【作者】 罗秋燕；

【导师】 靳瑞；

【作者基本信息】 广州中医药大学 ， 针灸学， 2009， 博士

【摘要】 本文系统研究了注意缺陷多动障碍现代医学及中医学方面的文献资料,并从临床和实验角度对针刺治疗注意缺陷多动障碍进行了研究。目的观察针刺治疗注意缺陷多动障碍的临床疗效,并从实验角度对其机理进行初步探讨,为注意缺陷多动障碍的治疗提供新思路。方法临床观察,以美国精神病学会编制的精神障碍《诊断和统计手册》（Diagnostic andStatistical Manual of Mental disorders,DSM）第四版修订版（DSM-Ⅳ-R）关于注意缺陷多动障碍的诊断为诊断标准,将符合诊断及纳入标准的33名6-12岁注意缺陷多动障碍儿童纳入针刺组（靳三针）。基本腧穴处方包括:四神针、定神针、手智针;辨证配穴处方:心脾气虚者配三阴交、足三里;湿热内蕴,痰火扰心者配少府、丰隆;肾虚不足,肝阳偏旺者配太溪、行间。针刺治疗每次1小时,寒暑假期间每天针刺1次,每周六次,上学期间隔天针刺1次,每周三次,45次为一疗程。观测指标:注意缺陷多动障碍儿童Conners父母行为问卷（PSQ）量表,按品行问题、学习问题、心身障碍、冲动一多动、焦虑5个因子得分和多动指数情况对儿童行为进行评定,分别于治疗前、第一个疗程及第二个疗程后分别进行评定,对测评结果进行统计分析。实验研究,选取了多层次模拟了ADHD的临床特征,并被国际公认的且可以参比的动物模型,自发性高血压大鼠（SHR）模型。18只雄性SHR大鼠随机分为针刺组、利他林组、模型对照组,每组6只,另设SPF级正常大鼠6只作空白对照组。治疗情况:针刺组针刺取穴百会、印堂,选用30号华佗牌不锈钢0.5寸毫针,头部穴位平刺,进针后觉针下沉紧即可,每天针刺1次,每次3—5秒钟,共治疗20天;西药组每天灌服利他林水溶液4 mg·kg^-1·d^-1,模型对照组灌服等量的生理盐水,每天上午灌服,1次/d,连续灌服20d。观察SHR大鼠体重变化情况,实验结束后采用高效液相法检测SHR大鼠血清与脑组织去甲肾上腺素（NE）、多巴胺（DA）、5-羟色胺（5-HT）含量并与空白对照组进行比较。结果临床观察结果显示,对治疗前后进行比较,多动指数的分值在治疗后第一疗程、第二疗程与治疗前相比较有显著性差异（P＜0.05）,提示针刺治疗注意缺陷多动障碍是有效的,总有效率达84.85%。Conners父母问卷中的品行问题、学习问题、心身障碍、冲动一多动及焦虑5个因子得分在治疗后第一疗程、第二疗程同治疗前相比较具有显著性差异（P＜0.05）,说明针刺对注意缺陷多动障碍症状的改善是整体的,全面的。6～8岁年龄组的疗效比8⁺～12岁年龄组的好,有显著性差异（x²=9.0659,P＜0.05）,显示年龄与疗效有非常显著性关系,提示年龄小针刺疗效较好;病程≥4年的针刺疗效较差,有显著性差异（P＜0.05）,提示注意缺陷多动障碍儿童应尽早进行针刺治疗,以免错失最佳治疗时机。第二疗程的总有效率比第一疗程显著提高,有显著性差异（P＜0.05）,提示针刺治疗注意缺陷多动障碍的疗效随疗程延长而提高。ADHD类型中混合型的最多,占63.64%,其次是注意缺陷型,占30.3%,多动障碍型最少,占6.06%;ADHD不同类型的针刺疗效有显著性差异（P＜0.05）,显示多动障碍型的疗效较佳。ADHD中医辨证分型中心脾气虚,神失所养型最多,占51.52%,其次是湿热内蕴,痰火扰心型,占36.36%,肾阴不足,肝阳偏旺型较少,占12.12%。ADHD不同证型的针刺疗效有显著性差异（P＜0.05）,显示心脾气虚,神失所养证型的疗效较佳。实验研究方面,针刺组、利他林组大鼠各个测定时间点的体重与模型对照组比较,均无显著性差异（P＞0.05）,针刺组大鼠各个测定时间点的体重与利他林组比较,均无显著性差异（P＞0.05）。提示针刺与利他林治疗对SHR大鼠的体重的影响无差异。模型组血清的NE、DA、5-HT含量浓度均高于空白组,均有显著性差异（P＜0.05）,而模型组脑组织的NE、DA含量浓度均低于空白组,均有显著性差异（P＜0.05）。提示SHR大鼠血清中的NE、DA、5-HT含量浓度是比正常大鼠的升高,而脑组织中的NE、DA含量浓度是比正常大鼠的降低。针刺组、利他林组血清的NE、5-HT含量较模型组均有所升高,DA的浓度较模型组稍降低,均无显著性差异（P＞0.05）,针刺组血清的NE、5-HT含量浓度均低于利他林组,均无显著性差异（P＞0.05）,针刺组血清的DA含量浓度较利他林组降低,有显著性差异（P＜0.05）。针刺组、利他林组的脑组织NE、DA含量与模型组比较,浓度均比模型组的稍升高,均无显著性差异（P＞0.05）,针刺组脑组织的NE、DA含量与利他林组的比较,浓度稍高于利他林组,均无显著性差异（P＞0.05）。以上结果提示针刺组与利他林组较模型组对单胺类神经递质含量的影响无差异,但针刺组降低血清DA含量较利他林组有显著性差异。结论针刺可以改善注意缺陷多动障碍儿童的品行、心身、焦虑问题,减轻冲动多动症状,提高学习能力,针刺治疗注意缺陷多动障碍有效;年龄较小、病程较短的ADHD针刺疗效较好,提示注意缺陷多动障碍儿童应尽早进行针刺治疗,以免错失最佳治疗时机;针刺起效较慢,治疗注意缺陷多动障碍的疗效随疗程延长而提高;针刺对多动障碍型与心脾气虚,神失所养型疗效较佳。SHR大鼠血清的NE、DA、5-HT含量均显著高于正常对照组大鼠,认为血液中单胺类神经递质含量反映交感神经的兴奋性,这很可能是导致ADHD儿童动作、活动过多的原因;而SHR大鼠脑组织中的NE、DA含量均显著低于正常对照组大鼠,证实了儿茶酚胺系统功能不足假说,CA功能不足以致脑的抑制功能不足,这很可能是ADHD患儿注意力不集中、多动冲动的原因之一。针刺组较模型组对单胺类神经递质含量的影响无差异,但针刺组降低血清DA含量优于利他林组。这可能提示针刺治疗SHR大鼠的机理不是通过影响单胺类神经递质来实现的。更多还原

【Abstract】 This text studied the literature of modern medicine and Chinese medicine on attention deficit hyperactivity disorder,and carried on a research about acupuncture from clinical observation and experiment.ObjectiveTo observe the clinical curative effect of acupuncture for treating attention deficit hyperactivity disorder,and mechanism from the experimental point of view of its preliminary study carried out for attention deficit hyperactivity disorder to provide new ideas for treatment.MethodsAt clinical observations,to the preparation of the American Psychiatric Institute of the mental disorders,"Diagnostic and Statistical Manual" (Diagnostic and Statistical Manual of Mental disorders,DSM) fourth and revised edition(DSM-Ⅳ-R) on attention deficit hyperactivity disorder diagnosis for the diagnosis standards,would be consistent with the diagnosis and the standard of 33 6-12 year-old ADHD children into the group acupuncture (Jin three-needle).Prescription:sishenzhen,dingshenzhen,shouzhizhen; modification:deficiency Qi of heart and spleen,sanyinjiao,zusanli;phlegm and fire