【作者】 张瓈云；

【导师】 许能贵；

【作者基本信息】 广州中医药大学 ， 针灸推拿学， 2011， 博士

【摘要】 腕管综合征(Carpal tunnel syndrome, CIS)是因管内压力增高,压迫从管内通过的正中神经、屈指肌腱而产生的一系列临床症状,又称为“腕管卡压综合征”,好发于中老年人,女性多于男性。临床上以患手拇指、食指、中指及环指桡侧(桡侧三个半手指)有感觉异常、麻木、刺痛,可向肘部、肩部放射。叩击腕管时可引起正中神经分布区手指放射性触电样刺痛。症状以晨起、夜间较重,作腕关节活动、或上举手部,可使症状缓解。患侧手指可有胀、僵、凉的感觉,皮肤颜色可见苍白或紫绀,后期患者可出现大鱼际萎缩、麻痹、肌力减弱,桡侧三个半手指感觉明显减退或消失,对掌功能障碍。肌肉萎缩的程度与病程长短有密切关系。雷射针灸,即激光针灸,是用低功率激光照射生物体,产生弱激光生物刺激效应,使患者得到康复治疗。其治疗作用主要表现在改善局部血液循环,改善神经系统功能,抗感染,促进组织再生作用,镇痛作用等。激光针灸以无痛、无感染、无明显禁忌穴、安全、不晕针且剂量可控、操作简便等优点,开始被广泛的应用于临床,并且取得了较好的临床疗效。目的基于以往的研究,本课题藉由GSS评分量表(global symptoms score, GSS)、神经传导检查(nerve conduction study, NCS)以及Kelly评定标准,观察雷射针灸疗法治疗腕管综合征的临床疗效,以及对CTS患者生存质量的影响,并与伪雷射组做比较。方法本课题病例来源于台湾台中光田医院门诊患者,经神经内科专科医师诊断为轻至中度的腕管综合症患者,共收集符合纳入标准的病例60例。随机分为雷射针灸(laser acupuncture)组和伪雷射针灸(sham laser acupuncture)组。两组按1：1的比例,每组至少各30例。治疗组：雷射针灸组,取穴：患侧内关穴、大陵穴。操作方法：使用德国Reimers & Janssen GmbH生产的Handylaser Trion 150810(class IIIb lasers,150mW,红光,810nm波长。以810nm波长的红外线雷射,输出150mW的低能量雷射,直接照射患侧的内关穴及大陵穴,每穴5min,共10min。对照组：伪雷射针灸组,取穴：患侧内关穴、大陵穴。操作方法：使用与雷射针灸组的相同机器,无激光束输出,以红光闪烁直接照射患侧内关穴及大陵穴,每穴5min,共1Omin。疗程：两组疗程均为：5次/周,4周为1疗程,共1疗程。疗效评估：两组治疗前后均从以下几个方面进行临床观察：(1)全般性症状分数评估(Global symptom score,GSS)。(2)运动神经传导检查：①运动神经远端潜伏期(distal motor latency,DML);②复合肌肉电位波振幅(compound muscle action potential,CMAP);③运动神经传导速度(motor nerve conduction velocity,MNCV)。(3)感觉神经传导检查：①感觉神经远端潜伏期(distal sensory nerve latency,DSL);②感觉神经电位波振幅(sensory nerve action potential,SNAP);③掌-腕感觉神经传导速度(wrist-palm sensory nerve conduction velocity,W-P SNCV)。以上测量项目均广泛使用于临床,有较好的信度、效度和代表性。(4)采用Kelly评定标准结合GSS量表进行疗效评估。将全部数据输入SPSS13.0统计软件,对数据资料进行统计学处理及分析,得出结论。结果治疗前两组患者在性别、年龄、病程、症状等各项基本资料间统计学差异(P>0.05),提示彼此间具有较好的可比性。雷射针灸组中,疗程结束后,运动神经远端潜伏期与治疗前比较,差异非常显著(P<0.05)。可认为雷射针灸对于腕管综合征运动神经传导里的运动神经远端潜伏期DML该项改善显著。患者全般性症状分数(GSS)的总分即2周后与治疗前对,4周后与治疗前对比,4周后与2周后对比,雷射组的组内比较有明显差异(P=0.00),雷射针灸组治疗前后的分值差异与伪雷射组治疗前后的分值差异相比也有显著意义(P=0.00),可认为雷射针灸在治疗腕管综合症时,该病的常见症状如疼痛,麻木,笨拙,夜间觉醒等有显著改善的效果。单项指标治疗后的组间比较,除运动神经远端潜伏期时长雷射针灸有明显改善外。其余单项指标无明显统计意义。且虽然感觉神经电位波振幅(SNAP)的积分与治疗前比较,差异非常显著(P<0.05)。但伪雷射组在感觉神经电位波振幅(SNAP)和掌-腕感觉神经传导速(W-P SNCV)亦有明显差异(P<0.01),且组间比较与预期结果相反,出现这种情况有2种可能：(1)雷射针灸对本病除DML外其他指标的改善作用不大,出现的两组内前后差异可能由于本病的自愈造成的；(2)雷射针灸对这些指标都有改善,但伪雷射可能也有治疗作用,除了DML外对其他指标也有改善。两组治疗后组间疗效比较,经Ridit检验,得P=0.00,可见两组的疗效有显著性差异,且其Ridit平均值经比较,雷射组(0.6242)>伪雷射组(0.3758),故可认为雷射针灸组的疗效优于伪雷射针灸组。结论雷射针灸在治疗腕管综合征这一疾病上,有着确实的疗效。从可以改善患者的临床症状来看,雷射针灸在一定程度上可以减轻病人疾患的痛苦,提高患者的生存质量。相对于传统针灸,雷射针灸有着无痛、无菌、安全、易控制等优势,病人在心理上更易接受该治疗方法。是腕管综合征保守治疗方案中可选择的方法之一,并可作为辅助治疗,在临床上得以广泛运用。更多还原

【Abstract】 Carpal tunnel syndrome is a series of clinical symptoms caused by the increased pressure on median nerve and flexor digitorium through the tunnel. Clinically, this disease is mainly characterized by numbness and stabbing pain in the thumb, index finger, middle finger and ring finger (three and a half fingers at the radial side) that radiate to the elbows and shoulders. Stabbing pain like pain like electronic shock can be felt in the three and a half finger at the radial side when carpal tunnel is knocked. The symptoms are severe at night and in the morning, alleviated