影响睡眠的行为与认知因素,改变与消除导致失眠慢性化的持续性因素。其次是帮助患者重建较“正常”的睡眠模式,恢复正常的睡眠结构,摆脱失眠的困扰。因此,在使用药物安眠以前,失眠的治疗应该从培养睡眠卫生和纠正不良睡眠习惯开始。虽然单一的非药物治疗也能达到一定的治疗效果,但是采用心理行为治疗与药物治疗相结合的方法可以增强治疗效果,这种增强是通过药物治疗的快速效果和心理行为治疗的持续作用实现的。非药物治疗包括睡眠卫生教育、认知行为治疗、针灸治疗、推拿治疗、穴位敷贴治疗、光照治疗等。非药物治疗的首要原则是“睡眠卫生”,这对各种原因引起的失眠都是必要的,当失眠严重而睡眠卫生宣教和/或其他非药物治疗无效时,药物治疗才成为首选。目前最常用于治疗失眠的镇静催眠药包括第2代苯二氮卓类如阿普唑仑、氯硝西泮等和第3代非苯二氮卓类如思诺思。虽然这些药物对不同的失眠都有改善作用,但由于患者无法耐受副作用和害怕药物依赖而常常求诊于中医,中药因为副作用相对较小,容易被失眠者接受。中医根据不同的病因病机和临床表现进行辨证论治,经过几千年的临床实践,积累了大量行之有效的验方。可以预计中医药将符合治疗失眠理想药物的更多特征。目前中医药对失眠治疗方案的欠缺在于虽然治疗方法种类繁多,但大都凭各自经验,不易重复验证,缺乏规范化的临床研究设计,标准化的随机双盲及远期疗效观察。基于中医药对亚健康状态认识和干预方面的优势,以及目前尚缺乏干预亚健康失眠状态安全、有效和公认的治疗方案的现状,本课题组在前期工作的基础上,针对亚健康失眠状态人群提出我们设计的治疗方案,中医特色睡眠卫生宣教加中医药辨证论治。首先,亚健康失眠状态主要由于不良的生活方式造成睡眠节律紊乱,采用中医养生保健理念纠正不良睡眠习惯、改变歪曲的睡眠认知非常重要,这些因素既可能是失眠的诱因,也会促使失眠慢性化;其次,对亚健康失眠者进行中医药辨证论治。研究目的1.研究特定人群睡眠质量,筛选亚健康失眠者;研究亚健康失眠状态的中医证型分布情况,筛选亚健康失眠主要中医证型;研究亚健康失眠失眠程度特征。2.探讨中医特色睡眠卫生宣教加中医药辨证论治对亚健康失眠的治疗作用,探索亚健康失眠治疗方案。研究方法1.对551名护士应用匹兹堡睡眠质量指数量表进行量表测量,对146亚健康失眠者应用亚健康失眠中医证型调查表做量表调查。2.采用随机对照试验设计,将40例亚健康失眠者随机分配入对照组和试验组各20例,对照组采用中药辨证论治治疗,试验组采用辨证论治加中医特色睡眠卫生宣教治疗,疗程为4周,治疗前后均进行匹兹堡睡眠质量指数量表、亚健康中医证候评定量表、WHO生存质量测定量表简表和临床医生总体印象(根据访谈)CGI等的测量。研究结果1.护士群体睡眠质量存在问题,低睡眠质量率达45.19%;护士群体的睡眠质量问题与年龄、作息制度等因素有关。亚健康失眠状态的常见中医证型有阴虚火旺型、心脾两虚型、肝郁化火型、痰热内扰型、心胆气虚型等,其中以阴虚火旺型(41.1%)和心脾两虚型(26.7%)最为常见。146名亚健康失眠者PSQI总分均＞7分,其中以8-12分轻度失眠为主(约80.1%)。2.通过本研究随机对照试验研究结果显示,定性分析治疗后两组的PSQI总分正常和异常例数,试验组为19例和1例,对照组为14例和6例,即试验组的睡眠质量完全改善率为95%,对照组的睡眠质量完全改善率为70%(P＞0.05),提示定性分析两组在改善睡眠质量方面没有明显差异,定量分析两组各自的治疗效果,40例亚健康失眠者治疗前后PSQI各维度分及总分比较,结果显示试验组在睡眠质量、入睡时间、睡眠时间、睡眠效率、日间功能五个维度及PSQI总分治疗前后比较差异有统计学意义(P＜0.05),对照组在睡眠质量、入睡时间、日间功能及PSQI总分治疗前后比较有统计学意义(P＜0.05),表明两组亚健康失眠者者治疗前后睡眠质量均有改善。两组亚健康失眠者治疗后匹兹堡睡眠质量指数量表各维度及总分比较,结果显示两组治疗后匹兹堡睡眠质量指数量表各维度及总分比较在入睡时间、睡眠时间、日间功能和PSQI总分差异有统计学意义(P＜0.05),提示试验组在改善入睡时间、睡眠时间、日间功能和PSQI总分方面优于对照组,表明试验组在改善睡眠治疗方面效果优于对照组。在中医症状改善方面,结果提示试验组的总有效率为100%,而对照组的总有效率达90%(P＞0.05),表明定性分析两组在改善中医症状方面比较无明显差异;两组治疗前后中医症候计分组内比较有统计学意义(P＜0.05),表明两组均能改善亚健康失眠人群中医症候。两组治疗后中医症候计分比较,结果显示,两组亚健康失眠者中医症候比较差异无统计学意义(P＞0.05),表明两组在改善中医症候效果方面没有明显差异。定量分析两组治疗前后WHO生存质量测定量表生理领域、心理领域、社会关系领域、环境领域和主观感受得分比较,结果显示两组在治疗前后WHO生存质量测定量表生理领域、心理领域、社会关系领域、环境领域和主观生存质量感受得分组内比较差异有统计学意义(P＜0.05),表明两组在生存质量各领域及主观生存质量感受均有改善。两组治疗后WHO生存质量测定量表生理领域、心理领域、社会关系领域、环境领域和主观感受得分比较,结果显示在心理领域、社会关系领域和主观生存质量感受比较差异有统计学意义(P＜0.05),表明试验组在改善WHO生存质量测定量表心理领域、社会关系领域和主观生存质量感受方面作用效果优于对照组。在临床医生总体印象方面,试验组显著进步11例,进步8例,稍进步1例,而对照组显著进步7例,进步11例,稍进步2例。比较两组亚健康失眠者治疗后CGI评分情况,结果显示两组亚健康失眠者治疗后CGI评分情况比较差异无统计学意义(P＞0.05),表明两组在改善CGI方面的效果方面比较无明显差异研究结论1.护士群体睡眠质量存在问题,护士群体睡眠质量远低于其他人群,应该采取相关措施改善护士的睡眠质量。护士群体的睡眠质量问题与年龄、作息制度等因素有关。亚健康失眠状态的中医证型以阴虚火旺型和心脾两虚型最为常见。亚健康失眠人群的失眠程度以轻度失眠为主。2.中医特色睡眠卫生宣教加中医辨证治疗能够改善亚健康失眠人群的睡眠质量,中医特色睡眠卫生宣教加中医辨证治疗能够提高亚健康失眠人群生存质量。中医特色睡眠卫生宣教加中医辨证治疗干预亚健康失眠状态在改善亚健康失眠人群睡眠质量、生存质量方面较单纯中医辨证治疗效果好。更多还原

【Abstract】 BackgroundSub-health state of the body means that although the checks were no significant disease,but showed fatigue,vitality,responsiveness and adaptability to diminish the ability to create a weak,self-there are symptoms of a physiological state.Insomnia is the most common sub-health syndrome, sub-health state of insomnia is the modern way of life associated with the causes of the sleep rhythm(biological clock) is often difficult due to sleep disorders,or easy to wake up after sleeping,it’ s a state of imbalance is caused by brain functional disorder.Chinese medicine practitioners believe that the process of people’s sleep function is the coordination of organs, blood and accessibility,the results of Ying and Wei Fair,which particularly with the heart,liver,spleen,kidney close.Department of the occurrence of insomnia internal body Seven,Six Exogenous,diet,aging or illness,such as endowments less than a variety of reasons,causing organ dysfunction,business Wei disharmony,caused by yin-yang nothing.The occurrence rate of insomnia in china is 29.9 percent.Clinical treatment of insomnia in a wide range,can be summed up in the treatment of