从整体观谈强壮穴与类风湿性关节炎的相关性

【作者】 黄俊中；

【导师】 张露芬；

【作者基本信息】 北京中医药大学 ， 针灸推拿学， 2010， 硕士

【摘要】 类风湿性关节炎(RA)是一种以关节周围对称性、多发性滑膜炎症为特征的慢性全身性、消耗性自身免疫性疾病,好发于青壮年及少儿,患病高峰年龄为30-50岁,女性发病率高于男性,为临床常见多发病,属中医“痹病”范畴。中国传统医学对本病的认识较早,并积累了丰富的经验。中医学认为：痹病多因人体营卫失调,感受风寒湿之气,合而为病,或病久体虚,内生痰浊、瘀血、毒热,正邪相争,使经络、肌肤、血脉、筋骨乃至脏腑气血痹阻,失于濡养所致,从而出现肢体疼痛、肿胀、酸楚、麻木、着重、变形、僵直及活动受限等一系列症状,甚则累及脏腑。RA因其病程反复缠绵难愈,致残率高,严重影响人们的日常生活,危害人类健康。目前,国内外就类风湿性关节炎的发病机制进行了大量研究,认为感染和自身免疫反应是RA发病的中心环节,而内分泌、遗传和环境因素等也是相关诱发因素,但具体病因与发病机制尚不明确。目前治疗RA的常用西药毒副作用明显、病人难以长期耐受的缺点,使之在RA的治疗上仍然缺乏理想的疗效和药物,特别是在改善和阻止RA病情发展方面缺乏特异性的高疗效、低风险的干预手段。而RA的手术适应症往往是病情后期,或是要求患者全身情况比较稳定,在稳定前亦往往以内科方法治疗,治疗费用昂贵,非患者能普遍接受。中医学具有的辨证施治、个体化治疗、安全有效、可长期使用的特点,正日益受到国内外医学界的关注。众所周知,中医学的基本特点是整体观念指导下的辨证论治,与西医学相比,这既是特色,也是优势所在。中医的思维具有整体性、辩证性的特点。与现代医学理论提出的神经-内分泌-免疫网络的整合调节具有明显的相似之处。中医药治疗RA整体性、多途径、多环节的调节作用不仅能减轻病人的临床症状,延缓病情发展,还能调节机体免疫机能,增强患者体质。而针灸作为祖国医学的传统疗法,同样具有多层次、多水平、多靶点的整体调节作用,还可避免胃肠道功能对药物吸收的影响,有效减少了药物的不良反应,操作亦简便灵活。1996年世界卫生组织召开了意大利米兰会议,提出64种针灸适应证,其中针灸疗法或传统疗法采用随机对照试验有效的针灸适应证中包括RA。针灸治疗RA的疗效显著。传统医学认为,针灸可以扶助正气,祛除邪气,具有整体调节作用；现代医学则认为,针灸具有较好的抗炎免疫作用,可有效抑制炎症的发生发展,整体调控神经-内分泌-免疫网络是针灸治疗RA的疗效机制所在。通过对针灸治疗RA的临床文献总结,在辩证选穴上足三里、关元、命门的使用较为频繁。而足三里、关元、命门三穴作为历代医家公认的强壮穴,已有研究证明针灸强壮穴对RA疗效显著。已有研究证明针灸强壮穴对RA有较显著的疗效。因而有必要在现代研究基础上对RA古今文献进行梳理,以整体观为切入点探讨强壮穴与RA的相关性,不仅有助于进一步认识类风湿关节炎与针灸强壮穴的疗效作用机制,亦为现代临床用药及多方法治疗提供了新的思路和借鉴。笔者通过整理近十余年来类风湿性关节炎的相关文献资料,初步得出了以下结论：1. RA的病因病理至今尚未完全明确。现代医学目前认为与自身免疫、遗传、感染(如支原体、分枝杆菌、肠道细菌、衣原体等)及内分泌失调等因素有关。现已有大量资料证实,RA是免疫系统调节紊乱所致的炎症反应性疾病,不仅有体液免疫紊乱,细胞免疫紊乱亦参与作用。2.西医对类风湿关节炎的治疗主要以保持关节活动或协调功能、抗炎止痛、减轻症状、尽量维持病人正常生活和劳动能力为原则,但目前治疗RA的常用西药存在毒副作用明显、病人难以长期耐受的缺点,手术适应症又往往是病情后期,或是要求患者全身情况比较稳定,在稳定前亦配合内科方法治疗,治疗费用昂贵,非患者所能普遍接受。3. RA的病因病机特点为本虚标实,肝肾不足,气血亏虚是本源；风、寒、湿、热、痰浊、瘀血是其标。辨证时要明辨寒热病性及邪正虚实。首辨寒热,以关节有无红肿热痛为要；次辨病邪盛衰,以关节疼痛性质为主。再辨证候虚实,一般新病多实,久病多虚,或呈虚实相兼。疾病早期常见风寒湿证、寒湿热证、寒热夹杂证；证型病程较长,中晚期以痰癖痹阻证、正虚邪恋证多见。4.中医治疗以整体观为指导,扶正祛邪,攻补兼施。急性期以祛除邪实为主,通络止痛,并依据其病邪偏盛不同各有侧重；缓解期以正虚为主或虚实夹杂者,治当攻补兼施。中医药治疗RA用药以温性、苦味、辛味为主,配伍寒性、甘味药物。药物归经以肝、脾、肾经为主。5.运用中药治疗RA,辨证论治仍是主导。虽然中药治疗RA毒副作用小,疗效显著,但也存在一些问题,例如：临床证候分型、分期不统一,可重复性差；临床样本量少,疗效评价标准不统一,结论缺乏可信度；近期临床疗效观察多,中远期疗效观察少；缺乏对有效中药作用机制的深入探讨,有关药效、毒理学等方面的实验研究有待深化。6.针灸治疗RA的机理是通过“扶正祛邪”,使机体达到一种“阴平阳秘”的自身稳定状态实现的；现代医学则认为可能与针灸对神经—内分泌—免疫网络的整合调节关系密切。针灸治疗RA临床辩证取穴以局部循经取穴为主,配合局部施灸疗效较好。穴位应用以足三里,关元,命门3大强壮穴调整机体的整体状态选用频率较高,疗效显著。研究表明,在临床治疗中选取足三里、关元、命门等强壮穴可调节体液免疫与细胞免疫功能,改善血液流变学和微循环状态,促进自由基代谢,抗应激等,较好地体现了针灸多层次、多水平、多靶点的调节作用,对强壮穴的普及应用具有重要的指导价值。7.针灸从整体上着眼于调节各种因素引起的机体异常反应,改善多个系统功能失调,消除病理产物的复合刺激,纠正病理偏颇,因势利导地调动机体抗病能力和适应调节能力,恢复内稳态,达到综合调理的结果。针灸刺激腧穴,通过复杂的自稳调节系统,使治疗信息经经脉输入从而激发调动机体提高抗御病邪的能力。其内在机制也是通过启动神经-内分泌-免疫网络而实现的。综上所述,关元、足三里、命门三穴同为人体强壮穴,对机体都有整体、双向调节作用,但其调节侧重点又各有不同。关元穴为任脉与足三阴经交会穴,有培肾固本,补益精血,调理冲任,固护先天之本的功效。足三里为足阳明之脉的合土穴,土经之土穴,回阳九针穴之一,可调理脾胃,补益气血生化之源,固护后天之本。而命门位于两肾之间,其下肾间动气为坎中之阳,且位置与命门学说中命门的位置相同；命门穴又属督脉,督脉为阳脉之海,总督一身之阳,所以命门有补肾培元,益精生髓,疏经和血的功用。