【作者】 贾超；

【导师】 庄礼兴；

【作者基本信息】 广州中医药大学 ， 针灸推拿， 2009， 博士

【摘要】 目的:探讨靳三针疗法对脑梗塞后偏瘫患者不同时期神经功能缺损、综合功能、肢体活动能力、日常生活能力的影响,进一步规范靳三针疗法在脑梗塞后不同时期的取穴、针刺角度、深度、刺激方法等参数,促进靳三针疗法治疗脑梗塞后偏瘫的标准化与规范化。方法:选择120例符合脑梗塞诊断标准,发病在2周-3个月内的偏瘫患者,按照1:1:1的比例,随机分为靳三针组40例、康复组40例和靳三针结合康复组40例。3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,给予拜阿斯匹林防止血小板聚集,给予胞二磷胆碱以营养神经,对症治疗、防治并发症等。治疗方法:(1)弛缓瘫:靳三针组:取穴:主穴:颞三针、手三针、足三针。随症配穴:口角歪斜加口三针;语言不利、吞咽困难加舌三针。辨证配穴:肝阳暴亢加太冲;风痰阻络加丰隆;气虚血瘀加足三里;阴虚风动加太溪。所有穴位均规范针刺方法、刺激方法、行针次数等参数。康复组:康复训练方案主要依据人民卫生出版社卫生部规划教材《康复医学》第三版制定。操作包括:床上良肢位摆放,关节被动活动,防止关节挛缩和变形,床上活动,起坐训练,桥式运动,兴奋性促进手法如利用联合反应、共同运动,感觉刺激(拍打、挤压)诱发主动运动。靳三针加康复组:其治疗方案为靳三针治疗同时加康复治疗,具体方法如上述。(2)痉挛瘫:靳三针组:取穴:颞三针、上肢挛三针、下肢挛三针。随症配穴:失语加舌三针;口角歪斜加口三针;腕关节严重痉挛加腕三针;踝关节内翻加踝三针;上下肢痉挛无法伸展加开三针;指趾浮肿加八邪、八风。辨证配穴同上。所有穴位均规范针刺方法、刺激方法、行针次数等参数。康复组:操作包括:缓解肌张力,坐位平衡训练,坐站转换,立位平衡训练,步行训练,上肢控制能力训练。靳三针加康复组其治疗方案为靳三针治疗同时加康复治疗,具体方法见上述。疗程均为28天,康复和针刺治疗每周5次,休息2天再继续治疗,共治疗4周;常规基础药物治疗28天。结果:1.神经功能缺损评分变化三组治疗14天后、28天后均较治疗前有显著性差异(P＜0.05与P＜0.01)。三组治疗前、治疗14天后神经功能缺损程度评分组间比较未见明显差异(P＞0.05),治疗28天后三组之间两两比较,靳三针加康复组神经功能缺损程度明显轻于康复组(P＜0.05),而靳三针组与康复组、靳三针加康复组之间均未见明显差异(P＞0.05);三组数据采用平行轮廓分析F=2.322,P=0.048＜0.05,说明三组组间轮廓不相似(不平行),即三组评分在时间上的变动趋势不相同,从三组轮廓上可以明显看出治疗28天后靳三针加康复组神经功能缺损改善最好。2.四肢简化Fugl-Meyer评分比较三组治疗14天后、28天后上肢FM评分均较治疗前有显著性差异(P＜0.05与P＜0.01)。三组治疗前、治疗后14天三组间评分比较未见明显差异(P＞0.05),治疗28天后三组间两两比较,靳三针加康复组上肢简化Fugl-Meyer评分组间明显优于康复组(P＜0.05),而靳三针组与康复组、靳三针加康复组之间均未见明显差异(P＞0.05)。三组数据采用平行轮廓分析F=8.940,P=0.000＜0.01,说明三组组间轮廓不相似(不平行),即三组评分在时间上的变动趋势不相同,从三组轮廓上可以明显看出,在治疗28天后靳三针加康复组上肢FM评分改善最好。三组治疗14天后、28天后下肢FM评分均较治疗前有显著性差异(P＜0.05与P＜0.01)。三组治疗前、治疗后14天下肢简化Fugl-Meyer评分组间比较均无明显差异(P＞0.05),治疗28天后三组之间两两比较,靳三针加康复组评分明显优于靳三针组和康复组(P＜0.05),而靳三针组与康复组之间未见明显差异(P＞0.05)。三组数据采用平行轮廓分析F=0.182,P=0.000＜0.01,说明三组组间轮廓不相似(不平行),即三组评分在时间上的变动趋势不相同,从三组轮廓上可以明显看出在治疗28天后靳三针加康复组下肢FM评分改善最好。从上肢、下肢轮廓图上均可以看出靳三针加康复组在治疗14天后,功能改善有一个飞跃,提示经过规范的靳三针治疗和康复治疗14天后,患者上肢、下肢功能明显改善,表明针刺与康复治疗具有良好的协同作用。3.功能综合评定量表的变化靳三针组和靳三针加康复组在治疗14天后、28天后FCA评分均较治疗前有显著性差异(P＜0.05与P＜0.01),康复组在治疗14天后与治疗前未见明显差异(P＞0.05),治疗28天后均治疗前有显著性差异(P＜0.01)。三组治疗前、治疗14天后功能综合评定量表评分组间比较未见明显差异(P＞0.05),治疗28天后三组之间两两比较,靳三针加康复组功能综合评定量表评分明显优于康复组(P＜0.05),而靳三针组与康复组、靳三针加康复组之间均未见明显差异(P＞0.05);三组数据采用平行轮廓分析F=3.448,P=0.009＜0.01,说明三组组间轮廓不相似(不平行),即三组评分在时间上的变动趋势不相同,从三组轮廓上可以明显看出在治疗28天后靳三针加康复组FCA评分改善最好。4.日常活动能力的影响靳三针组和靳三针加康复组治疗14天后、28天后ADL评分均较治疗前有显著性差异(P＜0.05与P＜0.01),康复组治疗在治疗14天后与治疗前未见明显差异(P＞0.05),28天后较治疗前有显著性差异(P＜0.01)。三组治疗前、治疗后14天、治疗后28天日常生活活动能力评分组间比较均无明显差异(P＞0.05)。三组之间的两两比较显示,在治疗28天时,靳三针加康复组优于康复组(P＜0.05),而靳三针组与康复组未见明显差异(P＞0.05)。三组数据采用平行轮廓分析F=3.548,P=0.008＜0.01,说明三组组间轮廓不相似(不平行),即三组评分在时间上的变动趋势不相同,从三组轮廓上可以明显看出在治疗28天后靳三针加康复组ADL评分改善最好。结论:靳三针疗法、康复疗法和靳三针结合康复疗法均可明显改善脑卒中后偏瘫的临床症状,减轻神经功能缺损,改善肢体功能活动,提高综合功能,改善日常生活能力。靳三针疗法结合康复的疗效优于单纯采用靳三针疗法和康复疗法,而靳三针疗法疗效与康复疗法之间未见明显差异。在脑梗塞早期,靳三针疗法和康复的介入同等重要,针刺与康复具有良好的协同作用。更多还原