after moving or lifting the hands. Fingers at the affected side may feel distending, stiff and cold with pale or cyanotic color. In the advanced stage, the symptom seen are thenar atrophy, numbness, reduced muscular tension, loss or impairment of sensation in the finger, and dysfunction of palm opposing function. The degree of muscular atrophy is related to the course of disease.Laser acupuncture utilizes low energy to radiate biological tissue, then cause the corresponding effect and enable patients to restore their health with the help of this equipment. The wave of near-infrared and the laser of visible light have many physiological actions and treatment functions to organism and these can be shown by the improvement of partial blood circulation, nervous system function and anti-infection and the promotion of polygenesis of organism, as well as the analgesia function. Low energy laser acupuncture has been applied to the clinical treatment extensively now.Objective: Based on the previous study, this subject aim to investigate the efficacy of laser acupuncture compared with sham laser acupuncture treatment in patients with mild-to-moderate carpal tunnel syndrome (CTS) as measured by subjective symptoms assessment as global symptoms Assessment (GSS); the Kelly assessment.standard and objective changes in nerve conduction studies (NCS) and in a randomized, controlled study, and observed the change of quality of life of CTS patients.Methods:A total of 60 consecutive and prospective CTS patients confirmed by NCS were enrolled in the study. According to the principle of randomization, the CTS patients were divided into 2 treatment groups: 1. the group of laser acupuncture,2. the group of sham laser acupuncture. Specific research methods of each group are:Group of laser acupuncture, adoption point:Neiguan (PC 6), Daling (PC 7). Operation:use Handy laser Trion 150810 (class IIIb lasers,150mW, redlight,810nm wavelength. Direct exposure to the Neiguan and Daling points of the affected hand by use 810nm infrared wavelength laser, the output 150mW low-energy laser. Each points 5 min, a total of 10 min.Group of sham laser acupuncture, adoption point:Neiguan (PC 6), Daling (PC 7).Operation:use the same machine as Group of laser acupuncture. No laser beam output, just direct exposure to red light flashes to the Neiguan and Daling points of the affected hand. Each points 5 min, a total of 10 min.Course of treatment:The treatment lasted of two groups:5 times/week,4 weeks made 1 course of treatment, a total of one course of treatment. Efficacy evaluation:Two groups before and after treatments should be observed with thefollowing aspects:(1) Global symptom score, GSS. (2) Measurement of Motor nerve conduction velocity:①distal motor latency, DML.②ompound muscle action potential, CMAP.③motor nerve conduction velocity, MNCV.(3) Measurement of Sensory nerve conduction velocity:①distal sensory nerve latency,DSL.②sensory nerve action potential, SNAP.