sedative and hypnotic drugs,traditional Chinese medicine syndrome differentiation,non-drug treatment.According to the survey,the general population take measures to insomnia are:sleeping pills to 33.4 percent,22.3 percent see a doctor,14.5 percent of Chinese medicine to drink,alcohol 13.1% and so on,the overall treatment of insomnia,only 45.9%satisfaction.From the current status of treatment of insomnia,many issues to be resolved.First of all,the goal of the treatment of insomnia is to establish good sleep hygiene practices and proper sleep cognitive function,education, patients learn to control and correct the effects of sleep behavior and cognitive factors that lead to change and the elimination of persistent chronic insomnia factors.The second is to help the reconstruction in patients with more "normal" sleep mode,the resumption of normal sleep architecture,from the troubled sleep.Therefore,the use of drugs in sleep before the treatment of insomnia sleep training should be to correct the adverse health and sleep habits.Although a single non-drug treatment can achieve a certain therapeutic effect,but the use of psychological-behavioral therapy with a combination of drug therapy can enhance the therapeutic effect,which is enhanced through the rapid effect of drug treatment and psychological role of behavior therapy to achieve sustained.Non-pharmacological treatments include sleep hygiene education,cognitive behavioral therapy,acupuncture therapy,massage therapy, Point Application therapy,light therapy.Non-pharmacological treatment of the primary principle is "sleep hygiene",which caused a variety of reasons for insomnia are necessary,when severe insomnia and sleep hygiene education and / or other non-drug therapy fails,drug therapy has become the first choice.At present,the most commonly used to treat insomnia include sedative-hypnotics No.2 on behalf of benzodiazepines such as Alprazolam, Clonazepam,etc.and 3 on behalf of non-benzodiazepines such as Zolpidem. Although these drugs have been improved in a different role in insomnia,but patients can not tolerate the side effects and drug-dependent and are often afraid to seek treatment in Chinese medicine,Chinese medicine because of side effects is relatively small,easy to accept insomnia.After thousands of years of clinical practice,a large number of the accumulation wree established. Chinese medicine can be expected in line with the treatment of insomnia to be more characteristic of an ideal drug.Chinese medicine treatment of insomnia is that although the lack of a wide range of treatments,but mostly by their own experience,not easy to repeat the verification,the lack of standardization of clinical study design,standardization of the randomized, double-blind and long-term curative effect.Chinese medicine based on the sub-health state of awareness and intervention areas,and the current lack of state intervention sub-health insomnia safe,effective and accepted treatment of the status quo,in the preparatory work of the Task Force on the basis of population for sub-health state of insomnia design our treatment programs,Chinese characteristics and increase in sleep medicine health Treatment and Education.First of all,mainly due to sub-health state of insomnia adverse lifestyle rhythm sleep disorders, the use of Chinese medicine concept of health care to correct bad sleep habits, changes the distorted perception of sleep is very important to both of these factors may be the incentive for insomnia,chronic insomnia will be prompted of;Secondly,the sleepless sub-health Treatment in Chinese medicine.Objective:1.Study on the quality of a specific group of people sleep,Explore the characteristics of Chinese medicine sleep2.Health Treatment and Education of Chinese Medicine plus sub-health role in the treatment of insomnia.Method:1.Application