膝关节骨性关节炎中医经筋辨证研究

【作者】 秦谊；

【导师】 李峰；

【作者基本信息】 北京中医药大学 ， 中医诊断学， 2010， 博士

【摘要】 膝关节骨性关节炎(Knee Osteoarthritis, KOA),又称退行性膝骨关节病,增生性膝骨关节炎等,是一种多发于中老年人的慢性骨关节疾患。其病理特点为关节软骨变性、破坏、软骨下硬化,关节边缘和软骨下骨反应性增生、骨赘形成。由于人类预期寿命的延长,人口老龄化问题的日益严重,膝骨关节炎的发病率也明显增加,给家庭和社会造成了巨大的负担。2002年～2012年已被确定为我国的“骨与关节十年”,骨关节炎的研究得到了高度的重视。临床膝骨关节炎患者多存在膝关节骨质增生,使人们对该病的认识多集中到骨性改变,治疗也针对软骨及软骨下骨的骨性改变,往往难以取得良好的疗效。我们在以往的研究中发现膝骨关节炎患者的临床症状表现与骨性改变严重程度不符,更多与关节周围组织病变相关联。这使我们的关注目光投向了关节周围组织—在中医属于经筋范畴的部位。中医膝骨关节炎多归于“骨痹”、“筋痹”、“骨痿”、“筋痿”的范畴。通过对大量古今文献的研究,我们发现,膝关节骨性关节炎从发病、生理病理表现和临床治疗都可以归于经筋病证的范畴。首先,膝关节是人体最大的关节,“膝为筋之府”,膝关节周围软组织即经筋系统的功能正常决定了膝关节正常的生理活动。足三阴三阳经筋都经过并结于膝,膝关节的病变必然与经筋有着密不可分的关系。其次,膝关节骨性关节炎的发病也多与经筋系统有关。1995年国际OA专题研讨会提出OA是力学和生物学因素共同作用下导致软骨细胞、细胞外基质、软骨下骨质三者降解和合成失衡的结果。虽然多种因素的综合作用导致膝骨关节炎的发生,但关节周围组织的力学平衡失调的因素在其中占据了绝大部分,即使生物学因素使关节软骨变性,但关节软骨的磨损乃至骨质增生的形成都主要是由于关节内异常应力的作用。经筋系统的平衡失调仍然是造成膝骨关节炎发病的最主要因素。其三,膝骨关节炎的主要症状是疼痛、僵硬、屈伸不利、肿胀等,这些表现究其原因主要是经筋系统的病变表现。疼痛的部位主要分布于经筋的结筋病灶点,关节的僵硬、屈伸不利也是由于经筋的粘连、挛缩引起。最后,膝骨关节炎的治疗如果只针对关节软骨进行治疗多是暂时的缓解症状,远期疗效不佳。而针对经筋系统的治疗,不论是锻炼肌力还是解除结筋病灶,在临床都取得了不错的疗效。因此我们可以发现膝关节骨性关节炎的本质是一种经筋病证。经筋疗法的核心在于辨证和治疗,作为经筋病证膝关节骨性关节炎,经筋辩证适用于其诊断和治疗。经筋辨证采集信息最常用的手段是经筋手触诊察法,通过检查关节周围软组织,查找异常反应点,据此判断病变性质、严重程度等。手触诊察法是现在临床经筋疗法中运用最为广泛的诊察方法,同时对后期治疗也有重要的指导作用。现代技术在经筋疗法中的运用也逐渐开展,如步态分析技术、软组织张力检测、表面肌电、人体运动影像测量等等,这些技术都是基于膝关节周围力学平衡失调这一膝骨关节炎病变过程中的重要因素来进行检测和分析,但是这些技术尚不成熟,还需进一步完善。经筋病证的治疗从《内经》时代就有了详细的论述,由于经筋病证的关键病变是关节周围软组织的炎症、渗出、粘连、挛缩引起的关节周围力学平衡失调,“解结”是经筋疾病的治疗总原则。临床中治疗经筋病证所用的治疗方法多种多样,主要有火针疗法、理筋手法、针灸治疗、针刀疗法等等,究其原理都是通过对筋结部位的治疗,疏通经络,松解粘连,恢复关节周围力学平衡,以缓解疼痛,通利关节。经筋理论在膝骨关节炎中的应用在临床中已较为广泛,但对其机理及其理论体系的研究鲜有报道,为了完善经筋理论体系,指导临床膝骨关节炎的治疗,我们对膝骨关节炎经筋理论进行了一系列的研究。本研究主要分为两个部分,第一部分是选取经筋疗法的典型代表—针刀松解法和电针疗法作用于膝关节骨性关节炎模型动物,观察其疗效,分析其作用机理；第二部分通过临床调查,总结经筋辨证规律。针刀松解法运用于膝骨关节炎的治疗已有三十余年的历史,取得了不错的临床疗效,其基本原理是通过剥离关节周围软组织的粘连、挛缩,恢复关节力学平衡；电针疗法在《灵枢·官针》刺法的基础上进行了发展,其优势是刺激强度可控,在动物实验和对照研究中有广泛的运用,两者的治疗核心在于“解结”,都是经筋疗法典型代表。本研究通过对兔后肢伸直位制动形成膝关节骨性关节炎,用电针疗法和针刀松解法进行治疗,结果发现两种疗法均可明显改善KOA模兔的疼痛、步态、关节活动度和关节肿胀,其机理可能是针刀松解法作用于关节周围“筋结”部位,使关节周围的力学平衡得到恢复,作用于关节面的异常应力得到解除,电针疗法通过缓解关节周围组织炎症反应,使得骨关节炎的过程被中断,关节软骨细胞和胶原纤维排列和形态得到修复,局部胶原纤维结构紊乱得到改善,最终达到其治疗效果。经筋理论在临床治疗膝骨关节炎中得到了广泛的运用,但对其经筋辨证方法、特点及其规律尚未形成体系,本研究通过对临床膝骨关节炎患者进行规范化的经筋证候调查,同时结合中医证候调查,JOA关节功能评分,分析膝骨关节炎经筋辨证的特点,以及不同经筋证候与中医证候、JOA评分的关系,以探讨膝骨关节炎经筋证候的规律。结果发现,膝骨关节炎经筋证候最常见的为足阳明经筋证型和足太阳经筋证型,各经筋证型的中医证型表现也不尽相同,总体是以肝、脾、肾虚为主,足阳明经筋、足少阳经筋和足三阴经筋以肾虚表现最多,足太阳经筋则以肝虚表现最多,足少阳经筋还有较高比例的肝郁表现,这对我们以后临床进行经筋辨证论治的时候有重要的参考意义。结合JOA评分,我们发现随着病变经筋的数量增多,膝关节功能评分降低,说明病变经筋的数量决定了病情的严重程度。同时各经筋证型从疼痛、活动度、肿胀等单项指标上也有明显的差异,足阳明经筋证型各项指标表现最严重,足少阳经筋证型相对最轻,足太阳经筋证型屈伸单项指标较重,足三阴经筋证型则仅次于足阳明经筋。这对我们临床判断病情也提供了一定的依据,更说明膝骨关节炎的病情轻重与经筋证型有明显的相关性,更加印证了膝关节骨性关节炎是一种经筋病证的观点。本研究从理论、实验和临床的角度阐述了膝关节骨性关节炎的经筋病证实质,对其经筋病变机理,经筋辨证规律,经筋疗法的作用途径进行了系统研究,初步对膝骨关节炎的经筋辨证理论体系进行了探索,为经筋疗法在临床中的运用提供了理论基础,丰富了经筋理论的内容。更多还原