研究表明,足三里穴具有缓解平滑肌痉挛、调节神经系统、增强机体应激能力、增强免疫功能、提高机体抗病能力等作用。针刺足三里穴可调节中枢神经系统单胺类介质及阿片系统产生镇痛作用,通过调节血液循环和组织微循环状态以增强机体免疫功能、抗炎镇痛。关元穴的整体性调整作用是现代学者较为重视的研究课题,总结近年来对关元穴现代作用机理的研究发现关元穴具有抗氧化、延缓衰老的重要作用,针刺关元穴能够显著提高机体抗氧化防御系统的酶活性,能通过提高组织中SOD、谷胱甘肽过氧化物酶(GSH-PX)、过氧化氢酶(CAT)及NOS的含量,增强清除自由基的能力,从而减少或抑制脂质过氧化产物的生成；同时提高单核巨噬系统、红细胞的免疫粘附功能及红细胞的免疫促进因子活性的功能。还可影响各种淋巴因子、淋巴细胞活性的变化,进而对机体体液免疫、细胞免疫及免疫系统整合调节。进一步的研究还发现关元穴具有调节免疫状态,减轻炎症反应的作用：关元穴可调节多种细胞因子水平,通过对神经、免疫、内分泌三大系统的调控,改善机体下丘脑-垂体-甲状腺轴功能,以发挥补肾固本之功效,还可调节下丘脑-垂体-性腺轴的功能,对生殖系统产生调节作用。动物实验结果证实,关元穴通过多方面的调节可改善血液流变状态及自主神经功能紊乱。从而使机体状态从紊乱恢复到正常,实现对神经-内分泌-免疫网络各个环节的整体调控。命门穴作为强壮要穴之一,现代学者对其功用和作用机理也做了较为深入的研究。针灸命门穴对人体的整体、双向的调节功能的实现依赖于神经-内分泌-免疫三大系统共同调控,研究证明它对神经-内分泌-免疫网络的各个环节都具有调节作用：现代实验研究结果显示,针刺命门穴能够促进中枢神经系统损伤后的各种生长因子的分泌,对维持损伤部位神经元的存活以及引导神经纤维的再生具有重要意义。针灸命门穴能在神经-内分泌-免疫网络不同水平影响细胞因子、阿片肽系统、下丘脑-垂体-肾上腺皮质系统,发挥其抗炎免疫的调节作用；能明显提高血清睾酮的水平,提示其可能是通过神经-内分泌-免疫途径,在不同程度上激发或者诱导体内调节系统增强下丘脑-垂体-性腺轴的功能,从而提高人体的生殖功能。此外,针灸命门穴可明显改善学习记忆功能,增强脑组织乙酰胆碱酯酶(AchE)的活性,提高大脑乙酰胆碱含量,对机体的认知、行为等产生积极的影响。故神经-内分泌-免疫网络可能是命门穴作用机制的重要通路。因此,三穴通过各自的作用形式整体上调整人体功能,以达到治疗风湿性关节炎的目的。更多还原

【Abstract】 Rheumatoid Arthritis (RA) is an autoimmune systemic disease, causing membranes or tissues lining (also known as the synovium) of the joints to become swollen, stiff, and painful (inflamed). The disease usually affects both sides of the body at the same time. Over time, this inflammation may destroy the joint tissues including cartilage, ligaments, tendons and bone, and, in rare but severe cases, may cause organ damage. This can limit your daily activities and make it hard for you to walk and use your hands. This disease can happen during childhood, as juvenile RA. Adults RA usually happen more to women than men at the age between 30 and 50 years old. The disease also runs in some families. This disease comes under the category of arthralgia syndrome in Traditional Chinese Medicine (TCM), which is also projected in different syndrome type due to its different nature of causes known to TCM. In ancient documentation Traditional Chinese Healer came to know about this disease and had been treating them successfully as far back as several thousand years ago. TCM believes that imbalance to the essence of the body and invasion of pathogenic factors is the fundamental for the cause of RA. Also, weak constitution of qi and the insufficiency of qi and blood, disharmony between yin and yang systems which result the forming of phlegm, blood stasis, heat-toxicity thus affecting the regularity of the body’s meridians, muscle and bones, skins, blood vessels and the organs presented as RA today. These can result in swelling, aches and pains, numbness, overall fatigue, deformation and stiffness thus limiting movements, even organ damage.Rheumatoid arthritis