for 551 nurses Scale Pittsburgh Sleep Quality Index(PSQI) for measuring scale on the 146 sub-health applications sleepless insomnia sub-health TCM Syndrome Scale questionnaire survey done.2.A randomized controlled trial design,will be 40 cases of insomnia were randomly assigned to sub-health to the control group and 20 cases of the experimental group,control group Treatment using Chinese medicine treatment, the pilot group of sleep characteristics of syndrome differentiation of TCM increases the treatment of health education,treatment for 4 weeks,both before and after treatment for Pittsburgh Sleep Quality Index Scale,sub-health TCM Syndrome Scale,WHO Quality of Life BREF and the determination of clinicians overall impression(based on interviews) CGI and other measurements.Result:1.Nursing groups has problems in sleep quality,low sleep quality rate of 45.19%;nurses groups sleep quality with age,factors such as the rest of the system.Sub-health insomnia TCM common state of deficiency type Huowang type,Heart-type deficiency,stagnation of liver-type of fire,heat inside the disturbance type,heart type,such as false courage,of which deficiency Huowang type(41.1%) and Heart deficiency type(26.7%) most common.146 sleepless sub-health PSQI scores were＞7 minutes,with mild insomnia mainly 8-12 minutes(about 80.1%).2.Through randomized controlled trials of this study results showed that a qualitative analysis of two groups after treatment PSQI scores the number of normal and abnormal cases,test group and 19 cases of group 1 cases,the control group 14 cases and 6 cases,that is,sleep quality test group fully improve the rate of 95%,the control groups to improve the quality of sleep was 70%(P＞0.05),test group tips to improve sleep quality in the group not better than the control group.Improve symptoms in traditional Chinese medicine,the results suggest that test group total effective rate was 100%, while the control group total effective rate was 90%(P＞0.05),show that the test group of Chinese medicine in improving the symptoms the same as the control group.Improvement in quality of life in the psychological field,the field of environment and subjective insomnia sub-health feelings three aspects of quality of life by comparing score before and after treatment,test group scored higher than the control group,suggesting that test group to improve the quality of life should be better than the control group.Doctors in the clinical aspects of the overall impression,test group 11 persons significant progress,progress 8,1 is slightly better,while significant progress the control group 7,progress of 11,2 is slightly better(P＜0.05).Conclusion:1.Nursing groups has problems in sleep quality,sleep quality groups of nurses is far lower than that of other groups,should take the relevant measures to improve the sleep quality of nurses.Sleep quality nursing groups with age, factors such as the rest of the system.Sub-health state of insomnia to TCM Syndrome and Heart deficiency Huowang the most common type.Degree of of Sub-health stste of insomnia in people is mild insomnia mainly.More women than men suffer from insomnia sub-health state of a high proportion of 30-year-old medical staff following a high proportion of sub-health state of insomnia,tertiary and postgraduate education of medical personnel is also a higher state of sub-health insomnia.2.sleep characteristics of Chinese medicine TCM Canada Health and Education can improve the treatment of insomnia crowd sub-health sleep quality,Sleep characteristics of Chinese medicine TCM health education plus treatment can improve the quality of life in the crowd sub-health insomnia. Sleep characteristics of Chinese medicine health education intervention plus TCM treatment of insomnia sub-health state TCM treatment better than a simple effect.更多还原