confusing the heart,shaofu,fenglong;deficiency of kidney and flaring-up of liver-yang,taixi,xingjian.1 hour each time,take acupuncture every day during the winter and summer vacations,six times a week;take acupuncture every two days during going to school,three times a week;45 times as a period of treatment.The outcome measures are Childhood attention deficit hyperactivity disorder rating scale;Conners Parents questionnaire(PSQ) scale.Evaluate was carried on before and after treatment, statistical analysis the values with software of spss 15.0.In experimental studies,spontaneously hypertensive rats(SHR) model was selected,having multi-level simulation of the clinical features of ADHD,and being internationally recognized and referencing the animal model.18 male SHR rats were randomly separated into group acupuncture,group Ritalin,model control group,and six in each group.And another 6 normal rats were set up as blank control group.Treatment:group acupuncture took baihui,yintang, selecting 30th 0.5-inch needles,inserted into the acupoints of head,one time each day,3-5 seconds each time,continued 20 days.Group Ritalin gavaged with Ritalin aqueous solution 4 mg·kg-1·d-1 each morning,model control group fed with the same amount of normal saline each morning,one time each day, continued 20d.To observe the changes of the SHR rats’ weight,after the end of the experiment,the content of noradrenaline(NE),dopamine(DA),and 5-hydroxytryptamine(5-HT) in serum and brain tissue of SHR rats was detected by the therapy of high performance liquid and compared with the blank control group.ResultsClinical observation indicated that a comparison of before and after treatment,the hyperactivity index scores in the treatment of the first course of treatment,the second course of treatment compared with before treatment were significantly different(P＜0.05),clued on acupuncture for treatment of Attention Deficit Hyperactivity Disorder to be effective,total effective rate was 84.85%.Compared with pre-treatment,it was significantly different (P＜0.05) about the 5 factors of morality,learning,psychosomatic disorder, impulse-hyperactivity and anxiety in Conners Parent Questionnaire of the first and the second treatment,showed that acupuncture for Attention Deficit Hyperactivity Disorder was the overall and comprehensive improvement of symptoms.It was significantly different(x~2=9.0659,P＜0.05) between the group of 6～8-year-old and the group of 8~+～12-year-old,and the former was more effective than the latter,showed that the curative effect of the younger was better.Duration≥4 years was poor effective,and the difference was significant(P＜0.05),showed that the children of Attention Deficit Hyperactivity Disorder should be treated with acupuncture as early as possible, so as not to miss the best time of treatment.The second course of treatment was more efficient than the first course of treatment,the difference was significant(P＜0.05),suggesting that the curative effect of acupuncture for ADHD increased with extended treatment.ADHD mixed type was the most, accounting for 63.64 percent,followed by attention deficit-based,accounting for 30.3%,hyperactivity disorder-type was the least,accounting for 6.06%; the curative effect of acupuncture for the different types of ADHD were significantly different(P＜0.05),hyperactivity disorder-type and mixed type showed a better effect.In the TCM Syndrome Types of ADHD,the type of deficiency qi of heart and spleen was the most,accounting for 51.52%,followed by the type of phlegm and fire confusing the heart,36.36%,the type of deficiency of kidney and