【作者】 石志勇；

【导师】 朱立国；

【作者基本信息】 中国中医科学院 ， 中医骨伤科学， 2010， 博士

【摘要】 腰椎间盘突出症是指退变的间盘在外力的作用下,纤维环部分或全部破裂,间盘组织向外突出,压迫临近的窦椎神经和神经根,再加上神经根局部炎症刺激和自体免疫反应,从而引起以腰腿疼痛为主要症状,伴有下肢感觉异常以及感觉减退或过敏等感觉障碍的疾病。在非手术疗法中,推拿手法可以解除腰部肌肉痉挛,纠正腰椎小关节紊乱,改变突出物位置,减轻或解除局部的机械压迫；减少炎性细胞对疼痛感受器的刺激；提高神经根局部疼痛阈值。针刺可以改善神经周围微循环,促进内源性镇痛物质阿片肽的释放,缓解疼痛,改善神经功能。所以,将推拿和针刺结合起来治疗腰椎间盘突出症不失为一种很好的治疗选择。针灸和推拿是中医传统治疗方法的重要组成部分,有着共同的理论基础——中医基础理论,都以经络学说为指导,都能够舒经通络、行气活血；都具有疗效好、费用低、操作简单、无副作用的特点；不同点在于：手法可以缓解肌肉痉挛,调整关节以纠正解剖异常,解除对临近组织的压迫；而针刺可以调节神经功能,即时镇痛,缓解肢体远端的疼痛、麻木等神经症状。目的：观察两种方案(针刺留针配合推拿手法、推拿手法加牵引)治疗腰椎间盘突出症的临床疗效差异,比较各个中医分型组内及组间在多个观察指标中的不同之处,探索治疗方案的适宜证型,从而为今后进一步临床研究提供参考。方法：1研究对象：选择2007年6月至2009年6月在中国中医科学院广安门医院推拿科门诊就诊的腰椎间盘突出症患者,共120例,采用SPSS13.0软件随机分为两组,各60例。2干预方法：治疗组采用针刺留针配合推拿手法治疗,依次进行辨证针刺、按揉松脊、捻转行针、弹拨理脊、捻转行针、纵横捏脊、起针、斜扳整脊和虚掌拍脊,整个治疗过程约需30分钟；对照组采用推拿手法加牵引治疗,参照俞大方主编的高等医药院校《推拿学》教材中推荐的腰椎间盘突出症的治疗方法,约需30-40分钟；隔日1次,10次为1个疗程。3观察指标：比较两组组内及组间JOA(日本矫形外科学会腰痛疾患疗效评定标准)积分变化、VAS(直观模拟量表)评分变化、腰椎活动度(用三维腰椎活动度测量仪测量)的改善程度、下肢感觉障碍的评分变化、以及夹脊穴按压反应强度(压痛)的变化。4疗效评定：参照国家中医药管理局中医药行业标准《中医病证诊断疗效标准》中的腰椎间盘突出症疗效评定标准拟定。5统计方法：运用SPSS13.0统计软件进行分析,计数资料采用卡方(X2)检验,计量资料采用t检验,等级／频数资料采用两独立样本非参数检验,有序分类变量相关性分析用Kendall’s等级相关系数分析。结果：1两组间性别、年龄、身高、体重、病程以及中医分型所占比例比较无显著差异,组间均衡,具有可比性。2两组JOA积分、VAS评分、腰椎活动度、下肢感觉障碍评分在治疗前均无显著差异,具有可比性。3两组组内治疗前后JOA积分有显著差异；两组组间治疗后JOA积分有显著差异,两组间第1次治疗后JOA积分无显著差异,第3次和第10次治疗后JOA积分有显著性差异；第3次治疗后血瘀型和肾虚型JOA积分改善程度在治疗组和对照组间无显著差异,寒湿型和湿热型JOA积分改善程度在两组间有显著差异；第10次治疗后四个中医分型JOA积分改善程度两组间均有显著差异。4两组组内治疗前后VAS评分有显著差异；两组组间治疗后VAS评分有显著差异;当次治疗前后VAS最大差值两组间比较,第1次治疗前后VAS差值在两组间无显著性差异,而在第3、6、10次治疗前后VAS差值在两组间有显著性差异；治疗组血瘀型、寒湿型、湿热型均在治疗第3次出现VAS差值最大,而对照组血瘀型、寒湿型以及湿热型则在治疗第6次出现VAS差值最大,肾虚型两组间差别不大。5两组组内治疗前后腰椎活动度改善程度有显著差异；两组腰椎活动度改善程度组间比较,左旋、右旋改善程度无显著差异,前屈、后伸、左侧屈、右侧屈改善程度有显著性差异；寒湿型的腰椎活动改善程度组间比较,前屈、后伸有显著差异；左侧屈、右侧屈、左旋、右旋组间比较无显著差异；血瘀型、湿热型、肾虚型腰椎活动改善程度组间比较,各方向活动均无显著差异。6两组组内治疗前后下肢感觉障碍评分有显著差异；两组组间治疗后下肢感觉障碍评分有显著差异；两组治疗后感觉障碍改善程度有显著差异；血瘀型两组间无显著差异；而肾虚型、湿热型、寒湿型均有显著性差异。7两组组内治疗前后夹脊穴按压反应有显著差异,两组肾虚型治疗前后夹脊穴按压反应无显著差异,而两组血瘀型、寒湿型、湿热型治疗前后夹脊穴按压反应有显著差异。两组组间治疗后夹脊穴按压反应有显著差异；治疗后两组组间血瘀型、肾虚型和湿热型无显著差异,而寒湿型有显著差异。8两组组间疗效比较无显著差异,寒湿型的疗效两组间比较有显著差异；两组疗效与病程、疗效与夹脊穴按压反应均显著相关。结论：1两组治疗方法都能改善腰椎间盘突出症患者的JOA积分；针刺留针配合推拿优于推拿手法加牵引治疗,尤其是寒湿型和湿热型腰椎间盘突出症患者治疗第3次后的JOA积分改善明显优于对照组,而在第10次治疗后四个分型的JOA积分改善程度都明显优于对照组。提示针刺留针配合推拿在改善JOA积分方面更适用于寒湿型和湿热型。2两组治疗方法都能降低腰椎间盘突出症患者的VAS评分；针刺留针配合推拿优于推拿手法加牵引的对照组,在第3次治疗后两组间就有明显区别；治疗组血瘀型、寒湿型、湿热型三型在治疗第3次时就能使疼痛明显改善,而对照组的上述三型在治疗第6次时出现疼痛改善明显,肾虚型两组差别不大。提示针刺留针配合推拿在降低VAS评分方面较适用于血瘀型、寒湿型、湿热型。3两组治疗方法都能改善腰椎间盘突出症患者的腰椎活动度；针刺留针配合推拿在改善患者前屈、后伸、左右侧屈活动度方面优于推拿加牵引治疗；在改善寒湿型腰椎间盘突出症患者前屈、后伸活动度方面同样优于推拿手法加牵引治疗的对照组；其他三型在改善腰椎活动度方面两组治疗方法之间无明显区别。提示针刺留针配合推拿在改善腰椎活动度方面较适用于寒湿型。4两组治疗方法都能改善腰椎间盘突出症患者的下肢感觉障碍；针刺留针配合推拿优于推拿手法加牵引治疗,尤其是对肾虚型、湿热型和寒湿型腰椎间盘突出症患者。提示针刺留针配合推拿在减轻腰椎间盘突出症患者下肢感觉障碍方面更适用于肾虚型、湿热型和寒湿型。5两组治疗方法都能降低腰椎间盘突出症患者的夹脊穴按压反应强度,但两组方法对肾虚型患者改善不明显。针刺留针配合推拿优于推拿手法加牵引治疗,尤其是对寒湿型患者的夹脊穴按压反应。提示针刺留针配合推拿在改善患者夹脊穴按压反应方面更适用于寒湿型。6两组方法治疗腰椎间盘突出症都能取得很好的疗效；对于寒湿型腰椎间盘突出症患者,配合针刺留针的治疗组疗效优于推拿加牵引治疗的对照组；提示针刺留针配合推拿在提高腰椎间盘突出症患者的疗效方面更适用于寒湿型。两组的疗效与病程显著相关,即病程越长,疗效越差；两组的疗效与夹脊穴按压反应呈负相关,即治疗后夹脊穴按压反应越强,疗效越差。更多还原