【Abstract】 Knee Osteoarthritis (KOA) also known as degenerative knee osteoarthritis, hypertrophic knee osteoarthritis, etc, which is a chronic multiple degenerative joint disease in middle and aged people. The basic pathological characteristic of it is articular cartilage degeneration, destruction, subchondral sclerosis, reactive hyperplasia of articular cartilage edge and cartilage sending down fishbone and the formation osteophyte. With the extension of human life, serious problems of the aging population have appeared, the incidence of this KOA is increased markedly, which has brought heavy burden to home and society.2002-2012 has been confirmed as "Bone and Joint Decade" so the research of knee osteoarthritis has been paid high attention.In the clinical observation the most KOA patients have knee hyperosteogeny, so the most cognitions of this disease focus on the bone changes, as well as, the treatments are for the bone changes of cartilage and cartilage sending down fishbone, however, it is difficult to gain satisfactory therapeutic effects in some cases. In our previous studies we found that the clinical manifestation of KOA patients disagrees with the severity of the bone changes, but it had more relationships with the surrounding tissues of lesions joints. So we put our attention to the surrounding tissues of joints-the meridian sinew in traditional Chinese medicine.In traditional Chinese medicine KOA belongs to the category of "arthralgia syndrome of bone", "tendontious pain", "Wei (atrophy) syndrome of bone" or "A Wei (atrophy) syndrome of sinew". Through a mass of ancient and modern archival research, we found that KOA belongs to the category of meridian sinew disease whether in physiological and pathological or in clinical treatment. First of all, the knee is the biggest joint in the body, "the knee is the mansion of tendon", and the function of the soft tissues surrounding knee, known as the meridian sinew system, decides the normal physiological activity of knee. The meridian sinew of three yang meridians and the three yin meridians of the foot both pass by and knit knee, so the diseases of knee have a close relationship with meridian sinew. Secondly, the pathogenesis of KOA also relates to the pathogenesis system.In 1995,a definition was released in the international meeting for OA, which is, OA is a result of disequilibrium of decompose and anabolic metabolism among cartilage cell, ECM and cartilage sending down fishbone, caused by the integration of mechanical and biological factors. Though many factors could lead to KOA, the factor of the mechanical unbalance of the soft tissues surrounding knee is the leading one. Even biological factors make the cartilage degeneration, but the cartilage abrasion and the hyperostosis formation are the consequence of the unbalance of joints tress.So the unbalance of meridian sinew system is still the leading case of KOA. Thirdly, the main clinical manifestations of KOA are joint pain, rigidity, motor dysfunction and intumescences, etc. The cause of these manifestations is the lesions of meridian sinew system. The location of pain is mainly on the point of结筋病. The rigidity and motor dysfunction of joint are caused by the adhesion and contracture of tendon as well.Finally, if the treatment of KOA only points at the knee articular cartilage, it just relieves the symptom temporarily and is poor for long-term. But the treatment for meridian sinew system has achieved a good clinical efficacy either in exercising muscular strength or in lifting Jiejing. Therefore, we could infer that the essence of KOA is a meridian sinew disease.The core of the meridian sinew therapy is dialectical and treatment. In the meridian sinew dialectical, the most commonly used means to gather information is the hand-touch meridian sinew method, which find abnormal reaction points according to examine the soft tissue around joints, then judge the disease nature, the severity index and so on. The hand-touch method is the most widely used in clinical meridian sinew therapy. At the same time, it also has an important guide pole in post-treatment. The modern technologies are increasing widely applied in meridian sinew therapy, such as motion analysis, detection of soft tissue tension, sEMG and human motion image measure. These techniques check and analyze the diseases, which are all based on the knee mechanics imbalance which is an important factor in KOA disease process. But they are still immature and need further refinement.There is a detailed discussion of the treat of the meridian sinew disease from the NeiJing age. Because the key pathological in meridian sinew disease is the joint