【Abstract】 Objective:To investigate the effect of Neural function Deficient Scale(NDS), Functional Comprehensive Assessment(FCA),simplified Fugl-Meyer assessment(FMA) and Activities of Daily Living(ADL),that is Barthel Index(BI) in treatment of hemiplegia after cerebral infarction using Jin’ 3-Needl therapy.To standardize point’ s selection,acupuncture point of view, depth,stimulating methods of Jin’ s 3-Needl in the treatment of hemiplegia after cerebral infarction,to promote the standardization and the standardization of Jin’ s 3-Needle.Method:120 cases met the diagnostic criteria for cerebral infarction,the incidence in 2 weeks -3 months in patients with hemiplegia,in accordance with the ratio of 1:1:1,were randomly divided into Jin’ s 3-Needl group of 40 patients,the rehabilitation group of 40 cases and the Jin’ s 3-Needl combination rehabilitation group of 40 cases.The drug therapy in the 3 groups is based on reference to "China’s disease prevention and treatment of brain Guide"(Ministry of Health Disease Control Division of Neurology Institute of the Chinese Medical Association,2005) program to control blood pressure, blood sugar,regulate blood lipids,to give thanks aspirin to prevent platelet gathered Citicoline given to nutrition nerves,symptomatic treatment,and prevent complications.Treatment methods:(1) flaccid paralysis:Jin’ s 3-needle group:the main point:the temporal three-needle,hand 3-needle,foot needle 3-needle.Distribution points:the numbness of the mouth plus the skew 3-needle;language disadvantage,difficulty swallowing plus tongue 3-needle. points with differentiation:liver-yang violence:Taichong;wind and phlegm blocking channel:Fenglong;Qi deficiency and blood stasis:Zusanli;pneumatic deficiency:Taixi.Acupuncture points are all the way to regulate the parameters such as the method of acupuncture,stimulation and the times moving needles and so on.Rehabilitation groups:The rehabilitation training program mainly based on "rehabilitation medicine"(the third edition) published by People’s Health Publishing House.Operation include:displaying good limb; joint passive motion to prevent joint contracture and deformation;bed activities;up training;bridge movement;excited about the promotion of practices such as use of a joint response to the common movement,sensory stimulation(tapping,squeezing ) induced by active exercise.Jin’s 3-needle plus rehabilitation groups:the treatment including the treatment of Jin’ s 3-needle and rehabilitation treatment at the same time,the specific method as above.(2)spastic paralysis:Jin’ 3-needle group:Selection:temporal three needles,Luan 3-needles in upper limb and lower limbs,distribution points: plus tongue 3-needle;the numbness of the mouth plus the skew 3-needle;severe spastic wrist plus wrist 3-needle;ankle varus plus ankle 3-needl e;upper and lower limb plasticity can not be extended plus Kai 3-needle.finger and toe swelling increases Eight-xie and Eight-feng.Points with differentiation are as above.Acupuncture points are all the way to regulate the parameters such as the method of acupuncture,stimulation and the times moving needles and so on.Rehabilitation groups:operations,including:ease muscle tension; sitting balance training;sit converter station;orthostatic balance training; walk training;training in upper limb control.Jin’ 3-needle therapy plus rehabilitation group:the treatment including the treatment of Jin’ s 3-needle and rehabilitation treatment at the same time,the specific method as above. The method is as above.Treatment were 28 days,rehabilitation and acupuncture treatment 