causes deterioration of life during flares, it is chronic and relapse spontaneously leading to progressive joint damage, deformity, disability and shortened lift expectancy. There is no known cure for this disease. A great deal amount research has been conducted all around the world. Many modern science studies shows that infection leading to inflammation and autoimmune is the basic fundamental causes of RA while Internal secretion and family history are secondary. But the precise causes are still not fully understood. Many of the Western medicines used today to treat rheumatoid arthritis contain serious side effects, these treatments may help relieve symptoms and control the disease and they continues throughout their life. Surgery may be an option. Total joint replacement can be done for many joints in the body, but they are very costly, and it’s only considered usually at the later stage of its progression.TCM treatments using acupuncture on the other hand, based on the recent laboratory studies and applications in hospitals has been proven to be able to both produce great results in the control rheumatoid arthritis and with minimal side effects even with long term treatments. These treatments are very convenient and does not requires and any administration of drugs or medicines.64 types of acupuncture treatments for various disease were introduced during a World Health Organization Meeting in Milan Italy, of those includes the treatment for RA. This is display of great acceptance and effectiveness of treatments using acupuncture around the world. Apparently, the "holistic concept" is the essential feature of TCM when it comes to understanding all types of disease and their symptoms. Modern TCM believes this is the same expression to the body’s Immune-Neuro-Endocrine network identified in Modern Health Science. Already proven, acupuncture is able to improve etiological factor and dispel pathogen in a living organism, this is similar to the up-bringing of a body’s immune system, thereby reducing the inflammations and the progression of RA. After consolidating various studies and articles, it is found that the usage of 3 particular strengthening acupuncture points has been exceptionally frequent thus their effectiveness; they are the Zu San Li, Guan Yuan and Ming Men. The usage of these acupuncture points is known to have overwhelmed results against RA. The content of the following dissertation will be a presentation of modern Traditional Chinese Medicine and Acupuncture in the treatments to RA, from the extraction of Chinese ancient time’s literature and modern scientific researches. These cases will be refine with the relationship of Chinese Holistic