③wrist-palm sensory nerve conduction velocity, W-P SNCV. (4) The Kelly assessment standard was used for efficacy assessment scale with GSS.We enter all data into SPSS13.0 the statistical software for data processing and analysis of statistical data and finally draw conclusions. Result:There was no difference of signification between the two groups of patients in aspect of gender, age, disease duration, syndromes, and other basic information (P> 0.05), suggesting a better comparability among them.After treatment, the distal motor latency(DML) of laser acupuncture group shows significant statistical difference the difference was significant compared with before treatment (p<0.01). It can be consider that laser acupuncture could improvement the distal motor latency obviously.Compared with before treatment,2 weeks ago,4 weeks ago and after 4 weeks compared with 2 weeks, all general symptom score (GSS) of the total score of patients of the laser group were have significant differences (p=0.00). It also show significant differences by compared with sham laser acupuncture group (p=0.00). It can conclusion that laser acupuncture could improvement the symptoms of Carpal tunnel syndrome like pain, numbness, clumsy, nocturnal and so on.Individual index between the two groups after treatment, except the distal motor latency(DML), there were no significant statistical difference in the other aspects. In the fact, the sensory nerve action potential(SNAP) and wrist-palm sensory nerve conduction velocity(W-P SNCV) have an unexpected result-the sham laser acupuncture group have a significant statistical difference. There is twu possible for this happens:(1) Laser acupuncture had little improvement in this indicators except DML. The difference between the two groups of before and after may be due to the self-healing. (2) Laser acupuncture had some improved on these indicators, but the sham laser acupuncture also had some effect on these indicators except DML.After treatment,the efficacy comparison between the two groups were have significant differences (P=0.00). It shows the efficacy of the two groups was significant difference.So that it can be considered laser acupuncture group have more effective than sham laser acupuncture group by comparison the average of Ridit of Laser group (0.6242)> pseudo laser (0.3758).Conclusion: Laser acupuncture has a definite effect on the treatment of carpal tunnel syndrome. For the aspect of laser acupuncture could improved the clinical symptoms, Laser acupuncture can alleviate the suffering of patients with diseases at some extent, improve the quality of life of patients. Compared with the traditional acupuncture, laser acupuncture has a painless, sterile, safe, easy to control and other advantages so that patients could have more acceptable at psychologically. Laser acupuncture can be a good option that used in the Conservative treatment of carpal tunnel syndrome, and this method can be used as adjuvant therapy widely in clinical practice.更多还原