5 times a week,rest two days to continue treatment,a total of four weeks treatment;conventional drug therapy is 28 days.Results:1.Changes in NDSThe scale of three groups after treatment of 14 days and 28 days 1 were significantly different than those before treatment(P <0.05 and P <0.01). The scale of three groups before treatment,14 days after treatment were no significant difference among groups(P>0.05),the NDS of Jin’ 3-needle plus rehabilitation group is obvious light in the rehabilitation group(P<0.05) after treatment of 28 days between the three groups comparisons,there is no significant differences between Jin’ s 3-needle group and respectively rehabilitation group,Jin’ 3-needle plus rehabilitation group(P>0.05). three sets of data analysis using parallel contour:F =2.322,P=0.048 <0.05, note the outline of the three groups are not similar between groups(parallel), or three sets of ratings changes in time trends are different,from the three sets of contours can be clearly seen that the NDS of Jin’ 3-needle plus rehabilitation group is the best improvement in functional impairment,then Jin’ s 3-Needle group.2.Changes in Limb simplified FMAThe FM score of three groups after treatment of 14 days and 28 days were significantly different(P<0.05 and P<0.01) than those in the upper limbs before treatment.There is no significant difference among the three groups before treatment,and after 14 days treatment.The score of Jin’ s 3-needle plus rehabilitation group is better than the rehabilitation group(P<0.05), but there is no no significant differences between Jin’ s 3-needle group and respectively rehabilitation group,Jin’ 3-needle plus rehabilitation group(P>0.05).three sets of data analysis using parallel contour:F = 8.940, P= 0.000<0.01,note the outline of the three groups are not similar between groups(parallel),or three sets of ratings changes in time trends are different,from the three sets of contours can be clearly seen that the FM score of Jin’ 3-needle plus rehabilitation group is the best improvement in functional impairment after 28 days treatment.The FMA score of three groups after treatment of 14 days and 28 days were significantly different(P<0.05 and P<0.01)than those in the lower limbs before treatment.There is no significant difference among the three groups before treatment,and after 14 days treatment.The score of Jin’ s 3-needle plus rehabilitation group is better than the rehabilitation group(P<0.05), but there is no significant differences between Jin’ s 3-needle group and respectively rehabilitation group,Jin’ 3-needle plus rehabilitation group(P>0.05).Three sets of data analysis using parallel contour:F = 0.182, P= 0.000 <0.01.note the outline of the three groups are not similar between groups(parallel),or three sets of ratings changes in time trends are different,from the three sets of contours can be clearly seen that the FMA of Jin’ 3-needle plus rehabilitation group is the best improvement in functional impairment after 28 days treatment.From the upper limb,lower limb contour maps can be seen Jin’ s 3-needle plus rehabilitation group after 14 days treatment has a