flaring-up of liver-yang was the least,accounting for 12.12%.The curative effect of acupuncture for the different TCM Syndrome Types of ADHD were significantly different(P＜0.05),the type of deficiency qi of heart and spleen showed a better effect.In experimental research,the measured body weight of rats in the group acupuncture and group Ritalin compared with the model control group in all time points,were no significant difference(P＞0.05),comparing with group acupuncture and group Ritalin,there was also no significant difference (P＞0.05).The body weight of SHR rats was not affected by the treatments of acupuncture and Ritalin.The serum levels of NE,DA,5-HT in Model rats were higher than the concentration of the blank control group,that were significantly different(P＜0.05),and the content of NE and DA in brain tissue of model group,was lower than the concentration of the blank control group, that was significantly different(P＜0.05).The serum levels of NE,5-HT in the group acupuncture and group Ritalin,was little higher,and the serum levels of DA was lower compared with the model group,which were no significant difference(P＞0.05).The serum levels of NE,5-HT of group acupuncture were lower than the concentration of group Ritalin,which was no significant difference(P＞0.05);the serum levels of DA of group acupuncture was lower than the concentration of group Ritalin,which was significant difference (P＜0.05).The levels of NE,DA in brain tissue of the group acupuncture and Ritalin,was little higher compared with the model group,which were no significant difference(P＞0.05).The levels of NE,DA in brain tissue of group acupuncture was higher than the concentration of group Ritalin,which was no significant difference(P＞0.05).These results suggestd that the content of monoamine neurotransmitter was not significantly influenced by the group acupuncture and group Ritalin,but the group acupuncture and group Ritalin were significantly different in reducing the content of DA in serum. ConclusionAcupuncture can improve ADHD in morality,psychosomatic disorder,and anxiety problems,reduce impulse-hyperactivity symptoms,and improve the learning ability,it is effective in treating ADHD by acupuncture.There is better curative effect in smaller age and shorter duration,suggesting the children of Attention Deficit Hyperactivity Disorder should be treated with acupuncture as early as possible,so as not to miss the best time of treatment. Slowly effecting,the curative effect of acupuncture for ADHD increased with extended treatment.There is better curative effect on the type of hyperactivity disorder and Deficiency Qi of heart and spleen by acupuncture. The serum levels of NE,DA,5-HT in SHR rats were significantly higher than the concentration of the normal control group which was considered that the content of monoamine neurotransmitters in blood reflects the sympathetic excitability.It seems likely that the action resulted in the activities of ADHD children;and the content of NE and DA in brain tissue of SHR rats was significantly lower than the normal control group,that was confirmed the hypothesis of deficient function in catecholamine system.CA was insufficiency resulting in the lack of inhibition in brain function,which is likely to be one of the reasons for inattention,hyperactivity impulse of ADHD.The content of monoamine neurotransmitter was not significantly influenced by acupuncture, but group acupuncture was better than group Ritalin in reducing the content of DA in serum.Its treatment mechanism may not relevant with influencing the monoamine neurotransmitter.更多还原