【Abstract】 Lumbar Intervertebral Disc Protrusion (LIDP) is a common and frequently occurred disease in the clinic and often manifests as lumbago and leg pain. Among all the non-operative therapies, manual manipulation can relieve spasm in the lumbar muscles, adjust the small joint disorders in the lumbar vertebrae, change the position of the protrusion and relieve the local mechanical compression, while acupuncture functions as improving the peripheral microcirculation of the nerves, promoting the release of endogenous opioid peptide, relieving pains and improving the nervous functions. Hence, the combination of manual manipulation and acupuncture is one of the choices for LIDP treatment.Objective:To compare the effects on LIDP treatment by acupuncture combining with manual manipulation versus pure manual manipulation, observe the effect difference by the two treatments among different syndromes (including types of Blood Stasis, Cold Dampness, Damp Heat and Kidney Deficiency), thus find out the proper treatment protocols for different syndromes to guide the clinical practice.Methods:The subjects were LIDP patients collected from June,2007 to June,2009 in the Massage Department of Guang’anmen Hospital, China Academy of Chinese Medical Sciences. Totally 120 cases were included and randomized into two groups with 60 cases in each group. The treatment group was applied with acupuncture with manual manipulation while the control group was with manual manipulation only, both once every other day, ten times as a course. The following items were recorded, measured and compared for the clinical effect evaluation and group comparison:JOA scores (standards for evaluating lumbago therapeutic effect by Japanese Orthopedic Association), VAS scores (Visual Analogue Scale), lumbar mobility (measured by self-made three-dimensional lumbar actometer), scores of sensory disturbance in the lower limbs and pressing response intensity in the Jiaji points (EX-B2) (measured by self-made manometer with same pressure before and after the treatment). The data was analyzed by SPSS13.0 Software. Qualitative data was tested by Chi-square test, measurement data by t-test, ranked counting data by Two-independent-samples nonparametric test, and correlation analysis for ordinal categorical variables by Kendall’s rank correlation coefficient analysis.Results:1. There is no significant difference between the two groups in the gender, age, body height, weight, disease course, duration after the attack, location of the