concepts and the body’s Immune-Neuro-Endocrine network. The aim is to provide a better and clearer interpretation to the treatment of RA in near future.The author gathered large amount of both Chinese ancient’s time literature and modern science researches for the past 10 over years, discovers that the Chinese Holistic concept plays a very important role in the treatment of RA. Especially the acupuncture’s multi-strata, multi-leveling and multi-targeting features resulting in positively adjust a living body holistically. Display astonishing results during the treatment of RA. After systemically organizing all of the information gathered, the author preliminary conclude the followings:1) The cause of RA is still not yet understood, but a lot has already been discovered. It is known as an autoimmune systemic disease which may eventually cause permanent joint damage and painful disability. In rare but severe cases, they may cause organ damage.2) The aim of rheumatoid arthritis treatment in Modern Health Science is in controlling a patient’s signs and symptoms of inflammation and minimizing joint damage, thus to maintain their quality of life and ability to function. In some cases, treatment may also involve surgery. 3) The characteristic for RA in TCM is sufficient in etiological factor ("qi" and blood) with active pathogen (Wind, Coldness, Dampness, Heat, phlegm and blood stasis).4) Acupuncture is a technique to adjust a body’s Immune-Neuro-Endocrine network. This improve etiological factor and dispel pathogen in a human body, which is able to bring up a body’s immune system.5) Treatments for RA should be in reference to the Chinese Holistic concepts by improving etiological factor and dispel pathogen. Each consultation should be handled differently due the fact that none of the individual is the same although there may partial similar during the treatment.6) Even though treatments to RA using TCM in the studies response positively, the patients usually only comprise of individuals with acute symptoms, there is a lack of studies to be done on different specific stages.7) By creating positive adjustment to the body’s Immune-Neuro-Endocrine network, several organic mechanisms are triggered to the reinstate the balance in a living body.Although they are identically classified under strengthening acupuncture points, Zu San Li, Guan Yuan, Ming Men each has its own characteristics. Each of the strengthening acupuncture points benefits RA treatments differently. Zu San Li promotes secretion of IL-2 and suppress IL-1. Guan Yuan provide more active NK Cells. Ming Men regulates CRH, Cort. These various pathology therefore enables a body’s self activated recovery.更多还原