mechanics imbalance caused by inflammation, effusion, adhesion, and contracture of the soft tissue around the joint, "Jie Jie" is a general principle of the meridian sinew disease treatment. In clinical, the ways of treating meridian sinew disease are various, such as fire needle therapy, tendon-soothing maneuver, acupuncture and needle-knife therapy. The principle is that the treatment in the Jinjie points could dredge meridians, release adhesion and restore mechanical balance around the joint, so as to ease the pain and lubricate the joint. The theory of meridian sinew has widely used in KOA in clinical, but few researches about its mechanism and theoretical system are reported. In order to improve the system of the meridian sinew theory and guide to the treat in clinical, we have carried out a series of studies in KOA meridian sinew theory.This study is divided into two parts. The first part is animal study, which selected by the typical meridian sinew therapy-the acupotome therapy operating at the animal model of KOA, to observe the effect and analyze the mechanism. In the second part, we summarized the meridian sinew dialectical regular according to clinical investigation.The acupotome therapy has been used to treat KOA for thirty years and achieved a good clinical effect. Its basic principle is to restore the joint mechanics balance according to peeling the adhesion, contracture of the soft tissue around joints. And its treatment core is "Jie Jie", which is one of the therapies of meridian sinew.The hindlimb KOA rabbit that observed in our study was made by extension position on the brake and be treated with acupotome therapy, the results showed that the acupotome therapy can improve the KOA rabbit of pain, gait, range of motion and joint swelling significantly. The mechanism may be that acupotome therapy restore the joint’s mechanical equilibrium by acting on the joints around the "bar end" position, so the inflammation around the joint be reduced, the formation of osteoarthritis of the process be interrupted, arrangement and shape of chondrocytes and collagen fiber be repaired, then improved the local collagen fiber structure, and achieve the therapeutic effect eventually.Muscle meridian theory has been widely used in the clinical treatment of KOA, but its dialectical method and characteristics of the system of law has not yet formed. Through the standard clinical investigation of KOA patients, combined with TCM Syndrome survey and JOA joint function score, analyze the characteristics of muscle meridian dialectical of KOA and the relationship betwen different muscle meridian、TCM Syndrome and JOA score, so as to find the law of muscle meridian symptom of KOA. Results showed that the foot-yangming Syndrome and foot-taiyang Syndrome are the most common Syndromes, meanwhile, the TCM syndrome type performances are also not the same in the muscle meridian symptoms, hepatic asthenia, spleen deficiency and Kidney Deficiency are the main Syndromes, such as muscle meridians of foot-yangming, foot-shaoyang and three yin meridians of foot usually show the Kidney Deficiency, muscle meridian of foot-taiyang usually show the hepatic asthenia, muscle meridian of foot-shaoyang also have a higher proportion of stagnation performance, all these have important reference value when we use muscle meridian theories in clinical treatment in future. Combine the JOA score, we also found that with the increase in the number of lesion muscle meridian, knee function score decreased, this shows that the number of lesion muscle meridian determine the tendons severity. The muscle meridian symptoms are also have significant individual differences in pain, mobility, swelling and other indicators, indicators of muscle meridian of foot-taiyang are the most serious and with foot-shaoyang relatively the lightest, the single index of flexion and extension of foot-taiyang are more serious, indicators of muscle meridian symptoms of three-yin of foot behind that of foot-yangming, this also shows that the severity of KOA have significant correlation with muscle meridian symptoms, confirmed the views that KOA is a muscle meridian diseases.In this study, the essence of muscle meridian diseases of KOA are described from the view of theoretical, experimental and clinical point, mechanism of their disease, the dialectical law of muscle meridian and the pathway of acupotome therapy were systematically studied, conducted a preliminary exploration of theoretical system of muscle meridian dialectical of KOA, provide a theoretical basis for the use of muscle meridian therapy in clinical therapy, enrich the contents of muscle meridian theory.更多还原