affected intervertebral disc, direction of the protrusion, and rates of different syndromes. The two groups are with homogeneity and comparable.2. There is no significant difference between the two groups in JOA scores, VAS scores, lumbar mobility, scores of sensory disturbance in the lower limbs and pressing response intensity in the Jiaji points (EX-B2) before the first treatment. The two groups are comparable.3. There is no obvious difference of the effects between the two groups but significant difference of the effects on the Cold Dampness syndrome in the two groups.4. There is significant difference of the JOA scores, VAS scores, lumbar mobility, scores of sensory disturbance in the lower limbs, and pressing response intensity in the Jiaji points (EX-B2) in the groups before and after the treatment, and also between the two groups after the treatment.5. The effects are obvious correlated with the disease course and pressing response intensity in the Jiaji points (EX-B2).Conclusion:1. Acupuncture with manual manipulation is better than pure manual manipulation in improving the JOA scores, especially after the third treatment in the Cold Dampness and Damp Heat syndromes of the LI DP patients, and in the four syndromes after ten times of treatment.2. Acupuncture with manual manipulation is better than pure manual manipulation in decreasing the VAS scores, especially in the Blood Stasis, Cold Dampness and Damp Heat syndromes after the third treatment.3. Acupuncture with manual manipulation is better than pure manual manipulation in improving the lumbar mobility of anteflexion, posterior extension and lateroflexion, and better in improving the anteflexion and posterior extension in the Cold Dampness syndrome.4. Acupuncture with manual manipulation is better than pure manual manipulation in improving the scores of the sensory disturbance in the lower limbs in the Kidney Deficiency, Damp Heat and Cold Dampness syndromes.5. Acupuncture with manual manipulation is better than pure manual manipulation in relieving the pressing response intensity in the Jiaji points (EX-B2); there are no obvious changes of the response intensity in the Kidney Deficiency syndrome before and after the treatment; the effects and the Jiaji points response intensity are with negative correlation, i.e., the stronger the response intensity after the treatment, the worse the effects.6. The effects in the treatment group and control group both are good; acupuncture with manual manipulation is better than pure manual manipulation in the Cold Dampness syndrome of the.LIDP patients; the effects and the disease course are obviously correlated, i.e., the longer the disease course, the worse the effects.更多还原