leap of functional improvement,suggesting that after the treatment 14 days with Jin’ s 3-needle standardized treatment and rehabilitation,the function improves significantly in upper limb and lower limb,indicating that acupuncture treatment and rehabilitation have good synergy.3.Changes in FCAThe FCA score of Jin’ s 3-needle groups and Jin’ s 3-needle plus rehabilitation group in the treatment after 14 days,28 days were significantly different than those of pre-treatment score(P<0.05 and P <0.01),There was a significant difference after 28 days before treatment in the rehabilitation group(P<0.01).There is no significant difference among the three groups before treatment,and after 14 days treatment.The score of Jin’ s 3-needie plus rehabilitation group is better than the rehabilitation group(P<0.05), but there is no significant differences between Jin’ s 3-needle group and respectively rehabilitation group,Jin’ 3-needle plus rehabilitation group(P>0.05).Three sets of data analysis using parallel contour:F=3.448, P=0.009<0.01.note the outline of the three groups are not similar between groups(parallel),or three sets of ratings changes in time trends are different,from the three sets of contours can be clearly seen that the FCA of Jin’ 3-needle plus rehabilitation group is the best improvement in functional impairment.4.Changes in ADLThe ADL score of Jin’ s 3-needle groups and Jin’ s 3-needle plus rehabilitation group in the treatment after 14 days,28 days were significantly different than those of pre-treatment score(P<0.05 and P<0.01),There was a significant difference after 28 days before treatment in the rehabilitation group(P<0.01).There is no significant difference among the three groups before treatment,and after 14 days and 28 days treatment.The comparison between the three groups showed that The score of Jin’ s a-needle plus rehabilitation group is better than the rehabilitation group(P<0.05),but there is no significant differences between Jin’ s a-needle group and respectively rehabilitation group,Jin’ 3-needle plus rehabilitation group(P)0.05).Three sets of data analysis using parallel contour:F=3.548, P=0.008<0.01.note the outline of the three groups are not similar between groups(parallel),or three sets of ratings changes in time trends are different,from the three sets of contours can be clearly seen that the ADL of Jin’ 3-needle plus rehabilitation group is the best improvement in functional impairment after 28 days treatment.Conclusion:Jin’ s 3needle therapy,rehabilitation therapy and Jin’ s 3-needle therapy combined with rehabilitation can significantly improve clinical symptoms of hemiplegia after stroke and reduce neurological deficits and improve physical function,improve function,improve daily living skills. However,three-needle therapy combined with Jin rehabilitation more effective than simply using Jin’ s 3-needle therapy and rehabilitation therapy,Jin’ s 3-needle and rehabilitation have the same effect.The intervention of Jin’ s 3-needle therapy and rehabilitation are equally important early in the cerebral infarction.Acupuncture and rehabilitation have good synergy.更多还原